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https://openalex.org/W4308881928	http://dspace.vutbr.cz/bitstream/11012/208535/1/22_04_0553_0563.pdf	English	null	Uncooperative Emitter Localization Based on Joint Sensor Selection and Semidefinite Programming	Radioengineering	2,022	cc-by	9,380	1 Nanjing University of Information Science and Technology, Nanjing, China 2 The Sixty-Third Research Institute, National University of Defense Technology, Nanjing, China 20201249250@nuist.edu.cn, jianzhao63s@nudt.edu.cn, lyx63s@163.com, 001520@ nuist.edu.cn, jqdeng@nudt.edu.cn, guokai.chen@nudt.edu.cn Submitted August 9, 2022 / Accepted October 25, 2022 / Online first November 7, 2022 ment, making it suitable for large-scale IoT with resource- constrained radio sensors [9–13]. Abstract. Radio emitter localization based on Received Signal Strength (RSS) is promising in large-scale Internet of Things (IoT) and wireless sensor networks (WSNs) for its low hardware and computation costs. To improve its localization accuracy and reduce the system energy con- sumption, we propose an improved RSS localization algo- rithm based on the joint sensor selection and semidefinite programming (SDP). An initial position estimate is first obtained using RSSs available at a random set of sensors. A refined sensor set is then selected to complete the second estimation by analyzing the geometric structure of sensing network. Performance of the method is evaluated in terms of localization accuracy and execution time, and compared with existing methods. Extensive simulations demonstrate that the proposed approach achieves a localization accu- racy of approximately 1.5 m with 8 to 10 sensors. The method outperforms the second-order cone programming (SOCP) and the least squared relative error (LSRE)-based SDP algorithms in terms of both the location and the transmit power estimation accuracy. RSS-based localization includes fingerprint localiza- tion and ranging localization. The fingerprint localization is realized in two steps. Firstly, a collection of RSS values is carried out in a certain area and an RSS-fingerprint map is created to fulfill the so-called offline training phase. Secondly, in the online test phase, the actual monitored RSS is compared to the entries in the fingerprint map to estimate the emitter location. The authors in [9] and [10] matched the actually monitored RSS with the fingerprint map using commonly used machine learning models such as K-nearest neighbor, decision tree and support vector machine to perform highly accurate emitter localization. Fingerprint localization and most traditional ranging locali- zation algorithms assume that emitter transmitting power is known. However, the power is usually unknown in an uncooperative scenario, and methods for estimating the transmit power have been rarely investigated. We focus on the scenario where both the emitter location and transmit power need to be estimated. The authors in [14] had pro- posed an uncooperative RSS-based localization scheme utilizing a maximum likelihood (ML) estimator. It tried to solve a non-linear and non-convex optimization problem, which is challenging in wireless sensor network (WSN) with limited computation resources. RADIOENGINEERING, VOL. 31, NO. 4, DECEMBER 2022 RADIOENGINEERING, VOL. 31, NO. 4, DECEMBER 2022 553 Keywords Received signal strength, sensor selection, semidefi- nite programming, least squared relative error 1 Nanjing University of Information Science and Technology, Nanjing, China 2 The Sixty-Third Research Institute, National University of Defense Technology, Nanjing, China To address such an issue, Ziskind et al. [15] proposed an iterative-based algorithm to reduce the computation complexity, but the estimation result depends on the initial value used and the optimality of the algorithm cannot be guaranteed. In [16], unscented transformation (UT) and weighted least squares (WLS) methods were applied to develop a low complexity algorithm for joint estimation of location and transmit power. In [17] and [18], the ML problem was modeled as a WLS problem, and then the WLS problem was converted into a convex semidefinite programming (SDP) or second- order cone programming (SOCP) problem, which has low- er computation complexity. 1. Introduction Then, they applied a first-order Taylor series to approximate the received power. However, in the case of noise with significant shadowing effect, this ap- proximate representation can lead to a significant increase in position estimation error. The authors in [12] and [13] converted the traditional RSS measurement model into a multiplication model without a logarithm term. After- ward, they transformed the multiplication model to a least squared relative error (LSRE) model. The LSRE model was further relaxed into an SDP problem by semidefinite relaxation (SDR). These transformations can avoid the errors introduced by the approximation of the first-order Taylor series. The above schemes still suffered from pro- hibitive hardware costs and power consumption due to the usage of all the sensors in the networks. Generally, some sensors in the network do not improve the estimation per- formance due to the restricted communication range, while increasing the system runtime and energy consumption. Thus, this paper tries to select an optimal subset of all sen- sors to estimate the location and transmit power with low energy and computation overhead.  Extensive simulations for different scenarios show that the proposed algorithm can achieve higher locali- zation accuracy with less calculation time than exist- ing SDP and SOCP optimization algorithms. The remaining sections are structured as follows. In Sec. 2, the sensor selection problem and the RSS meas- urement model are presented. Subsequently, Section 3 describes RSS-based emitter localization model. Section 4 gives the proposed sensor selection algorithm in detail. The simulation results are shown in Sec. 5. Finally, Section 6 summarizes the work of this paper and gives an outlook on future research. The corresponding Cramer-Rao lower bound (CRLB) for the RSS measurement model is derived in the Appendix. In the following, tr (.) and rank (.) represent the trace and the rank of a matrix, respectively, [.]T denotes the transpose of a matrix. Im represents the m by m identity matrix. . denotes 2 norm. Few existing LSRE-based localization algorithms take the sensor selection problem into consideration. In the uncooperative RSS-based localization, Ababneh et al. [19] pointed out that a reasonable selection of sensors was the key factor to determine the quality of the overall network estimation. In [20], the sensor selection was molded as an optimization problem that satisfied the localization er- ror, yet without the selection feedback mechanism. Bopardikar et al. 1. Introduction [21] proposed an alternation-free sensor selection and localization approach based on the TDOA, which had low complexity. Nevertheless, the approach did not take into account the differences among the sensors. Bel et al. [22] solved the sensor selection problem for RSS- based localization by deriving an RSS threshold depending on the total number of sensors. Then all sensors with RSS measurements above the threshold were selected. This resulted in selecting the sensors that were closest to the emitter. 2. Problem Statement and Measure- ment Model In this section, we first provide a description of the sensor selection problem and the RSS measurement model. 1. Introduction Large-scale network localization techniques in 5G and beyond 5G wireless networks are essential for many Internet-of-Things (IoT), smart city and military applica- tions, including spectrum monitoring, intelligent transpor- tation, asset tracking and battlefield monitoring [1], [2]. Compared with methods relying on time of arrival (TOA) [3], [4], time difference of arrival (TDOA) [5], [6], or an- gle of arrival (AOA) [7], [8] measurements, received signal strength (RSS) based localization method features low hardware cost and low network synchronization require- The above-mentioned ranging localization algorithms are based on least squares (LS) criterion, where the sum of DOI: 10.13164/re.2022.0553 HANG, Y.X. LIU, ET AL., UNCOOPERATIVE EMITTER LOCALIZATION BASED ON JOINT SENSOR SELECTION… 554 L.M. CAO, J.Z. ZHANG, Y.X. LIU, ET AL., UNCOOPERATIVE EMITTER LOCALIZATION BASED ON JOINT SENSOR SELECTION…  A sensor selection algorithm is proposed to reduce the system runtime and improve the system efficiency by exploring the sensor network geometry structure via network area splitting, and selecting sensors relatively close to the emitter. squares of the absolute errors is minimized. To obtain a formula without a logarithm term, most researchers firstly convert the conventional RSS measurement to the absolute power domain. Then, they applied a first-order Taylor series to approximate the received power. However, in the case of noise with significant shadowing effect, this ap- proximate representation can lead to a significant increase in position estimation error. The authors in [12] and [13] converted the traditional RSS measurement model into a multiplication model without a logarithm term. After- ward, they transformed the multiplication model to a least squared relative error (LSRE) model. The LSRE model was further relaxed into an SDP problem by semidefinite relaxation (SDR). These transformations can avoid the errors introduced by the approximation of the first-order Taylor series. The above schemes still suffered from pro- hibitive hardware costs and power consumption due to the usage of all the sensors in the networks. Generally, some sensors in the network do not improve the estimation per- formance due to the restricted communication range, while increasing the system runtime and energy consumption. Thus, this paper tries to select an optimal subset of all sen- sors to estimate the location and transmit power with low energy and computation overhead. squares of the absolute errors is minimized. To obtain a formula without a logarithm term, most researchers firstly convert the conventional RSS measurement to the absolute power domain. 2.1 Sensor Selection Problem In the RSS-based localization problem, multiple spa- tially separated sensors capture the radiated signal from an unknown radio emitter. Typically, there is an infor- mation fusion center (FC) responsible for collecting RSS measurements, which are the input for the localization algorithm. Due to the limited communication range, the computational complexity, and the limited battery power of the sensor, it is impractical to use all sensors for localiza- tion in a sensor network [23]. Hence, the selection of sen- sors is necessary in a practical scenario. In this paper, we comprehensively consider the dif- ferences among sensors, and the geometric structure to select an optimized set of sensors. To improve the localiza- tion accuracy, lower the deployment and computational complexities in large-scale WSNs, an improved RSS local- ization algorithm based on joint sensor selection and SDP is proposed. Main contributions of this paper are: We consider a representative case where there is an unknown emitter and the N fixed sensors in a 2D net- work. Figure 1 provides an example of network scenario. First, a few random sensors passively perform the RSS measurement and feed the measurements to FC to perform the initial location estimation. A refined set of sensors are then selected and activated to measure the RSSs from the emitter to achieve higher localization accuracy. The trans- mission of data is performed in two steps. Firstly, the raw signals captured are processed locally by the individual sensors and converted into RSS data. Then, the RSS data is sent to FC to obtain the emitter location. It is worth raising  Using a series of auxiliary matrices, a bivariate joint estimation model of transmit power and location is constructed. Furthermore, we design an uncoopera- tive emitter localization algorithm based on joint sen- sor selection and semidefinite programming. The al- gorithm achieves a good localization performance via three steps, i.e., initial position estimation, sensor se- lection, and refined position estimation. RADIOENGINEERING, VOL. 31, NO. 4, DECEMBER 2022 555 Fig. 1. Example of a sensing network. , 1 j N i i j j j P P N = = ∑ (3) , 1 j N i i j j j P P N = = ∑ (3) (3) where Pi,j represents the j-th RSS value at the i-th sensor, and Nj represents the total number of samples. 2.2 Measurement Model where [ ] T 1, , N v v v =  and [ ] T 1, , N µ µ µ =  . To decrease the complexity of obtaining unknown pa- rameters and jointly estimate θ , a symmetric matrix z containing X is defined. Z = z ⋅L02 is taken as a joint esti- mation matrix. Describing L02di2 term in (8) with Z, we get: 2.1 Sensor Selection Problem To formulate the LSRE estimation problem, the RSS measurement model in (1) is first converted into a multipli- cative model. After that, we divide both sides of the model by 10β and take the power of ten, and we have [25]: 0 10 10 10 10 i i P P n i X S β β − − = − . (4) Let 0 10 0 10 P l β = , 10 10 iP il β − = , and 10 10 i i n β ξ − = , the prob- 0 10 10 10 10 i i P P n i X S β β − − = − . (4) (4) Let 0 10 0 10 P l β = , 10 10 iP il β − = , and 10 10 i i n β ξ − = , the prob- Fig. 1. Example of a sensing network. lem (4) can be rewritten as [12]: lem (4) can be rewritten as [12]: the fact that information transmission requires energy. To reduce the overall energy consumption of the system, one sensor closest to the emitter (i.e., the sensor with the high- est RSS) is selected to take on the role of FC. The FC is responsible to perform both the emitter localization and sensor selection tasks. In our assumed localization of a small area only one FC is set. However, deploying more FCs in a larger localization area is valuable to reduce local- ization errors. 0 i i i l l d ξ = (5) (5) where iξ represents the composite noise term. Clearly, if ni and nj are independent, iξ and j ξ are independent for the case with i ≠ j. The parameters to be estimated are denoted by T T 0 , . X P θ   =    Motivated by [12], the LSRE-based equivalence estimation then can be formulated as: 0 2 2 2 0 2 2 2 , 1 0 arg min N i i X l i i i d l l l l d θ =   = +     ∑  . (6) (6) 2.2 Measurement Model The N fixed sensor locations are denoted by Si = [xi;yi], i = 1,…,N, while the emitter is denoted by X = [a;b]. According to the widely-used RSS measurement model [11–13], the received power (in dBm) at the i-th sensor can be modeled as: There are optimization variables both in the numera- tor and denominator as in (6). Therefore, problem (6) is non-convex and difficult to solve. Using traditional SDR technique cannot immediately convert the problem (6) into a standard form [13]. To apply SDR, two variables Li and L0 are introduced to replace 1/li and 1/l0 in (6), respective- ly. Then problem (6) is equivalent to [12], [13]: 0 10 0 10 log , 1, , i i i d P P n i N d β = − + = … (1) (1) 0 T T 2 2 2 0 0 2 2 2 , 1 0 1 , arg min N i i X L i i i X L L L d L L d =    = +       ∑   . (7) where P0 represents the received power at the reference distance d0, and β is the path loss exponent (PLE). di = X – Si represents the distance from the emitter to Si, and ni is the log-normal shadowing effect usually modeled as a zero-mean Gaussian distributed random variable with variance σi2, i.e., 2 ~ (0, ) i i n σ  . (7) The problem (7) can be modified as [13]: The problem (7) can be modified as [13]: ( ) 0 , 1 min N i i X L i v µ = + ∑ , (8a) 2 2 2 0 s.t. i i i L L d v ≤ , (8b) 2 2 2 0 1 i i i L L d µ ≤ (8c) (8b) In the case of unknown transmit power, the ML esti- mation problem can be expressed as [12]: (8c) 0 2 0 10 2 , 1 0 1 arg min 10 log N i i X P i i d P P d β σ =   − +     ∑ . (2) (2) where [ ] T 1, , N v v v =  and [ ] T 1, , N µ µ µ =  . 3. Bivariate RSS Localization Model The RSS of each sensor is disturbed by channel shad- owing. Therefore, the sample mean is evaluated to mitigate the interference, which is given by [24]: ( ) 2 2 0 tr , 1, , i i L X S ZW i N = = − … (9) (9) 556 L.M. CAO, J.Z. ZHANG, Y.X. LIU, ET AL., UNCOOPERATIVE EMITTER LOCALIZATION BASED ON JOINT SENSOR SELECTION… 556 where T 3 3 1 i i i i w S W S × −   =   −   , T 1 T 2 0 0 i i i i i S c S w S c S   =       1 1 0 0 0 c   =     , 2 0 0 0 1 c   =     , and 2 T T 3 3 I X z X X X ×   =     . posed selection method is to use information of the relative location of a sensor to the emitter. On the one hand, the RSS-based localization performance is closely related to the qualities of the measured RSSs. Theoretically, the clos- er the sensor is to the emitter, the more effective it is in improving localization accuracy [26]. This means that the higher RSS, the more reliable the estimation results will be. On the other hand, the objective function of ML is non- linear, which leads to a non-linear relationship between the accuracy and the number of sensors used [26]. Consequent- ly, using more sensors does not always improve the locali- zation performance. Based on (9), the constraint problem can be written Based on (9), the constraint problem can be written as: as: ( ) 2 tr 0, 1 i i i v ZW L        (10) ( ) tr 1/ 0 1/ i i i i ZW L L µ        , (11) Z 0  , (12) rank( 2 ) Z = (13) (10) Furthermore, the geometry structure of the sensor- emitter network is also an important factor [27] and the sensors selected should be distributed around the emitter [28]. The distribution structure of the sensors with a uni- form angular separation around the emitter is the geometric structure [27]. 3. Bivariate RSS Localization Model A successful geometry structure can be established by selecting sensors from different spatial di- rections of the emitter. However, the emitter is not always located in the center of the sensing area, it may locate on the boundaries of the sensing area. To select the sensors spaced around the emitter, we divide the sensing area into multiple equiangular partitions and examine whether there is at least one sensor in each partition. where  stands for the positive semidefinite symbol. (12) and (13) derive from the following significant equivalence: 2 2 0 2 0 2 T 2 T 0 0 3 3 0,rank( ) 2 L I L X Z Z L X L Z X X ×   = ⇔     =  . (14) The fact that a matrix is positive semidefinite implies that problem (8) is solvable. Hence, neglecting (13), the final SDP formulation is expressed as: ( ) ( ) ( ) , , min 8a s.t 10 , 11 ,( 2 . . 1 ) Z ν µ (15) The selection algorithm is described in detail in the following. First, due to the unknown emitter location, m (m < N) random sensors measure the RSS values and report the measurements to the FC. Using the localization method provided in Sec. 3, we perform the first estimation and obtain an initial emitter location (i.e., X1). Then, depending on the number of sensors (i.e., M) required in the second estimation, we divide the sensing area with the center of X1 into M partitions equally in the polar angle domain. The M partitions are numbered clockwise or counterclockwise by partition i, i = 1, ···, M, where clockwise or counterclock- wise numbering yields similar results. Subsequently, we proceeded with the analysis in a counterclockwise fashion. For two neighboring partitions I and J (I < J), a sensor on the boundary of the two partitions is considered to be in partition I. Finally, we search for the sensor closest to the emitter in each partition in turn. When there is an empty partition, the empty partition will be skipped and its num- ber will be recorded until all partitions are traversed. We record the number of these empty partitions as e. The e empty partitions are renumbered counterclockwise by par- tition ii, ii = 1, ···, e. 3. Bivariate RSS Localization Model (15) With { } * * * , , Z ν µ denotes the solution to the SDP. Following the definition of Z, the location X can be calcu- lated as: ( ) ( ) * * 1: 2,3 1,1 X Z Z =  (16) ( ) ( ) * * 1: 2,3 1,1 X Z Z =  (16) and the transmit power P0 is obtained as: ( ) ( ) * 0 10 10 log 1 1,1 P Z β =  . (17) (17) As mentioned before, sensor selection is a problem of finding an optimized subset of sensors. To avoid the influ- ence of the battery power of the nodes on the localization system, we assume that the power level of the nodes is sufficient. Thus, the localization accuracy heavily depends on the distances between sensors and the emitter. In sensor selection, we should consider the sensor-emitter geometry structure and its relative distance. In next section, we will investigate how to find a subset of sensors that gives posi- tioning results with high accuracy. For the e empty partitions, we first select the nearest e sensors to the emitter among the set of unselected sensors. The e sensors are denoted by Sii, ii = 1, …, e. The distances of e sensors to the emitter are denoted as Dii, ii = 1, …, e. If two sensors are equal in distance from the emitter, their RSS values are similar. From this aspect, we deduce that there is a point of the length equal to Dii on the angle bisec- tor of the empty partition ii. The e locations are denoted by Sii. Then, we express the RSS measurements at coordinate Sii by using the RSSs at the Sii. We refer to these points as 4.1 Sensor Selection Scheme The accuracy associated with the localization process relies on several factors. The main idea behind our pro- RADIOENGINEERING, VOL. 31, NO. 4, DECEMBER 2022 557 Polar coordinate transformation; Set the number of sensor selections; Area division; i = 1 Is there at least one sensor in partition i ? Make the first estimation; Removes selected sensor from partition i Yes Record partition i is empty. Select the sensor with the highest RSS in partition i. i = i+1 No If i > M ? end Yes Sort the RSS at unselected sensors. Simulation of RSS Fill some empty partition No i = i+1 Fig. 3. Flow chart of the proposed sensor selection method. simulated sensor nodes. Specifically, these simulated sen- sors are imaginary, and their information can only be in- ferred by Sii. We give the inference process in the follow- ing. Make the first estimation; Polar coordinate transformation; Set the number of sensor selections; Area division; i = 1 The coordinates of sensors Sii are converted into a po- lar coordinate system. The polar coordinates of the e real and simulated sensors are denoted by (rii,ρii) and (rii,ρ ii), for ii = 1, …, e, where rii = rii, ρ ii = (2πi – π)/M, and i is the initial number of the empty partition. Thus, we obtain the Cartesian coordinates of the simulated sensors given by (rii cos(ρ ii), rii sin(ρ ii)). More sensors are deployed to avoid too many empty partitions. In addition, when there are more empty partitions, all partitions are rotated around the emitter location. The rotation acts like a re-division of the area. Is there at least one sensor in partition i ? Record partition i is empty. When all partitions have available sensors, all select- ed sensors are activated to perform measurement. The measured data are then transferred to FC to perform the second refined estimation. An example without empty Partition 1 Partition 2 Partition 3 Partition 5 Partition 4 Partition 6 1 5 6 4 3 2 (a) Sensing area splitting with 6 partitions and sensor locations Partition 1 Partition 2 Partition 3 Partition 5 Partition 4 Partition 6 1 5 6 4 3 2 Partition 1 Fig. 3. Flow chart of the proposed sensor selection method. partitions is given, as shown in Fig. 2(a). An example with one empty partition is shown in Fig. 4.1 Sensor Selection Scheme 2(b), where the simu- lated sensor is inferred by the fifth sensor. Figure 3 details the process of the sensor selection method. 4.2 Algorithm Framework (a) Sensing area splitting with 6 partitions and sensor locations With sensor selection, the localization algorithm needs to be executed twice. In the first step, m random deployed sensors are used to passively measure the RSSs from the emitter and report the values to FC. The initial location estimate is obtained by performing the first esti- mation using the sensed RSS measurements based on SDP as in Sec. 3. According to the initial estimation and selec- tion algorithm, other M sensors are selected to actively measure RSSs. Then a second estimation step is executed at the FC to give a more accurate result. Figure 4 depicts the flow of the localization. Partition 1 Partition 2 Partition 3 Partition 5 Partition 4 Partition 6 1 5 3 2 4 Simulated sensor angle bisector 7 6 Polar axis Partition 1 Partition 2 Partition 3 Partition 5 Partition 4 Partition 6 1 5 3 2 4 Simulated sensor angle bisector 7 6 Polar axis (b) Sensing area splitting with one empty partition Fig. 2. Sensing area partition. Partition 2 Partition 1 Polar axis Collect RSS values Input Output First Estimation Second Estimation Sensor selection Fig. 4. Framework of the RSS-based localization algorithm. First Estimation Sensor selection Second Estimation (b) Sensing area splitting with one empty partition Fig. 2. Sensing area partition. Fig. 4. Framework of the RSS-based localization algorithm. 558 L.M. CAO, J.Z. ZHANG, Y.X. LIU, ET AL., UNCOOPERATIVE EMITTER LOCALIZATION BASED ON JOINT SENSOR SELECTION… -100 -75 -50 -25 0 X(m) -75 -50 -25 0 Y(m) (-30 -30) Sensor Emitter Fig. 5. Scenario with 30 sensors and one emitter. -20 -10 10 20 30 40 transmit power(dBm) 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 RMSE(m) SS-SDP Fig. 6. RMSE at different P0. The RMSE data for different transmitted powers are rec- orded as shown in Fig 6 It can be seen that the RMSE is -100 -75 -50 -25 0 X(m) -75 -50 -25 0 Y(m) (-30 -30) Sensor Emitter Fig. 5. Scenario with 30 sensors and one emitter. 5.1 Simulation Settings In this section, two optimization schemes presented in [13] and [17] are compared to validate the proposed algo- rithm (denoted by “SS-SDP”). The two counterpart schemes are represented by “SOCP-random” and “LSRE- random”, respectively. The results are also compared with the CRLB, which is widely used to represent the lower bound of an unbiased estimator. All of the mentioned algo- rithms were solved using the MATLAB R2020a package CVX [29]. The times were captured by a laptop with an AMD R7-5800H 3.3 GHz CPU and 16 GB RAM. Fig. 5. Scenario with 30 sensors and one emitter. -20 -10 10 20 30 40 transmit power(dBm) 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 RMSE(m) SS-SDP Fig. 6. RMSE at different P0. In the simulated scenario, 100 known sensors are de- ployed in a 2-D area, with 50 sensors randomly distributed within the area and the remainder uniformly distributed on the boundary of the area. We assume that the sensors are equipped with omnidirectional antennas [16]. As the sen- sors are fixed and will work for a long period of time, we simply choose the more stable sensors. The emitter is ran- domly placed in this area. Figure 5 represents a scenario with 30 sensors and an emitter. The PLE is taken as a known parameter, unless otherwise stated. Our experi- mental environment is line-of-sight. Only the environmen- tal noise and path loss are considered in the information transmission. The propagation model in (1) is employed to generate the RSS measurements. The shadowing variables ni is generated using a Gaussian distribution  (0, σi2) with consistent variances σi2 = σ for i = 1, …, N. The root mean square error (RMSE) is used to measure the localization performance, and is defined by: Fig. 6. RMSE at different P0. The RMSE data for different transmitted powers are rec- orded as shown in Fig. 6. It can be seen that the RMSE is independent of the P0. Thus, in the following, we select the transmitted power arbitrarily.  2 1 1 RMSE Mc i i i X X Mc = = − ∑ (18) (18) 5.2 Sensor Selection Simulation Results 1 2 3 4 5 6 shadowing(dB) 0 1 2 3 4 5 6 7 8 RMSE(m) SS-SDP CRLB LSRE-random SOCP-random shadowing(dB) Fig. 8. Impacts of number of sensors on average running time Fig. 9. RMSE of the location estimation versus σ. the number of sensors increases. The average running time of the algorithm is shown in Fig. 8. It shows using more sensors will increase the running time of the algorithm. Figures 7 and 8 also show that it takes a longer time with more sensors while the localization accuracy is slightly increased. The proposed algorithm performs well when fewer sensors are selected. The gains from the algorithm are not optimal when more sensors are selected. the number of sensors increases. The average running time of the algorithm is shown in Fig. 8. It shows using more sensors will increase the running time of the algorithm. Figures 7 and 8 also show that it takes a longer time with more sensors while the localization accuracy is slightly increased. The proposed algorithm performs well when fewer sensors are selected. The gains from the algorithm are not optimal when more sensors are selected. 1 2 3 4 5 6 shadowing(dB) 0 0.5 1 1.5 2 2.5 3 3.5 RMSE(dBm) SS-SDP CRLB LSRE-random SOCP-random Fig. 10. RMSE of the transmit power estimation versus σ. 5.3 Impact of Standard Deviation of Shadow- ing Effect on RMSE We then investigate the scenario with varying shad- owing levels. In this scenario, the number of sensors used is fixed as 13 (i.e., M = 13). The RMSE curves for the considered algorithms are given in Fig. 9. In general, the RMSE and the CRLB increase with σ . The gap between the RMSE of the SS-SDP and the LSRE-random is larger than 0.4. As σ increases, the RMSE gap between the two algorithms increases. Moreover, Figure 9 shows that the RMSE growth rate of SS-SDP slows down. LSRE-random has a significant performance improvement over the SOCP-random. The RMSE curves for the estimated trans- mit power are shown in Fig. 10. The results in Fig. 9 and 10 show that SS-SDP has higher accuracy for both the location and transmit power estimations. Notably, the vari- ation range of RMSE of SS-SDP is the smallest. Hence, SS-SDP results in the lowest sensitivity to channel shad- owing. Fig. 10. RMSE of the transmit power estimation versus σ. 5.2 Sensor Selection Simulation Results To verify the importance of sensor selection, 10, 20, 30, 40, 50, and 60 sensors are selected respectively to per- form the three localization algorithms in the scenario with σ = 3 dB. Figure 7 shows the impact of the number of sensors on RMSE of the emitter location estimation. The results indicate that the proposed SS-SDP performs well with different numbers of sensors. The RMSE decreases as where Mc represents the number of Monte Carlo (Mc) runs. Xi and  i X are the true emitter location and the esti- mated location in the i-th run, respectively. The simulation parameters are shown in Tab. 1. In our simulations, the proposed algorithm invokes m = 5 sensors randomly to passively sample the radio sig- nals and perform the initial estimation. Then we select M = 13 sensors to actively measure the RSSs and perform the second estimation. The other two algorithms to be compared also use 13 sensors randomly to perform the localization. To verify the effect of unknown P0 on the estimated performance, we set σ = 3 and select M sensors. 10 20 30 40 50 60 number of sensor 0 1 2 3 4 5 RMSE(m) SS-SDP LSRE-random SOCP-random Fig. 7. RMSE performances with different numbers of sen- sors. Parameter Value Field dimension 100×100 m2 Transmitted power at d0 (P0) (–20, –10, 10, 20, 30, 40) dBm Reference distance (d0) 1 m Path loss exponent (β) 4 Standard deviation (σ) 1, 2, 3, 4, 5, 6 Number of samples (Nj) 100 Monte Carlo runs (Mc) 3000 Tab. 1. Model simulation parameter values. Fig. 7. RMSE performances with different numbers of sen- sors. Tab. 1. Model simulation parameter values. RADIOENGINEERING, VOL. 31, NO. 4, DECEMBER 2022 559 1 2 3 4 5 6 shadowing(dB) 0 1 2 3 4 5 6 7 8 RMSE(m) SS-SDP CRLB LSRE-random SOCP-random Fig. 9. RMSE of the location estimation versus σ. 1 2 3 4 5 6 shadowing(dB) 0 0.5 1 1.5 2 2.5 3 3.5 RMSE(dBm) SS-SDP CRLB LSRE-random SOCP-random Fig. 10. RMSE of the transmit power estimation versus σ. 10 20 30 40 50 60 number of sensor 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 Average Running Time(s) SS-SDP LSRE-random SOCP-random Fig. 8. Impacts of number of sensors on average running time. 5.4 Impact of the Number of Sensors on RMSE With a fixed σ = 3 dB, we examine the localization performance for different numbers of sensors, with M vary- ing between 8 and 18. The RMSE of the emitter location estimates versus the number of sensors is shown in Fig. 11. The result shows that the CRLB and the RMSE decrease as the number of sensors increases. The SS-SDP algorithm still outperforms the other two algorithms. When M = 8, the SS-SDP performs roughly 60% and 70% better than the LSRE-random and SOCP-random algorithms, respectively. As the number of sensors increases, the RMSE gap be- tween the LSRE-random and the SS-SDP decreases. With σ = 3 and M = 13, we find a threshold value of m. The range of m is from 3 to 6. The results of the two estimations are shown in Tab. 2. According to Tab. 2, the final results do not outperform the LSRE-random algo- rithm at m = 3 or 4. But when m is bigger than 5, the result is better than that of LSRE-random algorithm. To further validate the performance of the SS-SDP, we estimate the location with a different number of sensors while keeping the RMSE between 0.90 and 1.00. Table 3 shows the relationship between the number of sensors involved in localization and the RMSE of location estima- tion. Therefore, the SS-SDP uses about 1/2 of the LSRE- random and about 1/7 of the SOCP-random in terms of the number of sensors to achieve similar performance. It sig- nificantly indicates the superiority of the SS-SDP algo- rithm. First estimation m 3 4 5 6 RMSE 11.29 9.29 5.38 3.87 Second estimation RMSE 2.17 1.79 0.68 0.61 Tab. 2. RMSE for the two estimations. Tab. 2. RMSE for the two estimations. 560 L.M. CAO, J.Z. ZHANG, Y.X. LIU, ET AL., UNCOOPERATIVE EMITTER LOCALIZATION BASED ON JOINT SENSOR SELECTION… Algorithm Number Accuracy SS-SDP Selecting 8 or 9 sensors 0.91~0.97 LSRE-random Randomly selecting 20 or 21 sensors 0.94~0.98 SOCP-random Randomly selecting 75 or 76 sensors 0.91~0.97 Tab. 3. The number of sensors versus RMSE. 8 10 12 14 16 18 number of sensor 0 2 4 6 8 10 12 RMSE(m) SS-SDP CRLB LSRE-random SOCP-random Fig. 11. RMSE of location estimation versus the number of sensors. tigated and the complexities of the considered algorithms are summarized in Tab. 4. 5.4 Impact of the Number of Sensors on RMSE The average running time as the number of sensors varies is shown in Fig. 12. The results reveal that the aver- age running time of the LSRE-random is about 2 to 3 times that of the SOCP-random. The SS-SDP performs twice in our scheme, so it takes more time than the LSRE-random. The results in Fig. 12 and Tab. 4 match well. We conclude that the SS-SDP achieves better performance with relative- ly low complexity. Tab. 3. The number of sensors versus RMSE. 8 10 12 14 16 18 number of sensor 0 2 4 6 8 10 12 RMSE(m) SS-SDP CRLB LSRE-random SOCP-random Fig. 11. RMSE of location estimation versus the number of sensors. 8 10 12 14 16 18 number of sensor 0 2 4 6 8 10 12 RMSE(m) SS-SDP CRLB LSRE-random SOCP-random Fig. 11. RMSE of location estimation versus the number of sensors. 5.5 Localization Error versus Emitter Loca- tion 8 10 12 14 16 18 number of sensor 0 2 4 6 8 10 RMSE(m) LSRE-random SOCP-random Fig. 11. RMSE of location estimation versus the number of sensors. Algorithm Complexity SS-SDP ( )( ) ( ) 3 2 M k M k + +  LSRE-random ( )( ) ( ) 3 2 M k M k + +  SOCP-random ( ) 3.5 2 M  Tab. 4. Computational complexity. (Note: The number of sen- sors and the localization dimension are denoted by M and k, respectively.) 8 10 12 14 16 18 number of sensor 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Average time(s) SS-SDP LSRE-random SOCP-random Fig. 12. Average running time versus the number of sensors. Computational complexity is also an important facto In this experiment, the locations of the emitter are changed, the effects of the location on the estimation per- formance are investigated. The emitter location is assumed to vary from the center to the edge of the sensing area. Typical locations are (–60, –60), (–70, –70), (–80, –80), and (–90, –90). The results of the RMSE are plotted in Fig. 13. It is shown that the RMSE of the three methods in- creases gradually as the emitter moves from the center of the area to the boundary. The SS-SDP algorithm has the smallest RMSE increment and shows the best performance in the central area. When only 8 sensors are employed, the Fig. 11. RMSE of location estimation versus the number of sensors. Fig. 11. RMSE of location estimation versus the number of sensors. Algorithm Complexity SS-SDP ( )( ) ( ) 3 2 M k M k + +  LSRE-random ( )( ) ( ) 3 2 M k M k + +  SOCP-random ( ) 3.5 2 M  Tab. 4. Computational complexity. (Note: The number of sen- sors and the localization dimension are denoted by M and k, respectively.) Algorithm Complexity SS-SDP ( )( ) ( ) 3 2 M k M k + +  LSRE-random ( )( ) ( ) 3 2 M k M k + +  SOCP-random ( ) 3.5 2 M  Tab. 4. Computational complexity. 5.5 Localization Error versus Emitter Loca- tion (Note: The number of sen- sors and the localization dimension are denoted by M and k, respectively.) 8 10 12 14 16 18 number of sensor 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Average time(s) SS-SDP LSRE-random SOCP-random Fig. 12. Average running time versus the number of sensors. Computational complexity is also an important factor that affects the performance of the algorithm. The trade-off between estimation accuracy and complexity is also inves- 8 10 12 14 16 18 number of sensors 1 2 3 4 5 6 RMSE(m) SS-SDP LSRE-random SOCP-random (a) 8 10 12 14 16 18 number of sensors 1 2 3 4 5 6 7 8 9 10 RMSE(m) SS-SDP LSRE-random SOCP-random (b) 8 10 12 14 16 18 number of sensors 1 2 3 4 5 6 RMSE(m) SS-SDP LSRE-random SOCP-random (a) 8 10 12 14 16 18 number of sensors 1 2 3 4 5 6 7 8 9 10 RMSE(m) SS-SDP LSRE-random SOCP-random (b) 8 10 12 14 16 18 number of sensors 1 2 3 4 5 6 RMSE(m) SS-SDP LSRE-random SOCP-random (a) 8 10 12 14 16 18 number of sensors 1 2 3 4 5 6 7 8 9 10 RMSE(m) SS-SDP LSRE-random SOCP-random (b) 8 10 12 14 16 18 number of sensors 1 2 3 4 5 6 RMSE(m) SS-SDP LSRE-random SOCP-random (a) Tab. 4. Computational complexity. (Note: The number of sen- sors and the localization dimension are denoted by M and k, respectively.) Tab. 4. Computational complexity. (Note: The number of sen- sors and the localization dimension are denoted by M and k, respectively.) 8 10 12 14 16 18 number of sensor 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Average time(s) SS-SDP LSRE-random SOCP-random 8 10 12 14 16 18 number of sensors 1 2 3 4 5 6 7 8 9 10 RMSE(m) SS-SDP LSRE-random SOCP-random (b) Fig. 12. Average running time versus the number of sensors. Computational complexity is also an important factor that affects the performance of the algorithm. The trade-off between estimation accuracy and complexity is also inves- Computational complexity is also an important factor that affects the performance of the algorithm. The trade-off between estimation accuracy and complexity is also inves- (b) RADIOENGINEERING, VOL. 31, NO. 5.5 Localization Error versus Emitter Loca- tion 4, DECEMBER 2022 561 8 10 12 14 16 18 number of sensors 2 4 6 8 10 12 14 16 18 RMSE(m) SS-SDP LSRE-random SOCP-random (c) 8 10 12 14 16 18 number of sensors 2 4 6 8 10 12 14 16 18 RMSE(m) SS-SDP LSRE-random SOCP-random (d) Fig. 13. Localization errors versus emitter location. (a), (b), (c), and (d) represents the corresponding RMSE of location estimation under the four locations of (–60, –60), (–70, –70), (–80, –80), and (–90, –90). 8 10 12 14 16 18 number of sensors 2 4 6 8 10 12 14 16 18 RMSE(m) SS-SDP LSRE-random SOCP-random (c) Acknowledgments This research of this paper was supported by the Na- tional Natural Science Foundation of China under Grant 62131005, 61901497 and 61801231. References [1] ZAFARI, F., GKELIAS, A., LEUNG, K. A survey of indoor local- ization systems and technologies. 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DOI: 10.3390/s21134605 We have proposed an uncooperative emitter localiza- tion method based on joint sensor selection and semidefi- nite programming optimization to increase the accuracy in RSS-based localization and to lower computation complex- ity. The superiority of the algorithm has been demonstrated through extensive simulations, compared to other typical localization methods. We show that in future IoT or WSN localization scenarios with massive radio frequency sen- sors, sensor selection is a critical step in lowering the algo- rithm complexity and the energy consumption. In future work, a more practical path loss model for the non-line-of- sight propagation should be considered and the investigat- ed joint optimization approach in this study will be extend- ed to the new scenario. [10] ALTAF KHATTAK, S. B., FAWAD, NASRALLA, M. M., et al. WLAN RSS-based fingerprinting for indoor localization: A ma- chine learning inspired bag-of-features approach. 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We then apply them to form the Fisher information matrix ( ) I θ : ( ) 2 ln ( ; ) 1,2,3; 1,2,3 ij i j p F I E i j θ θ θ θ   ∂ = − = =   ∂ ∂       . (21) Appendix: Cramer-Rao Lower Bound (21) The Cramer-Rao lower bound (CRLB) is defined as a lower bound on the variance of any unbiased estimator and is widely used as a benchmark for localization perfor- mance. The CRLB for RSS-based localization had been derived in [17] and [18]. It was derived from the inverse matrix of Fisher's information matrix. A concise derivation process is given below. From the measurement model in (1), the probability density function of the RSS measure- ments is written as [17]: Following (20) and (21), the ( ) I θ can be written as: ( ) 2 2 2 2 0 2 2 2 2 0 2 2 2 2 0 0 0 ln ( ; ) ln ( ; ) ln ( ; ) ln ( ; ) ln ( ; ) ln ( ; ) ln ( ; ) ln ( ; ) ln ( ; ) p F p F p F E E E a a b a P p F p F p F I E E E b a b b P p F p F p F E E E P a P b P θ θ θ θ θ θ θ θ θ θ       ∂ ∂ ∂       ∂ ∂∂ ∂∂             ∂ ∂ ∂ = −       ∂∂ ∂ ∂∂            ∂ ∂ ∂     ∂∂ ∂∂ ∂                                        . (22) ( ) ( ) 2 0 10 2 2 1 10 log 1 ( ; ) exp 2 2 i i i M P P d p F β θ σ πσ =   − +   = −       ∏  (19) (22) The diagonal elements of the inverse of the Fisher in- formation matrix ( ) 1 I θ − are the CRLB of the unknown parameters. About the Authors … degree in Information and Communication Engineering from Nanjing University of Science and Technology, China, 2014. She is currently working as a lecturer at Nanjing University of Information Science and Technology, Nanjing, China. She worked as an academic visitor in University of Sheffield, UK, 2018. Her research interests include MIMO radar/communication spectrum sharing and intelligent signal processing. [23] DAI, Z., WANG, G., JIN, X., et al. Nearly optimal sensor selection for TDOA-based source localization in wireless sensor networks. IEEE Transactions on Vehicular Technology, 2020, vol. 69, no. 10, p. 12031–12042. DOI: 10.1109/TVT.2020.3011118 [24] YILMAZ, H. B., TUGCU, T. Location estimation-based radio en- vironment map construction in fading channels. Wireless Commu- nications & Mobile Computing, 2015, vol. 15, no. 3, p. 561–570. DOI: 10.1002/wcm.2367 Junquan DENG received the B.Eng. degree in Automa- tion Engineering from Tsinghua University, Beijing, Chi- na, in 2011, the M.Sc. degree in Computer Science from the National University of Defense Technology (NUDT), Changsha, China, in 2013, and the Ph.D. degree in Infor- mation Theory from Aalto University, Aalto, Finland, in 2018. Since 2019, he is an Assistant Research Fellow with the Sixty-Third Research Institute, National University of Defense Technology, Nanjing, China. His research inter- ests include device-to-device communication, millimeter- wave communication, mobile relaying in 5G cellular net- works, and machine learning with wireless network data. [25] MUKHOPADHYAY, B., SRIRANGARAJAN, S., KAR, S. Signal strength-based cooperative sensor network localization using con- vex relaxation. IEEE Wireless Communications Letters, 2020, vol. 9, no. 12, p. 2207–2211. DOI: 10.1109/LWC.2020.3018679 [26] ABABNEH, A. A. Knapsack-based sensor selection for target lo- calization under energy and error constraints. IEEE Sensors Jour- nal, 2021, vol. 21, no. 23, p. 27208–27217. DOI: 10.1109/JSEN.2021.3123734 [27] BISHOP, A. N., JENSFELT, P. An optimality analysis of sensor- target geometries for signal strength based localization. In 2009 In- ternational Conference on Intelligent Sensors, Sensor Networks and Information Processing (ISSNIP). Melbourne (VIC, Austral- ia), 2009, p. 127–132. DOI: 10.1109/ISSNIP.2009.5416784 RADIOENGINEERING, VOL. 31, NO. 4, DECEMBER 2022 563 Taking the logarithm of both sides of (19), we obtain: Guokai CHEN received a B.S degree in Measurement and Control Technology from the National University of De- fense Technology in 2019. He is currently a Ph.D. student in the College of Intelligence Science at the National Uni- versity of Defense Technology. His research interests in- clude radio map construction methods and radio map-based localization. Appendix: Cramer-Rao Lower Bound where the matrix [ ] 1 T , , M P F P =  represents the signal strength values. M indicates the number of sensors. where the matrix [ ] 1 T , , M P F P =  represents the signal strength values. M indicates the number of sensors.
https://openalex.org/W4362543231	https://figshare.com/articles/journal_contribution/Supplementary_Figure_8_from_Cancer-Specific_Requirement_for_BUB1B_BUBR1_in_Human_Brain_Tumor_Isolates_and_Genetically_Transformed_Cells/22528634/1/files/39991640.pdf	English	null	Supplementary Figure 8 from Cancer-Specific Requirement for BUB1B/BUBR1 in Human Brain Tumor Isolates and Genetically Transformed Cells	null	2,023	cc-by	835	Ding et al., Figure S8 C 0 0.2 0.4 0.6 0.8 1.0 1.2 Control RasV12 shControl shBUB1B-2 shKIF11 ** Relative Growth IKD: long short A Human Astrocytes 0 0.2 0.4 0.6 0.8 1.0 1.2 Control RasV12 shControl shBUB1B-2 shKIF11 Relative Growth 0 0.2 0.4 0.6 0.8 Fraction of mitotic cells Aligned Part. aligned Unaligned Control RasV12 shControl shBUB1B-2 shControl shBUB1B-2 n=31 n=31 n=33 n=34 P=2.8E-07 Metaphase Chromosomes IKD: long short A B Human Astrocytes Human Astrocytes B 0 0.2 0.4 0.6 0.8 Fraction of mitotic cells Aligned Part. aligned Unaligned Control RasV12 shControl shBUB1B-2 shControl shBUB1B-2 n=31 n=31 n=33 n=34 P=2.8E-07 Metaphase Chromosomes B Human Astrocytes shControl shBUB1B-2 shKIF11 Control IKD: long RasV12 sh MG-132 Induced Arrest siControl siBUB1B DAPI BUB1B Merge RPE-1 DAPI CREST α-Tubulin Merge Hela siControl siBUB1B C C RPE-1 MG-132 Induced Arrest MG-132 Induced Arrest Figure S8. Effects of BUB1B knockdown on in human astrocytes, RasV12 transformed astrocytes, Hela cells and RPE-1 cells. (A) & (B) Knockdown of BUB1B in Ras-transformed human astrocytes phenocopies BUB1B requirement observed in BTICs. (A) BUB1B knockdown results in growth defects in RasV12-astrocytes but not untransformed astrocytes. Assays were performed as in Figure 2C. indicates p<.001 by student’s t-test. . (B) Chromosome alignment assays in NHAs and Ras-NHAs as performed in Figure 5E. (C) Chromosome alignment assays in Hela cells and RPE-1 cells transfected with siControl or siBUB1B. BUB1B/BUBR1 knockdown results in severe chromosome alignment defects in Hela cells but not in untransformed RPE-1 cells. Cells were transfected with control or BUB1B/BUBR1 siRNA (Dharmacon) and 48hrs later treated with MG-132 for 2hrs to induce mitotic arrest and stained for BubR1, CREST, Tubulin and/or DAPI. 93% of HeLa cells treated with siBUB1B have severe KT-MT attatchment defects (n>100), compared to only 17% for control; while KT-MT attachment was similar regardless of siBUB1B treatment (n>150). Figure S8. Effects of BUB1B knockdown on in human astrocytes, RasV12 transformed astrocyte Hela cells and RPE-1 cells. requirement observed in BTICs. (A) BUB1B knockdown results in growth defects in RasV12-astrocytes but not untransformed astrocytes. Assays were performed as in Figure 2C. indicates p<.001 by student’s t-test. . (B) Chromosome alignment assays in NHAs and Ras-NHAs as performed in Figure 5E. (C) Chromosome alignment assays in Hela cells and RPE-1 cells transfected with siControl or siBUB1B. BUB1B/BUBR1 knockdown results in severe chromosome alignment defects in Hela cells but not in untransformed RPE-1 cells. Ding et al., Figure S8 Ding et al., Figure S8 0 0.2 0.4 0.6 0.8 1.0 1.2 Control RasV12 shControl shBUB1B-2 shKIF11 Relative Growth 0 0.2 0.4 0.6 0.8 Fraction of mitotic cells Aligned Part. aligned Unaligned Control RasV12 shControl shBUB1B-2 shControl shBUB1B-2 n=31 n=31 n=33 n=34 P=2.8E-07 Metaphase Chromosomes IKD: long short A B Human Astrocytes Human Astrocytes MG-132 Induced Arrest siControl siBUB1B DAPI BUB1B Merge RPE-1 DAPI CREST α-Tubulin Merge Hela siControl siBUB1B C 0 0.2 0.4 0.6 0.8 1.0 1.2 Control RasV12 shControl shBUB1B-2 shKIF11 Relative Growth 0 0.2 0.4 0.6 0.8 Fraction of mitotic cells Aligned Part. aligned Unaligned Control RasV12 shControl shBUB1B-2 shControl shBUB1B-2 n=31 n=31 n=33 n=34 P=2.8E-07 Metaphase Chromosomes IKD: long short A B Human Astrocytes Human Astrocytes MG-132 Induced Arrest siControl siBUB1B DAPI BUB1B Merge RPE-1 DAPI CREST α-Tubulin Merge Hela siControl siBUB1B C 0 0.2 0.4 0.6 0.8 1.0 1.2 Control RasV12 shControl shBUB1B-2 shKIF11 Relative Growth 0 0.2 0.4 0.6 0.8 Fraction of mitotic cells Aligned Part. aligned Unaligned Control RasV12 shControl shBUB1B-2 shControl shBUB1B-2 n=31 n=31 n=33 n=34 P=2.8E-07 Metaphase Chromosomes IKD: long short A B Human Astrocytes Human Astrocytes MG-132 Induced Arrest siControl siBUB1B DAPI BUB1B Merge RPE-1 DAPI CREST α-Tubulin Merge Hela siControl siBUB1B Figure S8. Effects of BUB1B knockdown on in human astrocytes, RasV12 transformed astrocytes, Hela cells and RPE-1 cells. (A) & (B) Knockdown of BUB1B in Ras-transformed human astrocytes phenocopies BUB1B requirement observed in BTICs. (A) BUB1B knockdown results in growth defects in RasV12-astrocytes but not untransformed astrocytes. Assays were performed as in Figure 2C. indicates p<.001 by student’s t-test. . (B) Chromosome alignment assays in NHAs and Ras-NHAs as performed in Figure 5E. (C) Chromosome alignment assays in Hela cells and RPE-1 cells transfected with siControl or siBUB1B. BUB1B/BUBR1 knockdown results in severe chromosome alignment defects in Hela cells but not in untransformed RPE-1 cells. Cells were transfected with control or BUB1B/BUBR1 siRNA (Dharmacon) and 48hrs later treated with MG-132 for 2hrs to induce mitotic arrest and stained for BubR1 CREST, Tubulin and/or DAPI. 93% of HeLa cells treated with siBUB1B have severe KT-MT attatchment defects (n>100), compared to only 17% for control; while KT-MT attachment was similar regardless of siBUB1B treatment (n>150). Ding et al., Figure S8 Cells were transfected with control or BUB1B/BUBR1 siRNA (Dharmacon) and 48hrs later treated with MG-132 for 2hrs to induce mitotic arrest and stained for BubR1, CREST, Tubulin and/or DAPI. 93% of HeLa cells treated with siBUB1B have severe KT-MT attatchment defects (n>100), compared to only 17% for control; while KT-MT attachment was similar regardless of siBUB1B treatment (n>150).
https://openalex.org/W2083644236	https://zenodo.org/records/2229506/files/article.pdf	German	null	Über den Einfluß der Amplitude auf die Tonhöhe und das Dekrement von Stimmgabeln und zungenförmigen Stahlfederbändern	Annalen der Physik	1,904	public-domain	12,282	1) Meine bisherigen Veriiffentlichungen Bind unter dem Namen R. Kern p f- H ar t rn anu erschienen. 124 124 1) Dieses Referat lehnt sich an die Originalarbeit in bezug auf Form und Inhalt in durchaus freier Weise an. Wegen dcr Kiirze mu8 ich auf die Wiedcrgabe VOD Tabellen verzichten, oftmals auch auf ein- gehende BegrUndungen odcr auf Einzelheiten experimentell-technischer Natur, und statt dessen auf die ausfiihrlichere Behandlung in der Original- arbeit hinweisen. Diese enthtilt die Tabellen zu den Auswertungen von iiber 120 photographischen Aufnahmen und ebeneoviel graphische Dar- stellungen, welche in Form und Kurvenbltitttxn auf 6 lithographischen Tafeln reproduziert sind. \'on den Originalphotogrammeii sind 33 durch Rotationsdruck der Neuen Photographischen Gesellschaft Berlin-Steglitz veroKentlicht. (Ich bin jederzeit erbiitig, ein solches Exemplar oder auf beaondcren Wunsch einzelne nicht veroffeutlichte Abziige abzugebcn.) Der GleichmaBigkeit zuliebe mull ,ich auch hier die fortlaufende Nume- rierung wahleu, wie sie sich auf die in meinem Besitz befindlichen Ori- ginalaufnabmen bezieht. Die durch Rotationsdruck veioffcntlichten Ko- pien sind durch fettgedruckte Nummern hervorgehoben. Als Abkurzungen bei den Hinweisen auf dic Dissertation sol1 z. B. gelten: (Diss. XIVIII) fur Dissertation Kurvenblatt XIV auf Kurventafel 111; (Dies. Ph. 51) fur Dissertation, Photogramrn 5 auf Pbotogrammtafel I; u. dgl. 5. Uber den Einflup der Amplitude auf die Tonh6hs 'Lcnd das Debrement von Stirtun- gnbellz zbn cl xumgenf6rmigert St ah If e der b dnd ern; von R. H n r t m a nn - E e m p f. I) (Hlereu Tnf. 1-111.) (Aussug aus der Wiirsburger Dissertation.) p (Hlereu Tnf. 1-111.) (Aussug aus der Wiirsburger Dissertation.) (Aussug aus der Wiirsburger Dissertation.) (Aussug aus der Wiirsburger Dissertation.) Unter obigem Titel sol1 in gedrangter Daretellungsweise ein Teil der wichtigsten Resultate meiner kiirzlich erschiene- nen Dissertation verijffentlicht werden. Diese umfa6t unter der Gesamtbenennung ,,Elektro-akustische Untersuchungen" au6er dem oben genannten Gegenstand noch Studien iiber die Verschiebung des Resonanzbereiches boi erzwungenen Schwin- gungen, wie sie a19 natiirliche Folge der Tonverstimmung eines Klangkorpers mit wachsender Amplitude auftreten muB. AuBer- dem sind daselbst noch eine Reihe von merkwiirdigen Begleit erscheinungen getrennt in einem Anhange behandelt, deren Besprechung ich hier nicht vollstandig durchfuhren kann. Da- gegen sollen die Untersuchungen uber das Wandern des Re- sonanzbereiches demnachst in einer gosonderten Abhandlung verijffentlicht werden, zumal es als eine zeitgemaBe Aufgabe betrachtet werden diirfte, fir die verscbiedenartigen ana- logen Vorgange in Systemen mit gedampften akustischen oder elektrischen Schwingungen eine figlirliche Darvtellung durch Kurven oder Photogramme zu bieten, aus denen, wenn auch nicht ein stets einschlagiges Vorbild, so doch ein quali- tativer Anhalt zur Beurteilung yon Folgeerscheinungen gewahr- leistet werden kann. Um iiber die Ursachen, welche das Gebiet der maximalen Resonanz eines schwingenden Systems, d. h. also die Ton- lage seiner besten Anspruchsfahigkeit auf die mit konstanter &infEup der Amplitude auf die Tonliohe etc. 125 Frequenz erregende periodische Kraft verschiebt, mi groI3erer Klarheit zu gelangen, mIisssn zuvor die Einfllisse, welche die T o n i 3 e des frei abklingenden Klangkorpers verhdern , ein- zelne erwogen und getrennt beobachtet werden. Diese kbnnen mannigfacher Art sein ; z. B. wird bei einem eingespannten Stahlfederband die mit wachsender Amplitude eintretende Verd kiirzung des mittleren Tragheitshalbmessers die Schwingungs- zahl vergroBern , und solcherart der durch die Luftdampfung hervorgerufenen Tonerniedrigung bis zu einem gewissen Grad entgegenwirken. Treten dann noch weitere verstimmende Mo- mente hinzu, so wird es ganz unmoglich, die Stiirke der Be- teiligung des einzelnen an der Gesam twirkung zu ubersehen, es sei denn, daI3 zuvor jeder EinfluB der GroI3e noch ermittelt worden ware. Eine derartige systematische Zergliederung in gesonderte Faktoren sol1 die Aufgabe der in vorliegender Ab- handlung referierten Untersuchung sein. l) DaB samtliche uns bekannter Klangkorper keine Norma- lien im strengen Sinn dieses Wortes sind, sondern daI3 ihre Tonhohe fur jede Amplitude eine urn einen geringen Betrag veranderte ist, gilt als langst bekannte Tatsache; die Ursachen sind aber bei den einzelnen Instrumenten ganz verschieden- artiger Natur, z. B. bei einer eingespannten Saite andere als R. Hartmann-Kmpc 126 bei einer Stimmgabel. 1) H. P o s k e , Pogg. Ann. 152. p. 448. 1847. 2) t'. Heerwagen, Mag.-Diss. Dorpat 1890. 3j A. Stefanini, Atti dclla reale academia lucchese, Luccs 1889. 4) F. Rraun, Pogg. Ann. 153. p. 4.18. 1874. 5. Uber den Einflup der Amplitude auf die Tonh6hs 'Lcnd das Debrement von Stirtun- gnbellz zbn cl xumgenf6rmigert St ah If e der b dnd ern; von R. H n r t m a nn - E e m p f. I) (Hlereu Tnf. 1-111.) (Aussug aus der Wiirsburger Dissertation.) Gerade mit der in der Physik wegen ihrer relativ hohen Konstanz der Tonhohe und ihrer verhaltnis- mabig geringen Abhangigkeit von der Amplitude mit Vorliebe angewandten Stimmgabel hat man sich vielfach beschaftigt; neben zahlreichen Bemuhungen, genaue Eichungsmethoden zu erproben, wurde auch versucht., die Abweichungen der Ton- hohen , welche mit der Differentialgleichung far gediimpfte, pendelartige Schwingungen: ds x d x d l d t K , + p - + B x = O nicht im Einklang stehen, in mathematische Ausdrticke zu formulieren. Zu nennen sind hauptsilchlich Poske,l) Heer- wagen2) und StefaniniSs) Ferner hat F. Braun') den Ein- flu6 der Amplitude auf die Tonhijhe bei keilfiirmigen Stabeii von niederer Schwingungszahl experimentell und theoretisch nachgewiesen. g Entsprechende Versuche an Stahlfederbilndern sind meines Wissens noch nirgends angestellt worden, obwohl man gerade in diesen eine typische Form zu erkennen hat, einmal schon wegen des geringen Querschnittes der Biegungsstelle, und ferner wegen des bedeutend starkeren Einflusses der Luftdampfung, der sich zumal bei breiten und dunnen Federn bemerklich macht. Vielleicht haben wir den Grund zu der Nichtbehand- lung besagten Qegenstandes in der Umstiiudlichkeit zu suchen, welche man beim Herantreten an solche Untersuchungen zu gewilrtigen hat; denn die bisherigen einfacheren Methoden direkter Beobachtung, wie sie bis zu einem gewissen Qrad zur Bestimmung des Dekrementes und der Tonhohe von schwach gedampften , mithin langsam abklingenden Stimmgabeln aus- reichten, erweisen sich als unzulanglich, wenn es sich um rasch abklingende, stark gedampfte Federbander oder dergl. handelt, zumal wenn man die Untersuchung nicht in den engen Grenzen niederer Schwingungszahlen und relativ kleinen Amplituden halten will. Was hierbei unter groBen Amplituden zu verstehen EinfEup der Amplitude auf die Tonh6lie etc. 127 ist, wird einerseits durch die Elastizitatsgrenze bez. die Dauer- haftigkeit solcher Federbander gekennzeicbnet , andererseits geht dieses MaB aus ihrem Verwendungszweck hervor. g g Der spezielle AnstoS zu einer griindlichen experimentellen Untersuchung ist tatsiichlich auf den praktischen Gebrauch eines Resonanzapparates im Laboratorium von Hartmann & B r a u n zuriickzufuhren, an welchem mir merkwiirdige Er- scheinungen von zunachst uniibersichtlichem Charakter auffielen. Das Auftreten der Resonanz an schwingenden Systemen, welche der Einwirkung iluSerer periodischer Krkfte unterliegen, ist eine langst bekannte Erscheinnng nnd es wurde wiederholt auf die Verwendbarkeit oszillierender Kbrper (Stimmgabeln, Federn Fig. 1. Fig. 1. und dergl.) zur Frequenzmessung nach dem Resonanzprinzip hingewiesen. 1) uber Verauchsbedingungen und weitere Konstruktionseinml- heiten geben meine friiheren Abhandlungen AufechluS: Elektrotechn. Zeitachr. 22. p. 9. 1901; L'industrie Blectrique p. 218. 1901; Physik. Zeitschr. 2. p. 546. 1901; ferner auch die neueren Kataloge von Hart- manu & Braun, Frankfurt a.M. 1) Da die Giite der Stimmgabeln meist nach ihrer moglichst geringen Dlmpfung beurteilt wird, so ist gleich zu bemerken, daL3 e8 sich hier urn ein au6ergewohnliches Modcll handelt , das vie1 echwgcher dimensioniert war urid das vielleicht auch durch Uberanstrengung bei den Resonanz- versuchen an Elastizitat eingebiih hat. Die allgemein riihmlicbst be- kannten Stimmgabeln Koenigs haben in der Regel ein sehr geringecr Dekrement. Ncuerdings werden diese Fabrikate von R. R o enigs langjiihrigem Mitarbeiter uiid Nachfolger, L. Lari d r y , rue Borromke 17, Paris, wieder auf den Markt gebracht 5. Uber den Einflup der Amplitude auf die Tonh6hs 'Lcnd das Debrement von Stirtun- gnbellz zbn cl xumgenf6rmigert St ah If e der b dnd ern; von R. H n r t m a nn - E e m p f. I) (Hlereu Tnf. 1-111.) (Aussug aus der Wiirsburger Dissertation.) Ich selbst war bestrebt, der Methode zur Messung und Fernmelduqg der Frequenz wellenformiger Strame eine bequeme Htlndhabe zu bieten durch eine skalenartige Anord- nung von zungenfijrmigen Federn, welche entweder einzeln oder beliebig viele zugleich der pulsierenden Einwirkung eines magnetischen Wechselfeldes ausgesetzt sind, wodurch sowohl das Aufsuchen der Frequenz (Polwechsel, Tonrexi, Unter- brechungen pro Sekunde etc.) erleichtert wird, als auch das Wandern des Resonanzbereiches bei Frequenzschwankungen ohne weiteres sichtbar gemacht werden kann. Vorstehende Fig. 1 stellt eine Ausfuhrungsform des Apparates dar, in welcher er wohl geeignet sein mag, das Resonanzprinzip zur Anschauung zu bringen. Er besteht aus einer grofleren Anzahl, hier 36 tonenden Stahlzungen, welche 128 R. Harhnann- Kempf. in skalenartigen Intervallen z. B. von 1 = 1 Schwingungen (= Polwechsel) abgestimmt sind und ein beliebiges Bereich, etwa das von 80-115 Polwechseln umfassen. Die Resonanz macht sich durch Tonen und deutlich sichtbares Schwingen der- jenigen Zunge bemerkbar, mit deren Schwingungszahl die Frequenz der Erregerstromquelle , worin das langs der Skala verschiebbare Magnetpaar eingeschaltet ist, iibereinstimmt. g p g Durch Auseinanderschieben des Magnetpaares kann man eine aufrecht zu erhaltende Frequenz eingabeln, so da0 sich der Eintritt einer Schwankung durch das beginnende T h e n einer Qrenzzunge verrat. Auch lassen sich gleichzeitig ver- schieden hohe Frequenzen messen, so z. B. die Schlupfung eines Asynchronmotors gegen die Tourenzahl des Wechsel- stromgeneratora, wobei man sich unter Umstanden besser eines gesonderten Magnetpaares bedient, welches in der Schienen- fuhrung auf der entgegengesetzten Seite lange der Skala lauft. Ebenso gestattet diese Anordnung die Vorfiihrung interessanter Schwebnngsversuche. l) Das Interferrikum zwischen Stahl- zunge und Magnet kann durch Drehen der Befestigungsstelle des Magnets verringert werden, mit RUcksicht auf unzu- reichende S w k e des Erregerstromes. Die dadurch hervor- gerufenen geringen Verschiebungen des Resonanzbereiches einer Stahlzunge sollen in dem gesonderten Teil des Referates zur Besprechung kommen. Als ich im physikalischen Institut der Universitiit Wiirz- burg unter Leitung des Vorstandes, des Hrn. Professor Dr. Willy Wien, an die systematische Behandlung der Aufgabe herantrat, schien es mir geboten, die Untersuchungen nicht weiter auszudehnen als auf folgende Modelle typischer Be- schaffenheit : 1. Stimmgabeln von verschieden groSer Dampfung. 2. Stahlfederband a) stark, b) schwach. hl i d h f h d ll 2. Stahlfederband a) stark, b) schwach. 3. Stahlzunge mit und ohne Kasten (feststehender Metall- rahmen). 129 Einflup der Amplitude auf die Tonhohe etc. Einflup der Amplitude auf die Tonhohe etc. Die Tonhohe wurde zu 100 Schwingungen pro Sekunde ge- wahlt, weil sich diese Zahl fiir viele Verwendungszwecke der Stimmgabel eignet und weil sich die mittels Resonanzinstrumenten zu messende Frcquenz wellenformiger Strome, namentlich bei Wechselstromanlagen, ebenfalls durchschnittlich auf 100 be- liiuft. In speziellen Fallen wurden auch durch Belasten auf 50 Schwingungen vertiefte Stimmgabeln, sowie Stahlzungen von 50 und 25 Schwingungen der Beobachtung unterwerfen. Zur Erleichterung der Ubersicht uber die hier zu b e sprechenden Ergebnisse diene die nachstehende Ncuerdings werden diese Fabrikate von R. R o enigs langjiihrigem Mitarbeiter uiid Nachfolger, L. Lari d r y , rue Borromke 17, Paris, wieder auf den Markt gebracht. Annalen der Physik. IV. Folge. 13. B. Theoretische Untersuchungen. B. Theoretische Untersuchungen. B. Theoretische Untersuchungen. 7. Wiirmeentwickelung einer im Vakuum stationar schwingenden Stahlzunge. g g 8. Einflu6 des mit der Amplitude variabeln Tragheits- momentes einer Stahlzunge auf deren Tonbohe und Schwingungsform. 1) Vgl. FnSnote 3, p. 126. Versuchsfolge: A. Bestimmung von Tonhiihe und Dekrement beim freien Abklingen. 1. Stimmgabel mit groBerer Dampfung von Rud 01 f K o en i g (t), Paris. l) 2. Stimmgabel mit geringer Dampfung von Max Kohl, Chemnitz. 3. Stimrngabel mit mittlerer Dampfung von An ton Bppunn (t), Hanau. 4. Eingespanntes starkes Stahlfederband. 5. Stahlzunge mit und ohne Kasten bei verschiedenem Luftdruck. 6. Schwaches Stahlfederband (Relaisfeder) bei verschie- denem Luftdruck. Fur 2. wurde noch der EinfluS der Belastung, fur 4-6 die Wirkung eines zugefiigten permanenten Magnetfeldes untersucht. 9 Annalen der Physik. IV. Folge. 13. 130 3. Hurtmann-Kempf. Methode Bur Beetimmung von Tonhohe und Dekrement. Wie schon erwahnt, reichen die Methoden direkter (stroboskopischer, vibroskopischer) Beobachtung nicht mehr aus, um Anderungen von Tonholie uiid Dekrement an rasch ab- klingenden Schwingungen zu verfolgen , vielmehr mu8 man suchen, ein graphisches Protokoll zu erlangen. Die A ufzeichnung \ A Fig. 2. Fig. 2. auf RuSpapier erweist eich in den vorliegenden Fallen als un- praktikabel nnd ist auch schon wegen der unkontrollierbaren Diimpfung verwerflich. Der naheliegende Gedanke, die Amplituden photographisch zu registrieren, wurde schon yon S tefanini’) zum Studium des Dekrementes von Stimmgabeln ausgefiihrt, allerdings in technisch etwas primitiver Weise und leider nur ftir Amplituden von mittlerer oder geringerer GroBe. Die Aufgabe, auf dern namlichen Photogramm samtliche Vor- gilnge festzuhalten, um fur jede Amplitude das Dekrement nnd die zugehorige Tonhohe finden zu kiinnen, laste ich durch folgende Anordnung, welche durch vorstehende Fig. 2, sowie durch Fig. 9 auf p. 148 veranschaulicht werden soll. Das leuchtende Kohlebild einer Bogenlampe (B) wird durch die Sammellinse La auf das feststeheude, punktfdrmige Dia- 1) Vgl. FnSnote 3, p. 126. Ein$u/l der Amplitude auf die Tonhohe etc. 131 phragma (0) geworfen, passiert den Spalt eines dahinter stehenden an einer (in der Figur nicht sichtbaren) Stimmgabel- ziuke befestigten Diaphragmas (G) aus gelbgefkrbten Glas- schciben, . wird durch das Linsensystem L, parallel gerichtet und trifft auf den Hohlspiegel H , welcher am beweglichen Ende des zu un tersuchenden Objektes (Stimmgabel, Zunge u. dgl.) befestigt ist. Dieser wirft das 'Licht nunmehr kon- vergent zuriick, zunachst auf einen aus der Symmetrielinic herausgeriickten , schrag nach abwarts gestellten Planspiegel (3, von wo aus es auf die Oberflache eines Trommelmantels (1') fhllt. Dortselbst ist eine Filmfolie (3') aufgespannt, worauf sich die beim Drehen der Trommel zu Sinuslinien aufgeliisten phragma (0) geworfen, passiert den Spalt eines dahinter stehenden an einer (in der Figur nicht sichtbaren) Stimmgabel- ziuke befestigten Diaphragmas (G) aus gelbgefkrbten Glas- schciben, . wird durch das Linsensystem L, parallel gerichtet und trifft auf den Hohlspiegel H , welcher am beweglichen Ende des zu un tersuchenden Objektes (Stimmgabel, Zunge u. dgl.) befestigt ist. Dieser wirft das 'Licht nunmehr kon- vergent zuriick, zunachst auf einen aus der Symmetrielinic herausgeriickten , schrag nach abwarts gestellten Planspiegel (3, von wo aus es auf die Oberflache eines Trommelmantels (1') fhllt. Dortselbst ist eine Filmfolie (3') aufgespannt, worauf sich die beim Drehen der Trommel zu Sinuslinien aufgeliisten Fig. 3 Fig. 3 Schwingungen der Versuchsstimmgabel und dergleichen photo- graphisch abbilden. Methode Bur Beetimmung von Tonhohe und Dekrement. Das Gelbscheibendiaphragma ist an eine elektromagnetisch betriebene Normalstimmgabel (vgl. vor, stehende Autotypie, Fig. 3) befestigt. y g g Wenn diese mit starken Amplituden schwingt, so wird das wei6e Licht nur fur die auBerst kurze Dauer des Durchganges des Spaltes durch die Ruhelage (ca. 0,0001 Sek. lang) hindurch- gelassen. Fur die ubrige Zeit der Schwingungsperiode wird die photographische Wirkung des Lichtes durch die Gelb- scheiben geschwacht. Demgema hebt sich beim Entwiclreln des Negatives ein kurzes Stuckchen der Schwingungskurven durch kraftigere Schwarzung aus dem ubrigen Verlaufe heraus. In den Kopien der Photogramme erscheinen die Kurven hell 9' 9' 132 R. flartmann-Kempf. auf dunklem Grunde. Die Verbindungslinien dieser ,,Licht- blitzpunkte" - es tinden entsprechend dem zweimaligen Durch- gang des Spaltes durch die Ruhelage jeweils zwei urn 180° Grad einer Schwingungsperiode symmetrisch verlaufende Lichtblitze statt - ergeben bei Synchronismus zwei gerade parallele Linien, bei Tondifferenz jedoch schwebungsartige, sinusformige Kurven. Zur Erlauterung diene Fig. 4 und Fig. 6 p. 134, sowie die beigeheftete Photogrammtafel I. g g Dem Tonabstand ist die Anzahl dieser Punkte proportional. Die Amplituden stehen in direktem Verhtiltnis zu der ange- wandten VergroBerung ; wenigstens gilt dies fur Stimmgabeln, woselbst der Ausschlagswinkel noch nicht diejenige Grenze Fig. 4. Fig. 4. uberschreitet, innerhalb deren die bekannten Vertauschungen der Sehne mit dem zugehorigen Kreisbogen erlaubt sind. Die Reduktion der Amplitudenordinaten auf Bogengrade - welches MaB bei Stimmgabeln von verschiedener Lange am ehesten Vergleiche zulafit - wird im Sinne der Fig. 5 nach der Formel Fig. 4. uberschreitet, innerhalb deren die bekannten Vertauschungen der Sehne mit dem zugehorigen Kreisbogen erlaubt sind. Die Reduktion der Amplitudenordinaten auf Bogengrade - welches MaB bei Stimmgabeln von verschiedener Lange am ehesten Vergleiche zulafit - wird im Sinne der Fig. 5 nach der Formel uberschreitet, innerhalb deren die bekannten Vertauschungen der Sehne mit dem zugehorigen Kreisbogen erlaubt sind. Die Reduktion der Amplitudenordinaten auf Bogengrade - welches MaB bei Stimmgabeln von verschiedener Lange am ehesten Vergleiche zulafit - wird im Sinne der Fig. 5 nach der Formel uberschreitet, innerhalb deren die bekannten Vertauschungen der Sehne mit dem zugehorigen Kreisbogen erlaubt sind. Die Reduktion der Amplitudenordinaten auf Bogengrade - welches MaB bei Stimmgabeln von verschiedener Lange am ehesten Vergleiche zulafit - wird im Sinne der Fig. 5 nach der Formel 1) Vgl. z. B. Figg. 2 u. 3 der Physik. Zeitschr. 2. p. 547 u. 548. 2) Vgl. Diss. Ph. IV. Muster einee Skalenblattes. 2) Vgl. Diss. Ph. IV. Muster einee Skalenblattes. vorgenommen. Nicht so leicht ist die Umrechnung der an der Photo- graphie abgemessenen Ordinatenlange -4 auf die in (21 mm aus- gedruckte Entfernung des freien Endes aus der Ruhelage, welche wiederum bei Zungenfedern zu bevorzugen ist, woselbst der Neigungswinkel in einer mathematisch nicht formulier- baren, aber jedenfalls syarkeren Weise wachst, als diese Ent- fernung des schwingenden Endes aus der Ruhelage. Auch Einflup der Amplitude auf‘ die Tonhohe etc. 133 kommt letztere GroBe bei der direkten Beurteilung der rela- tiven Schwingungsweite ausschlieBlich in Betracht. l) Deshalb empfiehlt es sich, mit Hilfe eines besonderen Gestelles, worin sich ein trcppenartig gezackter Schlitten, welcher von Stufe zu Stufe um 1 mm steigt, verschieben IaBt, die Eichung in L Fig. 5. Form eines Skalenblattes 7 vorzunehmen. Das Aufsuchen der Skalenwerte wird durch graphische Darstellung zu einer Kurve wesentlich erleichtert. Folgende Tabellenwerte zeigen beispiels- weise die Umrechnungsverhiiltnisse in einem Skalenblatt, das Skalenblatt zu Aufnahme 29, 31. 1 2 3 4 5 6 7 8 ~~ 590 9 918 10 14,55 11 19,35 12 24,2 13 29,9 14 33,9 15 3 8 3 16 Skalenblatt zu Aufnahme 29, 31. d 44,O 48,7 53,7 59,3 64,5 70,O 56,O 83,O zu den Versuchen an dem eingespannten Stnhlfederband ge- hort. Hierin bedeutet ?i die Entfernung des freien Endes aus der Ruhelage und d die zugehorige Ordinstenlange der im Skalenblatt photographierten Linien. Die VergroBerung hangt naturlich von der Brennweite des Hohlspiegels ab, die sich bei Zungen und starken Stahlfederbandern auf 13,5 cm bei R. Hartmann- Kempf. 134 Stimmgabeln und schwachen Federbtndern auf 30-50 cm be- lief. In erstereu Fallen muB man sich stets mit der Photo- graphie des Ausschlages nach nur einer Seite begniigen, au6er bei ganz kleinen Amplituden. Das Photogramm erhalt dann das charakteristische Aussehen der Fig. 6, wie es sich auch in der Photogrammtafel wiederfindet. Die Auswertung kann sich trotzdem auf ganze Schwebungsperioden erstrecken , weil Fig. 6. Fig. 6. Fig. 6. man ebensogut statt der Punkte die Anzahl Schwingungen abzahlen kann; doch wird man des oftsren das Auswerten halber Schwebungsperioden vorziehen. Nachfolgende Schemrts beziehen sich auf diese vorbild- lichen Verfahren, worin das AbschiZtzen der Bruchteile eines Lichtblitzintervalles zu Hilfe genommen wird , welches ober- und unterhalb der Ruhelinie liegt. Schema I. Fiir eine halbe Periode betriigt . . . . . . t n (in Sek.) Game Lichtblitzintervalle . . . . . . . . 255 165 35.5 33 19 + 2 + 2 = 20,138. vorgenommen. 19 23 Von der Mittellinie bis zum Anfang des ersten ~ 1 y; 1 in '/lo mm 91 9 , 91 ), Ende des letzten 33 t n insgwamt 19 + 0,648 + 0,516 = 20,164. Schema I. Im uogiinstigsten Falle ergibt ein Measungsfehler von mm: 255 165 35.5 33 19 + 2 + 2 = 20,138. 155 Einfltip der Amplitude auf die Ilbnhohe etc. Einfltip der Amplitude auf die Ilbnhohe etc. Bei gro0en Amplituden lassen sich solche betrachtliclie Fehler vermeiden, bei kleinen konnen sie indessen noch merk- licher werden ; in diesem Falle empfiehlt es sich, wenigsteils fur das Lichtblitzintervall den Fehler zu verringern dadurch, da0 man es bei der groSten Amplitude genau mi& und nun der Amplitude proportional abnehmen kSt. p p p Genauer noch ist das Verfahren nach p p p Genauer noch ist das Verfahren nach Schema 11. Beetimmung von l+ fiir eine gauze Schwebungsperiode. Nr. der Schwebungsperiode 1 19 22 15 39,5 86 555 418 19,976 - _ _ 2 19 10.5 33 582 319 - 19,901 3 19 5 30,3 681 165 19,846 ~ 4 19 etc. 835 Schema 11. Schema 11. Hier wurden n u bei der ersten Schwebungsperiode die Bruchteile am Anfang und Ende ermittelt; fur den Ailfang jeder nachsten Periode ergibt sich der Bruchteil aus der Differenz des letzten Bruchteiles gegen ein Ganzes. Dieses letztere Schema ist durchaus das bessere, weil sich die etwaigen Messuugsfehler ausgleichen. Zudem er- mittelt man in kurzerer Zeit bereits die Halfte der Punkte far die graphische Darstellung, aus welcher sich dann ersehen l%iSt, ob sie ausreichen oder ob es besser ist, die urn 180O verschobene Serie der Schwebungen ebenfalls auszuwerten. Das beschriebene Verfahreii ist zwar sehr muhsam und zeit- raubend, indessen wohl das denkbar genaueste, um ganz kleine Tonschwankungen zu verfolgen. Auf Grund der in meiner Arbeit gemachten Erfahrungen mochte ich befurworten, von vornherein durch Belasten der Normalstimmgabel einen Tonabstand von 2-3 Proz. gegen den Versuchsklangkorper herbeizufuhren. Man hat alsdann etwa 20 Lichtblitzpunkte fur eine halbe Schwebungsperiode zu er- warten, bez. 40 fur eine ganze, und ist deshalb in der Lage, nach Belieben die Messungen fur interessante Stellen des 136 R. Hartmann-Kempf. Photogramrnes besonders genau vorzunehmm, wiihrend man bei groBeren Schwebungsperioden oftmals gezwungen ist, diese zu unterteilen und die Lichtblitzpunkte innerhalb der Schwe- bungsabschnitte zu berechnen. nieses Hilfsmittel muBte ich hiiufig anwenden. Tab. 19 diene ale Muster. Sie zeigt zu- nachst die gewahnliche Art der Auswertung aus halben Schwe- bungsperioden, worin t n die Anzahl der Lichtblitzpunkte bez. die Zeit in 1/1,, Sek. bedeutet, ferner A die in Millimetern ge- messene Ordinate des Photogrammes, i?l den auf Millimeter- ausschlag des freien Federendes reduzierten Wert, und n die Schwingungszahl, wobei die Normalstimmgabel zu 100 Schwin- gungen angesetzt ist. Die laufenden Nummern bezeichuen Anzahl und Folge der ausgewerteten Schwebungsperioden. Tabelle 19. Tonh6h e der Stahlzunge ohne K a s t e n bei verschiedenem - - Nr. - ~ 3% 1 2 3 4 5 6 7 35 1 2 3 4 5 6 7 8 Luftdruck. Schema 11. (Aufnahme 32-35.) Aufnahme 32 33 34 verschlechtertes Atma Luftdrnck 0 mm Vakuum - - A ~ ~ 71,3 40,8 31,8 25,O 16,O 53,3 19,8 77,O 56,O 42,6 33,O 26,2 16,4 13,O 20,8 - - B ~ ~ 10,20 7,76 6,OO 4,70 3,72 3,OO 2,45 10,95 8,15 6,24 4,86 3,90 3,12 2,30 2,oo - - tA - ~ 53,O 49,6 47,6 47,O 47,5 47,8 48,3 54,6 49,7 48,O 47,3 47,2 47.35 47,60 47,90 - n 99,025 98,992 98,950 98,947 98,949 98,955 98,964 99,082 98,994 98,958 98,942 98,940 98,944 98,950 98,957 - - Nr. 3s - - 1 2 3 4 5 6 7 - 3: 1 2 3 4 5 6 7 - ~ A - - 69,5 47,O 34,5 26,2 20,2 15,8 12,3 45,O 30,6 16,3 22,o 12,2 993 733 - - nJL - - 10,o 6,88 5,lO 3,90 3,03 2,41 1,90 6,60 4,50 3,30 2,50 1,90 1,45 1,lO 35 1 Atm. - - ta - - 51,1 47,2 46,6 46,4 46,5 47,05 47,5 45,7 45,0 45,4 43,65 45,95 46,43 46,70 .- n 99,018 98,941 98,927 98,922 98,925 98,948 98,938 98,907 98,889 98,898 98,902 98,912 98.923 98,929 Tabelle 19. Tabelle 19. 7 - Nr. l a l b l c l a 1 6 l c If2 l b l e 0 l a 1 6 I c I d - - 10,77 9,68 - 11,62 10,20 - 10,72 8,76 - - 7,23 9,12 0,122 7,77 0,188 - 0,150 9,54 0,104 8,05 0,201 - 0,145 6,93 0,1125 6,lO 0,265 - 0,1225 - 12,5 5,23 12,8 - 4 75,7 67,2 I 82,4 71,4 - 75,2 60,5 - - 49,4 41,O - 32,7 83,5 75,7 67,2 89,5 82,4 71,4 - 75,2 60,5 63,l - 49,4 41,O - Tabelle 19a. Ber e c hnu ng aua Sc h w e bun g s a bac hni t t en. 19,l 63,l 53,2 26,3 66,3 53,3 - 47,3 41,5 44,2 40,4 35,5 31,3 - P. 1) F. Kohlrauech, Lehrbuch p. 101. der praktiechen Phyeik, 9. A d . Schema 11. 63,l 53,25 - 66,3 33,3 - 57,3 41,5 - - 35,5 31,3 - 25,l 99,125 99,060 99,025 99,132 99,080 99,037 99,075 99,025 98,969 98,947 Y8,900 98,888 98,924 98,888 8 0 11,79 10,77 9,68 12,50 11,62 10,20 - 10,72 8,75 9,14 - 7,23 6,OO - 783 71.0 63,l 85,8 76,6 67,2 79,O 67,3 57,O 59,3 44,5 38,4 52,O 28,9 - - V a - - 2,87 9,12 7,77 3,90 9,54 R,05 - 6,93 6,10 6,47 7,03 5,23 4,63 - 6,OO n b e d bedeuten Abecbnitte einer halben Schwebutigsperiode. t. 14 20 15,2 12,o 22,o 15,l 12,2 11,9 27,O 11,75 11,90 2 1 ,oo 12,68 12,77 - 9l 11,20 10,17 9,14 12,01 10,90 9,67 11,22 9,70 8,30 Y,6 7,6 695 5,65 4,27 - Tabelle 19a. Ber e c hnu ng aua Sc h w e bun g s a bac hni t t en. - 138 R. Hattmann-Kempf. R. Hattmann-Kempf. Tab. 19 a erweist das mlthsame, aber ganz zuverllssige Verfahren der Auswertung aus Schwebungsabschnitten. Hierin bedeutet : R. = Radiua des Kreieee R. = Radiua des Kreieee R. = Radiua des Kreieee Pa = Projektion dea Schwebungsstuckes ) am Anfang des Abechnittee, R. = das Entsprechende ] am Ende dee Abschnittea, P, = ,, 1 ) %,I, ?h, We, !& = daa Entsprechende in Werten dee Skalenblattee. s = der zu den Projektionen gehSrige Teil einer Kreieechwingung, t, = die dam erforderliche Zeit in l/loo Sek. R. = Radiua des Kreieee Pa = Projektion dea Schwebungsstuckes ) am Anfang des Abechnittee, R. = das Entsprechende ] am Ende dee Abschnittea, P, = ,, 1 ) %,I, ?h, We, !& = daa Entsprechende in Werten dee Skalenblattee. s = der zu den Projektionen gehSrige Teil einer Kreieechwingung, t, = die dam erforderliche Zeit in l/loo Sek. R. = Radiua des Kreieee Pa = Projektion dea Schwebungsstuckes ) am Anfang des Abechnittee, %,I, ?h, We, !& = daa Entsprechende in Werten dee Skalenblattee. Man verfolge den Sinn der Abkiirzungen an der Fig. 6, p. 134, sowie an der auf der beigehefteten Photogrammtafel I reproduzierten Aufnahme 5. (Uber Genauigkeit des Verfahrens vgl. Diss. p. 38; ebenda ist auch p. 220 eine Methode zur Erleichternng des Umrechneris angegebec.) Die Berechnung des Dekrementes geschieht in bekannter Weise.3 1st up die Grof3e des pm, uq die des 9”” Bogens, so gilt ( ) 1 ~ k = (z)q-p oder A = log up - log a q 4 - P 1 ~ k = (z)q-p oder A = log up - log a q 4 - P Hierin ist a durch 2 A zu ersetzen; eine Reduktion von 2 A auf Bogenwert ist iiberfliissig. Hierin ist a durch 2 A zu ersetzen; eine Reduktion von 2 A auf Bogenwert ist iiberfliissig. Wenn man im voraus davon iiberzeugt ist, da6 das Dekre- ment eine lineare Funktion der Amplitude ist, oder wenigstens nur ganz wenig davon abweicht, so darf man p - p ziemlich gro0 nehmsn. Das Resultat wird zwar dadnrch nicht genauer, aber rascher ermittelt. Alle anderen Mahahmen gehen aus der Tab. 2 hervor; es verlohnt sich indessen, ein rechnen und auch den Einfluf3 Beispiel ausfiihrlich durchzu- eines Ablesefehlers zu zeigen. Einpup der Amplitude aicf die Tonhohe etc. 139 8 9 10 11 12 13 14 15 16 17 Tabelle 2. D e k r e m e n t d e r S t i m m g a b e l v o n Rud. Koenig. R. = Radiua des Kreieee Aufnahme 4. 21,23 20,lO 1S,70 17,35 15,95 14,55 13,20 11,45 9,55 8,35 30,lO 6 6 6 6 6 ti 6 6 S 10 12 14 18 30 50 DO 240 2 A, 34,60 31,45 28,05 26,75 ?4,85 23,35 21,90 20,75 19,40 18,OO 16.65 15,% 13,85 12,30 10,45 8,80 a,. 1,660 1,510 1,390 1,192 1,283 1,120 1,050 0,996 0,992 0,865 0,800 0,732 0,665 0,59 1 0,502 0,425 log 2 A, - log 2 A , Q-P 0,00722 613 538 541 494 450 446 405 389 355 304 284 235 206 177 116 - k 1,0168 149 136 125 114 104 103 093 090 082 070 066 054 048 041 027 Tabelle 2. Hierin bedeuteri Hierin bedeuteri 2 Adie in Millimetern gemeasene Begrenzungsamplitude desIntervalleep bis q. 2 A, die dazugehorige mittlere Amplifude iu Millimetern. 2 Adie in Millimetern gemeasene Begrenzungsamplitude desIntervalleep bis q. 2 A, die dazugehorige mittlere Amplifude iu Millimetern. n den einseitigen Ausschlag in Bogengraden. k das DIimpfurigsverhiiltnis. 3) R. K e m p f - H a r t m a n n , Ann. d. Phps. 8. p. 494. 1902. 2. M. Wien, Wied. Ann. 42. p. 593. 1891. 1) F. N i e m o l l e r , Wied. Ann. 6. p. 301. 18'79. Aus Tab. 2, Nr. 1 entnehmen wir: Aus Tab. 2, Nr. 1 entnehmen wir: log 2 A, = 1,5605 10z 2 A, = 1,5172 2 A, = 36,35 mm; 2 A, =.32,90 mm; 1 = 0,0433 : 6 = 0,00722. Ein Schiitzungsfehler von 'la, mm - und ein groI3erer la& sich vermeiden - bewirkt, daI3 sich I um 1,4 Proz. iindert (2 A, = 33,6 mm, 1 = 0,00712). Dieser Fehler ist in der Folge weniger empfindlich als gerade am Anfang. Dem steht wiederum die leichtere Ab- lesbarkeit bei groI3eren Bmplituden gunstig gegeniiber. 140 I?. Hartmatin- Kempf: Fig. 7. Gleichstromunterbrccher mit elektromagnetiscli angetriebener Stahlseite. I?. Hartmatin- Kempf: 140 I?. Hartmatin- Kempf: Fig. 7. I?. Hartmatin- Kempf: 140 Fig. 7. Gleichstromunterbrccher mit elektromagnetiscli angetriebener Stahlseite. Fig. T a. Schlitten mit Magnet und Unterbrechungsvorriclltung. Fig. T a. Fig. T a. Schlitten mit Magnet und Unterbrechungsvorriclltung. 1 4 Binfliip der IImplitrcilc auf' die l'onhohe etc. Binfliip der IImplitrcilc auf' die l'onhohe etc. Zur elektromagnetischen Erregung der Hesonanzschwin- gungen wurde Wechsels trom und periodisch unterbrochener Gleichstrom benutzt. Erstere wurde einem sogenannten Gleich- strom-Drehstromumformer (von Siemens I% Halske) von ca. 1 Kilowatt Leistung entnommen , dessen Tourenzahl durch Widerstande, wovon sich einer fur ganz feine Einstellung in nachster Nahe meines Standortes befnnd, reguliert werden konnte. Sehr bequem geschieht dies mit Hilfe eines Frequenz- messers, bestehend aus einigen, etwrt 12 Zungen, welche ober- und unterhalb des Resonanzbereiches alle zugleich vor einem Magnet gerauschlos schwingen. g g g Den periodischen Gleichstrom lieferte ein Saitenunter- brecher (Autotypie Fig. 7) nach F. Niemollers l) Idee, dessen Konstruktion sich his zu einem gewissen Grade an ein von M. W i e n a) herruhrendes Modell anlehnt. Wegen Ausfiihrungs- einzelheiten verweise ich auf meine Originalabhandlung p. 222-231 ; ferner ist eine eingehende Beschreibung namentlich der in mechanisch-technischer Beziehung interessanten Teile in der ,,Zeitschrift ftir Instrumentenkunde" beabsichtigt. Die bereits an anderer Stelleg naher erlauterte Art der Unter- brechungsvorrichtung mit Spiilung durch flieBendes Wasser geht aus der Spezialabbildung Fig. 7 a deutlich hervor. Be- sondere Sorgfalt wurde der Spannvorrichtung, sowie der zen- trischen, isolierten Lagerung der Saite gewidmet. Die massive, durchweg aus GuSeisen oder Stahl bestehende Bauart sichert ein vollkommen gleichmiSiges Arbeiten des Unterbrechers bei groBer Konstanz der Scliwingungszahl. Betreffs der ubrigen wichtigen Restandteile des Instru- mentariums (Trommel mit Schutzgehause, Vorgelege und Mo- torantrieb, automatisch fun ktionierender Objektivverschluf.3 und dergl.) sei ebenfalls auf den Anhnng der Originalarbeit hinge- wiesen. A. Versuchsergebnisse. 1-3. Es erleichtert die Vergleichsmoglichkeit, wenn die Resultate uber den Verlauf von Tonhohe und Dekrement an Stimm- 142 R. Hurtmam-Kcmpf'. gabeln fur alle hier behandelten Fiille zugleich besprochen werden. Bus diesen GrIinden siud die graphischen Dar- stellungen auf Kurvenbliitt I, Taf. I1 vereinigt. Beim Auftragen der logarithmischen Dekremente 2 kann dies ohne Umstande geschehen, dagegen mu8 fur die Tonhohen n, welche sich bei samtlichen Stimrngabeln nicht weit von 100 Schwingungen pro Sekunde aufhalten, eine Transposition nach einem gemein- samen Anfangspunkt vorgenommen werden. Dies macht inso- fern Schwierigkeit, als die Toiiholie fur selir kleine Ampli- tuden bei jeder Stimmgabel aus den ursprunglichen Kurven (Diss. I-VIIIr) geschatzt werden muB. Denn anfiinglich wurde beim Studium dieser Verhaltnisse hauptsachlich den prak- tischen Bediirfnissen Rechnung getragen, fur welche man die Tonhohe bei ganz kleinen Amplituden als nahezu konstant voraussetzen mag. Interessanter ist nuch tatsachlich das Studium der verstimmenden Einflusse starker Amplituden wegen der Verwendung von Stimmgabeln zu selbstt'itigen Unterbrechern, Resonanzapparaten und dergl., ganz abgesehen von wertvollen Ergebnissen fur theoretische SchluSfolgerungen. Deshalb wurde die Steigerung der Amplitude bis zum hochst zulassigen MnB fur Dauerschwingungen getrieben, jn meist noch weiter, was man fur wenige Augenblicke riskieren darf; bei langerem Sahwingenlassen mit ubergroBen Amplituden kann die Elastizitlt nachlassen, oft infolge von kleinen Spriingen an den Stellen stiirkster Biegung. Ein solches HochstmaS ist z. B. bei der massiven Stimmgabel von M. Kohl (27 cm Zinken- liiuge) eine nach beiden Seiten des schwingenden freien Endes gemessene Gesamtamplitude von 10 mm ; bei schwacher dimen- sionierten Gabeln kann es noch mehr betragen. gabeln fur alle hier behandelten Fiille zugleich besprochen werden. Bus diesen GrIinden siud die graphischen Dar- stellungen auf Kurvenbliitt I, Taf. I1 vereinigt. Beim Auftragen der logarithmischen Dekremente 2 kann dies ohne Umstande geschehen, dagegen mu8 fur die Tonhohen n, welche sich bei samtlichen Stimrngabeln nicht weit von 100 Schwingungen pro Sekunde aufhalten, eine Transposition nach einem gemein- samen Anfangspunkt vorgenommen werden. Dies macht inso- fern Schwierigkeit, als die Toiiholie fur selir kleine Ampli- tuden bei jeder Stimmgabel aus den ursprunglichen Kurven (Diss. I-VIIIr) geschatzt werden muB. Denn anfiinglich wurde beim Studium dieser Verhaltnisse hauptsachlich den prak- tischen Bediirfnissen Rechnung getragen, fur welche man die Tonhohe bei ganz kleinen Amplituden als nahezu konstant voraussetzen mag. Interessanter ist nuch tatsachlich das Studium der verstimmenden Einflusse starker Amplituden wegen der Verwendung von Stimmgabeln zu selbstt'itigen Unterbrechern, Resonanzapparaten und dergl., ganz abgesehen von wertvollen Ergebnissen fur theoretische SchluSfolgerungen. A. Versuchsergebnisse. Deshalb wurde die Steigerung der Amplitude bis zum hochst zulassigen MnB fur Dauerschwingungen getrieben, jn meist noch weiter, was man fur wenige Augenblicke riskieren darf; bei langerem Sahwingenlassen mit ubergroBen Amplituden kann die Elastizitlt nachlassen, oft infolge von kleinen Spriingen an den Stellen stiirkster Biegung. Ein solches HochstmaS ist z. B. bei der massiven Stimmgabel von M. Kohl (27 cm Zinken- liiuge) eine nach beiden Seiten des schwingenden freien Endes gemessene Gesamtamplitude von 10 mm ; bei schwacher dimen- sionierten Gabeln kann es noch mehr betragen. Resultate anderer Autoren (vgl. Heerwagen, Diss. Dor- pat), die sich allerdings auf hochstens halb so groBe Ampli- tuden beziehen, haben bereits darauf schlieBen lassen, dab die Tonhohenabnahme eine lineare Yunktion der Amplitude sei, so da8 man die Schwjngungszalil etwa in Form der Gleichung n = no - p . u ausdriicken konne. 1) Die zum Belssten erforderlichen Gewichte eind aue der Autotypie, Fig. 3, p. 131 zu ereehen. ausdriicken konne. Aus dem vorliegenden mit weitaus gr6Berer Genauigkeit 211 drei Stimmgabeln ermittelten Tonhohenverlauf geht hcrbvor, 143 Eintup der Amplitude auf die Tonhiihe etc. da6 die Verstimmung etwas st;irker wachst, so da6 sich die Gleichung n = no - (p + d c()a der Kurve vielleicht besser anschmiegen wiirde. Indessen ist der Wert solcher empirischen Formeln nur gering. Die Gleichung wurde wesentlich komplizierter, wenn man noch den erh6henden Einflu0 berucksichtigen wollte, der aus der Ver- kiirzung des Tragheitsmomentes infolge der Deformation der schwingenden Zinke entspringt. Dieser scheint sich haupt- siicLlich bei der verhaltnismaBig dunnen Stimmgabel von A. Appunn bemerkbar gemacht zu haben. pp g Als Beispiel fur die praktische Nutzanwendung der Ver- suchsergebnisse sei die Verstimmung berechnet, welcher der Stimmgabelunterbrecher bei Spannungsschwankungen unter- liegt. Das hierzu benutzte Model1 ist der untersuchten Gabel von M. Kohl vollig gleich. Nehmen wir an, die Gesamt- amplitude verringere sich von 10 auf 9 mm, dann steigt die Tonhiihe um 0,005 Schwingungen oder ebensoviel Prozent. Fur die meisten Messungen bliebe der entstehende Fehler gitnz unbelanglich, dagegen dtirfte er bei den spater beschrie- benen Vakuumversuchen nicht mehr als 0,001 Schwingungen betragen, um nicht die charakteristischen Unterschiedo zu ver- wischen. Der Verlauf des logarithmischen Dekrementes la0t sich ebenfitlls annahernd als lineare Funktion der Amplitude il=p,.t% darstellen, wennschon auch hier mitunter ein etwas steileres Wachstum sich bemorkbar macht, z. B. bei der belasteten Stimmgabel von M. Koh1.l) DaB sich das Dekrement fiir c( = Oo ebenfalls dem Wert Null nahere, ist ein ideeller Fall, der aus irgend welchen Griinden mechanisch-physikalischer Natur nur annahernd erreicht wird. Im groBen Ganzen ist die Annahme berechtigt, da0 sich mit doppelt so gro0er Ampli- tude auch das Dekrement verdoppelt. darstellen, wennschon auch hier mitunter ein etwas steileres Wachstum sich bemorkbar macht, z. B. bei der belasteten Stimmgabel von M. Koh1.l) DaB sich das Dekrement fiir c( = Oo ebenfalls dem Wert Null nahere, ist ein ideeller Fall, der aus irgend welchen Griinden mechanisch-physikalischer Natur nur annahernd erreicht wird. Im groBen Ganzen ist die Annahme berechtigt, da0 sich mit doppelt so gro0er Ampli- tude auch das Dekrement verdoppelt. Was nun die Verstimmung der Eigenschwiiigungszahl anbelangt , welche das Dekrement hervorrufen miiBte, so ist R. Roenig . . . . . . 0,0042 0,00075 K. Kohl, belastet 50 ,, 0,00083 M. Kohl, frei 100 Schwing. 1) Vgl. F. Heerwagen, Mag.-Diss. Dorpat 1890. 1) An der diinnsten Stelle gemessen. Das keilformig dicker wer- dende Ende ist 0,8 mm stark. 2) Die Nummernbezeichnuug der Kurven gibt keinerlei AufschluS iiber die zeitliche Aufeinanderfolge, vielmehr h h g t eie nur mit der in der Originalarbeit eingehaltenen Reihenfolge zusammen. Annnalen der Physik. IV. Folge. 13. 10 ausdriicken konne. Mittel: 66 72 0,90 0,040 58,5 0,050 60 Hierin bedeutet d die Verstjmmung in ganzen Schwin- gungen oder in Prozenten jeweils fk die ziemlich groBe Ampli- tude von lo, worauf auch il zu beziehen ist. 4. Wennschon die Ergebnisse der Versuche an Stimmgabeln insofern neuartig waren, als sie sich auf eine gro0e Amplitude erstreckten und zugleich eine mit friiheren Methoden nicht annahernd erreichte Qenauigkeit aufwiesen, so haben sie nichts Uberraschendes gebracht. Anders verhalt es sich mit den jetzt und fernerhin zii besprechenden Resultaten der Untersuchungen von Tonhohe und Dekrement von Stahlbandern und Stahl- zungen, deren physikalische Beschaffenheit sich in drei fur uns wesentlichen Beziehungen von den Stimmgabeln unter- scheidet. a) Die Tonhahe wird nicht durch die Dlmpfung allein, sondern ungleich mehr durch die Verkiirzung des Tragheits- momentes beeinfluBt, welches namentlich hei starkeren Ampli- tuden zur Geltung kommt, weil ja die Durchbiegung uicht auf eine enge Stelle beschrankt ist, sondern sich ganz allmahlicb auf ein grof3eres Stuck ausdehnt. (Vgl. die schematisch dar- 145 Einfzus der Amplitude auf die Tonhohe etc. gestellten Falle in Fig. 10, p. 154, deren linksstehendes Bild ein sich verkiirzendes, das rechtsstehende ein konstantes Triigheitsmoment reprasentiert.) gestellten Falle in Fig. 10, p. 154, deren linksstehendes Bild ein sich verkiirzendes, das rechtsstehende ein konstantes Triigheitsmoment reprasentiert.) gestellten Falle in Fig. 10, p. 154, deren linksstehendes Bild ein sich verkiirzendes, das rechtsstehende ein konstantes Triigheitsmoment reprasentiert.) gestellten Falle in Fig. 10, p. 154, deren linksstehendes Bild ein sich verkiirzendes, das rechtsstehende ein konstantes Triigheitsmoment reprasentiert.) g p ) t)) Fur die innere Reibung kommt der dilnne Querschnitt in Betracht, welcher eine starke Verbiegung bei geringer Di- latation und Kompression der molekularen Struktur zuliibt. t)) Fur die innere Reibung kommt der dilnne Querschnitt in Betracht, welcher eine starke Verbiegung bei geringer Di- latation und Kompression der molekularen Struktur zuliibt. t)) Fur die innere Reibung kommt der dilnne Querschnitt in Betracht, welcher eine starke Verbiegung bei geringer Di- latation und Kompression der molekularen Struktur zuliibt. p c) Der Luftwiderstand tritt in ein ganz anderes QroBen- verhaltnis zu der potentiellen Energie des schwingenden Systems. Bei Stimmgabeln war er fast zu vernachlassigen. - : - 0 0 Lo Fig. : 8. Die a d e r e Beschaffenheit des Stahlfederbandes, sowie der Stahl- zunge und des Messingkastens zeigt uns Fig. 8. Als Dimensionen seien aufgefiihrt fur Stahlfederband bez. Stahlzunge: Freie Liinge 80 bez. 52 mm! Breite 9 bez. 7,5 mm, Dicke 0,75 bez. 1) An der diinnsten Stelle gemessen. Das keilformig dicker wer- dende Ende ist 0,8 mm stark. i i i i i A f S 2) Die Nummernbezeichnuug der Kurven gibt keinerlei AufschluS iiber die zeitliche Aufeinanderfolge, vielmehr h h g t eie nur mit der in der Originalarbeit eingehaltenen Reihenfolge zusammen. Annnalen der Physik. IV. Folge. 13. 10 ausdriicken konne. 0,45 mm.3 Die a d e r e Beschaffenheit des Stahlfederbandes, sowie der Stahl- zunge und des Messingkastens zeigt uns Fig. 8. Als Dimensionen seien aufgefiihrt fur Stahlfederband bez. Stahlzunge: Freie Liinge 80 bez. 52 mm! Breite 9 bez. 7,5 mm, Dicke 0,75 bez. 0,45 mm.3 Wir beginnen mit der Tonhahe des frei abklingenden Stahlfeder- bandes (Blatt XI11 a. lith. Taf. 11). Neuartig.ist das betrachtliche Sinken der Tonhohe gerade bei kleinen Am- plituden, welches mit der fast tradi- tionell gewordenen Annahme , dab 0 0 Lo Fig. : 8. die Schwingungszahl bei kleinen Amplituden konstant sei, in einem bemerkenswerten Widerspruch steht. Bei mittel- groben Amplituden passiert die Tonhohe ein Minimum, um denn wieder zu steigen, und einem vermutlichen Maximum zuzustreben. Kurve 29 steht urn 0,4 Schwingungen tiefer a19 31. Sie gehort zu einer zeitlich alteren Aufnahme,e) und es mag die Tondifferenz als Folgeerscheinung der magnetischen Remanenz (siehe weiter unten) oder der elastischen Uber- anstrengung der Feder angesehen werden. (Uber das Auf- 10 146 R. Hartmann- Kempf. treten der ,,Querschwingungen" infolge der Uberanstrengung und dergl. siehe Diss. p. 97, ferner dortselbst Photo- gramm 28.) treten der ,,Querschwingungen" infolge der Uberanstrengung und dergl. siehe Diss. p. 97, ferner dortselbst Photo- gramm 28.) treten der ,,Querschwingungen" infolge der Uberanstrengung und dergl. siehe Diss. p. 97, ferner dortselbst Photo- gramm 28.) g Das Abklingen geschah stets von einer groSen, durch ein starkes magnetisches Wechselfeld erzwungenen Amplitude ab ; die Lage der Frequenz fur die grogen Resonanzamplituden ist in Blatt XIII angegeben. Aus verschiedenen Griinden ist es nun interessant, den EinfluB eines perinanenten Magnetfeldes auf die Tonhohe etc. des abklingenden Federbandes zu unter- suchen, welches Feld im Moment der Unterbrechung des Er- regerstromes eingeschaltat wurde. Seine Starke la& sich einigermden aus der dauernden Ausbiegung der Feder von ihrer Ruhelage beurteilen. (Blatt XII.) Erstaunlich ist die gro6e Tonvertiefung , welche durchschnittlich etwa 4 Proz. betriigt. Auch wird eine etwaige Erhbhung durch Deformation vollig yon der dampfenden Wirkung des Magnetfeldes unter- druckt. Das Dekrement des Stahlfederbandes (Blatt XII) zeigt etwas ganz Unerwartetes; nij.mlich, da6 es flir kleine Ampli- tuden gr33er ist als fiir stiirkere. Dagegen wird es mit weiter wachsenden Amplituden nur schwach erhoht, fast bleibt es konstant. Die Einwirkung eines permanenten Magnetfeldes (siehe oben) auf das Dekrement ist nun wiederum erstaunlich gering im Vergleich zu der groBen Tonerniedrigung. 5. Wir betrachten zunPchst die Ergebnisse der in gleicher Weise wie an dem Stahlfederband nunmehr an der Stahlzunge angestellten Versuche. Vergegenwartigen wir uns die ge- ringere Dicke der Biegungsstelle, so darf es nicht verwundern, da6 das Dekrement der Stahlzunge (Blatt XIV) infolge des relativ bedeutenden Lnftwiderstandes nicht mehr anniihernd Iconstant bleibt, sondern fast proportional der Amplitude wllchst, und dies sehr stark, wenngleich es schlieglich doch geringer. bleibt als das des FederbandeR. Wir werden am den spiiter folgenden Vakuumvorsuchen lernen , da6 dies Anwachsen nur auf Rechnung des Luftwiderstandes zu setzen ist. ijbrigens war der ,,gasten" einstweilen abgenommen. Die Abszissen- EinfIup der Amplitude auf die Tonlrohe etc. 147 maBe beziehen sich von jetzt ab auf den fur die direkte Beob- achtung in Betracht kommenden doppelten Ausschlag in Milli- metern. Ein genaues Gegeniiberstellen der Resultate mit denen auf Blatt XI1 und XI11 ist sowieso wegen des ver- schiedenen Banes beider Federn nicht mtiglich. g Der Tonhohenverlauf ist aus Blatt XIX besser ereichtlich; im Blatt XV reprasentiere die Kurve 52 nur die Lage der Tonhohe bei frei abklingender ungedampfter (ttbgesehen von etwaiger Remanenz) Zunge. Die Verstimmung bei ktinstlich zugeschalteter magnetischer Dampfung ist ganz auBerordent- lich , beinahe 8 Proz. der Gesamtschwingungszahl. Solche Verauche gewinnen u. a. auch dadurch an Interesse, weil sie uns eine deutliche Vorstellung von der Einwirkung perma- nenter Felder auf Resonanzschwingungen geben, wie sie z. B. beim optischen Telephon von M. W ien, beim Vibrations- galvanometer von Rubens etc. vorhanden sind. g Die Einfliisse der durch Luftwiderstand bewirkten Dam- pfung auf Tonhohe und Dekrement wurde, wie schon erwahnt in einem Vakuum gesondert studiert. Der Aufbau ist durch Fig. 9 veranschaulicht. Hierbei wurde auch versucht, den allenfallsigen Unterschied zu ermitteln zwischen dem Wider- stand der Luft bei bestmoglichem Vakuum und demjenigen bei auBerst geringer Luftmenge , welche eben noch ausreicht, urn die Reibung der Gasmolekiile an den festen WBnden des schwingenden Systems wieder herzustellen. Das Max w e llsche Gesetz besagt, dab die Reibung der Gase erst dann wesentlich geringer zu werden beginnt, wenn die mittlere freie Weglange der Gasmolekiile in die GroBenordnung der Entfernungen zwischen feststehenden und bewegten W anden eintritt. Die Versuche von Kundt und Warburgl) an einer zwischen zwei engbenachbarten WLnden schwingenden Scheibe haben dies Gesetz hekanntlich bestatigt. I) F. Kundt u. E. Warburg, Pogg. Ann. 165. p. 337. 1575. 10* 1) Vgl. die theoretixhe Behandlung in Absatz 11. 1) Die nachteiligen Folgen der uberanstrengung verraten sich nicht sofort; zuerst wird das Dekrement erheblich vergr6Bertl ferner wandert das Rcsonanzmaximum immer mehr nach der Tiefe, aber die Maximal- amplituden werden zusehends geringer. Diese Erscheinung kann sich solcherart bis zu eiuer Verminderung der Schwingiingszahl von 20 Proz. fortspielen. 5. Allerdings liegen bei ciner Zungenfeder , welche in einem groDeren Raum frei (oder hochstens fiir ein kleines Wegstiick an den Wanden des Rahmenksstens vorbei) schwingt, die Verhaltnisse wesentlich uugiinstiger, wenn man eine groBere Wirkung erwarten will. Diesc lieBe sich bei entsprechender Abanderung, z. B. durch 10* 10* 148 R. Hartmann- Kempf. Befestigen einer diinnen Scheibe aus Aluminiumblech am freien Zungenende etc., ohne Zweifel herbeifihren. So aber blieb der fragliche Unterschied gering. Die eigentliche Luftreibung kommt kaum zur Geltung, Vergleiche Kurven 32 u. 33 auf den Blattern XVI und XIX, Tafel I1 u. 111. Zudem macht sich bei gro0er Verdlinnung eine andere Erscheiiiung in hochst un- erwiinschter Weise geltend, welche in gleicher Art wie die Fig. 9. Fig. 9. Beibung das Maxwellsche Gesetz befolgt, namlich die ver- minderte Wtirmeleitfahigkeit der Gase. Alsdann ksnn sich die beim Schwingen der Zunge entstehende Warme nicht schnell genug von der Biegungsstelle entfernen, weil die Warmeabgabe an die Luft durch Ileitung fortfallt und nur, abgesehen von der iiuf3erst geringen Ausstrahlung, die direkte Leitfahigkeit des Metalles in Frage kommt.') Diese reicht aber nicht aus, urn eine stationiire Erwtirmung der Biegungsstelle um immerliin 1 o. Beibung das Maxwellsche Gesetz befolgt, namlich die ver- minderte Wtirmeleitfahigkeit der Gase. Alsdann ksnn sich die beim Schwingen der Zunge entstehende Warme nicht schnell genug von der Biegungsstelle entfernen, weil die Warmeabgabe an die Luft durch Ileitung fortfallt und nur, abgesehen von der iiuf3erst geringen Ausstrahlung, die direkte Leitfahigkeit des Metalles in Frage kommt.') Diese reicht aber nicht aus, urn eine stationiire Erwtirmung der Biegungsstelle um immerliin 1 o. Einpup der Bmplihde auf' die lbnhohe etc. 149 zu verhindern , welcher Temperaturunterschied sich durch die wenn auch nur geringe Abnahme der elastischen Spannkraft geniigend bemerklich macht, um den wirklichen EinfluB der Luftreibung auf Tonhohe und Dekrement zu entstellen, wenn nicht ganz zu iiberdecken. Mehrere in der Originalarbeit auf- gefuhrte Versuche bestatigen das eben Gesagte. g g g Dessenungeachtet hahen die Vakuumversuche auch inter- essante positive Resultate gezeitigt. Das wichtigste besteht wohl darin, daB das Dekrement mit wachsender Amplitude archon bald einem Maximum zustrebt, welches man als konstant aiisehen darf, (Kurve 32 und 33, Blatt XVI); denn nach diesem Ergebnis bewahrheitet sich die Annahme , welche die innere molekulare Reibung der ersten Potenz der Geschwindigkeit, also nicht einer hoheren Potenz, proportional setzt. 5. Dieses Dekrement ist ziemlich klein, namentlich im Vergleich zu dem- jenigen bei normalem Luftdruck; denn sowie Energie an die Luftmassen abgegeben wird, steigt das Dekrement ungefahr entspreahend dem Atmospharendruck, wenigstens fur kleine und mittelgroBe Amplituden. Bei groBeren scheint der Kurven- verlauf des Dekrementes fur eine halbe Atmosphare Luftdruck noch etwas yon der Form der Kurven 32 und 33 fiir luft- leeren Raum in sich zu tragen; wogegen die Zunahme des Dekrementes bei vollem Luftdruck schlieBlich rapid steigt. In letzterem Falle muB der Zunge eine groBe Energiemenge zugefuhrt werden urn die Resonanzschwingungen aufrecht zu erhalten, darin ist auch der Grund zu erblicken, warum die Feder nur bis zu maBig groBen Amplituden dauernd erregt werden kann.') Vie1 starker, namentlich bei kloinen Amplituden, fillt das Dekrement begreiflicherweise aus, wenn die Zunge mit einem Rahmen (,,Kasten") versehen ist. Wir entnehmen seinen Ver- lauf aus Kurve 121, Blatt XXIIIa 11. I m Vakuum, oder besser gesagt, bei sehr geringem Luftdruck, tluBert sich der Ein- flu6 des Kastenrahmens nur bei kleinen Amplituden; die Kurve 150 H. Hartmann- Kempfi des Dekrements bildet an dieser Stelle ein Knie (1" = ca. 0,00255) und strebt von da ab langsam zu einem geringeren, fur die Folge wohl ziemlich konstanten Wert (Iw = ca. 0,00270) zu. g ( , ) Den entsprechenden Tonhijhenverlauf bei variablem Luft- druck lehrt Blatt XIX, woselbst Kurve 32 streckenweise ge- schatzt wurde (gestrichelte Linie). Es ist zu vermuten? dab, wenn eine bessere Abkuhlung wahrend des Schwingens statt- gefunden Eatte, die Kurve 32 eine durchweg etwas hohere Lage einnehmen durfte. Kurve 35 ist absichtlich nicht abge- rundet, weil sich der Knick zwischen 2 d = 6 und 2 -4 = 7 mm als charakteristisch auch in anderen Aufnahmen erwiesen hat. Die ganze Tondifferenz zwischen Vakuum und normslem Luft- druck ist erstaunlich gering. Haben wir doch gesehen, da6 eine magnetische Ulimpfung, welche das Dekrement relativ weit weniger YergrbBerte, als bier der hinzutretende Luftwider- stand, eine au6erordentlich starke Tonerniedrigung im Gefolge hat. (Blatt XIV und XV.) Hier aber, wo das Dekrement durch den Lufthinzutritt bis auf das Dreifache des Anfangs- wertes etc. eihijht wird, betragt die ganze Tondifferenz noch nicht 0,l Proz. Etwas bedeutender (ca. 0,12 Proz.) und eben- falls ziemlich gleichbleibemd fallt die Differenz aus zwischen der ftir das Vakuum giiltigen Schwingungszahl und derjenigen beim Abklingen in Luft. (Diss. 5. XXIVv.) Die Tonhohen- unterschiede bei vijllig beseitigter Luftreibung gegen diejenigen bei verschlechtertem Vakuum sind sehr gering ; sie betragen, sofern dies aus den infolge der Warmeentmickelung etwas ent- stellten Resultaten geschlossen werden darf, etwa 0,O 1 Proz. 1) Die Amplitude erstreckt sich hier nicht uber a = 2 O , d. i. etwa 1 mm eiuseitiger Ausschlag. Dieser gcniigt fur den genannten Zweck des Relaia; fur Beobachtung mit Spiegel und Skala (bei Nullmethoden) ist er mehr als hinreichcnd. SpLterhin wurden die Amplitudeu sogar nur halb so groB gewghlt. Die VergrBBerung erzielte ich mit Hohlspiegeln von 30-50 em Brennweite. 6. 6. Mit dem vielleicht nicht ganz bezeichnenden Susdruck ,,Relaisfeder" belege ich im vorliegenden Falle schwache Federn, nelche zu Resonanzrelais Verwendung finden kannen. Hierbei ist an ganz geringe Erregerstroine gedacht, wennschon das untersuchte Stahlfederband bedeutend stiirkere Dimensionen aufweist als z. B. das zu dem optischen Telephon von M. Wien benutzte. Bei seiner Auswahl hatte ich die Aufgabe im Sinne, mit Hilfe der Resonanzschwingungen einen Kontakt oder irgend eine mecha- nische, empfindliche Eir richturg zur Signnlgehung zu betatigen, (Dicke 0,l mm, Lange 29 mm, Breite 6 mm.) Einflup der Amplitude auf die Tonhohe etc. 151 und es schien mir interessant, auch fiir solch kleine Federn die gleichcn Einfiiisse der Amplitude auf Tonhohe und Dekre- ment der GroBe nach festzustellen. Solche Resonanzrelais kann man unter Umstiinden durch Hinzunahme eines permanenten Magnetfeldes, auf welches die oszillierenden Stromimpulse schwachend oder verstkkend ein- wirken , empfindlicher machen. Selbstredend spielt auch der Abstand der Peder vom Erregermagnet eine wichtige Rolle, wenngleich die Annahme falsch ware, da8 man das Inter- ferrikum miiglicbst klein machen milsee. Denn die vergroBerte Dampfung durch Luftwiderstand und magnetische Induktion, schlieBlich auch die permanente Ausbiegung der Feder setzen die Empfindlichkeit und Zuverlassigkeit des Relais bedeutend herunter. (Naheres Diss. 6 21.) Die Untersuchungen wurden ebenfalls bei verschiedenem Luftdruck angestellt und gliedern sich in folgende Hauptfalle : I. Erregung lediglich durch oszillierendes Magnetfeld. Ab- stand des freien Endes vom Polschuh 3 mm. Kurz: Relais- feder I. 11. Erregung unter Zuhilfenahme eines permanenten Magnet- feldes. a) Abstand des freien Endes 3mm, Relaisfeder IIa. b) ? 9 7 7 7, 7 7 1 I 7 ,7 I1 b. Beginnen wir mit dem Dekrement der Relaisfeder I (Blatt XXV). Eine besondere Wirkung der eigentlichen Luft- reibung laBt sich noch kaum nachweisen. Es wurden deshalb die Werte aus Aufnahme 55 und 56 zu einer einzigen Linie zusammengezogen. Wiederum begegnen wir der hochst auf- falligen Erscheinung, da8 das Dekrement mit der Amplitude. l) nicht zunimmt, sondern geringer wird. Der Mittelwert 3. = 0,0025 ist gering, er stimmt der GroBenordnung nach gut mit dem an Zungen beobachteten iiberein und scheint dieser fur Stahl- federbander gewisserma0en spezifisch zu sein. b) ? 9 7 7 7, 7 7 1 I 7 ,7 I1 b. Beginnen wir mit dem Dekrement der Relaisfeder I (Blatt XXV). Eine besondere Wirkung der eigentlichen Luft- reibung laBt sich noch kaum nachweisen. Es wurden deshalb die Werte aus Aufnahme 55 und 56 zu einer einzigen Linie zusammengezogen. 2) Es ist zu bemerken, daE der permanente Magnetisinus nicht stLrker aIs gerade notwendig erzeugt wurde. (Vgl. Diss. p. 149, ebendort aueh Aufnahme 97a auf Ph. T. IX.) 1) In Aufnahme 59 ist leider ein Stuck wegen Versagens der Bogen- lampe verdorben, waa ich erst beim Entwickcln bemerkte. 6. Aber der Widerstand bei normalem Luftdruck wachst wegen der kleinen Entfernung des freien Federendes von den Magnetpolen (1 mm) ganz enorm; er steigert das Dekrement auf das Vierfache des Wertes fur luftleeren Raum. Der Vergleichl) des Kurvenblattes XXVIII mit XXVI lafit den Ein0uB der magnctischen Dampfung auf die Tonhiihe erkennen, die mit zunehmender Amplitude nun nicht mehr ansteigt, sondern fallt. Auch der Luftzutritt auBert sich merk- lich, indessen wiederum fur ganz kleine Schwingungen am starksten. Nicht unbedeutend ist ferner die Wirkung der Luftreibung nach Einlassen der Luft bis auf 3 mm Druck. Sie darf wohl auch groger angenommen werden; denn der Schnittpunkta) beider Kurven ist unverstandlich und im Zweifelsfalle hat die Ermittelung fur die Aufnahme bei 3 mm Druck den groBeren Anspruch auf instruktiven Wert. Ganz enorm fallt die Tonvertiefung aus bei Wiederhinzu- tritt der Luftdampfung, beinahe urn 5 Proz., eine Erscheinung, die um so weniger verstandlich sein durfte, wenn wir uber- legen, daS das mit der Amplitude ziemlich ansteigende Dekre- ment (Kurve 64, XXVII) cine weiterhin vie1 merklicher mit der Amplitude wachsende Verstimmung hervorrufen sollte, als es die Kurve 64, XXIX, tatsachlich aufweist. Der Vergleichl) des Kurvenblattes XXVIII mit XXVI lafit den Ein0uB der magnctischen Dampfung auf die Tonhiihe erkennen, die mit zunehmender Amplitude nun nicht mehr ansteigt, sondern fallt. Auch der Luftzutritt auBert sich merk- lich, indessen wiederum fur ganz kleine Schwingungen am starksten. Nicht unbedeutend ist ferner die Wirkung der Luftreibung nach Einlassen der Luft bis auf 3 mm Druck. Sie darf wohl auch groger angenommen werden; denn der Schnittpunkta) beider Kurven ist unverstandlich und im Zweifelsfalle hat die Ermittelung fur die Aufnahme bei 3 mm Druck den groBeren Anspruch auf instruktiven Wert. g p Ganz enorm fallt die Tonvertiefung aus bei Wiederhinzu- tritt der Luftdampfung, beinahe urn 5 Proz., eine Erscheinung, die um so weniger verstandlich sein durfte, wenn wir uber- legen, daS das mit der Amplitude ziemlich ansteigende Dekre- ment (Kurve 64, XXVII) cine weiterhin vie1 merklicher mit der Amplitude wachsende Verstimmung hervorrufen sollte, als es die Kurve 64, XXIX, tatsachlich aufweist. Wir sind nun des ofteren und namentlich hei den letzthin besprochenen Ergebnissen auf mannigfache, weder vorauszu- sagende, noch stets mit Sicherheit zu erklarende Hrscheinungen gestoben, die geeignet sein durften, das Interesse an solch experimentellen Studien zu erhohen und ihre Notwendigkeit zu erweisen, sobald es sich darum handelt, genaue Messungen mit schwingenden Systemen dieser Gattung vorzunehmen. 6. Wiederum begegnen wir der hochst auf- falligen Erscheinung, da8 das Dekrement mit der Amplitude. l) nicht zunimmt, sondern geringer wird. Der Mittelwert 3. = 0,0025 ist gering, er stimmt der GroBenordnung nach gut mit dem an Zungen beobachteten iiberein und scheint dieser fur Stahl- federbander gewisserma0en spezifisch zu sein. 52 R H t 152 R. Hartmam- Kempf. Das Dekrement bei normalem Luftwiderstand (Kurve 57) ist wesentlich groBer, au6er bei allerkleinsten Amplituden, woselbst es sich mit den Werten fur luftleeren Raum zu decken scheint. Die entsprechenden Kurven fir den Tonhohenverlauf sind Nr. 65 mit 56 und 57 auf Blatt XXVI. In Ubcreinstimmung mit dem Dekrement geben sie keinen Anla6 zu Auffalligkeiten, abgesehen von der Merkwtirdigkeit, dab Kurve 57 fiir kleine Amplituden hSher liegt als 56/56. Eine Erklarung konnte sich in dem TTorhandensein einer kleinen Remanenz bei 55/56 finden, doch darf ich nicht verschweigen, dafi das Auswerten der Schwebungen fur ganz kleine Amplituden mit Schwierig- keiten verbunden war und nicht mit der sonst vorliegenden Genauigkeit geschehen konnte. g g DaB eine Remanenzwirkung an sich vorliegt, geht mit Sicherheit aus dem Unterschied zwischen dem Kurvenpaar 56/56 und der Iiurve 54 hervor; bei letzterer Aufnahme wnrden die Resonanzschwingungeri durch Wechselstrom erzeugt ! welche Erregungsart eine Remanenz im Hufeisenmagnet vollig aus- schlieBt. Dagegen macht sich eine merkwiirdige Polarisation geltend, deren Ursache durch die Mutmafiung, da6 die Stahl- feder remanenten Nagnetismus behalten habe, nicht geniigend begriindet wird. (Vgl. iiber diese Erscheinung vorlau6g Diss. p. 151 und Aufnahme 91 u. 92. Ph. T. VI.) Bei der Anordnung I1 lu6ern sich a.lle dampfenden Ein- wirkungen in stiirkerem MaBe. Es ist mir dank der starkeren VergroBerung (50 cm Brennlhge bewirkt hier mehr als dreihig- fache Ubertragung) gelungen , einen merklichen Unterschied im Dekrement bei volligem Evakuieren gegen dasjenige bei 3 mm (IIa und IIb, Kurve 58-59 und 62-43! Blatt XXVII).’) zu finden. Wir beobachten wieder eine ganz merkwurdige Steigung desDekrementes nach den ganz kleinen Amplituden hin, Kurve 60 und 61. Das Dekrement in letzterer Kurve erreicht bereits einen relativ sehr hohen Wert, die geringe Sattigung des Eisens durch permanenten Magnetismus j ) macht sich durch hhfZu/3 der Amplitude auf die lonhohe etc. 153 eine nicht unbedeutende VergroBerung des Dekrementes be- merklich; selbstredend gilt dies fur alle Kurven in gleicheni MaBe. In der Anordnung I1 ist das permanente Feld noch ge- ringer; demgemiiB auch die Dampfung in den Aufnahmen 62 und 63. 1) Die in beiden Blattern wcit auseinander liegende Schwingungszahl riihrt lediglich von verschiedener Hohe der Befestigungsstelle des Hohl- spiegels her. 2) Die Werte sind wiederholt kontrolliert und richtig befuunden worden. 6. Wir werden nun ini spgter erscheinenden zweiten Teil des Refe- rates Qelegenheit haben, die meisten Erscheinungen in ihrer Einwirkune; auf das Resonanzbereich zu verfolgen. 154 R. Iiartmann-Kempfi 7. W ii r m een t w i c k e 1 u n g in ein e I B t a t io n &r 8 e h w i ng e n d en S t a hlzu n g e. Bei konstanter Breite a wachse der Lhngsschnitt einer Zunge keilfirmig, so wie es in nachstehendem Bilde angedeutet ist. Aus dem Dekrement der in Luft schwingenden Zunge findet man, da0 die Energie bei einer Amplitude von A = 10 mm von einer Schwingung bis zur nilchsten um ca. 4 Proz. abnimmt. Dieser Difierenzbetrag hat sich in Reibungswarme umgesetzt. Bei stationarem Schwingungszustand wird dem schwingen- den System die verlorene Energie immer wieder ersetzt und dadurch die Amplitude auf konstanter Hohe gehalten. Die in Warme umgesetzte Energie erfahrt man BUS dem Verluste an lebendiger Kraft. Die mittlere lebendige KreftLmeines Massenpunktes, bez. einer Querschicht von der Hohe d x ist: T T Lm= Tv:= M -N s v a d t = 1 2 T T Lm= Tv:= M -N s v a d t = 1 2 T q = Querschnitt, u = spez. Gewicht, ~t = Schwingungszabl, = 100 pro Sek., q = a(7 + 8 4 , y = 0,02 em, a = 0,75 em, 1 = 5 cm. p = 0,01, Der Einfachheit halber nehmen wir an, da6 sich die Durchbiegung ausschlie8- lich im Punkt (bez. der Linie) D vollziehe, damit man setzen kann: A L L a = -x. 1 Fig. 10. Ferner sei: A = c.cp = a r c y . Der Einfachheit halber nehmen wir an, da6 sich die Durchbiegung ausschlie8- lich im Punkt (bez. der Linie) D vollziehe, damit man setzen kann: A L L a = -x. 1 Ferner sei: Ferner sei: A = c.cp = a r c y . 155 Einjl,p der Amplitude auf die Tonhohe etc. Einjl,p der Amplitude auf die Tonhohe etc. Es bedeute LM die mittlere lebendige Kraft des ganzen Sy s terns. 0 0 2' 0 denn 26 2 r c = z , 2 0 1 Nun ist aber die Differenz der lebendigen Kraft zweier aufeinander folgender Schwingungen Lo - L, = B(di - 11;); 8% - A: = 0,04. Lo - L, = B(di - 11;); 8% - A: = 0,04. In einer Sekunde, d. h. fur n = 100 Schwingungen mu6 dem stationar schwingenden System eine Arbeit zugefiihrt werden : : SB = n B (A: - A:) Erg., = 100.0,75.8.0,096. z2, 10000.0,04 Erg., 230 000 42 000 000 m = ~- - -- 0,0055 g-Kal. SB = n B (A: - A:) Erg., = 100.0,75.8.0,096. 7. W ii r m een t w i c k e 1 u n g in ein e I B t a t io n &r 8 e h w i ng e n d en S t a hlzu n g e. z2, 10000.0,04 Erg., 230 000 42 000 000 m = ~- - -- 0,0055 g-Kal. Diese Wiirmemenge wird an die umgebenden Metallmassen abgeleitet, hauptsachlich aber an die Luft, durch welche die schwingende Zunge eine geradezu ideale Abkiihlung erfhhrt; besonders bevorzugt werden in dieser Beziehung die au6eren Schichten der Biegungsstelle, allwo die Reibungswarme am sttirksten auftritt. Die im Vakuum schwingende Zunge erleidet keine Ab- ktihlung durch die Luft. Datiir ist aber auch die Energie zur Erhaltung des stationaren Schwingungszustandes weitaus ge- 156 R H t K f 156 R. Hartmann-Kempf: ringer, entsprechend dem Dekrement, welches hei B = 1 cm nur 0,6 Proz. betragt. g A: - 8: = la - 0,994' = 0,012. g A: - 8: = la - 0,994' = 0,012. 0 012 Dann ist obiger Wert fur 83 mit --!- - zu multiplizieren. 0,040 0,040 'BVakuum = 0,00165 g-Kal. , 'BVakuum = 0,00165 g-Kal. Da das obere Ende sicli kaum verbiegt, so werde die Annahme zugelassen, daB alle Warmeerzeugung auf das kleine Stuck von 2 cm beschrankt sei, gemessen von B ab. g Das Stuck der Feder betragt: 1=2 n u / ~ ( y + p z) d x = 0,06 cm3. I =o 1st s die spezifische Warme des Stahles gleich 0,12, so wird das genannte Stuck der Zungenfeder in der Sekunde um je Um einigermaBen beurteilen zu konnen, wie warm die Biegungsstelle bleibt, wollen wir annehmen , daS von den ge- semten 0,00165 g-Kal. pro Sekunde 10 Proz. durch Strahlung verloren gelien, gleich 0,00015 g-Kal. Wir fragen nun nach dem Temperaturgefalle an der Biegnngsstelle , welche in An- betracht ihrer groBen Masse selbst nicht merklich erwarmt wird. Der Querschnitt sei dort: q = 0,02.0,75 = 0,015 cm2. q = 0,02.0,75 = 0,015 cm2. Das Warmeleitvermiigen des halbweichen Stahles sei gleieh 0,l. Dann wird das stationare Temperaturgefalle: Auf jeden Fall erhellt aus dcr Rechnung, dd3 die Temperatur- erhijhung bei stationarem Schwingungszustand der Maximal- amplitude von 10 mm in der GroBenordnung von 1 O C. liegt, und daB diese Temperaturerhohung vollauf geniigt , um die Fehler zu erklaren, welche bei den Vakuumversuchen auftreten, sobald die Warmeleitung der Luft beseitigt war. Des weiteren leuchtet ein, da6 dieser Fehler um so kleiner wird, je weniger Zeit es kostet, um durch Herstellen der 157 A'infEUp cler Amplitude auf die lonhiihe ctc. groBten Resonanz die Maximalamplitude zu erzielen, von welcher aus das Abklingen erfolgen soll. 7. W ii r m een t w i c k e 1 u n g in ein e I B t a t io n &r 8 e h w i ng e n d en S t a hlzu n g e. groBten Resonanz die Maximalamplitude zu erzielen, von welcher aus das Abklingen erfolgen soll. Bei dieser ganzen Betrachtung ist noch keine Riicksicht genommen auf die Warme, welche durch die induzierten Strtime (Foucaultstrome) entstehen mag. Es ist dam jedoch zu be- merken, daB diese Warmeentwickelung in erster Linie in der Nahe des freien Endes stattfindet , woselbst der Querschnitt der Zunge und der Kraftlinienschnitt am starksten ist. 8. EinfluB der Deformation einer schwingenden Stahlzunge auf deren Schwingungsdauer und deren Schwingungsform. Wir machen die Annahme, daB das Tragheitsmoment sicb beim Ausbiegen der Zunge verkiirze, und zwar soll diese Ver- kiirzung eine quadratische Funktion der Am- plitude sp sein. uu Fig. 11 p Dann gilt der Ansntz: k ( l - by')$ =- C a y , worin k das Tragheitsmoment und c2 die der Amplitude 'p proportionale Kraft bedeutet. Durch Substitution p = d sppldt gelingt die einmalige Integration : Bei den Experimenten uberschreitet cp selten '1, der Winkeleinheit; eine rohe Mes- sung zeigt, daB alsdann der mittlere Tragheits- halbmesser urn etwa 2 Proz. verkleinert wird, das Tragheih- moment daher urn 4 Proz. uu Fig. 11 6 rp' = 0,04, 6 = N 0,004. 6 rp' = 0,04, 6 = N 0,004. Entwickelt man 111 - b y in die Reihe: 1 + b q2 + (b fp2)2 + (by33 + * - , 1 + b q2 + (b fp2)2 + (by33 + * - , so geniigt die Berucksichtigung der ersten zwei Glieder, da, (b v2)a = 0,0016 das Tragheitsmoment k urn weniger als 158 R H t K f 158 R. Hartmann-Kempf. 2 Promille und die Schwingungsdauer t = $'(li) in verscbwin- dend geringem MaBe beeinflufit. Es ist nun weiter Setzt man hierin b = 0, so erhalt man die bekannte Formel fur die Abhangigkeit des Ausschlages cp von der Zeit t. y = Csin -t = Csin(2nnt), (;z i welche Gleichung aussagt, da8 die Schwingungszahl n konstant bleibt und die Schwingung selbst sinusformig verlauft. 1st aber b > 0, so fuhrt die Gleichung (4) auf elliptische Integrale erster Gattung und man muB suchen, diesen Aus- druck auf die Normalform zu rcduzieren, namlich auf das Integral worin x den Modul der elliptischen Funktionen bezeichnet. Zur Umwandlung empfiehlt sich folgende speziellere Form: worin x den Modul der elliptischen Funktionen bezeichnet. worin x den Modul der elliptischen Funktionen bezeichnet. Zur Umwandlung empfiehlt sich folgende speziellere Form: Zur Umwandlung empfiehlt sich folgende speziellere Form: Hierin ist - vT= 1/y2((.?'y2 + Cd'J@' - 9') man hat sich der Substitutionen zu bedienen : Durch Entwickelung der Wurzelausdrucke in (4) und (8) Gleichstellung der Koeffizienten erhalt man: Durch Entwickelung der Wurzelausdrucke in (4) und (8) Gleichstellung der Koeffizienten erhalt man: Einfiup der Amplitude auf die Tonhohe etc. Einfiup der Amplitude auf die Tonhohe etc. 159 Aus (7) folgt: (22) Die Schwingungszahl wird demnach erhoht, und zwar ist die Erhohung bei kleinen Amplituden sehr gering. In dem Kurvenblatt XXXVI ist die Tonerhohung der Zunge bei der Deformation graphisch dargestellt. Gleichzeitig wurde versucht, die experimentell erhaltene Tonhohenlnderung zu analysieren. Es gelingt dies ziemlich gut, wenn man als Ver- stimmungsgrofie einen mit der Amplitude linear wachsenden Faktor annimmt. Die resultierende Kurve entspricht demnach der Gleichung: g (23) EinfluS der Deformation s n f die Schwingungsform einer Zunge. t = sinam(y1-t). t = sinam(y1-t). (13) t = sinam(y1-t). (13) Da nun Da nun y = p l r - = F , so ist auch y = p c o s a m ( y v m (1 4) y = p c o s a m ( y v m (1 4) y = p c o s a m ( y v m Es sei in der Folge rp = y + Const. Es sei in der Folge rp = y Es sei in der Folge rp = y + Const. Den Wert fur C2 findet man aus dem Wurzelausdruck f~ die Amplitude = 8 a19 In (15) eingesetzt: yb=O = 8 c o s a m [ ;Tt] + Const. J [ (1 6) (16 a) yb=O = 8 c o s a m [ ;Tt] + Const. J Die Schwingungsdauer (171 (171 160 R. Hartmann-Eiempf: q = b + 2 2 5 + ..., (19) (20) (21) T = n (19) (20) (21) worin n die Schwingungszahl des Systems fiir nnendlich kleine Amplituden bedeutet. Die Schwingungszahl des Systems bei der Deformation ist: Die Schwingungszahl des Systems bei der Deformation ist: (22) EinfluS der Deformation s n f die Schwingungsform einer Zunge. Wir gehen von der Gleichung (16) aus: [ b 16) y = a cos a m [ ;K t (1 + v))] + Const. (16) 161 Xinfiup der Amplitude aiif die Tonhohe etc. Da Da 2 K X' COB (m t ) 4- . . . (24) cosam ( -- n 7n t - - 1 / 1 . 2 ' ~ - 2 * e o s ( 8 m t ) + . . . ' so wird h (25) y = cu (1 - -8 (u'j Setzt man so erhalt man 2 K X' COB (m t ) 4- . . . (24) cosam ( -- n 7n t - - 1 / 1 . 2 ' ~ - 2 * e o s ( 8 m t ) + . . . ' i d 2 K X' COB (m t ) 4- . . . (24) cosam ( -- n 7n t - - 1 / 1 . 2 ' ~ - 2 * e o s ( 8 m t ) + . . . ' so wird (24) so wird h (25) y = cu (1 - -8 (u'j Setzt man so erhalt man h (25) y = cu (1 - -8 (u'j Setzt man so erhalt man cos (2 7t N t ) 0 y = Olcos(2 n K t ) [l - 'u'(1 - cos4 n Nt)] - n . (4 (26) Disk us8 i o n d e r S e h win gu ngsgl ei chlun g. Disk us8 i o n d e r S e h win gu ngsgl ei chlun g. Wenn b = 0, verlauft die Schwingung sinusformig. 1st aber b > O , so nimmt das Kor- rektionsglied A alle Werte an zwischen 0 uiid (2 b / 8 ) 2f2, und zwar in der Weise, wie es durch die beigegebene Fig. 12 veranschaulicht werden mag. Da 1 - A als Faktor einer Kosinusfumktion auf- tritt, so ist die Verkleinerung der Am- plitude relativ am starksteu, wenn die die Amplituden y an und fur sich sehr klein sind. Deshalb wird sich die Am- plituclenverkleinerung bei den Abmes- sungen selhst etwa in der Gegend von cp = 45" bez. 135O etc. am ehesten be- merkbar machen. hnnalen der Phyeik. 1V. Folge. 13. EinfluS der Deformation s n f die Schwingungsform einer Zunge. Bei der Methode der teilweisen Aus- wrtung einer optischen Schwebung wurde stets eine sinusformige Schwingung voraus- &i Zunge die Ruhelage passiert, wenn also 0 Fig. 12. hnnalen der Phyeik. 1V. Folge. 13. 11 Wenn b = 0, verlauft die Schwingung sinusformig. Wenn b = 0, verlauft die Schwingung si 1st aber b > O , so nimmt das Kor- rektionsglied A alle Werte an zwischen 0 uiid (2 b / 8 ) 2f2, und zwar in der Weise, wie es durch die beigegebene Fig. 12 veranschaulicht werden mag. Da 1 - A als Faktor einer Kosinusfumktion auf- tritt, so ist die Verkleinerung der Am- plitude relativ am starksteu, wenn die die Amplituden y an und fur sich sehr klein sind. Deshalb wird sich die Am- plituclenverkleinerung bei den Abmes- sungen selhst etwa in der Gegend von cp = 45" bez. 135O etc. am ehesten be- merkbar machen. Zunge die Ruhelage passiert, wenn also Bei der Methode der teilweisen Aus- wrtung einer optischen Schwebung wurde stets eine sinusformige Schwingung voraus- hnnalen der Phyeik. 1V. Folge. 13. g 11 g 11 162 B. Hartmann-Kempf. BinfEup der Amplitude etc. gesetzt. Da diese niemals uber % = 1. cm gingen, so betrug A bei b = 0,004 und 3 cos 45O erst 0,05 Proz. der ganzen Ordinatenlange. g Diese, zu 5 cm angenommen, wurde demnach urn 0,025 mm zu groB gemessen, also um eincn Betrag, der langst unterhalb der GroBenordnung der ubrigen Fehler liegt. Eine graphische Darstellung der tatsachlichen Schwingungs- form verlohnt knum dcr Miihe, weil die Abweichungen zu ge- ring ausfallen. Die diinnen IIohlspiegel (Galvlruometcrspiegel von Hartmann 6 Braun) stellt die optische Prtizisionswerkstiitte von 1’. Schiill, Frank- furt a. M. her. cber Oberfliichenversilberung vgl. Ann. d. Phys. 8. p. 537. 1902. Zu den photographischen Aufnahmcn benutzte ich 0,25 mm dicke Blattfilmfolien der A.-G. fiir Anilinfabrikation, Berlin SO. 36. Hrn. Prof. M a x W i e n verdanke ich neuerdings den Vorschlag, bei kiinftigen Versuchen uber das Dekrement von Stimmgabeln den mit intermittierendeni Qleichstrom gespeisten Erregermagnet zu Beginn dez Abklingens vijllig zu entfernen, um die dlimpfenden Wirkungen des remanenten Magnetismusses auszuschlieben, der somohl im Eiscnkern des antreibenden Bltittermagnetes 01s auch in den Stimmgabelzinken seinen Sib haben kann. Die entspreclienden Versucbe ail der Stimmgabel von M. Kohl (Diss. IV VI, I) durften dank der Anordnung nach Fig. 3 (p. (Eingegangen 18. Oktober 1903.) EinfluS der Deformation s n f die Schwingungsform einer Zunge. 131) von dcr Remanenz nur gering beeinflufit sein; denn das fiir die Strom- magnetisicrung gut geschlossene Kraftlinienfeld diirfte doch in Bezug auf den remanenten Stabmagnetismus wegen der Lange der Stahlzinken eine starke Streuung aufmeisen. Jedcnfalls ist die Erregung durch Wechscl- strom, wie sic fiir Zungenfedern und dcrgleichcn susschlieblich znr An- wcndung kam, auch fur Stimmgabelversuche zu bevorzugen. - Ferner habe ich zu berichtigen, daE die auf p. 12 der Diss. ge- nannte Methode zur Photographie schwingende Saiten nicht von A. Kundt, sondcrn von 0. Raps ersonnen worden ist (Sitzungsber. d. k. Akad. d. Wissensch. zu Berlin 32. 1901). Die hier besprochenen Versuche wurden im Sommer 1902 zu Wiirzburg im physikalischen Institut der Universitat aus- gefiihrt, dessem Vorstand, Hrn. Prof. Willy Wien, ich auch an dieser Stelle meinen aufrichtigsten Dank fur seine wert- vollen Anregungen aussprechen mochte. Paris, Oktober 1903. Paris, Oktober 1903. (Eingegangen 18. Oktober 1903.) p> S --h -I 0 3 m3 p> S --h -I 0 3 m3 3J I 3 5 B 3 3 3 0 .+ Registrierung vonTonhohe u. Decrement bei freiem Abklingenlassen aus erzwungenen Schwingungen: 31. eingespanntes Stahlfederband, 5. u.11. Stimmgabeln von 100 Schwingungen, 8 b. von 50 Schwingungen per Sekunde. pS - - ** Registrierung vonTonhohe u. Decrement bei freiem Abklingenlassen aus erzwungenen Registrierung vonTonhohe u. Decrement bei freiem Abklingenlassen aus erzwungenen Schwingungen: 31. eingespanntes Stahlfederband, 5. u.11. Stimmgabeln von 100 Schwingungen, 8 b. von 50 Schwingungen per Sekunde. 3J I 3 5 B 3 3 3 0 .+
https://openalex.org/W273611013	https://molmed.biomedcentral.com/track/pdf/10.1007/BF03402025	English	null	PI3K Blockade by Ad-PTEN Inhibits Invasion and Induces Apoptosis in Radial Growth Phase and Metastatic Melanoma Cells	Molecular medicine	2,002	cc-by	8,894	Authors contributed equally. Address correspondence and reprints to: S. Chada, Introgen Therapeutics, Inc., 2250 Holcombe Blvd., Houston, Texas 77030, USA. Phone: 713-610-4007; fax: 713-797-1349; e-mail: s.chada@introgen.com Molecular Medicine 8(8): 451–461, 2002 © 2002 North Shore-LIJ Research Institute Molecular Medicine 8(8): 451–461, 2002 © 2002 North Shore-LIJ Research Institute Abstract Background: Melanoma is an aggressive tumor with a propensity to rapidly metastasize. The PTEN gene encodes a phosphatase with an unusual dual speciﬁcity for pro- teins and lipids. Mutations of PTEN have been found in various human cancers, including glioblastoma, prostate, breast, lung, and melanoma. Here we investigate in vitro the effects of blocking PI3K signaling using adenoviral- delivered PTEN (Ad-PTEN) in cell lines derived from both early- and late-stage melanoma. melanoma cells containing wild-type PTEN alleles led to tumor-speciﬁc apoptosis and growth inhibition, with co- ordinate inhibition of AKT phosphorylation. Ad-PTEN suppressed cell migration by metastatic melanoma cells with concomitant increase in the level of cell surface E-cadherin. Immunohistochemical and confocal analyses localized PTEN to the cytoplasm and demonstrated en- richment at the cell membrane. Ad-PTEN inhibited angio- genesis as demonstrated by the tube formation assay using human vascular endothelial cells. melanoma cells containing wild-type PTEN alleles led to tumor-speciﬁc apoptosis and growth inhibition, with co- ordinate inhibition of AKT phosphorylation. Ad-PTEN suppressed cell migration by metastatic melanoma cells with concomitant increase in the level of cell surface E-cadherin. Immunohistochemical and confocal analyses localized PTEN to the cytoplasm and demonstrated en- richment at the cell membrane. Ad-PTEN inhibited angio- genesis as demonstrated by the tube formation assay using human vascular endothelial cells. y g Materials and Methods: Ad-PTEN transduced melanoma cell lines or normal cells were assayed for cell death, apoptosis, gene expression, invasion and migration, and regulation of angiogenesis. Conclusions: These studies indicate that Ad-PTEN can in- hibit tumor cells via multiple mechanisms and has pro- apoptotic, anti-metastatic, and anti-angiogenic properties. Thus, PI3K blockade via Ad-PTEN may be a promising ap- proach for the treatment of early- and late-stage melanoma, even in tumors that do not harbor PTEN mutations. Results: The PTEN locus from RGP and metastatic mela- noma cell lines was sequenced; no coding region muta- tions were found. Adenoviral transfer of PTEN into PI3K Blockade by Ad-PTEN Inhibits Invasion and Induces Apoptosis in Radial Growth Phase and Metastatic Melanoma Cells Alexis L. Stewart,1 Abner M. Mhashilkar,1* Xiaohong Helena Yang,1* Suhendan Ekmekcioglu,2* Yuji Saito,3 Kerry Sieger,1 Robert Schrock,1 Eric Onishi,1 Xin Swanson,1 John B. Mumm,2 Lou Zumstein,1 Graham J. Watson,4 David Snary,4 Jack A. Roth,3 Elizabeth A. Grimm,2 Rajagopal Ramesh,3 and Sunil Chada1,2 1Department of Research, Introgen Therapeutics, Inc., Houston, Texas, USA 1Department of Research, Introgen Therapeutics, Inc., Houston, Texas, USA 1Department of Research, Introgen Therapeutics, Inc., Houston, Texas, USA 2Department of Bioimmunotherapy, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA 2Department of Bioimmunotherapy, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA 2Department of Bioimmunotherapy, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA 3Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA 3Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center Houston, Texas, USA 3Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA 4Imperial Cancer Research Fund, Applied Development Laboratory, London, UK 4Imperial Cancer Research Fund, Applied Development Laboratory, London, UK Contributed by A. Pardee. Accepted June 25, 2002 Contributed by A. Pardee. Accepted June 25, 2002 Authors contributed equally. Introduction considered to possess competence for metastatic spread. Unlike most other human cancers, melanoma affects a much younger population and is charac- terized by an extremely high potential to develop metastases (2,3). Currently, there is no conven- tional therapy for metastatic melanoma that pro- vides a response rate greater than 20%. New ther- apeutic regimens for malignant melanoma are therefore urgently needed. Melanoma is an aggressive human cancer whose incidence is increasing more rapidly than any other cancer in the United States (1,2). Based on clinical and histopathologic studies, it has been proposed that melanoma develops and progresses in a sequential fashion. In this model, the ﬁrst step is the common acquired and congenital nevi with structurally normal melanocytes, followed by dys- plastic nevus with structural and architectural atypia. Genetic changes are often associated with progression to radial growth phase (RGP) primary melanoma as well as to the next stage of vertical growth phase or invasive primary melanoma, Genetic lesions of chromosome 10 have been observed in 30–50% of early and advanced-stage melanomas (4–7). PTEN was ﬁrst identiﬁed as a candidate tumor suppressor gene at chromosome 10q23, a region frequently deleted or mutated in human glioblastoma, prostate, kidney, and breast cancer (8,9). PTEN was also independently discov- ered as a novel protein tyrosine phosphatase regu- lated by tumor growth factor beta (10). Since then, a signiﬁcant number of PTEN mutations have been reported in other human malignancies including Molecular Medicine, Volume 8, Number 8, August 2002 452 endometrial, lung, bladder, testis, head and neck cancers, melanoma, and lymphoma (11–14). In ma- lignant melanoma, mutations of PTEN have been found in approximately 40% of tumors (5,15,16). Germ-line mutations of PTEN have also been found in patients with juvenile polyposis coli, Cowden disease, and the rare Bannaya–Zonana syndrome (18–21), underscoring the critical role of PTEN in the prevention of tumorigenesis. Further- more, the phenotype of PTEN-knockout mice con- ﬁrmed the role of PTEN as a tumor suppressor (22,23). Materials and Methods Cell Lines and Cell Culture Materials and Methods Cell Lines and Cell Culture Melanoma cell lines used in this study have been previously described (34). Cells were grown in DMEM medium (Gibco, Rockville, MD, USA) with the addition of 10% fetal bovine serum (FBS) and routinely harvested with 0.125% Trypsin 1.3 mM EDTA (Gibco). Normal human epidermal melanocytes (NHEM) and human vascu- lar endothelial cells (HUVEC) were obtained from Clonetics (San Diego, CA, USA) and were used in the supplier-recommended media. Experiments were performed during the logarithmic phase of cell growth. ( , ) The product of the PTEN gene is a 55-kDa protein with signiﬁcant homology to protein phos- phatases and tensin (8–10). Most of the tumor- associated PTEN mutations are clustered at the phosphatase domain, suggesting that the phos- phatase activity of PTEN plays a critical role in controlling tumorigenesis (21,25–26). PTEN is able to dephosphorylate focal adhesion kinase (FAK), a key molecule governing cell–cell adhe- sion, and Shc, also associated with regulation of cell spreading and migration. The lipid phosphatase activity of PTEN acts on the lipid phosphatidyli- nositol phosphates, the primary products of the phosphatidylinositol 3-kinase (PI3K) (13,27). The latter activity of PTEN is critical for its tumor sup- pressor function, because a mutation in Cowden disease speciﬁcally abolishes the lipid phos- phatase activity of PTEN (28). Furthermore, the phosphorylation of the AKT/PKB oncogene, a protein serine/threonine kinase and a down- stream target of PI3K, is also inhibited by PTEN (29–33). Adenovirus Production The replication-deﬁcient human type 5 adenovirus carrying the PTEN gene was constructed by sub- cloning the full-length PTEN cDNA from a plasmid construct, pCDNA3-PTEN (obtained from Dr. David Snary, ICRT) into a shuttle plasmid containing the CMV promoter and SV40 poly (A) elements. The resulting PTEN-containing plasmid, pIN233, was cotransfected with pJM17 into 293 cells to obtain Ad-PTEN virus. Ad-PTEN vector was plaque puri- ﬁed, ampliﬁed, and viral DNA puriﬁed using the QIAmp DNA puriﬁcation kit (Qiagen, Valencia, CA, USA). The expression cassette was PCR ampli- ﬁed and the sequence was conﬁrmed. The vector doses are reported in this study in viral parti- cles per milliliter (vp/ml). The stock titers of the vectors used was 1.6 1012 vp/ml for Ad-PTEN and 5.5 1012 vp/ml for Ad-Luciferase (Ad-luc). These vectors were also tested by plaque assay and had a vp/pfu ratio of approximately 50 and 30, respectively. ( ) Despite recent advances in our understanding of PTEN mutations in disease progression, the ther- apeutic value of PI3K inhibition via PTEN aug- mentation as an anti-melanoma strategy has not been investigated. We report here that the adenovi- ral transfer of PTEN into melanoma cells that contain wild-type PTEN alleles results in PI3K inhibition, growth inhibition, and apoptosis. This is evident in cells derived from both early-stage as well as metastatic melanoma. Overexpression of PTEN in these cells suppressed the activation of AKT/PKB and increased expression of E-cadherin on the cell surface, and inhibited cell invasion and migration in metastatic melanoma cells. Immuno- histochemical analysis of adenoviral-delivered PTEN (Ad-PTEN) transduced cells localized PTEN to the cell membrane and the cytoplasm. Confocal imag- ing indicated that supraphysiologic expression levels of PTEN resulted in enrichment in adhesion plaques. Furthermore, Ad-PTEN potently inhibited endothelial differentiation, an in vitro correlate of angiogenesis. Thus, PI3K blockade via Ad-PTEN can inhibit growth and spread of tumor cells via multiple mechanisms, and may provide a useful tool in the armamentarium to ﬁght this deadly disease. Genomic Sequencing Exon-speciﬁc primers of PTEN were prepared and the PTEN coding region was sequenced from genomic DNA prepared from melanoma cell lines. Confocal Microscopy Cells were grown and transduced on coverslips. Af- ter transduction, viruses were removed, and the cells were ﬁxed with 4% paraformaldehyde in PBS for 10 min at room temperature (RT). Cells were subse- quently permeabilized with 0.1% ice-cold Triton X-100. Anti-PTEN antibody was diluted in 0.2% ﬁsh skin gelatin and incubated with the cells for 20 min at RT. After washing, diluted secondary an- tibody was added for 1 hr and cells washed. The cells were ﬁxed with Mowiol:DABCO (Calbiochem, San Diego, CA, USA) and visualized with a Zeiss Axiovert 100M equipped with a LSM 510 scanning system. Annexin V Apoptosis Assay and Trypan Blue Exclusion Assay Transduced tumor cells were analyzed for apoptosis using the ApoAlert Annexin V-FITC kit (Clontech, Palo Alto, CA, USA) according to manufacturer’s in- structions. The FITC staining was measured by FACS analysis. Following infection, cells were har- vested and stained with 1% Trypan blue (Sigma) to visualize dead cells under light microscopy. The number of blue cells (dead cells) was counted to obtain the percentage of cell killing. Antibodies and Western Blotting Analysis The following antibodies were used in this study: anti-PTEN was obtained from Oncogene Science (Cambridge, MA, USA). A mouse monoclonal against -actin was obtained from Sigma (St. Louis, MO, USA). Monoclonal antibodies against AKT and Ser472 phosphorylated AKT were obtained from Cell Signaling (Beverly, MA, USA). Anti–Apaf-1 and anti–caspase-3 were purchased from BD Pharmingen (Los Angeles, CA, USA). To perform Western Blotting analysis, cells were trypsinized and harvested by centrifugation. After washing with ice-cold PBS, cells were lysed with EBC buffer (120 mM NaCl, 10 mM Tris at pH 8.0, 0.1 mM EDTA, 1 mM DTT) containing 0.5% NP-40 (Sigma), and protease inhibitors (Roche, Indianapolis, IN, USA). Cell lysates were normalized before loading onto 420% SDS-PAGE gradient gels (Invitrogen, Carlsbad, CA, USA). Proteins were subsequently transferred to nitrocellulose membrane (Invitrogen) and probed with primary and secondary antibodies. The proteins were visualized by the Supersignal A. L. Stewart et al.: PI3K Blockade in RGP and Malignant Melanoma 453 Surface Labeling Three days after adenoviral infection, cells were trypsinized and harvested by centrifugation. Cell pellets were washed with ice-cold PBS and were re- suspended in PBS containing 1:500 E-cadherin anti- body (BD Transduction Laboratories, Los Angeles, CA, USA) and incubated on ice. After extensive washing with PBS, cells were again resuspended in PBS containing 1:1000 FITC anti-mouse (Santa Cruz Biotechnology, Santa Cruz, CA). After washing again with PBS, cell pellets were resuspended in PBS containing 2% formaldehyde for FACS analysis using a FACScan (EPICS XL-MCL; Beckman Coul- ter, Fullerton, CA, USA). West Dura Extended Duration Substrate (Pierce, Rockford, IL, USA). Immunohistochemical Staining for PTEN West Dura Extended Duration Substrate (Pierce, Rockford, IL, USA). Immunostaining of human melanoma cell lines was performed using the mouse monoclonal antibody against human PTEN, as was used in immunoblot- ting, using the avidin–biotinylated–peroxidase com- plex method. In brief, the endogenous peroxidase was blocked by immersing slides in 0.3–3% hydro- gen peroxidase (Sigma) in methanol for 20–30 min, and then washing in PBS. The avidin–biotin– peroxidase complex (ABC) kit (Vectastain, Vector Laboratories, Burlingame, CA, USA) was then used for staining. Nonspeciﬁc binding was blocked by in- cubating with normal horse serum for 30 min. Slides were blotted to remove excess serum and incubated for 1 hr at room temperature with primary antibody. Monoclonal anti-PTEN antibody was diluted at 1:100 in PBS containing 0.05% Triton X-100 and 0.1–1% BSA. The slides were washed in PBS and then incubated for 30 min with the ABC reagent. Af- ter washing in PBS, the immunostaining was devel- oped with the use of 3-amino-9-ethylcarbazole as a chromogen for 10–15 min. Slides were counter- stained with hematoxylin (Sigma) and washed with tap water. All slides were mounted using Aqua- Mount (Lerner Laboratories, Pittsburgh, PA, USA). An isotype-matched negative control monoclonal antibody was used to test for background staining. To conﬁrm the antigenicity of samples, we used vimentin antibody (BioGenex, San Ramon, CA, USA) at 1:500 dilution as a positive control. Transduction and Cell Proliferation Studies Transduction and Cell Proliferation Studies Transduction and Cell Proliferation Studies Tumor or normal cell lines used in this study were infected with Ad-PTEN or Ad-Luc at increasing multiplicity of infection (MOI). Cells were plated at 1–2 105 cells/well in a 6-well plate for protein ex- pression or apoptosis assays. Cells were exposed to adenoviral vectors 24 hr post-plating and the viruses were subsequently removed after 1 day of infection. Cultures were assessed for protein expression on day 1 or 2 postinfection and day 3 or 4 for apoptosis and Trypan blue dye exclusion assays. Cell Invasion Assay For the invasion assay, cells were seeded at 5 105 cells/well in 6-well tissue culture plates, and in- fected with Ad-Luc or Ad-PTEN at MOI of 5000 vp/cell. Following transduction, cells were replen- ished with complete medium. Twenty-four hours after infection, cells were trypsinized, washed in PBS, and resuspended in RPMI 1640 medium sup- plemented with FBS. Invasion assay was carried out in a 24-well transwell unit (Millipore, Cambridge, MA, USA). Brieﬂy, polycarbonate ﬁlters with 8-m pores were used. The lower chambers of the tran- swells were ﬁlled with serum-free medium and the upper chambers were seeded with 1 104 cells from each treatment in triplicate wells. After a 24- and 48-hr incubation, the number of cells that had passed through the ﬁlter into the lower wells was counted. Endothelial Cell Tube Formation Assay Tube formation assay was performed according to a protocol from BioSource (BD Systems). Brieﬂy, 250 l of Matrigel solution (10 mg/ml) was added to each well of 24-well plate. Incubate the plate at 37C for 5–15 min to allow gel formation. Add 250 l of medium (MEM containing 0.1% BSA) or test sample in each well along side of well. Add 50,000 endothelial cells (either Ad-PTEN transduced or Molecular Medicine, Volume 8, Number 8, August 2002 454 454 Molecular Medicine, Volume 8, Number 8, Augu Table 1. Melanoma cell lines used in the study Cell Lines Melanoma Stage PTEN Alleles WM35 RGP Wild-type A375 Metastatic Wild-type A375-S2 Metastatic Wild-type MeWo Metastatic Wild-type WM1342 Metastatic Wild-type NHEM Normal melanocytes Wild-type *Not sequenced. metastatic melanoma. All PTEN exons in these cell lines were individually ampliﬁed by PCR and se- quenced. All ﬁve melanoma lines contained wild- type PTEN sequence; no mutations were detected in the coding region (Table 1). Additional alterations in the noncoding regions of the PTEN locus cannot be ruled out. Total cell lysates from all of these cell lines were fractionated by SDS-PAGE and evaluated for endogenous PTEN protein expression. Although none of these cell lines had PTEN coding region mu- tations, little or no endogenous PTEN protein could be detected by IHC or Western blotting (Figs. 1 and 4), suggesting that additional epigenetic mechanisms might compromise the expression of PTEN in these cancer cells, consistent with the tumor suppressor role of PTEN. Mock-transduced) in 50 l volume (1 106 cells/ml) to each well. Incubate at 37C and observe under microscope at regular intervals (4–24 hr). Ad-PTEN Expresses High Levels of Transgene Protein in Melanoma Cells The full-length PTEN cDNA was subcloned into the replication-impaired adenovirus vector (Ad-PTEN) to express PTEN protein upon infection. Melanoma cells were infected with 5000 MOI of Ad-PTEN or Ad-Luc for 24 hr followed by immunohistochemical analysis using a speciﬁc antibody against PTEN. As shown in Figure 1, intense PTEN expression was primarily lo- calized to the cytoplasm and the membrane in WM35, Examination of the PTEN Alleles in Melanoma Cell Lines Five different melanoma lines were analyzed, based on their invasion characteristics: WM35 derived from early stage RGP melanoma; A375, A375-S2, WM1342, and MeWo were derived from malignant Fig. 1. High-level expression of PTEN after transduction of melanoma cells with Ad-PTEN. WM35 (RGP), A375-S2, and MeWo (malignant melanoma) cells were transduced with Ad-Luc or Ad-PTEN for 24 hr and ﬁxed for immunohistochemistry with anti-PTEN monoclonal. Fig. 1. High-level expression of PTEN after transduction of melanoma cells with Ad-PTEN. WM35 (RGP), A375-S2, and MeWo (malignant melanoma) cells were transduced with Ad-Luc or Ad-PTEN for 24 hr and ﬁxed for immunohistochemistry with anti-PTEN monoclonal. A. L. Stewart et al.: PI3K Blockade in RGP and Malignant Melanoma 455 Fig. 2. Ad-PTEN, but not Ad-Luc, causes cell death in melanoma cells. Increasing doses of viruses (0, 1000, 2500, 5000, 7500, and 10,000 vp/cell) were used to treat cells and cells were harvested 3 days after infection, treated with Trypan blue and counted. The percentage of dead cells is displayed on the y axis. (A) WM35 cells. (B) A375-S2 cells. (C) MeWo cells. (D) NHEM cells. All graphs are the average of three experiments, except that of NHEM, which is the average of two experi- ments. The error bars represent the standard error of the mean. Fig. 2. Ad-PTEN, but not Ad-Luc, causes cell death in melanoma cells. Increasing doses of viruses (0, 1000, 2500, 5000, 7500, and 10,000 vp/cell) were used to treat cells and cells were harvested 3 days after infection, treated with Trypan blue and counted. The percentage of dead cells is displayed on the y axis. (A) WM35 cells. (B) A375-S2 cells. (C) MeWo cells. (D) NHEM cells. All graphs are the average of three experiments, except that of NHEM, which is the average of two experi- ments. The error bars represent the standard error of the mean. A375-S2, and MeWo cells. Negligible staining was seen in the nucleus. Furthermore, no staining was observed in the untreated or Ad-Luc–infected cells, demonstrating the speciﬁcity of antibody binding. The expression or subcellular localization of PTEN did not appear to change across the cell cycle as asynchronous cells were used in these staining experiments. 2 days after infection and resolved by SDS-PAGE. As shown in Figure 4A high levels of ectopic ex- pression of PTEN were seen in all Ad-PTEN trans- duced cells but not in Ad-Luc transduced cells. Examination of the PTEN Alleles in Melanoma Cell Lines The overexpression of PTEN triggers the dephos- phorylation of AKT/PKB in all melanoma cell lines, consistent with the role of PTEN in interfering with the PI3K-dependent cell survival pathway. Furthermore, the kinase activity of AKT/PKB was also inhibited upon Ad-PTEN infection, but not Ad-Luc infection (Fig. 4B). MeWo cells were treated with Ad-PTEN and the kinetics of phospho- AKT (p-AKT) evaluated. p-AKT levels strongly decreased within 24 hr after Ad-PTEN treatment and remained decreased at 48 hr (Fig. 4C). The decrement of p-AKT induced by Ad-PTEN treat- ment was comparable to that observed with the PI3K inhibitor, LY 294002 (20 M), demonstrating that Ad-PTEN is a potent inhibitor of PI3K and AKT/PKB kinase. PTEN Blocks PI3K Signaling and Causes Apoptosis in Melanoma Cell Lines Fig. 2. Ad-PTEN, but not Ad-Luc, causes cell death in melanoma cells. Increasing doses of viruses (0, 1000, 2500, 5000, 7500, and 10,000 vp/cell) were used to treat cells and cells were harvested 3 days after infection, treated with Trypan blue and counted. The percentage of dead cells is displayed on the y axis. (A) WM35 cells. (B) A375-S2 cells. (C) MeWo cells. (D) NHEM cells. All graphs are the average of three experiments, except that of NHEM, which is the average of two experi- ments. The error bars represent the standard error of the mean. PTEN Blocks PI3K Signaling and Causes Apoptosis in Melanoma Cell Lines RGP and metastatic melanoma cell lines (WM35, A375-S2, and MeWo) and NHEM (Normal Human Epithelial Melanocytes) were infected with in- creasing MOI of Ad-PTEN or Ad-Luc as control. The percentage of dead cells was measured by Try- pan blue exclusion assay after 3 days of infection. As shown in Figure 2A–C, dose-dependent cell death was observed in both early- and late-stage melanoma lines after transduction with Ad-PTEN, but not with Ad-Luc. Furthermore, NHEM cells were resistant to cell death by Ad-PTEN infection, indicating that the effect of Ad-PTEN is tumor cell- speciﬁc (Fig. 2D). To conﬁrm the cell death was caused by apoptosis, the Annexin V staining assay was used to identify apoptotic cells after 3 days of infection with either Ad-PTEN or Ad-Luc (Fig. 3A). All Ad-PTEN–sensitive cell lines displayed ele- vated levels of apoptosis as measured by the per- centage of Annexin V–positive cells. This indicates that Ad-PTEN triggers the onset of apoptosis in melanoma cells even when they carry wild-type PTEN alleles. Ad-PTEN transduction did not result in signiﬁ- cant change in the steady state levels of AKT/PKB, or p27, an inhibitor of the cyclin E-CDK2 kinase (Fig. 4A). The level of Apaf-1, a key player in the ex- ecution of mitochondria-mediated apoptosis, also remained constant in these cells. Caspase activation was also examined in these cells. Activation of cas- pase-3 was observed in Ad-PTEN transduced MeWo and WM35 cells and, to a lesser extent, in A375-S2 cells (data not shown). Caspase-3 activation was speciﬁc for Ad-PTEN treatment; no activation was observed in Ad-Luc treated cells. No activation of caspase-8 or caspase-9 was observed by Western blotting (data not shown). These data suggest that PI3K inhibition by Ad-PTEN directly or indirectly participates in the regulation of the onset of apopto- sis in melanoma cells. To gain insight into how Ad-PTEN triggers apoptosis in these cells, three melanoma lines, WM35, A375-S2, and MeWo were infected with Ad-Luc or Ad-PTEN. Total cell lysates were prepared Molecular Medicine, Volume 8, Number 8, August 2002 456 Fig. 3. Melanoma cells undergo apoptosis following Ad-PTEN, but not Ad-Luc, treatment. (A) WM35, A375-S2, and MeWo cells were treated with 5000 vp/cell viruses, harvested 4 days after infection, the Annexin V assay performed, and the cells analyzed by ﬂow cytometry. The peak signal of apoptotic cells are shown with arrows. The percentage of apoptotic cells is indicated. PTEN Blocks PI3K Signaling and Causes Apoptosis in Melanoma Cell Lines (B) Ad-PTEN regulates cell-cycle progression in melanoma cells. WM35 and MeWo cells were treated with 2500 vp/cell of Ad-PTEN or Ad-Luc and 3 days postinfection; cells were harvested and stained with PI for cell-cycle analysis using a FACScan. Ad-PTEN treatment causes a G2/M block in tumor cells as indicated by arrows. B B B Fig. 3. Melanoma cells undergo apoptosis following Ad-PTEN, but not Ad-Luc, treatment. (A) WM35, A375-S2, and MeWo cells were treated with 5000 vp/cell viruses, harvested 4 days after infection, the Annexin V assay performed, and the cells analyzed by ﬂow cytometry. The peak signal of apoptotic cells are shown with arrows. The percentage of apoptotic cells is indicated. (B) Ad-PTEN regulates cell-cycle progression in melanoma cells. WM35 and MeWo cells were treated with 2500 vp/cell of Ad-PTEN or Ad-Luc and 3 days postinfection; cells were harvested and stained with PI for cell-cycle analysis using a FACScan. Ad-PTEN treatment causes a G2/M block in tumor cells as indicated by arrows. Ad-luc treatment had only minor effects on the cell cycle compared to mock treatment. Ad-luc treatment had only minor effects on the cell cycle compared to mock treatment. PTEN Causes G2/M Cell-Cycle Block WM35 or MeWo cells were treated with Ad-luc or Ad-PTEN and 48 hr later, the cells were ﬁxed and cell- cycle analysis was performed. In both RGP and metastatic melanoma cells, Ad-PTEN caused a sig- niﬁcant increase in the G2/M population of cells, with an attendant decrease in G1 phase cells (Fig. 3B). PTEN Suppresses Tumor Cell Invasion Cell invasion and migration are two critical parame- ters for tumor metastasis. Melanoma is characterized by its rapid propensity to metastasize. To investigate Fig. 4. Molecular targets of PTEN. (A) WM35 (lanes 1 and 2), A375-S2 (lanes 3 and 4), and MeWo (lanes 5 and 6) cells were transduced with either Ad-Luc (odd lanes) or Ad-PTEN (even lanes). Twenty- four hours postinfection, cells were har- vested, lysed, and resolved by SDS-PAGE. Proteins were transferred to nitrocellulose and probed with antibodies against PTEN, AKT/PKB, Phospho-AKT, p27, Apaf-1, and actin. (B) AKT kinase activity is inhibited by Ad-PTEN. Mock treated, Ad-Luc–, or Ad-PTEN–treated MeWo cells were extracted and their AKT kinase activity was mea- sured by 32P-labeling using GS3K as sub- strate. (C) The level of phospho-speciﬁc AKT/PKB decreased following Ad-PTEN transduction. MeWo cells were mock in- fected or infected with Ad-PTEN or Ad- Luc and harvested after 24 or 48 hr follow- ing infection. Total cell lysates were prepared and probed for p-AKT. The treat- ment of cells with LY 294002 was used as a positive control for AKT/PKB dephos- phorylation. Fig. 4. Molecular targets of PTEN. (A) WM35 (lanes 1 and 2), A375-S2 (lanes 3 and 4), and MeWo (lanes 5 and 6) cells were transduced with either Ad-Luc (odd lanes) or Ad-PTEN (even lanes). Twenty- four hours postinfection, cells were har- vested, lysed, and resolved by SDS-PAGE. Proteins were transferred to nitrocellulose and probed with antibodies against PTEN, AKT/PKB, Phospho-AKT, p27, Apaf-1, and actin. (B) AKT kinase activity is inhibited by Ad-PTEN. Mock treated, Ad-Luc–, or Ad-PTEN–treated MeWo cells were extracted and their AKT kinase activity was mea- sured by 32P-labeling using GS3K as sub- strate. (C) The level of phospho-speciﬁc AKT/PKB decreased following Ad-PTEN transduction. MeWo cells were mock in- fected or infected with Ad-PTEN or Ad- Luc and harvested after 24 or 48 hr follow- ing infection. Total cell lysates were prepared and probed for p-AKT. The treat- ment of cells with LY 294002 was used as a positive control for AKT/PKB dephos- phorylation. A. L. Stewart et al.: PI3K Blockade in RGP and Malignant Melanoma 457 Fig. 5. (A) Cell invasion was inhibited by Ad-PTEN in MeWo cells. Mock, Ad-Luc, or Ad-PTEN treated MeWo cells were used. The number of invading cells is indicated on the y axis. Error bars indicate the standard deviation. (B) Cell-surface E-cadherin levels are increased by Ad-PTEN transduction in MeWo cells. PTEN Suppresses Tumor Cell Invasion Cells were mock, Ad-Luc, or Ad-PTEN treated (2500 or 5000 vp/cell), harvested, and subjected to E-cadherin surface labeling and analyzed by FACS. Error bars indicate the standard deviation. Fig. 5. (A) Cell invasion was inhibited by Ad-PTEN in MeWo cells. Mock, Ad-Luc, or Ad-PTEN treated MeWo cells were used. The number of invading cells is indicated on the y axis. Error bars indicate the standard deviation. (B) Cell-surface E-cadherin levels are increased by Ad-PTEN transduction in MeWo cells. Cells were mock, Ad-Luc, or Ad-PTEN treated (2500 or 5000 vp/cell), harvested, and subjected to E-cadherin surface labeling and analyzed by FACS. Error bars indicate the standard deviation. with adhesion plaques. PTEN also was enriched in cell–cell junctions in A375-S2 cells. the effects of Ad-PTEN on tumor metastasis, metasta- tic MeWo cells were transduced with Ad-PTEN or Ad-Luc and 2 days later were evaluated for inva- sion/migration using the Boyden chamber assay. As shown in Figure 5A, treatment of MeWo cells with Ad-PTEN led to a signiﬁcant decrease in invading cells compared to Ad-Luc treated or mock treated cells. Similarly, cell migration in monolayer culture was also inhibited by Ad-PTEN in the same cells (data not shown). These observations suggest that Ad-PTEN might be a potent anti-metastatic agent in melanoma. We then evaluated the effect of Ad-PTEN on expression of a molecule causally implicated in metastatic spread. E-cadherin is a molecule involved in homotypic cell–cell interactions and is altered in the majority of epithelial cancers (24,35). Forced expression of E-cadherin in cultured cancer cells and transgenic mice harboring tumors reduced the inva- sive and metastatic phenotypes in these cells. Cell- surface labeling of E-cadherin was evaluated in cells infected with Ad-PTEN or Ad-Luc at 3 days postin- fection. The levels of E-cadherin (Fig. 5B) increased approximately 3- to 4-fold following Ad-PTEN transduction, as compared to Ad-Luc transduction. Cellular Localization of PTEN in Melanoma Cells Due to the sequence similarity of PTEN to tensin and auxilin, it has been proposed that PTEN might be a cytoplasmic protein with the potential to bind cell membranes. However, published studies evaluating subcellular localization of PTEN have produced con- ﬂicting results. Immunohistochemical analyses of Ad-PTEN treated melanoma cells showed PTEN staining in the cytoplasm and the membrane (Fig. 1). Confocal microscopy was used to further evaluate the subcellular localization of PTEN (Fig. 6). Speciﬁc staining was observed only in Ad-PTEN treated cells. As shown above by conventional immuno- histochemistry (Fig. 1), cytoplasmic staining was observed; however, confocal evaluation demonstrated high levels of PTEN protein concentrated in discrete regions of the plasma membrane (Fig. 6). These regions of enriched PTEN localization are consistent Ad-PTEN Blocks Angiogenesis by In Vitro Inhibition of Endothelial Differentiation The tumor suppressor PTEN down-regulates PI3K signaling (36), and PI3K is important in controlling angiogenesis via regulation of VEGF expression. We thus evaluated the effects of Ad-PTEN on angio- genesis using an in vitro endothelial differentiation assay as a correlate for angiogenesis. When primary HUVECs are plated on Matrigel, they differentiate into tubelike structures; this is believed to be an in vitro model for neo-angiogenesis. As shown in Figure 7, Ad-PTEN speciﬁcally inhibited VEGF- mediated tube formation. HUVECs treated with Ad- Luc as control were indistinguishable from media- treated control cultures. Ad-PTEN at 3000 vp/cell was as effective at blocking tube formation as the positive control suramin, a known inhibitor of en- dothelial differentiation. Note that Ad-PTEN does not kill HUVECs (data not shown), but blocks their dif- ferentiation. This ﬁnding demonstrates that Ad-PTEN potently modulates VEGF-mediated signaling and function, and that PTEN may be a target in thera- peutic approaches to inhibit angiogenesis. Discussion To investigate the therapeutic potential of inhibiting PI3K signaling via PTEN in the treatment of melanoma, we constructed a replication-impaired adenovirus vector carrying the PTEN tumor suppres- sor gene under the control of the CMV promoter. Our study indicated that Ad-PTEN infection into melanoma cell lines resulted in high levels of exogenous PTEN expression (Figs. 1 and 4A). Ectopic PTEN expression led to growth inhibition and apoptotic cell death in all melanoma lines in vitro (Figs. 2 and 3). The ability to induce apoptosis by adenovirus-mediated PTEN gene transfer was evident in cell lines derived from both early-stage RGP melanoma as well as highly metastatic Molecular Medicine, Volume 8, Number 8, August 2002 458 Fig. 6. Subcellular localization of PTEN in melanoma cells. A375-S2 or MeWo cells were transduced with Ad-Luc or Ad-PTEN for 24 hr and monitored by confocal microscopy. Ad-PTEN treated cells exhibited high levels of PTEN expression in cytoplasm and cell periphery. Note concentration of PTEN in speciﬁc regions of membrane consistent with adhesion plaques and intercellular structures. Another possibility for the widespread apoptosis we observe compared to the limited apop- tosis and growth arrest observed by others may be due to the differences in the PTEN delivery efﬁ- ciency. Note that the PTEN gene in our vector is un- der the control of the CMV promoter and is therefore capable of expressing very high supraphysiologic levels of PTEN (Figs. 4 and 6) as compared to other gene transfer systems. Others have reported limited apoptosis and primarily growth arrest in glial cells after PTEN transfection or retroviral transduction (37). It is also interesting to note that although growth of endometrial carcinoma cell lines with en- dogenous wild-type PTEN was mildly suppressed in one study using adenovirus-mediated PTEN gene delivery (43), growth of the same endometrial carcinoma cell line was completely unaffected in a separate study using a retrovirus-mediated gene transfer system (44). In addition, PTEN-induced cell-cycle arrest was observed in the latter study in- stead of apoptosis observed in the earlier study. Alternatively, the degree of cell growth inhibition and ability to undergo apoptosis might also be asso- ciated with the transduction efﬁciency of particular cell lines as observed in studies involving ovarian cancer cells (42). p We showed that the cell killing by Ad-PTEN is tumor selective; apoptosis or growth suppression was not observed in normal melanocytes transduced with Ad-PTEN (Fig. 2). In addition, Ad-PTEN did not induce signiﬁcant growth suppression in other normal human cell lines, including ﬁbroblast and endothelial cells (data not shown). The mechanism underlying the tumor selectivity of Ad-PTEN is not clear. Our cell-cycle analyses demonstrate that Ad- PTEN treatment causes G2/M block in melanoma cells (Fig. 3B). Previous reports evaluating PTEN gene transfer into tumor cells have reported G1 cell- cycle arrest with concomitant increased levels of p27 expression (31,37). In melanoma cells, we do not see alterations in p27 expression and no evidence of G1 arrest. One difference between our results and the previously published data may be that we have used cell lines containing wt PTEN, whereas other stud- ies have evaluated PTEN mutated or deleted cell lines (31,33,37,44). ( , , , ) Consistent with earlier experiments using glial (41), breast (32), bladder (48), prostate (39), thy- roid (47), and endometrial (44) cancer lines, we also showed that the introduction of PTEN results in efﬁcient dephosphorylation of AKT/PKB with- out a decrease in total AKT/PKB protein. Fig. 6. Subcellular localization of PTEN in melanoma cells. A375-S2 or MeWo cells were transduced with Ad-Luc or Ad-PTEN for 24 hr and monitored by confocal microscopy. Ad-PTEN treated cells exhibited high levels of PTEN expression in cytoplasm and cell periphery. Note concentration of PTEN in speciﬁc regions of membrane consistent with adhesion plaques and intercellular structures. Fig. 6. Subcellular localization of PTEN in melanoma cells. A375-S2 or MeWo cells were transduced with Ad-Luc or Ad-PTEN for 24 hr and monitored by confocal microscopy. Ad-PTEN treated cells exhibited high levels of PTEN expression in cytoplasm and cell periphery. Note concentration of PTEN in speciﬁc regions of membrane consistent with adhesion plaques and intercellular structures. wild-type PTEN into tumor cell lines caused growth arrest, anoikis, or apoptosis only in cells containing mutated PTEN alleles, especially with studies in- volved glial cells (37–41). However, more recent studies conducted in breast (32), ovarian (42), and melanomas (Fig. 4). Furthermore, the killing induced by Ad-PTEN was independent of PTEN mutational status because all cell lines evaluated have wild- type PTEN alleles (Table 1). The latter result is different from earlier reports that introduction of Fig. 7. Ad-PTEN inhibits angiogenesis in vitro. HUVEC cells were transduced with Ad-Luc or Ad-PTEN (3000 vp/cell) or treated with Suramin or media for 24 hr. The cells were then plated onto Matrigel and incu- bated at 37C. Control HUVEC exhibited mature tube formation by 12–16 hr after plating whereas Suramin and Ad-PTEN treatment blocked tube structure formation. Fig. 7. Ad-PTEN inhibits angiogenesis in vitro. HUVEC cells were transduced with Ad-Luc or Ad-PTEN (3000 vp/cell) or treated with Suramin or media for 24 hr. The cells were then plated onto Matrigel and incu- bated at 37C. Control HUVEC exhibited mature tube formation by 12–16 hr after plating whereas Suramin and Ad-PTEN treatment blocked tube structure formation. A. L. Stewart et al.: PI3K Blockade in RGP and Malignant Melanoma 459 wild-type PTEN-expressing tumors might also be responsive to Ad-PTEN treatment. endometrial (43) cancer cell lines using adenovirus vector–mediated gene transfer also indicated that genotypically wild-type PTEN cancer cells can be growth inhibited with or without induction of apoptosis upon reintroduction of high levels of ex- ogenous PTEN protein. We suspect the difference between these studies could be attributed to differ- ent tumor types and/or experimental systems. Be- cause tumors and tumor cell lines contain multiple, and often different mutations, it is possible that the mutational status of the PTEN gene is not the only rate-limiting factor in apoptosis induction. In addi- tion, although the cell lines we tested here contain wild-type PTEN alleles, the endogenous levels of PTEN protein remain extremely low or unde- tectable. Another possibility for the widespread apoptosis we observe compared to the limited apop- tosis and growth arrest observed by others may be due to the differences in the PTEN delivery efﬁ- ciency. Note that the PTEN gene in our vector is un- der the control of the CMV promoter and is therefore capable of expressing very high supraphysiologic levels of PTEN (Figs. 4 and 6) as compared to other gene transfer systems. Others have reported limited apoptosis and primarily growth arrest in glial cells after PTEN transfection or retroviral transduction (37). It is also interesting to note that although growth of endometrial carcinoma cell lines with en- dogenous wild-type PTEN was mildly suppressed in one study using adenovirus-mediated PTEN gene delivery (43), growth of the same endometrial carcinoma cell line was completely unaffected in a separate study using a retrovirus-mediated gene transfer system (44). In addition, PTEN-induced cell-cycle arrest was observed in the latter study in- stead of apoptosis observed in the earlier study. Alternatively, the degree of cell growth inhibition and ability to undergo apoptosis might also be asso- ciated with the transduction efﬁciency of particular cell lines as observed in studies involving ovarian cancer cells (42). endometrial (43) cancer cell lines using adenovirus vector–mediated gene transfer also indicated that genotypically wild-type PTEN cancer cells can be growth inhibited with or without induction of apoptosis upon reintroduction of high levels of ex- ogenous PTEN protein. We suspect the difference between these studies could be attributed to differ- ent tumor types and/or experimental systems. Be- cause tumors and tumor cell lines contain multiple, and often different mutations, it is possible that the mutational status of the PTEN gene is not the only rate-limiting factor in apoptosis induction. In addi- tion, although the cell lines we tested here contain wild-type PTEN alleles, the endogenous levels of PTEN protein remain extremely low or unde- tectable. References 1. Meier F, Satyamoorthy K, Nesbit M, et al. (1998) Molecular events in melanoma development and progression. Front. Biosci. 3: 1005–1010. 1. Meier F, Satyamoorthy K, Nesbit M, et al. (1998) Molecular events in melanoma development and progression. Front. Biosci. 3: 1005–1010. 2. Saida T. (1993) Recent advances in melanoma research. J. Dermatol. Sci. 26: 1–13. 3. Herlyn M. (1993) Molecular and Cellular Biology for Melanoma. Austin, TX: R.G. Landes Co.; pp. 1–102. 4. Healy E, Belgaid CE, Takata M, et al. (1996) Allelotypes of primary cutaneous melanoma and benign melanocytic nevi. Cancer Res. 56: 589–593. 5. Bastian BC, LeBoit PE, Hamm H, Brocker EB, Pinkel D. (1998) Chromosomal gains and losses in primary cutaneous melanomas detected by comparative genomic hybridization. Cancer Res. 58: 2170–2175. 6. Thompson FH, Emerson J, Olson S, et al. (1995) Cytogenet- ics of 158 patients with regional or disseminated melanoma. Subset analysis of near-diploid and simple karyotypes. Cancer Genet. Cytogenet. 83: 93–104. 7. Herbst RA, Weiss J, Ehnis A, Cavenee WK, Arden KC. (1994) Loss of heterozygosity for 10q22-10qter in malignant melanoma progression. Cancer Res. 54: 3111–3114. 8. Li J, Yen C, Liaw D, et al. (1997) PTEN, a putative protein tyrosine phosphatase gene mutated in human brain, breast, and prostate cancer. Science 275: 1943–1947. 9. Steck PA, Pershouse MA, Jasser SA, et al. (1997) Identiﬁca- tion of a candidate tumour suppressor gene, MMAC1, at chromosome 10q23.3 that is mutated in multiple advanced cancers. Nat. Genet. 15: 356–362. 10. Li DM, Sun H. (1997) TEP1, encoded by a candidate tumor suppressor locus, is a novel protein tyrosine phosphatase reg- ulated by transforming growth factor beta. Cancer Res. 57: 2124–2129. 11. Tamura M, Gu J, Matsumoto K, Aota S, Parsons R, Yamada KM. (1998) Inhibition of cell migration, spreading, and focal adhesions by tumor suppressor PTEN. Science 280: 1614–1617. In summary, we constructed an Ad-PTEN vector, which causes the expression of high levels of PTEN protein and blocks PI3K signaling pathways. Dys- regulation of the PI3K pathway is involved in con- trolling tumor cell survival and also appears to mediate resistance to conventional chemo- and ra- diotherapeutic approaches in a broad spectrum of tumors. We have tested the ability of Ad-PTEN to in- hibit the proliferation of melanoma cell lines. Our results indicate that Ad-PTEN has anti-proliferative and pro-apoptotic activity in melanoma cells but not in normal melanocytes. The PTEN protein is a protein and lipid phosphatase, and exerts its effects by altering the phosphoryla- tion state of multiple signaling pathways. It has been reported that PTEN dephosphorylates FAK, which leads to inhibition of integrin-mediated cell spreading, migration, and focal adhesion forma- tion. Previous studies evaluating the effect of PTEN transfection into murine 3T3 cells or U87 glioblastoma cells demonstrated inhibition of cell invasion and migration. Here, we show for the ﬁrst time that Ad-PTEN inhibits cell invasion and mi- gration in metastatic melanoma cells (Fig. 5A). The combination of pro-apoptotic and anti-metastatic activities suggests that Ad-PTEN may be a promis- ing agent in treating tumors that are prone to metastasis. ( ) In this study, the exogenous PTEN protein is functional because the AKT/PKB kinase activity and phospho-AKT/PKB levels are reduced following Ad-PTEN treatment. It is possible that overcoming cellular survival signals to induce AKT-dependent apoptosis may only occur when very high levels of PTEN are expressed. On the other hand, the status of other oncogenic factors and cell growth condition may also attribute to PTEN-induced apoptosis in our assay system. This hypothesis is further supported by studies that PTEN reintroduction into different cell lines or the same cell lines under different cul- ture conditions (45–47) resulted in either cell-cycle arrest or apoptosis. Note that the Ad-PTEN vector used here is capable of inducing cell death in cells containing wild-type PTEN alleles. This ﬁnding may be very signiﬁcant in a clinical setting; only 30–40% of melanomas contain PTEN mutations and our ﬁndings suggest that the remaining 60–70% of We have shown that Ad-PTEN inhibits endothe- lial cell differentiation and migration (data not shown) in a dose-dependent and transgene-speciﬁc manner in vitro (Fig. 7). This further supports the notion that Ad-PTEN may play an important role in inhibiting the tumor metastasis pathway. As a mol- ecular correlate for metastatic potential, we evalu- ated the levels of cell surface E-cadherin in response to Ad-PTEN. Cadherins are a large group of cell ad- hesion molecules located at intercellular junctions called adherens junctions. They play important roles in embryogenesis and morphogenesis in ani- mals and humans due to their adhesive and cell- signaling functions. Disturbances of the expression or function of cadherins and their associated pro- teins called catenins are crucial for the initiation Molecular Medicine, Volume 8, Number 8, August 2002 460 and development of many pathologic states. E- cadherin is an epithelium-speciﬁc cadherin re- quired for the development and maintenance of the normal function of all epithelial cells in tissues. The loss or down-regulation of E-cadherin is a key event in the process of tumor invasion and metasta- sis. The levels of E-cadherin on the cell surface of MeWo cells increased substantially in a dose-de- pendent manner following Ad-PTEN transduction, but not Ad-Luc transduction (Fig. 5B). Similar re- sults were obtained in other melanoma cell lines (data not shown). These results indicate that Ad- PTEN regulates cadherin-mediated cell–cell adhe- sion and migration processes. The exact mechanism by which PTEN causes up-regulation of E-cadherin is currently under investigation. of melanoma lines to Ad-PTEN treatment does not correlate with PTEN gene mutational status. In this same set of cell lines, we have also evaluated p53 mutational status (data not shown) and do not ﬁnd a correlation between p53 mutation and Ad-PTEN apoptotic activity. Melanoma is a very aggressive tu- mor with a propensity to metastasize rapidly. PI3K blockade via Ad-PTEN inhibited cell invasion and migration in metastatic melanoma cells, and also in- hibited angiogenesis, in vitro, suggesting Ad-PTEN might be useful in treating both early- and late-stage tumors. Acknowledgments This work was supported by Introgen Therapeutics Inc., Houston, Texas, and NCI grant CA86587 to S. C. and NCI grant CA 89778 to E. A. G. y v g Ad-PTEN is able to inhibit endothelial differen- tiation in the tube formation assay (Fig. 7). PTEN in- activation is associated with increased angiogenesis in different tumors (49). Several studies have evalu- ated endogenous or ectopic PTEN localization (10,49–52); epitope-tagged PTEN was transfected into several mammalian cell lines by transient trans- fection and was found to be localized primarily to the cytoplasm (10,37). Immunohistochemical stud- ies of endogenous PTEN in esophageal squamous cell carcinoma and endocrine pancreatic tumors also suggested that PTEN is localized predominantly in the cytoplasm (50,51). In contrast, predominantly nuclear or perinuclear staining was observed in nor- mal islet cells, neurons and endothelial cells (51,52). Differential nuclear and cytoplasmic expression of endogenous PTEN was observed in normal thyroid tissue and epithelial thyroid tumors (49). In our initial immunohistochemical analyses, PTEN protein was found in the cytoplasm and appeared enriched around the membrane of Ad-PTEN treated cells (Fig. 1). The subcellular localization of PTEN did not change in cells in different cell-cycle compartments. Confocal imaging of ectopically expressed PTEN in A375-S2 and MeWo cells supported this pattern of expres- sion, but also revealed that in metastatic melanoma cells, PTEN was enriched in membrane processes that appeared to be adhesion plaques (Fig. 6). 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https://openalex.org/W2108994867	https://pure.eur.nl/files/47182513/00307.pdf	English	null	Evaluation of direct inoculation of the BD PHOENIX system from positive BACTEC blood cultures for both Gram-positive cocci and Gram-negative rods	BMC Microbiology	2,011	cc-by	5,067	© 2011 Beuving et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. RESEARCH ARTICLE Open Access Evaluation of direct inoculation of the BD PHOENIX system from positive BACTEC blood cultures for both Gram-positive cocci and Gram-negative rods dith Beuving1, Christina FM van der Donk1, Catharina FM Linssen1, Petra FG Wolffs1* and Anne Abstract Background: Rapid identification (ID) and antibiotic susceptibility testing (AST) of the causative micro-organism of bloodstream infections result in earlier targeting of antibiotic therapy. y In order to obtain results of ID and AST up to 24 hours earlier, we evaluated the accuracy of direct inoculation of the Phoenix system from positive blood cultures (BACTEC) by using Serum Separator Tubes to harvest bacteria from positive blood cultures. Results were compared to those of standard Phoenix procedure. Discrepancies between the two methods were resolved by using the API system, E-test or microbroth dilution. Results: ID with the direct method was correct for 95.2% of all tested Enterobacteriaceae (n = 42) and 71.4% of Pseudomonas aeruginosa strains (n = 7). AST with the direct method showed a categorical agreement for Gram-negative rods (GNR) of 99.0%, with 0.7% minor errors, 0.3% very major errors and no major errors. All antibiotics showed an agreement of >95%. The direct method for AST of Staphylococcus (n = 81) and Enterococcus (n = 3) species showed a categorical agreement of 95.4%, with a minor error rate of 1.1%, a major error rate of 3.1% and a very major error rate of 0.4% All antibiotics showed an agreement of >90%, except for trimethoprim-sulfamethoxazole and erythromycin. Conclusions: Inoculation of Phoenix panels directly from positive blood cultures can be used to report reliable results of AST of GNR a day earlier, as well as ID-results of Enterobacteriaceae. For Staphylococcus and Enterococcus species, results of AST can also be reported a day earlier for all antibiotics, except for erythromycin and trimethoprim-sulfamethoxazole. Early administration of adequate antibiotic therapy has been shown to reduce mortality [10-12]. Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 * Correspondence: p.wolffs@mumc.nl 1Department of Medical Microbiology, Care And Public Health Research Institute (CAPHRI), Maastricht University Medical Center, PO Box 5800, 6202AZ, Maastricht, the Netherlands Full list of author information is available at the end of the article Background Bloodstream infections are a common condition, affect- ing approximately 2% of all hospitalised patients and up to 70% of all patients in the Intensive Care Unit, and the incidence is rising [1-4]. Mortality is high, ranging from 14 to 57% [5]. In this group of patients, rapid iden- tification (ID) and antibiotic susceptibility testing (AST) of the causative microorganism are essential since they result in earlier targeting of antibiotic therapy [6-9]. The introduction of automated blood culture systems and automated systems for ID and AST have reduced the time to diagnosis in bloodstream infections. How- ever, for these systems, blood cultures have to be sub- cultured on agar before ID and AST can be performed, which can take up to 24 hours. An alternative for subculture on agar is harvesting the bacteria needed for inoculation of these systems directly from positive blood cultures by using Serum Separator Tubes, thereby reducing the time needed to obtain results of ID and AST by a day. Although this method has been successfully tested for many automated sys- tems [13-17], direct inoculation was reported only twice * Correspondence: p.wolffs@mumc.nl 1Department of Medical Microbiology, Care And Public Health Research Institute (CAPHRI), Maastricht University Medical Center, PO Box 5800, 6202AZ, Maastricht, the Netherlands Full list of author information is available at the end of the article Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Page 2 of 7 for the BD Phoenix Automated Microbiology System (BD), once for Gram-negative rods (GNR) [18] and once for Gram-positive cocci (GPC) [19]. Both studies com- pared their results of the direct method with results of the Vitek system. for the BD Phoenix Automated Microbiology System (BD), once for Gram-negative rods (GNR) [18] and once for Gram-positive cocci (GPC) [19]. Both studies com- pared their results of the direct method with results of the Vitek system. isolates, 25 μl of this suspension were transferred into a tube of Phoenix system AST broth (product no. 246002; BD) in which one drop of AST indicator (product no. 246004; BD) was previously added, according to manu- facturers’ guidelines. Since the inoculum of GPC in ID broth was shown to be almost 10 times lower than is standard in a 0.5 McFarland suspension, 250 μl of inoculated ID broth was added to AST broth for GPC, instead of the 25 μl in the manufacturers’ guidelines. Identification of GPC Since the Phoenix system is not used for ID of GPC in routine diagnostics, ID by direct inoculation was not tested in this group. To discern Staphylococcus species from other GPC, a catalase test was performed. For the identification of Staphylococcus species, catalase-positive strains were tested for coagulase and DNAse produc- tion. If both tests were negative, the strain was identified as a coagulase-negative Staphylococcus species (CoNS). All samples were used according to the code for proper use of human tissue as formulated by the Dutch Federation of Medical Scientific Societies. Routinely used inoculation For the routinely used method, a small volume of posi- tive blood culture was inoculated on Columbia sheep blood agar plates and incubated at 35°C with 5% CO2. A standard inoculum in ID broth was prepared from the bacteria grown on the agar medium and inoculated into Phoenix panels, following the manufacturer’s recommendations. Blood cultures l d d f To discern Enterococcus species from other catalase- negative GPC, bile esculin and tellur diagnostic tablets (Rosco Diagnostica, Taastrup, Denmark) were used, according to manufacturer’s guidelines. If both tests were positive, the strain was identified as Enterococcus faecalis, whereas in case of a positive bile esculin test but a negative tellur test, an API 20 Strep test (Biomér- ieux SA, Marcy l’Etoile, France) was performed to further identify the strain. Blood drawn from patients admitted in the MUMC and suspected for bloodstream infection was incubated in blood culture bottles (Plus+Aerobic (product no. 442192; BD) and Plus+Anaerobic (product no. 442193; BD)) and monitored for microbial growth in the Bac- tec™9240 instrument (BD). When growth was detected by the instrument, Gram-staining was performed. Sample collection Between January and April 2009, blood cultures grown in the previous 24 hours in the Bactec automated blood culture device (Bactec™9240, BD Diagnostic Systems, Sparks, MD, USA) and containing Staphylococcus spe- cies, Enterococcus species or obligate aerobic and facul- tative anaerobic GNR were evaluated. Polymicrobial cultures as well as cultures containing anaerobes or fungi were excluded from the analysis. Streptococcus spp. are not routinely processed in the Phoenix system in our lab and were therefore also excluded from the analysis. One positive blood culture per patient per epi- sode of bloodstream infection was included in the study. The study was performed in the Department of Medical Microbiology of the Maastricht University Medical Cen- ter (MUMC), a 750-bed referral hospital. Direct inoculation Results of identification were adjusted in the Phoenix results retrospectively for both the standard and direct method, after which the software automatically adjusted MIC cutoff values to those of the identified species. For the direct method, 5 ml of grown blood culture was aspirated from the blood culture bottle and the aspirate was injected in a Serum Separator Tube (SST) (BD Diagnostic Systems, Sparks, MD, USA). This tube was centrifuged at 2000 × g for 10 minutes, after which the supernatant was discarded. Bacteria were harvested from the gel layer using a sterile cotton swab and suspended in a Phoenix system ID broth tube (product no. 246000; BD) until a 0.5 McFarland standard suspension was obtained. To obtain optimal results, for Gram-negative Background For GNR, the Phoenix system panel NMIC/ID-75 (pro- duct no. 448087; BD) was used. For GPC, the PMIC-58 panel (product no. 448052; BD) was used. No studies are available comparing results of direct inoculation with the routinely used method of inoculat- ing the Phoenix system, which is the standard procedure for ID and AST in many microbial diagnostic labora- tories. Here, we evaluated the accuracy of direct inocula- tion of the Phoenix system with positive blood culture isolates, compared to the routinely used procedure. To calculate the original number of CFU/ml in the ID broth and to serve as purity control, dilutions of ID broth were also subcultured, using the Eddy Jet spiral plater (IUL, S.A., Barcelona, Spain). Data analysis l f Results of AST with the direct method (susceptible, intermediate or resistant) were analysed for categorical agreement with the results of the standard method. Also, minor errors (any false result involving an inter- mediate result), major errors (false-resistant results) and very major errors (false-susceptible results) were calculated. Inoculum of bacteria in ID broth after use of serum separator tubes (SSTs) In total, 134 blood cultures were included, from 116 patients. The inoculum of GPC in ID broth was on average 3.6 × 107 CFU/ml, whereas that of GNR was 1.8 × 108 CFU/ml, which was a significant difference (95% CI between -1.7 × 108 and -1.2 × 108; P < 0.001). Discussion This study shows SSTs can be used to inoculate Phoenix ID broth to a 0.5 McFarland standard, as was also shown by Funke et al. for GNR [18]. However, a 0.5 McFarland standard for GPC obtained by using SSTs was shown to consistently contain a lower inoculum than 1.5 × 108 CFU/ml. This may be due to the pre- sence of blood culture components other than bacteria, since they could also contribute to the turbidity in the ID broth. AST of GPC AST of GPC AST using the direct method was performed for 84 GPC (22 Staphylococcus aureus, 59 CoNS, 2 Enterococ- cus faecalis and 1 Enterococcus faecium). Categorical agreement for the tested GPC was 93.1% compared with results of the standard method. After discrepancy analy- sis this was 95.4%, with a minor error rate of 1.1%, a major error rate of 3.1% and a very major error rate of 0.4% (Table 2). Except for erythromycin and trimetho- prim-sulfamethoxazole, all antibiotics showed a categori- cal agreement of the direct method of >90% (table 4). Again, all very major errors (n = 4) occurred with tri- methoprim-sulfamethoxazole, all in CoNS strains. The major errors were divided as follows: 10 for S. aureus, 23 for CoNS and 1 for Enterococcus spp.. ID of GNR with the direct Phoenix method ID with direct inoculation was correct for 95.2% of all tested Enterobacteriaceae. One Escherichia coli strain was incorrectly identified as Salmonella choleraesuis with the direct method. One Serratia marcescens strain could not be identified with the direct method. Identifi- cation for Pseudomonas spp. was correct in 71.4%. Both errors in this group involved strains of Pseudomonas aeruginosa that were incorrectly identified as Pseudomo- nas fluorescens (Table 1). No errors in ID were observed for the routine method. This study shows very good results for ID of Entero- bacteriaceae. Only two errors occurred with ID in this group. One strain was not identified and one strain of E. coli was misidentified as S. choleraesuis. Results of ID for Pseudomonas species were less reliable. Both errors in this group were P. aeruginosa strains that were iden- tified as P. fluorescens, a rare cause of bloodstream infections. These misidentifications did not lead to errors in interpretation of AST, but rare or unlikely results of ID should be dealt with carefully and be con- firmed using additional tests. Other studies also showed that ID of non-fermenting GNR was less reliable than that of Enterobacteriaceae [18,23]. This may be due to Statistical analysis Bacterial load in ID broth for GPC and GNR was com- pared using an independent samples t-test. Categorical agreement for the standard method after discrepancy analysis was 97.3% (see table 2). One very major error occurred for amoxicillin-clavulanate, 1 for ampicillin, 1 for erythromycin, 4 for gentamicin, 1 for moxifloxacin, 2 for oxacillin, 1 for tetracycline and 3 for trimethoprim-sulfamethoxazole (Table 4). Discrepancy analysis To resolve differences in ID of GNR, the API system was used (API 20E for Enterobacteriaceae and API 20NE for non-fermenters (Biomérieux)). In case of dis- crepancies in AST between results of the direct method Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Page 3 of 7 major errors, and 2 very major errors (0.3%) (Table 2). Both very major errors occurred with trimethoprim-sul- famethoxazole in Pseudomonas aeruginosa strains. Cate- gorical agreement of the standard method after discrepancy analysis was 98.4% (table 2). One very major error occurred with trimethoprim-sulfamethoxa- zole. No antibiotic showed a categorical agreement of <95% (Table 3). and the routinely used method for ceftazidime, ceftriax- one, cefuroxime, ciprofloxacin, clindamycin, levofloxa- cin, moxifloxacin, linezolid, penicillin, piperacillin, piperacillin-tazobactam, and tobramycin an E-test (Biomérieux) was performed according to manufac- turer’s guidelines, and used as gold standard [20,21]. Discrepancies for amoxicillin, amoxicillin-clavulanate, erythromycin, gentamicin, oxacillin, rifampin, tetracy- cline and trimethoprim-sulfamethoxazole were resolved using microbroth dilution, as described in the CLSI- guidelines [22]. Antibiotic susceptibility testing (AST) of GNR Results of AST were available for 49 strains, one P. aer- uginosa strain failed to grow sufficiently in the Phoenix system so no results were available for the direct method. Categorical agreement of the direct method with results of the standard method for GNR was 97.6%. After discrepancy analysis of the results of AST, this percentage rose to 99.0%, with 5 minor errors (0.7%), no Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Page 4 of 7 Table 1 Results of identification of GNR with the direct method Total no. of strains No. of unidentified strains No. of misidentified strains ID of misidentified strains Enterobacteriaceae E. coli 26 1 Salmonella choleraesuis K. pneumoniae spp. pneumoniae 8 S. marcescens 4 1 K. oxytoca 1 P. mirabilis 1 E. cloacae 1 M. morganii 1 Non-fermenters P. aeruginosa 7 2 Pseudomonas fluorescens Table 1 Results of identification of GNR with the direct method 1 Salmonella choleraesuis 2 Pseudomonas fluorescens Some studies on direct methods for AST showed poor results for GPC [15,16] or focus on GNR only due to unfavorable results for GPC [17]. However, in this study, direct AST for Staphylococcus species and Entero- coccus species showed good agreement with conven- tional methods, comparable to results of the standard method, but with fewer very major errors. Lupetti et al. [19], who tested the direct Phoenix method for GPC and compared their results with those of the Vitek 2, found an even higher agreement. They incubated a por- tion of the positive blood culture with saponin in order to harvest more bacteria from a positive blood culture through the release of intracellular bacteria. the lower growth rate of non-fermenters, which could result in weaker fluorescent biochemical reactions in the Phoenix ID panel. Errors in ID with the direct method could also be caused by traces of blood culture compo- nents in the ID broth. This however seems less likely, since with Enterobacteriaceae, errors in ID were rare. Since the Phoenix system was not used for ID of GPC, ID by direct inoculation was not tested in this group. Antibiotic susceptibility testing (AST) of GNR But since ID is required for interpretation of AST, in clinical practice, rapid AST will have to be combined with a rapid method of ID, such as PCR-based methods on whole blood, like LightCycler® SeptiFast Test MGRADE (Roche), VYOO Sepsis Test (SIRS-Lab), Sep- siTest™(Molzym), or MALDITOF-MS on positive blood cultures [24]. Other studies that presented results of direct methods for AST of GPC showed variable results [13-16,25,26], which makes comparison difficult. But our results were comparable to those of the routine Phoenix method. Moreover, categorical agreement for most tested anti- biotics in this study, including oxacillin and vancomycin, were well over 90% and the percentage of major and very major errors is low, meeting the standards pro- posed by Jorgensen et al. [27]. Only erythromycin and trimethoprim-sulfamethoxazole showed lower agree- ments. The majority of errors for erythromycin were minor errors, but also some major errors occurred. Tri- methoprim-sulfamethoxazole was the only antibiotic for both GPC and GNR showing very major errors. Lupetti et al. showed a lower agreement of 94% for erythromy- cin as well, but observed no very major errors for tri- methoprim-sulfamethoxazole. Some other studies on direct methods for AST showed some very major errors for trimethoprim-sulfamethoxazole [15,16,18], but only Kerremans et al. [13] found a very high percentages of very major errors for this antibiotic in GPC, but not in GNR. Therefore, we conclude that the direct Phoenix method using SSTs can be used to reliably report results of AST for GPC, except for trimethoprim-sulfamethoxa- zole and erythromycin. Table 2 Agreements and errors for AST of GPC and GNR for the direct and routinely used Phoenix method Direct vs routinely used method Direct method after discrepancy analysis Routine method after discrepancy analysis GPC (n = 84) Categorical agreement 93.1% 95.4% 97.3% Minor errors 1.7% 1.1% 0.7% Major errors 4.2% 3.1% 0.8% Very major errors 0.9% 0.4% 1.6% GNR (n = 49) Categorical agreement 97.6% 99.0% 98.4% Minor errors 1.9% 0.7% 1.4% Major errors 0.1% 0.0% 0.1% Very major errors 0.4% 0.3% 0.1% Table 2 Agreements and errors for AST of GPC and GNR for the direct and routinely used Phoenix method The direct method of AST for GNR showed very good agreement with conventional methods for both Beuving et al. Antibiotic susceptibility testing (AST) of GNR BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Page 5 of 7 Table 3 Agreement and errors of the direct method for AST for GNR, after discrepancy analysis Antimicrobial agent No. of tested strains % categorical agreement No. of minor errors (%) No. of major errors (%) No. of very major errors (%) Amikacin 49 100 0 0 0 Amoxicillin/clavulanate 49 98.0 1 (2.0) 0 0 Ampicillin 49 98.0 1 (2.0) 0 0 Ceftazidime 49 100 0 0 0 Ceftriaxone 49 98.0 1 (2.0) 0 0 Cefuroxime 49 98.0 1 (2.0) 0 0 Ciprofloxacin 49 100 0 0 0 Colistin 49 100 0 0 0 Gentamicin 49 100 0 0 0 Levofloxacin 49 100 0 0 0 Meropenem 49 100 0 0 0 Piperacillin 49 98.0 1 (2.0) 0 0 Piperacillin/tazobactam 49 100 0 0 0 Tobramycin 49 100 0 0 0 Trimethoprim/ sulfamethoxazole 49 96.0 0 0 2 (4.0) Total 735 99.0 5 (0.7) 0 (0) 2 (0.3) Table 3 Agreement and errors of the direct method for AST for GNR, after discrepancy analysis d errors of the direct method for AST for GNR, after discrepancy analysis thod for AST for GNR, after discrepancy analysis results of the direct Phoenix method for AST can be used to guide antibiotic therapy in bloodstream infections. Enterobacteriaceae and Pseudomonas species, compar- able to the routinely used method, with essential agree- ments and categorical agreements of over 95% for all antibiotics tested (see table 3). Both very major errors occurred with trimethoprim-sulfamethoxazole in Pseu- domonas aeruginosa strains that were correctly identi- fied. For these strains, it would never be considered an adequate treatment, due to intrinsic resistance. These errors thus would not have clinical consequences. Funke et al. [18] also described a categorical agreement of 99.0%, which is comparable with or higher than results from studies on other direct methods of AST [7,13-16,26]. Therefore, we conclude that also for GNR, The strains tested in this study are a representative sample of the strains most frequently encountered in clinical practice. A limitation of the study is the low number of tested Enterococcus and Pseudomonas strains (3 and 7, respectively), however, both groups show very good agreement, with only few errors. Inoculating ID and AST broth by using SSTs can be performed as soon as blood culture bottles are taken out of the BACTEC system and takes approximately 30 minutes, whereas a subculture takes up to 24 hours. Conclusions From these results we conclude that AST by inoculating Phoenix panels with bacteria harvested directly from positive blood culture bottles is as reliable as using bac- teria from a subculture on agar, with the exception of results for erythromycin and trimethoprim-sulfamethox- azole in Staphylococcus and Enterococcus spp., which should not be reported due to their low agreement. Results of ID of Enterobacteriaceae were shown to be very reliable. ID of Staphylococcus and Enterococcus spp. was not performed with the direct method. Caution is warranted about interpretation of results of Enterococcus and Pseudomonas spp., of which only a limited number of strains was tested. 7. Bruins M, Oord H, Bloembergen P, Wolfhagen M, Casparie A, Degener J, Ruijs G: Lack of effect of shorter turnaround time of microbiological procedures on clinical outcomes: a randomised controlled trial among hospitalised patients in the Netherlands. Eur J Clin Microbiol Infect Dis 2005, 24(5):305-313. 8. Kerremans JJ, Verboom P, Stijnen T, Hakkaart-van Roijen L, Goessens W, Verbrugh HA, Vos MC: Rapid identification and antimicrobial susceptibility testing reduce antibiotic use and accelerate pathogen- directed antibiotic use. The Journal of antimicrobial chemotherapy 2008, 61(2):428-435. 9. Doern GV, Vautour R, Gaudet M, Levy B: Clinical impact of rapid in vitro susceptibility testing and bacterial identification. Journal of clinical microbiology 1994, 32(7):1757-1762. 9. Doern GV, Vautour R, Gaudet M, Levy B: Clinical impact of rapid in vitro susceptibility testing and bacterial identification. Journal of clinical microbiology 1994, 32(7):1757-1762. 10. Fraser A, Paul M, Almanasreh N, Tacconelli E, Frank U, Cauda R, Borok S, Cohen M, Andreassen S, Nielsen AD, et al: Benefit of appropriate empirical antibiotic treatment: thirty-day mortality and duration of hospital stay. The American journal of medicine 2006, 119(11):970-976. Thus, by only a small change in daily laboratory rou- tine, results of ID and AST of positive blood culture iso- lates can be obtained up to a day earlier than with the standard method, thereby leading to earlier targeting of antibiotic therapy in patients with bloodstream infections. 11. Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH: The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 2000, 118(1):146-155. 12. Antibiotic susceptibility testing (AST) of GNR Table 4 Agreement and errors of the direct method of AST for GPC after discrepancy analysis Antimicrobial agent No. of tested strains % categorical agreement No. of minor errors (%) No. of major errors (%) No. of very major errors (%) Amoxicillin/clavulanate 84 91.7 0.0 7 (8.3) 0 Ampicillin 84 94 0 5 (6.0) 0 Clindamycin 84 96.4 2 (2.4) 1 (1.2) 0 Erythromycin 84 86.9 8 (9.5) 2 (3.6) 0 Gentamicin 84 100 0 0 0 Linezolid 84 91.6 1 (1.2) 6 (7.2) 0 Moxifloxacin 84 100 0 0 0 Oxacillin 84 96.4 0 3 (3.6) 0 Penicillin 84 98.8 0 1 (1.2) 0 Rifampin 82 98.8 0 1 (1.2) 0 Tetracycline 84 97.6 1 (1.2) 1 (1.2) 0 Trimethoprim/ Sulfamethoxazole 84 89.2 0 5 (6.0) 4 (4.8) Vancomycin 84 98.8 0 1 (1.2) 0 Total 1090 95.4 12 (1.1) 34 (3.1) 4 (0.4) d errors of the direct method of AST for GPC after discrepancy analysis Table 4 Agreement and errors of the direct method of AST for GPC after discrepancy analysis Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Page 6 of 7 Page 6 of 7 Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Therefore, by using the direct method, results of ID and AST can be available up to 23.5 hours earlier than with the routinely used method. 4. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D: Sepsis in European intensive care units: results of the SOAP study. Critical care medicine 2006, 34(2):344-353. 5. Bearman GM, Wenzel RP: Bacteremias: a leading cause of death. Archives of medical research 2005, 36(6):646-659. 6. Barenfanger J, Drake C, Kacich G: Clinical and financial benefits of rapid bacterial identification and antimicrobial susceptibility testing. Journal of clinical microbiology 1999, 37(5):1415-1418. Author details 1 15. Waites KB, Brookings ES, Moser SA, Zimmer BL: Direct susceptibility testing with positive BacT/Alert blood cultures by using MicroScan overnight and rapid panels. Journal of clinical microbiology 1998, 36(7):2052-2056. 1Department of Medical Microbiology, Care And Public Health Research Institute (CAPHRI), Maastricht University Medical Center, PO Box 5800, 6202AZ, Maastricht, the Netherlands. 2Department of Internal Medicine, Erasmus University Medical Center, PO Box 2040, 3000CA, Rotterdam, the Netherlands. 16. de Cueto M, Ceballos E, Martinez-Martinez L, Perea EJ, Pascual A: Use of positive blood cultures for direct identification and susceptibility testing with the vitek 2 system. Journal of clinical microbiology 2004, 42(8):3734-3738. 17. Bruins MJ, Bloembergen P, Ruijs GJ, Wolfhagen MJ: Identification and susceptibility testing of Enterobacteriaceae and Pseudomonas aeruginosa by direct inoculation from positive BACTEC blood culture bottles into Vitek 2. Journal of clinical microbiology 2004, 42(1):7-11. Authors’ contributions JB: conceived of the study, performed the gold standard tests and statistical analysis, and drafted the manuscript. CFMD: carried out the direct Phoenix method, performed the analysis and helped to draft the manuscript. CFML: participated in the design of the study and helped to draft the manuscript. PFGW: participated in the design of the study and helped to draft the manuscript. AV: conceived of the study, coordinated it, and helped to draft the manuscript. 18. Funke G, Funke-Kissling P: Use of the BD PHOENIX Automated Microbiology System for direct identification and susceptibility testing of gram-negative rods from positive blood cultures in a three-phase trial. Journal of clinical microbiology 2004, 42(4):1466-1470. 19. Lupetti A, Barnini S, Castagna B, Nibbering PH, Campa M: Rapid identification and antimicrobial susceptibility testing of Gram-positive cocci in blood cultures by direct inoculation into the BD Phoenix system. Clin Microbiol Infect 2010, 16(7):986-991. All authors read and approved the final manuscript. All authors read and approved the final manuscript. Received: 14 January 2011 Accepted: 30 June 2011 20. Baker CN, Stocker SA, Culver DH, Thornsberry C: Comparison of the E Test to agar dilution, broth microdilution, and agar diffusion susceptibility testing techniques by using a special challenge set of bacteria. Journal of clinical microbiology 1991, 29(3):533-538. Conclusions Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti S, Taiberg L, et al: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical care medicine 2006, 34(6):1589-1596. 13. Kerremans JJ, Goessens WH, Verbrugh HA, Vos MC: Accuracy of identification and susceptibility results by direct inoculation of Vitek 2 cards from positive BACTEC cultures. Eur J Clin Microbiol Infect Dis 2004, 23(12):892-898. Acknowledgements Thi k This work was supported by Profileringsfonds azM (PF245). The Profileringsfonds azM had no role in the study design, in the collection or analysis of data, or in the writing or submission of the manuscript. 14. Chapin KC, Musgnug MC: Direct susceptibility testing of positive blood cultures by using Sensititre broth microdilution plates. Journal of clinical microbiology 2003, 41(10):4751-4754. References 1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR: Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical care medicine 2001, 29(7):1303-1310. 1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR: Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical care medicine 2001, 29(7):1303-1310. 21. Brown DF: The E-Test challenged with selected strains. Diagnostic microbiology and infectious disease 1992, 15(5):465-468. 22. CLSI: Performance Standards for Antimicrobial Susceptiblity Testing; Seventeenth Informational Supplement. CLSI Document M100-17. Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania, 19087-1898, USA; 200727. 2. Dombrovskiy VY, Martin AA, Sunderram J, Paz HL: Facing the challenge: decreasing case fatality rates in severe sepsis despite increasing hospitalizations. Critical care medicine 2005, 33(11):2555-2562. 3. Martin GS, Mannino DM, Eaton S, Moss M: The epidemiology of sepsis in the United States from 1979 through 2000. The New England journal of medicine 2003, 348(16):1546-1554. 23. Ling TK, Liu ZK, Cheng AF: Evaluation of the VITEK 2 system for rapid direct identification and susceptibility testing of gram-negative bacilli 23. Ling TK, Liu ZK, Cheng AF: Evaluation of the VITEK 2 system for rapid direct identification and susceptibility testing of gram-negative bacilli Page 7 of 7 Page 7 of 7 Page 7 of 7 Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 Beuving et al. BMC Microbiology 2011, 11:156 http://www.biomedcentral.com/1471-2180/11/156 from positive blood cultures. Journal of clinical microbiology 2003, 41(10):4705-4707. from positive blood cultures. Journal of clinical microbiology 2003, 41(10):4705-4707. 24. La Scola B, Raoult D: Direct identification of bacteria in positive blood culture bottles by matrix-assisted laser desorption ionisation time-of- flight mass spectrometry. PloS one 2009, 4(11):e8041. 25. Diederen BM, Zieltjens M, Wetten H, Buiting AG: Identification and susceptibility testing of Staphylococcus aureus by direct inoculation from positive BACTEC blood culture bottles. Clin Microbiol Infect 2006, 12(1):84-86. 25. Diederen BM, Zieltjens M, Wetten H, Buiting AG: Identification and susceptibility testing of Staphylococcus aureus by direct inoculation from positive BACTEC blood culture bottles. Clin Microbiol Infect 2006, 12(1):84-86. 26. Wellinghausen N, Pietzcker T, Poppert S, Belak S, Fieser N, Bartel M, Essig A: Evaluation of the Merlin MICRONAUT system for rapid direct susceptibility testing of gram-positive cocci and gram-negative bacilli from positive blood cultures. Journal of clinical microbiology 2007, 45(3):789-795. 26. Wellinghausen N, Pietzcker T, Poppert S, Belak S, Fieser N, Bartel M, Essig A: Evaluation of the Merlin MICRONAUT system for rapid direct susceptibility testing of gram-positive cocci and gram-negative bacilli from positive blood cultures. 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https://openalex.org/W3188055443	https://www.researchsquare.com/article/rs-720315/latest.pdf	English	null	Blood transfusion had no influence on the 5-year biochemical recurrence after robot-assisted radical prostatectomy: a retrospective study	BMC urology	2,021	cc-by	3,982	Jiwon Han Jiwon Han Seoul National University Bundang Hospital Young-Tae Jeon Seoul National University Bundang Hospital Jung-Hee Ryu Seoul National University Bundang Hospital Ah-Young Oh Seoul National University Bundang Hospital Hwanik Kim Seoul National University Bundang Hospital Yu Kyung Bae Seoul National University Bundang Hospital Chang-Hoon Koo (  vollock9@gmail.com ) Seoul National University Bundang Hospital Jiwon Han Seoul National University Bundang Hospital Young-Tae Jeon Seoul National University Bundang Hospital Jung-Hee Ryu Seoul National University Bundang Hospital Ah-Young Oh Seoul National University Bundang Hospital Hwanik Kim Seoul National University Bundang Hospital Yu Kyung Bae Seoul National University Bundang Hospital Chang-Hoon Koo (  vollock9@gmail.com ) Seoul National University Bundang Hospital Research Article Keywords: Biochemical recurrence, Red blood cell transfusion, Robot-assisted laparoscopic radical prostatectomy, Prostate cancer Posted Date: August 3rd, 2021 DOI: https://doi.org/10.21203/rs.3.rs-720315/v1 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Keywords: Biochemical recurrence, Red blood cell transfusion, Robot-assisted laparoscopic radical prostatectomy, Prostate cancer Posted Date: August 3rd, 2021 Results A total of 1311 patients were included in the final analysis. Of these, 30 patients (2.3%) were transfused with RBC either during robot-assisted laparoscopic radical prostatectomy or during their hospital stay, which corresponded to 5-year biochemical recurrence of 15.7%. Multivariate Cox proportional hazard regression analysis showed that RBC transfusion had no influence on the 5-year biochemical recurrence. Variables including pathologic T stage (Hazard ratio [HR] 3.5, 95% confidence interval [CI] 2.4-5.1 p < 0.001), N stage (HR 2.3, 95% CI 1.5-3.7, p < 0.001), Gleason score (HR 2.4, 95% CI 1.8-3.2, p < 0.001), and surgical margin (HR 2.0, 95% CI 1.5-2.8, p < 0.001) were independently associated with the 5-year biochemical recurrence. Conclusions RBC transfusion had no significant influence on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy. DOI: https://doi.org/10.21203/rs.3.rs-720315/v1 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. R d F ll Li License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Version of Record: A version of this preprint was published at BMC Urology on November 17th, 2021. See the published version at https://doi.org/10.1186/s12894-021-00926-0. Page 1/14 Page 1/14 Background Although red blood cells (RBC) transfusion is known to be significantly associated with biochemical recurrence in patients undergoing open prostatectomy, its influence on biochemical recurrence after robot- assisted laparoscopic radical prostatectomy remains unclear. Therefore, this study aimed to validate the effect of RBC transfusion on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy. Methods This study retrospectively analyzed the medical records of patients who underwent robot-assisted laparoscopic radical prostatectomy at single tertiary academic hospital between October 2007 and December 2014. Univariate and multivariate Cox proportional hazard regression analysis was performed to identify any potential variables associated with 5-year biochemical recurrence. Ethics statement This retrospective study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (SNUBH; Approval number: B-2005/615 − 105). Given the retrospective design, the need for informed consent was waived. Background Robot-assisted laparoscopic radical prostatectomy (RARP) is widely used to treat prostate cancer [1]. Advantageously, RARP reduces blood loss, lowers postoperative pain, leads to fewer complications, and promotes better functional outcomes, when compared to conventional approaches [2–4]. In addition, RARP provides better pathological and oncological outcomes when compared to laparoscopic prostatectomy [5]. One common benchmark for evaluating treatment efficacy is biochemical recurrence (BCR), which is used as a surrogate marker for prostate cancer [6]. The 5-year BCR after RARP is reported to be approximately Page 2/14 14% [7]. By contrast, the 5-year BCR after open prostatectomy is reported to be substantially higher, between 20 ~ 40% [8]. Previous work has identified preoperative prostate specific antigen (PSA), pathologic T stage, surgical margin, as independent predictors of 5-year BCR following open prostatectomy [6]. Moreover, a recent meta-analysis showed that blood transfusion increased the 5-year BCR in patients undergoing open prostatectomy [9]. However, it has not yet been established whether blood transfusion can increase the 5-year BCR in patients undergoing RARP. Therefore, this study aimed to evaluate the effect of blood transfusion on the 5-year BCR in patients undergoing RARP. Population We examined the electronic medical records of patients who were diagnosed with prostate cancer and underwent RARP at SNUBH between October 2007 and December 2014. RARP has been performed in our institution using the da Vinci Surgical System since October 2007. We excluded patients who received radiation therapy or hormonal treatment prior to surgery. Patients whose baseline or postoperative PSA data were missing or incomplete, were also excluded. We also excluded patients whose RARP was converted to open surgery. Data collection and outcomes Blood transfusion data were retrieved from electronic medical records of SNUBH and used to evaluate the efficacy of transfusion. Perioperative transfusion was defined as red blood cells (RBC) transfusion either during RARP or within the postoperative hospital stay. RBC was transfused according to the clinical decision of physicians. The demographic (age and body mass index), clinical, and pathological data of patients were collected as covariates. Collected clinical data included American society of anesthesiologists physical status, smoking history, main anesthetic agents, the administration of intraoperative fluid, estimated blood loss during surgery, duration of surgery and anesthesia, and length of hospital stay. Pathologic evaluation of the specimens was consistently performed by urologic pathologists. Pathologic T stage, N stage, margin status, and Gleason score were collected. BCR was defined as two consecutive serum PSA level of ≥ 0.2 ng/mL. The initial postoperative PSA was evaluated after 6 weeks. Thereafter, PSA was assessed every 3 months for the first year, and every 6 months during the subsequent 4 years. Statistical analysis Statistical analysis Page 3/14 Page 3/14 Continuous variables were presented as median with interquartile ranges (IQR), categorical variables were presented as number with percentage. Univariate Cox proportional hazard regression analysis was performed to identify any potential variables associated with the 5-year BCR. Subsequently, variables with a p-value < 0.1 in univariate analysis were selected for multivariate Cox proportional hazard regression analysis using forward selection step. In regression analyses, we categorized the pathologic T stage as < pT3 or ≥ pT3, and the Gleason score as < 8 or ≥ 8. All statistical analyses were performed using SPSS 24. A p value < 0.05 was considered statistically significant. Results A total of 1341 patients underwent RARP between October 2007 and December 2014 at SNUBH. Among them, 12 patients were excluded due to a lack of preoperative or postoperative PSA data. An additional 15 patients were excluded for receiving radiation therapy or hormonal treatment prior to surgery. Finally, three additional patient was excluded because they were converted from RARP to the open technique or they received re-operation before discharge. As such, a total of 1311 patients were included in the final analysis (Fig. 1). Demographic characteristics are summarized in Table 1. Among 1311 patients, 30 patients (2.3%) were transfused with RBCs during RARP or the hospital stay. The median follow-up period after RARP was 102 [IQR 60–146] months, and the 5-year BCR was 15.7% (n = 206). The median time to BCR was 9.8 [IQR 3.4–30.1] months. Page 4/14 Table 1 Clinical and pathological characteristics of included patients (n = 1311) Variable Preoperative variables Age, year 66 [61–71] BMI, kg/m2 24.6 [22.8–26.2] ASA physical status, n I 436 (33.3%) II 829 (63.2%) III 46 (3.5%) Smoker, n 490 (37.4%) Preoperative PSA, ng/ml 8.9 [5.6–15.8] Preoperative Hb, g/dl 14.6 [13.8–15.4] Preoperative Hct, % 42.8 [40.4–44.9] Year 2007–2008 196 (15.0%) 2009–2010 372 (28.4%) 2011–2012 377 (28.8%) 2013–2014 366 (27.9%) Intraoperative variables Main anesthetic agent, n Inhalation agent 1217 (92.8%) Propofol 94 (7.2%) Fluid administered Crystalloid, ml 1204 [900–1651] Estimated blood loss, ml 200 [100–300] Duration of surgery, min 200 [175–225] Statistically significant p value (< 0.05) are highlighted in bold. Values are expressed as median [interquartile range] or number (percentage). Abbreviations: BMI, Body mass index; ASA, American society of anesthesiologists; PSA, Prostate-specific antigen; Hb, hemoglobin; Hct, hematocrit; BCR, Clinical and pathological characteristics of included patients (n = 1311) Statistically significant p value (< 0.05) are highlighted in bold. Values are expressed as median [interquartile range] or number (percentage). Abbreviations: BMI, Body mass index; ASA, American society of anesthesiologists; PSA, Prostate-specific antigen; Hb, hemoglobin; Hct, hematocrit; BCR, Biochemical recurrence. Results Page 5/14 Variable Duration of anesthesia, min 250 [225–275] Perioperative transfusion Patients who transfused, n 30 (2.3%) Number of packed RBC in patients transfused 2 [2–3] Pathological variables Pathologic T stage, n pT2 3 (0.2%) pT2a 109 (8.3%) pT2c 771 (58.8%) pT3a 291 (22.2%) pT3b 129 (9.8%) pT4 8 (0.6%) Pathologic N stage, n Nx 792 (60.4%) N0 486 (37.0%) N1 33 (2.5%) Gleason score, n ≤ 6 116 (8.8%) 7 1025 (78.2%) 8 62 (4.7%) 9 108 (8.2%) Surgical margin positive, n 393 (30.0%) Length of hospital stay, d 11 [9–12] 1 year BCR 79 (6.0%) 5 year BCR 206 (15.7%) Statistically significant p value (< 0.05) are highlighted in bold. Values are expressed as median [interquartile range] or number (percentage). Abbreviations: BMI, Body mass index; ASA, American Variable Duration of anesthesia, min 250 [225–275] Perioperative transfusion Patients who transfused, n 30 (2.3%) Number of packed RBC in patients transfused 2 [2–3] Pathological variables Pathologic T stage, n pT2 3 (0.2%) pT2a 109 (8.3%) pT2c 771 (58.8%) pT3a 291 (22.2%) pT3b 129 (9.8%) pT4 8 (0.6%) Pathologic N stage, n Nx 792 (60.4%) N0 486 (37.0%) N1 33 (2.5%) Gleason score, n ≤ 6 116 (8.8%) 7 1025 (78.2%) 8 62 (4.7%) 9 108 (8.2%) Surgical margin positive, n 393 (30.0%) Length of hospital stay, d 11 [9–12] 1 year BCR 79 (6.0%) 5 year BCR 206 (15.7%) Statistically significant p value (< 0.05) are highlighted in bold. Values are expressed as median [interquartile range] or number (percentage). Abbreviations: BMI, Body mass index; ASA, American f fi Statistically significant p value (< 0.05) are highlighted in bold. Values are expressed as median interquartile range] or number (percentage). Abbreviations: BMI, Body mass index; ASA, American society of anesthesiologists; PSA, Prostate-specific antigen; Hb, hemoglobin; Hct, hematocrit; BCR, Biochemical recurrence. Page 6/14 Table 2 shows the results of univariate and multivariate Cox proportional regression analysis for the 5- year BCR. In univariate analysis, RBC transfusion was associated with the 5-year BCR (HR 2.159, 95% CI 1.107–4.211, p = 0.024). The result also showed the significant association between the number of transfused RBC and 5-year BCR (HR 1.335, 95% CI 1.094–1.631, p = 0.005). However, when they were included in the multivariate analysis with preoperative PSA level, pathologic T stage, N stage, gleason score and surgical margin status, both variables were not statistically significant, respectively (p > 0.05). Results Other variables, including preoperative PSA (HR 1.005, 95% CI 1.002–1.009, p < 0.001), pathologic T stage ≥ pT3 (HR 3.510, 95% CI 2.426–5.078, p < 0.001), N stage (HR 2.337, 95% CI 1.465–3.729, p < 0.001), Gleason score ≥ 8 (HR 2.373, 95% CI 1.756–3.207, p < 0.001) and positive surgical margin (HR 2.010, 95% CI 1.452–2.782, p < 0.001) were found to be independent predictor of 5-year BCR. Table 2 shows the results of univariate and multivariate Cox proportional regression analysis for the 5- year BCR. In univariate analysis, RBC transfusion was associated with the 5-year BCR (HR 2.159, 95% CI 1.107–4.211, p = 0.024). The result also showed the significant association between the number of transfused RBC and 5-year BCR (HR 1.335, 95% CI 1.094–1.631, p = 0.005). However, when they were included in the multivariate analysis with preoperative PSA level, pathologic T stage, N stage, gleason score and surgical margin status, both variables were not statistically significant, respectively (p > 0.05). Other variables, including preoperative PSA (HR 1.005, 95% CI 1.002–1.009, p < 0.001), pathologic T stage ≥ pT3 (HR 3.510, 95% CI 2.426–5.078, p < 0.001), N stage (HR 2.337, 95% CI 1.465–3.729, p < 0.001), Gleason score ≥ 8 (HR 2.373, 95% CI 1.756–3.207, p < 0.001) and positive surgical margin (HR 2.010, 95% CI 1.452–2.782, p < 0.001) were found to be independent predictor of 5-year BCR. Page 7/14 Table 2 Univariate and Multivariate Cox proportional hazard regression analysis for 5-year biochemical recurrence of prostate cancer Variable Univariate Analysis Multivariate Analysis HR (95% CI) p-value HR (95% CI) p-value Preoperative variables Age, year 1.015 (0.994–1.035) 0.155 BMI, kg/m2 0.991 (0.951–1.034) 0.678 ASA physical status I 1 (reference) II 0.794 (0.597–1.056) 0.112 III 0.934 (0.451–1.934) 0.854 Diabetes mellitus 1.321 (0.887–1.968) 0.171 Hypertension 1.188 (0.887–1.592) 0.248 Coronary artery disease 1.421 (0.840–2.404) 0.190 Cerebrovascular accident 1.382 (0.651–2.937) 0.400 Smoker 0.933 (0.702–1.241) 0.634 Preoperative PSA, ng/ml 1.015 (1.013–1.018) < 0.001* 1.005 (1.002– 1.009) < 0.001* Preoperative Hb, g/dl 0.916 (0.826–1.016) 0.098 Intraoperative variables Main anesthetic agent Inhalation agent 1 (reference) Propofol 0.957 (0.556–1.646) 0.874 Crystalloid, ml 1.000 (1.000–1.000) 0.968 Colloid, ml 1.000 (1.000-1.001) 0.034* Estimated blood loss, ml 1.001 (1.000-1.001) 0.042* Perioperative RBC transfusion Statistically significant p value (< 0 05) are highlighted in bold Abbreviations: BMI Body mass index; Statistically significant p value (< 0.05) are highlighted in bold. Results Abbreviations: BMI, Body mass index; ASA, American society of anesthesiologists; PSA, Prostate-specific antigen; Hb, hemoglobin; Hct, hematocrit. Statistically significant p value (< 0.05) are highlighted in bold. Abbreviations: BMI, Body mass index; ASA, American society of anesthesiologists; PSA, Prostate-specific antigen; Hb, hemoglobin; Hct, hematocrit. Page 8/14 Page 8/14 Variable Univariate Analysis Multivariate Analysis None 1 (reference) Transfusion 2.159 (1.107–4.211) 0.024* Number of packed RBC 1.335 (1.094–1.631) 0.005* Pathological variables Pathologic T stage < pT3 1 (reference) ≥ pT3 7.197 (5.264–9.839) < 0.001* 3.510 (2.426– 5.078) < 0.001* Pathologic N stage Nx or N0 1 (reference) N1 7.080 (4.504– 11.129) < 0.001* 2.337 (1.465– 3.729) < 0.001* Gleason score < 8 1 (reference) ≥ 8 5.478 (4.137–7.254) < 0.001* 2.373 (1.756– 3.207) < 0.001* Surgical margin positive 4.821 (3.628–6.404) < 0.001* 2.010 (1.452– 2.782) < 0.001* Statistically significant p value (< 0.05) are highlighted in bold. Abbreviations: BMI, Body mass index; ASA, American society of anesthesiologists; PSA, Prostate-specific antigen; Hb, hemoglobin; Hct, hematocrit. Statistically significant p value (< 0.05) are highlighted in bold. Abbreviations: BMI, Body mass index; ASA, American society of anesthesiologists; PSA, Prostate-specific antigen; Hb, hemoglobin; Hct, hematocrit. Conclusion The evidence from this study suggests that blood transfusion was not associated with an increased 5- year BCR in patients undergoing RARP. We hope that our research will be helpful in terms of perioperative blood management in patients undergoing RARP. Discussion It is important to recognize that BCR is not a definitive indicator for the clinical relapse of prostate cancer. However, BCR has been associated with increased mortality [23]. Therefore, physicians should be aware of predictive factors for BCR in prostate cancer patients, and therein stratify high risk patients to prevent clinical progression. It is important to recognize that BCR is not a definitive indicator for the clinical relapse of prostate cancer. However, BCR has been associated with increased mortality [23]. Therefore, physicians should be aware of predictive factors for BCR in prostate cancer patients, and therein stratify high risk patients to prevent clinical progression. There are several limitations in this study. First, transfusion was performed in accordance with conventional criteria but without a predefined protocol. Given that our results are based on a retrospective analysis, further prospective studies are therefore required to validate the association between transfusion and 5-year BCR. Second, the impact of RBC storage was not considered in this study. It has been reported that prolonged RBC storage may have detrimental clinical impacts [24]. However, the small number of patients who were transfused in this study was seemingly insufficient to draw meaningful results from a subgroup analysis based on the duration of RBC storage. Discussion This study showed that perioperative transfusion was not independent factor for 5-year BCR in patients undergoing RARP. In addition, this study found that pathologic T stage, N stage, Gleason score, and surgical margin were independently associated with an increased 5-year BCR. Several studies focused on how transfusion causes pro-tumorigenic environment and supported a significant association between transfusion and increased recurrence in patients undergoing surgery for colon, stomach, liver, or bladder cancer [10–13]. There are several pathophysiology to explain the effect of blood transfusion on tumor recurrence in patients undergoing cancer surgery. Surgical manipulation may enable malignant cells to circulate in the bloodstream [14, 15]. Moreover, anesthetics and opioids attenuate host immunity, leading to a permissive tumor environment [16]. Indeed, previous work assessed perioperative changes in the ratio of Th1/Th2 cells period in surgical patients, and observed a shift Page 9/14 Page 9/14 Page 9/14 toward a Th2 immune response, indicative of a significant alteration in the composition of the immune system [17]. Post-surgical immunosuppression may be further aggravated by transfusion as RBCs can also modulate the immune system, a phenomena referred to as transfusion related immunomodulation (TRIM). There are 4 mechanisms for TRIM; 1) suppression of cytotoxic cell and monocyte activity; 2) release of immunosuppressive prostaglandins; 3) inhibition of interleukin-2 production; 4) increased suppressor T-cell activity [18]. Contrary to those studies, we found that transfusion was not associated with increased 5-year BCR in patients undergoing RARP. In the present study, the average patient blood loss was 200 ml, and transfusion rate was 2.3%. These are comparable to previous work which showed that RARP reduced blood loss (188 ml vs. 745 ml) and transfusion rates (16.5% vs. 1.8%) when compared with open prostatectomy [19]. Among the patients who received blood transfusion, the median number of transfused RBC was 2 units. Given that relatively low blood loss and volume, it can be inferred that the volume of transfused RBC was not enough to induce pro-tumor environment or immunomodulation. Consistent with previous work, this study showed that Gleason score, T stage, N stage, and surgical margin, were independent predictors of 5-year BCR. Several large studies with a follow-up more than 5 years have identified predictors of BCR after RARP [7, 20–22]. Despite slightly different definitions of variables among these studies, most studies have reported that Gleason score, pathologic stage, and/or surgical margin were independently associated with 5-year BCR. Acknowledgements Not applicable Authors’ contributions J.H. and C-.H.K. wrote the main manuscript text, Y-.T.J and C-.H.K. developed protocol and edit the manuscript, J-.H.R. managed and analyzed data, A-.Y.O., H.K. and Y.K.B. collected and analyzed data. All authors reviewed the manuscript. Declarations Page 10/14 Page 10/14 Ethics approval and consent to participate This study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Seoul National University Bundang Hospital (No. B-2005/615-105 and approval date: May 20, 2020). Patient consent was waived due to the retrospective design. Availability of data and materials Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests No funding received References 1. Mottrie A, De Naeyer G, Novara G, Ficarra V. Robotic radical prostatectomy: a critical analysis of the impact on cancer control. Curr Opin Urol. 2011;21(3):179-84. 1. Mottrie A, De Naeyer G, Novara G, Ficarra V. Robotic radical prostatectomy: a critical analysis of the impact on cancer control. Curr Opin Urol. 2011;21(3):179-84. 2. Gandaglia G, Sammon JD, Chang SL, Choueiri TK, Hu JC, Karakiewicz PI, et al. Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era. J Clin Oncol. 2014;32(14):1419-26. 3. Murphy DG, Kerger M, Crowe H, Peters JS, Costello AJ. Operative details and oncological and functional outcome of robotic-assisted laparoscopic radical prostatectomy: 400 cases with a minimum Page 11/14 Page 11/14 of 12 months follow-up. Eur Urol. 2009;55(6):1358-66. of 12 months follow-up. Eur Urol. 2009;55(6):1358-66. 4. Novara G, Ficarra V, Mocellin S, Ahlering TE, Carroll PR, Graefen M, et al. Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):382-404. 5. Okegawa T, Omura S, Samejima M, Ninomiya N, Taguchi S, Nakamura Y, et al. Laparoscopic radical prostatectomy versus robot-assisted radical prostatectomy: comparison of oncological outcomes at a single center. Prostate Int. 2020;8(1):16-21. 6. McCormick BZ, Mahmoud AM, Williams SB, Davis JW. Biochemical recurrence after radical prostatectomy: Current status of its use as a treatment endpoint and early management strategies. Indian J Urol. 2019;35(1):6-17. 7. Liss MA, Lusch A, Morales B, Beheshti N, Skarecky D, Narula N, et al. Robot-assisted radical prostatectomy: 5-year oncological and biochemical outcomes. J Urol. 2012;188(6):2205-10. 8. Carroll PR, Parsons JK, Andriole G, Bahnson RR, Barocas DA, Castle EP, et al. NCCN Clinical Practice Guidelines Prostate Cancer Early Detection, Version 2.2015. J Natl Compr Canc Netw. 2015;13(12):1534- 61. 9. Pushan Z, Manbiao C, Sulai L, Jun L, Ruidong Z, Hanshen Y. The impact of perioperative blood transfusion on survival and recurrence after radical prostatectomy for prostate cancer: A systematic review and meta-analysis. J Cancer Res Ther. 2018;14(Supplement):S701-S7. 10. Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev. 2006(1):CD005033. 10. Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev. 2006(1):CD005033. 11. Linder BJ, Frank I, Cheville JC, Tollefson MK, Thompson RH, Tarrell RF, et al. The impact of perioperative blood transfusion on cancer recurrence and survival following radical cystectomy. Eur Urol. 2013;63(5):839-45. 12. References Makino Y, Yamanoi A, Kimoto T, El-Assal ON, Kohno H, Nagasue N. The influence of perioperative blood transfusion on intrahepatic recurrence after curative resection of hepatocellular carcinoma. Am J Gastroenterol. 2000;95(5):1294-300. 13. Squires MH, 3rd, Kooby DA, Poultsides GA, Weber SM, Bloomston M, Fields RC, et al. Effect of Perioperative Transfusion on Recurrence and Survival after Gastric Cancer Resection: A 7-Institution Analysis of 765 Patients from the US Gastric Cancer Collaborative. J Am Coll Surg. 2015;221(3):767-77. 14. Bosch B, Guller U, Schnider A, Maurer R, Harder F, Metzger U, et al. Perioperative detection of disseminated tumour cells is an independent prognostic factor in patients with colorectal cancer. Br J Surg. 2003;90(7):882-8. Page 12/14 Page 12/14 15. Yamaguchi K, Takagi Y, Aoki S, Futamura M, Saji S. Significant detection of circulating cancer cells in the blood by reverse transcriptase-polymerase chain reaction during colorectal cancer resection. Ann Surg. 2000;232(1):58-65. 16. Ash SA, Buggy DJ. Does regional anaesthesia and analgesia or opioid analgesia influence recurrence after primary cancer surgery? An update of available evidence. Best Pract Res Clin Anaesthesiol. 2013;27(4):441-56. 17. Ishikawa M, Nishioka M, Hanaki N, Miyauchi T, Kashiwagi Y, Ioki H, et al. Perioperative immune responses in cancer patients undergoing digestive surgeries. World J Surg Oncol. 2009;7:7. 18. Cata JP, Wang H, Gottumukkala V, Reuben J, Sessler DI. Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions. Br J Anaesth. 2013;110(5):690-701. 19. Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE, Wiklund P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol. 2012;62(1):1-15. 20. Menon M, Bhandari M, Gupta N, Lane Z, Peabody JO, Rogers CG, et al. Biochemical recurrence following robot-assisted radical prostatectomy: analysis of 1384 patients with a median 5-year follow-up. Eur Urol. 2010;58(6):838-46. 21. Sooriakumaran P, Haendler L, Nyberg T, Gronberg H, Nilsson A, Carlsson S, et al. Biochemical recurrence after robot-assisted radical prostatectomy in a European single-centre cohort with a minimum follow-up time of 5 years. Eur Urol. 2012;62(5):768-74. 22. Suardi N, Ficarra V, Willemsen P, De Wil P, Gallina A, De Naeyer G, et al. Long-term biochemical recurrence rates after robot-assisted radical prostatectomy: analysis of a single-center series of patients with a minimum follow-up of 5 years. Urology. 2012;79(1):133-8. 23. Uchio EM, Aslan M, Wells CK, Calderone J, Concato J. References Impact of biochemical recurrence in prostate cancer among US veterans. Arch Intern Med. 2010;170(15):1390-5. 24. Tinmouth A, Fergusson D, Yee IC, Hebert PC, Investigators A, Canadian Critical Care Trials G. Clinical consequences of red cell storage in the critically ill. Transfusion. 2006;46(11):2014-27. Figures Page 13/14 Figure 1 Flow diagram outlining the inclusion and exclusion criteria with assignment of study cohort. Page 14/14 Page 14/14
https://openalex.org/W4248840134	https://neuropsychiatry.imedpub.com/personality-disorders-who-are-we.pdf	English	null	Journal of Neuropsychiatry	Journal of Neuropsychiatry	2,019	cc-by	228	Personality Disorders – Who are we? Soumya Sree Tangirala University of Dundee Medical School, Scotland, United Kingdom Personality Disorders – Who are we? Soumya Sree Tangirala University of Dundee Medical School, Scotland, United Kingdom Abstract Personality disorders cover a wide range of areas and it is quite hard to understand. I suffer from borderline personality disorder and its hard for me to even get the idea of things. Terms are given not because it makes you suddenly a different person but so it is easier for you to find acceptance within yourself. In addition to this it allows other people to gain an understanding of our complex brains. There is simply not enough awareness of how common these personality disorders are and how it affects us on a daily basis. This talk will explain the types of disorders classification, how common they are and some real life stories from myself, managing my traits of borderline personality disorder. care assisstant in a care home and a support worker for autistic adults. In 2019, she got accepted into Dundee Medical School and now she is a 2nd year medical student. © Under License of Creative Commons Attribution 3.0 License \| This article is available in: https://neuropsychiatry.imedpub.com/ 2021 2021 2021 Vol 5. No. S3 Vol 5. No. S3 Biography Soumya embarked on a Gap year in 2018 and worked as a
https://openalex.org/W2149751153	https://europepmc.org/articles/pmc2956463?pdf=render	English	null	Calix[4]arene-click-cyclodextrin and supramolecular structures with watersoluble NIPAAM-copolymers bearing adamantyl units: <i>“Rings on ring on chain”</i>	Beilstein journal of organic chemistry	2,010	cc-by	3,112	Abstract We describe the calixarene-cyclodextrin-coupling via click reaction starting from 5,11,17,23-tetra-tert-butyl-25,27-dipropargyl- ether-26,28-hydroxy-calix[4]arene (calix[4]arene-dipropargylether) (2) onto 6I-azido-6I-deoxycyclomaltoheptaose (3) under microwave assisted conditions. The coupling was proven by MALDI-TOF mass spectrometry, 1H NMR and IR-spectroscopy. The pH dependent supramolecular complex formation with poly(NIPAAM) bearing attached adamantyl units was investigated by dynamic light scattering (DLS) and turbidity measurements. Email: * Corresponding author β-cyclodextrin; calix[4]arene; click chemistry; poly(NIPAAM) Full Research Paper Beilstein J. Org. Chem. 2010, 6, 784–788. doi:10.3762/bjoc.6.83 Address: Institut für Organische Chemie und Makromolekulare Chemie, Heinrich-Heine-Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany Received: 16 June 2010 Accepted: 08 July 2010 Published: 05 August 2010 Guest Editor: H. Ritter © 2010 Garska et al; licensee Beilstein-Institut. License and terms: see end of document. Calix[4]arene-click-cyclodextrin and supramolecular structures with watersoluble NIPAAM-copolymers bearing adamantyl units: “Rings on ring on chain” Bernd Garska, Monir Tabatabai and Helmut Ritter* Full Research Paper Open Access Address: Institut für Organische Chemie und Makromolekulare Chemie, Heinrich-Heine-Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany Email: Bernd Garska - bernd.garska@uni-duesseldorf.de; Monir Tabatabai - tabatabai@uni-duesseldorf.de; Helmut Ritter* - h.ritter@uni-duesseldorf.de * Corresponding author Keywords: β-cyclodextrin; calix[4]arene; click chemistry; poly(NIPAAM) Beilstein J. Org. Chem. 2010, 6, 784–788. doi:10.3762/bjoc.6.83 Received: 16 June 2010 Accepted: 08 July 2010 Published: 05 August 2010 Guest Editor: H. Ritter © 2010 Garska et al; licensee Beilstein-Institut. License and terms: see end of document. Full Research Paper Address: Institut für Organische Chemie und Makromolekulare Chemie, Heinrich-Heine-Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany Email: Bernd Garska - bernd.garska@uni-duesseldorf.de; Monir Tabatabai tabatabai@uni-duesseldorf.de; Helmut Ritter* - h.ritter@uni-duesseldorf.de * Corresponding author Keywords: β-cyclodextrin; calix[4]arene; click chemistry; poly(NIPAAM) Introduction encouraged to couple these two different types of macrocycles via click type reactions. Recent progress in the field of supra- molecular chemistry is based on click chemistry, a versatile and powerful tool that permits the modular assembly of new mo- lecular entities [6,7]. Both CDs as well as calixarenes have already been modified by click chemistry [8-14]. However, the coupling of calixarenes and β-CD via click reaction and their application in the field of supramolecular chemistry has not yet been reported. Herein, we describe the synthesis and complexa- Supramolecular interactions of macrocycles with different types of guest molecules are of increasing practical and theoretical interest [1-3]. In this context, we recently coupled cyclodextrin (CD) with cucubituril via a click reaction and investigated the special interactions with some suitable copolymers [4]. Because of their capability to form host–guest superstructures, CDs and calixarenes turned out to be very attractive not only as molecu- lar receptors but also as building blocks for the construction of supramolecular architectures [5]. For that reason, we were 784 784 Beilstein J. Org. Chem. 2010, 6, 784–788. tion behavior of a dual type calix[4]arene-click-cyclodextrin (4) receptor by the cycloaddition of a dipropargylether of calix[4]arene (2) onto 6I-azido-β-CD (3) under microwave assisted conditions. propargyl proton signal at 2.50 ppm. Furthermore, the aromatic signals at about 7.0 ppm and the tert-butyl groups at 1.0 to 1.2 ppm indicates the presence of the calix[4]arene component. The CD was confirmed by the presence of the H2–H6 protons at about 3.3 to 3.6 ppm, the primary hydroxy group at 4.5 ppm and the secondary hydroxy groups at 5.7 ppm. The 1H NMR spec- trum of the successful cycloaddition of 2 and 3 indicates that the di-substituted calix[4]arene 4 was the major product along with a little amount of the mono-substituted compound. In add- ition, the MALDI-TOF-MS clearly confirmed the existence of the covalently combined rings (4) with a molecular mass of [M + Na+] = 3066 m/z (1 calix[4]arene-click- 2 CD). Host–guest complexion of 4 and 5 An adamantane containing copolymer 5 was prepared via free radical polymerization of 6-acrylamido-N-adamantyl-hexane amide and NIPAAM. Copolymer 5 was mixed with 4 subse- quently (Scheme 2) to form supermolecular structures. Synthesis and characterization of compound 4 The calixarene-click-CD compound (4) was synthesized as shown in Scheme 1. The successful microwave assisted cycloaddition of 5,11,17,23- tetra-tert-butyl-25,27-dipropargylether-26,28-hydroxy- calix[4]arene (calix[4]arene-1,3-dipropargylether) (2) onto 6I-azido-6I-deoxycyclomaltoheptaose (3) was proven by IR spectroscopy by the disappearance of the bands for the azide group at 2105 cm−1 and for the propargyl group at 2115 cm−1, whilst the formation of the triazole ring was confirmed by the appearance of a new band at 1654 cm−1. The structure of com- pound 4 was additionally confirmed by 1H NMR spectroscopy with the appearance of an olefinic proton signal at 8.07 ppm (–C=CH–N) and the disappearance of the characteristic DLS measurements were performed to evaluate the hydro- dynamic diameter of the prepared compounds. Surprisingly, the number averaged hydrodynamic diameter of 4, which is about 150 nm in aqueous solution, which suggests the formation of aggregates. In comparison, the hydrodynamic diameter of β-CD in water is about 1.5 nm, and that of calix[4]arene-1,3-dipro- pargylether (2) in CHCl3 is only 0.64 nm. To reduce the agglomeration, compound 4 was deprotonated by dissolution in Scheme 1: Synthesis of calixarene-click-cyclodextrin 4 via click chemistry and structure of copolymer 5. Scheme 1: Synthesis of calixarene-click-cyclodextrin 4 via click chemistry and structure of copolymer 5. Scheme 1: Synthesis of calixarene-click-cyclodextrin 4 via click chemistry and structure of copolymer 5. 785 Beilstein J. Org. Chem. 2010, 6, 784–788. aqueous NaOH at pH 12. The negative charge was expected to cause intermolecular electrostatic repulsion. Accordingly, the hydrodynamic diameter of 4 decreased in NaOH solution from 150 nm to 9.0 nm, which can actually be attributed to the exist- ence of trimers. adamantyl carboxylate was added to the solution as a competi- tive guest molecule. As expected, a decrease of the hydro- dynamic diameter from 53 nm to 13 nm was observed. Adamantyl carboxylate is known to be a more effective guest [15] than the polymer attached adamantane moiety itself. Thus, the inclusion of the low molecular weight adamantyl carboxy- late into the cavity of the CD component of 4 leads to a replace- ment of copolymer 5. Experimental molecular electrostatic repulsion takes place which decreases the agglomeration in the system. Materials. β-Cyclodextrin (β-CD) was purchased from Wacker Chemie GmbH (Burghausen, Germany) and used after drying overnight over P4O10 under an oil pump vacuum. N-Isopropyl- acrylamide (NIPAAM) 97%, sodium azide (99.5%) and azobis- isobutyronitrile (98%) were purchased from Aldrich Chemicals (Germany) and used as received. Copper-(II)-sulfate penta- hydrate (99%) was obtained from Carl Roth GmbH & CO., and sodium L(+)-ascorbate (99%) obtained from AppliChem (Germany). N,N-Dimethylformamide (DMF) and sodium hydroxide (NaOH) were purchased from VWR (USA). Dimethylsulfoxide-d6 99.9% atom% D was obtained from Deutero GmbH (Germany). Commercially available reagents and solvents were used without further purification. calix[4]arene 1 [19], calix[4]arene-1,3-dipropargylether 2 [8], 6I-azido-6I-deoxycyclomaltoheptaose 3 [20] and poly(6-acryl- amido-N-adamantyl-hexane amide-co-NIPAAM) 5 [4] (Mw: 94900 g/mol, PDI: 3.5) were prepared according to methods described in literature. The turbidity point of copolymer 5 in water, 29 °C, is signifi- cant lower than that of the unmodified poly(NIPAAM) at 34 °C, which can be ascribed to the existence of the hydrophobic adamantyl units in the copolymer. The host–guest effect of the coupled rings 4 on the cloud point of copolymer 5 was evalu- ated by turbidity measurements. Only a slight positive shift of the cloud point temperature from 29 °C to 30 °C was found (Table 1). The temperature shift relative to the cloud point of poly(NIPAAM) itself, can be explained by the inclusion of the hydrophobic adamantyl units of 5 by the CD moiety of 4, which, in principal, should increase the cloud point temperature. In contrast to this, the unavoidable presence of the hydrophobic calixarene units of 4 leads to a reduction of the cloud point temperature. Repeating the turbidity experiment at pH of 12, the cloud point temperature of the copolymer 5 decreased from the original 29 °C to 23 °C due to salt and pH effects [18]. However, after adding the calixarene-click-cyclodextrin (4) to copolymer 5 under similar conditions at pH 12, the cloud point increased to 30.5 °C. This increase of the cloud point can be explained by the deprotonation of the calixarene moiety of 4 to the corresponding phenolate structure, which causes an increase in hydrophilicity. Measurements. IR spectra were recorded with a Nicolet 6700 FTIR (Fourier transform infrared) spectrometer equipped with an ATR unit. The measurements were performed in the rage of 4000–300 cm−1 at room temperature. Experimental 1H NMR spectra were recorded on a Bruker Avance DRX 200 at 20 °C. Chemical shifts were referenced to the solvent value δ 2.51 for DMSO-d6. Matrix assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF-MS) was performed on a Bruker Ultraflex TOF mass spectrometer. Ions formed with a pulsed nitrogen laser (25 Hz, 337 nm) were accelerated to 25 kV, the molecular masses being recorded in linear mode. 2-(4-Hydroxy- phenylazo)benzoic eacid (HABA) in DMF (25 mg/mL) was used as matrix. The samples (1 mg/mL in DMF) were mixed with the matrix solution at volumetric ratios of 1:10. Gel perme- ation chromatography (GPC) analyses were performed on a GPC system from PPS with PPS-WIN-GPC software 4.01, 6.1 with N,N-dimethylformamide as eluent. The flow rate was 1 ml min−1 and the column temperature was maintained at 60 °C. A 0.1% (w/w) polymer solution (100 µL) was applied to a hydroxyethyl methacrylate (HEMA) column combination that consisted of a precolumn of 40 Å and main columns of 40, 100 and 3000 Å porosities. The weight-average molecular weight (Mw) and the polydispersity (PD) were calculated by a calibra- tion curve generated by polystyrene standards with a molecular weight range from 370 to 1000000 Da. DLS experiments were carried out on a Malvern HPPS-ET apparatus at a temperature value of 10 °C. The particle size distribution was derived from a deconvolution of the measurement number averaged auto- correlation function of the sample by the general purpose mode algorithm included in the DTS software. Each experiment was preformed five times to obtain statistical information. Cloud Table 1: Experimental cloud point temperature (LCST) and hydro- dynamic diametera depending on the balance of hydrophobic/ hydrophilic interactions of calixarene-click-cyclodextrin 4 with copolymer 5 depending on pH. Compound number (pH) Turbidity point (°C) Number averaged hydrodynamic diameter (nm) 4 (7) 150 4 (12) 9.0 5 (7) 29.0 8.5 5 (12) 23.0 8.5 5 + 4 (7) 30.0 53.0 5 + 4 (12) 30.5 17.5 aDLS measurements were performed at 10 °C, below the turbidity point of the copolymer. pH-Depending and LCST measurements of the host–guest complex To prevent the agglomeration effects of the CD in compound 4 as discussed above, copolymer 5 and compound 4 were dissolved in an aqueous NaOH solution at pH 12 to deproto- nate the free phenolic groups of the calix[4]arene-derivative 4. After that, the hydrodynamic diameter of copolymer 5 increased due to complexation with negatively charged 4 from 8.5 nm to 17.5 nm. This increase of the hydrodynamic diameter again indicates the inclusion of the polymer attached adamantane moiety into the cavity of the CD-component. Comparing the diameters of complex (4 + 5) at pH 7 (53 nm) and at pH 12 (17.5 nm), it can be supposed, that due to deprotonation inter- The hydrodynamic diameter of copolymer 5 increased from 8.5 nm to 53 nm after addition of 4. This clearly indicates the inclu- sion of a polymer attached adamantane moiety into the cavity of CD. The adamantane moiety is known to be one of the best guest molecules for β-CD [15]. A relatively high complex stability constant for a polymer attached adamantane groups with CD is about 5000 M−1 [16]. Therefore, as shown in Scheme 2, compound 4 obviously is expected to act as an inter- molecular linker between the copolymer chains. To prove the assumed agglomeration of the CD-moieties in water [17], Scheme 2: Superstructure of calixarene-click-cyclodextrin 4 and copolymer 5. Scheme 2: Superstructure of calixarene-click-cyclodextrin 4 and copolymer 5. 786 Beilstein J. Org. Chem. 2010, 6, 784–788. Conclusion Macromolecules 2005, 38, 5897–5904. doi:10.1021/ma0508606 17.Bonini, M.; Rossi, S.; Karlsson, G.; Almgren, M.; Lo Nostro, P.; Baglioni, P. Langmuir 2006, 22, 1478–1484. doi:10.1021/la052878f 17.Bonini, M.; Rossi, S.; Karlsson, G.; Almgren, M.; Lo Nostro, P.; Baglioni, P. Langmuir 2006, 22, 1478–1484. doi:10.1021/la052878f 18.Saeed, A.; Georget, D. M. R.; Mayes, A. G. React. Funct. Polym. 2010, 70, 230–237. doi:10.1016/j.reactfunctpolym.2009.12.004 Host–guest complexion of polymer 5 and calix[4]arene- click-cyclodextrin 4. For further investigations, polymer 5 (50 mg, 5.3 × 10−3 mmol) was dissolved in 5 ml water or aqueous NaOH at pH 12. Product 4 (10 mg, 3.2 × 10−3 mmol) was added and the solution was mechanical stirred for 24 h. This solution was centrifuged to remove undissolved particles. License and Terms License and Terms This is an Open Access article under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The license is subject to the Beilstein Journal of Organic Chemistry terms and conditions: (http://www.beilstein-journals.org/bjoc) The definitive version of this article is the electronic one which can be found at: doi:10.3762/bjoc.6.83 This is an Open Access article under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The license is subject to the Beilstein Journal of Organic Chemistry terms and conditions: (http://www.beilstein-journals.org/bjoc) The definitive version of this article is the electronic one which can be found at: doi:10.3762/bjoc.6.83 Conclusion A calixarene-click-cyclodextrin combi-receptor (4) was synthe- sized via copper-catalyzed Huisgen 1,3-dipolar cycloaddition. Investigations of the interactions with an adamantyl moiety containing copolymer have been carried out, showing the exist- ence of a supramolecular structure. Due to deprotonation of the calixarene moieties at higher pH values, a significant change in solubility and hydrodynamic diameter was observed and corre- lated to the formation of superstructures. 787 Beilstein J. Org. Chem. 2010, 6, 784–788. 6. Kolb, H. C.; Finn, M. G.; Sharpless, K. B. Angew. Chem., Int. Ed. 2001, 40, 2004–2021. doi:10.1002/1521-3773(20010601)40:11<2004::AID-ANIE2004>3.0.CO ;2-5 6. Kolb, H. C.; Finn, M. G.; Sharpless, K. B. Angew. Chem., Int. Ed. 2001, 40, 2004–2021. points were determined by transmission changes (at 500 nm) of the solution heated at 1 K/min in a magnetically stirred cell; cloud points were defined as the temperature at which the trans- mission decreases by 50%. Microwave assisted synthesis was performed using a CEM Discover synthesis unit (monomode system). The temperature was measured by infrared detection with control and maintained at constant value by power modu- lation. Reactions were performed in closed vessels under controlled pressure. doi:10.1002/1521-3773(20010601)40:11<2004::AID-ANIE2004>3.0.CO ;2-5 ;2-5 7. Rostovtsev, V. V.; Green, L. G.; Fokin, V. V.; Sharpless, K. B. Angew. Chem. 2002, 114, 2708–2711. doi:10.1002/1521-3757(20020715)114:14<2708::AID-ANGE2708>3.0. CO;2-0 7. Rostovtsev, V. V.; Green, L. G.; Fokin, V. V.; Sharpless, K. B. doi:10.1002/1521-3757(20020715)114:14<2708::AID-ANGE2708>3.0. CO;2-0 8. Zhan, J.; Tian, D.; Li, H.; New, J. New J. Chem. 2009, 33, 725–728. doi:10.1039/b816467c 9. Bew, S. P.; Brimage, R. A.; L'Hermite, N.; Sharma, S. V. Org. Lett. 2007, 9, 3713–3716. doi:10.1021/ol071047t Synthesis of calix[4]arene-click-cyclodextrin 4. The microwave assisted click reaction of calix[4]arene-1,3-dipro- pargylether (2) (100 mg, 0.14 mmol) with 6I-azido-6I- deoxycyclomaltoheptaose (3) (324.8 mg, 0.28 mmol) was carried out in DMF in the presence of Cu(I) generated by the reduction of copper sulfate (0.014 mmol) with sodium ascor- bate (0.07 mmol). The tube was sealed, placed in the CEM monomode microwave and irradiated at 150 °C and 100 W for 30 min. The solvent was removed under reduced pressure. The crude product 4 was washed with water and dried in vacuum to afford a brown solid (yield: 70%). 10.Pérez-Balderas, F.; Ortega-Muñoz, M.; Morales-Sanfrutos, J.; Hernández-Mateo, F.; Calvo-Flores, F. G.; Calvo-Asín, J. A.; Isac-García, J.; Santoyo-González, F. Org. Lett. 2003, 5, 1951–1954. doi:10.1021/ol034534r 11.Ortega-Muñoz, M.; Morales-Sanfrutos, J.; Pérez-Balderas, F.; Hernández-Mateo, F.; Girón-González, M. D.; Sevillano-Tripero, N.; Salto-González, R.; Santoyo-González, F. Org. Biomol. Chem. 2007, 5, 2291–2301. Conclusion doi:10.1039/b706331h 12.Chan, T. R.; Hilgraf, R.; Sharpless, K. B.; Fokin, V. V. Org. Lett. 2004, 6, 2853–2855. doi:10.1021/ol0493094 13.Hoogenboom, R.; Moore, B. C.; Schubert, U. S. Chem. Commun. 13.Hoogenboom, R.; Moore, B. C.; Schubert, U. S 2006, 38, 4010–4012. doi:10.1039/b608313g 2006, 38, 4010–4012. doi:10.1039/b608313g 14.Munteanu, M.; Choi, S. W.; Ritter, H. Macromolecules 2008, 41, 9619–9623. doi:10.1021/ma8018975 15.Rekharsky, M. V.; Inoue, Y. Chem. Rev. 1998, 98, 1875–1918. doi:10.1021/cr970015o MALDI-TOF: m/z 3066 [M + Na+]. 1H NMR (DMSO-d6, δ(ppm)): 1.05 (s, 9H, -C-(CH3)3), 1.13 (s, 9H, -C-(CH3)3), 1.17 (s, 9H, -C-(CH3)3), 1.19 (s, 9H, -C-(CH3)3), 3.37 (br, 28H, H-2,4), 3.66 (br, 56H, H-3,5,6), 4.48 (br, 7H, O-CH-O), 4.75 (br, 7H, O-CH-O), 4.85 (br, 12H, OH-6), 5.78 (br, 2H, Ar-OH), 6.97 (s, 2H, Ar-H), 7.01 (s, 2H, Ar-H), 7.06 (s, 2H, Ar-H), 7.10 (s, 2H, Ar- H), 7.78 (s, 1H, N-CH=C), 8.07 (s, 1H, N-CH=C). IR: 3328 (-OH), 2929 (aryl, alkyl), 1654 (triazole), 1482 (-C=N-), 1386 (-C(CH3)); further intensive signals, 1151, 1078, 1022 cm−1. MALDI-TOF: m/z 3066 [M + Na+]. 1H NMR (DMSO-d6, δ(ppm)): 1.05 (s, 9H, -C-(CH3)3), 1.13 (s, 9H, -C-(CH3)3), 1.17 (s, 9H, -C-(CH3)3), 1.19 (s, 9H, -C-(CH3)3), 3.37 (br, 28H, H-2,4), 3.66 (br, 56H, H-3,5,6), 4.48 (br, 7H, O-CH-O), 4.75 (br, 7H, O-CH-O), 4.85 (br, 12H, OH-6), 5.78 (br, 2H, Ar-OH), 6.97 (s, 2H, Ar-H), 7.01 (s, 2H, Ar-H), 7.06 (s, 2H, Ar-H), 7.10 (s, 2H, Ar- H), 7.78 (s, 1H, N-CH=C), 8.07 (s, 1H, N-CH=C). IR: 3328 (-OH), 2929 (aryl, alkyl), 1654 (triazole), 1482 (-C=N-), 1386 (-C(CH3)); further intensive signals, 1151, 1078, 1022 cm−1. 16.Amajjahe, S.; Ritter, H. Macromolecules 2008, 41, 716–718. doi:10.1021/ma702271p 16.Amajjahe, S.; Ritter, H. Macromolecules 2008, 41, 716–718. doi:10.1021/ma702271p 17.Bonini, M.; Rossi, S.; Karlsson, G.; Almgren, M.; Lo Nostro, P.; Baglioni, P. Langmuir 2006, 22, 1478–1484. doi:10.1021/la052878f 18.Saeed, A.; Georget, D. M. R.; Mayes, A. G. React. Funct. Polym. 2010, 70, 230–237. doi:10.1016/j.reactfunctpolym.2009.12.004 19.Gutsche, C. D.; Iqbal, M. Org. Synth. 1990, 68, 234–237. 20.Ohga, K.; Takashima, Y.; Takahashi, H.; Kawaguchi, Y.; Yamaguchi, H.; Harada, A. Macromolecules 2005, 38, 5897–5904. doi:10.1021/ma0508606 16.Amajjahe, S.; Ritter, H. Macromolecules 2008, 41, 716–718. doi:10.1021/ma702271p 17.Bonini, M.; Rossi, S.; Karlsson, G.; Almgren, M.; Lo Nostro, P.; Baglioni, P. Langmuir 2006, 22, 1478–1484. doi:10.1021/la052878f 18.Saeed, A.; Georget, D. M. R.; Mayes, A. G. React. Funct. Polym. 2010, 70, 230–237. doi:10.1016/j.reactfunctpolym.2009.12.004 19.Gutsche, C. D.; Iqbal, M. Org. Synth. 1990, 68, 234–237. 20.Ohga, K.; Takashima, Y.; Takahashi, H.; Kawaguchi, Y.; Yamaguchi, H.; Harada, A. References 1. Abraham, W. J. Inclusion Phenom. Macrocyclic Chem. 2002, 43, 159–174. doi:10.1023/A:1021288303104 1. Abraham, W. J. Inclusion Phenom. Macrocyclic Chem. 2002, 43, 159–174. doi:10.1023/A:1021288303104 2. Ikeda, A.; Shinkai, S. J. Am. Chem. Soc. 1994, 116, 3102–3110. doi:10.1021/ja00086a045 2. 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https://openalex.org/W4321348727	https://zenodo.org/records/7620910/files/The%20impact%20of%20self-management%20education-08022023-3.pdf	English	null	The impact of self-management education on prevention and control of type-2 Diabetes mellitus	Zenodo (CERN European Organization for Nuclear Research)	2,023	cc-by	2,590	Sonam Sahu1, Shadma Siddiqui2, Rajni Bagdi3 Professor, Faculty of Paramedical Sciences, SAM Global University Raisen, Madhya Pradesh, India 3Associate Professor, Department of Medical Laboratory Sciences, Faculty of Paramedical Sciences, SAM Global University Raisen, Madhya Pradesh, India 3Associate Professor, Department of Medical Laboratory Sciences, Faculty of Paramedical Sciences, SAM Global University Raisen, Madhya Pradesh, India DOI: https://doi.org/10.5281/zenodo.7620910 Published Date: 08-February-2023 Abstract: DM is metabolic disorder characterized by the decrease ability or complete inability of the tissues to utilise carbohydrate, accompanied by changes in the metabolism of fat, protein, water & electrolytes. The disorder is due to deficiency or diminished effectiveness of the hormone insulin. DM affects some 120 million people world-wide & is in increases. Aims & objectives: To assess the impact of diabetes education among young adults & adult’s diabetics on the control of blood sugar. To assess the diet & nutrient intake of adults by 24 hour diet recall/food frequency questionnaire. Result: During the study it was found that the 36% subjects strongly agreed to that healthy eating makes a big difference in getting disease while 58% subjects somewhat agreed. After the second counselling it was found that the subjects follow the diet chart very carefully and do exercise regularly and also follow to SMBG method regularly and their FBG were control and also PPBS were control. Discussion: Close observation and follow-up during the study period, it was observed that most of the subjects had lack of physical activity. No consumption of fruits and vegetables in an average day, probably it was the cause of obesity. However only the Walnuts maintained flexibility of the arteries. Conclusion: As far as consumption of food is concerned it was found that the adults understudy were taking less nutrient dense but high energy and unbalance carbohydrate foods when compared to the doses recommended by ICMR, therefore most of them were high blood glucose level. Keywords: DM-Diabetes Mellitus, BMI-body mass index, FBG-fasting blood glucose,HbA1C, Protein, PPBS-Post parindial blood glucose level. ISSN 2394-966 International Journal of Novel Research in Life Sciences Vol. 10, Issue 1, pp: (23-26), Month: January - February 2023, Available at: www.noveltyjournals.com The impact of self-management education on prevention and control of type-2 Diabetes mellitus Sonam Sahu1, Shadma Siddiqui2, Rajni Bagdi3 1Assistant Professor, Department of Human Nutrition and Dietetics, Faculty of Paramedical Sciences, SAM Global University Raisen, Madhya Pradesh, India 2Professor, Faculty of Paramedical Sciences, SAM Global University Raisen, Madhya Pradesh, India 3Associate Professor, Department of Medical Laboratory Sciences, Faculty of Paramedical Sciences, SAM Global University Raisen, Madhya Pradesh, India DOI: https://doi.org/10.5281/zenodo.7620910 Published Date: 08-February-2023 ISSN 2394-966X International Journal of Novel Research in Life Sciences International Journal of Novel Research in Life Sciences ol 10 Issue 1 pp: (23-26) Month: January - February 2023 Available at: www noveltyjournals com International Journal of Novel Research in Life Sciences (23 26) M th J F b 2023 A il bl t lt j l International Journal of Novel Research in Life Sciences pp: (23-26), Month: January - February 2023, Available at: www.noveltyjourna Novelty Journals I. INTRODUCTION P \| 23 Diabetes mellitus is a metabolic disorder characterized by the decrease ability or complete inability of the tissues to utilise carbohydrate, accompanied by changes in the metabolism of fat, protein, water & electrolytes. The disorder is due to deficiency or diminished effectiveness of the hormone insulin.1 In diabetes, insulin secreted by the pancreas is either insufficient or ineffective. This may be due to a primary disorder of insulin secretion or due to insulin resistance because of a receptor defect in the target tissue.2 Diabetes affects some 120 million people world-wide & is in increases.3 Over the past three decades, the number of people with diabetes mellitus has more than doubled globally, making it one of the most Page \| 23 International Journal of Novel Research in Life Sciences (23-26) Month: January - February 2023 Available at: www.noveltyjournals.com A formula combining BMI, age, and gender can be used to estimate a person's body fat percentage to an accuracy of 4%. An alternative method, body volume index (BVI), is being developed in an effort to better take into account different body shapes.8 International Journal of Novel Research in Life Sciences (23-26) Month: January - February 2023 Available at: www.noveltyjournals.com Vol. 10, Issue 1, pp: (23-26), Month: January - February 2023, Available at: www.nove Vol. 10, Issue 1, pp: (23-26), Month: January - February 2023, Available at: www.noveltyjournals.com important public health challenges to all nations. Type 2 diabetes mellitus (T2DM) and prediabetes are increasingly observed among children, adolescents and younger adults. The causes of the epidemic of T2DM are embedded in a very complex group of genetic and epigenetic systems interacting within an equally complex societal framework that determines behaviour and environmental influences.4 Severe untreated diabetes of which hyperglycaemia is just one aspect of metabolic derangement can lead to both macro and microvascular complications. A relatively simple and non-invasive method of preventing these complications is to recognize the impact of diet on insulin production and maintenance. Therefore, people with diabetes mellitus need help in planning and accepting a daily diet which contains the appropriate amounts of CHO, protein, fat and fibre, together with adequate amounts or vitamins and minerals.5 Diabetes education provided by certified diabetes educators can help improve the lives of patients with diabetes mellitus. With morbidity and medical costs or increasing concern, diabetes educators must provide patients and primary are given with the tools to improve their DM and the motivation and understanding to help them meet their goals. The impact of early onset Type 2 DM is extensive. The individuals are likely to be obese, have a multigene –rational family history of Type 2 DM, lead a sedentary lifestyle is of black or minority ethnic (BME) origin and come from a socially deprived group.6 we can estimate our energy needs by measuring the amount of oxygen we consume. We eat, we digest, we absorb, we store, we transfer energy, we burn the energy, and then we repeat. Energy balance is determined by caloric intake versus caloric expenditure. Complex control systems promote energy storage (primarily as adipose tissue fat) during periods of food surplus and mobilization of energy stores when food is scarce.7 Body mass index or BMI is a simple and widely used method for estimating body fat mass. BMI was developed in the 19th century by the Belgian statistician and anthropometrist Adolphe Quetelet. BMI is an accurate reflection of body fat percentage in the majority of the adult population. It however is less accurate in people such as body builders and pregnant women. Material and methods The present study was conducted to assess the causes and impact on young type 2 diabetes mellitus from January 2017 to December 2017 it include 60 patients with diabetes mellitus at chirayu hospital Bhopal & Arogya niketan clinic gulmohar of Bhopal city of Madhya Pradesh. For this study data were collected through 2 methods: 1. Survey Method 2. Observation Method For survey an interview method (Written Questionnaire Method) was used. Questionnaire was divided into 7 sections: General information, Food habits, Blood glucose level, Family history, Physical factors, 24 hr Dietary recall, Anthropometric Measurements. Questionnaire was divided into 7 sections: General information, Food habits, Blood glucose level, Family history, Physical factors, 24 hr Dietary recall, Anthropometric Measurements. METHOD OF STUDY - Assess the obesity of the sample was collected by using the BMI chart adopted by NATIONAL INSTITUTE OF HEALTH, USA. METHOD OF STUDY - Assess the obesity of the sample was collected by using the BMI chart adopted by NATIONAL INSTITUTE OF HEALTH, USA. To assess the food intake of the sample, a 24 hr dietary recall method of diet survey was adopted. The young diabetic adults were asked to give an account of view on different factors and quantity of food items consumed. From the height and weight BMI of the individual adult was calculated. The dietary intake was compared with the Recommended Daily Allowance (RDA) given by the Indian Council of Medical Research (ICMR). The data was analyzed by appropriate statistical tools. Liver function test – It has been done to detect comorbidity related to liver. t– It has been done to detect comorbidity related to kidney. enal function test– It has been done to detect comorbidity related to kidney. Renal function test– It has been done to detect comorbidity related to kidney. 24 hour dietary recall – with the help of Questionnaire, it has been collected the information related to daily routine. 24 hour dietary recall – with the help of Questionnaire, it has been collected the information related to daily routine. It has used some educational tools to educate the subjects about diabetes mellitus. has used some educational tools to educate the subjects about diabetes mellitus. Page \| 24 Novelty Journals Novelty Journals ISSN 2394-966X International Journal of Novel Research in Life Sciences Vol. 10, Issue 1, pp: (23-26), Month: January - February 2023, Available at: www.noveltyjournals.com ISSN 2394-966X International Journal of Novel Research in Life Sciences Novelty Journals Novelty Journals ISSN 2394-966X International Journal of Novel Research in Life Sciences Vol. 10, Issue 1, pp: (23-26), Month: January - February 2023, Available at: www.noveltyjournals.com OBSERVATIONS AND RESULTS – TABLE: I Frequency of consuming outside food in a week Number of subject % Never/ Rarely 10 16 % Once in a week 16 26 % 2-3 times in a week 8 13 % 4 or more time in a week 20 33 % Don’t know 6 10 % Only 16 % were consuming outsider foods rarely and 26 % were consuming once in a week and 13 % are consume 2-3 times in a week and 33% were consuming more outsides foods. International Journal of Novel Research in Life Sciences International Journal of Novel Research in Life Sciences International Journal of Novel Research in Life Sciences e 1, pp: (23-26), Month: January - February 2023, Available at: www.noveltyjournals.com International Journal of Novel Research in Life Sciences Vol. 10, Issue 1, pp: (23-26), Month: January - February 2023, Available at: www.noveltyjournals.com OBSERVATIONS AND RESULTS – TABLE: I Frequency of consuming outside food in a week Number of subject % Never/ Rarely 10 16 % Once in a week 16 26 % 2-3 times in a week 8 13 % 4 or more time in a week 20 33 % Don’t know 6 10 % O l 16 % i id f d l d 26 % i i k d 13 % 2 3 Frequency of consuming outside food in a week Number of subject % Never/ Rarely 10 16 % Once in a week 16 26 % 2-3 times in a week 8 13 % 4 or more time in a week 20 33 % Don’t know 6 10 % Only 16 % were consuming outsider foods rarely and 26 % were consuming once in a week and 13 % are consume 2-3 times in a week and 33% were consuming more outsides foods. Only 16 % were consuming outsider foods rarely and 26 % were consuming once in a week and 13 % are consume 2-3 times in a week and 33% were consuming more outsides foods. TABLE: III Glucose level of the subject after imparting the education. S.No. Number of subject average Range 1 Fasting blood glucose level 60 135.26 85 - 234 2 Post parindial blood glucose level 60 194.16 120 - 297 The average of the fasting blood glucose level of the 60 young Diabetic adults was 135.26 and the range between lowest and highest level of the fasting blood glucose level was 85 and 234 respectively. The average of the post parindial blood glucose level of the same 60 young Diabetic adults was 194.16 and the range between lowest and highest level of the post parindial blood glucose level was 120 and 297 respectively. Novelty Journals TABLE: II Test Name Number of subject Average Range Fasting blood glucose level 60 146.56 89 - 260 Post parindial blood glucose level 60 213.8 134 - 356 The average of the fasting blood glucose level of the 60 young adults was 146.56 and the range was 89 – 260, and the average of the post parindial blood glucose level of the 60 young adults is 213.8 and the range was 134-356. The average of the fasting blood glucose level of the 60 young adults was 146.56 and the range was 89 – 260, and the average of the post parindial blood glucose level of the 60 young adults is 213.8 and the range was 134-356. The average of the fasting blood glucose level of the 60 young adults was 146.56 and the range was 89 – 260, and the average of the post parindial blood glucose level of the 60 young adults is 213.8 and the range was 134-356. International Journal of Novel Research in Life Sciences International Journal of Novel Research in Life Sciences , Issue 1, pp: (23-26), Month: January - February 2023, Available at: www.noveltyjournals.com (23-26), Month: January - February 2023, Available at: www.noveltyjournals.com III. CONCLUSION Correlation of height, weight and BMI level of the young diabetic adults belonging to higher and middle income group was analyzed in the present study. Associated factors like lack of physical activity, consumption of fast foods/sodas, fried foods, hormonal factors were included.Results indicated that there was a marked deficiency in the nutritional level. 50 % diabetic adults were obese as they were consuming more outsider foods and less diet as recommended by ICMR. As far as consumption of food is concerned it was found that the adults under study were taking less nutrient dense but high energy and unbalance carbohydrate foods when compared to the doses recommended by ICMR, therefore most of them were high blood glucose level. Although the genetic factors and hormonal imbalance leads to diabetes mellitus but still it can be controlled. The study concluded that deficit consumption of various food stuffs ultimately leads to inadequate intake of nutrients which in turn affect the nutritional status of young adults. Their BMI status proved their food intake resulting in various complications. Emphasis should be laid on the consumption of more green leafy vegetable, seasonal fruits, salad, whole grains and legumes so that they can get valuable nutrients and protein in sufficient amount. Emphasis should be laid on the consumption of balanced, moderate and complex carbohydrate so that they can maintain their blood glucose level. Emphasis to do some exercise and games so that they can maintain their weight. Page \| 25 Novelty Journals ISSN 2394-966X REFERENCES 1] Textbook of Nutrition and Dietetics, Kumud Khanna Ph.D ,Elite Publishing House PVT.LTD.2005 2] A Textbook of Nutrition, Darshan Sohi, S.Vikas & Company (Medical Publishers ) INDIA. 3] Jonathan E Shaw, Paul Z Zimmet, Daniel McCarty, Maximillian De Courten. Diabetes care 23 ( 4), B [3] Jonathan E Shaw, Paul Z Zimmet, Daniel McCarty, Maximillian De Courten. Diabetes care 23 ( 4), B5-B5, 2000 [4] Lei Chen, Dianna J. Magliano & Paul Z. Zimmet Nature Reviews Endocrinology volume 8, pages228–236 (2012) [4] Lei Chen, Dianna J. Magliano & Paul Z. Zimmet Nature Reviews Endocrinology volume 8, pages228–236 (2012) [5] MA Valero, M León-Sanz, I Escobar, P Gomis, A de la Cámara & JM Moreno ,European Journal of Clinical Nutrition volume 55, pages1111–1116 (2001) [6] Journal of Nutrition & Health, Volume 34, issue 1/pages. 69-78/2001 /2288-3886(pISSN) [6] Journal of Nutrition & Health, Volume 34, issue 1/pages. 69-78/2001 /2288-3886(pISSN) [7] Journal of Hydrology, Volume 535, pages 581-597. [8] A Textbook of Nutrition, Darshan Sohi,S.Vikas & Company (Medical Publishers ) INDIA Page \| 26 Page \| 26 Novelty Journals
https://openalex.org/W2956688197	https://zenodo.org/records/3344581/files/35277__1_207565_LE_317654.pdf	Dutch	null	Waardebepaling bij financiële herstructureringen en de nieuwe WHOA	MAB	2,019	cc-by	10,593	Trefwoorden Trefwoorden Waardering, WHOA, dwangakkoord, insolventierecht, reorganisatiewaarde, ondernemingswaarde, distress Waardering, WHOA, dwangakkoord, insolventierecht, reorganisatiewaarde, ondernemingswaarde, distress Samenvatting Geïnspireerd op de Engelse Scheme of Arrangement en het Amerikaanse Chapter 11, is door de regering op 5 juli 2019 het wets voorstel voor de Wet homologatie onderhands akkoord (“WHOA”) ingediend bij de Tweede Kamer. De WHOA beoogt een regeling voor een gerechtelijk dwangakkoord buiten faillissement te introduceren, hetgeen het reorganiserend vermogen van ondernemingen dient te versterken en onnodige faillissementen te voorkomen. In dit artikel beschouwen de auteurs de belangrijke rol die waarde bepaling bij financiële herstructureringen speelt. Ze gaan eerst in op financiële herstructureringen in het algemeen en het doel en de opzet van de WHOA. Vervolgens wordt de rol van waardebepaling binnen het kader van de WHOA uiteengezet en bespreken de auteurs welke vraagstukken zich daarbij in de praktijk kunnen voordoen. Waardebepaling bij financiële herstructureringen en de nieuwe WHOA Wim Holterman, Sebastiaan van den Berg Wim Holterman, Sebastiaan van den Berg Received 8 April 2019 \| Accepted 8 July 2019 \| Published 12 July 2019 Relevantie voor de praktijk De WHOA beoogt een nieuwe wettelijke regeling voor financiële herstructureringen buiten faillissement of surseance van betaling te introduceren. Waardebepaling speelt daarbij een belangrijke rol. Dit artikel gaat in op de plaats van waardebepaling binnen de WHOA en de vraagstukken die zich daarbij in de praktijk kunnen voordoen. Maandblad voor Accountancy en Bedrijfseconomie 93(5/6) (2019): 159–170 DOI 10.5117/mab.93.35277 Maandblad voor Accountancy en Bedrijfseconomie 93(5/6) (2019): 159–170 DOI 10.5117/mab.93.35277 Copyright Holterman W, van den Berg S. This is an open access article distributed under the terms of the Creative Commons Attribu tion License (CC-BY-NC-ND 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. Inleiding Financial distress kan het gevolg zijn van economic dis tress, maar kan zich ook voordoen als de onderneming er bedrijfsmatig goed voorstaat, geen economic distress ondervindt, maar enkel te veel vreemd vermogen heeft.5 van belang vanwege het feit dat veel surseances eindigen in faillissement en dat de uitkeringen aan schuldeisers in faillissement (‘recovery rates’) in Nederland bijzonder laag zijn (zie Boot and Ligterink 2000a; MvT, p. 3). Mo gelijke verklaringen voor deze lage ‘recovery rates’ zijn de lange duur van surseance- en faillissementsprocedu res en dat activa tegen een te lage prijs worden verkocht. Een andere verklaring is dat surseance- en faillissement sprocedures te laat worden gestart en de onderneming er financieel al slecht voor staat (zie Boot and Ligterink 2000b). De WHOA biedt levensvatbare ondernemingen een instrument om tijdig en snel te herstructureren zodat meer waarde behouden kan blijven. j Bij de besluitvorming en onderhandelingen over een dwangakkoord speelt waardebepaling een belangrijke rol. Zo dient de vraag te worden beantwoord of de finan ciële herstructurering en de voortzetting van de onderne ming gunstig zijn voor de gezamenlijke vermogensver schaffers. Daartoe dient de waarde van de onderneming bij herstructurering vergeleken te worden met de waarde zonder herstructurering. Als zonder herstructurering een faillissement onafwendbaar is, betreft dit een vergelij king met de waarde in faillissement. In het meest nega tieve scenario is deze waarde gelijk aan de verkoopop brengst van afzonderlijke activa bij beëindiging van de ondernemingsactiviteiten. Daarnaast is voor individuele vermogensverschaffers van belang of de waarde van het aangepaste recht/vermogenstitel (of uitkering in contan ten) die zij krijgen in het kader van de financiële her structurering, hoger is dan de uitkering die zij zouden ontvangen in faillissement.i Financial distress heeft negatieve gevolgen voor de onderneming. In de financieringsliteratuur wordt onder meer gewezen op het feit dat aandeelhouders in een der gelijke situatie weinig belang hebben om te investeren in betrekkelijk risicoloze projecten met een positieve netto contante waarde maar wel een belang hebben bij risico volle investeringen met een negatieve contante waarde (het zogenaamde onder- en overinvesteringsprobleem; zie bijvoorbeeld Jensen and Meckling 1976 en Myers 1977). Financial distress kan een negatieve spiraal op gang brengen die zonder adequaat ingrijpen kan leiden tot economic distress en uiteindelijk de ondergang van een onderneming. Financial distress kan ertoe leiden dat ook andere belangrijke stakeholders, zoals leveranciers, werknemers en klanten zich terugtrekken en dat de le vensvatbaarheid van de onderneming (verder) wordt aangetast. 1. Inleiding van de rechtbank kan overgaan tot goedkeuring van een akkoord betreffende de herstructurering van de schulden van een onderneming en de aanpassing van de rechten van de aandeelhouders, zodat de schuldeisers of aandeel houders die niet met het akkoord hebben ingestemd op grond van nader toe te lichten voorwaarden toch aan het akkoord kunnen worden gebonden. Om deze reden wordt ook gesproken van een dwangakkoord. Het doel van het dwangakkoord is om het reorganiserend vermogen van ondernemingen te versterken en te voorkomen dat een kleine groep van schuldeisers of aandeelhouders de be langen van de overige bij de ondernemingen betrokken partijen schaadt door een herstructurering, waarmee een faillissement kan worden afgewend, tegen te houden.4 De mogelijkheid een akkoord te implementeren buiten de situatie van surseance van betaling en faillissement, is Op 5 juli 2019 heeft de regering het wetsvoorstel voor de Wet homologatie onderhands akkoord (“WHOA”) en de Memorie van Toelichting (“MvT”) daarbij, ingediend bij de Tweede Kamer.1 Ten aanzien van het reeds in 2017 ge publiceerde voorontwerp voor de WHOA heeft eind 2017 een consultatie plaatsgevonden.2 Vervolgens heeft de Raad van State over het wetsvoorstel geadviseerd.3 Wij gaan in dit artikel in op de waarderingsvragen die een rol spelen bij financiële herstructureringen in het algemeen en de WHOA in het bijzonder. De WHOA heeft betrekking op ondernemingen die wel levensvatbaar zijn, maar vanwege een te zware schuldenlast toch insolvent dreigen te raken (MvT, p. 1). De WHOA voorziet in een regeling op basis waar Holterman W, van den Berg S: Waardebepaling bij financiële herstructureringen en de nieuwe WHOA 160 trekking tot de levensvatbaarheid en rentabiliteit van de ondernemingsactiviteiten (‘economic distress’) en moei lijkheden met betrekking tot het kunnen voldoen aan fi nanciële verplichtingen (‘financial distress’). Zie bijvoor beeld Andrade and Kaplan 1998. Economic distress doet zich voor als de ondernemingsactiviteiten onvoldoende rendabel zijn en de onderneming op basis van het be staande beleid niet levensvatbaar is. Dit kan bijvoorbeeld veroorzaakt worden door ontwrichtende veranderingen in de afzetmarkt, technologische ontwikkelingen, een on juiste strategie of zwak management. Financial distress doet zich voor als een onderneming niet meer aan haar financiële verplichtingen kan of dreigt te kunnen voldoen. 1. Inleiding Dit leidt tot een verdere verslechtering van de financierbaarheid van de onderneming en verdere aantas ting van de levensvatbaarheid. Als deze negatieve spi raal niet gekeerd wordt komt er een moment waarop de onderneming niet meer aan haar operationele betalings verplichtingen kan voldoen en dreigt faillissement. Deze neerwaartse spiraal van financial distress leidt ertoe dat in toenemend tempo en onomkeerbaar waarde van de on derneming verdampt en vermogensverschaffers uiteinde lijk niet meer rest dan de liquidatiewaarde in faillissement (Van den Berg 2019, par. 3.3.1.2). Hoewel waardebepaling bij financiële herstructure ringen op grond van de WHOA dus een belangrijke rol speelt, komt dit onderwerp in het wetsvoorstel en de MvT slechts summier aan de orde. In dit artikel bespreken wij de rol van waardebepaling onder de WHOA en welke vraagstukken zich daarbij in de praktijk kunnen voordoen.i Paragraaf 2 bevat een korte introductie over financi ële herstructureringen en de functie van een dwangak koord. In paragraaf 3 wordt de WHOA kort toegelicht. In paragraaf 4 wordt weergegeven wat de rol van waar debepaling is bij de toetsing van de voorwaarden voor goedkeuring door de rechtbank. In paragraaf 5 wordt besproken dat onzekerheden, die inherent zijn aan waar deringen, deze toets in de praktijk kunnen bemoeilijken. Daarna wordt ingegaan op waarderingsvraagstukken die zich in de praktijk kunnen voordoen bij de bepaling van de waarde onder het akkoord (paragraaf 6) en de waarde bij faillissement (paragraaf 7). Paragraaf 8 bevat enkele conclusies en aanbevelingen. Om deze neerwaartse spiraal te doorbreken dient de onderneming geherstructureerd te worden, uiteraard mits de onderneming na herstructurering levensvatbaar is. Hoe eerder de herstructurering plaatsvindt, hoe meer waarde behouden kan blijven. Herstructurering bestaat in de praktijk meestal uit een combinatie van operationele en financiële herstructurering. Operationele herstructu rering betreft een herstructurering van de ondernemings activiteiten teneinde de onderneming weer rendabel en levensvatbaar te maken, zodat geen sprake meer is van economic distress. Hierbij kan gedacht worden aan maat regelen gericht op een wijziging van de strategie, aan passingen van de organisatie, nieuw management, de ver koop van bedrijfsonderdelen, of een combinatie van deze 2. Financiële herstructurering en de functie van een dwangakkoord Op het moment dat een akkoord onder de WHOA wordt aangeboden, ligt het voor de hand dat de mogelijkheid tot verkoop van de onderneming al is on derzocht en dat de conclusie is getrokken dat een verkoop niet mogelijk is of tot lagere opbrengst zou leiden dan de waarde die bij een financiële herstructurering kan worden gerealiseerd en daarom als alternatief is afgevallen.f belangentegenstelling tussen verschillende klas sen vermogensverschaffers. Ook als de waarde van een onderneming bij een financiële herstructurering hoger is dan bij faillissement, kunnen vermogens verschaffers toch een economisch belang hebben om niet mee te werken aan een financiële herstruc turering. Zo hebben aandeelhouders van een onder neming in distress vaak nog weinig te verliezen maar profiteren zij wel als de onderneming zich tegen de verwachting in gunstig ontwikkelt.6 Een financiële herstructurering betekent veelal dat aandeelhouders gezien hun rang in de vermogensstructuur, hun recht en geheel of gedeeltelijk verliezen en dus ook de mogelijkheid om te profiteren van het onwaarschi jnlijke herstel van de onderneming. Aan het andere uiterste van het spectrum bevinden zich de banken die financiering met zekerheden hebben verstrekt. Als zij bij een faillissement naar verwachting 100% van hun vordering kunnen innen, ligt het niet zonder meer voor de hand dat voortzetting van financiering van een geherstructureerde onderneming voor hen aantrekkelijk is. Er is immers een mogelijkheid dat als de financiële herstructurering uiteindelijk niet succesvol blijkt te zijn, de banken minder dan 100% van hun vordering kunnen innen. De belangentegenstelling uit zich ook in een verschil van mening tussen de vermogensverschaffers over de onderlinge verdeling van het ‘surplus’ van de ‘going concern’-waarde van de onderneming bij financiële herstructurering boven de waarde die zij zonder fi nanciële herstructurering zouden kunnen ontvangen. Als vermogensverschaffers het niet eens zijn over de ‘eerlijke’ verdeling van het surplus kan dit een onder hands akkoord in de weg staan. Indien voor alle vermogensverschaffers evident is dat de onderneming levensvatbaar is en financiële herstruc turering – al dan niet in combinatie met operationele her structurering – tot waarde-optimalisatie leidt, kan berede neerd worden dat een dwangakkoord zoals voorgesteld in de WHOA niet nodig is. Iedereen heeft dan immers een economisch belang bij de financiële herstructurering. In de praktijk bestaan echter verschillende belemmeringen om onderhands tot een akkoord te komen: Strategisch gedrag van individuele vermogensver schaffers om een akkoord te dwarsbomen (‘hold out’). 2. Financiële herstructurering en de functie van een dwangakkoord Bij ondernemingen in moeilijkheden – ‘distress’ – wordt veelal onderscheid gemaakt tussen problemen met be https://mab-online.nl Maandblad voor Accountancy en Bedrijfseconomie 93(5/6): 159–170 161 gatiehouders. Outsiders kunnen daarom geen goede inschatting maken van de levensvatbaarheid van de onderneming, de daaraan verbonden waarde en de opbrengsten bij een faillissement. Deze infor matieachterstand in combinatie met de natuurlijke belangentegenstelling tussen de verschillende ver mogensverschaffers leidt ertoe dat het door insiders opgestelde reorganisatieplan en de waarderingen die ten grondslag liggen aan het akkoord met sceps is zullen worden bekeken (Brown 1989; Giammari no 1989). maatregelen. Financiële herstructurering is gericht op het reduceren van de schuldenlast en het normaliseren van de uit het lood geslagen vermogensstructuur. De belangrijk ste instrumenten voor financiële herstructurering zijn: (i) aanpassing van de schuldvoorwaarden, bijvoorbeeld een verlenging van de looptijd, een afboeking van de hoofd som en aanpassing van overige leningsvoorwaarden, (ii) een omzetting van schulden in aandelen (‘debt-for-equi ty swap’), en (iii) nieuw vermogen, bijvoorbeeld via een aandelenemissie of het aangaan van een achtergestelde lening (vgl. Couwenberg 1997, pp. 21 e.v.).i g ( g g , pp ) Bij financiële herstructurering blijft de onderneming – goeddeels – in handen van de bestaande financiers. Een alternatief voor financiële herstructurering is de verkoop van de onderneming als going concern aan een derde, waarbij de opbrengst vervolgens op basis van de wette lijke rangorde aan de vermogensverschaffers uitgekeerd wordt. Diverse auteurs achten verkoop aan een derde, idealiter via een veiling, superieur aan een financiële re organisatie (zie bijvoorbeeld Baird 1986). Een veiling leidt volgens hen tot de hoogste opbrengst, terwijl een financiële reorganisatie vaak veel tijd vergt, kostbaar is en overschaduwd wordt door belangenconflicten, vertra gingstactieken en discussies over waardebepaling. Tegen deze opvatting kan het nodige worden ingebracht. Onder nemingen in problemen zijn vaak moeilijk te verkopen, onder meer omdat kopers in dezelfde bedrijfstak mogelijk te kampen hebben met vergelijkbare problemen. Verder staan de grote informatieasymmetrie bij ondernemingen in distress en de zwakke onderhandelingspositie van de verkoper een optimale verkoopprijs in de weg (zie bij voorbeeld Shleifer and Vishny 1992). In die omstandig heden zal de prijs die gerealiseerd kan worden bij verkoop aan een derde lager zijn dan de waarde van de onderne ming in handen van de huidige vermogensverschaffers. Of verkoop te verkiezen is boven een financiële herstruc turering zal van de omstandigheden in een concreet ge val afhangen. 3. De hoofdlijnen van de WHOA Het akkoord kan aan de rechter ter goedkeuring wor den voorgelegd indien ten minste één klasse van de ver mogensverschaffers met het akkoord heeft ingestemd. Dat betekent dat het akkoord aan (een) tegenstemmende klasse(n) kan worden opgelegd, de zogenoemde ‘cram down’ (Tabb 2009, par. 11.30; Broude 1984). Aan deze goedkeuring zijn voorwaarden verbonden die op verzoek van één of meer tegenstemmende vermogensverschaf fers uit een tegenstemmende klasse ingeroepen kunnen worden.8 De voor het doel van het onderhavige artikel meest essentiële voorwaarden houden in dat de verdeling van waarde van de rechten over de verschillende klassen onder het akkoord conform juridische rang dient plaats te vinden (Tollenaar 2016, p. 78). Een klasse kan pas waarde ontvangen (in de vorm van een vermogenstitel of uitkering in contanten) als de leden van de hoger ge schikte klasse(n) 100% van, kort gezegd, hun geverifi eerde vordering hebben ontvangen9; daarnaast mag een klasse niet meer ontvangen dan 100% (de ‘not more than 100% rule’). De goedkeuringscriteria van de WHOA zijn geïnspireerd op Chapter 11, waarin ze gezamenlijk de ‘absolute priority rule’ worden genoemd (Tabb 2009, p. 1168).10 Ook geldt dat gelijk gerangschikte vermogens verschaffers gelijk moeten worden behandeld: de ‘no un fair discrimination test’.11 De WHOA voorziet in een regeling op basis waarvan de rechtbank kan overgaan tot goedkeuring van een akkoord betreffende de sanering en herstructurering van de schul den van een onderneming en de aanpassing van de rech ten van de aandeelhouders, zodat de schuldeisers of aan deelhouders die niet met het akkoord hebben ingestemd toch aan het akkoord kunnen worden gebonden. Het uitgangspunt van de WHOA is dat de onderneming het initiatief neemt en het akkoord aanbiedt. Het akkoord kan aan alle schuldeisers en de aandeelhouders van de vennootschap, of slechts aan een aantal van hen, worden aangeboden. Het akkoord dient alle informatie te bevatten die voor een geïnformeerd oordeel door de vermogensver schaffers nodig is. Onder andere moet inzichtelijk worden gemaakt hoe de financiële en eventueel operationele her structurering uitzicht geven op een gezonde levensvatbare onderneming (artikel 375 lid 2 sub e WHOA).i Het akkoord specificeert de wijziging van de rechten van de vermogensverschaffers in het kader van de financi ële herstructurering. Het akkoord dient tevens waarderin gen te bevatten op basis waarvan vermogensverschaffers een oordeel kunnen vormen; hiervoor verwijzen wij naar paragraaf 4 van dit artikel. 2. Financiële herstructurering en de functie van een dwangakkoord Voor wijzigingen in de rechten van vermo gensverschaffers is in de meeste gevallen medew erking van alle individuele vermogensverschaffers noodzakelijk.7 Individuele crediteuren, maar ook aandeelhouders, kunnen een akkoord buiten surse ance of faillissement thans dus frustreren door geen medewerking aan de herstructurering te verlenen. De overige crediteuren hebben dan geen andere keus dan de dwarsliggende crediteuren 100% van hun vorder ing aan te bieden, waardoor de kosten van herstruc turering volledig op hen worden afgewenteld. – ‘asymmetrische informatie’: ‘insiders’, zoals man agement en afhankelijk van de situatie ook de aandeelhouders en banken beschikken over meer informatie dan ‘outsiders’ zoals bijvoorbeeld obli https://mab-online.nl Holterman W, van den Berg S: Waardebepaling bij financiële herstructureringen en de nieuwe WHOA 162 – Spreiding van schulden over meerdere schuldeisers en verschillende soorten schuldtitels. Naarmate schulden gespreid zijn over meerdere crediteuren, zoals bij obligatieleningen en gesyndiceerde leningen het geval is, is de kans op coördinatieproblemen en meningsverschillen groter. Dat is ook het geval naar mate een onderneming meer soorten schuld met ver schillende voorwaarden en looptijden heeft uitstaan. – Spreiding van schulden over meerdere schuldeisers en verschillende soorten schuldtitels. Naarmate schulden gespreid zijn over meerdere crediteuren, zoals bij obligatieleningen en gesyndiceerde leningen het geval is, is de kans op coördinatieproblemen en meningsverschillen groter. Dat is ook het geval naar mate een onderneming meer soorten schuld met ver schillende voorwaarden en looptijden heeft uitstaan. tal uitgebrachte stemmen. Met deze stemprocedure kan een 2/3 meerderheid van een klasse haar wil opleggen aan de minderheid. Deze stemverhoudingen bieden een op lossing voor het in paragraaf 2 besproken ‘hold out’-pro bleem. Een tegenstemmende vermogensverschaffer ge niet echter wel bescherming. De rechtbank zal op verzoek van één of meer vermogensverschaffers – ongeacht of de klasse waartoe zij behoren voor of tegen heeft gestemd – het verzoek tot goedkeuring van het akkoord weigeren als de desbetreffende aandeelhouder of schuldeiser rechten zou krijgen die een aanmerkelijk lagere waarde hebben dan de betaling die zij naar verwachting ontvangen bij een vereffening van het vermogen van de schuldenaar in faillissement. In het Amerikaanse systeem wordt dit cri terium de ‘best interest of creditors test’ genoemd (Tabb 2009, par. 11.26). Een dwangakkoord, zoals de WHOA, kan soelaas bie den voor deze belemmeringen. In de volgende paragraaf lichten we dat nader toe. https://mab-online.nl 3. De hoofdlijnen van de WHOA In de praktijk zal de onder neming met de vermogensverschaffers in overleg treden en onderhandelen tegen de achtergrond van het alternatief van een dwangakkoord. Het ligt voor de hand dat pas als de onderneming verwacht dat het akkoord op voldoende steun kan rekenen, een definitief akkoord wordt aangebo den. De WHOA voorziet ook in de mogelijkheid om reeds in het voortraject gerezen geschillen, bijvoorbeeld over de verschafte informatie en waarderingen, aan de rechter voor te leggen.f f Deze criteria bieden regels voor het vraagstuk dat wij in paragraaf 2 signaleerden over het belangenconflict tus sen vermogensverschaffers en de ‘eerlijke’ verdeling van het surplus van de going concern-waarde (boven de waar de zonder herstructurering) over de verschillende klassen van vermogensverschaffers. De ‘absolute priority rule’ komt er in essentie op neer dat vanwege het akkoord (in de Amerikaanse literatuur wordt in dit verband gesproken van de ‘day of reckoning’, zie bijvoorbeeld Baird 2017, p. 792) de uitstaande vermogenstitels hun optiewaarde – preciezer: de verwachtingswaarde van hun optie – ver liezen. De aandeelhouders verliezen de verwachtings waarde van hun call optie12, de senior-schuldtitels worden ontdaan van de negatieve verwachtingswaarde van de geschreven put optie (Brealey et al. 2011, pp. 590–591). Er vindt de facto een overheveling van de optiewaarden plaats van junior-vermogensverschaffers naar meer seni De vermogensverschaffers stemmen vervolgens over het aangeboden akkoord. Alleen de vermogensverschaf fers van wie de rechten worden gewijzigd zijn stemgerech tigd. Voor de stemming worden de vermogensverschaf fers die verschillende rechten hebben in verschillende klassen ingedeeld. Voor het aannemen van het akkoord door een klasse schuldeisers is vereist dat ten minste 2/3 van het totale bedrag aan vorderingen waarvan een stem wordt uitgebracht, voor het akkoord stemt. Bij een klasse aandeelhouders gaat het om ten minste 2/3 van het aan 163 Maandblad voor Accountancy en Bedrijfseconomie 93(5/6): 159–170 ïnformeerd oordeel te kunnen vormen over het akkoord, waaronder: or-vermogensverschaffers. De ‘cram down’-bepaling van de WHOA biedt de andere vermogensverschaffers be scherming voor het geval vermogensverschaffers uit het oogpunt van het behoud van de optiewaarde (of omdat zij de geschatte reorganisatiewaarde te laag achten) tegen het akkoord zouden stemmen. “d. de financiële gevolgen van het akkoord per klasse van schuldeisers en aandeelhouders; e. 3. De hoofdlijnen van de WHOA de waarde die naar verwachting gerealiseerd kan worden als het akkoord tot stand komt; Er is in de literatuur discussie over de vraag of de ‘ab solute priority rule’ efficiënt is, dat wil zeggen of deze in overeenstemming is met het uitgangspunt van waarde maximalisatie van de onderneming. Een alternatief is de ‘relative priority rule’, welke regel in het kader van de op 6 juni jl. aangenomen Europese herstructureringsrichtlijn13 overigens anders wordt uitgelegd dan in de Amerikaanse literatuur (zie bijvoorbeeld Casey 2011; Baird 201714; De Weijs et al. 2019). Verschillende auteurs (zie bijvoorbeeld Gertner and Scharfstein 1991 en White 1989) wijzen erop dat afwijkingen van de ‘absolute priority rule’ (door juni or-vermogensverschaffers waarde toe te kennen terwijl de senior-vermogensverschaffers nog niet volledig zijn vol daan) de in paragraaf 2 genoemde problemen van onder- en overinvesteringen kunnen mitigeren. f. de opbrengst die naar verwachting gerealiseerd kan worden bij een vereffening van het vermogen van de schuldenaar in faillissement; g. de bij de berekening van de waardes, bedoeld onder e en f, gehanteerde uitgangspunten en aannames;” De “waarde die naar verwachting gerealiseerd kan worden als het akkoord tot stand komt” duiden we in dit artikel aan als de ‘reorganisatiewaarde’ (vgl. Van den Berg et al. 2019; MvT, p. 57). En “de opbrengst die naar verwachting gerealiseerd kan worden bij een vereffening van het vermogen van de schuldenaar in faillissement” is in het meest negatieve scenario de verkoopopbrengst van de afzonderlijke activa bij beëindiging van de onderne mingsactiviteiten, maar kan in een gunstiger scenario ook de opbrengst van een gedeeltelijke going concern-ver koop inhouden. In de paragrafen 6 en 7 lichten we dit na der toe. Een vergelijking van beide waarderingen geeft inzicht in de mate waarin de herstructurering voor de ge zamenlijke vermogensverschaffers te verkiezen is boven faillissement. Een voorstel voor een akkoord dient alle informatie te omvatten die de stemgerechtigde schuldei sers en aandeelhouders nodig hebben om zich voor het plaatsvinden van de stemming een geïnformeerd oordeel te kunnen vormen over het akkoord. Gelet op het boven staande vallen hieronder: Ten slotte wijzen wij op het recht dat schuldeisers, die behoren tot een tegenstemmende klasse, hebben om in plaats van wat hen onder het akkoord wordt aangeboden, een uitkering in contanten te ontvangen ter hoogte van het bedrag dat zij in faillissement naar verwachting aan betaling in geld zouden ontvangen. 3. De hoofdlijnen van de WHOA Deze bepaling vinden we niet terug in de Engelse Scheme of Arrangement en Amerikaanse Chapter 11. Het recht op uitkering in con tanten is met name aantrekkelijk voor financiers met ze kerheden die bij faillissement een relatief hoge uitkering kunnen verwachten. In de MvT (p. 19) wordt dit recht als volgt onderbouwd: “De afwijzingsgrond opgenomen in artikel 384, vierde lid, onder b, omvat een extra waarborg voor schuldeisers die niet met de vereiste meerderheid met het akkoord heb ben ingestemd. Deze schuldeisers kunnen niet gedwongen worden om in de onderneming te blijven investeren, als zij bij een faillissement van de schuldenaar een uitkering in geld tegemoet zouden kunnen zien.” – de waardering van de vermogenstitels die vermo gensverschaffers op basis van het akkoord verkri jgen. Het gaat hierbij in essentie om een verdeling van de reorganisatiewaarde over de verschillende vermogenstitels die op basis van het voorstel worden toegekend. Een waardering van deze vermogenstitels is nodig om te beoordelen of het akkoord voldoet aan de ‘absolute priority rule’ (waaronder de ‘not more than 100% rule’) en is ook nodig voor de ‘best inter est of creditors’-test (zie paragraaf 3); enf Een mogelijk bezwaar van het recht op een uitkering in contanten is dat dit een akkoord mogelijk kan frustreren, omdat het de onderneming voor een herfinancieringspro bleem stelt in een situatie van distress waarbij herfinan ciering per definitie al moeilijk is. De betreffende finan ciers kunnen hiermee een situatie van ‘hold out’ creëren omdat zonder hun medewerking een financiële herstruc turering onmogelijk is (Van den Sigtenhorst et al. 2017, par. 2.2.14). de opbrengst die individuele vermogensverschaffers bij faillissement ontvangen. Het gaat hier om een verdeling van de opbrengst bij faillissement volgens de wettelijke rangorde. Deze waardering is nodig in het kader van de ‘best interest of creditors test’ en kan ook nodig zijn om te kunnen bepalen welk be drag vermogensverschaffers, die onder het akkoord mogen opteren voor een uitkering in contanten, naar verwachting in geld zouden ontvangen bij faillisse ment (zie paragraaf 3). 4. De WHOA en waardering – Een senior-lening met een marktwaarde van 50 en een nominale waarde van 100; – Een senior-lening met een marktwaarde van 50 en een nominale waarde van 100; – Een senior-lening met een marktwaarde van 50 en een nominale waarde van 100; – Een achtergestelde lening met een marktwaarde van 20 en een nominale waarde van 60; en – Een achtergestelde lening met een marktwaarde van – Een achtergestelde lening met een marktwaarde van 20 en een nominale waarde van 60; en 20 en een nominale waarde van 60; e – Eigen vermogen met een marktwaarde van 10. De ondernemingswaarde van XYZ is gelijk aan de som van de marktwaarden van de uitstaande vermogenstitels, namelijk 80 (10 + 20 + 50). De financiële problemen van XYZ blijken uit de verhouding van de marktwaarde van het eigen vermogen (10) en de ondernemingswaarde (80) en de forse discount van de marktwaarde van de schulden ten opzichte van de nominale waarde. Wij veronderstellen dat als XYZ failleert, de op brengst bij liquidatie slechts 40 bedraagt. De vermogens verschaffers menen het beste af te zijn met een operatio nele en financiële herstructurering van XYZ. XYZ biedt de vermogensverschaffers een akkoord aan met de vol gende elementen: – De herstructurering resulteert in een reorganisa tiewaarde van 120. – De senior-schuld met een hoofdsom van 100 wordt omgezet in een nieuwe schuld met een waarde van 40. De senior-crediteuren verkrijgen daarnaast 75% van het aandelenkapitaal met een waarde van 60. – De achtergestelde lening met een hoofdsom van 60 wordt eveneens omgezet in aandelenkapitaal; de houders krijgen 25% van het aandelenkapitaal met een waarde van 20. – De oude aandeelhouders ontvangen niets. Tabellen [1], [2] en [3] tonen de waarderingen in res pectievelijk de huidige situatie van distress, bij faillisse ment en bij financiële herstructurering. 5. Waarderingsonzekerheid bemoeilijkt effectieve toets homologatievoorwaarden https://mab-online.nl 4. De WHOA en waardering De WHOA en de MvT zijn zeer summier over waarde bepaling. De WHOA geeft in artikel 375 lid 1 weer dat het akkoord informatie dient te bevatten die de stemge rechtigde schuldeisers en aandeelhouders nodig hebben om zich voor het plaatsvinden van de stemming een ge Uit het bovenstaande blijkt dat toetsing van een ak koord aan de wettelijke voorwaarden (voor goedkeuring van het akkoord door de rechtbank) in belangrijke mate https://mab-online.nl https://mab-online.nl Holterman W, van den Berg S: Waardebepaling bij financiële herstructureringen en de nieuwe WHOA Holterman W, van den Berg S: Waardebepaling bij financiële herstructureringen en de nieuwe WHOA 164 een waarderingsvraagstuk is. We sluiten deze paragraaf af met enkele procesmatige aspecten van de waardebepa ling in het kader van de WHOA. De gang van zaken kan zijn dat de schuldenaar een conceptakkoord aanbiedt aan de vermogensverschaffers dat ook de benodigde waarde ringen bevat. De kans is groot dat over de waarderingen discussie ontstaat. Die discussie zal niet alleen de waarde ringsuitkomsten en gehanteerde uitgangspunten betreffen, maar ook de adequaatheid van de informatie die overlegd wordt om de waarderingen te kunnen beoordelen. Het me chanisme is zodanig dat de schuldenaar de mogelijkheid heeft om geschillen over de waarderingen en adequaatheid van de overlegde informatie in een vroegtijdig stadium ter toetsing aan de rechter voor te leggen (artikel 378 lid 1 WHOA). De schuldenaar zou hiertoe bijvoorbeeld kun nen overgaan als er sprake is van een belangrijk verschil van inzicht met een voor de stemming over een akkoord cruciale klasse van vermogensverschaffers. Meningsver schillen over de waardering kunnen ook in het kader van de homologatiezitting worden behandeld (artikel 384 lid 6 jo. artikel 378 lid 5 WHOA). De rechter kan in voor noemde situaties een deskundige aanwijzen om bepaal de waarderingsvragen te beantwoorden (artikel 378 lid 5 WHOA). Deze waarderingsopdracht zal, gelet op de situa tie van distress, uiteraard in een korte doorlooptijd moeten worden uitgevoerd. De mogelijkheid dat de rechter in het kader van een homologatiezitting een waarderingsdeskun dige kan aanwijzen betekent dat partijen in het onderhan delingsproces voorafgaand aan het aanbieden van het fina le akkoord en bij het uitbrengen van hun stem een prikkel hebben om – uiteindelijk – een zo realistisch mogelijk standpunt over de waarderingen in te nemen. Tabel 5. Reorganisatiewaarde van 140 in plaats van 100. De waarderingsonzekerheid bemoeilijkt dus de toet sing van het akkoord aan de hand van de ‘absolute pri ority rule’, waaronder de ‘not more than 100% rule’. Strikt genomen kan men bij toepassing van deze criteria niet uit de voeten met een waarde-bandbreedte maar is een puntschatting nodig. Een puntschatting is bij meer senior-schuldtitels wel te geven, maar in veel mindere mate bij aandelen en andere junior-instrumenten als ach De waarderingsonzekerheid bemoeilijkt dus de toet sing van het akkoord aan de hand van de ‘absolute pri ority rule’, waaronder de ‘not more than 100% rule’. Strikt genomen kan men bij toepassing van deze criteria niet uit de voeten met een waarde-bandbreedte maar is een puntschatting nodig. Een puntschatting is bij meer senior-schuldtitels wel te geven, maar in veel mindere mate bij aandelen en andere junior-instrumenten als ach De waarderingsonzekerheid bemoeilijkt dus de toet sing van het akkoord aan de hand van de ‘absolute pri ority rule’, waaronder de ‘not more than 100% rule’. Strikt genomen kan men bij toepassing van deze criteria niet uit de voeten met een waarde-bandbreedte maar is een puntschatting nodig. Een puntschatting is bij meer senior-schuldtitels wel te geven, maar in veel mindere mate bij aandelen en andere junior-instrumenten als ach 6. Enkele vraagstukken bij de bepaling van de reorganisatiewaarde 5. Waarderingsonzekerheid bemoeilijkt effectieve toets homologatievoorwaarden Tabel 1. Huidige marktwaarde XYZ in distress. Ondernemingswaarde 80 Eigen vermogen 10 Achtergestelde schuld 20 Senior-schuld 50 Totaal 80 Totaal 80 Tabel 2. Opbrengst XYZ bij faillissement. Liquidatiewaarde 40 Uitkering aan senior-schuld 40 Tabel 3. Waarde XYZ bij financiële herstructurering. Reorganisatiewaarde 120 Eigen vermogen - geconverteerde senior-schuld 75% 60 - geconverteerde achtergestelde schuld 25% 20 80 Senior-schuld 40 Totaal 120 Totaal 120 Tabel 1. Huidige marktwaarde XYZ in distress. Ondernemingswaarde 80 Eigen vermogen 10 Achtergestelde schuld 20 Senior-schuld 50 Totaal 80 Totaal 80 Tabel 2. Opbrengst XYZ bij faillissement. Liquidatiewaarde 40 Uitkering aan senior-schuld 40 Tabel 3. Waarde XYZ bij financiële herstructurering. Reorganisatiewaarde 120 Eigen vermogen - geconverteerde senior-schuld 75% 60 - geconverteerde achtergestelde schuld 25% 20 80 Senior-schuld 40 Totaal 120 Totaal 120 Tabel 1. Huidige marktwaarde XYZ in distress. In de vorige paragraaf hebben we besproken dat de toet sen van het akkoord aan de homologatievoorwaarden, zo als de ‘absolute priority rule’ (waaronder de ‘not more than 100% rule’) en de ‘best interest of creditors’, geba seerd zijn op waarderingen. Een kenmerk van waarderingen van ondernemingen is dat ze subjectief zijn en vaak uitgedrukt worden in gro te bandbreedtes. Discussies over te hanteren methoden, prognoses en andere uitgangspunten kunnen ertoe leiden dat partijen er een geheel verschillende visie op de waarde van een onderneming op nahouden. Dit doet zich des te meer voor bij ondernemingen in distress waar onzeker heden groter zijn dan bij gezonde ondernemingen. Deze waarderingsonzekerheid bemoeilijkt een effectieve toets van het akkoord aan de homologatievoorwaarden. We il lustreren dat aan de hand van een gestileerd voorbeeld.i Tabel 3. Waarde XYZ bij financiële herstructurering. Reorganisatiewaarde 120 Eigen vermogen - geconverteerde senior-schuld 75% 60 - geconverteerde achtergestelde schuld 25% 20 80 Senior-schuld 40 Totaal 120 Totaal 120 Onderneming XYZ verkeert in financiële problemen. XYZ heeft een vermogensstructuur met drie uitstaande vermogenstitels: https://mab-online.nl Maandblad voor Accountancy en Bedrijfseconomie 93(5/6): 159–170 165 Tabel 5. Reorganisatiewaarde van 140 in plaats van 100. Reorganisatiewaarde 140 Eigen vermogen - geconverteerde senior-schuld 75% 75 - geconverteerde achtergestelde schuld 25% 25 100 Senior-schuld 40 Totaal 140 Totaal 140 Uit de tabellen blijkt het volgende: Tabel 5. Reorganisatiewaarde van 140 in plaats van 100. – Het plan voldoet aan de ‘best interest of creditors test’: geen van de vermogensverschaffers is slechter af dan in faillissement. Wij introduceren vervolgens onzekerheid over de reor ganisatiewaarde van XYZ. Schattingen van deze waarde variëren in een bandbreedte tussen 100 en 140; wij veron derstellen voorts dat deze onzekerheid zich vertaalt in on zekerheid over de waarde van het eigen vermogen in een bandbreedte van 60 tot 100. Uit tabel 4 blijkt dat bij een reorganisatiewaarde van 100 het akkoord niet langer vol doet aan de ‘absolute priority rule’: de senior-crediteuren worden niet volledig voldaan; ze krijgen slechts 85% van het nominale bedrag van hun vordering (namelijk 25% van het eigen vermogen met een waarde van 45 plus een nieuwe senior-schuld van 40), terwijl de achtergestelde schuldeisers 25% van het eigen vermogen ontvangen. Volgens Baird and Bernstein 2006 vormt waarde ringsonzekerheid een verklaring van het feit dat in de praktijk vaak afgeweken wordt van de ‘absolute priority rule’. De redenering daarbij is dat de onderhandelingen over de hoogte van de reorganisatiewaarde plaatsheb ben in de schaduw van een bindende waardebepaling die van toepassing is als er geen positief onderhan delingsresultaat is (op grond van de WHOA heeft de rechtbank de mogelijkheid een deskundige te benoemen die de rechtbank kan adviseren omtrent allerlei geschil len, waaronder de waardering). De uitkomst van zo’n deskundigenonderzoek en de daarop gebaseerde rech terlijke beslissing is voor partijen onzeker. Baird and Bernstein 2006 beredeneren dat deze waarderingson zekerheid in het voordeel van de junior-vermogensver schaffers uitvalt en dat senior-vermogensverschaffers er daarom belang bij kunnen hebben junior-vermogens verschaffers in afwijking van de ‘absolute priority rule’ waarde te doen toekomen.17 Tabel 4. Reorganisatiewaarde van 100 in plaats van 120 ). Reorganisatiewaarde 100 Eigen vermogen - geconverteerde senior-schuld 75% 45 - geconverteerde achtergestelde schuld 25% 15 60 Senior-schuld 40 Totaal 100 Totaal 100 Tabel 4. Reorganisatiewaarde van 100 in plaats van 120 ). Tabel 5 laat zien dat bij een reorganisatiewaarde van 140 het akkoord niet langer voldoet aan de ‘not more than 100% rule’. De senior-crediteuren verkrijgen in dit geval 115% van het nominale bedrag van hun oorspronkelijke vordering. Tabel 5 laat zien dat bij een reorganisatiewaarde van 140 het akkoord niet langer voldoet aan de ‘not more than 100% rule’. De senior-crediteuren verkrijgen in dit geval 115% van het nominale bedrag van hun oorspronkelijke vordering. Tabel 5. Reorganisatiewaarde van 140 in plaats van 100. Reorganisatiewaarde 140 Eigen vermogen - geconverteerde senior-schuld 75% 75 - geconverteerde achtergestelde schuld 25% 25 100 Senior-schuld 40 Totaal 140 Totaal 140 – De reorganisatie is gunstig voor de gezamenlijke vermogensverschaffers: de reorganisatiewaarde be draagt 120, terwijl in faillissement slechts 40 zou kunnen worden gerealiseerd. – Het akkoord voldoet aan de ‘absolute priority rule’ (waaronder de ‘not more than 100% rule’). De se nior-schuldeisers verkrijgen aandelen en een nieuwe senior-schuld met een gezamenlijke waarde gelijk aan het nominale bedrag van de oorspronkelijke vorder ing. De houders van de achtergestelde lening ontvan gen aandelen ter waarde van 33,3% van het nominale bedrag van hun oorspronkelijke vordering.15 De besta ande aandeelhouders verliezen hun belang volledig, volgens de ‘absolute priority rule’ mogen ze ook ni ets ontvangen omdat de houders van de achtergestelde leningen niet volledig worden voldaan.16 – Het akkoord voldoet aan de ‘absolute priority rule’ (waaronder de ‘not more than 100% rule’). De se nior-schuldeisers verkrijgen aandelen en een nieuwe senior-schuld met een gezamenlijke waarde gelijk aan het nominale bedrag van de oorspronkelijke vorder ing. De houders van de achtergestelde lening ontvan gen aandelen ter waarde van 33,3% van het nominale bedrag van hun oorspronkelijke vordering.15 De besta ande aandeelhouders verliezen hun belang volledig, volgens de ‘absolute priority rule’ mogen ze ook ni ets ontvangen omdat de houders van de achtergestelde leningen niet volledig worden voldaan.16 tergestelde leningen, omdat de waarderingsonzekerheid omtrent de reorganisatiewaarde zich met name vertaalt in de meer junior-instrumenten. De waarderingsdiscus sie rond een akkoord zal dus voornamelijk gaan over de waardering van de aandelen en minder over de waar dering van de schuldtitels. Deze discussie krijgt in de onderhandelingen in het kader van een financiële her structurering extra kleur vanwege de grote onzekerhe den en belangentegenstellingen die zich dan voordoen. Senior-schuldeisers die onder het akkoord via een ‘debt- for-equity swap’ aandelen krijgen aangeboden, hebben er belang bij dat de reorganisatiewaarde beperkt is. De ‘absolute priority rule’ betekent in zo’n geval immers dat hoe lager de reorganisatiewaarde is, hoe groter het aandelenbelang is dat zij in de geherstructureerde onder neming verkrijgen. Omgekeerd hebben aandeelhouders en junior-crediteuren belang bij een zo hoog mogelijk vastgestelde reorganisatiewaarde, omdat dit de kans ver groot dat zij onder het akkoord een aandeel behouden in de onderneming. – Het plan voldoet aan de ‘best interest of creditors test’: geen van de vermogensverschaffers is slechter af dan in faillissement. 6.1 Het begrip reorganisatiewaarde in relatie tot het begrip ondernemingswaarde Waardemaatstaven kunnen worden onderscheiden in maatstaven die een transactie veronderstellen en maat staven die dat niet doen (Fishman et al. 2013). Bij op een transactie gebaseerde maatstaven als ‘waarde in het economische verkeer’, ‘fair market value’ en ‘fair value’ is ‘waarde’ de verwachte of geschatte prijs die een on derneming of vermogenstitel bij verkoop kan opleveren. Wordt geen transactie verondersteld dan heeft de waar demaatstaf betrekking op de waarde voor een specifie ke eigenaar, bijvoorbeeld de huidige eigenaar. Maatsta ven die dan gebruikt worden om het begrip ‘waarde’ te duiden zijn onder meer: ‘economische waarde’, ‘going concern’-waarde en ‘stand alone’-waarde (Van den Berg 2019, par. 3.2 en 8.3). Zoals hiervoor in paragraaf 2 is besproken is het transactieperspectief in het kader van de WHOA meestal niet (meer) relevant. In aansluiting op wat in de Amerikaanse Chapter 11-pro cedure gebruikelijk is, duiden we ‘de te verwachten waarde van de activa en activiteiten van de schuldenaar indien het akkoord tot stand komt’ aan als de ‘reorgani satiewaarde’ (vgl. MvT, p. 57). Behalve van ‘reorgani zation value’ wordt in de V.S. ook gesproken van ‘value of the reorganized debtor’ en ‘total distributable value’ (vgl. Gilson 2010, p. 216; Pantaleo and Ridings 1996, p. 419–420; In Re Spansion, Inc. 2010). De reorganisa tiewaarde is op het oog identiek aan wat in het vakge bied van de ondernemingswaardering de ondernemings waarde (of ‘enterprise value’) wordt genoemd: de totale waarde van de onderneming die onder de verschillende vermogensverschaffers wordt verdeeld (zie Koller et al. 2015, hoofdstuk 14). In de praktijk zal daarom worden uitgegaan van de reorganisatiewaarde als ‘stand alone’- en ‘going con cern’-waarde in handen van de vermogensverschaffers onder het akkoord. Hier past echter een belangrijke kanttekening: de ca tegorieën schuldeisers die bij een akkoord onderkend kunnen worden, hoeven niet overeen te komen met de schuldcategorieën (in waarderingsjargon: ‘debt or debt equivalents’) die normaal gesproken bij onderne mingswaardering onderscheiden worden (zie Koller et al. 2015, hoofdstuk 14). Dit geldt bijvoorbeeld voor de post handelscrediteuren. Deze is bij de ondernemings waardering besloten in de ondernemingswaarde, maar dient in het kader van een akkoord als een klasse van schuldeisers te worden aangemerkt. Omgekeerd is het mogelijk dat bepaalde posten die bij ondernemingswaar dering als schuld (in waarderingsjargon: ‘debt or debt like item’) behandeld worden, geen verifieerbare schuld onder het akkoord vormen. Hierbij kan bijvoorbeeld ge dacht worden aan bepaalde voorzieningen en transito rische posten. 6.2 De te hanteren waardemaatstaf WHOA in de praktijk zullen voordoen. Achtereenvolgens komen aan de orde: WHOA in de praktijk zullen voordoen. Achtereenvolgens komen aan de orde: De WHOA bevat geen bepalingen omtrent de te hanteren waardemaatstaf. In de ondernemingsrechtpraktijk worden verschillende waardemaatstaven gehanteerd. Hoewel bij de uitkoopprocedure of de geschillenregeling door de Ondernemingskamer van het Gerechtshof Amsterdam de waarde in het economische verkeer wordt gebruikt, ont breekt voor de blokkeringsregeling een bepaling over de waardemaatstaf (Van den Berg 2019, par. 8.4). – de betekenis van het begrip reorganisatiewaarde in relatie tot het begrip ondernemingswaarde; – de te hanteren waardemaatstaf; en – de te hanteren prognoses en disconteringsvoet. 6. Enkele vraagstukken bij de bepaling van de reorganisatiewaarde In deze paragraaf bespreken we enkele vraagstukken die zich bij de bepaling van de reorganisatiewaarde onder de https://mab-online.nl https://mab-online.nl Holterman W, van den Berg S: Waardebepaling bij financiële herstructureringen en de nieuwe WHOA 166 6.1 Het begrip reorganisatiewaarde in relatie tot het begrip ondernemingswaarde Ten slotte wijzen we op de mogelijkheid dat de WHOA de schuldenaar de mogelijkheid biedt om overeenkomsten, bijvoorbeeld huurovereenkomsten, te wijzigen of beëindigen. De verhuurder heeft dan recht op schadevergoeding en het akkoord kan voorzien in een wijziging van dit recht. De huurverlaging heeft een posi tief effect op de omvang van de vrije kasstromen en dus de reorganisatiewaarde.18 6.3 De te hanteren prognoses en disconteringsvoet De negatieve spiraal waarin de onderneming in financiële moeilijkheden zich bevindt, betekent dat de ‘going con cern’-waarde in steeds sneller tempo verdampt. Het mes snijdt daarbij aan twee kanten: enerzijds verslechteren de financiële vooruitzichten waardoor de voor vermogens verschaffers beschikbare kasstromen minder worden en de bestaande vermogensstructuur niet langer houdbaar is, anderzijds verhogen vermogensverschaffers hun ren tabiliteitseis met een ‘distress premium’ die het risico op faillissement reflecteert.19 Hoe dient met deze distress bij de bepaling van de reor ganisatiewaarde te worden omgegaan? Naar onze mening dient het reorganisatieplan dat ten grondslag ligt aan het akkoord als uitgangspunt te worden genomen. Een ‘dis tress premium’ in de disconteringsvoet is dan niet meer van toepassing omdat het uitgangspunt van een akkoord onder de WHOA een levensvatbare onderneming is en het akkoord juist ziet op het weer gezond maken van de ver mogensstructuur. Voor wat betreft de prognoses vormt het door de onderneming opgestelde reorganisatieplan een belangrijk houvast. Deze geeft inzicht in de maatregelen om de negatieve ontwikkelingen en de financiële effec ten daarvan te keren. De onderbouwing en geloofwaar digheid van dit plan zal in belangrijke mate bepalen of vermogensverschaffers vertrouwen hebben in de reorga Het bovenstaande betekent dat voor de bepaling van reorganisatiewaarde diverse aanpassingen van bepaalde posten uit de ondernemingswaarde en ‘debt en debt like items’ nodig zijn. De waardeerder zal zich uiteraard met juristen dienen te verstaan over welke posten voor het doel van de WHOA als schuld dienen te worden aange merkt. Voor een verdere uitwerking zie Van den Berg et al. 2019. https://mab-online.nl 167 Maandblad voor Accountancy en Bedrijfseconomie 93(5/6): 159–170 hoger zijn dan de liquidatiewaarde van de afzonderlijke activa. In dat geval dient de ‘going concern’ waarde die bij een dergelijke verkoop kan worden gerealiseerd te worden vermeld.” nisatie. Ook als het reorganisatieplan goed onderbouwd is, hoeven de daaraan ontleende prognoses niet zonder meer de enige basis te vormen voor de bepaling van de reorganisatiewaarde. De prognoses van herstel van een onderneming die zich in een dal bevindt, zijn met meer onzekerheden omgeven dan die van een gezonde onder neming. Het herstel gaat gepaard met zogenaamde ‘exe cutierisico’s’ die op enige wijze, bijvoorbeeld via een af slag op de prognoses, in de waardering verwerkt dienen te worden. Deze onzekerheid wordt groter als het resultaats herstel niet alleen afhankelijk is van interne maatregelen, maar ook van externe omstandigheden zoals economisch en marktherstel. 6.3 De te hanteren prognoses en disconteringsvoet Bij het wegen van de onzekerheden dient gelaveerd te worden tussen de belangen van de senior- en junior-vermogensverschaffers. Zoals we in paragraaf 5 hebben gezien bevoordeelt een te hoge waardering de junior-vermogenverschaffers, een te lage waardering be voordeelt de senior-vermogenverschaffers.20 Het uitgangspunt wordt dus gevormd door de daad werkelijke opbrengstverwachtingen bij faillissement die ten tijde van het opstellen en aanbieden van het akkoord bestaan. Zo kan de mogelijkheid bestaan dat de onderne ming (gedeeltelijk) ‘going concern’ verkocht kan worden. Het meest ongunstige scenario is volledige discontinuïteit, waarbij de activa op ‘piece meal’-basis verkocht wordt. Daartussen bevinden zich scenario’s waarbij delen van de onderneming worden voortgezet en andere beëindigd. 7. De opbrengst bij faillissement De WHOA bepaalt dat het akkoord informatie bevat over “... de opbrengst die naar verwachting gerealiseerd kan worden bij een vereffening van het vermogen van de schuldenaar in faillissement”. Met het oog op de ‘best interest of creditors’-test en de bepaling van de uitkering in contanten aan crediteuren die daarvoor mogen opteren dient ook de verdeling van de opbrengst over de vermo gensverschaffers volgens de wettelijke rangorde in het akkoord te zijn opgenomen. De MvT licht over deze op brengst bij faillissement het volgende toe (MvT, p. 57): 7.1 Opbrengst bij (gedeeltelijke) going concern-ver koop in faillissement De mogelijkheid bestaat dat vanuit faillissement een doorstart plaatsvindt waarbij de onderneming geheel of gedeeltelijk going concern wordt verkocht. Gezien de waarde-erosie bij distress mag verwacht worden dat deze going concern-waarde lager is dan de reorganisatie waarde ten tijde van het aanbieden van het akkoord. De publieke bekendmaking van financiële problemen en het faillissement zullen verdere negatieve gevolgen voor de waarde hebben. Interessant is hier te vermelden het voorstel dat het American Bankruptcy Institute (‘ABI’) in 2014 in haar advies over de modernisering van de Chapter 11-proce dure heeft gedaan voor de oplossing van dit dilemma. Het ABI constateert dat op het moment van de reorganisatie de onderneming zich op een dieptepunt kan bevinden en dat daarna een sterke groei van de waarde kan plaatsvinden.21 Achteraf bezien is de vastgestelde reorganisatiewaarde dan niet zelden te laag, zo is de redenering. Het ABI stelt de introductie van een ‘redemption option’ voor, deze op tie komt erop neer dat de klasse vermogensverschaffers die net out of the money is (‘the immediate out of the mo ney creditors’), alsnog waarde ontvangt: een optiewaarde die uitdrukking geeft aan de ‘upside’ van de onderneming na reorganisatie (Van den Berg 2019, hoofdstuk 6). Dit voorstel maakt onderdeel uit van een bredere discussie over de houdbaarheid van de ‘absolute priority rule’ (zie paragraaf 3). Het ten tijde van het aanbieden van het akkoord bepa len van een going concern-waarde bij faillissement zal in de praktijk met de nodige schattingsproblemen gepaard gaan. Deze worden versterkt doordat niet volstaan kan worden met een waardering, het gaat immers om de ver koopopbrengst van de onderneming in faillissement. Dat vergt een inventarisatie van mogelijke kopers, schattingen van de prijzen die deze mogelijk willen betalen en een inschatting van de onderhandelingspositie van de curator. Naar onze mening dient met deze onzekerheden reke ning te worden gehouden bij de waardering onder de ver onderstelling van faillissement. In de WHOA wordt ge sproken over ‘... de opbrengst .... in faillissement...’. Het ligt in de rede dat deze opbrengsten contant gemaakt wor den, rekening houdend met risico’s en tijdsverloop, naar het (verwachte) tijdstip van de beoogde sanctionering van het akkoord, zodat een zuivere vergelijking gemaakt kan worden met de reorganisatiewaarde. 7.2 Opbrengst bij beëindiging van de bedrijfsactiviteiten Het andere uiterste in het spectrum van de opbrengsten bij faillissement betreft een volledige beëindiging van de be drijfsactiviteiten en uitkering van de betreffende liquida tiewaarde. Dit is in dit scenario het bedrag dat gerealiseerd wordt bij afzonderlijke verkoop van de activa, verminderd met liquidatiekosten en eventuele andere kosten tot het moment van verkoop. In de praktijk wordt hierbij vaak ge bruik gemaakt van ficties over het verkoopproces, bijvoor beeld of sprake is van een ‘fire sale’ of van een ordelijk verkoopproces. Naar onze mening kan in het kader van de WHOA niet worden volstaan met een fictie, maar die “Deze bepaling verwijst naar de waarde die voor de schuldeisers overblijft als het akkoord niet tot stand komt. Dit betreft niet zonder meer de liquidatiewaarde van acti va als deze in faillissement los van elkaar te gelde worden gemaakt. Bestaat er een mogelijkheid dat in faillissement een activatransactie zou kunnen plaatsvinden waarbij bedrijfsonderdelen worden verkocht die vervolgens door de koper worden voortgezet, dan zal de opbrengst vaak https://mab-online.nl Holterman W, van den Berg S: Waardebepaling bij financiële herstructureringen en de nieuwe WHOA 168 nen de daadwerkelijke verwachtingen ten aanzien van het verkoopproces ten tijde van het akkoord als uitgangspunt te worden genomen. Ook de inschatting van de opbrengst bij beëindiging van de bedrijfsactiviteiten zal met de no dige onzekerheden en schattingsproblemen gepaard gaan. In onze optiek dient rekening te worden gehouden met ri sico’s en de tijd benodigd voor de ontmanteling, door de betreffende waarde contant te maken naar het (verwachte) tijdstip van de beoogde sanctionering van het akkoord. akkoord wordt getoetst verschillende waardebepalingen vergt. Schattings- en dus waarderingsonzekerheid be moeilijkt de uitvoering van deze toetsen. Die onzekerheid is bij een onderneming in distress groter dan bij gezon de ondernemingen. De vaak gebrekkige informatie, het belangenconflict tussen ‘senior’- en ‘junior’-vermogens verschaffers en de tijdsdruk waaronder waarderingen uit gevoerd dienen te worden vergroten de waarderingspro blematiek van ondernemingen in distress. nen de daadwerkelijke verwachtingen ten aanzien van het verkoopproces ten tijde van het akkoord als uitgangspunt te worden genomen. Ook de inschatting van de opbrengst bij beëindiging van de bedrijfsactiviteiten zal met de no dige onzekerheden en schattingsproblemen gepaard gaan. In onze optiek dient rekening te worden gehouden met ri sico’s en de tijd benodigd voor de ontmanteling, door de betreffende waarde contant te maken naar het (verwachte) tijdstip van de beoogde sanctionering van het akkoord. 8. Conclusies en aanbevelingen In dit artikel hebben we het doel van het dwangakkoord en de rol van waardebepaling onder de WHOA toegelicht. Waardebepaling speelt bij een akkoord onder de WHOA een belangrijke rol omdat de voorwaarden waaraan een Mr. drs. S.W. van den Berg is advocaat bij RESOR N.V. en in januari 2019 gepromoveerd op het onderwerp “Waarderingsvragen in het ondernemings- en insolventierecht”. 7.2 Opbrengst bij beëindiging van de bedrijfsactiviteiten De bepalingen over waardebepaling zijn in de WHOA erg summier. In onze optiek is de herstructureringsprak tijk gediend met aanvullende handvatten. In dit artikel hebben wij een aantal vraagstukken besproken die zich volgens ons bij waardering onder de WHOA voordoen en hebben we suggesties gegeven voor antwoorden. Daar mee hopen we bij te dragen aan een succesvolle imple mentatie van de WHOA. Prof. dr. W.G.M. Holterman is hoogleraar Business Valuation aan de Rijksuniversiteit Groningen en partner bij Value Insights in Amsterdam. Noten 1. Het wetsvoorstel en de MvT zijn te raadplegen op respectievelijk https://www.rijksoverheid.nl/documenten/rapporten/2019/07/08/tk-wvs-ho mologatie-onderhands-akkoord en https://www.rijksoverheid.nl/documenten/rapporten/2019/07/08/tk-mvt-homologatie-onderhands-akkoord. 2. Voluit: Wijziging van de Faillissementswet in verband met de invoering van de mogelijkheid tot homologatie van een onderhands akkoord (Wet homologatie onderhands akkoord). 1. Het wetsvoorstel en de MvT zijn te raadplegen op respectievelijk https://www.rijksoverheid.nl/documenten/rapporten/2019/07/08/tk-wvs-ho mologatie-onderhands-akkoord en https://www.rijksoverheid.nl/documenten/rapporten/2019/07/08/tk-mvt-homologatie-onderhands-akkoord. 2. Voluit: Wijziging van de Faillissementswet in verband met de invoering van de mogelijkheid tot homologatie van een onderhands akkoord (Wet homologatie onderhands akkoord). tps://wetgevingskalender.overheid.nl/Regeling/WGK005179. 4. Dat dit middel vanuit juridisch perspectief moet worden beschouwd in het kader van verhaalsuitoefening door vermogensverschaffers, wordt toegelicht door Tollenaar (2017). 5. Deze situatie kan zich bijvoorbeeld voordoen als de afzetmarkt van een onderneming geslonken is en de onderneming heeft moeten inkrimp en. De activiteiten zijn dan nog wel rendabel, maar het niveau van de schulden is te hoog ten opzichte van de kleinere ondernemingsomvang 6. Aandelen van een onderneming in distress kunnen vanuit een waarderingsoptiek gekarakteriseerd worden als een call-optie die ‘at the money’ of ‘out of the money’ is, met als onderliggende waarde de ondernemingswaarde en als uitoefenprijs de hoofdsom van de schulden van de on derneming. Zie: Black and Scholes 1973; Brealey et al. 2011, pp. 530 e.v. De waarde van een call-optie neemt onder meer toe bij een langere looptijd (lees: aandeelhouders weten een herstructurering langer voor zich uit te schuiven) en bij een hogere volatiliteit van de onderliggende waarde (lees: de aandeelhouders nemen grotere risico’s, zij profiteren als deze gunstig uitpakken en hebben slechts weinig te verliezen als deze ongunstig uitpakken). 7. De Hoge Raad heeft bepaald dat bij de toewijzing van een vordering tot medewerking aan een buitengerechtelijk akkoord terughoudendheid is geboden. Slechts onder zeer bijzondere omstandigheden kan plaats zijn voor een bevel aan een schuldeiser om aan de uitvoering van een hem aangeboden akkoord mee te werken. Zie: HR 12 augustus 2005, NJ 2006/230 en JOR 2005/257 (Groenemeijer/Payroll); HR 24 maart 2017, JOR 2017/209 (Mondia Investment/Van de Meent q.q. (V&D)). 7. De Hoge Raad heeft bepaald dat bij de toewijzing van een vordering tot medewerking aan een buitengerechtelijk akkoord terughoudendheid is geboden. Slechts onder zeer bijzondere omstandigheden kan plaats zijn voor een bevel aan een schuldeiser om aan de uitvoering van een hem aangeboden akkoord mee te werken. Zie: HR 12 augustus 2005, NJ 2006/230 en JOR 2005/257 (Groenemeijer/Payroll); HR 24 maart 2017, JOR 2017/209 (Mondia Investment/Van de Meent q.q. (V&D)). 8. Mr. drs. S.W. van den Berg is advocaat bij RESOR N.V. en in januari 2019 gepromoveerd op het onderwerp “Waarderingsvragen in het ondernemings- en insolventierecht”. 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Amsterdam Law School Research Paper no. 2019-10. https:// doi.org/10.2139/ssrn.3350375 Baird DG (1986) The uneasy case for corporate reorganizations. The Journal of Legal Studies 15(1): 127–147. https://www.jstor.org/sta ble/724364 Baird DG, Bernstein DS (2006) Absolute priority, valuation uncer tainty, and the reorganization bargain. The Yale Law Journal 115(8): 1930–1970. https://doi.org/10.2307/20455676 Fishman JE, Pratt SP, Morrison WJ (2013) Standards of value: The ory and applications, 2nd edition. John Wiley & Sons, Inc. https://doi. org/10.1002/9781119204244 Baird DG (2017) Priority matters: absolute priority, relative priority, and the costs of bankruptcy. University of Pennsylvania Law Review 165(4): 785–830. Giammarino RM (1989) The resolution of financial distress. Review of Financial Studies 2(1): 25–47. https://doi.org/10.1093/rfs/2.1.25 Gilson SC (2010) Creating value through corporate restructuring. Case studies in bankruptcies, buyouts, and breakups, 2nd edition. 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Noten De achterliggende gedachte is, naar analogie van een financiële call-optie, dat junior-vermogensverschaffers meer profiteren van een te hoge waardering door een deskundige dan dat ze nadeel ondervinden van een te lage waardering. Voor senior-crediteuren geldt het omgekeerde. 18. Als gevolg van de aanpassing van de huurovereenkomst wordt de huur weliswaar lager, ook de tax shield (aftrekbaarheid van de operationele winst) neemt af. Daar tegenover ontstaat in het kader van het akkoord een schuld aan de verhuurder (welke schuld onder het akkoord ook kan worden gewijzigd). De mogelijke fiscale implicaties hiervan vallen buiten het bestek van dit artikel. 19. In de praktijk wordt een veelheid aan benaderingen gehanteerd om distress in de waardering te verwerken, waarbij onderscheid gemaakt kan worden in benaderingen waarin de discount rate wordt verwerkt. Zie bijvoorbeeld Damodaran 2018, chapter 12, pp. 431–491. 20. Zie de voorbeelden in tabellen 4 en 5. 21. ABI report 2014, p. 213: “(…) to the extent that a plan is confirmed during a downturn in the economy generally or the debtor’s industry more specifically, the valuations used to support the plan distributions may value the reorganized entity at a low point in the valuation cycle.” 21. ABI report 2014, p. 213: “(…) to the extent that a plan is confirmed during a downturn in the economy generally or the debtor’s industry more specifically, the valuations used to support the plan distributions may value the reorganized entity at a low point in the valuation cycle.” Noten Richtlijn van het Europees Parlement en de Raad betreffende preventieve herstructureringsstelsels, betreffende kwijtschelding van schuld https://mab-online.nl Maandblad voor Accountancy en Bedrijfseconomie 93(5/6): 159–170 169 en beroepsverboden, en betreffende maatregelen ter verhoging van de efficiëntie van procedures inzake herstructurering, insolventie en kwi jtschelding van schuld, en tot wijziging van Richtlijn (EU) 2017/1132 (Richtlijn betreffende herstructurering en insolventie). Zie: https://www. consilium.europa.eu/nl/press/press-releases/2019/06/06/giving-entrepreneurs-a-second-chance-new-rules-on-business-insolvency-adopted/ 14. Baird 2017, p. 793: “The essential difference between absolute and relative priority is the effect of bankruptcy on the exercise date of the en beroepsverboden, en betreffende maatregelen ter verhoging van de efficiëntie van procedures inzake herstructurering, insolventie en kwi jtschelding van schuld, en tot wijziging van Richtlijn (EU) 2017/1132 (Richtlijn betreffende herstructurering en insolventie). Zie: https://www. consilium.europa.eu/nl/press/press-releases/2019/06/06/giving-entrepreneurs-a-second-chance-new-rules-on-business-insolvency-adopted/ p p p g g p y p 14. Baird 2017, p. 793: “The essential difference between absolute and relative priority is the effect of bankruptcy on the exercise date of the call-option component of the junior investment instrument. Under absolute priority, the bankruptcy accelerates the exercise date; a regime of relative priority leaves it untouched.” 14. Baird 2017, p. 793: “The essential difference between absolute and relative priority is the effect of bankruptcy on the exercise date of the call-option component of the junior investment instrument. Under absolute priority, the bankruptcy accelerates the exercise date; a regime of relative priority leaves it untouched.” 15. In het onderhavige voorbeeld is de waarde toevallig gelijk aan de marktwaarde van de achtergestelde lening in de situatie van distress. 16. Naar analogie van de call-optie (zie voetnoot 6 van dit artikel): een financiële herstructurering impliceert dat de looptijd van de call-optie nihil is, waardoor de optie geen verwachtingswaarde meer heeft. De optie expireert “out of the money”: de onderliggende ondernemingswaarde is 120 en de uitoefenprijs (nominale bedrag van de senior- en achtergestelde schuld) bedraagt 160. 15. In het onderhavige voorbeeld is de waarde toevallig gelijk aan de marktwaarde van de achtergestelde lening in de situatie van distress. 16. Naar analogie van de call-optie (zie voetnoot 6 van dit artikel): een financiële herstructurering impliceert dat de looptijd van de call-optie nihil is, waardoor de optie geen verwachtingswaarde meer heeft. De optie expireert “out of the money”: de onderliggende ondernemingswaarde is 120 en de uitoefenprijs (nominale bedrag van de senior- en achtergestelde schuld) bedraagt 160.ifi 17. Noten De term “tegenstemmende klasse” is niet helemaal accuraat. Wij bedoelen ermee aan te geven dat de vereiste meerderheid binnen de klasse niet is behaald om het akkoord als door die klasse aangenomen te beschouwen. Dit betekent echter niet noodzakelijkerwijs dat de klasse of een meerderheid binnen de klasse daadwerkelijk tegen heeft gestemd. Het is best mogelijk dat een meerderheid vóór heeft gestemd, zij het niet met de vereiste gekwalificeerde meerderheid om instemming met het akkoord aan die klasse toe te dichten. Deze nuance brengen wij verder niet aan. Vgl. Tollenaar 2016, p. 5. 8. De term “tegenstemmende klasse” is niet helemaal accuraat. Wij bedoelen ermee aan te geven dat de vereiste meerderheid binnen de klasse niet is behaald om het akkoord als door die klasse aangenomen te beschouwen. Dit betekent echter niet noodzakelijkerwijs dat de klasse of een meerderheid binnen de klasse daadwerkelijk tegen heeft gestemd. Het is best mogelijk dat een meerderheid vóór heeft gestemd, zij het niet met de vereiste gekwalificeerde meerderheid om instemming met het akkoord aan die klasse toe te dichten. Deze nuance brengen wij verder niet aan. Vgl. Tollenaar 2016, p. 5. el de verificatieregels in faillissement niet van toepassing zijn, moeten deze regels waar nodig analoog worden toegepast. Vgl. Tollen par. 2.11.1. 10. Hiernaast geldt de (restrictief toegepaste) ‘new value exception’: aandeelhouders mogen een belang behouden indien zij in ruil daarvoor nieuw geld of nieuwe waarde inbrengen die minimaal gelijk is aan waarde van het behouden belang. 10. Hiernaast geldt de (restrictief toegepaste) ‘new value exception’: aandeelhouders mogen een belang behouden indien zij in ruil daarvoor nieuw geld of nieuwe waarde inbrengen die minimaal gelijk is aan waarde van het behouden belang. 11. Chapter 11 U.S. Code § 1129(b)(1). https://mab-online nl 11. Chapter 11 U.S. Code § 1129(b)(1). 12. Om de analogie van noot 6 te vervolgen: homologatie betekent dat de looptijd van de optie ten einde komt en ‘out of the money’ eindigt. 13. Richtlijn van het Europees Parlement en de Raad betreffende preventieve herstructureringsstelsels, betreffende kwijtschelding van schuld p § ( )( ) 12. Om de analogie van noot 6 te vervolgen: homologatie betekent dat de looptijd van de optie ten einde komt en ‘out of the money’ eindigt. 13. Van den Berg SW, Holterman WGM, Haanappel HT (2019). De reorganisatiewaarde onder de WHOA. Tijdschrift voor Insolventi erecht 2019(10): 81–90. Van den Sigtenhorst R, Vriesendorp RD, Hermans RM (2017) Reactie De Brauw Blackstone Westbroek op consultatie WHOA, 30 november 2017. https://www.debrauw.com/wp-content/up loads/2014/11/20171130-Reactie-De-Brauw-op-consultatie- WHOA.pdf Van den Berg SW (2019) Waarderingsvragen in het ondernemings- en insolventierecht (Onderneming en recht nr. 107). Proefschrift Radboud Universiteit Nijmegen. Wolters Kluwer (Deventer). Tollenaar NWA (2017) De akkoordprocedure onder het Vooront werp WHOA. In Bobeldijk ACP, Van Hees JJ, Josephus Jitta MW, De Kluiver HJ, Tollenaar NWA, Veder PM, Verstijlen FMJ, Van Vugt MHF (2017). Het dwangakkoord buiten faillissement. Beschouwin gen over het Voorontwerp Wet homologatie onderhands akkoord ter voorkoming van faillissement. Preadvies van de Vereeniging ‘Han delsrecht’, Uitgeverij Paris (Zutphen): 29–34. Tollenaar NWA (2017) De akkoordprocedure onder het Vooront werp WHOA. In Bobeldijk ACP, Van Hees JJ, Josephus Jitta MW, De Kluiver HJ, Tollenaar NWA, Veder PM, Verstijlen FMJ, Van Vugt MHF (2017). Het dwangakkoord buiten faillissement. Beschouwin gen over het Voorontwerp Wet homologatie onderhands akkoord ter voorkoming van faillissement. Preadvies van de Vereeniging ‘Han delsrecht’, Uitgeverij Paris (Zutphen): 29–34. Van den Berg SW (2019) Waarderingsvragen in het ondernemings- en insolventierecht (Onderneming en recht nr. 107). Proefschrift Radboud Universiteit Nijmegen. Wolters Kluwer (Deventer). Literatuur Koller T, Goedhart M, Wessels D (2015) Valuation, measuring and managing the value of companies, 6th edition. John Wiley & Sons, Inc. Brealey RA, Myers SC, Allen F (2011) Principles of corporate fi nance, 10e druk. McGraw-Hill. Myers SC (1977) Determinants of corporate borrowing. Journal of Financial Economics 5(2): 147–175. https://doi.org/10.1016/0304- 405X(77)90015-0 Broude RF (1984) Cramdown and Chapter 11 of the Bankruptcy Code: The settlement imperative. The Business Lawyer 39(2): 441– 454. https://www.jstor.org/stable/40686562 Pantaleo PV, Ridings BW (1996) Reorganization value. The Busi ness Lawyer 51(2): 419–442. https://www.jstor.org/stable/40687646 Brown DT (1989) Claimholder incentive conflicts in reorganization: The role of bankruptcy law. Review of Financial Studies 2(1): 109– 123. https://doi.org/10.1093/rfs/2.1.109 Shleifer A, Vishny RW (1992) Liquidation values and debt capacity: A market equilibrium approach. Journal of Finance 47(4): 1343– 1366. https://doi.org/10.1111/j.1540-6261.1992.tb04661.x Casey A (2011) The creditor’s bargain and option-preservation priori ty in Chapter 11. University of Chicago Law Review 78(3): 759–807. Tabb CJ (2009) The law of bankruptcy, 2nd edition. Foundation Press. Tollenaar NWA (2016) Het pre-insolventieakkoord. Proefschrift Rijkuniversiteit Groningen. Wolters Kluwer (Deventer). http://hdl. handle.net/11370/744e2372-3da4-49d0-b514-123b1070e069 Couwenberg O (1997) Resolving financial distress in the Nether lands. Dissertatie Rijksuniversiteit Groningen. http://hdl.handle. net/11370/f337d8e4-e922-4259-a6fb-b471218f121a https://mab-online.nl Holterman W, van den Berg S: Waardebepaling bij financiële herstructureringen en de nieuwe WHOA Holterman W, van den Berg S: Waardebepaling bij financiële herstructureringen en de nieuwe WHOA 170 https://mab-online.nl https://mab-online.nl
W2005716396.txt	https://zenodo.org/records/2232463/files/article.pdf	de		Der Aufbau der St�rke und des Glycogens	Naturwissenschaften	1,921	public-domain	3,476	DIE NATURWISSENSCHAFTEN WOCHENSCHRIFT F~)R DIE FORTSCHRITTE D E R NATURWISSENSCHAFT, D E R MEDIZIN U N D D E R TECHNIK HERA~S~EGEBEN DR. A R N O L D B E R L I N E R Neunter Jahrgang. U~D P R O F . DR. A U G U S T P ~ T T E R 27. Mai 1921. Der A u f b a u der St~rke u n d des Glycogens. Von P. Karrer, Zi~rlch. Die ]~artoffe]st~rke ist, wie a,ndere Reservekohlenhydrate, ~bisher als ein sehr hochmolekularer Stoff aufgefal~t worden, in dem zahlreiche Trau,benzuckerreste glukosid'artig zu Ketten ver~inigt sin& Schemat,iseh gestattet sich xtieses Bild etwa wie fol,gt: C~HuO~- 0 --CsIt~oO~--O--CsH~o04-- 0 - - . . . . CsHnO~ ~Solehe ~hochmolekulare Formel.n ha~ man haupts~bhlick dxtrch ~[Olekulargewichtsb~stimmungen gestfitzt. )~ur ganz vereinzelt tauchte der Verdaekt auf, des ]~olekfil (ler Stiirke-kfnne nicht so groB, die T~:aubenzue,kerkette nicht so lang sein, wie dies .die ]~olekulargewichtsbestimmungen glauben mach;eu wollen. So hatte z. B. sc~kon Myl~us 1) bei der Untersuahuag der $odsthrke den ,Eindruck, ,,dell die SchluBfol,gerungen, welche "zu einer umfangreichen Stiirkemolekel ge~iihrt haben, "auf •Voraussetzuagen gegrfindet sind, ,dererr Richtigkeit niekt aut]er Zwei~el stehff'. Besonders aber hat H. Pringsheim ~) in neuerer Zeit ,bel sein~n wertvoll~n Untersuchungen fiber die Amylosen (tie ,,]~[utmaBung ausgespr0chen, dab im ~olekiil tier Stiirke ein Gru,ndkfrper vorhanden ist, des sen polymerer Zustand einen nlcht unbetr~ichtIichen Teil der St~rkechemle zu erkliiren imstande ist". Den Grun(l'kfrper h~lt Pringsheim fiir einen Ringzucker; er dachte zun~chst an die sog. Triamylose, auf welche welter unten eingegangen wird, hat diese Hypothese aber selbst wied~r verworfen. Die Molekulargewieht~bestiinmungen ~ter St~irke sind East immer ia Wasser ausgefiihrt worden; es liegt auf" .der Hand', dab sie ~fir die Bestim~nung der eigentliehen MolekfilgrfBe nutzlos sind, sofern .die Stiirke in Wasser kol'toide Lfsungen bildet. Da letzteres d:er Fall ist, so darf' diesen ]~olekulargewiehtsbestimmun~en keine Bedeutung zugemesse.n werden. E. "Beck, man~ u.nd Maria Maxim a) fanden, dal] sog. l'fstiehe St~rke sich in Chloralhydrat .aufliist. Sie bestimmten in diesem L~sungsmit~l ~hr Mo]ekuta~gewieht and fan(l'en es (Calicoes)a; dock lageu sie der t~estimmung selber nicht grebes Gewieht bei, d~a i) Bet. 20, 6886 (1887). ~) Ber. 45, 2533 (1912), 46, 2959 (1913), 4q, 2565 (1914). Die Polysacch~ride. Berlin 1919. a) Ber. 47, 2875 (1914). Nw. 1921. VON Heft 21. Chloralhydrat manche Zueker, wie z. B. den Rahrzucl~er, abztrbauen scheint. ]t~eine bisherigen Untemuchungen iiber de~ Ban der Kaxtoffel~t~irke, die" ieh ~usammen mit inehreren jiingeren Mitarbeiter~a ausffihrte, zerfMlen in 3 Teile: tier erste' Tell um£a$t d,ie Me~hy}ierung der ,St£rke, der zweite die Untersachung d'er dtrrch den Baeillus macerans aus ~Stiirke entatehenden Amylosen, der dri¢te d'ie Acetylierung der St~ir.ke. Die Yersuche sind groBenteils ver8ffentlicht in den Helvetica Chimica Acts0. 1. Methyllerung der Stfrke. Dutch ff~d:methyl und Silberoxy4, dutch Alkali und Dimethylsulfat una c~urch Barytwasser un,d Dimethylsutfat l~it~t sich die St~irke methylieren. Die ]~ethylostiirke hat, je n ac~r der ben'utztea Dar stelhingsmethode, verschiedenen Met~oxylgehalt. Maximal ~konmtea bisher ca. 35 % O~H3 eingeffihrt wer(len, das entspricht ann~hernd 5 ]~ethoxylgrupper~ auf den Zuckerrest C~H~oOlo; meistens wurden abet Priiparate gewonnen, die genau 4 Methoxy]e, d. h, 32% OCHa besaBen. Die :MeVhylost~irke ist sowohl in Was~er wie in Chloroform, Bromeform, Phenol, Alkohol teicht Ifslieh. Die w~sserigen Lfsung.en sind u]~rafiltrierbar und nach tier F41~ration optisch leer; sie zeigen ]~einert Tyndalteffekt. &us ihnen .l~iiit sigh ,die ]~[ethylosfiirke bei vorsichtigem Eindunsten zuriickg6wianen; si¢~ kann nachher ia Was~er oder Chloroform wieder aufgelfst werden; solche Lfsuagen zeigen im Ultramikroskop keine Koltoidteilchen. Die MethyJost~irke ist somit in Wasser, Chloroform, such t~henol in echter L&sung. ]~olekuIargewiehtsbestimmungen der Methylost~rke in Wasser und Phenol ergaben ]~fo]ekulargewichCe yon 800 'bis 1200, ~rnc~ zwar fi'bereinstimmend Lb'el methylierter Kartoffelst~irke wie b ei Weizen und Reisstiirke. Es erhebt sich jetzt ,die Frage, ob d~ese~[ole kular,gewiehte tier ~/[et~hylost~irke such etwas iibe~, die G.rfBe der St~irkemoleket seib,st aussagen kfnnen. ~Soll .dies der Fall sein, so muB ers~ der Nachweis erbracht werden, dab unter 3en angewand~en- Met"nylierungsbedingungen glukosidische Biadungen, d. h. Bind~.n,gen, welche die einzelneu Zuekerreste miteinander verketten, nicht zer1) ttelv. 3~ 620 (1920), 4, 169, 174, 185, 249, 263 (1921). 52 400 Karrer: Der Aufbau der Starke und des Glycogens. stSrt werde.n. Zu diesem Zwecke wurde die Sthrke' eine¢ Behandlung mit Kalilauge, Barytwasser und Sitberoxy~ u nter Bedingun.gen ausgesetzt, tvie ,sie bei d'er ]ffethylierung in Anwen,clung kamen: eine nennenswer.te Ver~ind.erung der St~irke trat n:icht ein. Fern, er wurde ein wohlbekanntes, aus zwei Traubenzu, ckerresten zusammengesetztes Disaccharicl, die Cellobiose, als Methyleellosid o CH20H.CHOH.~H. f Die Natur- [wissensehaften eine Rei'he sog. kri.stallisierter Dextrine entstehen, die H. Pringsheim spiiter mit dem zweckm~ii~igen \ a m e n ,,Amy~osen" :belegte. Es sind bis heute die folgenden Amylosen bekannt: a-Reihe: Oktamylo.e (C~:H~oO~oh + XC~H~OIt9 a-Hexamylose (C~H~0010)~-~- C~HsOH)1 Tetramy] ose (CI~H20OI0) ~-~-2 C2H5OH Diamylose CI~H20Ot0 ~ 2 tt20 I CHOH ' CHOH. CH "--o,o F--o HOH~C--~H • CH CHOH !. • CHOH • \ OCH~ in se'hr starker (20--30proz.) :Kalilauge mit Dimethylsulfat methyliert. Dabei wurde in ~ast theoretisc~er Ausbeute das Heptamethyl-methylceltosid ~) er.halten; es ~an<l also bei dleser alkalischen Methylierung eine LSst~ng ,tierdie beiden Zuckerresto zus,ammenhaltend~en ~lukos~disehen B i n d u a g nicht start. Daraus ist tier Sch,iut~ zu ziehen,, dal~ aueh ,bei ,d:er St~irkemethylierun.g glukosidische Bindungen nicht gelSst werclen, Dfi.e ':M[o]ekular,gewichte 80(}--1200, die ich bei tier :~ethylost~rke land, sagen ,daher aus, dal]~ nicht nur alas Methyi~ostfirkemolekiil, sondern auch die Molekel der Sfiirke selbst aus hScbsten,s 4----6 glukosi~disch miteinander verbundenen Trau.benzuckerresten bestehen kann. A n ~er MeVhy]ost~irke wurde die Beobachtu.ng gemacht, dab dieser Stoff zur Polymerisation ,neigt. Wenn man, seine klare, opiisch ]eere LSsung ~n Wasser oder Bromoform ausfriert od'er erhitzt, so triibt sie sich, es bilden sich Kolloidparti.kelchen, die i:hre Entstehung einem Assoz~ationsvorgang verda~_ken. Damit ste~g~ der Verdaeht auf, dal] unsere ~¢[e.thylostfirke mSglicherweise die po]ymere Form eines GrundkSrpers m i t noch ,geringerem Moleku,largewicht ist und 4urch ,die ~[ethylierung ,keine volIkommene Depolymerisation erzi,el.t wurde. 2. D~e Konstitution der Amylosen. Vet ungefi~hr 17 J a h r e n hat Schardinger ~) gefunden, dal] bei der Ztichtung des Bacillus macerans auf St~rkelS.sunger~ aus tier Stiirke 1) Aus Heptarnet.hy~-methylteHosi,d~ gewannen wir ~lureh ,S~urehydroly~e d~ie T,etv~me~hylglukos~ I o I CH--CH--CH • CH--CH--CH \ \ \ \ \ OCH3OCH3 OCH3OCH3OH Lind die Trimefihylglukose ioigender Konstitut~ion i O ) CH--CHOH • CH • Ctt • CH CH \ \ \ \ OCH3 OCH:~ OCH.~ OH Diese Spaltuag~stiicke beweisen ftir 4ie Cellob4ose tie oben geo,,ebene Konstitutionsformel. 2) Wiener, klinis.che Woehenschrift 1904, Nr. 81. ~.Reihe : ~-Hexamylose Triamylose (C1~H30OI5)~-[- 9 H20 (CIsHa9OI5)-~- H~O Al]e diese V erMndungea sind ei.nheitl~ch a n d gut kristallisiert. Die O,ktankvlose, c~e a-Itexa.mylose und <lie Tetramylose sind ~ach ~en Beobachtungen yon Schardinger unct Pringsheim Polymere der Diamy]ose, denn sie werden scbon durch di,o schonends~en. Subs ti~utionsprozesse wie Acety]ierung u~d Benzoyli,erung bei gewShnlicher Temperatur in ISubstitutionsproduk.te ,der Diamylose ii.bergefiihrt. Auch spricht ihre gegenseitigo Umwandlung d u t c h ~Erhitzen in LSsun,~s~mitteln. ~iir Pol:ymerie. Au,s ~]lnliehen Grfinden i~st die fl-Itexamy]ose ein Polymerisat~onspro,d:ukt der Triamylose; 4urch Acetyliertm,g und Benzoylierung gibt sie Derirate d'er letzteren. Die Konstitution clef Diamylose und der T r i amylose, der beid~en~ Grundkiirper tier Amylosegruppe, war bisher unbek~nnt, D.ie Diamy]ose ist als alas Anhydrid eines Disacchar£ds u n d die Triamy]~se a]s dasjen[ge eines Trisacchari,ds aufzufassan. Belde geben bei :hyc~rolytischen P r o zesseu ausschlieBlich ,d-Ghkose. Ich ,konnte jetzt zeigen, d:al] die Tetramy]ose bei der t~inwirku~g yon Acetylbromid glatt in Aeetobrom,maltose iibergeh,t. Diesen Ubengang hat man sieh so vorzustellen, dal] die TeSramy]ose zun~chst d'nrch Acety]ierung and ,Entpo]ymerisation in aeetylierte a-Diamyloso verwanSelt und hierauf deren Anhydridrin~ durch Acetyibromk~ geSffnet wird. Diamylose ist somit Maltosean,hyc~rid. Fiir ,die Maltose h a~en Haworth und Leit(,h ~) fo],gend',e Formel bewiesen: Centr~lblatt f. B~kt. IL AbL 14, 772 (1905), 19, J6l (1907), 22, 98 (1909), 29, 188 {1911). 1) D,ie Molek~l,griiBe ,4er a-ttexamytose und der a-Octamylc~sa sin.d noeh etwas unsi~cher. 2) Soc. 115, 809 (1919), Heft 21. ] 27. 5. 1921/. Karrer: Der Aufbau der St~rke und des Glycogens. . . . . . o ............... 4ol I CH~OH. CHOH. C • CHOH. CHOtt. CH 12 11 10 9 8 7 ~ I I O ! ! o. 6 5 4 3 2 1-~% OH Die Acetobromma]tose ]citer siclt von der Maltose dadurch a.b, dalt die OH-Gruppe am Kdhlenstoffatam 1 dutch Br,om ersetzt u n d at}e fibrigen Ityd~oxylgruppen acetylier~ sind. Da die Diamylose kein Rec~uktionsvermSgen besltzt, uad ,bei tier AnhydridSffnung mit~elst Acetylbromic~ Acetobr.ommal~ose e ntsteht, so muB ia der Diamylose der Anhydridrlng yon der Hydroxylgruppe 1 nach irgendelner anderen geschlagea sein. Diese zweite 0H-Gruppe l~iflt sieh noch nicht genauer bestimmea. Die fl-Triamylose ist ihrer K onstitution nach noch unau£gekl~rt. Sic gibt bMm Au~bewa'hren mit Acety£bro~id ~bei gew5hnllcher Temt~era~ur heine Bromverbindung. 3. Acetylierung der StSr~ce mittels~ Acetylbrom~d.~ Nac~dem mir dde ~ber~ihrung der a-Amylosen mi~ Acetyl~bromi,c~ zu Acetobrommalt~)se get~ngen war, babe ieh such ,die St~irke der analogen Einwir kung yon Acetylbromid au,sgesetzt. Dabei konnten wlr his ,zu 60 % Aeetobrommaltose gew[nnen. Eine Spur Eisessig mug bei d:er Reaktion anwesend seifi. Um dlesen Ver,such r~chtig einzusch~i~z~n, ist es notwendig, sieh zu erinnern, d~aB AcetyIbromid bei gewShnticher Temperatur im ~ e r l a u f ein~ger Tage gt.ukosidische Bindung~n :nieht, oder hSchstens spurenweise, 15sen kann. Sowohl Cello- l -cH o I . CII01I. CH, CHOH. o ........ I CHOH. CH c) durch den Bacillus macerans w[rd St~irke ia MalCvsean,hydrid (Diamy]ose) und deren ~olymere verwandelt: Daneben entsbeht d:ie /%tIexamylose, das Polymerc der Triamylose. d) Acetytbromid:; d as gluko,si,d~ische Bindun~en kaum an greift, ~baut ~St~irke zu Acetohrommaltose ab; such hier wurde ein Trioder Tetr.asaccharid nicht ,beobachtet. In allen diesen Abbaureaktionen, aneh jenen, die glukasidische ~indu~gen erfa,hrangsgem~il] nich~ ]5~en, erscheint als 'hSchs'tes kristallisiertes Produkt die Maltose oder deren Anhydr,id, die Diamylose (~die Triamylose i,st di'e "einzige "Ausnahme; yon ihr soll ,unten die, Rede seln ). Au~ der a~deren~Seite slnd die Amylosen ~ie andere Z~ckeranhydride ~) Stoffe, die ,au~eroMer/tlich zur Polymerisation neigen, deren Polymerisation man schon im Reagenzg]as his cur Oktamylose durehfiihren kann und die sich in Wasser oder Glycerin ineinander umwan, detn. Diese Grii~de fiihren reich zum. Schlul~ : die Stiirke ist polymeres Maltosec~nhydrid, polymere Diamylose; sie'ste]lt sich tier ~:Tetra=, a-I-Iexa-., und ~-Oktamylose an die Sei~e, hat aber eiaen anderen Polymerisation,sgrad als d'ies~). Die St~irkefvrmel ist et/va in ~o]geader Art zu schreiben: ",o biose, als auch Ro.hrzucker, M.Mtose, Lactose. usw. werdea durch Aeetylbromid untev den angegebener~ Bedingung,en nieht in die Monosaceharide zerlegL Wenn d~her die St~irke, wie d,ie AmyIos~n d.er a-Rei'he, dutch Aeetylbromid in Acetobrommaltose fiber,gent, so kann diese Tatsaehe nur dahin ged~utet werd~n,-,dM] in der Stiirke nizht ~met~i~wie zwei Glu,kosereste in der Maltoseform d~rch Hauptvaleazen chemlsch vereinigt sind. 4. Dzskusszon der Versuche. h n folgenden ;seien alle jene St~irkegbbaureaktionen zusammengestell% die his'her zu einheittichen, kristallislerten Produkten ~ h r t e n : a)~ d'ureh Diastase wird S ~ r k e zu 100% in Maltose iibergeffihr¢. Ein Tri- o d:er Tetrasacehari,d wurd'e nie beobachtet. b) ,bei wrsldht£ger S£urel~ydrolyse bildet slch neben Traubenzucker Maltose; ein hSheres. kristalI~siertes Saccharid wurde nie beobaeh'tet: • . $ . CH 2 • CH wobei i O- • CH. CHOH. die Lage x CHOH. CH ,der Aahydrosauerstoffbrficke noch unbestimm~ ~st. Wean diese Auff~ssung richtig ist, so wird man verlangen'mfissen, dab die ~-Amylos,en uud die St~irrke in ihrem ehemlschan Verhalten weltgehende ~hnlichkeit zeig~n. Dies ist nun in der Tat~ der Fall. Die Stiirke gib~ bekarLntlich mit ff~4 die pr~chtig biaue ffodst~irke, die unter geeigneten Bed:]ngungen such aus d e r LSs~4ng ausgef~illt werden kann. Die Farbe der Jodst~il:ke verschwinAet beim Erw~irmen, kommt abet beim Erkalten ~ler, LSsung wieder zum ¥orsc'hMn. Anal~ogverhalten sich die ~-Amylosen. Teer,amylose z. B. gibt in nicht zu l) H, Pri~gshvim un4 E~[3ler ]t6, 2959 (1913); P. Karrer, Helv. (}him. Act~ 4, 169; H. Pictet, ttelv. Chim. Act~a 1, 226 (1918). 3) Da Polymerisa~ionen ,u, U. in verschiedener ~Richtung verlaufen k~nnen, so sei .die Frage noch offen gelassen, ob sie bei der St~trke und den Amylasen genau i.n .dem~elben Sinn vor sich gegangen i~t oder ob PolTmer,i~ation~sisomere vorlie~e,n. 402 Karrer: Der Aufbau der Starke und des Glycogens. ve~,diinnter w~,sseri,ger L~sung mit god eine praghtvolle blaue LSsung, aus der sich naeh kurzem Stehen blaue Kristallnadeln absetzen. Die blaue Fa~be verachv¢indet-beim Er'hitzen, kehrt aber beim Grkalten wieder zuriick. Ein kleiner Unterschled besteht allerdings in der Best~nd'igkeit der,'blauen Farbe gegen~,ber V.erd.finnu~g. W~ihrend St~irke mit fled aueh in sehr verd~innter LSsung blat~ ,ge£~r'bt wird, kommt ,bei der ~-Tetramylose die FKrbe erst bei einer gewissen Konzentra~ien zum ¥orschein. A~ber solche graduell,e Unterschiede 'in d ev ffo4reaktion existieren aueh unter den Amylosen selber: die-~-Oktamylose gibt vnit ;[o~4 keine eigen~Hch .blaue LSsung, wohl a.ber 'blaue Nadeln tier Additi~nsverbindung, un4 hei der Diamylose liegen die Verh~iltnisse wieder etwas anders. Die wicktige ~nalogie 'in bezug auf die ffodreakt.lon i st bei der St~i~ke ur~d den ~¢-Amylosen ~ffensiehtlich: alle $reten mit fled unter gee~gneten Bedingungen zu blauen Additionsprodukten zusammen, deren Far'be in der W~irme versekwindet, ~bei,m Erkalten neuerd'ings erscheint. F_iir St~irke ehar akterS,stlsch ist ihre ]~igenscha£t mit Bariumhydroxyd, Strontiumhydroxyd und Cal,ciumhy~mxyd; schwer 15sliche Doppelsalzo z~ geben; die sog. Dextrine lessen mit den Erdkali'hydroxyden erst au£ Zusatz yon etwas A1kohol Niederschliige aus£allen. Bei den Amylosen erkaante irk eLn v.ollkommen analoges Verhal~en~). "~-Oktamylose gi'b¢ mit Barytwasser elnen sehr ,sehwer lSsliehen Niedersehlag der Barytverbir~ung; bei der ~¢-Tet~amylose fKll,t die Doppelverbind'ung erst auf Zusatz von wenig Alkohol ellS. St~irke liefert nach A. P~ctet ~) bei der Vakuumdes'tillation Laevoglucosan; aus Maltose und gewShnlicher ~-,Gluk6se bi-ldet sick solches nach demselben Au¢or .bei der Destillation nur spurenvceisc, wiihrend die fl-Ghtkose dutch Yakuumdestillati,on neck meinen Beobachtungen zum Teit in Laevo,glucosan iibergehtS). Die a-Tetramylose verhfilt :slch b~l der Vacuumdestillation ge~an wie St~irke: wir konnten aus ihr sogar b~sonders gute AusbSute ~n La~voglucosan er: zielen). Aus allen diesen mitgeteilten Ta~tsachen geht hervor, dab die Analegie zwischen den c¢-Amylosen ~nd der St~irke eine wei~ge~hende ist. Sic stfitzt racine Auf£assu,ng, dab die .St~i~,ke einen ganz bestimm~en polymeren Zustand der Diamylose, ,des Maltoseanhydrids darstell$. Wie hoeh der Polymerisationsgrad ist, kann vorl~ufig nicht entschieden werden. Der kristallisier~e Zustand der S~irke SCtleint uns ctaffir zu sprechen, dab er .nlch¢ sehr hoeh sein kann. Die dutch Molekulargewiektsbestimmungen vorget~iuschten hohen Molekulazgewichte der St~irke sind' darauf z~riick~) Unwerfiffenflicht. ~) l~Ielv. Ohim. Act~ 1, 87 (1918}. ~) l~e~v. Chim. Act~ 3, 258 (1920}. a) Unver~ffentlioht. f Dio Natur~ [wissens~haften zu~ii,hren, dab ,die .St~irke in Wasser un]Sslieh ist und eine Zertrfimmerung der St~rkekris'talle bis zum Molekularzustand durch Aufquellen in Wasser night elntritt~). In einem l~unkte besteht zwiscken den ~-Amylosea und der S,t~rke eLn grSBerer Unter~c'hied: wEhrend ~etztere dutch Diastase bekanntlich in Maltose iibergeh~, sind die ~-Amylosen gegan gewS'hnlic'he Diastase .resigtent, werden allerdings dutch Takadiastase hyd'rolysiert. Bei der fiberaus-grol]en Spezifit~it ,der Fermente ist/es wahrscheinlivh, ,daJ] die Diastase nur au£ den speziellen Polymer:isationsgrad der 'St~irke eingeste]lt ist. M~a weiB, wie w~ihlerisch z. B. des Trypsin ist und wie es nur ganz ,bestimmte Polypeptide abbaut, andere vollkommen unber/ihrt l~il]~. Die fl-&mylosen, auf die oben kurz verwiesen wurde, weft die fl-Hexamylose bei der Entpolymer~satlon der St~irke dutch den Bazillus macerans neben den c¢-A,mylosen /~uftritt, halten wir ~iir Produkte, die mit tier St~rke nur indirekte Beziehung hab~n. -V~i¢" stiitzen diese Anslcht darauf, dab .die fl-Amylosen mit Acetylbromid bei gewSknlicher Temperatur keine Bromverbindu.ng li,e£ern und sick darin" also vollkommen anders verkalten wie S~iske und die ~-Amylosen. Mit fled geben die fl-Amylosen nicht blaue, sondern brawne Ad:ditionsverbindungen. ~ Die fl-Triamylose l~I]t sick i m Reagenzglas experimentelJ aus ~-Amylose durch ~r,hitzen mit Wasser bereiten; sie entsteht leicht aus tier ~¢-R,eihe. Des Auftreten der fl-Amylosen bei .der St~irkeentpolymerisation <turck den Bacillus mace rans f~hren wir daher au£ einen analogen ?2bergang aus der ~- in die fl-Reihe zurfick. Die s og. ,,15slidhe StEr,ke" und ,die rStiirkedextrine betrachten wir als Polymere der Diamylose mit niedrigerem Polymerisationsgra& als ihn St~rke aufweist; siehe,r liegen in di,esen Sto~fen immer Gemlsche yon verschiedenen Polymeren vor, was ~Ere Kri,stal.lisation verhindert. Unter den reduzier~nden St~rkedextrinen hat man sieh polymerisierte Amylosekomp]exe vorzustellen in denen die Sauerstoff,br/icken der Diamylosemolekel teiiweise gesprengt sin~d; :so kommen aldehydische Eigenschaften h,nd damit Reduk~ionskraft ge~eniiber Fehlingscher, LSsung zum ¥o~schein. Des Glykogen ist nach allem, was wir bisher wissen, mit der St~irke sehr nahe verwandt. Sowohl bei fermentativer Spaltung wie bei der Sfiurehydrolyse lie£ert es dieselben Spal,tungsprodukte wie die St~irke. Der Bacillus macerans 'baut nach H. Pringsheim das Glykogen zu d'enselben Amylosen ab, die auc~h aus St~rke erhalten wurd'en~). Ich konnte zeigen, ~al] Acetyl~bromi4 mit Glykagen in ganz dersel'ben Weise reagiert wie mit St~irke. Man erh~ilt Acet~brom-mal~ose. Die Betrach%ungen, d,ie wir iiber den A~ifbau der St~irke ~) l~el.v. Chim. Act~ 8; 620 (1920). ~) Bd. 49, 364 (1916). Heft 21. ] 27. 5..192tj L{Jwenstein: Uber die Bedeutung der unbewuBten Ausdracksbewegungen usw. 403 anstellten, haben daher such fiir das Glykogen GtiIti,gkeit; ich fasse Gtykogen a]s polymerisierte Diamylose auf: der Polymerisati'onsgrad ist abet ela anderer als derjenige d'er Stiirke. gefgBe betreffen, m in den letzten J.a~rzehntea Gegenstand vielfacher U~nte~suchungen" gewesen. Und wenn diese Untersuchungen .auch keineswe_gs zu eind'eutlgen Resul~atel~ beziiglich der Gesetzm~Bigkeiten, d i e ' im psychophysischen GeDie Stiirko ist der wichtigste R'eeervestoff get schehert obwalten, gefiihrt haben, so 'haben sic Pflanzen. Ihre Bestimmung br.ingt es m i t aieh, doch alas eine aufier allen Zweifel .~est'ellt: dab es dal~ sic yon der Pflanze r~sch gebilde~ un~c~"unter niim]ich iiberhaupt GesetzmiiBigkeiterr .sind, die Umst~nden ebenso vasch wieder in Zucker zuriick- das psychophysisehe Gesche'hen alSgemMn b,dheregefikhrt werden muff: Mart darf daher erwarten, schen, wenn auch die besonder,e Form ,dleser Gedab die lP~anze zur Bitdung ihres. Reservesto~fes setzm~l]£gkeit noch ,bei weitem ni.cht iiber,all ereine Reaktion wiihlen wird, d'ie mS'g]ichst 'wenig kannt ist. Das scheiat auf ,den ersten Blick eine Ener,gieumeatz benStigt. Dies wiire offenbae SelbstverstRndlichkeit ztt se:i,n, zu deren Festnicht der Fall, wenn ,sie aus, T.raubenzuckermole- stelh~ng .es nicht eret umfan,grelc~er experimenkeln'lange Ketten ,ghkosid:isch aufgebauter Poly- tell,er Untersuchungen bedurft .h/itte; ,denn es ist saccharlde synthetisieren wilt,de, um ~d~i.ese Ketten doch. eine dem Zqaturwissenschaftler selbstvervi.eIleicht nach ganz kurzer Zeit, bei dem Yer- stiindliche ~orstellung und ~ sogar eine .8er notbrauch der St~r.ke, wiec~er zu spalten. I m .Si.m? wen digen Voraussetzungen allot Naturf.orschung, meiner Auffa.ssung der Stiirke ale potymere Form daB jedem Zqaturgeschehen seine GesetzmiiBigdee Maltoseanhydrids .stellt ~sic~ die Reservestof£- kei%en innewohnen. Das ]fo~nte .natiirtleh auch bildung in d'er Pfl'aaze j.etzt ,in folgender W~eise ffir diejenigen nicht fraglic'h sein, ,die das Verdar: will die P f l a n z e die Kehlenhydrate ,8epo- hiltnis der psych:ischen ATorgiing% zu ihren ~kSrpernieren, so anhydrisiert sic d~e aus Gtn,lcoe6 ent- lichen. Begle iterscheinungen z:um Gegenstand stehende ~[altos, e. Dabei entsteht ,die Diamylose, ihrer Untersuchungen mach~en. Aber es war fiir das MMto.~eanhydrld, das zur _Nebdnzcalenzbe±.iiti- sic doch die Frage, inwieweit die bier geltenden dung neigt und .daher in elne polymere Form, c~ie Gesetzmii.Bigkeiten individueH begrenzt wiiren; ob St~rke, iiber.~eht. Ob .diese Pol,ymeri.sa~io.n exo- nicht der Besonderheit, .dl.e jedem menschllchen thermer odor en~dotherme¥ ~ a t n r let, w~u'de noeh tndiViduum im Denken, Fiih]en und Wollen zunieht untersucht~ jeden~Mls ver]~iuft Me "aber komme, auch' ihre besondere .kSrperlict/e Ausunter verhiiltnismRl~ig 'ger:inger W~irm.etSnung drucksf.orm ehtsprec'he, ,die von def. aller andern und, wirct d!a'her d~n Ener,gieumsatz tier P~lanze Menschen verechieden sol. Und w e a n auch bei wenig belasten. Die Stiirke;bildung aus Diamy- dem gleichen Indi,viduum zu dem gleichen ,Soelenlose s,tellt sich einem ein£aehen Kristallisationszustand i mmer die gteiche kSrper~iche Au,s.drueksvorgang oder elne~ Aus~ockung ar~ die Seite, die form gehSre, so war doch d:ie Frage,. ob diesem auch 'infolge Zqebenva]enzbetiitigung der Stoffe gleichen Seetenzustanc~ ,die analo.ge Ausdrucksvor e lch.gehen. In dem :Yfoment, irt dem die form auchbeij,edem and era I~di~r~duum zu,komme. StRrk.e in Zucken zuriickverwandelt werden mut], Dean es w~re - - aIlgemei.n naturwissenschaftlich werden die Fermente (Diastase) die Entpolymeri- gesproc4~en - - edhr wohl denlcbar, ,dab :die bei versargon einleiten, der eich .gleiehz'eiti.g o der nach- schiedenen Menschen verschi,edene ind~vi:duelle trRg],ich die Offaurtg 8es Anhydridri.nges der An- kSrperliche {lnd see]ische Konstitution die kSrperhydromaltose be~gesel]t. lichen Ausdrueksformen i n charakterlstischer~ :Es erscheint ~eh,' wahrscheinlich, dab nicht Weise bee~nflul~ten; dab ebensowenig, wie es zwei .nu,r~ die St~irke urtd dlae (}]ycogen Po]ymere von Meaechen gibt, die kSrperlich nnd geistig einAn hydrozuekern sind, sondern dab auch zahl- ander gleich sind, d.al~ es ebensowenig elne l~berreich,e andere-Res,erw-es.toffe der Pflanze ~ach die- einstimmung in den kSrpertich'en Be.g]eitersc%eisere ~rinzip eich aufbauen. E.s diir5te dies vor nv~ngen see],ischer Vorgiinge bei .den verschiedenen .aHem zutref:~cn, fiir das Inulin, mSglicherWeise Menschen geben kSnne. D i e emp~rischen, besonders die experimentell,en Untersuchungen haben .auch fiir die sod. Gummlarten un& Pent0~ane. Ob .dage~en die e~gentliehen Gerfistsu,bstanzen, wie j.edooh ~gelehf% dat] das ~icht riehtig ist; sie haben gezeigt, daB es im psyc'hophysischen Gedie Zellu]ose, sich d~esem Prinzip nni:eror.dnen, schehen in der Tat eine GesetzmiiBigt~eit gibt, kann theute noch nicht gesagt werden. deren GelSungsbereich nicht i,ndividuell begrenzt tst, die viel.mehr das menschliohe Seelen]eben in einer prlnzipiell fiir atle i~[ens.chen gleichen Form Uber die Bedeutung beherrscht. Das psyehophyslsche Geschehen zeigt der unbewu~tenAusdrucksbewegungen bei allgn ~[enschen die gleiehen Er.scheinungsfiir die Identifizierung geistiger formea und die g]eichen GesetzmiiBigkeiten, wo immer, die gIeichen Bedingungen ;herrschen; frei¥org~nge. lich sind d:iese ,,Bedingungen" yon zusammenYon Otto Ldwen~tein, Bon~. gesetzter m psyehischer u~,d physis'cher --" Natur; Die kSrperliehe, Begleiterscheinung~n l~sy- und .diese Doppe~natur bringt es mit sich, dab chischer Vor,g~inge sind ~ soweit e.ie Yuls, A~- ihre einwandfreie experimen{elle Herstellung mit mur~g, Blutdruck unct Fiillungszustand d',er Blutsehr viol grSBeren Schwierigkeiten verkniipft i.st, Nw, 1921. 58
https://openalex.org/W157535741	https://europepmc.org/articles/pmc4472797?pdf=render	English	null	Prevalence and clinical significance of early endotoxin activity in septic shock patients	Critical care	2,015	cc-by	274,729	Introduction To assess cerebral hemodynamics in an experimental sepsis model. Methods The study was a prospective, observational pilot study conducted in our hospital. Consecutive adult patients with severe sepsis, on a mechanical ventilator with an IL-6 blood concentration ≥100 pg/ml in the acute phase, defi ned as being up to the 28th day of illness in the ICU, were entered in this study between June 2011 and December 2012. Subjects were divided into those who were treated with steroids (steroid treatment group) and those who were not (no- steroids group) during the target period, because steroids strongly aff ect IL-6 blood levels. Methods Nineteen juvenile female Hungahib pigs were subjected into control group (n = 9) or septic group (n = 10). Under general anesthesia in animals of the sepsis group, Escherichia coli culture (2.5 × 105/ml; strain: ATCC 25922) was intravenously administrated in a continuously increasing manner as follows: 2 ml in the fi rst 30 minutes, then 4 ml in 30 minutes and afterwards 16 ml/hour for 2 hours (so a total of 9.5 × 106 E. coli within 3 hours). In the control group the anesthesia was maintained for 8 hours, infusion was administered as a similar volume of isotonic saline solution and no other intervention was made. Hemodynamic monitoring of all animals was performed by PiCCo monitoring system. The middle cerebral artery of the pigs was insonated through the transorbital window and cerebral blood fl ow velocity (MCAV) and pulsatility index was registered. Results The subjects were fi ve adult patients in the acute phase of severe sepsis on a mechanical ventilator. Gastrointestinal motility was measured for a total of 62,399 minutes: 31,544 minutes in three subjects in the no-steroids group and 30,855 minutes in two subjects in the steroid treatment group. In the no-steroids group, the bowel sound counts were negatively correlated with IL-6 blood concentration (r = –0.76, P <0.01), suggesting that gastrointestinal motility was suppressed as IL-6 blood concentration increased. However, in the steroid treatment group, gastrointestinal motility showed no correlation with IL-6 blood concentration (r = –0.25, P = 0.27). The IL-6 blood concentration appears to have decreased with steroid treatment irrespective of changes in the state of sepsis, whereas bowel sound counts with the monitoring system refl ected the changes in the state of sepsis, resulting in no correlation. MEETING ABSTRACTS MEETING ABSTRACTS P1 but long-term observation and objective evaluation of gastrointestinal motility are diffi cult. We developed a non-invasive monitoring system capable of quantifying and visualizing gastrointestinal motility in real time. In the study gastrointestinal motility was performed in patients with severe sepsis using this developed bowel sound analysis system, and the correlation between bowel sounds and changes over time in blood concentrations of IL-6, which is associated with sepsis severity, was evaluated. P1 Cerebral autoregulation testing in a porcine model of intravenously administrated E. coli induced fulminant sepsis L Molnar1, M Berhes1, L Papp1, N Nemeth2, B Fulesdi1 1Deoec Aneszteziologia, Debrecen, Hungary; 2University of Debrecen, Hungary Critical Care 2015, 19(Suppl 1):P1 (doi: 10.1186/cc14081) P1 Cerebral autoregulation testing in a porcine model of intravenously administrated E. coli induced fulminant sepsis L Molnar1, M Berhes1, L Papp1, N Nemeth2, B Fulesdi1 1Deoec Aneszteziologia, Debrecen, Hungary; 2University of Debrecen, Hungary Critical Care 2015, 19(Suppl 1):P1 (doi: 10.1186/cc14081) Introduction To assess cerebral hemodynamics in an experimental sepsis model. Introduction To assess cerebral hemodynamics in an experimental sepsis model. Results In the septic group, as expected, all animals developed fulminant sepsis and died within 3 to 7 hours two animals in 3 to 4 hours, and three in 6 to 7 hours). In the septic animals the heart rate rose and mean arterial pressure dropped, their ratio increased signifi cantly compared with both the base values (at the 6th hour: P <0.001) and the control group (P = 0.004). The control animals showed stable condition over the 8-hour anesthesia. MCAV signifi cantly decreased during the development of sepsis (from 23.6 ± 6.6 cm/s to 16.0 ± 3.9 cm/s, P <0.01) and pulsatility indices increased (from 0.68 ± 0.22 to 1.37 ± 0.58, P <0.01), indicating vasoconstriction of the resistance vessels. A signifi cant relationship was fund between percent change of the MAP and the pulsatility index in septic animals (R2 = 0.32) referring to maintained cerebral autoregulation. Conclusion The new real-time bowel sound analysis system provides a useful method of continuously, quantitatively, and non-invasively evaluating gastrointestinal motility in severe patients. Furthermore, this analysis may predict disease severity in septic patients. Conclusion Cerebral autoregulation is preserved in the pig model of experimentally induced fulminant sepsis. P3 Usefulness of sepsis screening tools and education in recognising the burden of sepsis on hospital wards EJ Galtrey, C Moss, H Cahill Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK Critical Care 2015, 19(Suppl 1):P3 (doi: 10.1186/cc14083) P2 New real-time bowel sound analysis may predict disease severity in septic patients J Goto1, K Matsuda1, N Harii1, T Moriguchi1, M Yanagisawa1, D Harada1, H Sugawara1, O Sakata2 1University of Yamanashi School of Medicine, Chuo, Japan; 2University of Yamanashi, Kofe, Japan Critical Care 2015, 19(Suppl 1):P2 (doi: 10.1186/cc14082) Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 35th International Symposium on Intensive Care and Emergency Medicine Brussels, Belgium, 17-20 March 2015 Publication charges for this supplement were funded by ISICEM. p CE Thakker1, P Crook1, B Davies1, L Mawer1, T Tomouk1, E Williams1, C Gray2, K Turner2 p CE Thakker1, P Crook1, B Davies1, L Mawer1, T Tomouk1, E Williams1, C Gray2, K Turner2 1University of Cambridge, UK; 2Ipswich Hospital, Ipswich, UK Critical Care 2015, 19(Suppl 1):P5 (doi: 10.1186/cc14085) 1University of Cambridge, UK; 2Ipswich Hospital, Ipswich, UK Critical Care 2015, 19(Suppl 1):P5 (doi: 10.1186/cc14085) fi Methods All referrals to our critical care response team with a diagnosis of sepsis over a 3-month period (September to November 2014) were investigated to determine how many had an EPR sepsis alert comprising a prompt for blood cultures, serum lactate measurement, fl uid challenge if hypotensive, and antibiotics within 1 hour. Introduction Severe sepsis results in ~36,800 UK deaths each year [1]. Prior studies demonstrate the benefi t of early recognition and treatment of sepsis in reducing mortality [2]. The Sepsis Six [1] bundle aims to optimise the fi rst hour of sepsis management. We assessed the proportion of emergency department (ED) patients with severe sepsis receiving the Sepsis Six bundle and whether this was improved by a combination of staff education and use of Sepsis Six management stickers in patient notes. l g yp Results Only 25/174 (14%) patients with a diagnosis of sepsis had an EPR sepsis alert. There was no signifi cant diff erence between acute and nonacute ward areas in their likelihood of using the screening tool or alert, in contrast to previous audits of the alerted population which showed that acute areas such as A&E and medical acute admission wards had higher utilisation and bundle completion rates. Methods A closed loop audit was completed in the ED at Ipswich Hospital, UK. Each cycle was 14 days with interventions made in a 4-week period between the two cycles. The interventions consisted of: Sepsis Six management stickers and posters placed in the ED; two training sessions for all ED nurses on sepsis recognition and management; a teaching session for all middle-grade doctors; and a trolley in the ED with equipment required for the Sepsis Six. The notes of all patients with lactate ≥2 mmol/l were retrospectively reviewed. Those with ≥2 systemic infl ammatory response syndrome criteria and a documented suspicion of infection were deemed to have severe sepsis. The times at which these patients had each of the Sepsis Six completed were recorded, as were the fi nal diagnosis and 7/28 day mortality. P5 tool and electronic order set (EPR alert) alongside an education programme to improve delivery of the SSC bundle. Previous audits showed only 43% full bundle compliance in those that were alerted, and this raised concerns regarding the burden of unalerted sepsis. We sought to estimate the number of unalerted sepsis episodes to assess the effi cacy of our screening tool and improve early recognition. p CE Thakker1, P Crook1, B Davies1, L Mawer1, T Tomouk1, E Williams1, C Gray2, K Turner2 Results In Cycle 1, 31/106 patients met the criteria for severe sepsis, compared with 36/120 in Cycle 2. The delivery of the Sepsis Six interventions was highly variable. In Cycle 1 lactate levels and i.v. access had the highest 60-minute completion rates (90.3%, 83.9% respectively). Blood cultures and i.v. fl uid resuscitation were completed for 61.3% and 64.5% of patients within 60 minutes. Only 38.7% of septic patients were given i.v. antibiotics within 60 minutes. In total, 58.9% of patients received antibiotics in accordance with trust guidelines. High fl ow oxygen, catheters and fl uid balance charts had the lowest 60-minute completion rates (35.5%, 6.5%, 6.5% respectively). In Cycle 2, post intervention, there was no signifi cant change in the percentage of patients receiving the Sepsis Six bundle. Methods A closed loop audit was completed in the ED at Ipswich Hospital, UK. Each cycle was 14 days with interventions made in a 4-week period between the two cycles. The interventions consisted of: Sepsis Six management stickers and posters placed in the ED; two training sessions for all ED nurses on sepsis recognition and management; a teaching session for all middle-grade doctors; and a trolley in the ED with equipment required for the Sepsis Six. The notes of all patients with lactate ≥2 mmol/l were retrospectively reviewed. Those with ≥2 systemic infl ammatory response syndrome criteria and a documented suspicion of infection were deemed to have severe sepsis. The times at which these patients had each of the Sepsis Six completed were recorded, as were the fi nal diagnosis and 7/28 day mortality. Conclusion Despite these interventions, most patients still do not receive the full recommended treatment bundle. These fi ndings have prompted a point prevalence audit at ward level, which will examine all patients’ notes for the preceding 24 hours to ascertain if sepsis is truly unrecognised or whether it is simply that our current tool is not a helpful adjunct to care. With national guidelines expected within the year, we will redesign and re-launch our screening tools and education programme to improve awareness and management of this common medical emergency. Continuous versus intermittent temperature measurement in the detection of fever in critically ill patients p g p Conclusion The low rates of Sepsis Six completion require improvement to meet the targets set out by the College of Emergency Medicine. Our results suggest that simple interventions are ineff ective in increasing Sepsis Six completion and thus lend support to the case for integrated interventions such as electronic recording and alert systems. References Introduction An elevated body temperature is one of the four criteria in diagnosing systemic infl ammatory response syndrome (SIRS), and is often used at the bedside to trigger diagnostic investigations for infection. Standard intermittent temperature measurement may, however, delay the detection of an elevated temperature or miss this altogether. The aim of the study is to compare intermittent non- invasive versus continuous invasive body temperature measurement as a tool to detect an elevated body temperature. References References 1. Dellinger R, et al. Crit Care Med. 2013;41:580-637. 2. http://bit.ly/1nzV3Kp. 3. http://bit.ly/12Y3KHq. 4. http://bit.ly/10PYi8G. 1. Dellinger R, et al. Crit Care Med. 2013;41:580-637. 2. http://bit.ly/1nzV3Kp. 3. http://bit.ly/12Y3KHq. 4. http://bit.ly/10PYi8G. i g y y Results In Cycle 1, 31/106 patients met the criteria for severe sepsis, compared with 36/120 in Cycle 2. The delivery of the Sepsis Six interventions was highly variable. In Cycle 1 lactate levels and i.v. access had the highest 60-minute completion rates (90.3%, 83.9% respectively). Blood cultures and i.v. fl uid resuscitation were completed for 61.3% and 64.5% of patients within 60 minutes. Only 38.7% of septic patients were given i.v. antibiotics within 60 minutes. In total, 58.9% of patients received antibiotics in accordance with trust guidelines. High fl ow oxygen, catheters and fl uid balance charts had the lowest 60-minute completion rates (35.5%, 6.5%, 6.5% respectively). In Cycle 2, post intervention, there was no signifi cant change in the percentage of patients receiving the Sepsis Six bundle. P4 Continuous versus intermittent temperature measurement in the detection of fever in critically ill patients A Heyneman, V Bosschem, N Mauws, D Van Der Jeught, E Hoste, J Decruyenaere, J De Waele Ghent University Hospital, Ghent, Belgium Critical Care 2015, 19(Suppl 1):P4 (doi: 10.1186/cc14084) interventions References 1. Daniels et al. Emerg Med J. 2011;28:507-12. 1. Daniels et al. Emerg Med J. 2011;28:507-12. 1. Daniels et al. Emerg Med J. 2011;28:507-12. 2. Kumar et al. Crit Care Med. 2006;34:1589-96. 2. Kumar et al. Crit Care Med. 2006;34:1589-96. New real-time bowel sound analysis may predict disease severity in septic patients J G t 1 K M t d 1 N H ii1 T M i hi1 M Y i 1 D H d 1 p p J Goto1, K Matsuda1, N Harii1, T Moriguchi1, M Yanagisawa1, D Harada1, H Sugawara1, O Sakata2 1University of Yamanashi School of Medicine, Chuo, Japan; 2University of Yamanashi, Kofe, Japan Critical Care 2015, 19(Suppl 1):P2 (doi: 10.1186/cc14082) J Goto1, K Matsuda1, N Harii1, T Moriguchi1, M Yanagisawa1, D Harada1, H Sugawara1, O Sakata2 1University of Yamanashi School of Medicine, Chuo, Japan; 2University of Yamanashi, Kofe, Japan Critical Care 2015, 19(Suppl 1):P2 (doi: 10.1186/cc14082) Introduction Sepsis is defi ned as the presence of infection with systemic signs of infection, and severe sepsis as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion [1]. Since the Surviving Sepsis Campaign (SSC) in 2002, the Health Service Ombudsman for England published recommendations for improving recognition and treatment of sepsis [2], the Royal College of Physicians issued a toolkit for the management of sepsis in the acute medical unit [3], and NHS England released a patient safety alert to support prompt recognition and treatment of sepsis [4]. In 2012 our Trust introduced a sepsis screening Introduction Sepsis is defi ned as the presence of infection with systemic signs of infection, and severe sepsis as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion [1]. Since the Surviving Sepsis Campaign (SSC) in 2002, the Health Service Ombudsman for England published recommendations for improving recognition and treatment of sepsis [2], the Royal College of Physicians issued a toolkit for the management of sepsis in the acute medical unit [3], and NHS England released a patient safety alert to support prompt recognition and treatment of sepsis [4]. In 2012 our Trust introduced a sepsis screening Introduction Healthy bowel function is an important factor when judging the advisability of early enteral nutrition in critically ill patients, © 2015 BioMed Central Ltd © 2015 BioMed Central Ltd © 2015 BioMed Central Ltd S2 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P5 Assessment of specifi c risk scores for patients admitted to the ICU for severe community-acquired pneumonia Assessment of specifi c risk scores for patients admitted to the ICU for severe community-acquired pneumonia y q p C Joya-Montosa, MD Delgado-Amaya, E Trujillo-García, E Curiel-Balsera Hospital Regional de Málaga, Spain C Joya-Montosa, MD Delgado-Amaya, E Trujillo-García, E Curiel-Balsera Hospital Regional de Málaga, Spain p g g p ritical Care 2015, 19(Suppl 1):P9 (doi: 10.1186/cc14089) Introduction The aim of the study is to evaluate the calibration and discrimination of two specifi c risk scores for community-acquired pneumonia (CAP) in patients with this illness who required ICU admission. Results Severe sepsis criteria were fulfi lled in 31% (n = 91) of the patients. These were older (median age: 79 years vs. 71 years) and experienced more symptoms (mean: 2.2, SD 0.9 vs. mean: 1.4, SD 0.7) than patients without severe sepsis, while there was no diff erence in C-reactive protein levels (OR per 50 mg/l: 1.07, 95% CI: 0.96 to 1.20). Among individual symptoms, altered mental status (OR: 4.4, 95% CI: 2.2 to 9.0), dyspnea (OR: 3.5, 95% CI: 2.1 to 5.9), and muscle weakness (OR: 2.2, 95% CI: 1.0 to 4.4) were signifi cantly related to severe sepsis. Adjusting for age and sex, altered mental status (adj. OR: 4.1, 95% CI: 2.0 to 8.4) and dyspnea (adj. OR: 3.1, 05% CI: 1.8 to 5.3) remained signifi cant. Conclusion General symptoms, especially altered mental status and dyspnea, appear to be more common in severe sepsis than in milder infections. These symptoms might be utilized as a diagnostic aid for severe sepsis in the clinical setting, complementing vital signs and laboratory tests. Methods A retrospective descriptive study of patients with severe CAP admitted to the ICU between January 2008 and September 2013. We analyzed clinical and epidemiological variables and APACHE II, SAPS III, CURB-65 and Pneumonia Severity Index (PSI) that were recorded in the fi rst 24 hours. We used the Student t test to compare means and the chi-square test for univariate analysis. The standardized mortality ratio (SMR) and Hosmer–Lemershow test were calculated to analyze the calibration and ROC curve analysis for discrimination of diff erent scores. Results We analyzed 111 patients aged 57.5 ± 17.7 years, with 63.1% (70) males. The APACHE II score at admission was 19.8 ± 17.7 and SAPS III was 60.6 ± 16.7. ICU mortality was 29.7% (33). There was association between the four scores and mortality. P9 weakness, gastrointestinal symptoms, localized pain, altered mental status) that were part of the reason the patient sought medical care were registered. Additionally, age, sex, vital signs, C-reactive protein, and blood cultures were registered. Patients that within 48 hours from admission fulfi lled any criteria for severe sepsis were compared with patients that did not. Odds ratios for severe sepsis were computed using univariable as well as multivariable logistic regression, controlling for age and gender as confounders. 1. Shapiro NI, Wolfe RE, Wright SB, Moore R, Bates DW. Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med. 2008;35:255-64. 2. Müller F, Christ-Crain M, Bregenzer T, Krause M, Zimmerli W, Mueller B, et al. Procalcitonin levels predict bacteremia in patients with community-acquired pneumonia: a prospective cohort trial. Chest. 2010;138:121-9. P6 Systemic symptoms as markers for severity in sepsis J Edman-Wallér1, L Ljungström2, R Andersson3, G Jacobsson2, M Werner1 1Södra Älvsborg Hospital, Borås, Sweden; 2Skaraborg Hospital, Skövde, Sweden; 3Institute of Biomedicine, University of Gothenburg, Sweden Critical Care 2015, 19(Suppl 1):P6 (doi: 10.1186/cc14086) Methods This was a secondary analysis of a prospective study in 25 critically ill patients comparing diff erent measurement techniques. Temperature was measured intermittently with an axillary digital thermometer every 4 hours, and a urinary bladder thermistor catheter was used for continuous temperature measurement; the latter was considered the reference method. Fever (core temperature ≥38.3°C) episodes occurring within 60 minutes after each other were classifi ed as one episode. We compared the fever detection rate of both methods and calculated the diff erence in timing between both techniques. Introduction The objective of this study was to evaluate six general symptoms as markers for severe sepsis in patients with suspected bacterial infections. Severe sepsis is a common cause of death and morbidity. Early detection and treatment is critical for outcome. Clinical presentation varies widely and no single test is able to discriminate severe sepsis from uncomplicated infections or non-infectious emergencies. Apart from local symptoms of infection, the systemic infl ammatory reaction itself may give rise to general symptoms such as muscle weakness and vomiting. f Results Twenty-nine episodes of fever were detected in 10 patients (seven male) with a median APACHE II score of 10 (IQR 3 to 24) and a median SOFA score of 10 (IQR 8 to 11). Median duration of a fever episode was 1 hour 24 minutes (IQR 47 minutes to 2 hours 59 minutes) and median maximum temperature was 38.4°C (IQR 38.3 to 38.7). Median axillary temperature was 0.7°C (IQR 0.3 to 0.9) lower than core temperature. Using intermittent, non-invasive measurement, 27 out of 29 fever episodes (93.1%) remained undetected. Methods We present an observational, consecutive study. Data from ambulance and hospital medical records were analyzed. The survey included 290 patients (mean age: 70.6 years; median age: 74 years; male: 47%) who were admitted to a 550-bed secondary care hospital, receiving intravenous antibiotics for suspected community-acquired infections. General symptoms (fever/shivering, dyspnea, muscle Conclusion Intermittent, non-invasive temperature measurement failed to detect most of the fever episodes as measured by a bladder thermistor catheter and should not be used to screen for elevated body temperature in critically ill patients. Clinical scores and blood biomarkers for prediction of bacteremia in emergency department patients: Bacteremia Assessment in Clinical Triage (BACT) study g y S Laukemann1, N Kasper1, N Kasper1, A Kutz1, S Felder1, S Haubitz2, B Müller1, P Schuetz1 Figure 1 (abstract P9). 1Kantonsspital Aarau, Switzerland; 2University Hospital, Bern, Switzerland Critical Care 2015, 19(Suppl 1):P8 (doi: 10.1186/cc14088) Introduction Collection of blood cultures is routinely performed in patients with suspicion of infection in the emergency department (ED) despite a low yield of positive culture results. To increase sensitivity, diff erent clinical prediction rules and blood biomarkers have been put forward. Herein, we validated the performance of diff erent promising clinical prediction rules alone and in combination with novel blood biomarkers to predict blood culture positivity. Methods This is an observational cohort study including consecutive medical patients with suspected infection and collection of ED admission blood cultures. Five clinical prediction rules were calculated and admission concentrations of procalcitonin (PCT), C-reactive protein, neutrophil–lymphocyte count ratio (NLCR), lymphocyte count, white blood cell count, and red blood cell distribution width were measured. True blood culture positivity was assessed by two independent physicians. We used logistic regression models with area under the curve (AUC) to establish associations between clinical prediction rules and blood culture positivity. Figure 1 (abstract P9). y Results Of 1,083 included patients, 106 (9.8%) cultures were positive. Of the clinical prediction rules, the Shapiro rule performed best (AUC 0.733) followed by the Metersky rule (AUC 0.609). The best biomarkers were PCT (AUC 0.796), NLCR (0.692) and lymphocyte count (AUC 0.671). Combination of the Shapiro rule and PCT showed the best combination result (AUC of combined model 0.822). Limiting blood cultures to either the Shapiro rule ≥4 points or PCT >0.11 μg/l would reduce negative sampling by 25.6% while still identifying 100% of positive cultures. Using a Shapiro rule ≥3 points or PCT >0.25 μg/l limit would reduce negative sampling by 42.1% while still identifying 96.2% of positive cultures. Conclusion The four analyzed scores presented good calibration, but discrimination seems better in SAPS III. Given the diffi culty of calculating PSI, and its low discrimination (similar to CURB-65), we prefer to use the CURB-65 score in routine clinical practice. 1. Shapiro NI, Wolfe RE, Wright SB, Moore R, Bates DW. Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med. 2008;35:255-64. 2. Müller F, Christ-Crain M, Bregenzer T, Krause M, Zimmerli W, Mueller B, et al. Procalcitonin levels predict bacteremia in patients with community-acquired pneumonia: a prospective cohort trial. Chest. 2010;138:121-9. P6 S3 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Assessment of specifi c risk scores for patients admitted to the ICU for severe community-acquired pneumonia The SMR for APACHE II was 0.87 and 0.85 for the SAPS III. Figure 1 shows the ROC curve for the four scores, the best observed discrimination obtained was for SAPS III score (AuC 0.79) and the worst was obtained for CURB-65 score (AuC 0.7). The Hosmer–Lemeshow test showed acceptable calibration for the four predictive systems (P > 0.05). Clinical scores and blood biomarkers for prediction of bacteremia in emergency department patients: Bacteremia Assessment in Clinical Triage (BACT) study S Laukemann1, N Kasper1, N Kasper1, A Kutz1, S Felder1, S Haubitz2, B Müller1, P Schuetz1 1Kantonsspital Aarau, Switzerland; 2University Hospital, Bern, Switzerland Critical Care 2015, 19(Suppl 1):P8 (doi: 10.1186/cc14088) Clinical scores and blood biomarkers for prediction of bacteremia in emergency department patients: Bacteremia Assessment in Clinical Triage (BACT) study Pre-exposure to mechanical ventilation and endotoxin infl uence bacterial growth and immune response during experimental ventilator-associated pneumonia Table 1 (abstract P10) Sternal infection P value Insulin 9/85 0.001 Current smoker 4/272 0.037 COPD 11/197 <0.001 Transfusion >3 19/302 0.001 J Sperber1, A Nyberg1, M Lipcsey2, A Larsson2, J Sjölin2, M Castegren2 1Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden; 2Uppsala University, Uppsala, Sweden Introduction Overproduction of nitric oxide (NO) is correlated with adverse outcomes in sepsis. NO is additionally a central part of the innate immune system defense against pathogens causing ventilator- associated pneumonia (VAP), which can complicate the clinical course during mechanical ventilation (MV). We hypothesized that pre-exposure to MV and systemic infl ammation from endotoxin each would infl uence bacterial growth in lung tissue, based on an altered immune response in experimental pneumonia. We used a porcine Pseudomonas aeruginosa VAP model with ventilatory and infl ammatory pre-exposures before inoculation to evaluate bacterial growth, development of lung damage, total NO production and infl ammatory cytokine response. Conclusion Postoperative deep sternal wound infections have statistical signifi cant correlation with the following parameters: transfusion with >3 red blood cell units, history of COPD, insulin dependence and when the patient is a current smoker. Also there is a tendency for correlation with CBP time >120 minutes (P = 0.056). References 1. Diez C, et al. Risk factors for mediastinitis after cardiac surgery – a 1. Diez C, et al. Risk factors for mediastinitis after cardiac surgery – a retrospective analysis of 1700 patients J Cardiothor Surg. 2007;2:23. 1. Diez C, et al. Risk factors for mediastinitis after cardiac surgery – a retrospective analysis of 1700 patients J Cardiothor Surg 2007;2:23 1. Diez C, et al. Risk factors for mediastinitis after cardiac surgery – a retrospective analysis of 1700 patients J Cardiothor Surg. 2007;2:23. 2. Schimmer C, et al. Prevention of sternal dehiscence and infection in high-risk patients: a prospective randomized multicenter trial. Ann Thorac Surg. 2008;86:1897-904. y Methods Three groups of mechanically ventilated pigs were subjected to experimental VAP for 6 hours with intrapulmonary 1 × 1011 CFU P. aeruginosa at baseline. Two groups were pre-exposed to MV for 24 hours before bacterial inoculation: MV + Etx (n = 6, received endotoxin 0.063 μg × kg–1 × hour–1) and MV (n = 6, received saline in equivalent volume). One group, Un (n = 8), started the experiment unexposed to both MV and endotoxin, directly from the initiation of VAP. Postmortem lung tissue samples rendered bacterial cultures. References 1. Hoenig M, et al. Procalcitonin fails to predict bacteremia in SIRS patients: a cohort study. Int J Clin Pract. 2014;68:1278-81. y 2. Hoeboer SH, et al. Old and new biomarkers for predicting high and low risk microbial infection in critically ill patients with new onset fever: a case for procalcitonin. J Infect. 2012;64:484-93. y 2. Hoeboer SH, et al. Old and new biomarkers for predicting high and low risk microbial infection in critically ill patients with new onset fever: a case for procalcitonin. J Infect. 2012;64:484-93. q y Results A total of 35 patients (3.44%) were complicated by deep sternal wound infections. No statistical correlation was found with age >75, gender, DM, BMI >30, steroids, emergent operation, prolonged ventilation, CBP time >120 minutes, reintubation and NIV. Factors with statistical signifi cant correlation are presented in Table 1. P10 Predisposing factors for deep sternal wound infection after cardiac surgery Predisposing factors for deep sternal wound infection after cardiac surgery F Ampatzidou, M Sileli, A Madesis, K Antoniou, A Baddur, G Kechagioglou, T Asteri, G Drossos General Hospital G. Papanikolaou Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P10 (doi: 10.1186/cc14090) Conclusion Combination of clinical parameters combined in the Shapiro rule together with admission levels of PCT allows reduction of unnecessary blood cultures with minimal false negative rates. References Introduction The aim of our study was to investigate perioperative risk factors associated with deep sternal wound infections in complicated cardiac surgery. 2. Müller F, Christ-Crain M, Bregenzer T, Krause M, Zimmerli W, Mueller B, et al. Procalcitonin levels predict bacteremia in patients with community-acquired pneumonia: a prospective cohort trial. Chest. 2010;138:121-9. y Methods A total of 1,017 patients underwent cardiac surgery in a 2-year period. We investigate the correlation between deep sternal S4 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 factors might be useful to know whether or not adult febrile patients have bacteremia. wound infection with the following 14 preoperative characteristics and perioperative parameters: age >75, female gender, diabetes mellitus (DM), insulin dependence, body mass index (BMI) >30, current smokers, COPD, cardiopulmonary bypass time (CBP) >120 minutes, use of steroids, emergency operation, prolonged mechanical ventilation (>48 hours), reintubation, transfusion with more than 3 units of red blood cells, and the postoperative use of non-invasive ventilation (NIV). The chi-square test was used for statistical analysis. wound infection with the following 14 preoperative characteristics and perioperative parameters: age >75, female gender, diabetes mellitus (DM), insulin dependence, body mass index (BMI) >30, current smokers, COPD, cardiopulmonary bypass time (CBP) >120 minutes, use of steroids, emergency operation, prolonged mechanical ventilation (>48 hours), reintubation, transfusion with more than 3 units of red blood cells, and the postoperative use of non-invasive ventilation (NIV). The chi-square test was used for statistical analysis. P11 Risk factors for bacteremia in adult febrile patients in emergency settings g A Mikami1, Y Natori1, F Omata2, S Ishimatsu1 1St Luke’s International Hospital, Tokyo, Japan; 2St Luke’s Life Science Institute, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P11 (doi: 10.1186/cc14091) Results The animals pre-exposed to endotoxin (MV + Etx) displayed higher bacterial growth (CFU × g–1) (P <0.05), lower PaO2/FiO2 (P <0.05) and lower nitrate levels (P <0.01) than the unexposed animals (Un). Plasma TNFα levels were higher in Un than in both pre-exposed groups MV + Etx and MV (P <0.01). There were no signifi cant diff erences between the two pre-exposed groups. Critical Care 2015, 19(Suppl 1):P11 (doi: 10.1186/cc14091) Introduction Blood culture is a critical procedure for detecting potentially life-threatening bloodstream infections (BSI). At the same time, early diagnosis and appropriate treatment of BSI are the key factors in order to improve prognosis. The purpose of the current analysis was to identify risk factors for bacteremia in adult febrile patients in emergency settings. g Conclusion Mechanical ventilation for 24 hours with concomitant endotoxin exposure enhances bacterial growth and lung damage during P. aeruginosa VAP, compared with inoculation without any pre- exposure to MV or endotoxin. The greater bacterial clearance in the unexposed animals was associated with higher NO production and higher levels of pro-infl ammatory cytokines. Methods We conducted a retrospective case–control study within a population of adult patients visiting the emergency department at a community hospital (St Luke’s International Hospital, Tokyo, Japan) and who underwent two sets of blood culture testing between 2003 and 2012. Among a total of 13,582 patients, 1,322 (10%) were detected as bacteremia. We included in this study 179 randomly selected patients from the bacteremia group and 321 randomly selected patients from the negative blood culture group to serve as the comparison group. Multivariate logistic regression was used to evaluate the relationship between clinical characteristics factors and bacteremia. Pre-exposure to mechanical ventilation and endotoxin infl uence bacterial growth and immune response during experimental ventilator-associated pneumonia NO production was measured with urinary nitrate levels over 6 hours of VAP. retrospective analysis of 1700 patients J Cardiothor Surg. 2007;2:23. 2. Schimmer C, et al. Prevention of sternal dehiscence and infection in high-risk patients: a prospective randomized multicenter trial. Ann Thorac Surg. 2008;86:1897-904. P15 ICU mortality rates in patients with sepsis before and after the Surviving Sepsis Campaign ICU mortality rates in patients with sepsis before and after the Surviving Sepsis Campaign g p p g J Melville, S Ranjan, P Morgan East Surrey Hospital, Redhill, UK Critical Care 2015, 19(Suppl 1):P15 (doi: 10.1186/cc14095) Introduction The aim of this study was to evaluate the eff ect of the Surviving Sepsis Campaigns on mortality rates, before and after the second surviving sepsis publication, and to assess whether patients with sepsis being admitted to the ICU had a lower APACHE II score on admission. Patients with sepsis, who require ICU care, have an extremely poor prognosis. It has been shown that the mortality rates range from 20.7% (severe sepsis) to 45.7% (septic shock) [1]. The surviving sepsis campaign was initiated in 2002. The fi rst, second and third publications were published in 2004, 2008 and 2012 respectively [2]. g Results According to elevation of CT grades, severity of illness was signifi cantly associated with high score (APACHE II: 10.5 to 4.0, 12.8 to 4.2, 16 to 4.2, SOFA: 2.6 to 1.5, 2.9 to 1.9, 6.8 to 3.7, CRP: 17.8 to 10.6, 22.4 to 10.1, 33.3 to 11.9) and also duration of mechanical ventilation and length of hospital stay were longer (duration of mechanical ventilation: 10.9 to 6.6, 11.5 to 6.7, 15.8 to 7.2, length of hospital stay: 23.4 to 10.6, 27.9 to 21.4, 48.7 to 36.2). y Methods A retrospective case note review was performed, looking at a sample of 5,954 patients who were 18 years or older who had been admitted to East Surrey Hospital (ESH) ICU between 1 January 2005 and 31 October 2014. The total number of patients with sepsis was 941. We compared results before and after the second publication of the surviving sepsis campaign, looking at mortality rates, age of patients, admission length prior to ICU transfer, APACHE II score and the length of stay on the ICU. Conclusion Novel classifi cation of CNF based on CT fi ndings showing the extension of fl uid collection is a useful indicator of the disease severity and predicting clinical outcome. These fi ndings may infl uence the strategy for the success of percutaneous catheter drainage. y Results From the beginning of 2005 to the end of 2008, the mortality rates for septic patients was 51.9% compared with 41.3% from the beginning of 2009 to end of October 2014. P15 ICU mortality rates in patients with sepsis before and after the Surviving Sepsis Campaign Fisher’s two-tailed test showed a signifi cant diff erence (P = 0.003) between the mortality before and after the second publication. The median ages before and after 2009 were 63.9 and 64.8 years. The time in hospital before admission to the ICU was greater before 2009 (6.15 days) compared with after 2009 (5.53 days). There was no signifi cant diff erence (Mann–Whitney test) between the APACHE II scores, with the mean and median score the same at 17.6 and 18 for both groups. The mean length of stay was 1 day longer after 2009 (8.07 days compared with 9.07 days). P15 this study. Cervical spaces were subdivided into three components according to the concept of interfascial planes. The extension of acute fl uid collection in cervical spaces was classifi ed into three grades: Grade I, fl uid collection confi ned to one component; Grade II, fl uid collection spreading into two or three components; and Grade III, fl uid collection spreading into four components or mediastinum. We analyzed association with CT grades and severity of illness (SOFA score, APACHE II score, CRP). All patients underwent percutaneous catheter drainage either ultrasonography guided or CT guided. We compared treatment outcome of CNF with CT grades. 1. Estaban A, et al. Crit Care Med. 2007;35:1284-9. 2. Alberti C, et al. Intensive Care Med. 2002;28:108-21. ICU mortality rates in patients with sepsis compared with patients without sepsis p J Melville, S Ranjan, P Morgan East Surrey Hospital, Redhill, UK Critical Care 2015, 19(Suppl 1):P14 (doi: 10.1186/cc14094) Introduction The aim of the study was to evaluate the diff erence in mortality rates between those admitted to the ICU with and without sepsis, and to assess the proportion of patients who had sepsis. Septic patients are one of the key groups of patients admitted to ICUs around the world. Septic patients have an extremely poor prognosis with published mortality rates ranging from 20.7% (severe sepsis) to 45.7% (septic shock) [1]. With septic patients making up roughly 21% of patients admitted to ICUs, it is important to assess whether these rates of mortality hold true to a district general ICU and to assess the extent of the diff erence in prognosis between patients with and without sepsis [2]. g y p y Conclusion Patients with sepsis admitted to ESH ICU had a 20% relative decrease in mortality after the second publication of surviving sepsis guidelines. The original aim of the campaign was to reduce mortality from sepsis by 25% in 5 years [3]. This decrease was not due to a signifi cant diff erence between the sets of patients. The decreased time to admittance to ICU may be due to improved recognition of the need for ICU care. Overall the surviving sepsis campaign has had a signifi cantly benefi cial eff ect on mortality rates in patients with sepsis. References 1. Estaban A, et al. Crit Care Med. 2007;35:1284-9. Methods We performed a retrospective case note review, looking at a sample of 5,954 patients 18 years or older who were admitted to East Surrey Hospital (ESH) ICU, which has an elective admissions rate of 3%, between 1 January 2005 and 31 October 2014. The total number of patients with sepsis was 941 compared with 5,013 without sepsis. We looked at mortality rates, APACHE II scores and length of stay on the unit. 2. Dellinger RP, et al. Crit Care Med. 2013;41:580-637. 3. Slade E, et al. Crit Care. 2003;7:1-2. Percutaneous drainage for patients with cervical necrotizing fasciitis with novel CT classifi cation based on extension of fl uid collection along the deep cervical space T Kiguchi, S Fujimi Osaka General Medical Center, Osaka, Japan Critical Care 2015, 19(Suppl 1):P13 (doi: 10.1186/cc14093) Percutaneous drainage for patients with cervical necrotizing fasciitis with novel CT classifi cation based on extension of fl uid collection along the deep cervical space T Kiguchi, S Fujimi Osaka General Medical Center, Osaka, Japan Critical Care 2015, 19(Suppl 1):P13 (doi: 10.1186/cc14093) Results In a multivariate logistic regression model, a statistically signifi cant independent eff ect was found for body temperature (BT) >38°C (OR = 2.58, 95% CI, 1.76 to 3.79, P <0.001), systolic blood pressure (SBP) <100 mmHg (OR = 1.72, 95% CI, 1.11 to 2.65, P = 0.01), CRP >10 mg/dl (OR = 3.03, 95% CI, 2.05 to 4.49, P <0.001) and PaCO2 <32 mmHg (OR = 2.3, 95% CI, 1.57 to 3.37, P <0.001). Receiver operating characteristic curve analysis revealed an area under the curve value of 0.725 for diff erentiating patients with bacteremia from negative culture. Introduction Cervical necrotizing fasciitis (CNF) is a rapidly evolving and life-threatening condition. Therefore, it is important for physicians to evaluate the severity of illness and to predict clinical outcome exactly in the early phase. We focused on extension of acute fl uid collection along the deep cervical space by CT fi ndings. The purpose of this study was to produce the CT grade and to analyze whether our CT grade is related to the clinical features and the responses to treatment of CNF. Methods Between June 2004 and December 2012, 42 patients diagnosed and treated for CNF in two institutions were included in p Methods Between June 2004 and December 2012, 42 patients diagnosed and treated for CNF in two institutions were included in Conclusion BT >38°C, SBP <100 mmHg, CRP >10 mg/dl and PaCO2 <32 mmHg are independently associated with bacteremia. These S5 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P17 Methods A prospective study design was used in order to investigate all sepsis patients either presenting to the emergency department or admitted to the ICU of a regional trauma centre. A total of 106 patients were recruited and all patients were considered eligible as per the SIRS and sepsis criteria [1]. The Sepsis-related Organ Failure Assessment score was determined over the fi rst 24 hours to assess organ function. Patients were assigned to groups as follows: sterile SIRS; uncomplicated sepsis; severe sepsis or septic shock as per the criteria. Assignment into groups was blinded and performed by an intensive care specialist independent of the study. Baseline demographics, clinical characteristics and outcomes were collected and surviving patients were sent a SF-12v2 survey at between 6 months and 2 years post hospital discharge. P18 P18 Long-term health-related quality of life in survivors of sepsis: an epidemiological study CE Battle1,2,3, G Davies1, M Vijayakumar3, PA Evans1 1NISCHR HBRU Morriston Hospital, Swansea, UK; 2College of Medicine, Swansea University, Swansea, UK; 3Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK Critical Care 2015, 19(Suppl 1):P18 (doi: 10.1186/cc14098) Independent risk factors for long-term mortality in patients with severe infection Results From the beginning of 2005 to the end of October 2014, mortality rates in septic patients were 44.6% compared with 26.2% in nonseptic patients. Fisher’s two-tailed test showed a signifi cant diff erence (P <0.0001) between the mortality in septic and nonseptic patients. There was a signifi cant diff erence (Mann–Whitney) between APACHE II scores, with median scores of 18 and 13 in septic and nonseptic patients respectively. Septic patients had longer lengths of stay, with the mean and median 8.73 and 3.89 days respectively, compared with 4.90 and 2.5 in nonseptic patients. Septic patients made up 15.8% of all patients admitted to the ICU. J Francisco, I Aragão, T Cardoso J Francisco, I Aragão, T Cardoso Centro Hospitalar do Porto – Hospital Geral de Santo António, Porto, Portugal Critical Care 2015, 19(Suppl 1):P16 (doi: 10.1186/cc14096) Introduction The purpose of this study was to examine long-term mortality, 5 years after severe infection, and to identify independent risk factors associated with it. Methods A prospective cohort study developed at a tertiary care university-affi liated 600-bed hospital including all patients with severe infection admitted into intensive care, medical, surgical, haematology and nephrology wards, over a 1-year period (2008/2009). The outcome of interest was mortality 5 years following hospitalisation and its association with specifi c risk factors was studied through logistic regression. Conclusion Patients with sepsis admitted to ESH ICU made up a signifi cant minority of patients admitted to the ICU. Septic patients had a 70% relative higher mortality rate compared with nonseptic patients. The mortality rate of 44.6% fi ts with previously quoted mortality rates in septic shock. Patients with sepsis had a signifi cantly higher predicted mortality, recorded by their APACHE II score, which was statistically signifi cant. This also meant they needed longer ICU care, with the average length of stay almost doubled. Results There were 1,013 patients included in the study. Hospital mortality rate was 14% (n = 137) and 5-year mortality was 37% (n = 379). Factors independently associated with 5-year mortality were (adjusted odds ratio (95% confi dence interval)): age = 1.04 per year (1.03 to 1.05), cancer = 8.00 (3.06 to 20.88), chronic hepatic disease = 3.06 (1.06 to 8.87), chronic respiratory disease = 2.21 (1.06 to 4.62), haematologic Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S6 Figure 1 (abstract P17). P18 Long-term health-related quality of life in survivors of sepsis: an epidemiological study Figure 1 (abstract P16). disease = 3.40 (1.64 to 7.04), Karnovsky Index <70 = 2.56 (1.63 to 3.71), infection by an ESKAPE pathogen = 1.65 (1.02 to 2.66) and severity of infection (reference is infection without SIRS): sepsis = 1.14 (0.7 to 1.83), severe sepsis = 1.18 (0.73 to 1.93), septic shock = 3.69 (1.78 to 7.65). The fi nal model had a very good discrimination for long-term mortality with an area under the ROC curve of 0.78 (Figure 1).ii disease = 3.40 (1.64 to 7.04), Karnovsky Index <70 = 2.56 (1.63 to 3.71), infection by an ESKAPE pathogen = 1.65 (1.02 to 2.66) and severity of infection (reference is infection without SIRS): sepsis = 1.14 (0.7 to 1.83), severe sepsis = 1.18 (0.73 to 1.93), septic shock = 3.69 (1.78 to 7.65). The fi nal model had a very good discrimination for long-term mortality with an area under the ROC curve of 0.78 (Figure 1). Conclusion The authors identifi ed several factors that were signifi cantly associated with increased long-term mortality in patients with severe infection. This information will help clinicians in the discussion of individual prognosis and clinical decision-making. Introduction Survivors of sepsis report persistent problems that can last years after hospital discharge. The main aim of this study was to investigate long-term health-related quality of life in survivors of SIRS and sepsis compared with Welsh normative data, controlling for age, length of stay and pre-existing conditions. The second aim was to investigate any diff erences in long-term health-related quality of life specifi cally with the patients categorised into three groups: SIRS, uncomplicated sepsis, and severe sepsis/septic shock. Conclusion The authors identifi ed several factors that were signifi cantly associated with increased long-term mortality in patients with severe infection. This information will help clinicians in the discussion of individual prognosis and clinical decision-making. Independent risk factors for long-term mortality in patients with severe infection Median ICU costs per patients and ICU cost per day according to study years. Figure 1 (abstract P16). Figure 1 (abstract P16). Figure 1 (abstract P17). Median ICU costs per patients and ICU cost per day according to study years. intensivists to contribute a high standard of care within a restricted budget. The cost-eff ectiveness analysis should be evaluated in sepsis care cases. Direct intensive care costs of severe sepsis and septic shock patients in Thailand B Khwannimit, R Bhurayanontachai Songklanagarind Hospital, Hat Yai, Thailand Critical Care 2015, 19(Suppl 1):P17 (doi: 10.1186/cc14097) Introduction Costs of severe sepsis care from middle-income countries are lacking. This study investigated direct ICU costs and factors that could aff ect the fi nancial outcomes. fi Methods A prospective cohort study was conducted in the medical ICU of a tertiary referral university teaching hospital in Thailand over a 4-year period. y p Results A total of 897 patients, with 683 (76.1%) having septic shock. Overall ICU mortality was 38.3%. The median (interquartile range) ICU length of stay (LOS) was 4 (2 to 9) days. Community, nosocomial and ICU-acquired infection were documented in 574, 282 and 41 patients, respectively. The median ICU costs were €2,067.2 (986.3 to 4.084.6) per patient and €456.6 (315.3 to 721.8) per day. The ICU costs accounted for 64.7% of the hospital costs. In 2008 to 2011, the ICU costs signifi cantly decreased by 40% from €2,695.7 to €1,617, whereas the daily ICU costs decreased only 3.3% from €463.9 to €448.7 (Figure 1). The average ICU costs of patient with nosocomial and ICU-acquired infection were signifi cantly higher than patients with community-acquired infection. By multivariate logistic regression analysis, age, nosocomial or ICU infection, admission from emergency department, number of organ failures, ICU LOS, and fl uid balance in the fi rst 72 hours were independently associated with total ICU costs.i Results A total of 106 patients were included in the study. A mortality rate of 34% was recorded, leading to a fi nal response rate of 72% by the end of the data collection period. Quality of life was signifi cantly reduced in all patients when compared with local normative data (all P <0.0001). Reductions in the physical components of health-related quality of life were more pronounced in severe sepsis/septic shock patients when compared with uncomplicated sepsis and SIRS patients. Conclusion This is the fi rst observational study to specifi cally focus on the diff erent groups of SIRS and sepsis patients to assess long-term quality of life. Local population norms were used for comparison, rather than wide geographical norms that fail to refl ect the intricacies of a country’s population. Signifi cant reductions in quality of life were found in severe sepsis/septic shock patients compared with in uncomplicated sepsis and SIRS patients, when controlling for age, pre- existing conditions, hospital and ICU length of stay. Reference g Reference P21 P21 Global burden of sepsis: a systematic review C Fleischmann1, A Scherag1, NK Adhikari2, CS Hartog1, T Tsaganos3, P Schlattmann1, DC Angus4, K Reinhart1 1Jena University Hospital, Jena, Germany; 2University of Toronto, ON, Canada; 3University of Athens, Greece; 4University of Pittsburgh, PA, USA Critical Care 2015, 19(Suppl 1):P21 (doi: 10.1186/cc14101) Introduction Sepsis is a global healthcare challenge. However, comprehensive information on sepsis morbidity and mortality across the world is scarce. We aimed to estimate the global burden of sepsis and to identify knowledge gaps based on available evidence from observational epidemiological studies. g Methods We searched 15 international and national citation databases for population-level estimates on incidence rates of sepsis or severe sepsis per 100,000 person-years and case fatality rates in adult populations using consensus criteria and published in the last 40 years. No language or publication restrictions were applied. Studies were stratifi ed into four subgroups (setting: hospital or ICU for sepsis and severe sepsis) and meta-analyzed using metaprop of the R 3.0.2 package. Heterogeneity of the underlying eff ects across studies was expressed by the estimated τ, the square root of the between-study variance. y Conclusion Patients admitted to the ICU with severe CAP and immunosuppressive therapy have higher mortality, with no diff erences between HCAP and CAP. The delay in intubation as well as bacterial and inappropriate antibiotic treatment are factors that increase mortality. Results The search yielded 1,553 reports from 1979 to 2013, of which 37 met our criteria and 33 provided data for meta-analysis. The included studies were from 15 high-income countries in North America, Europe, Asia, and Australia. For these countries, the population incidence rate was 256 (95% CI, 182 to 360, τ = 0.43) hospital-treated sepsis cases and 151 (95% CI, 94 to 242, τ = 0.98) hospital-treated severe sepsis cases per 100,000 person-years, with large between-study heterogeneity. Restricted to the last decade, the incidence rate was 427 (95% CI, 281 to 648, τ = 0.24) sepsis cases and 331 (95% CI, 207 to 530, τ = 0.59) severe sepsis cases per 100,000 person-years. Hospital mortality was 15% for sepsis and 25% for severe sepsis during this period of time. There were no population-level sepsis incidence estimates from lower income countries. A tentative extrapolation from high-income-country data suggests global estimates of 30.7 million sepsis and 23.8 million severe sepsis cases, with potentially six million deaths each year. Analysis of the mortality rate in patients admitted to the ICU for severe community-acquired pneumonia Conclusion Severe sepsis and septic shock are conditions that consume large amounts of resources. Nonsurvivors had higher average spending than survivors. Patients admitted with septic shock had higher mortality than patients with severe sepsis with high mortality in relation to the prognostic indices adopted. The beginning of the antibiotics was longer in the nonsurvivors. We should adopt measures aimed at recognizing and earlier treatment of sepsis. If we improve our treatment, especially in septic shock, we will prevent deaths and decrement costs. Introduction The aim of the study was to analyze the factors associated with hospital mortality in patients with severe community-acquired pneumonia (CAP) who required ICU admission. Methods An observational, retrospective study of patients with severe CAP admitted to the ICU between January 2008 and September 2013. We analyzed clinical, epidemiological and outcome variables. Quantitative variables were expressed as the mean and standard deviation. Qualitative variables are expressed as the percentage and absolute value. We applied the Mann–Whitney and Fisher’s exact test, as needed, with an alpha error of 5%. P21 p Results We analyzed 111 patients, 57.5 ± 17.7 years old, with 63.1% (70) males and APACHE II score on admission of 19.8 ± 17.7. ICU mortality was 29.7% (33) and in-hospital mortality was 32.4% (36). Ten percent of patients met criteria for medical care-associated pneumonia (HCAP); there were no signifi cant diff erences in mortality between HCAP and CAP (P = 0.075). Patients chronically taking immunosuppressive therapy had a signifi cantly higher mortality compared with the rest of the patients (47.8% vs. 28.4%, P = 0.07). The mortality rate was also higher in patients in whom NIV fail in the fi rst 24 hours (42.9% vs. 17.6% with P = 0.09). Patients who required intubation and mechanical ventilation in the fi rst 24 hours had a higher mortality rate (47.2% vs. 19%, P = 0.002). Regarding the etiology of pneumonia, in 11 patients the viral origin of infection was confi rmed (10 patients had H1N1 pneumonia and one patient CMV pneumonia), with a mortality rate signifi cantly lower than in patients with bacterial pneumonia (3.6% vs. 35.3%, P = 0.06). The use of the right antibiotic therapy at admission was associated with mortality (P = 0.0001). M Borges Velasco, MA Leitão, MB Leitão, DM Dalcomune, LP Massete Hospital Meridional S.A., Vila Velha, Brazil Introduction Sepsis is a high-prevalence disease in ICUs, associated with high mortality and high costs, mainly in developing countries. The aim of this study is to demonstrate the ICU costs, in a private hospital, in patients admitted with severe sepsis and septic shock. p p p Methods A retrospective, observational, single-center study of patients admitted from November 2013 to March 2014 with severe sepsis and septic shock. The records data were taken from the Software Epimed, MV System, and IBM SPSS Statistics 21. The classifi cation was based on the Surviving Sepsis Campaign 2012. We included all 50 beds of an adult ICU, clinical and surgical. All patients older than 18 years with severe sepsis and septic shock were included. We evaluated the costs of patients during their ICU stay, and its relation to clinical presentation (severe sepsis and septic shock), antibiotic start time, permanence of ICU stay, and mortality. Only the fi rst episode per patient was recorded. Results From November 2013 to March 2014 were included 82 patients with criteria for severe sepsis and septic shock. The mean age of patients was 62.5 ± 21.8 years, divided equally between the genres. The overall mortality rate was 34.15%. The SAPS 3 was 56.43, with death probability set to Latin America 38.83%. Patients with severe sepsis had a mortality of 23.2% and those with septic shock had a mortality rate of 58%. The average total cost during ICU admission per patient was US$17,834 and the average daily cost was US$1,641. The daily cost in patients with severe sepsis and septic shock was US$1,263 and US$2,465 (P = 0.002), respectively, and in survivors and nonsurvivors was US$1,189 and US$2,512 (P = 0.001). The length of stay of patients Conclusion Our analyses underline the urgent need to implement global strategies to monitor sepsis morbidity and mortality – especially in low-income and middle-income countries. For further epidemiological studies, more consistent and standardized methodological approaches are needed to reduce between-study heterogeneity. In particular, further research on sepsis coding using administrative data seems necessary to derive sensitive and specifi c sepsis case identifi cations. g Reference Conclusion The ICU costs of severe sepsis management signifi cantly declined in Thailand. However, the ICU costs were a fi nancial burden accounting for two-thirds of the hospital costs. It is essential for Levy MM, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS. International Sepsis Defi nitions Conference. Crit Care Med. 2003;31:1250-6. Levy MM, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS. International Sepsis Defi nitions Conference. Crit Care Med. 2003;31:1250-6. Levy MM, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS. International Sepsis Defi nitions Conference. Crit Care Med. 2003;31:1250-6. S7 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P19 in the ICU was 11.09 days, being 11.3 days in patients with severe sepsis and 10.7 days in patients with septic shock (P = 0.785). The beginning of the antibiotics in nonsurvivors was 73.7 minutes and in survivors was 64.7 minutes (P = 0.757), with the earliest onset in patients with septic shock than in patients with severe sepsis (38.5 vs. 81.5 minutes, P = 0.141). P19 Analysis of the mortality rate in patients admitted to the ICU for severe community-acquired pneumonia C Joya-Montosa, MD Delgado-Amaya, H Molina-Diaz, E Curiel Balsera Hospital Regional de Málaga, Spain Critical Care 2015, 19(Suppl 1):P19 (doi: 10.1186/cc14099) Evaluation of the cost of severe sepsis and septic shock in a private ICU in Brazil Evaluation of the cost of severe sepsis and septic shock in a private ICU in Brazil Evaluation of the cost of severe sepsis and septic shock in a private ICU in Brazil M Borges Velasco, MA Leitão, MB Leitão, DM Dalcomune, LP Massete Hospital Meridional S.A., Vila Velha, Brazil Critical Care 2015, 19(Suppl 1):P20 (doi: 10.1186/cc14100) M Borges Velasco, MA Leitão, MB Leitão, DM Dalcomune, LP Massete Hospital Meridional S.A., Vila Velha, Brazil P22 P22 Disparities in acute sepsis care: a systematic review D Yamane, N Huancahuari, P Hou, J Schuur Brigham and Women’s Hospital, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P22 (doi: 10.1186/cc14102) P22 Disparities in acute sepsis care: a systematic review D Yamane, N Huancahuari, P Hou, J Schuur Brigham and Women’s Hospital, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P22 (doi: 10.1186/cc14102) P22 Disparities in acute sepsis care: a systematic review D Yamane, N Huancahuari, P Hou, J Schuur Brigham and Women’s Hospital, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P22 (doi: 10.1186/cc14102) Introduction Disparities in the incidence and outcomes of sepsis have been documented in observational studies but little is known about S8 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods We included adult (age >18 years) ED patients presenting with severe sepsis/septic shock (sepsis with elevated lactate (>4 mmol/l)) or hypotension) from the prospective clinical ProCESS trial. We studied a subset of patients with microcirculatory videos obtained along with non-infected control patients. Using a sidestream dark-fi eld videomicroscope, we obtained image sequences from the sublingual mucosa and used video stabilization and frame averaging techniques to visualize slowly-moving leukocytes. We quantifi ed the number of rolling and adhered leukocytes present per 1 mm × 1 mm visual fi eld in a standardized 3-second clip. Furthermore, we extracted the total length of vessels candidate for counting of rolling/adhered leukocytes (vessels with an adequate focus). We report sample means with standard deviation and compare them with Student’s t test. how these occur and how we might prevent them. Our objective is to identify disparities by race, language, gender, socioeconomic status, insurance status and geography in acute sepsis care in emergency department (ED) or ICU settings in the published literature. p g p Methods We performed a systematic review of disparities in sepsis care. The search strategy and inclusion and exclusion criteria were defi ned a priori. A medical librarian searched the entire MEDLINE (PubMed), EMBASE and Cinahl databases prior to 2013. One author reviewed all abstracts and a second author reviewed 10% of all abstracts for agreement. Both reviewers independently reviewed each included article using an explicit study review tool. P22 We included studies that met the following inclusion criteria: ED or ICU setting; disparities due to race, language, gender, socioeconomic status, insurance status or geography; process of care measures (antibiotics, lactate, i.v. fl uid resuscitation, central line placement, vasopressor use) or outcome measures (mortality, length of stay, complications, costs). We excluded studies involving organ-specifi c infectious conditions, pediatric populations, case reports, and review articles.i p Results We included a total of 64 patients with severe sepsis/septic shock and 32 non-infected controls. The mean number of adhered leukocytes per fi eld in the sepsis group was 2.1 (SD 2.3) compared with 0.4 (SD 0.8) in the non-infected group (P <0.001). This corresponded to a mean number of adhered leukocytes per unit vessel length of 0.16/mm (SD 0.22) and 0.03/mm (SD 0.06) for sepsis and non-infected groups, respectively (P <0.001). For the rolling leukocytes, we observed a mean number of 27.8 (SD 19.4) in the sepsis group and 12.0 (SD 8.7) in the non-infected group (P <0.001) per fi eld. This corresponded to a mean number of rolling leukocytes per unit vessel length of 2.00/mm (SD 1.67) and 0.75/mm (SD 0.55), respectively (P <0.001). Results We identifi ed 778 abstracts; yielding 31 for inclusion (k = 0.95), 26 of 31 studies were excluded due to quality issues. Five articles met our inclusion criteria. Only one of the studies [1] contained data on process of care measures, showing that central venous monitoring was less likely to occur in older patients. Three studies [2-4] showed that Black patients had a higher incidence of sepsis, a higher hospitalization rate, and higher mortality rate. Plurad and colleagues [5] reported that Asian patients had increased incidence of post-traumatic sepsis. Overall, Black patients with sepsis were younger, had lower socioeconomic status and were more likely to be cared for in urban settings compared with their cohorts. p y Conclusion Our results show a higher number of rolling and adhered leukocytes in patients with severe sepsis/septic shock when compared with non-infected controls. This also applies when taking the total vessel length in the fi eld of view into consideration. This may hold potential as a useful tool in sepsis assessment. Conclusion We found little published data addressing whether disparities due to race, language, gender, socioeconomic status, insurance status or geography exist in the acute care of sepsis. P23 S bli g y Methods This is a prospective observational study in patients scheduled for elective cardiac surgery. Serum samples were drawn prior to surgery, after connection to cardiopulmonary bypass (ischemia), after opening of cross-clamp (reperfusion) and after termination of surgery. The redox status of patients was measured using the bedside point of care RedoxSYS Diagnostic System™ (Luoxis, USA). Simultaneously the antioxidant capacity in serum samples were calculated in all perioperatively obtained serum samples. P24 P24 Time course of redox potential and antioxidant capacity in patients undergoing cardiac surgery C Stoppe1, G Schaelte1, S Kraemer2, C Benstoem2, D Bar-Or3, A Goetzenich2 1RWTH Aachen University, Aachen, Germany; 2RWTH Aachen University, University Hospital, Aachen, Germany; 3Swedish Medical Center, Trauma Research, Engelwood, CO, USA Critical Care 2015, 19(Suppl 1):P24 (doi: 10.1186/cc14104) References Lagu T, Rothberg MB, Nathanson BH, et al. Variation in the care of se 1. Lagu T, Rothberg MB, Nathanson BH, et al. Variation in the care of septic shock: the impact of patient and hospital characteristics. J Crit Care. 2012;27:329-36. 2. Barnato AE, Alexander SL, Linde-zwirble WT, Angus DC. Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics. Am J Respir Crit Care Med. 2008;177:279-84. 3. Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Occurrence and outcomes of sepsis: infl uence of race. Crit Care Med. 2007;35:763-8. Introduction Cardiac surgery regularly provokes infl ammation and oxidative stress which contribute to the development of organ failure and mortality of patients. While the assessment of single markers does not refl ect a comprehensive investigation of redox status, the measurement of oxidation–reduction potential (ORP) provides a reliable measure to assess the balance between total prooxidant and antioxidant balance in the blood. The aim of the present study was to investigate the overall redox potential in patients undergoing cardiac surgery. 4. Mayr FB, Yende S, Linde-zwirble WT, et al. Infection rate and acute organ dysfunction risk as explanations for racial diff erences in severe sepsis. JAMA. 2010;303:2495-503. 5. Plurad DS, Lustenberger T, Kilday P, et al. The association of race and survival from sepsis after injury. Am Surg. 2010;76:43-7. 5. Plurad DS, Lustenberger T, Kilday P, et al. The association of race and survival from sepsis after injury. Am Surg. 2010;76:43-7. P22 As sepsis is a leading cause of in-hospital mortality, future research should determine whether such disparities exist. Specifi cally, prospective studies of the process of care in sepsis management may further elucidate additional factors that may contribute to these disparities. R f Fatty acid composition of erythrocytes in multiple organ dysfunction syndrome y y A Osipenko1, A Marochkov2 A Osipenko1, A Marochkov2 1A. Kuleshov Mogilev State University, Mogilev, Belarus; 2Mogilev Regional Hospital, Mogilev, Belarus Critical Care 2015, 19(Suppl 1):P25 (doi: 10.1186/cc14105) Results We found that severe septic patients showed lower CIV activity/ protein quantity than controls at day 1 (P <0.001), day 4 (P <0.001) and day 8 (P <0.001) of severe sepsis diagnosis. Survivor severe septic patients (n = 130) showed lower CIV activity/protein quantity than controls at day 1 (P <0.001), day 4 (P <0.001) and day 8 (P <0.001) of severe sepsis diagnosis. In addition, nonsurvivor severe septic patients (n = 68) showed lower CIV activity/protein quantity than controls at day 1 (P <0.001), day 4 (P <0.001) and day 8 (P <0.001) of severe sepsis diagnosis. Besides, nonsurvivor severe septic patients showed lower CIV activity/protein quantity than survivor ones at day 1 (P <0.001), day 4 (P <0.001) and day 8 (P <0.001) of severe sepsis diagnosis.i p , g , Critical Care 2015, 19(Suppl 1):P25 (doi: 10.1186/cc14105) Introduction Change in fatty acid composition of erythrocytes and blood plasma in cases of various pathological conditions is evidence of lipid metabolism disorder and can indicate the reasons for and the degree of these disorders [1]. The aim of this study was to assess the FA composition of plasma and erythrocytes in patients with multiple organ dysfunction syndrome (MODS). g y y Methods The objects of study were 19 people with MODS (37.6 ± 8.3 years) of various etiologies. The blood of 17 healthy volunteers aged 38.4 ± 3.3 years served as control. The FA analysis was conducted using capillary gas–liquid chromatography. Quantitative evaluation of individual FA content was made as a mass percentage of their total (C14:0 to C22:6). Statistical analysis was performed using the Mann–Whitney U test (P <0.05). y p g Conclusion The major fi nding of our work, that represents the largest series of severe septic patients with data on OXPHOS function, was that survivor and nonsurvivor severe septic patients showed lower platelet CIV activity than healthy controls during the fi rst week of severe sepsis diagnosis. y Results Our data indicate that changes in blood plasma FA composition in patients with MODS are mainly caused by activation of lipolysis in fat depots and are accompanied by an increase of monounsaturated fatty acids, a decrease in saturated stearic acid and polyunsaturated fatty acids in the ratio. Sublingual leukocyte activation in patients with severe sepsis or septic shock BK Fabian-Jessing1, MJ Massey1, MR Filbin2, PC Hou3, H Kirkegaard4, HE Wang5, DM Yealy6, JA Kellum6, DC Angus6, NI Shapiro1 1Beth Israel Deaconess Medical Center, Boston, MA, USA; 2Massachusetts General Hospital, Boston, MA, USA; 3Brigham and Women’s Hospital, Boston, MA, USA; 4Aarhus University Hospital, Aarhus, Denmark; 5University of Alabama at Birmingham, AL, USA; 6University of Pittsburgh, PA, USA Critical Care 2015, 19(Suppl 1):P23 (doi: 10.1186/cc14103) y Results All patients’ sera (n = 17) demonstrated a signifi cant increase of ORP upon start of myocardial ischemia (141.0 ± 4.8 mV vs. 157.9 ± 4.9 mV; P = 0.002) and compared with reperfusion (141.0 ± 4.8 mV vs. 158.6 ± 4.9mV; P <0.001, Figure 1A). In parallel, the antioxidant capacity signifi cantly decreased during surgery (0.505 ± 0.190 μC vs. 0.384 ± 0.120 μC; P = 0.022) corresponding to the increase of oxidative stress (Figure 1B). Introduction The objective of this study was to compare the number of rolling and adhered leukocytes in patients with severe sepsis/septic shock with non-infected controls. Microcirculatory fl ow alterations and endothelial cell dysfunction are elements of sepsis pathophysiology. Traditionally, microcirculatory emphasis has been on red blood cell vessel perfusion. However, assessment of interactions between white blood cells and endothelial cells may be another early diagnostic modality. Introduction The objective of this study was to compare the number of rolling and adhered leukocytes in patients with severe sepsis/septic shock with non-infected controls. Microcirculatory fl ow alterations and endothelial cell dysfunction are elements of sepsis pathophysiology. Traditionally, microcirculatory emphasis has been on red blood cell vessel perfusion. However, assessment of interactions between white blood cells and endothelial cells may be another early diagnostic modality. Conclusion This preliminary study is the fi rst to highlight the time course of overall redox potential and antioxidant capacity in cardiac surgery patients. Further studies are underway to evaluate the clinical signifi cance on outcome in cardiac surgery patients. Critical Care 2015, Volume 19 Suppl 1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S9 Figure 1 (abstract P24). (A), (B) Perioperative time course of oxidative stress and antioxidant capacity. acids. In the test group of patients, as compared with the control group there was an elevated level (27.12 ± 0.78% vs. 25.80 ±0.77%, P <0.05) of saturated palmitic (C16:0) acid combined with the reduced (11.46 ± 0.52% vs. 13.95 ± 1.09%, P <0.001) level of linoleic (C18:2) acid. Reference 1. Kremmyda LS, et al. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011;155:195-218. P26 Lower platelet mitochondrial function in severe septic patients than in controls L Lorente1, M Martin2, J Blanquer3, J Solé-Violán4, L Labarta5, C Díaz6, A Jiménez1, E López-Gallardo7, J Montoya7, E Ruiz-Pesini7 1Hospital Universitario de Canarias, La Laguna, Tenerife, Spain; 2Hospital Universitario Nuestra Señora Candelaria, Santa Cruz, Tenerife, Spain; 3Hospital Clínico Universitario de Valencia, Spain; 4Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain; 5Hospital San Jorge, Huesca, Spain; 6Hospital Insular, Las Palmas de Gran Canaria, Spain; 7Universidad de Zaragoza, Spain Critical Care 2015, 19(Suppl 1):P26 (doi: 10.1186/cc14106) Introduction The oxidative phosphorylation system (OXPHOS) in septic patients has been scarcely analyzed in studies of small sample size and the results are apparently inconsistent. Previously, including 96 severe septic patients, we found that nonsurviving severe septic patients showed lower platelet respiratory complex IV (CIV) activity than surviving patients at the moment of severe sepsis diagnosis and during the fi rst week of sepsis diagnosis. However, we did not examine this enzyme activity in normal individuals. Thus, the objective of this study was to compare the CIV activity between severe septic patients and healthy control individuals in a larger series of patients (including 198 severe septic patients). Introduction The oxidative phosphorylation system (OXPHOS) in septic patients has been scarcely analyzed in studies of small sample size and the results are apparently inconsistent. Previously, including 96 severe septic patients, we found that nonsurviving severe septic patients showed lower platelet respiratory complex IV (CIV) activity than surviving patients at the moment of severe sepsis diagnosis and during the fi rst week of sepsis diagnosis. However, we did not examine this enzyme activity in normal individuals. Thus, the objective of this study was to compare the CIV activity between severe septic patients and healthy control individuals in a larger series of patients (including 198 severe septic patients). Figure 1 (abstract P24). (A), (B) Perioperative time course of oxidative stress and antioxidant capacity. Methods This was a prospective, multicenter, observational study in six Spanish ICUs. We obtained blood samples from 198 severe septic patients at days 1, 4 and 8 of the severe sepsis diagnosis and from 96 sex-matched and age-matched healthy control individuals and determined platelet CIV activity/protein quantity. The endpoint of the study was 30-day mortality. Infl uence of genetic variants in the susceptibility and outcome of infl uenza virus infection J Sole-Violan1, M López-Rodríguez1, E Herrera-Ramos1, J Ruiz-Hernández1, J Horcajada2, L Borderías3, J Blanquer4, J Ferrer1, O Rajas5, J Aspa5, F Rodríguez de Castro1, C Rodríguez-Gallego1 1Hospital GC Dr Negrín, Las Palmas de Gran Canaria, Spain; 2Hospital del Mar, Barcelona, Spain; 3Hospital San Jorge, Huesca, Spain; 4Hospital Clínico, Valencia, Spain; 5Hospital de la Princesa, Madrid, Spain Critical Care 2015, 19(Suppl 1):P27 (doi: 10.1186/cc14107) Fatty acid composition of erythrocytes in multiple organ dysfunction syndrome In conditions of increased level of monounsaturated palmitoleic (C16:1) and oleic (C18:1) FA in blood plasma (2.53 ± 0.40% vs. 1.55 ± 0.29%, P <0.001 and 25.18 ± 2.15% vs. 16.55 ± 1.17%, P <0.001, respectively), only the level of palmitoleic (C16:1) acid is increased in erythrocytes (0.56 ± 0.12% vs. 0.16 ± 0.12%, P <0.001). Despite the high content of oleic (C18:1) acid in blood plasma in case of MODS, in erythrocytes its relative level is not changed as compared with the control group. The disorder of lipid composition constancy in erythrocyte membranes is also manifested by change in the content of saturated palmitic (C16:0) and polyunsaturated linoleic (C18:2) fatty Infl uence of genetic variants in the susceptibility and outcome of infl uenza virus infection J Sole-Violan1, M López-Rodríguez1, E Herrera-Ramos1, J Ruiz-Hernández1, J Horcajada2, L Borderías3, J Blanquer4, J Ferrer1, O Rajas5, J Aspa5, F Rodríguez de Castro1, C Rodríguez-Gallego1 1Hospital GC Dr Negrín, Las Palmas de Gran Canaria, Spain; 2Hospital del Mar, Barcelona, Spain; 3Hospital San Jorge, Huesca, Spain; 4Hospital Clínico, Valencia, Spain; 5Hospital de la Princesa, Madrid, Spain Critical Care 2015, 19(Suppl 1):P27 (doi: 10.1186/cc14107) 1. Kremmyda LS, et al. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011;155:195-218. Sublingual leukocyte activation in patients with severe sepsis or septic shock Conclusion The changes revealed in fatty acid composition of erythrocytes may indicate systemic modifi cations of cell membranes in MODS. Phenotypic factors associated with outcome in 977 intensive care patients with faecal peritonitis: analysis of trends in the GenOSept cohort Results Patients who developed sepsis (n = 18) presented with signifi cantly higher platelet fi brinogen binding at T1 compared with patients who did not get infected (basal: P = 0.0014, upon stimulation: P <0.0035). At T1, ROC AUC for association of basal fi brinogen binding with the occurrence of sepsis was 0.79 (95% CI: 0.68 to 0.89). Elevated basal CD62P expression level was associated with increased 90-day mortality (P = 0.042, ROC AUC = 0.78 (0.64 to 0.88)). Kaplan–Meier survival curves illustrated that mortality was signifi cantly higher after stratifi cation based on T1 basal CD62P level (cutoff MFI >31.56, HR = 13.6, P = 8.23 × 10–6). Multivariate logistic regression analysis using clinical scores (SOFA, APACHE II, SAPS II, SAPS III) indicated that addition of CD62P level or of bound fi brinogen level signifi cantly improved prediction of mortality (odds ratio 1.078, P = 0.003) and sepsis (odds ratio 1.033, P = 0.0012), respectively. A Tridente, G Clarke, A Walden, A Gordon, P Hutton, J Chiche, P Holloway, G Mills, J Bion, F Stuber, C Garrard, C Hinds, GenOSept Investigators St Helens and Knowsley, Liverpool, UK l l (d ) Introduction Patients admitted to intensive care following surgery for faecal peritonitis present particular challenges in terms of clinical management and risk assessment that require close collaboration between surgical and intensive care teams [1]. We aimed at establishing whether dynamic assessment of trends in selected variables may be associated with outcomes, and therefore inform medical decision-making. g Methods We analysed trends in all 35 variables available for the fi rst week of ICU stay in 977 patients from 102 centres across 17 countries. The primary study outcome was 6-month mortality. Secondary outcomes were ICU, hospital and 28-day mortality. For each trend, Cox proportional hazards (PH) regression analyses, adjusted for age and gender, were performed for each endpoint. Trends found to be signifi cant in these analyses, after Bonferroni correction for multiple testing, were entered into a multivariate Cox PH model, to determine independent associations with mortality.i Conclusion Predisposition to severe infection in selected critically ill medico-surgical adults can be identifi ed on day 1 of admission based on circulating basally activated platelets. Levels of activated platelets may add incremental prognostic information to clinical scoring. Reference 1. de Stoppelaar SF, van ‘t Veer C, van der Poll T. The role of platelets in sepsis. Thromb Haemost. 2014;11:666-77. Phenotypic factors associated with outcome in 977 intensive care patients with faecal peritonitis: analysis of trends in the GenOSept cohort p y Results The trends over the fi rst 7 days of ICU stay (primary analysis) retained as independently associated with 6-month outcome were worsening thrombocytopaenia (mortality HR = 1.02, 95% CI = 1.01 to 1.03, P <0.001) and changes in renal function (total daily urine output HR = 1.02, 95% CI = 1.01 to 1.03, P <0.001; renal SOFA subscore HR = 0.87, 95% CI = 0.75 to 0.99, P = 0.047), highest recorded level of bilirubin (HR = 0.99, 95% CI = 0.99 to 0.99, P = 0.02) and GCS SOFA subscore (HR = 0.81, 95% CI = 0.68 to 0.98, P = 0.028). Changes in renal function (total daily urine output and renal component of the SOFA score), GCS component of the SOFA score, total SOFA and worsening thrombocytopaenia were also independently associated with secondary outcomes. Dynamic trends over the fi rst 7 days of ICU stay in all other measured laboratory variables, physiological parameters or radiological fi ndings failed to be retained as independently associated with outcome on multivariate analyses. Furthermore, changes in respiratory support, renal replacement therapy and inotropic and/or vasopressor requirements appeared not to be independently associated with any of the primary or secondary outcomes. Secondary post hoc analyses on trends over the fi rst 3 and 5 days corroborated these fi ndings. P29 P29 Elevated basal levels of circulating activated platelets predict ICU-acquired sepsis and mortality: a prospective study N Layios CHU Sart Tilman, Liège, Belgium Critical Care 2015, 19(Suppl 1):P29 (doi: 10.1186/cc14109) P30 Antiplatelet therapy does not infl uence outcome or host response biomarkers during sepsis: a propensity-matched analysis MA Wiewel1, SF De Stoppelaar1, LA Van Vught1, JF Frencken2, AJ Hoogendijk1, PM Klein Klouwenberg2, J Horn1, MJ Bonten2, MJ Schultz1, AH Zwinderman1, OL Cremer2, T Van der Poll1 1Academic Medical Center, University of Amsterdam, the Netherlands; 2University Medical Center Utrecht, the Netherlands Critical Care 2015, 19(Suppl 1):P30 (doi: 10.1186/cc14110) P28 P28 Phenotypic factors associated with outcome in 977 intensive care patients with faecal peritonitis: analysis of trends in the GenOSept cohort A Tridente, G Clarke, A Walden, A Gordon, P Hutton, J Chiche, P Holloway, G Mills, J Bion, F Stuber, C Garrard, C Hinds, GenOSept Investigators St Helens and Knowsley, Liverpool, UK Critical Care 2015, 19(Suppl 1):P28 (doi: 10.1186/cc14108) Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 have previously demonstrated that variants at SFTPA2 infl uence the severity of H1N1pdm infection. We have now studied genetic variants at diff erent genes, some of them previously associated with infections by infl uenza and/or other viruses. The purpose of this study was to analyze the role of genetic variants in the susceptibility and outcome of IVI. Conclusion Only deterioration in renal function, thrombocytopaenia and hyperbilirubinaemia over the fi rst 7 days of ICU stay were consistently associated with mortality at all endpoints. Reference 1. Tridente A, et al. Intensive Care Med. 2014;40:202-10. Methods In total, 136 white Spanish patients developed IVI (80.3% of them by H1N1pdm virus). The general population group consisted of 1,466 unrelated healthy volunteers. Patients and controls were analyzed for diff erent polymorphisms at 13 genes (FCGR2A, FCGR3A, FCGR3B, IL1RN, IL6, LTA, TIRAP, TLR1, TLR2, TLR3, TLR4, CCR5, IGHG2). Infl uence of genetic variants in the susceptibility and outcome of infl uenza virus infection Introduction The role of genetic variability in the susceptibility and outcome of infl uenza virus infection (IVI) remains largely unknown. We Introduction The role of genetic variability in the susceptibility and outcome of infl uenza virus infection (IVI) remains largely unknown. We S10 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 1. de Stoppelaar SF, van ‘t Veer C, van der Poll T. The role of platelets in sepsis. Thromb Haemost. 2014;11:666-77. 9 Elevated basal levels of circulating activated platelets predict ICU-acquired sepsis and mortality: a prospective study N Layios CHU Sart Tilman, Liège, Belgium Critical Care 2015, 19(Suppl 1):P29 (doi: 10.1186/cc14109) IVI was detected in nasopharyngeal swabs using real-time PCR. The Hardy–Weinberg equilibrium was analyzed by Haploview v. 4.2. The comparisons of genotypes distribution based on susceptibility and severity were performed using the chi-squared test or Fisher’s exact test when needed. The relationship between severity in hospitalized patients and genotypes was evaluated by binary logistic regression models. Introduction Platelets are now considered to be immune and infl am- matory agents as well as key cells in coagulation, and as such have been implicated in the pathophysiology of sepsis [1]. Thrombocytopenia is associated with sepsis severity and poor prognosis, and hyperactivated platelets probably contribute to microvascular thrombosis and organ failure. In the present study, we evaluated platelet activation markers as potential predictive markers of sepsis and of mortality among four commonly encountered populations of patients admitted to ICUs. Results No associations were found between the diff erent genetic variants and susceptibility or severity of IVI. Variants at LTA, FCGR2A, IGHG2, TLR3 and CCR5, previously associated with severity of IVI were not replicated in our study. Methods Ninety-nine non-infected ICU patients were prospectively screened at day 1 (T1) and day 3 (T2) of admission after elective cardiac surgery, trauma, acute neurologic dysfunction or prolonged ventilation (>48 hours). A third sample was drawn when infection was diagnosed (Tx). We evaluated platelet activation by measuring the expression of P-selectin (CD62P) and fi brinogen binding on the cell surface before and after stimulation with major platelet agonists (ADP, collagen, and TRAP) through fl ow cytometry. Clinical scores were obtained at admission. Conclusion Our study does not suggest that polymorphisms at LTA, FCGR2A, IGHG2, TLR3 and CCR5 genes are associated with susceptibility or severity of IVI. P32 Methods We performed a prospective observational study in patients admitted with sepsis to the mixed ICUs of two hospitals in the Netherlands between January 2011 and July 2013. Cox proportional hazards regression was used to estimate the eff ect of antiplatelet therapy on mortality. To account for indication bias, a propensity score was constructed, and used to match antiplatelet therapy users to nonusers. Plasma biomarker levels, providing insight into hallmark host responses to sepsis, including activation of endothelial cells and the cytokine network, were determined during the fi rst 4 days after ICU admission. Mitochondrial dysfunction and ischemia in critical illness: an adipose tissue microdialysis study in 203 ICU patients M Theodorakopoulou, S Apollonatou, N Nikitas, D Vassiliadi, A Diamantakis, V Tsagkari, F Frantzeskaki, I Dimopoulou University Hospital of Athens, Greece Critical Care 2015, 19(Suppl 1):P32 (doi: 10.1186/cc14112) Introduction Ischemia and mitochondrial dysfunction have been implicated in critical illness. The potential of MD to diagnose and separate ischemia and mitochondrial dysfunction in ICU patients remains currently unknown. Introduction Ischemia and mitochondrial dysfunction have been implicated in critical illness. The potential of MD to diagnose and separate ischemia and mitochondrial dysfunction in ICU patients remains currently unknown. Results Of 1,070 sepsis patients, 297 (27.8%) were on antiplatelet therapy, including acetylsalicylic acid, clopidogrel and dipyridamole, prior to ICU admission. Antiplatelet users and nonusers diff ered signifi cantly with regard to several baseline characteristics, such as age, gender and cardiovascular disease. Antiplatelet therapy was not related to sepsis severity at presentation, the primary source of infection, causative pathogens, the development of organ failure or shock during ICU stay, or mortality up to 90 days after admission, in either the unmatched or propensity-matched analyses. Antiplatelet therapy did also not modify plasma concentrations of biomarkers.l Methods A retrospective, observational study of 203 mechanically ventilated patients studied over a 6-year period with MD including medical, surgical and trauma patients. Sepsis stages: SIRS (n = 24), severe sepsis (n = 46) and septic shock (n = 133). Median age 67 years (range: 17 to 92 years). Mortality was 53%. All subjects had a MD catheter placed in femoral adipose tissue upon admission to the ICU. Interstitial fl uid samples were collected six times per day, for 3 consecutive days, and were analyzed for glucose, lactate, pyruvate, and glycerol levels. The lactate to pyruvate (LP) ratio was calculated. Blood lactate was measured. P31 Perioperative programmed death-1 expression on CD4+ T cells predicts the incidence of postoperative infectious complications following gastrointestinal surgery S Ono1, T Ikeda1, T Kubo2, H Tsujimoto2, M Kinoshita2, T Ueno1 1Hachioji Medical Center, Tokyo Medical University, Hachioji, Tokyo, Japan; 2National Defense Medical College, Tokorozawa, Saitama, Japan Critical Care 2015, 19(Suppl 1):P31 (doi: 10.1186/cc14111) Perioperative programmed death-1 expression on CD4+ T cells predicts the incidence of postoperative infectious complications following gastrointestinal surgery Antiplatelet therapy does not infl uence outcome or host response biomarkers during sepsis: a propensity-matched analysis l1 l 1 h 1 k 2 Introduction Sepsis is a life-threatening condition, during which triggering of infl ammatory and coagulation cascades, together with endothelial damage, invariably leads to activation of platelets. Although platelets are essential components of primary hemostasis, uncontrolled platelet activation during sepsis may contribute to organ failure. The aim of this study was to investigate whether chronic antiplatelet therapy impacts on the presentation and outcome of, and the host response to, sepsis. S11 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Perioperative programmed death-1 expression on CD4+ T cells predicts the incidence of postoperative infectious complications following gastrointestinal surgery g g g y S Ono1, T Ikeda1, T Kubo2, H Tsujimoto2, M Kinoshita2, T Ueno1 1Hachioji Medical Center, Tokyo Medical University, Hachioji, Tokyo, Japan; 2National Defense Medical College, Tokorozawa, Saitama, Japan Critical Care 2015, 19(Suppl 1):P31 (doi: 10.1186/cc14111) Introduction Programmed death-1 (PD-1) has been reported to be an immunoinhibitory receptor expressed by chronically stimulated T cells after T-cell activation. The present study was designed to evaluate the relationship between perioperative PD-1 expression on CD4+ T cells and the incidence of postoperative infectious complications in patients undergoing gastroenterological surgery. Conclusion Bedside subcutaneous adipose tissue MD is possible to diagnose and separate ischemia and mitochondrial dysfunction in general ICU patients. These two conditions are not so common; however, mitochondrial dysfunction seems to be associated with higher mortality rates. Methods This was a prospective observational study. The subjects of this study included 101 patients with gastroenterological disease who underwent elective abdominal surgery via laparotomy at the National Defense Medical College Hospital. Blood samples were taken on the preoperative day (Pre) and the fi rst postoperative day (POD1). We calculated CD4+ T-cell count and PD-1 expression on CD4+ T cells by fl ow cytometer. The occurrence of postoperative infectious complications was defi ned according to a combination of clinical fi ndings and the results of laboratory and other tests. The postoperative infectious complications in this study included incisional surgical site infections (SSIs), organ/space SSIs, enterocolitis, urinary tract infections, and pneumonia. Incisional and organ/space SSIs were diagnosed according to the defi nitions stated in the guidelines issued by the Center for Disease Control and Prevention. P32 Ischemia was defi ned as LP ratio >30 and pyruvate level <70 mmol, while mitochondrial dysfunction was defi ned as LP ratio >30 and pyruvate >70 mmol. y y Conclusion Pre-existing antiplatelet therapy does not infl uence clinical disease severity at presentation, nor the host response or outcome following sepsis. Acknowledgement This research was performed within the framework of CTMM, the Center for Translational Molecular Medicine (http://www. ctmm.nl), project MARS (grant 04I-201). py Results Analysis during the course of the 3-day period revealed three distinct patterns: no ischemia/mitochondrial dysfunction (n = 150 or 74%), ischemia (n = 27 or 13%) and mitochondrial dysfunction (n = 26 or 13%). On day 1, median blood lactate was higher in mitochondrial dysfunction (2.2 mmol/l) compared with both ischemia (1.3 mmol/l) and with no ischemia/mitochondrial dysfunction (1.3 mmol/l) (P = 0.004). Again on day 1, median interstitial fl uid lactate was higher in mitochondrial dysfunction (8.4 mmol/l), in comparison with ischemia (1.4 mmol/l) and with the group without ischemia/mitochondrial dysfunction (2.5 mmol/l) (P <0.001). Similar results were obtained with interstitial fl uid glycerol levels (P = 0.009). Median LP ratio was higher in ischemia (LP = 36), and mitochondrial dysfunction (LP = 33) compared with those without ischemia/mitochondrial dysfunction (LP = 17) (P <0.001). Median interstitial fl uid glucose was lower in ischemia (2 mmol/l) compared with both mitochondrial dysfunction (4 mmol/l) and with no ischemia/mitochondrial dysfunction (5 mmol/l) (P <0.001). ICU mortality was 77% in mitochondrial dysfunction, 52% in ischemia and 49% in the group without ischemia/mitochondrial dysfunction (P = 0.033). Pyruvate dehydrogenase levels are low in sepsis E Nuzzo, X Liu, K Berg, L Andersen, M Doninno Pyruvate dehydrogenase levels are low in sepsis E Nuzzo, X Liu, K Berg, L Andersen, M Doninno Beth Israel Deaconess Medical Center, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P33 (doi: 10.1186/cc14113) Introduction Pyruvate dehydrogenase (PDH) is a key component of aerobic metabolism. Multiple rodent studies have shown that PDH levels are low in sepsis. This leads to a shift to anaerobic metabolism, resulting in increased lactic acid. Alteration in PDH levels during sepsis, however, has never been studied in humans. The aim of this study was to identify whether PDH levels (activity and quantity) were altered in humans in sepsis. Results Postoperative infectious complications occurred in 30 of the 101 patients. CD4+ T-cell count was signifi cantly lower in the patients who developed postoperative infectious complications at POD1 compared with those from the patients who did not. In addition, PD-1 expression on CD4+ T cells was signifi cantly higher at Pre or POD1 in patients who developed postoperative infectious complications. Those results were similar for the incidence of organ/space surgical site infection. Preoperative PD-1 expression on CD4+ T cells tended to be higher in males than in females. We found there was a signifi cant negative correlation between preoperative PD-1 expression on CD4+ T cells and CD4+ T-cell count. Methods We conducted a case–control study at a single urban tertiary care center. We compared PDH levels between sepsis and healthy control subjects by measuring PDH levels in peripheral blood mononuclear cells via a novel assay. We measured PDH levels in control subjects at baseline and in sepsis subjects at 0, 24, 48 and 72 hours. Results There were 39 sepsis (age 67 ± 14 years, M ± SD) and 19 control (age 50 ± 12 years) subjects of similar gender (56% and 63% female, respectively) and race (79% and 68% Caucasian, respectively). PDH levels in the sepsis group were signifi cantly lower than the control Conclusion Perioperative CD4+ T-cell count or PD-1 expression on CD4+ T cells could be an early predictive marker for the development of postoperative infectious complications. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S12 group at all time points (Figures 1 and 2). After controlling for age, gender, race, and assay plate via multivariable linear regression, the eff ect of treatment group remained signifi cant. We were unable to control for comorbid illness, which was exclusively concentrated in the sepsis group. Pyruvate dehydrogenase levels are low in sepsis E Nuzzo, X Liu, K Berg, L Andersen, M Doninno Figure 1 (abstract P33). Figure 2 (abstract P33). Figure 2 (abstract P33). Conclusion In the nonsurvivor or the severe patient with sepsis requiring steroid administration, the enhancement of C1INH activity was not observed, and the C1INH quantitative values were low. Further evaluation of the serial change of C1INH and the validity of C1INH replacement therapy in patients with septic shock may lead to a new strategy for management in sepsis. Expression of apolipoproteins L in neutrophils during sepsis I Akl1, C Lelubre1, M Piagnerelli1, P Biston1, P Uzureau1, H Fayyad Kazan2, B Badran3, M Ezzedine3, K Zouaoui Boudjeltia1, L Vanhamme4 1CHU de Charleroi-Hopital Andre Vesale, Montigny-Le-Tilleul, Belgium; 2Institut Jules Bordet, Université Libre de Bruxelles, Belgium; 3Doctoral School of Sciences and Technology, Platform of Research and Environmental Sciences, Beirut, Lebanon; 4Institute of Medicine and Molecular Biology IBMM, Charleroi, Belgium Critical Care 2015, 19(Suppl 1):P35 (doi: 10.1186/cc14115) Figure 2 (abstract P33). Figure 2 (abstract P33). group at all time points (Figures 1 and 2). After controlling for age, gender, race, and assay plate via multivariable linear regression, the eff ect of treatment group remained signifi cant. We were unable to control for comorbid illness, which was exclusively concentrated in the sepsis group.i Introduction Sepsis is characterized by a strong systemic infl ammatory reaction. The pathogenesis is driven by alterations in the immune system and is associated with high neutrophil counts related to a specifi c delay in apoptosis [1]. The apolipoproteins L (ApoLs) family comprises six members in humans (ApoL1 to ApoL6). In light of their deregulated expression in several pathologies, they are likely to be important molecular players of programmed cell death [2]. We analyzed ApoL expression in cohorts of septic and nonseptic ICU patients and healthy volunteers in order to test whether ApoLs could be involved in the neutrophil apoptotic program. Introduction Sepsis is characterized by a strong systemic infl ammatory reaction. The pathogenesis is driven by alterations in the immune system and is associated with high neutrophil counts related to a specifi c delay in apoptosis [1]. The apolipoproteins L (ApoLs) family comprises six members in humans (ApoL1 to ApoL6). In light of their deregulated expression in several pathologies, they are likely to be important molecular players of programmed cell death [2]. Pyruvate dehydrogenase levels are low in sepsis E Nuzzo, X Liu, K Berg, L Andersen, M Doninno We analyzed ApoL expression in cohorts of septic and nonseptic ICU patients and healthy volunteers in order to test whether ApoLs could be involved in the neutrophil apoptotic program. Conclusion PDH levels are signifi cantly lowered in humans during sepsis when compared with healthy controls, even when controlling for age, race and gender. Further research is needed to determine whether this fi nding persists after adjustment for comorbid disease, and whether lower PDH levels are associated with clinical outcomes. Methods By means of magnetic cell sorting, peripheral neutrophils were purifi ed from 20 healthy volunteers and 40 ICU patients with (n = 20) or without sepsis (n = 20). ApoL expression was analyzed at the mRNA and protein levels by real-time PCR and western blot analysis respectively. Apoptosis of purifi ed neutrophils was assessed using fl ow cytometry following 4 and 24 hours of in vitro incubation. We monitored the expression of C-reactive protein (CRP), an infl ammatory marker, and its correlation with ApoL expression in PMNs was studied by linear regression analysis.i Pyruvate dehydrogenase levels are low in sepsis E Nuzzo, X Liu, K Berg, L Andersen, M Doninno Conclusion PDH levels are signifi cantly lowered in humans during sepsis when compared with healthy controls, even when controlling for age, race and gender. Further research is needed to determine whether this fi nding persists after adjustment for comorbid disease, and whether lower PDH levels are associated with clinical outcomes. P34 S i l h f C1 i hibit i ti t ith i li i Figure 1 (abstract P33). Figure 2 (abstract P33). Figure 1 (abstract P33). Figure 1 (abstract P33). but also the plasma kallikrein–kinin system, fi brinolytic system and coagulation system. The biologic activities of C1INH can be divided into the regulation of vascular permeability and anti-infl ammatory functions. In recent years, hereditary angioedema (HAE), caused by an inherited defi ciency of C1INH, has been focused. During HAE attacks, vascular permeability was markedly increased, which leads to angioedema. In sepsis, signifi cant endothelial hyperpermeability is similarly observed systemically, but the role of C1INH has not been clarifi ed in the pathogenesis. The serial change of C1INH in patients with sepsis is not clear. The objective of this study was to clarify the serial change in C1INH in patients with sepsis and evaluate the impact of C1INH on their clinical course. Methods We serially examined C1INH activity values (normal range 70 to 130%) and quantitative values (normal range 160 to 330 μg/ml) in patients with sepsis during the period between December 2012 and February 2013. We also analyzed their clinical course: prognosis, volume of infusion, body weight, urine volume, catecholamine administration, and steroid administration. Results The serial change of C1INH was evaluated in fi ve patients with sepsis (three male and two female; four survivors and one nonsurvivor; mean age, 68 ± 11 years). In the nonsurvivor, C1INH activity on admission value was 97.2% (normal range), and quantitative value was 133.1 μg/ml (below normal). In the patient with severe sepsis requiring fl uid resuscitation, catecholamine and steroid administration to maintain hemodynamics, C1INH activity value on admission was 94.4% (normal range), and quantitative value was 126.7 μg/ml (below normal range). His general condition was improved on day 6, and C1INH activity value and quantitative value increased (139.9%; above normal range, 250.1 μg/ml; normal range). In the other three patients with sepsis not requiring steroid administration, C1INH activity value on admission was 130.6 ± 8.7% (above normal range), and quantitative value was 215 ± 26.5 μg/ml (normal range). P34 Serial change of C1 inhibitor in patients with sepsis: a preliminary report T Hirose1, H Ogura1, K Jinkoo1, Y Nakamura1, H Hosotsubo1, T Shimazu1, E Kitano2, M Hatanaka2 1Osaka University Graduate School of Medicine, Suita, Japan; 2Kobe Tokiwa University, Kobe, Japan Critical Care 2015, 19(Suppl 1):P34 (doi: 10.1186/cc14114) Introduction C1 inhibitor (C1INH), belonging to the superfamily of serine protease inhibitors, regulates not only complement system, Results Our results showed a signifi cant downregulation in mRNA expression of ApoL1 (P <0.0001), ApoL2 (P = 0.0009), ApoL3 (P <0.0001) S13 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 correlates inversely with outcome. The aim of the study was to identify phenotypic and functional early markers of T cells and NK cells related to prognosis in the septic patient population. and ApoL6 (P = 0.0003) in purifi ed PMNs from ICU patients as compared with the healthy individuals. This downregulation was also validated at the protein level for ApoL1 and ApoL2, whereas ApoL 6 was upregulated in septic patients. We could not detect ApoL3 protein in any of the cohorts. This was accompanied by a signifi cant delay in PMN apoptosis in septic patients as compared with healthy volunteers (P <0.05) at 4 and 24 hours. We also showed a strong negative correlation in the three mixed groups between CRP and ApoL1 (R = –0.607), ApoL2 (R = –0.651), ApoL3 (R = –0.578) and ApoL6 (R = –0.506). and ApoL6 (P = 0.0003) in purifi ed PMNs from ICU patients as compared with the healthy individuals. This downregulation was also validated at the protein level for ApoL1 and ApoL2, whereas ApoL 6 was upregulated in septic patients. We could not detect ApoL3 protein in any of the cohorts. This was accompanied by a signifi cant delay in PMN apoptosis in septic patients as compared with healthy volunteers (P <0.05) at 4 and 24 hours. We also showed a strong negative correlation in the three mixed groups between CRP and ApoL1 (R = –0.607), ApoL2 (R = –0.651), ApoL3 (R = –0.578) and ApoL6 (R = –0.506). p g p p p p Methods We collected peripheral blood mononuclear cells from 47 patients with severe sepsis or septic shock at ICU admission (T0) and from 50 healthy controls. Reduced responsiveness of blood leukocytes to lipopolysaccharide does not predict nosocomial infections in critically ill patients LA Van Vught, MA Wiewel, AJ Hoogendijk, BP Scicluna, H Belkasim, J Horn, MJ Schultz, T Van der Poll Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P38 (doi: 10.1186/cc14118) Results The condition of the nonseptic patients was signifi cantly less severe than that of the septic patients. The SOFA score of septic patients and the nonseptic patients was 6 (3 to 18) and 2.5 (1 to 8), respectively (median (IQR), P = 0.02). The overall mortality rate was 29%. After stimulation with PMA, neutrophils isolated from septic patients released 4.08 ± 1.02% of their total DNA, whereas neutrophils from nonseptic patients released 29.06 ± 2.94% (P <0.0001). Immunofl uorescent staining of released DNA, elastase, and myeloperoxidase also revealed similar results. Neutrophils from nonseptic patients showed eff ective extracellular killing of E. coli through NETs, whereas neutrophils from septic patients did not (P <0.001). Plasma levels of cf-DNA and histones were higher in septic patients than in nonseptic patients (P <0.001). Introduction Critically ill patients show signs of immune suppression, which is considered to increase vulnerability to nosocomial infections. Whole blood stimulation is a frequently used functional test for immune suppression. We here aimed to assess the association between whole blood leukocyte responsiveness to lipopolysaccharide (LPS) and the subsequent occurrence of nosocomial infections in critically ill patients admitted to the ICU. g Conclusion The increase of the immature PMN count and immature/ total PMN ratio confi rmed recruitment of immature neutrophils from the bone marrow into the circulation. The ex vivo generation of NETs is downregulated in neutrophils isolated from patients with sepsis. However, it is unclear whether in vivo NET formation is also impaired during sepsis, so further investigation is necessary. Methods All consecutive critically ill patients admitted to the ICU between April 2012 and June 2013 with two or more systemic infl ammatory response syndrome criteria and an expected length of ICU stay of more than 24 hours were enrolled. Age-matched and gender-matched healthy individuals were included as controls. Blood was drawn the fi rst morning after ICU admission and stimulated ex vivo with 100 ng/ml ultrapure LPS for 3 hours. Tumor necrosis factor (TNF)α, interleukin (IL)-1β and IL-6 were measured in supernatants. Results Seventy-three critically ill patients were included, 10 of whom developed an ICU-acquired infection. Compared with healthy subjects, whole blood leukocytes of patients were less responsive to ex vivo stimulation with LPS, as refl ected by strongly reduced TNFα, IL-1β and IL-6 levels in culture supernatants. P34 Serial change of C1 inhibitor in patients with sepsis: a preliminary report On these subjects we evaluated frequency and absolute numbers of CD4+ and CD8+ T cells and of NK and B lymphocytes, the rates of regulatory CD4+CD25+Foxp3+ T cells (Tregs), the cytotoxic potential of CD4+, CD8+ T cells and of NK cells by evaluation of perforin (PER) and granzyme (GRA) expression and production of eff ector cytokines (namely IL-2, IL-17, IL-4, TNFα, IFNγ) by CD4+, CD8+ T cells and NK cells upon polyclonal stimulation. The markers were compared in patients with diff erent outcome. p p Conclusion The altered apoptotic fate of neutrophils in sepsis was correlated with the modifi cation of the expression profi le of ApoLs, a family of proteins thought to be involved in the apoptotic process. The role of these proteins in the sepsis-associated phenotype of neutrophils remains to be further elucidated. p pf Results Septic patients, compared with healthy donors, were characterized by global lymphopenia; we found increased frequencies of CD4+ T cells producing IL-2 (P = 0.0000000003), increased percentage of CD8 T cells producing IFNγ (P = 0.03), and reduced proportion of CD4+ T cells (P = 0.00007) and NK cells (P = 0.002) producing IFNγ. We also noticed an increased frequency of CD8+ T cells expressing PER (P = 0.00000025) and GRA (P = 0.01); moreover, the proportion of NK cells expressing GRA was also signifi cantly increased (P = 0.000019). To establish the prognostic value of these biological markers, we compared the cytokine expression by lymphocytes in septic patients that survived with those that died (D). We found that CD4+ and CD8+ TNFα-producing T cells were signifi cantly increased in D (P = 0.01 and P = 0.0001 respectively); similarly the percentage of CD8+ T cells producing IFNγ was more elevated in D (P = 0.006). The same was observed for IL-17 production by CD4+ T cells (P = 0.03) in D. On the contrary we observed a tendency to the reduction of circulating CD4+CD25+foxp3 (Tregs) in D (P = 0.08). References 1. Görgülü P, et al. Crit Care. 2011;15:R20. g 2. Vanhollebeke B, et al. Cell Mol Life Sci. 2006;63:1937-44. 2. Vanhollebeke B, et al. Cell Mol Life Sci. 2006;63:1937-44. Reduced responsiveness of blood leukocytes to lipopolysaccharide does not predict nosocomial infections in critically ill patients LA Van Vught, MA Wiewel, AJ Hoogendijk, BP Scicluna, H Belkasim, J Horn, MJ Schultz, T Van der Poll Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P38 (doi: 10.1186/cc14118) However, results were not diff erent between patients who did and those who did not develop an ICU- acquired infection (Figure 1). Ex vivo and in vivo generation of neutrophil extracellular traps by neutrophils from septic patients N Takeyama, MH Huq, M Ando, T Goc N Takeyama, MH Huq, M Ando, T Gocho, MH Hashiba, H Miyabe, H Kano, A Tomino, M Tsuda, T Hattori, A Hirakawa Fujita Health University, Aichi, Japan Critical Care 2015, 19(Suppl 1):P36 (doi: 10.1186/cc14116) Introduction The primary aim of this study was to determine the diff erences in ex vivo generation of neutrophil extracellular traps (NETs) by neutrophils from septic and nonseptic patients. We further sought to examine plasma levels of cell-free DNA (cf-DNA) and histones to assess in vivo NET formation. p g Conclusion Septic patients are characterized by a peculiar immunophenotype which includes global lymphopenia and a specifi c pattern of cytokines. Some of the evaluated markers seem to individuate those with worse outcome; in particular, this group showed an infl ammatory phenotype with a higher expression of IFNγ, TNFα, IL- 17 and a tendency to a reduction of Tregs. Methods We isolated neutrophils from consecutive patients with sepsis (n = 17) and without sepsis (n = 18) admitted to the ICU. Neutrophils were activated by incubation with phorbol myristate acetate to induce release of NETs and NET formation was assessed by measuring the extracellular DNA level. Immunolabeling and fl uorescence imaging were also performed. Extracellular killing of bacteria by NETs was studied by co-culture of Escherichia coli and neutrophils in the presence of the phagocytosis inhibitor cytochalasin D. To assess in vivo NET formation, plasma levels of cf-DNA and histones were measured.i Reduced responsiveness of blood leukocytes to lipopolysaccharide does not predict nosocomial infections in critically ill patients LA Van Vught, MA Wiewel, AJ Hoogendijk, BP Scicluna, H Belkasim, J Horn, MJ Schultz, T Van der Poll Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P38 (doi: 10.1186/cc14118) Alarming levels of heat shock proteins 72 and 90α in critically ill children Introduction The endothelium is a complex organ infl uenced by circulating mediators, adjacent cells, physico-chemical factors, and shear stress. During systemic infl ammation and sepsis, excessive and sustained activation of the endothelium result in the loss of its anti- coagulant and anti-adhesive characteristics as well as in a loss of endothelial barrier function. We set up a cell-culture model to study endothelial activation induced by lipopolysaccharide (LPS) or by plasma from septic patients and studied the eff ect of adsorbent-based mediator modulation on endothelial activation. Introduction The endothelium is a complex organ infl uenced by circulating mediators, adjacent cells, physico-chemical factors, and shear stress. During systemic infl ammation and sepsis, excessive and sustained activation of the endothelium result in the loss of its anti- coagulant and anti-adhesive characteristics as well as in a loss of endothelial barrier function. We set up a cell-culture model to study endothelial activation induced by lipopolysaccharide (LPS) or by plasma from septic patients and studied the eff ect of adsorbent-based mediator modulation on endothelial activation. Introduction Extracellular heat shock proteins (HSP) act as inducers of interleukins (IL) and stimulants for immune cells during systemic infl ammatory response syndrome (SIRS). Little is known about the alarming roles of extracellular HSP72 and HSP90α in the acute phase [1] of sepsis (S) or severe sepsis (SS). We determined serum HSP90α, HSP72 and neutrophil CD64 expression, IL-6, IL-8, IL-10, and TNFα in children with S or SS compared with SIRS (brain injury) or healthy children (H). Introduction Extracellular heat shock proteins (HSP) act as inducers of interleukins (IL) and stimulants for immune cells during systemic infl ammatory response syndrome (SIRS). Little is known about the alarming roles of extracellular HSP72 and HSP90α in the acute phase [1] of sepsis (S) or severe sepsis (SS). We determined serum HSP90α, HSP72 and neutrophil CD64 expression, IL-6, IL-8, IL-10, and TNFα in children with S or SS compared with SIRS (brain injury) or healthy children (H). Methods Critically ill children with S (n = 16), SS (n = 15) or SIRS (n = 18) and H (n = 21) were enrolled in the study. ELISA was used to evaluate HSPs, chemiluminescence to measure ILs, and fl ow cytometry to evaluate nCD64 expression (IRB approved). Methods Human whole blood was stimulated with LPS (100 ng/ ml) from Escherichia coli for 4 hours. P40 P40 Alarming levels of heat shock proteins 72 and 90α in critically ill children M Fitrolaki1, H Dimitriou2, M Venihaki2, M Katrinaki2, G Briassoulis1 1University Hospital, Heraklion, Greece; 2University of Crete, Medical School, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P40 (doi: 10.1186/cc14120) Alarming levels of heat shock proteins 72 and 90α in critically ill children The stimulated blood or plasma from septic patients was treated in vitro with 10 vol% polystyrene– divinylbenzene (PS-DVB)-based polymers (CG161, mean pore size 16 nm; CG300, mean pore size 30 nm) or left untreated. After adsorption, the plasma was separated and diluted with cell culture medium. The resulting conditioned medium was used to stimulate human umbilical vein endothelial cells (HUVEC) for 16 hours. HUVEC activation was assessed by the release of interleukin (IL)-1β, IL-6, IL-8, IL-10, and tumor necrosis factor (TNF)α, plasminogen activator inhibitor-1 (PAI- 1), as well as the expression of intercellular adhesion molecule (ICAM)- 1 and E-selectin. HUVEC were cultured at a shear stress of 5 dyne/ cm2 using the Ibidi perfusion system. Adhesion of monocytic THP-1 cells to HUVEC was studied after 4 hours of HUVEC stimulation with conditioned media. THP-1 cells were perfused over HUVEC at 1 dyne/ cm2 for 15 minutes, and adhering THP-1 were quantifi ed over time. p j y y Methods Critically ill children with S (n = 16), SS (n = 15) or SIRS (n = 18) and H (n = 21) were enrolled in the study. ELISA was used to evaluate HSPs, chemiluminescence to measure ILs, and fl ow cytometry to evaluate nCD64 expression (IRB approved). p pp Results Patients in both septic groups had elevated HSP90α (P <0.0001), HSP72 (P <0.05), IL-6 (P <0.0001), IL-8 (P <0.02) and IL-10 (P <0.05) levels compared with H, whereas SS had increased HSP72, IL6 and TNFα compared with SIRS (P <0.05). SIRS patients presented increased HSP90α, IL-6 and IL-8 compared with H (P <0.05). Both HSPs were dramatically increased among nonsurvivors. In a logistic regression model, only HSP90α was independently associated with mortality (P <0.0001). HSP90α related positively (P <0.001) to nCD64, IL-8, IL-10, CRP, PRISM, PELOD, TISS, and LOS and negatively to HDL (P <0.001) and LDL (P <0.02). HSP72 also related negatively to HDL (P <0.001). i Results The adsorbents CG161 and CG300 substantially decreased levels of TNFα, IL-1β, IL-6, IL-8 and IL-10 in LPS-stimulated blood. TNFα, a key stimulus for HUVEC, was reduced to 12% and 8% of the initial concentration by CG161 and CG300, respectively. Stimulation of HUVEC with the adsorbent-treated plasma resulted in signifi cantly diminished release of IL-6, IL-8, PAI-1 and decreased ICAM-1 and E-selectin expression, indicating reduced HUVEC activation. P37 Specifi c patterns of T-cell cytokines as an early marker of outcome in septic patients A Franci, A Peris, F Liotta, F Annunziato, P Ruggiano, M Ferraro A.O.U. Careggi, Firenze, Italy Critical Care 2015, 19(Suppl 1):P37 (doi: 10.1186/cc14117) A Franci, A Peris, F Liotta, F Annunziato, P Ruggiano, M Ferraro A.O.U. Careggi, Firenze, Italy Critical Care 2015, 19(Suppl 1):P37 (doi: 10.1186/cc14117) Introduction The infl ammatory response of sepsis is developed in two phases, an infl ammatory phase (SIRS) and a phase more variable in frequency and intensity (CARS): this balance has an important eff ect on morbidity and mortality. Lymphopenia aff ects particularly T cells, and Conclusion The extent of reduced LPS responsiveness of blood leukocytes in critically ill patients on the fi rst day after ICU admission does not relate to the subsequent development of ICU-acquired infections. S14 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P38). Similarly reduced responsiveness of whole blood leukocytes to lipopolysaccharide. Figure 1 (abstract P38). Similarly reduced responsiveness of whole blood leukocytes to lipopolysaccharide. mediators with porous polystyrene-based polymers attenuates endothelial activation and reduces monocyte adhesion. mediators with porous polystyrene-based polymers attenuates endothelial activation and reduces monocyte adhesion. 39 ell-culture model to study endothelial activation in sepsis y p T Eichhorn1, S Rauscher2, C Hammer2, B Führer2, M Gröger2, V Weber1 Early heat shock protein 72 and 90α intracellular and extracellular responses in patients with severe sepsis or systemic infl ammatory response syndrome p p g g p Results Nineteen controls, six SIRS patients and 25 severe sepsis patients were studied. The percent expression of HLADR on CD14+ monocytes was signifi cantly diff erent between the three groups showing progressive decrease from controls (mean 90.5 ± 3.8%) to SIRS (mean 61.2 ± 5.9%) to severe sepsis (mean 39.2 ± 5.5%) patients (controls vs. severe sepsis, P <0.001; controls vs. SIRS, P = 0.006; SIRS vs. severe sepsis, P = 0.03). hsp70 and hsp90 MFI were signifi cantly diff erent between controls (mean 49.5 ± 4.9 and 33.5 ± 3.4 respectively), SIRS (mean 69.9 ± 16.5 and 46.5 ± 5.7 respectively) and severe sepsis patients (mean 33.3 ± 4.5 and 21.7 ± 2.7 respectively) (P <0.05 for all comparisons). Notably, the hsp level rose from controls to SIRS and fell from SIRS to severe sepsis patients. APACHE score increased signifi cantly (P = 0.023) in septic patients compared with SIRS.if Introduction Heat shock proteins (HSPs) have intracellular cyto pro tec- tive actions, while they act extracellularly as inducers of cytokines and stimulants for immune cells during stress. Their induction constitutes a highly conserved cellular defense mechanism against all kinds of stress. Our objective was to determine the intracellular as well as extracellular levels of HSP72 and HSP90α in patients with severe sepsis (SS) or systemic infl ammatory response syndrome (SIRS) admitted to a general ICU, compared with those of healthy individuals; to correlate their expression with severity of illness. i Conclusion There were a signifi cant diff erence in CD14/HLADR, a marker of immune paralysis, between controls and patients with SIRS or severe sepsis. hsp70 and hsp90 showed an initial stimulation followed by exhaustion as sepsis progressed.i Methods Eighty-two consecutively admitted patients in the ICU (35 SIRS, 47 SS) as well as 35 healthy controls (H) were fi nally enrolled in the study. Patients’ demographic characteristics, laboratory examinations and Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded on admission. HSP levels were determined intracellularly using four-color fl ow cytometry. Mean fl uorescence intensity (MFI) values for each HSP were measured and analyzed. Extracellular levels of HSPs were determined via ELISA. Acknowledgements This research was co-fi nanced by the European Union (European Social Fund) and Greek national funds through the Operational Program ‘Education and Lifelong Learning’ of the National Strategic Reference Framework Research Funding Program: THALES. P42 P42 Heat shock proteins 70/90 and associations with immunosuppression along with sepsis: preliminary data P Papadopoulos1, A Pistiki2, T Christodoulopoulou1, M Theodorakopoulou1, V Tsagkari1, A Armaganidis1, S Tsiodras2, I Dimopoulou1, G Briassoulis3, G Briassoulis3 1University Hospital of Athens, Greece; 2University Hospital ATTIKON, Athens, Greece; 3University Hospital, University of Crete, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P42 (doi: 10.1186/cc14122) P42 Heat shock proteins 70/90 and associations with immunosuppression along with sepsis: preliminary data P Papadopoulos1, A Pistiki2, T Christodoulopoulou1, M Theodorakopoulou1, V Tsagkari1, A Armaganidis1, S Tsiodras2, I Dimopoulou1, G Briassoulis3, G Briassoulis3 1University Hospital of Athens, Greece; 2University Hospital ATTIKON, Athens, Greece; 3University Hospital, University of Crete, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P42 (doi: 10.1186/cc14122) Heat shock proteins 70/90 and associations with immunosuppression along with sepsis: preliminary data P Papadopo los1 A Pistiki2 T Christodo lopo lo 1 p p , , p , M Theodorakopoulou1, V Tsagkari1, A Armaganidis1, S Tsiodras2, I Dimopoulou1, G Briassoulis3, G Briassoulis3 1University Hospital of Athens, Greece; 2University Hospital ATTIKON, Athens, Greece; 3University Hospital, University of Crete, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P42 (doi: 10.1186/cc14122) p p p M Theodorakopoulou1, V Tsagkari1, A Armaganidis1, S Tsiodras2, I Dimopoulou1, G Briassoulis3, G Briassoulis3 1University Hospital of Athens, Greece; 2University Hospital ATTIKON, Athens, Greece; 3University Hospital, University of Crete, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P42 (doi: 10.1186/cc14122) Results Ninety-nine patients were included in the fi nal analysis. Eighteen patients developed severe sepsis or septic shock. They presented with signifi cantly higher levels of intermediate (CD14++/16+) and CD62L– monocytes and lower IL-2 levels at T1 compared with patients who did not get septic. ROC AUC for association of these parameters with the occurrence of sepsis were 0.78 (95% CI: 0.63 to 0.91), 0.72 (0.62 to 0.82) and 0.73 (0.65 to 0.82), respectively. High counts of these monocytic cells were also associated with increased 90- day mortality (P <0.01, ROC AUC = 0.87 (0.77 to 0.95), 0.79 (0.66 to 0.9)). Kaplan–Meier survival curves showed signifi cantly higher mortality after stratifi cation based on these cell counts at T1 (CD14++CD16+: cutoff >236.8 cells/μl, HR = 23.6 (P = 1.24 × 10–5); CD62L–: cutoff >95.4 cells/μl, HR = 6.67 (P = 7.6 × 10–4)). Multivariate logistic regression analysis using Introduction CD14/HLADR is an index of immune suppression. Heat shock proteins (hsp) regulate cell response to oxidative stress. Early heat shock protein 72 and 90α intracellular and extracellular responses in patients with severe sepsis or systemic infl ammatory response syndrome This abstract is part of the study ‘Heat Shock Proteins and Glutamine Alterations Related to Hormonal, Immunological, Infl ammatory and Molecular Response to Sepsis: A Combined Clinical and Experimental Study’. Results HSP expression diff ered signifi cantly between groups (Kruskal–Wallis), both intracellularly (HSP72 lower in SS, P <0.001), and extracellularly (higher levels of HSP90α (P <0.001) and HSP72 (P = 0.003) in SS). HSP72 and HSP90α intracellular expression was inversely correlated to severity of illness, as expressed by APACHE II score (Spearman’s, P = 0.003 and P = 0.025 respectively). Intracellular HSP72 was correlated to mortality when confounding factors were excluded from the analysis (logistic regression, P = 0.05). Extracellular HSP90α levels correlated with prolonged PT (P = 0.021) and INR (P = 0.008). Finally, in the SIRS group, intracellular levels of HSP90α were higher in nonsurvivors (P <0.001). Alarming levels of heat shock proteins 72 and 90α in critically ill children THP-1 adhesion was substantially decreased when HUVEC were stimulated with CG300-treated plasma as compared with untreated controls.lf Conclusion Extracellular HSP72 and HSP90α are alarmingly elevated in critically ill children, especially in severe sepsis. HSP90α levels are independently associated with mortality, related to CD64, IL-8, IL-10, severity of illness, and outcome. Both HSPs are inversely related to the low LDL/low HDL septic metabolic pattern [2].i Acknowledgements This research has been co-fi nanced by the European Union (European Social Fund) and Greek national funds through the Operational Program ‘Education and Lifelong Learning’ of the National Strategic Reference Framework Research Funding Program: THALES. Investing in knowledge society through the European Social Fund. Conclusion The fl ow model allows to study the eff ect of cytokine modulation on endothelial activation and to assess the interaction of activated endothelial cells with blood cells. Modulation of infl ammatory S15 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P41 Early heat shock protein 72 and 90α intracellular and extracellular responses in patients with severe sepsis or systemic infl ammatory response syndrome K Apostolou1, K Vardas1, E Briassouli1, K Psara1, D Goukos1, E Mageira1, S Nanas1, C Routsi1, G Briassoulis2 1Evangelismos Hospital, National and Kapodistrian University of Athens, Greece; 2University Hospital, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P41 (doi: 10.1186/cc14121) Prospective immune profi ling in critically ill adults: before, during and after severe sepsis and septic shock Introduction Rethinking the host’s defense mechanisms during severe infection has led to the use of fl ow cytometry (FCM) and to the current concept of sepsis-induced immunosuppression. However, organ dysfunctions that develop in the period preceding severe sepsis as a consequence of surgery, trauma or burn might also trigger immune reprogramming predisposing to overwhelming infection. Our aim was to look for correlation of specifi c phenotypes among four commonly encountered populations of patients and the later occurrence of severe sepsis and septic shock. g Conclusion SS is characterized by high levels of extracellular HSPs. Intracellular HSP72 is highly expressed during the acute phase of stress in SIRS, while being downregulated in SS. HSP72 and HSP90α intracellular expression and extracellular level variations correlate with severity of illness and mortality.i Acknowledgements This research was co-fi nanced by the European Union (European Social Fund) and Greek national funds through the Operational Program ‘Education and Lifelong Learning’ of the National Strategic Reference Framework Research Funding Program: THALES. p p Methods In total, 114 non-infected patients were prospectively screened via FCM on days 1 (T1) and 3 (T2) of elective cardiac surgery, trauma, acute neurologic dysfunction and prolonged ventilation (>48 hours). A third sample was drawn when infection was diagnosed (Tx) and 7 days later (Tx + 7). Exclusion criteria included use of immunosuppressive agent(s). The broad panel of cell-specifi c antibodies focused on B, T lymphocytes (Tregs, Th17, NKT), NK cells, monocytes and neutrophils. Plasmatic levels of IL-2/IL-6/IL-7/TNFα/ IFNγ were also determined.i References To evaluate the %HLA-DR expression on monocytes, the fresh whole blood was stained with anti-CD14-FITC, anti-HLA-DR-PE and CD45- PC5 while staining with anti-CD33-PE, anti-CD45-PC7, anti-hsp70-FITC and anti-hsp90-PE allowed evaluation of the MFI expression of hsps on CD33+ monocytes. Cells were then analyzed using fl ow cytometry. ANOVA with post hoc tests was used to compare CD14/HLADR cell counts and hsp70 and hsp90 levels among the three groups. References 1. Briassouli E, et al. Nutrition. 2014;30:1185-94. 2. Fitrolaki DM, et al. BMC Pediatr. 2013;13:31. References 1. Briassouli E, et al. Nutrition. 2014;30:1185-94. 2. Fitrolaki DM, et al. BMC Pediatr. 2013;13:31. P42 We evaluated the relationship of CD14/HLADR and hsp70/90 in patients with SIRS and severe sepsis versus healthy volunteers. Methods We evaluated 31 patients with SIRS or severe sepsis against a group of sex-matched healthy volunteers. Demographic data were obtained for all patients. APACHE score was calculated upon admission. Blood samples were collected upon diagnosis of SIRS or severe sepsis. S16 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 clinical scores indicated that addition of IL-2 levels at T1 signifi cantly improved prediction of sepsis (OR = 0.834, P = 0.02). that septic patients display a strong correlation between mHLA-DR and mRNA-levels of HLA-DRA in whole blood [1]. mRNA-based HLA- DR monitoring by PCR would improve the clinical usage and facilitate conduction of multicentre studies. The primary focus in this study was to evaluate the correlation between mHLA-DR and HLA-DRA at diff erent time points during sepsis. In addition, we assessed the dynamic expression of both mHLA-DR and HLA-DRA, in relation to sepsis severity. Conclusion Predisposition to sepsis in selected critically ill medico- surgical adults can be identifi ed on day 1 of admission based on high counts of circulating intermediate and CD62L– monocytes and low levels of IL-2 (the latter provide incremental prognostic information). High counts of these specifi c monocytes correlate with higher 90-day mortality. y Methods Study patients (n = 54) were included at day 1 to 2 after hospital admission if blood cultures turned positive. Repeated sampling at days 1 to 2, 3, 7, 14 and 28 was performed. mHLA-DR was monitored by FCM and HLA-DRA by quantitative RT-PCR. Mixed models for longitudinal data were used after logarithmic transformation to calculate the interactional eff ects of time and severity on HLA-DR expression. Macrophage phenotype in sepsis immunosuppression E Theodorakis, E Diamantaki, C Tsatsanis, D Georgopoulos, K Vaporidi University of Crete, School of Medicine, Heraklion, Greece Critical Care 2015, 19(Suppl 1):P44 (doi: 10.1186/cc14124) Figure 1 (abstract P45). Box plots of mHLA-DR, measured by fl ow cytometry. Figure 2 (abstract P45). Box plots of HLA-DRA, measured by qRT-PCR. Figure 1 (abstract P45). Box plots of mHLA-DR, measured by fl ow cytometry. Figure 1 (abstract P45). Box plots of mHLA-DR, measured by fl ow cytometry. Introduction Sepsis is followed by profound, yet poorly characterized, innate immune system suppression. P42 While low monocyte HLA-DR expression is observed in septic patients, its clinical signifi cance has not been established [1]. In vitro, repeated LPS stimulation induces a tolerant or M2 macrophage phenotype, characterized by decreased cytokine production [2], which could contribute to sepsis immunosuppression. The present study examines macrophage phenotype in a mouse model and in patients with sepsis immunosuppression. p p pp Methods Sepsis was induced in C57Bl6 mice by cecal ligation and puncture (CLP) followed by intratracheal instillation of Pseudomonas aeruginosa. Bronchoalveolar lavage fl uid (BALF), cells and serum, collected 12 hours after lung infection, were analyzed for bacterial load, cytokine levels and the classical M1 marker, iNOS. Peripheral blood monocytes isolated from septic adult patients admitted to the ICU on the 1st and 7th day after admission were analyzed by fl ow cytometry for the expression of HLA-DR and CD86 (co-stimulatory molecule and M1 marker), and for the M2 markers, CD163 and CD206. Additional blood samples from patients and healthy volunteers were exposed ex vivo to LPS prior to isolation and analysis of monocyte markers. p y y Results CLP-induced sepsis resulted in immunosuppression in mice, indicated by higher BALF bacterial load after infection in CLP than in sham-operated mice, and more severe injury on histology. Serum cytokines TNF and MIP2 were greater in CLP than in sham-operated mice. Although recruitment of CD11c+ alveolar macrophages post infection was threefold greater in CLP than in sham-operated mice, those macrophages expressed 40% lower levels of iNOS. Evidence of sepsis immunosuppression was present in most patients on the 7th day after ICU admission. Low expression of CD86 and/or HLA-DR was observed in 71% of patients, and increased expression of M2 markers in 15% of patients. Upon LPS stimulation the normal decrease in M2 markers was absent in all patients on day 1, and partially restored in 50% of patients on day 7. Figure 1 (abstract P45). Box plots of mHLA-DR, measured by fl ow cytometry. Figure 1 (abstract P45). Box plots of mHLA-DR, measured by fl ow cytometry. Figure 2 (abstract P45). Box plots of HLA-DRA, measured by qRT-PCR. Conclusion Sepsis is associated with decreased monocyte expression of M1 markers and increased expression of M2 markers in septic mice and critically ill patients. P42 Therefore, in addition to decreased HLA-DR expression, M2 macrophage polarization appears to be a component of sepsis-induced monocyte dysfunction, and should be considered for immune monitoring and targeted intervention. g g Acknowledgement Supported by GSRT research grant ExcellenceII-4620. R f References 1. Gomez H, et al. Crit Care Med. 2014;42:771. 2. Porta C, et al. Proc Natl Acad Sci U S A. 2009;106:14978. 2. Porta C, et al. Proc Natl Acad Sci U S A. 2009;106:14978. P45 P45 Expression of mRNA levels of HLA-DRA in relation to monocyte HLA-DR: a longitudinal sepsis study SC Cajander, ET Tina, AB Bäckman, AM Magnuson, KS Strålin, BS Söderquist, JK Källman Örebro University, Örebro, Sweden Critical Care 2015, 19(Suppl 1):P45 (doi: 10.1186/cc14125) Expression of mRNA levels of HLA-DRA in relation to monocyte HLA-DR: a longitudinal sepsis study SC Cajander, ET Tina, AB Bäckman, AM Magnuson, KS Strålin, BS Söderquist, JK Källman Örebro University, Örebro, Sweden Critical Care 2015, 19(Suppl 1):P45 (doi: 10.1186/cc14125) Introduction Decreased monocyte surface HLA-DR (mHLA-DR) measured by fl ow cytometry (FCM) is an independent marker of immunosuppression in sepsis. In a previous report we demonstrated S17 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results Correlation between mHLA-DR(FCM) and HLA-DRA(PCR) at day 1 to 2 (R = 0.78) and day 14 (R = 0.27). Both HLA-DR markers increased linearly on a log scale over time. The linear association was signifi cantly diff erent between the severe (n = 16) and nonsevere septic patients (n = 38) when measuring either mHLA-DR(FCM) or HLA-DRA(PCR). By pairwise comparison of means between the two severity groups, at every time point, the diff erences between groups were shown to be signifi cant at days 1 to 2 and 3 when monitoring mHLA-DR(FCM) and at days 1 to 2, 3 and 7 for HLA-DRA(PCR) (Figures 1 and 2).l used as a diagnostic criterion of sepsis. There are no published data to defi ne the role of dynamic control of EC in the process of intensive therapy as a prognostic marker and indicator of severity condition in critically ill patients. The aim was to determine the informative value of EC in the development of SIRS as a biomarker of sepsis and indicator of the severity condition and prognosis of outcome in the pathological process. Methods A total of 143 patients were enrolled in this study who were admitted to the ICU and had SIRS. All patients were divided into a septic group – patients with community-acquired pneumonia, complicated by sepsis – and two SIRS groups of noninfectious genesis – patients who had an acute cerebrovascular accident (CVA) and an acute myocardial infarction (AMI). The absolute EC was measured at admission and in the dynamics on days 3 to 5 of stay. HLA-DR monocyte antigen expression as predictors of outcome in patients with community-acquired infections presenting with fever D Logothetis, E Giourou, I Starakis, A Lekkou, G Theodorou, M Leotsinidis, M Karakantza, C Gogos University of Patras, Patra, Greece Critical Care 2015, 19(Suppl 1):P46 (doi: 10.1186/cc14126) y Critical Care 2015, 19(Suppl 1):P46 (doi: 10.1186/cc14126) Introduction The aim of the present study was to evaluate the prognostic value of HLA-DR antigen expression in monocytes, in patients with community-acquired infections presenting with fever, as possible markers for the patients’ fi nal outcome. Table 1 (abstract P47). Dynamics of eosinophil count depending on outcome in groups i Methods A total of 81 patients (males = 46; females = 35) presenting with fever >38°C to the emergency room (ER) of the Department of Internal Medicine of the Patras University Hospital were enrolled in the study during a period of 12 months. Sera for monocyte HLA-DR expression were obtained from the patients on admission (day 1) and on days 3, 7 or discharge/death. Results were expressed as percentages of HLA-DR-positive monocytes, calculated by the coexpression of CD14 and HLA-DR antigens in the total CD14+ population. Additionally, the patients were evaluated using the Simplifi ed Acute Physiology Score (SAPS-II), the Sequential Organ Failure Assessment (SOFA) and the Mortality in Emergency Department Sepsis (MEDS) score on the same days while all the indicated clinical, laboratory and imaging procedures as required for fever’s diff erential diagnosis were followed. A questionnaire regarding demographic characteristics, comorbidities, medications used and patients’ survival was also completed. All statistical analyses were performed using SPSS v.21. Table 2 (abstract P47). Informational value of eosinophil count in assessment of disease outcome Results Lower mean HLA-DR monocyte antigen expression percen- tages were signifi cantly correlated to lower Glasgow Scale scores on all days of measurement. HLA-DR expression was signifi cantly negatively correlated to MEDS, SOFA and SAPS-II scores whereas patients who developed sepsis, severe sepsis, septic shock and MODS had signifi cantly lower HLA-DR values compared with the ones who did not. HLA-DR expression on day 1 was lower in patients who would develop SIRS and/or sepsis on days 3 and 7 (P <0.01). Additionally, HLA- DR expression was signifi cantly decreased in nonsurvivors (n = 33) compared with survivors (n = 48), whereas lower HLA-DR expression was correlated to longest duration of hospital stay at all time points (P <0.01). Conclusion EC may be an additional diagnostic marker which characterizes the nature of SIRS. Eosinopenia associated with prognosis of outcome in critical conditions. P45 y g Conclusion The correlation between fl ow cytometry and PCR-based HLA-DR monitoring is stronger in the early phase of sepsis. However, the linear associations over time, in relation to sepsis severity, display similar results for both HLA-DR markers. HLA-DRA(PCR) as a biomarker could be an alternative approach in monitoring immune status in sepsis but needs to be evaluated in relation to clinically relevant immunosuppression. Reference y y y Results The median EC was 75 cells/mm3 in septic patients on admission, which was signifi cantly lower than in patients with CVA (120 cells/mm3) and AMI (130 cells/mm3). Comparison of EC in septic patients between survivors and those who died showed signifi cant diff erences (Table 1). Receiver operating characteristic (ROC) analysis determined a value less than 80 cells/mm3 as the optimal diagnostic cutoff value with a high level of confi dence in the comparison of septic and noninfectious groups. Area under the ROC curves was 0.94, sensitivity of 80.8%, specifi city of 95.6%, P <0.0001. There was a signifi cant increase of EC in survivors, while the EC did not change signifi cantly among those who died in the dynamics. ROC analysis determined the cutoff values of EC, which indicated a high risk of an adverse outcome in septic patients (Table 2). 1. Cajander S, et al. Crit Care. 2013;17:R223. 1. Cajander S, et al. Crit Care. 2013;17:R223. HLA-DR monocyte antigen expression as predictors of outcome in patients with community-acquired infections presenting with fever D Logothetis, E Giourou, I Starakis, A Lekkou, G Theodorou, M Leotsinidis, M Karakantza, C Gogos University of Patras, Patra, Greece Critical Care 2015, 19(Suppl 1):P46 (doi: 10.1186/cc14126) HLA-DR monocyte antigen expression as predictors of outcome in patients with community-acquired infections presenting with fever D Logothetis, E Giourou, I Starakis, A Lekkou, G Theodorou, M Leotsinidis, M Karakantza, C Gogos University of Patras, Patra, Greece Critical Care 2015, 19(Suppl 1):P46 (doi: 10.1186/cc14126) Conclusion Monocyte HLA-DR appears to be an early indicator for survival and infection progression and therefore it can be used as a predictive marker for the fi nal outcome of patients presenting in ER departments with fever. P48 Prevalence and clinical signifi cance of early endotoxin activity in septic shock patients M Bottiroli1, R Pinciroli1, G Monti2, M Mininni1, G Casella2, R Fumagalli2 1Anestesia Rianimazione 3, A.O. Niguarda, Milan, Italy; 2Anestesia Rianimazione 1, A.O. Niguarda, Milan, Italy Critical Care 2015, 19(Suppl 1):P48 (doi: 10.1186/cc14128) P47 Eosinopenia as a marker of sepsis and mortality in critically ill patients A Savitskiy, V Rudnov, V Bagin City Clinical Hospital # 40, Yekaterinburg, Russia Critical Care 2015, 19(Suppl 1):P47 (doi: 10.1186/cc14127) P47 Eosinopenia as a marker of sepsis and mortality in critically ill patients A Savitskiy, V Rudnov, V Bagin City Clinical Hospital # 40, Yekaterinburg, Russia Critical Care 2015, 19(Suppl 1):P47 (doi: 10.1186/cc14127) Introduction The endotoxin activity (EA) assay is a useful test to risk stratify critically ill patients and assess for Gram-negative (GN) infection. However, the prevalence and signifi cance of early high levels of EA in patients with septic shock (SS) has yet to be elucidated. Introduction The idea of using the eosinophil count (EC) as a diagnostic marker for clarifying the nature of systemic infl ammatory response syndrome (SIRS) belongs to K Abidi, who showed that EC could be Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 S18 pp http://ccforum.com/supplements/19/S1 Figure 1 (abstract P48). patients with systemic infl ammatory response syndrome (SIRS) and organ failure in ICU setting. Methods In total, 76 patients with SIRS and organ failure or who were suspected of sepsis during critical care were included. According to the levels of EAA, all patients were classifi ed into three groups (group L, EAA <0.4; group M, EAA ≥0.4 or EAA <0.6; group H, EAA ≥0.6). In order to evaluate the severity of illness, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score and catecholamine (CA) index were recorded. Blood samples were obtained to measure EAA levels, infl ammatory markers (procalcitonin, C-reactive protein and white blood cells), serum lactate level as an indicator of tissue hypoxia, and for blood culture. All patients were followed up for 6 months. APACHE II score, SOFA score, CA index, infl ammatory markers, serum lactate levels and blood culture results were examined for diagnosis of sepsis, severe sepsis, septic shock and for prognosis of 30-day mortality. Each value was also compared with EAA levels. Results Patient age was 69 ± 9.9 years (male: n = 48, female: n = 25). The total number of samples was 106 (group L/group M/group H: 35/35/36). Twenty-seven specimens were obtained from nonseptic patients and 83 specimens were obtained from septic patients. APACHE II score was highly correlated with SOFA score (P <0.05). In group H, the APACHE II score was signifi cantly higher (22.2 ± 0.8) than that in group M (18.4 ± 0.87) (P = 0.01). 1Institute of Medical Sciences, Toronto, ON, Canada; 2St. Michael’s Hospital, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P50 (doi: 10.1186/cc14130) Results A total of 107 consecutive patients were included. The overall median EA was 0.56 (0.44 to 0.71), with 46/107 (43%) patients testing positive for elevated EA (≥0.6). GN species were identifi ed in microbial cultures as the infective etiology in 49/107 (46%) patients, of which 28 (57%) developed bacteremia. GN infections were associated with higher levels of EA compared with other microbial causatives (0.61 (0.52 to 0.77) vs. 0.52 (0.38 to 0.64), P = 0.021). Patients with EA ≥0.6 showed signifi cantly higher lactate levels (2 (1 to 3) vs. 3.8 (1.7 to 6.4), P = 0.01), Sequential Organ Failure Assessment (9 (6 to 12) vs. 10 (8 to 14), P = 0.04) and inotropic score (20 (5 to 50) vs. 50 (16 to 100), P = 0.003) at inclusion. See Figure 1. Introduction Sepsis is a common reason for admission to ICUs throughout the world. During the past two decades, the incidence of sepsis in the USA has tripled and is now the 10th leading cause of death. As sepsis continues to impact negatively on critically ill patients, it is clear that early diagnosis and eff ective management could improve patient morbidity and mortality. Numerous studies have attempted to examine biomarkers and their ability to diagnose and prognosticate septic patients. Despite multiple eff orts, currently there are no reliable markers that can eff ectively improve our clinical eff ectiveness in diagnosing and managing septic patients. The purpose of our systematic review was to evaluate the diagnostic and prognostic value of various biomarkers used in septic patients. g Conclusion Elevated EA is a common fi nding in SS patients. In patients developing SS from a GN infection, higher levels of endotoxin activity could be measured within 24 hours. Furthermore, in our study, EA ≥0.6 identifi ed a subgroup of subjects at greater risk for worse clinical outcomes. We therefore propose use of the EA assay for the early identifi cation and risk stratifi cation of SS patients. Methods A systematic search of the literature was performed with MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases using terminology selected for biomarkers (through to and including November 2013). All articles involving neonates and not in English were excluded. Inclusion was agreed on by two independent reviewers of abstracts or full text. Biomarkers in sepsis: a systematic review Biomarkers in sepsis: a systematic review F Morriello1, J Marshall2 1Institute of Medical Sciences, Toronto, ON, Canada; 2St. Michael’s Hospital, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P50 (doi: 10.1186/cc14130) P47 Eosinopenia as a marker of sepsis and mortality in critically ill patients A Savitskiy, V Rudnov, V Bagin City Clinical Hospital # 40, Yekaterinburg, Russia Critical Care 2015, 19(Suppl 1):P47 (doi: 10.1186/cc14127) The SOFA score in group H was signifi cantly higher (9.9 ± 0.5) than that in group M (7.5 ± 0.6) and group L (7.9 ± 0.6) (P = 0.006). EAA levels were signifi cantly increased in septic patients (septic patients: 0.56 ±0.03, nonseptic patients: 0.42 ±0.05) (P = 0.011) and in the positive blood culture group (positive group: 0.66 ± 0.05, negative group: 0.48 ± 0.03) (P = 0.006). There was no relationship between EAA levels and other infl ammation markers or 30-day mortality. Conclusion In patients with suspected sepsis and positive blood culture, EAA levels were signifi cantly increased and had strong correlation with severity of disease. This result suggests that EAA indicates the state of sepsis regardless of the possibility of infection in patients with SIRS with organ failure. Figure 1 (abstract P48). Figure 1 (abstract P48). Methods We designed a prospective observational study including adult patients with clinically diagnosed SS. EA was measured on arterial blood by a chemiluminescent assay within the fi rst 24 hours from SS diagnosis. The fi nding of an EA value ≥0.6 was used as the cutoff for test positivity, as described elsewhere. In addition, laboratory, microbiological and clinical data were collected at inclusion. In-hospital follow-up was also conducted. Biomarkers in sepsis: a systematic review F Morriello1, J Marshall2 F Morriello1, J Marshall2 1Institute of Medical Sciences, Toronto, ON, Canada; 2St. Michael’s Hospital, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P50 (doi: 10.1186/cc14130) P53 Association between apoptosis and mortality in severe septic patients In the fully adjusted model, C C C C C d C d h d l L Lorente1, M Martín2, A González-Rivero1, J Ferreres3, J Solé-Violán4, L Labarta5, C Díaz6, A Jiménez1, J Borreguero-León1 1Hospital Universitario de Canarias, La Laguna, Tenerife, Spain; 2Hospital Universitario Nuestra Señora Candelaria, Santa Cruz, Tenerife, Spain; 3Hospital Clínico Universitario de Valencia, Spain; 4Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain; 5Hospital San Jorge, Huesca, Spain; 6Hospital Insular, Las Palmas de Gran Canaria, Spain Critical Care 2015, 19(Suppl 1):P53 (doi: 10.1186/cc14133) Introduction The apoptotic process, in which cells are actively elimi- nated by a programmed pathway, is increased in sepsis. Extrinsic and intrinsic apoptotic death cell pathways activate caspase-3, which leads to cell apoptosis. Cytokeratin 18 (CK-18), a protein present in most epithelial and parenchymal cells, is cleaved by the action of caspases and released into the blood as caspase-cleaved CK (CCCK)-18 during apoptotic death. The novel objectives of this study were to determine whether there are associations between serum caspase-3 levels, serum CK-18 levels and mortality in septic patients. WBC, CRP, LymC, NeuC, NLCR and EoC were entered into the model. Results A total of 1,302 patients were categorized as nonsepsis SIRS (816, 62.7%) and sepsis (486, 37.3%). In the sepsis group, age, APACHE II, SOFA, mortality, length of ICU stay, CRP, NLCR and EoC were higher; LymC was lower than in the nonsepsis SIRS group (P <0.001 for each). Likelihood of sepsis (reference to nonsepsis SIRS) increased 2.62 (2.05 to 3.34), 2.02 (1.42 to 2.88) and 1.88 (1.36 to 2.60) times (OR (95% CI)) by the values of CRP >4.4 mg/dl, LmyC <500/mm3 and NLCR >15.7 respectively in mutually adjusted multivariate logistic regression (P <0.001 for each). y p p Methods A prospective, multicenter, observational study in six Spanish ICUs, including 216 patients with severe sepsis. We collected blood samples at the severe sepsis diagnosis moment to determine serum levels of caspase-3 (to assess the main executor of apoptosis) and CCCK- 18 (to assess the apoptosis level). The endpoint was 30-day mortality. Results We found that nonsurvivor (n = 76) in comparison with survivor (n = 140) septic patients showed higher serum levels of caspase-3 (0.41 ng/ml (0.14 to 0.52) vs. 0.11 ng/ml (0.10 to 0.25); P <0.001) and CCCK- 18 (448 (310 to 723) vs. 319 (236 to 445); P <0.001). C-reactive protein and hemogram parameters for the nonsepsis SIRS and sepsis: what do they mean? p y B Gucyetmez1, HK Atalan2, M Berktas3, E Ozden4, N Cakar5 1International Hospital, Istanbul, Turkey; 2Atasehir Memorial Hospital, Istanbul, Turkey; 3Kappa Consulting, Istanbul, Turkey; 4Antalya Memorial Hospital, Antalya, Turkey; 5Acibadem University, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P51 (doi: 10.1186/cc14131) B Gucyetmez1, HK Atalan2, M Berktas3, E Ozden4, N Cakar5 1International Hospital, Istanbul, Turkey; 2Atasehir Memorial Hospital, Istanbul, Turkey; 3Kappa Consulting, Istanbul, Turkey; 4Antalya Memorial Hospital, Antalya, Turkey; 5Acibadem University, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P51 (doi: 10.1186/cc14131) y gi Results Reduced BChE activity correlated with trauma severity and the resulting systemic infl ammation. Compared with serum levels of routinely measured infl ammatory biomarkers, changes in the BChE activity were detected signifi cantly earlier, suggesting that the BChE activity might serve as an early indicator of systemic infl ammation. y gi Results Reduced BChE activity correlated with trauma severity and the resulting systemic infl ammation. Compared with serum levels of routinely measured infl ammatory biomarkers, changes in the BChE activity were detected signifi cantly earlier, suggesting that the BChE activity might serve as an early indicator of systemic infl ammation. Conclusion Our results suggest that BChE activity, measured using a POCT system, might play an important role in the early diagnosis of trauma-induced systemic infl ammation. Introduction The aim of this study was to investigate the laboratory parameters as an indicator of sepsis. Sepsis is one of the most common reasons of mortality and morbidity in the ICU [1]. Thus, it is important to distinguish sepsis from nonsepsis SIRS. CRP and hemogram parameters may be fast, easy and aff ordable alternatives in distinguishing sepsis from nonsepsis SIRS. Eosinophil count (EoC), lymphocyte count (LymC) and neutrophil–lymphocyte count ratio (NLCR) are used as sepsis indicators [1,2]. Conclusion Our results suggest that BChE activity, measured using a POCT system, might play an important role in the early diagnosis of trauma-induced systemic infl ammation. P53 Association between apoptosis and mortality in severe septic patients Methods A total of 2,777 patients admitted to the ICU of two centers between 2006 and 2013 were evaluated retrospectively. The patients were diagnosed as SIRS(–), nonsepsis SIRS or sepsis at ICU admission by the consensus of two doctors in accordance with 1992 sepsis guidelines [3]. The patients who were under 18 years old, readmitted, immunosuppressive, SIRS(–) and whose laboratory values and outcomes were unknown were excluded. In total, 1,302 patients were divided into two groups as the nonsepsis SIRS group and the sepsis group. The patient’s age, gender, diagnoses (medical, elective and urgent surgery), APACHE II, SOFA, CRP, WBC, neutrophil count (NeuC), LymC, NLCR, EoC, platelet, mean platelet volume, length of ICU stay and mortality were recorded by a third doctor. In the fully adjusted model, WBC, CRP, LymC, NeuC, NLCR and EoC were entered into the model. Results A total of 1,302 patients were categorized as nonsepsis SIRS (816, 62.7%) and sepsis (486, 37.3%). In the sepsis group, age, APACHE II, SOFA, mortality, length of ICU stay, CRP, NLCR and EoC were higher; LymC was lower than in the nonsepsis SIRS group (P <0.001 for each). Likelihood of sepsis (reference to nonsepsis SIRS) increased 2.62 (2.05 to 3.34), 2.02 (1.42 to 2.88) and 1.88 (1.36 to 2.60) times (OR (95% CI)) by the values of CRP >4.4 mg/dl, LmyC <500/mm3 and NLCR >15.7 respectively in mutually adjusted multivariate logistic regression (P <0.001 for each). Methods A total of 2,777 patients admitted to the ICU of two centers between 2006 and 2013 were evaluated retrospectively. The patients were diagnosed as SIRS(–), nonsepsis SIRS or sepsis at ICU admission by the consensus of two doctors in accordance with 1992 sepsis guidelines [3]. The patients who were under 18 years old, readmitted, immunosuppressive, SIRS(–) and whose laboratory values and outcomes were unknown were excluded. In total, 1,302 patients were divided into two groups as the nonsepsis SIRS group and the sepsis group. The patient’s age, gender, diagnoses (medical, elective and urgent surgery), APACHE II, SOFA, CRP, WBC, neutrophil count (NeuC), LymC, NLCR, EoC, platelet, mean platelet volume, length of ICU stay and mortality were recorded by a third doctor. P52 P52 Serum cholinesterase activity as an early indicator of systemic infl ammation References 1. Abidi K, et al. Crit Care. 2008;2:R59. 2. Castelli GP, et al. Minerva Anestesiol. 2006;1-2:69-80. 3. Bone RC, et al. Chest. 1992;101:1644-55. P53 Association between apoptosis and mortality in severe septic patients Multiple logistic regression showed that serum caspase-3 levels >0.25 ng/ml were associated with mortality at 30 days (odds ratio = 6.51; 95% confi dence interval = 3.32 to 12.77; P <0.001), controlling for SOFA score and age. Kaplan–Meier survival analysis showed a higher risk of death in septic patients with serum caspase-3 levels >0.25 ng/ml than in patients with lower levels (hazard ratio = 3.80; 95% CI = 2.35 to 6.15; P <0.001). We found a positive association between serum levels of caspase-3 and CCCK-18 (ρ = 0.32; P <0.001).i Methods A prospective, multicenter, observational study in six Spanish ICUs, including 216 patients with severe sepsis. We collected blood samples at the severe sepsis diagnosis moment to determine serum levels of caspase-3 (to assess the main executor of apoptosis) and CCCK- 18 (to assess the apoptosis level). The endpoint was 30-day mortality. Conclusion CRP, LymC and NLCR may distinguish sepsis from nonsepsis SIRS. Thus, CRP and hemogram parameters may contribute to early diagnosis of sepsis. Results We found that nonsurvivor (n = 76) in comparison with survivor (n = 140) septic patients showed higher serum levels of caspase-3 (0.41 ng/ml (0.14 to 0.52) vs. 0.11 ng/ml (0.10 to 0.25); P <0.001) and CCCK- 18 (448 (310 to 723) vs. 319 (236 to 445); P <0.001). Multiple logistic regression showed that serum caspase-3 levels >0.25 ng/ml were associated with mortality at 30 days (odds ratio = 6.51; 95% confi dence interval = 3.32 to 12.77; P <0.001), controlling for SOFA score and age. Kaplan–Meier survival analysis showed a higher risk of death in septic patients with serum caspase-3 levels >0.25 ng/ml than in patients with lower levels (hazard ratio = 3.80; 95% CI = 2.35 to 6.15; P <0.001). We found a positive association between serum levels of caspase-3 and CCCK-18 (ρ = 0.32; P <0.001). 1Institute of Medical Sciences, Toronto, ON, Canada; 2St. Michael’s Hospital, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P50 (doi: 10.1186/cc14130) B Gucyetmez1, HK Atalan2, M Berktas3, E Ozden4, N Cakar5 1International Hospital, Istanbul, Turkey; 2Atasehir Memorial Hospital, Istanbul, Turkey; 3Kappa Consulting, Istanbul, Turkey; 4Antalya Memorial Hospital, Antalya, Turkey; 5Acibadem University, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P51 (doi: 10.1186/cc14131) 1Institute of Medical Sciences, Toronto, ON, Canada; 2St. Michael’s Hospital, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P50 (doi: 10.1186/cc14130) Assessment was based on the biomarker’s ability to diagnose septic patients and its ability to predict mortality.i P49 Usefulness of endotoxin activity assay for early diagnosis of sepsis S Sekine, H Imaizumi, K Masumoto, H Uchino Tokyo Medical University, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P49 (doi: 10.1186/cc14129) Results Of 5,257 articles identifi ed, all abstracts were screened, and 750 full-text articles were selected for review. These included primarily randomized controlled trials, cohort studies and postmortem studies. Of 49 biomarkers examined, 72% of the studies examined procalcitonin. Comparing the serum of septic patients with that of controls, most biomarkers were elevated in septic patients, even though only a few had high sensitivity (>85%) and high specifi city (>80%). It was often Introduction The purpose of this study was to evaluate the diagnostic and prognostic value of the endotoxin activity assay (EAA) of sepsis in S19 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 an important role in the infl ammatory response. Serum cholinesterase (butyrylcholinesterase (BChE)) is the major Ach hydrolyzing enzyme in plasma. The role of this enzyme during infl ammation has not yet been fully understood. Here, we describe a correlation between the BChE activity and the early systemic infl ammatory response upon traumatic injury. diffi cult to compare study group with control group as the control group patients were usually not healthy controls. Conclusion Overall the heterogeneity of studies, small sample size and the lack of true healthy controls infl uenced the ability to use the biomarker for prognostication of a septic patient. Furthermore, the lack of healthy control raises the question of redefi ning selection criteria in order to better study septic patients. Methods We measured BChE activity in patients with traumatic injury admitted to the emergency room using a point-of-care-test (POCT) system. In addition, we measured levels of routine infl ammation biomarkers during the initial treatment period. We used the Injury Severity Score to assess the trauma severity. Data were statistically analyzed using the Friedman test. Correlation analysis was performed using Spearman’s rank correlation test. P <0.05 was considered statistically signifi cant. P51 C-reactive protein and hemogram parameters for the nonsepsis SIRS and sepsis: what do they mean? P56 P56 Validation of B·R·A·H·M·S PCT direct, a new sensitive point-of- care testing device for rapid quantifi cation of procalcitonin in emergency department patients: a prospective multinational trial A Kutz1, P Hausfater2, M Oppert3, C Alonso4, C Wissmann4, B Mueller1, P Schuetz1 1Kantonsspital Aarau, Switzerland; 2Hôpital Pitié-Salpêtrière and Univ- Paris 06, Paris, France; 3Klinikum Ernst von Bergmann, Potsdam, Germany; 4BRAHMS GmbH, Hennigsdorf, Germany Critical Care 2015, 19(Suppl 1):P56 (doi: 10.1186/cc14136) P56 Validation of B·R·A·H·M·S PCT direct, a new sensitive point-of- care testing device for rapid quantifi cation of procalcitonin in emergency department patients: a prospective multinational trial A Kutz1, P Hausfater2, M Oppert3, C Alonso4, C Wissmann4, B Mueller1, P Schuetz1 P56 Validation of B·R·A·H·M·S PCT direct, a new sensitive point-of- care testing device for rapid quantifi cation of procalcitonin in emergency department patients: a prospective multinational trial Results We included 87 patients (32 Group A, 25 Group B, 30 Group C). The serum concentration of S1P (mean ± SD) in the control group was 484.6 ± 152.6 μg/l and signifi cantly higher compared with Group A 239.4 ± 61.3 μg/l, Group B 248.6 ± 93.7 μg/l and Group C 141.6 ± 46.3 μg/l. We observed a negative correlation between S1P and SOFA score (Pearson r = –0.45, P <0.001, R2 = 0.2). The median SOFA score in our cohort was 6. We divided the cohort into two groups: SOFA score <6; and SOFA score >6. We tested the sensitivity and specifi city of S1P to indicate disease severity by ROC analysis. In our cohort the area under the curve (AUC) for S1P was 0.77 (CI 0.670 to 0.870) and therefore higher when compared with common markers of infl ammation (PCT, IL-6, CRP with AUC of 0.68 (0.560 to 0.796), 0.68 (0.554 to 0.786) and 0.67 (0.571 to 0.794), resp.).i 1Kantonsspital Aarau, Switzerland; 2Hôpital Pitié-Salpêtrière and Univ- Paris 06, Paris, France; 3Klinikum Ernst von Bergmann, Potsdam, Germany; 4BRAHMS GmbH, Hennigsdorf, Germany Critical Care 2015, 19(Suppl 1):P56 (doi: 10.1186/cc14136) Introduction Procalcitonin (PCT) is increasingly the standard in the emergency department (ED) for the diagnostic and prognostic workup of patients with suspected infections. Recently, B·R·A·H·M·S PCT direct, a new high-sensitive point-of-care test, has been developed for fast PCT measurement on capillary or venous blood samples with a measuring range of 0.1 to 10.0 μg/l. Methods This is a prospective, comparative international study conducted in three European EDs. P56 Consecutive patients with suspicion of bacterial infection were included. Duplicate determination of PCT was performed on two distinct B·R·A·H·M·S PCT direct test devices on capillary (fi ngertip) and venous whole blood (EDTA), and compared with the reference method (B·R·A·H·M·S PCT sensitive Kryptor or Elecsys B·R·A·H·M·S PCT, respectively). The diagnostic accuracy was evaluated by correlation and concordance analyses. Conclusion Our fi ndings suggest that S1P is a novel marker for severity of sepsis with severe sepsis and septic shock being associated with low levels of S1P. Moreover, blood concentrations of S1P might play a key role in sepsis pathophysiology. y gy Acknowledgements MSW and AN are equal contributors. Reference Acknowledgements MSW and AN are equal contributors. Reference 1. Maceyka M, et al. Sphingosine-1-phosphate signaling and its role in disease. Trends Cell Biol. 2012;22:50-60. y y Results A total of 303 patients were included over a 6-month period (60.4% male, median age 65.2 years). The correlation between capillary or venous whole blood and the reference method was excellent: r2 = 0.96 and 0.97, sensitivity 88.1% and 93.0%, specifi city 96.5% and 96.8%, concordance 93% and 95% respectively at a 0.25 μg/l threshold. No signifi cant bias was observed (–0.04 and –0.02 for capillary and venous whole blood) although there were 6.8% and 5.1% outliers, respectively. B·R·A·H·M·S PCT direct had a shorter time to result as compared with the reference method (25 vs. 147 minutes, diff erence 122 minutes, 95% CI = 110 to 134 minutes, P <0.0001). P55 Diagnostic accuracy and clinical relevance of an infl ammatory biomarker panel in early sepsis in adult critical care patients P Bauer, R Kashyap, S League, J Park, D Block, N Baumann, A Algeciras-Schimnich, S Jenkins, C Smith, O Gajic, R Abraham Mayo Clinic, Rochester, MN, USA Critical Care 2015, 19(Suppl 1):P55 (doi: 10.1186/cc14135) Diagnostic accuracy and clinical relevance of an infl ammatory biomarker panel in early sepsis in adult critical care patients Introduction Low awareness, late recognition and delayed treatment of sepsis are still common. CD64 is a marker of the innate immune response upregulated in sepsis. The primary goal of this prospective, double-blind study was to compare the diagnostic accuracy of neutrophil CD64 and other cellular markers, along with C-reactive protein (CRP) and procalcitonin (PCT) levels, in early sepsis. Conclusion This study found a high diagnostic accuracy and a faster time to result of the PCT direct in the ED setting. The B·R·A·H·M·S PCT direct may allow a more widespread use of PCT tests in outpatient clinics and smaller institutions. Methods Adult ICU patients, between 2012 and 2014 were eligible. The eight-color fl ow cytometric biomarker panel included CD64, CD163, HLA DR, CD15 and others. Diagnostic test results were compared with infection as the reference standard and sepsis as the target condition, using receiver operating characteristic curve analyses. Multivariable logistic regression was used to assess the relationship of sets of markers with the probability of sepsis, adjusting for other patient characteristics. Results A total of 219 patients were enrolled, 120 with sepsis, 99 served as controls. APACHE IV (median 70 vs. 57), SOFA (8 vs. 7), ICU (2 vs. 1) and hospital length of stay (6 vs. 4) were higher in the sepsis group. Serum cholinesterase activity as an early indicator of systemic infl ammation l AR Zivkovic, K Schmidt, J Bender, T Brenner, S Hofer Heidelberg University Hospital, Heidelberg, Germany Critical Care 2015, 19(Suppl 1):P52 (doi: 10.1186/cc14132) l AR Zivkovic, K Schmidt, J Bender, T Brenner, S Hofer Heidelberg University Hospital, Heidelberg, Germany Critical Care 2015, 19(Suppl 1):P52 (doi: 10.1186/cc14132) Conclusion The novel fi ndings of our study were that there is an association between serum caspase-3 levels, serum CK-18 levels and mortality in septic patients. There has been reported decreased apoptosis and increased survival in septic rats with the administration of caspase inhibitors; thus, it may be interesting to explore those agents in septic patients. Introduction Early diagnosis of systemic infl ammation, a generalised response to noxious stimuli, is fundamentally important for eff ective and goal-directed therapy. Various infl ammation biomarkers have been used in clinical and experimental practice. However, a defi nitive diagnostic tool for an early detection of systemic infl ammation remains to be identifi ed. Acetylcholine (Ach) has been shown to play Acknowledgements Funded by Grant FIS-PI-14-00220 from Instituto de Salud Carlos III (Madrid, Spain) and co-fi nanced by Fondo Europeo de Desarrollo Regional (FEDER). Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S20 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Mortality was not diff erent. After adjustment for APACHE IV, CRP and PCT, CD64 molecules/neutrophil measure remained a signifi cant predictor of sepsis (OR = 1.852 for one-unit increase on the log scale, 95% CI = 1.083 to 3.168, P = 0.02, AUC = 0.90). See Table 1. P54 Sphingosine-1-phosphate is a new biomarker for severity in human sepsis MS Winkler1, A Nierhaus1, E Mudersbach1, M Holzmann1, A Bauer1, L Robbe1, C Zahrte1, G Daum2, S Kluge1, C Zoellner1 1University Medical Center Eppendorf, Hamburg, Germany; 2University Heart Center, Hamburg, Germany Critical Care 2015, 19(Suppl 1):P54 (doi: 10.1186/cc14134) Table 1 (abstract P55). Area under the curve (AUC) for individual biomarkers Table 1 (abstract P55). Area under the curve (AUC) for individual biomarkers Table 1 (abstract P55). Area under the curve (AUC) for individual biomarkers Table 1 (abstract P55). Area under the curve (AUC) for individual biomarkers Cutoff for Sensitivity Specifi city Measure N AUC sepsis (%) (%) C-reactive protein (mg/l) 208 0.86 43 76.9 76.9 CD64 molecules/neutrophil 196 0.83 1,040.5 76.4 76.7 Procalcitonin (ng/ml) 216 0.82 0.74 73.1 73.2 %CD64+ neutrophils 196 0.81 49.96 74.5 74.4 Conclusion Neutrophil CD64 expression is an accurate predictor of early sepsis. Measure Introduction During sepsis a leading symptom is capillary leakage caused by endothelial damage, followed by multiorgan dysfunction. Sphingosine-1-phosphate (S1P) is a bioactive lipid with multiple functions. Cellular reactions depend on the S1P concentration in the blood and its binding to fi ve specifi c G-protein coupled receptors. S1P-regulated functions include: control of endothelial permeability; lymphocyte migration across microvessels depending on an S1P gradient; and control of vascular tone [1]. This clinical study will address the question of whether S1P blood concentrations are associated with sepsis severity.i p y Methods Following ethical approval we enrolled patients fulfi lling the ACCP/SCCM sepsis criteria into three groups (Group A: sepsis; Group B: severe sepsis; Group C: septic shock). A group of 20 healthy donors served as controls. Serum blood samples, laboratory data and clinical parameters are presented for day 1. The primary outcome variable was serum S1P concentration (μg/l) quantifi ed by mass spectrometry (Agilent®). The SOFA score was used to describe disease severity. Serum procalcitonin level correlates with endotoxin activity in patients with septic shock Serum procalcitonin level correlates with endotoxin activity in patients with septic shock B Adamik, J Smiechowicz, D Jakubczyk, B Adamiczka-Ciszewicz, T Kaiser, A Kübler Medical University, Wroclaw, Poland Critical Care 2015, 19(Suppl 1):P57 (doi: 10.1186/cc14137) B Adamik, J Smiechowicz, D Jakubczyk, B Adamiczka-Ciszewicz, T Kaiser, A Kübler Medical University, Wroclaw, Poland Critical Care 2015, 19(Suppl 1):P57 (doi: 10.1186/cc14137) B Adamik, J Smiechowicz, D Jakubczyk, B Adamiczka-Ciszewicz, T Kaiser, A Kübler Medical University, Wroclaw, Poland Critical Care 2015, 19(Suppl 1):P57 (doi: 10.1186/cc14137) Introduction Endotoxin, a key component on the outer membrane of Gram-negative bacteria, is considered to be the most important toxin Introduction Endotoxin, a key component on the outer membrane of Gram-negative bacteria, is considered to be the most important toxin S21 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Procalcitonin as prognostic marker in severe sepsis of abdominal origin g A Gonzalez-Lisorge1, C Garcia-Palenciano1, G Ercole1, T Sansano-Sanchez1, M Campos Aranda2, F Acosta Villegas1 1Hospital Universitario Virgen de la Arrixaca, Murcia, Spain; 2Universidad de Murcia, Murcia, Spain Critical Care 2015, 19(Suppl 1):P58 (doi: 10.1186/cc14138) Introduction We evaluated the utility of procalcitonin (PCT) as a marker of outcome in severe sepsis of abdominal origin (SSAO). SSAO is one of the most prevalent pathologies in surgical ICUs (sICUs). Mortality from 19 to 70% has been reported. Biomarkers are basic tools for diagnosis, follow-up and outcome of sepsis. One of the most studied in last decades has been PCT. Its levels and kinetics could be useful to evaluate the outcome of septic patients. Conclusion Both biomarkers, procalcitonin and lactate provide diagnostic and prognostic information in ICU patients with sepsis, particularly when looking at biomarker kinetics. An evidence- based protocol incorporating both markers may further improve management of septic patients. p p Methods We studied all patients admitted to a sICU with SSAO, from 2007 to 2008. Data collected were: PCT levels on days 1, 3 and 7, gender, age, APACHE II on admission, positivity of surgical cultures, microorganisms isolated and sepsis origin (community or nosocomial). Results Sixty-nine patients were included. Mortality was 23%. Median age was 64.94 years. Median APACHE II was 16.43 points. At day 1, PCT levels were higher in survivors (S) than in exitus (E) (S: 29.22 ng/ ml vs. E: 14.93 ng/ml, P <0.05). PCT levels were infl uenced by gender (males: 27.74 ng/ml vs. females: 15.04 ng/ml, P <0.05), positive cultures (positive: 25.25 ng/ml vs. negative: 13.49 ng/ml, P <0.05) and isolation of Gram-negative microorganisms (Gram-negative: 27.53 ng/ml vs. Gram-positive: 14.77 ng/ml, P <0.05). Patients with community- acquired sepsis had higher levels of PCT on admission (37.53 ng/ml vs. 13.29 ng/ml, P <0.02). None of these factors had an infl uence on mortality. On day 3 PCT levels where higher in S (S: 20.65 ng/ml vs. E: 16.23 ng/ml, P <0.05). On day 7 PCT levels were higher in E (S: 3.54 ng/ ml vs. E: 12.88 ng/ml, P <0.05). PCT kinetics was diff erent depending on outcome. E patients presented persistently higher levels, whereas PCT in S decreased over time (P <0.05). PCT on day 7 best identifi ed outcome (AUC ROC 0.768). PCT ≥3.5 ng/ml predicted mortality (sensitivity 55%, specifi city 73%). References involved in the development of septic shock, and procalcitonin (PCT) serum concentration has been strongly associated with the severity of sepsis. The eff ect of elevated endotoxin activity (EA) on PCT serum level, organ function and mortality of patients with septic shock was evaluated on the day of admission to the ICU. 1. Charles PE, et al. BMC Infect Dis. 2008;8:38. 2. Rau BM, et al. Arch Surg. 2007;142:134-42. 3. Dahaba AA, et al. Minerva Anestesiol. 2009;75:447-52. 4. Karlsson S, et al. Crit Care. 2010;14:R205. Methods ICU patients with diagnosis of septic shock were consecutively added to the study group within the fi rst 24 hours. Serum PCT level and whole blood EA was immediately measured in all patients on admission (n = 157). Endotoxemia was defi ned as EA >0.4 EAU. Critical Care 2015, 19(Suppl 1):P59 (doi: 10.1186/cc14139) Introduction Blood lactate level is a routinely used biomarker for management of patients in septic conditions in the ICU. There is a lack of clinical research data comparing lactate with novel sepsis biomarkers, such as procalcitonin, in regard to the diagnostic and prognostic potential. Herein, we investigated the diagnostic and prognostic value of initial lactate and procalcitonin levels and their kinetics within the ICU stay for prediction of positive blood cultures and fatal outcome in a well characterized cohort of sepsis patients in a US critical care setting. Methods This is a retrospective, observational cohort study of adult patients with confi rmed severe sepsis or septic shock and with at least one procalcitonin and lactate measurement on admission to the ICU of Morton Plant Hospital (Clearwater, FL, USA). Logistic regression models were calculated to assess the association of biomarkers with blood culture positivity and fatal ICU outcome with area under the curve (AUC) as a measure of discrimination. Conclusion Septic shock with endotoxemia was associated with biochemical and clinical consequences including a higher PCT level, higher frequency of bacteremia, kidney failure, and death. Results The in-hospital mortality rate of the 1,075 included patients (age 68 years) was 23.8% (95% CI = 21.2 to 26.3%) and 18.4% of patients had positive cultures. In regard to the diagnostic value for bacteremic disease, initial procalcitonin had a higher discriminatory value (AUC 0.71) compared with initial lactate levels (AUC 0.52). In regard to prognosis, initial lactate level was the better mortality predictor (AUC 0.69) compared with procalcitonin (AUC 0.55), although both initial levels were signifi cantly lower compared with APACHE III (P >0.05 for both comparisons). When looking at biomarker kinetics, procalcitonin decrease was more strongly associated with fatal outcome compared with initial levels alone (AUC 0.66), but still lower compared with lactate kinetics (AUC 0.73). Procalcitonin or lactate clearance, or both, for risk assessment in patients with sepsis? Results from a prospective US ICU patient cohort i Results Endotoxemia was present in 61% of patients (group 1, n = 95, age 66 (57 to 75)), and in 39% of patients EA was low (group 2, n = 62, age 63 (55 to 76)). Median EA was 0.57 EAU (0.46 to 0.67) in group 1 and 0.27 EAU (0.17 to 0.36) in group 2 (P <0.001). The PCT level was six times higher in group 1 than in group 2 (19.6 ng/ml vs. 3.1 ng/ml, P <0.001) and was correlated with EA (P <0.001, R = 0.5). Median APACHE II score was 23 points (16 to 29) in group 1 and 19 (16 to 25) in group 2; but observed diff erence was not signifi cant. The severity of clinical status estimated by SOFA score was similar in both groups (10 (7 to 13) in group 1 and 11 (8 to 12) in group 2; NS). Forty-six percent of patients in group 1 and 27% in group 2 required renal replacement therapy (P = 0.01). ICU mortality of patients was 41%. The mortality rate was higher in group 1, compared with group 2, and Kaplan–Meier survival analysis of time to death showed statistical signifi cance between the two groups (P = 0.001, log-rank test). A Gram-negative pathogen as the primary source of infection was identifi ed in 64% of patients in group 1 and in 44% in group 2 (P = 0.004); bacteremia was detected in 26% of cases in group 1 and in 12% in group 2 (P = 0.02). Diagnostic value of procalcitonin and IL-6 for sepsis of older patients and other patients in the emergency department SH Woo College of Medicine, The Catholic University of Korea, Incheon St. Mary’s Hospital, Incheon, South Korea College of Medicine, The Catholic University of Korea, Incheon St. Mary’s Hospital, Incheon, South Korea Critical Care 2015, 19(Suppl 1):P60 (doi: 10.1186/cc14140) Introduction Emergency physicians are able to identify severely ill older patients with SIRS in the emergency department (ED). A previous study showed that elevated procalcitonin (PCT) and IL-6 level is a known marker of sepsis and predicts bacteremia and mortality. We assessed the diagnostic value of PCT and IL-6 in older patients and other patients with SIRS and sepsis in the ED. Methods This retrospective cohort study was conducted from January 2013 to December 2013. We enrolled 122 patients with SIRS, 55 were classifi ed as the older age group (>65 years of age). Measurement of serum PCT, IL-6, and white blood cell count was performed on initial admission to the ED. We analyzed these markers in older patients and other patients groups with sepsis. Results Of the 55 patients in the older group 33 (60%) patients had sepsis, and 40 (59.7%) patients of the other group had sepsis. PCT and IL-6 levels were signifi cantly higher in other patients with sepsis (P <0.001, P <0.001). But PCT and IL-6 levels were not higher in old age i Conclusion PCT on day 7 and PCT kinetics can be useful to predict outcome in SSAO. PCT is higher in community-acquired sepsis, when surgical cultures are positive, in Gram-negative isolations and in males. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S22 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 activity; and enhancement of sensitivity to antibiotics. In the case of severe infectious disease, antibiotics are often supplemented with administration of IVIg. patients with sepsis (P = 0.400, P = 0.169). The area under the receiver operating characteristic curve (AUC) for diagnosis of sepsis according to PCT and IL-6 was 0.823, and 0.772 for the other patients group. The diagnostic sensitivity, specifi city, positive predictive value, and negative predictive value of PCT for sepsis in other patients group were 79.5%, 81.5%, 86.1%, and 73.3% respectively, with a PCT cutoff value of 0.18 ng/ml. The diagnostic sensitivity, specifi city, positive predictive value, and negative predictive value of IL-6 for sepsis in other patients group were 67.5%, 81.5%, 84.4%, and 62.9% respectively, with a IL-6 cutoff value of 74.43 pg/ml. Procalcitonin levels in patients undergoing left ventricular assist device implantation Results The patient APACHE II score were 24.9 ± 8.2, the SOFA score 9.1 ± 3.7, and the survival rate after 28 days 83.4%. The values before IVIg administration were: procalcitonin 36.0 ± 463.3 (median 110) ng/ml, presepsin 4,548 ± 4,250 (median 3,337) pg/ml, CRP 15.6 ± 9.6 (median 14.7) mg/dl, and IL-6 13,860 ± 47,299 (median 630) pg/ml. All values were thus elevated. On the days after the completion of IVIg administration and on day 7, the level of almost all mediators (procalcitonin, presepsin, CRP, IL-6) decreased signifi cantly. In patients with suspected severe sepsis and septic shock, presepsin reveals valuable diagnostic capacity to diff erentiate sepsis severity compared with procalcitonin, IL-6, CRP, and WBC. Additionally, presepsin and IL-6 reveal prognostic value with respect to 30 days and 6 months all-cause mortality throughout the fi rst week of ICU treatment [1]. p M Holek, J Kettner, J Franeková, A Jabor M Holek, J Kettner, J Franeková, A Jabor Institute for Clinical and Experimental Medicine, Prague, Czech Republic Critical Care 2015, 19(Suppl 1):P61 (doi: 10.1186/cc14141) Introduction Procalcitonin (PCT) is used for diagnosis of a bacterial infection. Several works described nonspecifi c elevation of PCT after cardiac surgery with cardiopulmonary bypass (CPB) caused by systemic infl ammatory response syndrome (SIRS) with various cutoff values for the presence of the infection (0.47 to 2.47 μg/l). However, in patients undergoing left ventricular assist device (LVAD), implantation data about PCT dynamics are lacking. y gi Conclusion The results of the present study found signifi cant decreases of procalcitonin, presepsin and IL-6 resulting from 3 days of immunoglobulin administration, but evidence is still limited and this needs to be confi rmed in larger studies. Methods PCT levels in 25 patients indicated for LVAD were prospectively assessed before surgery and during the postoperative period (days 1, 2, 14 and 30). Values were compared according to the presence of infectious complications (IC) and non-infectious complications such as acute renal failure (ARF) defi ned as injury by RIFLE criteria or necessity of right ventricular assist device (RVAD). Data were also analyzed using combined endpoints A (ARF, RVAD) and B (IC, ARF, RVAD). Values are presented as median with interquartile range (in μg/l). Diagnostic value of procalcitonin and IL-6 for sepsis of older patients and other patients in the emergency department SH Woo Methods The changes in sepsis markers (procalcitonin, presepsin, interleukin-6, C-reactive protein) followed by IVIg administration were investigated in severe sepsis or septic shock patients. The subjects were 410 patients admitted to an ICU with a diagnosis of severe sepsis or septic shock and from whom informed consent had been obtained for the present study. IVIg was administered intravenously for 3 days (5.0 g/ day) and measurements were undertaken before administration (day 1), on the day after completion of administration (day 4), and on day 7. The items measured were procalcitonin, presepsin, IL-6, and CRP. The eff ect of IVIg administration on these markers was then studied. The IVIg studied was polyethylene glycol-treated human immunoglobulin injection fl uid (2.5 g, 50 ml, one vial). f Conclusion PCT and IL-6 is useful predictive markers for diagnosing sepsis in adult patients (<65 years of age) with SIRS in the ED. But these markers are not useful for identifi cation of sepsis in older patients. Diagnostic and prognostic performance of PATHFAST Presepsin in patients with SIRS and early sepsis E Spanuth1 R Carpio2 R Thomae3 Diagnostic and prognostic performance of PATHFAST Presepsin i patients with SIRS and early sepsis E Spanuth1, R Carpio2, R Thomae3 1DIAneering GmbH, Heidelberg, Germany; 2Hospital Nacional Edgardo Rebagliati Martins-EsSalud, Lima, Peru; 3Mitsubishi Chemical Europe, Düsseldorf, Germany Critical Care 2015, 19(Suppl 1):P63 (doi: 10.1186/cc14143) p , p , 1DIAneering GmbH, Heidelberg, Germany; 2Hospital Nacional Edgardo Rebagliati Martins-EsSalud, Lima, Peru; 3Mitsubishi Chemical Europe, Düsseldorf, Germany Critical Care 2015, 19(Suppl 1):P63 (doi: 10.1186/cc14143) Introduction Presepsin (sCD14-ST) serves as a mediator of the response to infectious agents. First evidence suggested that presepsin may be utilized as a sepsis marker. Introduction Presepsin (sCD14-ST) serves as a mediator of the response to infectious agents. First evidence suggested that presepsin may be utilized as a sepsis marker. Methods Presepsin was determined at presentation (T0), after 8, 24 and 72 hours in 123 individuals admitted with signs of SIRS and/ or infection. Primary endpoint was death within 30 days. Presepsin was determined using the POC assay PATHFAST Presepsin (Mitsubishi Chemical, Japan). Conclusion PCT levels in patients undergoing LVAD implantation rise signifi cantly in the fi rst 2 days after surgery. Interestingly, this elevation is much higher than after routine cardiac surgery with CPB. Recent works suggest that PCT concentrations are aff ected by SIRS caused by contact with a nonphysiological surface. In the case of LVAD this immunological stimulation is long lasting and even more potent with additional RVAD or ARF treated with renal replacement therapy. In accordance with this hypothesis, our data show that the ability of PCT to detect infectious complication in LVAD patients is limited and its concentrations more probably correlate with postoperative complications in general. p Results Mean presepsin concentrations of the patient group at presentation and of the control group were 1,945 and 130 pg/ml, respectively (P <0.0001). Baseline presepsin diff ered highly signifi cant between patients with SIRS, sepsis, severe sepsis and septic shock. Table 1 (abstract P63). Presepsin levels during the course of the disease in survivors and nonsurvivors Table 1 (abstract P63). Presepsin levels during the course of the disease in survivors and nonsurvivors PSEP, median (IQR) (pg/ml) T0 T8 hours T24 hours T72 hours Survivors 590 622 574 533 (345 to 1,396) (367 to 1,912) (336 to 1,610) (324 to 1,246) Nonsurvivors 1,763 1,859 1,731 2,056 (705 to 6,616) (1,001 to 5,744) (809 to 4,586) (811 to 5,540) P value 0.0046 0.0005 0.0003 0.0013 P61 P61 Procalcitonin levels in patients undergoing left ventricular assist device implantation M Holek, J Kettner, J Franeková, A Jabor Institute for Clinical and Experimental Medicine, Prague, Czech Republic Critical Care 2015, 19(Suppl 1):P61 (doi: 10.1186/cc14141) Reference 1. Behnes M, Bertsch T, Lepiorz D, et al. Diagnostic and prognostic utility of soluble CD 14 subtype (presepsin) for severe sepsis and septic shock during the fi rst week of intensive care treatment. Crit Care. 2014;18:507. p q g μg Results PCT levels were low before surgery (0.16, 0.10 to 0.35), increased signifi cantly within the fi rst (5.72, 2.18 to 9.75; P <0.001) and second (5.94, 2.54 to 11.99; P <0.001) day after operation and decreased on the 14th (0.27, 0.11 to 0.74) and 30th (0.10, 0.06 to 0.19) day. There was no signifi cant diff erence in PCT values between patients with or without IC as well as with or without RVAD. ARF increased PCT level signifi cantly only 14 days after LVAD implantation (0.68, 0.37 to 1.65 vs. 0.15, 0.11 to 0.34; P = 0.015). Subjects with endpoint A had signifi cantly higher PCT values on the second (19.53, 5.66 to 63.12 vs. 3.95, 2.33 to 8.85; P = 0.033), 14th (0.55, 0.31 to 1.44 vs. 0.15, 0. to 0.34; P = 0.020) and 30th (0.19, 0.11 to 0.29 vs. 0.08, 0.05 to 0.13; P = 0.016) day after operation. Patients with endpoint B had signifi cantly elevated PCT levels 2 (11.99, 3.23 to 24.16 vs. 3.95, 2.54 to 7.39; P = 0.027) and 14 (0.55, 0.28 to 0.90 vs. 0.13, 0.09 to 0.23; P = 0.005) days after surgery. Changes in procalcitonin and presepsin before and after immunoglobulin administration in septic patients Changes in procalcitonin and presepsin before and after immunoglobulin administration in septic patients T Ikeda, S Ono, T Ueno, H Tanaka, S Suda Hachiouji Medical Center, Tokyo Medical University, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P62 (doi: 10.1186/cc14142) Examination of the diagnostic accuracy of sepsis using procalcitonin, presepsin and CD64 for patients with or without acute kidney injury Y Nakamura, H Ishikura, J Tanaka, T Nishida, M Mizunuma, D Ohta, N Matsumoto, A Murai Fukuoka University Hospital, Fukuoka, Japan Critical Care 2015, 19(Suppl 1):P64 (doi: 10.1186/cc14144) g p p Methods We analyzed data from 14 trials and 4,211 ARI patients to study associations of admission PCT levels and setting specifi c treatment failure and mortality alone at 30 days. We used multivariable hierarchical logistic regression and conducted sensitivity analyses stratifi ed by clinical settings and ARI diagnoses to assess the results’ consistency. Introduction At the moment, we have few reports about the diagnostic accuracy of procalcitonin (PCT), presepsin (P-SEP) and CD64 as a diagnostic marker of sepsis for patients with acute kidney injury (AKI). This study aimed to clarify which is a more useful diagnostic biomarker for sepsis using PCT, P-SEP and CD64 with or without AKI in ICU patients. Methods This study was a single-center observational retrospective study. Blood samples were collected from 334 patients admitted to our ICU between April 2013 and March 2014. Then, we classifi ed the patients with or without AKI. In this study, we adopted RIFLE criteria for AKI diagnosis. After that, the patients in each group were classifi ed into the sepsis group and the nonsepsis group. We measured PCT, P-SEP and CD64 levels at the time of ICU admission and subsequently investigated the diagnostic accuracy of these biomarkers for detecting sepsis. y Results Overall, 864 patients (20.5%) experienced treatment failure and 252 (6.0%) died. The ability of PCT to diff erentiate patients with and without treatment failure was highest in the emergency department setting (treatment failure; area under the curve (AUC): 0.64 (95% confi dence interval (CI): 0.61, 0.67), adjusted odds ratio (OR): 1.85 (95% CI: 1.61, 2.12), P <0.001 – mortality; AUC: 0.67 (95% CI: 0.63, 0.71), adjusted OR: 1.82 (95% CI: 1.45, 2.29), P <0.001). In lower respiratory tract infections, PCT was a good predictor of identifying patients at risk for mortality (AUC: 0.71 (95% CI: 0.68, 0.74), adjusted OR: 2.13 (95% CI: 1.82, 2.49), P <0.001). In primary care and ICU patients no signifi cant associations of initial PCT levels and outcome were found. See Figure 1. Conclusion Admission PCT levels are associated with setting specifi c treatment failure and provide most prognostic information in ARI in the emergency department setting. p Results In this study we met 225 patients with non-AKI and 109 patients with AKI. Examination of the diagnostic accuracy of sepsis using procalcitonin, presepsin and CD64 for patients with or without acute kidney injury We conducted ROC analysis for diagnosing sepsis. In non-AKI patients, the AUC of PCT, P-SEP and CD64 were 0.904 (95% CI: 0.824 to 0.950), 0.892 (95% CI: 0.794 to 0.947) and 0.917 (95% CI: 0.842 to 0.958), respectively. In AKI patients, the AUC were 0.933 (95% CI: 0.859 to 0.970), 0.755 (95% CI: 0.642 to 0.840) and 0.905 (95% CI: 0.803 to 0.957), respectively. P65 Prognostic value of procalcitonin in respiratory tract infections across clinical settings A Kutz, B Mueller, P Schuetz, for the IPD Study Group Kantonsspital Aarau, Switzerland Critical Care 2015, 19(Suppl 1):P65 (doi: 10.1186/cc14145) P65 Prognostic value of procalcitonin in respiratory tract infections across clinical settings A Kutz, B Mueller, P Schuetz, for the IPD Study Group Kantonsspital Aarau, Switzerland Critical Care 2015, 19(Suppl 1):P65 (doi: 10.1186/cc14145) P64 Examination of the diagnostic accuracy of sepsis using procalcitonin, presepsin and CD64 for patients with or without acute kidney injury Y Nakamura, H Ishikura, J Tanaka, T Nishida, M Mizunuma, D Ohta, N Matsumoto, A Murai Fukuoka University Hospital, Fukuoka, Japan Critical Care 2015, 19(Suppl 1):P64 (doi: 10.1186/cc14144) Introduction Whether the infl ammatory biomarker procalcitonin (PCT) provides prognostic information across clinical settings and diff erent acute respiratory tract infections (ARI) is poorly understood. Herein, we investigated the prognostic value of admission PCT levels to predict adverse clinical outcome in a large ARI population. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion CD64 and PCT were a useful biomarker for detecting sepsis for ICU patients with AKI. Conclusion CD64 and PCT were a useful biomarker for detecting sepsis for ICU patients with AKI. Twenty-four patients died during 30 days. The 30-day mortality was 19.5% in total, ranging from 10 to 32% between the fi rst and the fourth quartile of presepsin concentration. Nonsurvivors showed high presepsin values with increasing tendency during the course of the disease while in surviving patients this tendency was decreasing. See Table 1. Conclusion Presepsin demonstrated a strong relationship with disease severity and outcome. Presepsin provided reliable discrimination between SIRS and sepsis as well as prognosis and early prediction of 30- day mortality already at admission. Presepsin showed close association with the course of the disease. Changes in procalcitonin and presepsin before and after immunoglobulin administration in septic patients T Ikeda, S Ono, T Ueno, H Tanaka, S Suda Hachiouji Medical Center, Tokyo Medical University, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P62 (doi: 10.1186/cc14142) g p T Ikeda, S Ono, T Ueno, H Tanaka, S Suda T Ikeda, S Ono, T Ueno, H Tanaka, S Suda Hachiouji Medical Center, Tokyo Medical University, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P62 (doi: 10.1186/cc14142) T Ikeda, S Ono, T Ueno, H Tanaka, S Suda Hachiouji Medical Center, Tokyo Medical University, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P62 (doi: 10.1186/cc14142) Hachiouji Medical Center, Tokyo Medical University, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P62 (doi: 10.1186/cc14142) Introduction The potentially envisaged actions of intravenous immunoglobulin (IVIg) on severe infectious disease include: virus or toxin neutralizing action; opsonic eff ect; complement bacteriolytic S23 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P68 Diff erential diagnosis of bacterial from candidal bloodstream infections in ICU patients: the role of procalcitonin Introduction The objective of this study was to evaluate the neutrophil to lymphocyte count ratio (NLCR) versus procalcitonin (PCT) in diagnosing bacteremia in the emergency department (ED). The NLCR is a biomarker that appears early in the course of the acute infl ammatory response and reaches maximum levels within 4 hours after onset. An elevated NLCR has been shown to correlate to bacteremia at a cutoff level of >10 [1]. It is rapidly analyzed on a full blood cell count at low cost. The lowest recommended cutoff level for PCT is <0.5 ng/ml. E Angelopoulos1, E Perivolioti1, S Kokkoris1, E Douka1, E Barbouti1, P Temperekidis1, C Vrettou1, C Psachoulia1, G Poulakou2, S Zakynthinos1, C Routsi1 1Evangelismos Hospital, Athens, Greece; 2Attikon Hospital, Athens, Greece Critical Care 2015, 19(Suppl 1):P68 (doi: 10.1186/cc14148) Introduction Early diff erentiation of bacterial from candidal bloodstream infections (BSIs) in the presence of sepsis or septic shock is crucial because of the need for appropriate treatment initiation. Clinical data, although limited, suggest a role for procalcitonin (PCT) [1-3]. The aim of this study was to investigate a possible association between the etiology of BSIs and the serum PCT levels. f g Methods We randomly chose 425 patients from a 9-month epidemiologic study on the incidence of community-onset severe sepsis and septic shock in western Sweden 2011 to 2012. In total, 207 had severe sepsis and 218 had sepsis, mean age 71.2 versus 64.2 years; males 51%. Sampling was made on arrival in the ED. The NLCR was analyzed immediately, PCT later on plasma frozen at –80°C. A total of 122/425 patients had bacteremia, 72 (35%) in the severe sepsis group versus 50 (23%) in the sepsis group. Most common fi ndings were Escherichia coli (n = 33), Staphylococcus aureus (n = 24), streptococcal spp. (n = 33) and other enterobacteriacae spp. (n = 17).i y Methods ICU patients with clinical and laboratory signs of sepsis or septic shock, with documented BSIs and with both serum PCT and CRP measurements on the day of the positive blood sample (±1 day), were included. Illness severity was assessed by SOFA score on both admission and BSI day. Demographic, clinical, and laboratory data including PCT and CRP levels, as well as the white blood cell (WBC) count on the day of the BSI were recorded. PCT was measured by an electrochemiluminescence analyzer and CRP by the tholosimetric method (Roche, Switzerland). References Introduction The purpose of the study was to assess the prognosis value of pro-adrenomedullin (pADM), C-reactive protein (CRP) and procalcitonin (PCT), lactate (LT), albumin (ALB), cholesterol (CHOL), white blood cell (WBC) and severity score in patients with severe sepsis or septic shock. 1. Martini A, et al. J Infect. 2010;60:425. 2. Petrikkos GL, et al. Eur J Clin Microbiol Infect Dis. 2005;24:272. 3. Charles PE, et al. Intensive Care Med. 2006;32:1577. P68 Diff erential diagnosis of bacterial from candidal bloodstream infections in ICU patients: the role of procalcitonin Results The NLCR shows signifi cantly higher sensitivity than PCT at recommended cutoff levels for bacteremia. Interestingly, this is true even for all 207 patients with severe sepsis, irrespective of bacteremia or not. Sensitivity fi gures with 95% confi dence interval: bacteremia (n = 122): NLCR 80% (0.73 to 0.87) versus PCT 66% (0.58 to 0.75), P = 0.01; severe sepsis with bacteremia (n = 72): NLCR 85% (0.77 to 0.93) versus PCT 70% (0.59 to 0.81), P = 0.03; and severe sepsis but no bacteremia (n = 135): NLCR 71% (0.65 to 0.77) versus PCT 61% (0.54 to 0.68), P = 0.03. Conclusion The NLCR can be used in the ED as a biomarker for bacteremia as well as severe sepsis and seems to perform as well as or even better than PCT in this setting. Rapid response, low cost and no need for extra sampling make it useful as a screening tool. R f ( , ) Results A total of 64 ICU patients (mean age 58 ± 18 years, 39 males) with BSIs were included. SOFA sore was 9 ± 4 on ICU admission and 8 ± 4 on the day of BSI. In 30 of these patients Candida spp. were isolated in blood culture (candidemia group) whereas the remaining 34 had a bacterial etiology of BSI (bacteremia group). Serum PCT concentrations remained within normal ranges in most patients with candidemia whereas a wide range was observed in patients with bacteremia. Mean values of PCT and CRP levels were higher in the bacterial than in the candidemia BSI group: 18.5 ± 33.2 versus 0.73 ± 1.40 ng/ml, P <0.001 and 17.7 ± 10.3 versus 8.9 ± 8.0 mg/dl, P = 0.001, respectively. There was a signifi cant diff erence in WBC count between the two groups: 19,460 ± 10.174 versus 11,000 ± 5,440, P <0.001 for the bacteremia and candidemia BSI group, respectively. A ROC curve analysis of the predictive ability of PCT showed an AUC of 0.79 (P <0.001). When a cutoff point of 0.40 ng/ml was selected using Youden’s J statistic, a low value of PCT had in our sample a negative predictive value of 0.76 and a likelihood ratio (negative) of 0.30. 1. de Jager et al. Crit Care. 2010;14:R192. 1. de Jager et al. Crit Care. 2010;14:R192. Prognosis value of biomarkers in severe sepsis and septic shock MV De La Torre-Prados1, A García-de la Torre2, R Escobar-Conesa1, Conclusion A low serum PCT value could be considered as a diagnostic marker in distinguishing between BSIs of candidal or bacterial origin in ICU patients with varying severity of sepsis. R f g y Reference P66 Neutrophil to lymphocyte count ratio performs better than procalcitonin as a biomarker for bacteremia and severe sepsis in the emergency department LL Ljungström1, D Karlsson1, A Pernestig2, R Andersson3, G Jacobsson1 1Skaraborg Hospital Skövde, Sweden; 2School of Biosciences, University of Skövde, Sweden; 3Institute of Biosciences, Sahlgrenska Academy at the University of Gothenburg, Sweden Critical Care 2015, 19(Suppl 1):P66 (doi: 10.1186/cc14146) P68f P68 Diff erential diagnosis of bacterial from candidal bloodstream infections in ICU patients: the role of procalcitonin E Angelopoulos1, E Perivolioti1, S Kokkoris1, E Douka1, E Barbouti1, P Temperekidis1, C Vrettou1, C Psachoulia1, G Poulakou2, S Zakynthinos1, C Routsi1 1Evangelismos Hospital, Athens, Greece; 2Attikon Hospital, Athens, Greece Critical Care 2015, 19(Suppl 1):P68 (doi: 10.1186/cc14148) P68 Diff erential diagnosis of bacterial from candidal bloodstream infections in ICU patients: the role of procalcitonin E Angelopoulos1, E Perivolioti1, S Kokkoris1, E Douka1, E Barbouti1, P Temperekidis1, C Vrettou1, C Psachoulia1, G Poulakou2, S Zakynthinos1, C Routsi1 1Evangelismos Hospital, Athens, Greece; 2Attikon Hospital, Athens, Greece Critical Care 2015, 19(Suppl 1):P68 (doi: 10.1186/cc14148) g y Reference . Schuetz P, Briel M, Christ-Crain M, et al. Procalcitonin to guide initiation and duration of antibiotic treatment in acute respiratory infections: an individual patient data meta-analysis. Clin Infect Dis. 2012;55:651-62. Figure 1 (abstract P65). Multivariate regression analysis for estimation of predictive value of PCT levels on admission stratifi ed by adverse events and mortality in diff erent settings and diagnoses. Treatment failure, ~mortality. ARI, acute respiratory tract infection; ECOPD, exacerbated chronic obstructive pulmonary disease; CAP, community-acquired pneumonia; VAP, ventilator-associated pneumonia; Adj., adjusted; OR, odds ratio; CI, confi dence interval. Figure 1 (abstract P65). Multivariate regression analysis for estimation of predictive value of PCT levels on admission stratifi ed by adverse events and mortality in diff erent settings and diagnoses. Treatment failure, ~mortality. ARI, acute respiratory tract infection; ECOPD, exacerbated chronic obstructive pulmonary disease; CAP, community-acquired pneumonia; VAP, ventilator-associated pneumonia; Adj., adjusted; OR, odds ratio; CI, confi dence interval. S24 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 diff erences were signifi cant in pADM (2.46 (1.21 to 4.89) vs. 1.68 (0.94 to 3.32) nmol/l; P = 0.012), LT (2.6 (1.6 to 3.94) vs. 1.6 (1.2 to 2.43) mmol/l; P <0.001) and ALB (2 (1.55 to 2.38) vs. 2.22 (1.96 to 2.7) g/dl; P = 0.001). Conclusion The protein pADM, LT and ALB showed good prognosis accuracy when measured on admission of septic patients to the ICU. diff erences were signifi cant in pADM (2.46 (1.21 to 4.89) vs. 1.68 (0.94 to 3.32) nmol/l; P = 0.012), LT (2.6 (1.6 to 3.94) vs. 1.6 (1.2 to 2.43) mmol/l; P <0.001) and ALB (2 (1.55 to 2.38) vs. 2.22 (1.96 to 2.7) g/dl; P = 0.001). Conclusion The protein pADM, LT and ALB showed good prognosis accuracy when measured on admission of septic patients to the ICU. P67 Prognosis value of biomarkers in severe sepsis and septic shock MV De La Torre-Prados1, A García-de la Torre2, R Escobar-Conesa1, J Perez-Vacas1, A Puerto-Morlán1, E Cámara-Sola1, A García-Alcántara1 1Hospital Virgen de la Victoria, Málaga, Spain; 2Puerto Real University Hospital, Puerto Real, Cádiz, Spain Critical Care 2015, 19(Suppl 1):P67 (doi: 10.1186/cc14147) P69 Methods A prospective, observational study in adult patients with severe sepsis or septic shock in a polyvalent ICU. Demographics, severity scores (APACHE II and SOFA) and all of the biomarkers were studied within 24 hours from septic shock onset. Descriptive and comparative statistical analysis was performed using the statistical software packages SPSS v.15 and MedCalc® 9.2.1.0. P69 Performance of the beta-glucan test and a dynamic prediction rule to identify patients in the ICU at high risk to develop candidemia SA Nouer1, AL Colombo2, P Esteves2, T Guimaraes3, F Scapinello4, B Grassi de Miranda3, F Queiroz-Telles4, M Nucci1 1Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil; 2Federal University of São Paulo, Brazil; 3Hospital Servidor Publico Estadual de São Paulo, Brazil; 4Federal University of Parana, Curitiba, Brazil Critical Care 2015, 19(Suppl 1):P69 (doi: 10.1186/cc14149) Performance of the beta-glucan test and a dynamic prediction rule to identify patients in the ICU at high risk to develop candidemia SA Nouer1, AL Colombo2, P Esteves2, T Guimaraes3, F Scapinello4, B Grassi de Miranda3, F Queiroz-Telles4, M Nucci1 1Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil; 2Federal University of São Paulo, Brazil; 3Hospital Servidor Publico Estadual de São Paulo, Brazil; 4Federal University of Parana, Curitiba, Brazil Critical Care 2015, 19(Suppl 1):P69 (doi: 10.1186/cc14149) Performance of the beta-glucan test and a dynamic prediction rule to identify patients in the ICU at high risk to develop candidemia SA Nouer1, AL Colombo2, P Esteves2, T Guimaraes3, F Scapinello4, B Grassi de Miranda3, F Queiroz-Telles4, M Nucci1 1Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil; 2Federal University of São Paulo, Brazil; 3Hospital Servidor Publico Estadual de São Paulo, Brazil; 4Federal University of Parana, Curitiba, Brazil Critical Care 2015, 19(Suppl 1):P69 (doi: 10.1186/cc14149) Estimating the duration of a central venous catheter at time of insertion g g Results A total of 2,148 patients were screened, and 85 (4%) fulfi lled entry criteria. The incidence of candidemia in these 85 patients was 8.2%, compared with 0.5% in the remaining 2,063 patients (relative risk 16.9%, 95% confi dence interval (CI) = 6.63 to 43.55). Baseline BDG was positive in 74 patients (87%), with a median number of positive tests of 3 (range 1 to 3) and a median value of 523 pg/ml (range 83 to 6,860). All seven patients with candidemia had positive baseline BDG (median value 523 pg/ml, range 203 to 3,660). The best cutoff of baseline BDG for the diagnosis of candidemia was 522 pg/ml (area under the ROC curve 0.883, 95% CI = 0.769 to 0.997), with sensitivity and specifi city of 86% and 88%, respectively. The cutoff value of 80 pg/ml had sensitivity and specifi city of 73% and 27%, respectively.f MJ Holmberg1, LW Andersen1, A Graver1, SB Wright1, D Yassa1, MD Howell2, MW Donnino1, MN Cocchi1 1Beth Israel Deaconess Medical Center, Boston, MA, USA; 2University of Chicago, IL, USA Introduction The aim of this study was to investigate whether clinicians can estimate, at the time of insertion, the length of time a central venous catheter (CVC) will remain in place, and to identify clinical variables which may predict CVC duration. CVC-related bloodstream infection is a known complication among critically ill patients. As infection rates may increase with duration of catheterization, more expensive antimicrobial-coated catheters may be used in patients with anticipated long duration of CVC use. i Conclusion This dynamic prediction rule was able to diff erentiate a group of ICU patients at high risk to develop candidemia, with a relative risk of 16.9. BDG is frequently positive in ICU patients. A cutoff value of 522 pg/ml was able to discriminate between candidemic and noncandidemic patients. A revision of the cutoff value for BDG in the ICU is needed. p g Methods We conducted a single-center, prospective study from January 2012 to November 2012. Clinicians prospectively estimated the anticipated duration of CVC at the time of line placement in an electronic procedure note. We collected demographics, past medical history, type of ICU, vital signs, laboratory values, SOFA score, mechanical ventilation and use of vasopressors at the time of placement. Continuous variables were compared with the Wilcoxon rank-sum test and categorical variables with the Fisher’s exact test. Low serum iron as a risk factor for ICU-acquired bacteremia: study of a large cohort database y g S Fernandes1, D Bruno2, J Morgado3, C Calle4, C Ferreira5 1Centro Hospitalar Lisboa Norte CHLN, Lisbon, Portugal; 2Hospital Fernando Fonseca, Lisbon, Portugal; 3Centro Hospitalar de Lisboa Central, Lisbon, Portugal; 4Instituto Português de Oncologia, Lisbon, Portugal; 5National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal Critical Care 2015, 19(Suppl 1):P70 (doi: 10.1186/cc14150) Results We enrolled 150 patients; median age was 65 (IQR: 52 to 74), 63 (42%) were female and mortality was 22%. Median time from CVC placement to removal was 5 (IQR: 3 to 8) days. The correlation between estimated CVC time and actual time was low (r = 0.36, P <0.001). Forty- eight (32%) patients had a long CVC duration. Clinician estimate had 46% sensitivity and 76% specifi city for predicting long duration of CVC. Of 30 variables tested, only temperature at the time of insertion was signifi cantly associated with long duration (OR: 1.30, 95% CI: 1.04 to 1.63, P = 0.02). The AUC for this model was 0.59 (95% CI: 0.49 to 0.69). Results We enrolled 150 patients; median age was 65 (IQR: 52 to 74), 63 (42%) were female and mortality was 22%. Median time from CVC placement to removal was 5 (IQR: 3 to 8) days. The correlation between estimated CVC time and actual time was low (r = 0.36, P <0.001). Forty- eight (32%) patients had a long CVC duration. Clinician estimate had 46% sensitivity and 76% specifi city for predicting long duration of CVC. Of 30 variables tested, only temperature at the time of insertion was signifi cantly associated with long duration (OR: 1.30, 95% CI: 1.04 to 1.63, P = 0.02). The AUC for this model was 0.59 (95% CI: 0.49 to 0.69). Conclusion Our results suggest a low correlation between clinician prediction at time of insertion and actual duration of CVC. We did not fi nd any good predictors of long duration of CVC. Given our relatively low sample size, we may have been underpowered. It may not be feasible to identify patients at the time of insertion who may benefi t from antimicrobial-coated catheters. Introduction Bloodstream infections in the ICU are a major trigger of morbidity and mortality. Several risk factors for bacteremia have been previously identifi ed, such as presence of a central venous catheter or invasive ventilation [1,2]. Iron is a key element for bacteria growth, and its metabolism is extensively altered by infl ammation. References following: dialysis, surgery, pancreatitis, and receipt of corticosteroids, other immunosuppressive agents or parenteral nutrition. Diff erent from the original description of the score which considered only the fi rst 7 days of ICU stay, we selected patients who fulfi lled these criteria at any time during the ICU stay. Once a patient fulfi lled these criteria, AFT (anidulafungin 200 mg followed by 100 mg daily) was initiated provided that the patients also presented with any of the following: fever, hypothermia, hypotension, leukocytosis, acidosis or elevated C-reactive protein. Blood cultures (days 1 to 2) and baseline serum BDG (days 1 to 3) were performed. Patients with candidemia were treated for ≥14 days, those without candidemia but ≥1 positive BDG (≥80 pg/ml) received AFT for ≥10 days, and patients with negative blood cultures and negative BDG discontinued anidulafungin.i 1. Tabah A, Koulenti D, Laupland K, et al. Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: the EUROBACT International Cohort Study. Intensive Care Med. 2012;38:1930-45. 2. Prowle JR, Echeverri JE, Ligabo EV, et al. Acquired bloodstream infection in the intensive care unit: incidence and attributable mortality. Crit Care. 2011;15:R100. Performance of the beta-glucan test and a dynamic prediction rule to identify patients in the ICU at high risk to develop candidemia SA N 1 AL C l b 2 P E t 2 T G i 3 F S i ll 4 Performance of the beta-glucan test and a dynamic prediction rule to identify patients in the ICU at high risk to develop candidemia SA N 1 AL C l b 2 P E 2 T G i 3 F S i ll 4 SA Nouer , AL Colombo , P Esteves , T Guimaraes , F Scapinello , B Grassi de Miranda3, F Queiroz-Telles4, M Nucci1 1Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil; 2Federal University of São Paulo, Brazil; 3Hospital Servidor Publico Estadual de São Paulo, Brazil; 4Federal University of Parana, Curitiba, Brazil Critical Care 2015, 19(Suppl 1):P69 (doi: 10.1186/cc14149) Results We analyzed 246 consecutive episodes of severe sepsis (38%) or septic shock (62%). The 28-day mortality was 36.2%. The profi le of dead patients had a signifi cantly higher average age (65 (IQR: 75.5 to 57.5) vs. 63 (47 to 72); P <0.06), APACHE II (27 (22 to 30) vs. 23 (18 to 27); P <0.001) and SOFA (11 (9 to 12.75) vs. 9 (7 to 10); P <0.001). CRP (168.4 (106 to 285) vs. 165.4 (87.8 to 275) mg/dl; P = NS), PCT (6.5 (0.94 to 23.8) vs. 5.8 (0.97 to 19.59) ng/ml; P = NS) and WBC 14.7 (9.5 to 21.4) vs. 12.9 (5.5 to 17.5); P = NS) were increased in those who died, but CHOL (102 (75 to 134) vs. 108 (86 to 141) mg/dl; P = NS) had lower values. These Introduction Early initiation of antifungal therapy (AFT) improves the outcome in candidemic patients, but empiric AFT is not considered the standard of care. Methods We used a scoring system based on the presence of a central venous catheter and receipt of antibiotics, plus at least two of the S25 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P70 P70 Low serum iron as a risk factor for ICU-acquired bacteremia: study of a large cohort database S Fernandes1, D Bruno2, J Morgado3, C Calle4, C Ferreira5 1Centro Hospitalar Lisboa Norte CHLN, Lisbon, Portugal; 2Hospital Fernando Fonseca, Lisbon, Portugal; 3Centro Hospitalar de Lisboa Central, Lisbon, Portugal; 4Instituto Português de Oncologia, Lisbon, Portugal; 5National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal Critical Care 2015, 19(Suppl 1):P70 (doi: 10.1186/cc14150) Estimating the duration of a central venous catheter at time of insertion Pearson’s correlation coeffi cient was used to assess the correlation between estimated CVC time and actual time. Duration of CVC use was dichotomized into long (≥7 days) or short (<7 days), based on previous literature, and sensitivity and specifi city for predicting long duration was calculated. We performed a logistic regression analysis to identify variables associated with long CVC duration and calculated the area under the ROC curve (AUC). P72 Preventing catheter-related infections in ICUs: comparing catheter care techniques Preventing catheter-related infections in ICUs: comparing catheter care techniques S Ozden, R Iscimen, H Akalin, N Kelebek Girgin, F Kahveci, M Sinirtas Uludag University Faculty of Medicine, Bursa, Turkey Critical Care 2015, 19(Suppl 1):P72 (doi: 10.1186/cc14152) Low serum iron as a risk factor for ICU-acquired bacteremia: study of a large cohort database We aim to determine whether iron defi ciency is a risk or protective factor for bacteremia in the ICU. Conclusion Our results suggest a low correlation between clinician prediction at time of insertion and actual duration of CVC. We did not fi nd any good predictors of long duration of CVC. Given our relatively low sample size, we may have been underpowered. It may not be feasible to identify patients at the time of insertion who may benefi t from antimicrobial-coated catheters. Methods We performed a retrospective analysis of patients included in the MIMIC-II database, an ICU database that collected data from patients admitted to the medical, surgical, coronary and cardiac surgery ICU of Boston’s Beth Israel Deaconess Medical Center during a period of 7 years. We performed logistic regression models to assess the association between iron and bloodstream infection. Results We included 3,980 patients, 2,988 with low serum iron (<60 ng/ ml) and 992 with normal/high serum iron (≥60 ng/ml). During their fi rst stay in the ICU, 351 (8.82%) patients developed bloodstream infections. Low serum iron was associated with increased odds of bloodstream infection (OR: 1.37; 95% CI: 1.04 to 1.80). After adjusting for age, gender, Simplifi ed Acute Physiology Score, presence of central venous catheter, ICU type, transfusions performed before iron measured, neoplastic disease, diabetes mellitus, hepatic disease, congestive heart failure and ferritin levels, low levels of iron were still associated with an increased odds of bacteremia (OR: 1.41; 95% CI: 1.03 to 1.9). In contrast, low serum iron was associated with a decreased risk of death in the hospital (adj OR: 0.73, CI: 0.57 to 0.95). Catheter-associated bloodstream infections in an ICU of a university hospital in Wroclaw, Poland: an international nosocomial infection control consortium’s fi ndings i g W Duszynska1, VD Rosenthal2, A Litwin1, E Woznica1, A Kubler1 1University Hospital, Wroclaw, Poland; 2International Nosocomial Infection Control Consortium, Buenos Aires, Argentina Critical Care 2015, 19(Suppl 1):P74 (doi: 10.1186/cc14154) i g W Duszynska1, VD Rosenthal2, A Litwin1, E Woznica1, A Kubler1 1University Hospital, Wroclaw, Poland; 2International Nosocomial Infection Control Consortium, Buenos Aires, Argentina Critical Care 2015, 19(Suppl 1):P74 (doi: 10.1186/cc14154) Introduction Catheter-associated bloodstream infections are serious but potentially possible to reduce complication of treatment in the ICU. The aim of the study was to evaluate the frequency and etiology of central line-associated bloodstream infections (CLA-BSI) in ICU patients according to the International Nosocomial Infection Control Consortium (INICC) project. y Conclusion Continued education is important in preventing CRBSIs. Maximum precautions must be taken. Usage of antiseptic solutions with clorhexidine and chlorhexidine gluconate impregnated dressing decreased insertion side infections and usage of silver-coated needleless connectors reduced microorganism entry through the catheter lumen and provided a severe decrease in infection ratio. Reference p j Methods A prospective, observational study was conducted in the 20-bed ICU of the University Hospital in Wroclaw from January 2011 to November 2014. CLA-BSI were diagnosed and evaluated according to protocols standardized by the INICC. The density of CLA-BSI/1,000 central line-days, the incidence index/100 admissions to the hospital, the central line utilization ratio (CL-UR) as well as the microbiological profi le of CLA-BSI were evaluated. The results were compared with our earlier published data and with the fi ndings of international reports. Results Among 1,746 ICU patients, CLA-BSI were diagnosed in 69 cases. The incidence index was 3.88/100 admissions to the ICU. CLA-BSI were diagnosed in 18% of the overall number (381) of device-associated healthcare-associated infections. Central line was used in 91.41 ± 4.4% patients during 19,819 patient-days and 18,155 central line-days. The median density of CLA-BSI/1,000 central line-days was 3.88/3.77/3.36 and 0.0 accordingly in years 2011/2012/2013 and 2014 (from January to November). The main pathogens of CLA-BSI were CN staphylococci (22%), Staphylococcus aureus (21%), and Enterobacteriaceae (29%). In this study, the density of CLA-BSI was about 50% lower (2.75 (2.0 to 6.06)) than in our previous study and in the INICC’s report (2014), but higher than in the CDC’s NHSN (2012) report. j Methods A prospective, observational study was conducted in the 20-bed ICU of the University Hospital in Wroclaw from January 2011 to November 2014. P73 Results Among 1,746 ICU patients, CLA-BSI were diagnosed in 69 cases. The incidence index was 3.88/100 admissions to the ICU. CLA-BSI were diagnosed in 18% of the overall number (381) of device-associated healthcare-associated infections. Central line was used in 91.41 ± 4.4% patients during 19,819 patient-days and 18,155 central line-days. The median density of CLA-BSI/1,000 central line-days was 3.88/3.77/3.36 and 0.0 accordingly in years 2011/2012/2013 and 2014 (from January to November). The main pathogens of CLA-BSI were CN staphylococci (22%), Staphylococcus aureus (21%), and Enterobacteriaceae (29%). In this study, the density of CLA-BSI was about 50% lower (2.75 (2.0 to 6.06)) than in our previous study and in the INICC’s report (2014), but higher than in the CDC’s NHSN (2012) report. Comparison of three cutaneous antiseptic solutions for the prevention of catheter colonization in an ICU for adult patients: a multicenter prospective randomized controlled trial H Yasuda1, M Sanui2, T Komuro2, J Hatakeyama3, S Matsukubo4, S Kawano5, H Yamamoto6, K Andoh7, R Seo8, N Shime9, E Noda10, N Saito11 1Japanese Red Cross Musashino Hospital, Tokyo, Japan; 2Saitama Medical Center Jichi Medical University, Saitama, Japan; 3YokohamaCity Minato Red Cross Hospital, Kanagawa, Japan; 4Kurashiki Central Hospital, Okayama, Japan; 5The Jikei University School of Medicine, Tokyo, Japan; 6Toyonaka Municipal Hospital, Osaka, Japan; 7Sendai City Hospital, Miyagi, Japan; 8Kobe City Medical Center General Hospital, Hyogo, Japan; 9National Hospital Organization Kyoto Medical Center, Kyoto, Japan; 10Kyushu University Hospital, Fukuoka, Japan; 11Nippon Medical School Chiba Hokusoh Hospital, Tiba, Japan Conclusion The implementation of the infection control program and preventive interventions for patients with central venous catheters improved the safety and quality of healthcare in the ICU by reducing CLA-BSI rate. Critical Care 2015, 19(Suppl 1):P73 (doi: 10.1186/cc14153) Introduction The current CDC guideline for the prevention of intravascular catheter-related infections recommends skin preparation with a greater than 0.5% chlorhexidine with alcohol solution before central venous catheter (CVC) or peripheral arterial catheter (AC) placement. However, few studies investigated the superiority of 1% alcoholic chlorhexidine gluconate (1% CHG) over either 0.5% alcoholic chlorhexidine gluconate (0.5% CHG) or 10% aqueous povidone iodine (10% PVI) for the prevention of catheter colonization. The aim of this study is to compare the eff ectiveness of three skin antiseptic solutions for the prevention of intravascular catheter colonization. Reference 1. Kübler A, Duszyñska W, Rosenthal VD, et al. Device-associated infection rates and extra length of stay in an intensive care unit of a university hospital in Wroclaw, Poland: International Nosocomial Infection Control Consortium’s (INICC) fi ndings. J Crit Care. 2012;27:105.e5-10. Catheter-associated bloodstream infections in an ICU of a university hospital in Wroclaw, Poland: an international nosocomial infection control consortium’s fi ndings CLA-BSI were diagnosed and evaluated according to protocols standardized by the INICC. The density of CLA-BSI/1,000 central line-days, the incidence index/100 admissions to the hospital, the central line utilization ratio (CL-UR) as well as the microbiological profi le of CLA-BSI were evaluated. The results were compared with our earlier published data and with the fi ndings of international reports. 1. Safdar N, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med. 2014;42:1703-13. Preventing catheter-related infections in ICUs: comparing catheter care techniques S Ozden, R Iscimen, H Akalin, N Kelebek Girgin, F Kahveci, M Sinirtas Uludag University Faculty of Medicine, Bursa, Turkey Critical Care 2015, 19(Suppl 1):P72 (doi: 10.1186/cc14152) Introduction Catheter-related bloodstream infections (CRBSI) are common and an important cause of morbidity and mortality in critical patients. Optimum approaches for preventing infections are presented in guidelines. This study aims to evaluate effi cacy of diff erent care techniques and education, to defi ne risk factors for decreasing ratio of CRBSIs and to analyze eff ects on morbidity and mortality. Introduction Catheter-related bloodstream infections (CRBSI) are common and an important cause of morbidity and mortality in critical patients. Optimum approaches for preventing infections are presented in guidelines. This study aims to evaluate effi cacy of diff erent care techniques and education, to defi ne risk factors for decreasing ratio of CRBSIs and to analyze eff ects on morbidity and mortality. Conclusion Low serum iron increases the risk of bloodstream infection in the ICU, and should be considered as a risk factor to stratify patients’ risk of bacteremia during ICU stay. S26 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods After ethics committee approval, patients admitted to the ICU, older than 18 years, who were thought to have a central venous catheter (CVC) for more than 48 hours, and whose fi rst catheter was inserted in the ICU were included in the study. Staff were educated before the study and periodically during the study. Catheter care and insertion were applied according to the guidelines. The study was planned as three sequences. In the fi rst group, catheter care was made with a sterile gauze pad. In the second and third groups, catheter care was made with chlorhexidine gluconate impregnated dressing. Also in the third group, a silver-coated needleless connector was inserted into the tip of venous catheters. median duration of catheter indwelling in the entire population was 3.7 days with an interquartile range of 2.0 to 6.7 days, with no signifi cant diff erence between the groups (P = 0.36). Thirteen catheters (5.1%) in the 10% PVI group were positive for catheter-tip colonization, whereas six catheters (2.2%) in the 1% CHG group and fi ve catheters (1.9%) in the 0.5% CHG group were positive (P = 0.07). Preventing catheter-related infections in ICUs: comparing catheter care techniques The probability of catheter colonization was signifi cantly higher in the 10% PVI group than each CHG groups (P = 0.028, log-rank test). The incidence of catheter colonization and CRBSI is compared between the three groups. Conclusion In this randomized controlled trial comparing the eff ective- ness of three cutaneous antiseptic solutions for the prevention of catheter colonization, either 0.5% or 1.0% CHG was superior to 10% PVI. median duration of catheter indwelling in the entire population was 3.7 days with an interquartile range of 2.0 to 6.7 days, with no signifi cant diff erence between the groups (P = 0.36). Thirteen catheters (5.1%) in the 10% PVI group were positive for catheter-tip colonization, whereas six catheters (2.2%) in the 1% CHG group and fi ve catheters (1.9%) in the 0.5% CHG group were positive (P = 0.07). The probability of catheter colonization was signifi cantly higher in the 10% PVI group than each CHG groups (P = 0.028, log-rank test). The incidence of catheter colonization and CRBSI is compared between the three groups. Conclusion In this randomized controlled trial comparing the eff ective- ness of three cutaneous antiseptic solutions for the prevention of catheter colonization, either 0.5% or 1.0% CHG was superior to 10% PVI. p Results Totally 105 patients were included in the study and every group included 35 patients. There was no diff erence between groups when evaluating reasons for catheter insertion. There was no statistically signifi cant diff erence according to emergent or elective catheterization, trying times, or catheter insertion side (P >0.05). CRBSI was determined in two patients in group 1, in one patient in group 2, and in no patient in group 3. In group 1 it was observed on the 4th and 11th days. In group 2 it was observed on the 18th day after catheterization. Before the study, a statistically signifi cant decrease was determined in CRBSI ratios before and after education (16.4/1,000, 12.9/1,000 catheter-days (P <0.001)). According to Group 1 a statistically meaningful decrease was assigned in CRBSI ratios in Groups 2 and 3 (4.84/1,000, 2.22/1,000, 0/1,000 catheter-days) (P <0.001, P <0.001, P <0.001). P75 Removal of an implanted central venous catheter from neutropenic patients admitted to the ICU due to sepsis from any source B Civantos Martin, I Pozuelo Echegaray, C Guallar Espallargas, A Robles Caballero, C Briones, P Extremera Navas, P Millan Estañ, A Garcia de Lorenzo y Mateos Hospital Universitario La Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P75 (doi: 10.1186/cc14155) Removal of an implanted central venous catheter from neutropenic patients admitted to the ICU due to sepsis from any source B C P l h C G ll ll p p y B Civantos Martin, I Pozuelo Echegaray, C Guallar Espallargas, A Robles Caballero, C Briones, P Extremera Navas, P Millan Estañ, A Garcia de Lorenzo y Mateos Hospital Universitario La Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P75 (doi: 10.1186/cc14155) Methods This multicenter prospective randomized controlled trial was conducted in 15 Japanese ICUs from December 2012 to March 2014. Patients over 18 years of age undergoing CVC and AC placement in the ICU are randomized to have one of three skin antiseptic preparations before catheter insertion. After removal of the catheter, the distal tip is cultured using semiquantitative or quantitative techniques. The incidence of catheter colonization and catheter-related bloodstream infection (CRBSI) is compared between the three groups. Introduction Long experience in the treatment of neutropenic patients admitted to the ICU has taught us the importance of removing the permanent central venous catheter when infection is suspected, because of the great mortality associated. The problem usually comes when the origin of sepsis is not clear and we assume that mortality is Results A total of 997 catheters were placed, including 339 catheters using 1% CHG, 329 using 0.5% CHG, and 329 using 10% PVI. The S27 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 immune systems to suppress dissemination of infection by the netted chromatin decorated with antibacterial molecules. It was reported that NETs play an important role in various kinds of infections such as pneumonia. However, there is no report on NETs in patients of soft tissue infections. In this study, we evaluated NET production in pus and clarifi ed the role of NETs as a host defense in patients of soft tissue infections. not easy to avoid. It is important to know what happens to neutropenic patients admitted to the ICU because of sepsis from any source, in whom catheter infection cannot be excluded. Methods A retrospective, cohort, descriptive study was carried out between January 2013 and November 2014. Epidemiology data were collected from all neutropenic patients admitted to the ICU who came from hemato-oncology services and had an implanted central venous catheter. Microbiology results and data related to the catheter removal were described. Methods This study was conducted in the ICU of the Trauma and Acute Critical Care Center at Osaka University Hospital. Use of nanotechnology-based surface antiseptic solutions in the ICU Y Kuplay, N Akgun, C Agalar, H Aydýn, O Alýcý, G Turan FSM Teaching and Research Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P78 (doi: 10.1186/cc14158) Y Kuplay, N Akgun, C Agalar, H Aydýn, O Alýcý, G Turan FSM Teaching and Research Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P78 (doi: 10.1186/cc14158) Introduction In our study, we aimed to compare the application of benzalkonium chloride (BC) – a nanotechnology-based product – for 24-hour periods and didecyl dimethyl ammonium chloride (DDAC) for 12-hour periods regarding effi ciency in application of surface antiseptics in the ICU.f Introduction In our study, we aimed to compare the application of benzalkonium chloride (BC) – a nanotechnology-based product – for 24-hour periods and didecyl dimethyl ammonium chloride (DDAC) for 12-hour periods regarding effi ciency in application of surface antiseptics in the ICU.f y Methods A retrospective observational study in a medical and surgical ICU in a tertiary care hospital on adult patients admitted from January 2010 to December 2013. The study enrolled 845 patients divided into 283 internal jugular CVC (IJC), 270 subclavian CVC (SCC) and 287 femoral CVC (FC) in which the catheters were inserted in the ICU by experienced physicians with at least 50 previously successful trials of central line insertion, using CVC bundle checklist. ICU length of stay, incidence of complications, APACHE II score adjusted severity and mortality were calculated for each group. Methods Two diff erent areas with eight beds at both sides of a common corridor in the ICU were named as areas A and B. BC was applied in area A with 24-hour periods and DDCA was applied in area B with 12- hour periods for surface cleaning. Samples were taken from a total of 20 diff erent surfaces including nurse-station desks, phones, keyboards, beds, bedside monitors and ventilators by the same infection control nurse every 24 hours from area A and every 12 hours from area B for 7 days. Swab samples were cultured on 5% sheep bloody agar and McConkey agar in the laboratory. Then the cultured mediums were incubated at 35 to 37°C in an aerobic environment for 18 to 24 hours. NCSS (Number Cruncher Statistical System) 2007 and PASS 2008 Statistical Software (UT, USA) programs were used for the statistical analysis.f Results Patient and catheter characteristics including the duration of catheterization were similar in all groups. Removal of an implanted central venous catheter from neutropenic patients admitted to the ICU due to sepsis from any source B C P l h C G ll ll We collected pus from the patients of soft tissue infections at the time when drainage or debridement was performed and when clinical improvement was observed. The smears of pus specimens were examined by immunohistochemistry to visualize the major NET components: DNA, neutrophil elastase, and histone H1. Concurrently, the patients’ clinical data and laboratory data of blood were recorded to analyze the relationship with NET production.i Results A total of 15 patients were included, mean age was 53 years old and 66% were male. The implanted catheter was removed in 80% of patients. Platelet transfusion was needed in 100% of patients before catheter removal and no complication was observed during catheter removal or in the insertion of a new one. In 53% of patients, catheter infection was confi rmed a posteriori. i p Conclusion Removal of an implanted central venous catheter from neutropenic patients admitted to the ICU due to sepsis from any source can be benefi cial for this kind of patient as it was found that in more than 50% of patients catheter infection was confi rmed a posteriori. Results A total of fi ve patients were included in this study and drainage of abscess or debridement of infection site was performed in all of the cases. Four patients of them were diagnosed as necrotizing soft tissue infections by Clostridium spp. (n = 1) and Bacteroides spp. (n = 3) and the other was diagnosed as cervical abscess by Streptococcus spp. In all cases, no NETs but neutrophils were identifi ed in the fi rst pus: however, NETs appeared in the later smears as the patients’ condition was getting better. Eff ect of insertion route on risk of central line-associated bloodstream infection in critically ill patients R Alhubail, N Hassan g g Conclusion These results suggested that NETs also worked as an immune system against soft tissue infections. Drainage or debridement of infection focus might promote NET production. KFSH-D, Dammam, Saudi Arabia Introduction Femoral, jugular or subclavian central venous catheterization (CVC) is routinely performed during the care of the critically ill. These invasive procedures contribute to additional morbidity, mortality, and costs derived from the interactions between traumatic, infectious and other complications. The aim of this study is to determine whether the subclavian, jugular or femoral central venous access (CVA) routes have an eff ect on the incidence of CLABSI in critically ill patients and to compare between these routes regarding major complications and ICU mortality. P78 Use of nanotechnology-based surface antiseptic solutions in the ICU The rate of CLABSI in the IJC, SCC and FC groups was 5.8 versus 7.2 versus 3.45 per 1,000 catheter- days respectively with P = 0.35. ICU mortality was 134 (47%) cases of the IJC group, 108 (39%) cases of the SCC group and 113 (39%) cases of the FC group. There was no signifi cant diff erence between the three groups of CVC in the incidence of CLABSI rate in the critically ill patients, and a slight increase in ICU mortality in the IJC group compared with the other two groups. Pneumothorax occurred in six (2.2%) cases of SCC and 11 (3.8%) cases of IJC with no signifi cant diff erence between the two groups as the P value was 0.3.f Results There were no statistical diff erences between two groups (Table 1). Conclusion Site of insertion of CVC does not appear to aff ect the rate of CLABSI among critically ill patients. Pneumothorax was recorded in SCC and IJC groups with no statistical preference to either group. Table 1 (abstract P78). Isolated pathogen ratio percentage A (BC) B (DDCA) P value First day 25 20 1.000 Second day 5 15 0.605 Third day 30 20 0.715 Fourth day 65 50 0.527 Fifth day 45 60 0.527 Sixth day 25 25 1.000 Seventh day 60 45 0.527 Table 1 (abstract P78). Isolated pathogen ratio percentage Eff ect of daily bathing with chlorhexidine on hospital-acquired bloodstream infection in critically ill patients: a meta-analysis of randomized controlled trials h 1 k2 Eff ect of daily bathing with chlorhexidine on hospital-acquired bloodstream infection in critically ill patients: a meta-analysis of randomized controlled trials E Choi1, J Park2 1Yeungnam University College of Medicine, Daegu, South Korea; 2Uijeongbu St. Mary’s Hospital, Uijeongbu, South Korea Critical Care 2015, 19(Suppl 1):P81 (doi: 10.1186/cc14161) Eff ect of daily bathing with chlorhexidine on hospital-acquired bloodstream infection in critically ill patients: a meta-analysis of randomized controlled trials Results We observed a signifi cant reduction in DSSI rates in cardiac surgery following implementation of a multimodal ICP from 3.1% in 2010 down to 0.23% in November 2014 (Figure 1). Introduction Whole-body skin decolonization with chlorhexidine in critically ill patients reduces multidrug-resistant bacterial colonization, and catheter-related bloodstream infection (BSI). We performed a meta-analysis of randomized controlled trials to determine whether daily bathing with chlorhexidine decreased hospital-acquired BSIs in critically ill patients. Introduction Whole-body skin decolonization with chlorhexidine in critically ill patients reduces multidrug-resistant bacterial colonization, and catheter-related bloodstream infection (BSI). We performed a meta-analysis of randomized controlled trials to determine whether daily bathing with chlorhexidine decreased hospital-acquired BSIs in critically ill patients. Conclusion Implementing a multimodal ICP signifi cantly reduced the incidence of DSSI in our hospital but it remains diffi cult to identify which interventions were most eff ective. Reference 1. Guide for the prevention of mediastinitis surgical site infections following cardiac surgery. 2008. www.apic.org. Figure 1 (abstract P79). Incidence of DSSI. Figure 1 (abstract P79). Incidence of DSSI. y Methods We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases to identify randomized controlled trials that compared daily bathing with chlorhexidine and a control (daily bathing with soap and water or nonantimicrobial washcloths, or implementation of MRSA screening and isolation) in critically ill patients. The primary outcome was hospital-acquired BSIs. Secondary outcomes were adverse eff ects of chlorhexidine and the incidence of identifi ed pathogens. i Results This meta-analysis included four studies. The overall incidence of hospital-acquired BSIs was signifi cantly lower in the chlorhexidine group compared with the control 0.80 (95% CI, 0.71 to 0.90; P <0.001; I2 = 29.4%). Gram-positive (RR = 0.59, 95% CI, 0.44 to 0.79, P = 0.000; I2 = 46.0%) and MRSA-induced (pooled RR = 0.64; 95% CI, 0.47 to 0.88, P = 0.006; I2 = 0.0%) bacteremias were signifi cantly less common in the chlorhexidine group. Chlorhexidine did not aff ect Gram-negative bacteremia or fungemia. Eff ect of chlorhexidine and urinary catheter infection prevention in a Brazilian coronary ICU Eff ect of chlorhexidine and urinary catheter infection prevention in a Brazilian coronary ICU y GM Plantier1, CE Bosso1, BN Azevedo2, AC Correa3, AL Silva3, V Raso2 1Instituto do Coração de Presidente Prudente, Brazil; 2Faculdade de Medicina – UNOESTE, Presidente Prudente, Brazil; 3Santa Casa de Presidente Prudente, Brazil Critical Care 2015, 19(Suppl 1):P80 (doi: 10.1186/cc14160) Introduction Urinary catheter insertion is a common procedure in ICUs and can be an important cause of infection in the hospital environment [1,2]. We aimed to analyze the eff ect of chlorhexidine on long-term urinary catheter insertion and urinary tract infection (UTI) during a 5-year period in patients admitted to a coronary ICU. y p p y Methods Analysis of patients admitted to a coronary ICU of a medium- sized hospital in Brazil from January 2010 to May 2014. The institutional protocol of periprocedural antisepsis was changed from iodine-based antiseptic to chlorhexidine in 2012. The UTI diagnosis was based on urine culture (>105 colony-forming units per ml of urine) associated with at least one clinical/laboratory abnormality (fever >38°C, urination urgency, increased urinary frequency, dysuria, or suprapubic or lumbar pain). The UTI rate represents the urinary tract infections associated with long-term urinary catheter (patient with UTI associated with long-term urinary catheter divided by patients with long-term urinary catheter × 1,000). Results The urinary tract infection rates were 4.8 (year 2010: patients·day–1 (n: 2,511), long-term urinary catheter·day–1 (n: 1,455), device usage rate (958%)), 4.4 (year 2011: patients·day–1 (n: 2,529), long- term urinary catheter·day–1 (n: 1,140), device usage rate (45%)), 0.0 (year 2012: patients·day–1 (n: 2,660), long-term urinary catheter·day–1 (n: 783), device usage rate (29%)), 0.0 (year 2013: patients·day–1 (n: 2,573), long- term urinary catheter·day–1 (n: 960), device usage rate (37%)), and 0.0 (year 2014: patients·day–1 (n: 1,070), long-term urinary catheter·day–1 (n: 444), device usage rate (42%)). y y Methods Analysis of patients admitted to a coronary ICU of a medium- sized hospital in Brazil from January 2010 to May 2014. The institutional protocol of periprocedural antisepsis was changed from iodine-based antiseptic to chlorhexidine in 2012. The UTI diagnosis was based on urine culture (>105 colony-forming units per ml of urine) associated with at least one clinical/laboratory abnormality (fever >38°C, urination urgency, increased urinary frequency, dysuria, or suprapubic or lumbar pain). P79 P79 Reduction of deep surgical site infections in cardiac surgery by introducing a multimodal infection control program A Rutten, JP Ory, L Jamaer, A Van Assche, J Dubois Jessa Ziekenhuis, Hasselt, Belgium Critical Care 2015, 19(Suppl 1):P79 (doi: 10.1186/cc14159) Introduction Deep surgical site infections (DSSI) are a major compli- cation after cardiac surgery with a high mortality rate and reported incidences between 0.5 and 5%. Implementing a comprehensive infection control program (ICP) reduces this incidence [1]. The incidence in our hospital varied from 3.1 to 3.8%, which was considered too high. We evaluated the impact of introducing a multimodal ICP on the incidence of DSSI. Methods We noticed a too high incidence of DSSI after cardiac surgery during an observational 3-year period (Figure 1). In February 2013 we introduced a bundle of interdisciplinary infection control measures. Medical and nursing staff of all involved departments took part in developing and implementing these guidelines. Besides emphasizing the importance of existing guidelines (antiseptic shower, hair removal by clipper, strict hand hygiene, prophylactic antibiotics, limiting OR traffi c, tight glycemic control (80 to 110 mg/ dl), and so on), new strategies were introduced. The most important new strategies were nasal decolonization with mupirocin twice daily 48 hours perioperatively, preoperative antiseptic skin preparation twice (chlorhexidine gluconate 0.5%), applying topical skin adhesive to the sternal wound postoperatively and in the case of CABG procedures maintaining a strict barrier between the vein harvesting procedure and the chest procedure. Conclusion The use of chlorhexidine in the periprocedural antisepsis of urinary catheterization contributed to the decrease of urinary tract infections associated with long-term urinary catheter in patients admitted to the coronary ICU. P80 Eff ect of chlorhexidine and urinary catheter infection prevention in a Brazilian coronary ICU GM Plantier1, CE Bosso1, BN Azevedo2, AC Correa3, AL Silva3, V Raso2 1Instituto do Coração de Presidente Prudente, Brazil; 2Faculdade de Medicina – UNOESTE, Presidente Prudente, Brazil; 3Santa Casa de Presidente Prudente, Brazil Critical Care 2015, 19(Suppl 1):P80 (doi: 10.1186/cc14160) References 1. Silva E, et al. Crit Care, 2004;8:R251-60. 2. Vincent JL, et al. JAMA. 2009;302:2323-9. Eff ect of chlorhexidine and urinary catheter infection prevention in a Brazilian coronary ICU The UTI rate represents the urinary tract infections associated with long-term urinary catheter (patient with UTI associated with long-term urinary catheter divided by patients with long-term urinary catheter × 1,000). 1. Guide for the prevention of mediastinitis surgical site infections following cardiac surgery. 2008. www.apic.org. P77 P77 Role of neutrophil extracellular traps against soft tissue infections N Yamamoto1, M Ojima2, S Hamaguchi1, T Hirose2, R Takegawa2, N Matsumoto2, T Irisawa2, M Seki1, O Tasaki3, T Shimazu2, K Tomono1 1Division of Infection Control and Prevention, Osaka University Graduate School of Medicine, Suita, Japan; 2Osaka University Graduate School of Medicine, Suita, Japan; 3Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan Critical Care 2015, 19(Suppl 1):P77 (doi: 10.1186/cc14157) Critical Care 2015, 19(Suppl 1):P77 (doi: 10.1186/cc14157) Introduction Neutrophils work as the frontline of defense against infections and neutrophil extracellular traps (NETs) are one of the S28 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion The eff ect of a good surface disinfectant should begin immediately and it should have a long-lasting disinfecting eff ect on the surface. DDAC is an effi cient disinfectant used in medicine and the food industry to protect the surfaces. However, it may cause severe skin itching. BC, which is a nanotechnology-based product, leaves its active metabolites on the surface; it is applied by constituting a spongy layer. Since the effi ciency of BC lasts for 24 hours and it is applied to perform cleaning with 24-hour intervals, we think that it is preferable with regards to workforce gain and cost. Clinical validation of an electronic hand hygiene surveillance system y Methods A quasi-experimental study was done in three level III ICUs of a tertiary care hospital in Kolkata (January to April 2014). Data were collected on existing hand hygiene compliance rate, ventilator- associated pneumonia (VAP) rate, catheter-related bloodstream infection (CRBSI) rate, catheter-related urinary tract infection (CAUTI) rate, standardized mortality ratio (SMR) and average ICU length of stay in the abovementioned units. Root cause analysis was done and interventions were developed to improve hand hygiene compliance and was implemented (July to October 2014). Comparison was done between preintervention and postintervention periods. y P Levin, R Razon, MJ Cohen, CL Sprung, S Benenson Hadassah Hebrew University Medical Center, Jerusalem, Israel Critical Care 2015, 19(Suppl 1):P84 (doi: 10.1186/cc14164) P Levin, R Razon, MJ Cohen, CL Sprung, S Benenson Hadassah Hebrew University Medical Center, Jerusalem, Israel Critical Care 2015, 19(Suppl 1):P84 (doi: 10.1186/cc14164) Introduction Good hand hygiene (HH) is critical to infection control in the ICU. Electronic HH surveillance systems are purported to improve HH practices. Such a system was recently trialed in our ICU. The system is based on radiofrequency transponders in three locations: bracelets worn by ICU personnel; on all HH product dispensers; and above each patient’s bed. By correlating input from these three sources the system detects whether HH was performed before and after each patient contact. In the event that HH is not performed, the bracelet alerts the user (by vibration) in real time. This study represents a clinical validation of the system. Results In the preintervention period (January to April 2014) the hand hygiene compliance among the caregivers was found to be 40%, VAP rate (8.77), CRBSI rate (3.42), CAUTI rate (5.27), SMR (1.14) and average ICU length of stay was 6 days ± 5.85 SD (median 4.5). Interventions were developed and implemented as follows: education and awareness – road shows; positive reinforcement; secret watch nurse; e-ICU – electronic surveillance; ring the bell once every hour – baseline hand hygiene; visual reminders; availability of alcohol-based hand rub, soap and water and sinks; random hand swabs; and compliance audits. In the postintervention period (July to October 2014) data showed a signifi cant improvement in the hand hygiene compliance (75%). Further analysis showed an association with decrease in the incidence of VAP rate (4.71), CAUTI rate (3.51), CRBSI rate (2.65), SMR (1.05) and average ICU LOS 5.05 days ± 4.03 SD (median 4). Improving hand hygiene compliance leads to improved health outcome: an analysis y V Rao, A Datta, A Kar Medica Superspecialty Hospital, Kolkata, India p Conclusion Introduction of infection control bundle in the ICU reduced the incidence of nosocomial MDRO transmission and infection, which resulted in the reduction of anti-MRSA antibiotics and carbapenems use in critically ill patients. p p y p Critical Care 2015, 19(Suppl 1):P82 (doi: 10.1186/cc14162) Introduction Hand hygiene is the single most eff ective but least practiced action in breaking the chain of transmission of microbes. Studies have shown a correlation between the compliance of hand hygiene and its impact on the health outcome. Eff ects of infection control bundle to prevent nosocomial infection in the ICU in the ICU A Matsushima, M Kawanami, S Fujimi, N Inadome, N Kubo, T Yoshioka Osaka General Medical Center, Osaka, Japan Critical Care 2015, 19(Suppl 1):P83 (doi: 10.1186/cc14163) Introduction Multidrug-resistant organism (MDRO) infections in critically ill patients are often life-threatening. To prevent nosocomial infections of MDRO, we made an infection control bundle in our ICU in 2013. In this study we evaluated the eff ect of our infection control bundle to prevent nosocomial MDRO transmission and infection. Conclusion The electronic HH system consistently underestimated both HH opportunities and HH performance. The main reason for dissatisfaction with the system was inaccuracy of bracelet alerts. These data suggest that for an electronic system to be accepted by ICU staff , it has to be highly accurate and comfortable for the user. Methods Our infection control bundle consists of preemptive contact precaution to all care, active surveillance culture and isolation of patients with MDRO. This bundle was applied to all patients admitted to our ICU since 2013. The study period to evaluate the eff ects of the bundle was from April 2012 to March 2014, and we divided it into two periods; fi rst period (before introduction of the bundle) and second period (after introduction of the bundle). We compared the incidence of nosocomial transmission and infection of MDRO between the two periods. MDRO was defi ned as bacteria that were resistant to more than three kinds of antibiotics. Nosocomial transmission was defi ned when MDRO was detected later than 48 hours after admission. Nosocomial infection was diagnosed according to the National Nosocomial Infection Surveillance Manual. P83f Eff ects of infection control bundle to prevent nosocomial infection in the ICU A Matsushima, M Kawanami, S Fujimi, N Inadome, N Kubo, T Yoshioka Osaka General Medical Center, Osaka, Japan Critical Care 2015, 19(Suppl 1):P83 (doi: 10.1186/cc14163) Clinical validation of an electronic hand hygiene surveillance system y Methods ICU staff (nurses and physicians) were followed by a trained observer over 60-minute periods. Each movement and contact during the period was documented. HH opportunities were determined according to WHO criteria and actual HH performance recorded. Observer and electronic data were compared for number of opportunities, HH performance and compliance. A satisfaction questionnaire was distributed to all users. Paired Student’s t test was used for comparison of the observer and electronic data. Results Observations were made over 56 time periods that included 836 HH opportunities and 485 occasions when HH was performed. The observer recorded 10.9 ± 7.6 HH opportunities/hour compared with 6.8 ± 6.9 for the electronic system (P <0.001). HH performance occurred on 8.7 ± 3.9 occasions/hour versus 6.0 ± 3.1 occasions/hour as recorded by the electronic system (P <0.001). Overall HH compliance was 62.5 ± 17.7% versus 57.5 ± 21.0% respectively (P = 0.523). On comparison of specifi c observation periods, there was poor correlation between compliance as recorded by the observer and electronic system (r = 0.03, P = 0.915). Satisfaction questionnaires were completed by 41 personnel. Satisfaction with the system was low or very low for 21/41 (61%). System inaccuracy (either bracelet alerts without cause, or lack of bracelet alerts when HH was required) was the most common reason for dissatisfaction (31/41, 76%), followed by physical discomfort from the bracelet (18/41, 44%). Conclusion Improved hand hygiene compliance can be attributed to decreased incidence of VAP, CRBSI, CAUTI, SMR and average ICU LOS. This does defi nitely impact the overall clinical outcome. However, continued surveillance of hand hygiene compliance and regular audits is of utmost importance to make the change sustainable. Eff ect of daily bathing with chlorhexidine on hospital-acquired bloodstream infection in critically ill patients: a meta-analysis of randomized controlled trials h 1 k2 The overall incidence of adverse events, such as skin rashes, was similar in both groups. Conclusion Implementing a multimodal ICP signifi cantly reduced the incidence of DSSI in our hospital but it remains diffi cult to identify which interventions were most eff ective. Reference 1. Guide for the prevention of mediastinitis surgical site infections following cardiac surgery. 2008. www.apic.org. S29 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion Daily bathing with chlorhexidine was associated with a reduction in the rates of hospital-acquired BSI without signifi cant complications in critically ill patients. It also decreased the incidence of Gram-positive hospital-acquired BSIs, especially MRSA. Results Admission to the ICU comprised 363 patients in the fi rst period and 380 patients in the second period. The incidence of transmission was decreased from 48 (13.2%) to 21 (5.5%) in methicillin-resistant Staphylococcus aureus (MRSA), from 16 (4.4%) to zero (0%) in multidrug- resistant Acinetobacter baumannii. The incidence of nosocomial infection by MDRO was also decreased from 23 (6.3%) to 17 (4.5%) in pneumonia, from fi ve (1.4%) to two (0.3%) in urinary tract infection, and from 12 (3.3%) to one (0.3%) in surgical site infection. The incidence of antibiotic use for MDRO infection was decreased from 41 (11.3%) to 24 (6.3%) in anti-MRSA antibiotics, and from 19 (5.2%) to eight (2.1%) in carbapenems. P86 A survey of UK acute clinicians’ knowledge of personal protective requirements for infectious diseases and chemical, biological, and radiological warfare agents AR Bond1, A Buckingham2, J Schumacher1 1Guy’s and St Thomas’ NHS Trust, London, UK; 2St George’s Healthcare NHS Trust, London, UK Critical Care 2015, 19(Suppl 1):P86 (doi: 10.1186/cc14166) Evaluation of the microbial tightness of closed system transfer devices by simulating airborne and touch contamination University of Bonn, Germany Introduction The use of intravascular catheter devices is often associated with serious bloodstream infections due to microbial contaminations. To minimize risk of such infections NIOSH recommends S30 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 the use of closed system transfer devices (CSTDs). To evaluate the microbial tightness of CSTDs we developed two methods which simulate the bioburden in ambient air of operating rooms and ICUs. the use of closed system transfer devices (CSTDs). To evaluate the microbial tightness of CSTDs we developed two methods which simulate the bioburden in ambient air of operating rooms and ICUs. for clinicians treating patients exposed to infectious diseases and CBRN agents, ideally in a simulation setting. Further research into whether the required levels of PPE are readily available to clinicians would be pertinent. Methods The methods simulate airborne and touch contamination. We tested the microbial tightness of the integrated Safefl ow® valve of a Mini-Spike® which is used for drug admixture. The airborne contamination was done in an exposure chamber in which a nebulizer distributed defi ned B. subtilis spore aerosols [1]. A Mini-Spike® was inserted into a vial of 0.9% sodium chloride solution (NaCl). A nebulizer with a suspension of 4.8 × 105 CFU spores of B. subtilis per ml was used to generate an aerosol for 1 minute. The volume of B. subtilis suspension nebulized per minute was 0.278 ml. This corresponds to 1.34 × 103 aerosolized spores in the exposure chamber, which has a volume of 0.24 m3 (5.6 × 103 CFU per m3 air). The used concentration was 100 times higher than the microbial burden found in hospitals [2]. After nebulization the valve was disinfected and NaCl was withdrawn into a syringe at certain time intervals. The NaCl was incubated on tryptic soy agar at 37°C for 48 hours. Results were documented as CFU. For touch contamination, a Mini-Spike® was attached to a vial of NaCl. The valve of the Mini-Spike® was contaminated with 105 CFU Staphylococcus aureus. The subsequent procedure was done as described above. g References 1. Dunkelberg H, Fleitmann-Glende F. Measurement of the microbial barrier eff ectiveness of sterilization containers in terms of the log reduction value for prevention of nosocomial infections. Am J Infect Control. 2006;34:285-9. 1. Dunkelberg H, Fleitmann-Glende F. Measurement of the microbial barrier eff ectiveness of sterilization containers in terms of the log reduction value for prevention of nosocomial infections. Am J Infect Control. 2006;34:285-9. 2. Qudiesat K. Assessment of airborne pathogens in healthcare settings. AJMR. 2009;3:66-76. Results During the study period, 40 patients with TB were admitted to the ICU; 75% male and median age of 52 years (IQR 37.5 to 62.8). Overall, 22 (55%) patients died in the hospital, of whom 16 (40%) died in the ICU. Comorbid illness was identifi ed in 32 (80%) patients, with HIV infection being the most common, present in 15 (37.5%) patients. The main reason for ICU admission was respiratory failure (70%), followed by sepsis/septic shock (22.5%). Twenty-eight (70%) patients had isolated pulmonary disease, four (10%) had isolated extrapulmonary disease and eight (20%) had association of pulmonary and extrapulmonary disease. Mycobacterial cultures were positive in 31 (77.5%) patients; three patients presented monoresistant strains. Twenty-nine (72.5%) patients required mechanical ventilation and 21 (52.5%) required vasopressor infusion in the ICU; two patients were treated with ECMO. Thirty-four (85%) patients received antituberculosis therapy. The median length of stay was 11.5 (IQR 3.25 to 28.5) days in the ICU and 40.5 (IQR 21.0 to 62.8) days in the hospital. The presence of at least one comorbidity, smoking, age, sepsis/septic shock on admission, high SAPS II and APACHE II score, positive direct examination and PCR in respiratory samples, the need for mechanical ventilation or vasopressor infusion were signifi cantly associated with mortality (P <0.05). There was no association between mortality and HIV status, site of TB disease, concomitant acute disease or development of hospital infections. 2. Qudiesat K. Assessment of airborne pathogens in healthcare settings. AJMR. 2009;3:66-76. R Duro, P Figueiredo, A Ferreira, S Xerinda, C Lima Alves, L Santos, A Sarmento R Duro, P Figueiredo, A Ferreira, S Xerinda, C Lima Alves, L Santos, A Sarmento Introduction To describe the characteristics of the patients with tuberculosis (TB) requiring intensive care and to identify the factors associated with in-hospital mortality in an ICU in Portugal. Results Out of nine tested valves, none showed transmission of B. subtilis spores after airborne contamination. Three out of nine tested valves were contaminated with S. aureus after touch contamination. Conclusion Our study shows that both methods are suitable for evaluating the microbial tightness of CSTDs. References Methods A retrospective cohort study between January 2007 and July 2014 of all patients with TB admitted to the ICU of the Infectious Diseases Department of Centro Hospitalar de São João. Comorbid diagnoses, clinical features, radiological and laboratory investigations and outcomes were reviewed. The primary outcome was the in- hospital mortality. A univariate analysis was performed to identify risk factors for death. References References 1. Centers for Disease Control and Prevention. 2014 ebola outbreak in West Africa. http://www.cdc.gov/vhf/ebola/outbreaks/guinea/. 1. Centers for Disease Control and Prevention. 2014 ebola outbreak in West Africa http://wwwcdc gov/vhf/ebola/outbreaks/guinea/ 1. Centers for Disease Control and Prevention. 2014 ebola outbreak in West p g g 2. Brinker A, et al. Personal protection during resuscitation of CBW victims. A survey among medical fi rst receivers in the UK. Prehosp Disaster Med. 2009;24:525-8. A survey of UK acute clinicians’ knowledge of personal protective requirements for infectious diseases and chemical, biological, and radiological warfare agents AR Bond1, A Buckingham2, J Schumacher1 1Guy’s and St Thomas’ NHS Trust, London, UK; 2St George’s Healthcare NHS Trust, London, UK Critical Care 2015, 19(Suppl 1):P86 (doi: 10.1186/cc14166) Introduction We conducted a survey to assess clinicians’ knowledge of personal protective equipment (PPE) requirements for infectious diseases and biochemical warfare agents. A safe level of PPE is essential when treating patients with highly infectious diseases or those contaminated with hazardous substances. The recent Ebola virus disease (EVD) outbreak in West Africa has highlighted that, although uncommon, contagious diseases with high mortality rates can be a threat to healthcare systems at local, national, and international levels [1]. Chemical, biological, radiological or nuclear (CBRN) contamination presents similar risks. Conclusion In this cohort we found a high mortality rate in the TB patients requiring intensive care. The risk factors for mortality due to severe TB are mainly related to the severity of organ failure, patient characteristics and burden of disease and not to HIV status or site of TB disease. Methods A validated, hand-delivered, multiple-choice questionnaire [2] was used to assess intensive care, emergency medicine, and anesthetics specialist registrars’ knowledge of respiratory and skin protection needed during a resuscitation scenario with advanced life support. Participants selected the PPE required for the biological hazards: EVD, severe acute respiratory syndrome (SARS), inhalational anthrax, plague and smallpox; and the biochemical hazards: sarin, hydrogen cyanide, phosgene and mustard gas (dichlordiethyl sulfi de). Responses were compared with UK national recommendations and a previous survey in 2009 [2]. Tuberculosis in the ICU: a retrospective cohort study R Duro, P Figueiredo, A Ferreira, S Xerinda, C Lima Alves, L Santos, A Sarmento Centro Hospitalar de São João/Faculty of Medicine University of Porto, Portugal Critical Care 2015, 19(Suppl 1):P87 (doi: 10.1186/cc14167) Tuberculosis in the ICU: a retrospective cohort study R Duro, P Figueiredo, A Ferreira, S Xerinda, C Lima Alves, L Santos, A Sarmento Comparative analysis of microfl ora and antibiotic resistance in patients with sepsis in 1999 and 2013 Introduction Changes in infection agents and their sensitivity to antibiotics are the main cause of severity of surgical infections. In spite of development and introduction of new drugs and methods of treatment, the number of patients with sepsis increases, so the problem in diagnosing and treatment is still far from resolution. Introduction Changes in infection agents and their sensitivity to antibiotics are the main cause of severity of surgical infections. In spite of development and introduction of new drugs and methods of treatment, the number of patients with sepsis increases, so the problem in diagnosing and treatment is still far from resolution. Methods A comparative retrospective analysis of 52 histories of patients with sepsis, which were treated in the Department of Surgical Infections in 1999 and 2013. g g Methods A comparative retrospective analysis of 52 histories of patients with sepsis, which were treated in the Department of Surgical Infections in 1999 and 2013. Results The number of patients with sepsis in 2013 was raised 2.7 times, in comparison with 1999. Mortality decreased from 79% in 1999 to 55% in 2013. In most cases sepsis was accompanied with immunosuppressive disorders, such as diabetes, oncology, alcohol and drug addiction, and HIV infection. We analyzed crops of discharge from the wound and blood cultures in 52 patients with sepsis. Crops of wound were taken during the initial surgical intervention, then every 3 to 7 days, as well as the surgical interventions being repeated. Blood cultures were performed in the presence or suspected diagnosis of sepsis, in accordance with the classifi cation Bone criteria. In comparison of spectrum of infection agents, Staphylococcus aureus is still leading (1999 – 36.6% of isolates, 2013 – 25%), and the percentage of MRSA was 0% in 1999 and 37.5% in 2013. The frequency of Gram-negative fl ora has increased: E. coli (8.5%/20%), P. aeruginosa (8.5%/12%), Klebsiella pneumoniae (0%/16%) and Acinetobacter spp. (0%/16%). Speaking about the resistance of microorganisms, there is still a high percentage of sensitivity to aminoglycoside antibiotics (79.4%/75%), glycopeptides (77.2%/71%), carbapenems (88.4%/78%) and also to the combination therapy (71.8%/62.4%), but also a reduction in sensitivity to the group of beta-lactam antibiotics (58.2%/32.5%) and fl uoroquinolones (64.6%/36.4%). Conclusion Cutaneous mucormycosis is less common than other clinical forms, most frequently seen in inmunocompetent patients but potentially lethal if treatment is not rapid. Patients at risk are those with disruption of the normal protective cutaneous barrier. Low-pathogenicity mycoplasma species induce immunoparesis and are highly prevalent amongst patients with ventilator-associated pneumonia TJ Nolan1, N Gadsby2, TP Hellyer3, K Templeton2, R McMullan4, J McKenna5, J Rennie1, CT Robb1, TS Walsh1, AG Rossi1, AJ Simpson3, A Conway Morris6 1University of Edinburgh, UK; 2NHS Lothian, Edinburgh, UK; 3Newcastle University, Newcastle, UK; 4Queen’s University, Belfast, UK; 5Belfast Health and Social Care Trust, Belfast, UK; 6University of Cambridge, UK Critical Care 2015, 19(Suppl 1):P89 (doi: 10.1186/cc14169) Introduction Ventilator-associated pneumonia (VAP) remains a signifi cant problem within ICUs. There is a growing recognition of the impact of critical-illness-induced immunoparesis on the pathogenesis of VAP, but the mechanisms of this immunoparesis remain incompletely understood. We hypothesised that, because of limitations in their routine detection, Mycoplasmataceae are more prevalent amongst patients with VAP than previously recognised, and that these organisms potentially impair immune cell function. Conclusion The number of patients with sepsis has increased; the mortality of sepsis has decreased. The frequency of S. aureus isolation is still high, MRSA is the same. The frequency of Gram- negative fl ora isolation has increased, especially K. pneumoniae and Acinetobacter spp. The resistance of microorganisms to beta-lactams and fl uoroquinolones is rising but the sensitivity to aminoglycosides, glycopeptides, and carbapenems is still maintained. y Methods Two cohorts [1,2], totalling 159 patients, were recruited from 12 UK ICUs; all patients had suspected VAP and underwent bronchoscopy and bronchoalveolar lavage. VAP was defi ned as growth of organisms at >104 CFU/ml on conventional culture. Thirty- six healthy donors underwent lavage for comparison. Samples were tested for Mycoplasmataceae (Mycoplasma and Ureaplasma spp.) by PCR, and positive samples underwent sequencing for speciation. Additionally, healthy donor monocytes and macrophages (MDM) were exposed to Mycoplasma salivarium and their ability to respond to lipopolysaccharide and undertake phagocytosis was assessed. P91 2. Hellyer T, et al. Thorax. 2014 [Epub ahead of print]. 1. Conway Morris A, et al. Thorax. 2010;65:201-7. Infectious events and prescription of antimicrobials in the coronary ICU CE Bosso1, SV Ferreira2, GE Valerio2, JV Moraes2, V Raso2 1Instituto do Coração de Presidente Prudente, Brazil; 2Faculdade de Medicina – UNOESTE, Presidente Prudente, Brazil Critical Care 2015, 19(Suppl 1):P91 (doi: 10.1186/cc14171) Introduction The eff ectiveness of initially used antimicrobials represents an important factor in infectious events in coronary intensive care units (CICU) [1]. This study aimed to analyze the prevalence of infectious events and the prescribed antimicrobial in CICU. Results Mycoplasmataceae were found in 48% of patients with VAP, compared with 14% of patients without VAP (P <0.0001). Patients with sterile lavage had a similar prevalence to healthy donor lavage (10 vs. 8%, P = 0.54). The commonest organism identifi ed was M. salivarium. Human blood monocytes and MDM incubated with M. salivarium displayed impaired cytokine responses to lipopolysaccharide and MDM demonstrated impaired phagocytosis. Methods We analyzed the data of 2,005 patients admitted to the CICU for 3 years. The infectious events were based on general characteristics, main sites and outbreaks of infectious events in addition to the main microorganisms and pathogens. The prescription of antimicrobials was analyzed based on the isolated or associated use of antimicrobials. We also analyzed the adequacy of initial empirical antimicrobial according to the microbiological evidence. The general characteristics of events – that is, time, evidence of infection, infections by multidrug-resistant pathogens – are also presented. y Conclusion This study demonstrates a high prevalence of Mycoplasmataceae amongst patients with VAP, with a markedly lower prevalence amongst patients with suspected VAP in whom subsequent cultures refuted the diagnosis. The commonest organism found, M. salivarium, is able to profoundly impair the functions of key immune cells and thus suggests that Mycoplasmataceae may contribute to VAP pathogenesis. Results The prevalence of infection was 4% (n = 81). Ventilator- associated pneumonia was 35% (n = 28), whereas urinary and primary bloodstream associated with catheters was 14% (n = 11) and 9% (n = 7), respectively. There was 82% (n = 66) evidence of microbiological infection. The main pathogens and microorganisms found were Comparative analysis of microfl ora and antibiotic resistance in patients with sepsis in 1999 and 2013 In these patients, if signs are of sepsis it is very important to suspect the possibility of infection by Mucor and initiate empiric antifungal treatment with surgery to avoid high mortality. Surprisingly, in our series, determination of procalcitonin showed high levels in spite of not having value in fungal infection. P88 Cutaneous mucormycosis in the ICU Cutaneous mucormycosis in the ICU EH Herrero, M Sánchez, A Agrifoglio, L Cachafeiro, MJ Asensio, B Galván, A García de Lorenzo Hospital La Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P88 (doi: 10.1186/cc14168) Results Ninety-eight clinicians (anesthetics n = 51, emergency medicine n = 21, intensive care medicine n = 26) completed surveys. The best knowledge (76% correct) was for SARS, with less knowledge for anthrax, plague, EVD, and smallpox (60%). We found limited knowledge for chemical warfare agents (20 to 30%). Sixty to 80% of all incorrect responses were over-rated. There was no diff erence in knowledge compared with previous published results [2]. Introduction Mucormycosis is a devastating disease most commonly seen in immunosuppressed individuals. It has the propensity to disseminate in humans and cause rhinocerebral, pulmonary, gastrointestinal, and cutaneous infections. This study focuses on cutaneous mucormycosis, incidence, epidemiologic characteristics and mortality in intensive care medicine. Conclusion Despite national and regional training since previous surveys [2], the results indicate that further training on PPE is required S31 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods We present a descriptive study in an ICU between the years 2001 and 2013 on the incidence of patients with cutaneous mucormycosis. Sociodemographics, comorbidities and laboratory data were recorded. Clinical data were collected to calculate the APACHE score. The main outcome was to analyze the epidemiological characteristics of patients with cutaneous mucormycosis and mortality. Results Seven patients were identifi ed with cutaneous mucormycosis between the years 2001 and 2013. The mean age of patients was 52 ± 4, with an APACHE score of 19 ± 9, and 57% died. All patients were admitted for trauma-related injury suff ering blast, abrasive injuries or burns. Mortality among patients with signs of sepsis was 100%, and only in one of them was empirically antifungal therapy started; in the others antibiotic treatment was directed. Among patients without signs of sepsis, the survivor was treated with amputation where mucoral infection was isolated. Procalcitonin rose in all patients with signs of sepsis. P90 Comparative analysis of microfl ora and antibiotic resistance in patients with sepsis in 1999 and 2013 IV Avdoshin, LG Akinchits, ES Konstantinova, MA Shatil, ON Dobrydin, NA Bubnova Saint-Petersburg City Hospital of St. George, Saint-Petersburg, Russia Critical Care 2015, 19(Suppl 1):P90 (doi: 10.1186/cc14170) Analysis of Gram-negative rod bacteremia in the surgical and medical ICU Analysis of Gram-negative rod bacteremia in the surgical and medical ICU D Adukauskiene, D Valanciene D Adukauskiene, D Valanciene Lithuanian University of Health Sciences, Kaunas, Lithuania Critical Care 2015, 19(Suppl 1):P92 (doi: 10.1186/cc14172) Introduction The aim was to analyze the Gram-negative bacteremia profi le and the predisposing factors for length of stay in the surgical and medical ICU and outcome. Methods Retrospective data analysis of patients during 4 years treated in a surgical and medical ICU with positive blood culture for Gram- negative rod. g Results Gram-negative rod monobacteremia (n = 160) cultures revealed: Escherichia coli (n = 52, 32.5%), Acinetobacter spp. (n = 47, 29.4%), Klebsiella spp. (n = 22, 13.7%), Enterobacter spp. (n = 20, 12.5%), Proteus spp. (n = 11, 6.9%), anaerobes (n = 3, 1.9%) and other Gram-negative rods, including Stenotrophomonas maltophilia, Haemophilus infl uenzae, Neisseria meningitidis, Achromobacter spp. and Actinobacillus limirensi (n = 5, 3.1%). Both E. coli and Acinetobacter spp. were responsible for the vast majority of Gram-negative rod monobacteremia (n = 99, 61.8%, P = 0.0128). Also most often (n = 50, 72.5%, P = 0.049) primary bacteremia was caused by E. coli and Acinetobacter spp. Separate group’s multidrug resistance was found: E. coli in 12 (23.1%) cases, Acinetobacter spp. in 45 (95.7%, P = 0.02), Klebsiella spp. in nine (40.9%), Enterobacter spp. in 11 (55.0%), Proteus spp. in six (54.6%) cases. The vast majority of patients with multidrug-resistant bacteremia were aged over 65 years (n = 64, 77.1%, P = 0.042), stayed in the ICU less than 14 days (n = 70, 84.3%, P = 0.039), and had lethal outcome (n = 74, 89.2%, P = 0.03). Patients who stayed in the ICU less than 14 days presented with primary Gram-negative rod bacteremia (n = 67, 57.7%, P = 0.03), need for mechanical ventilation (n = 90, 77.6%, P = 0.043) and lethal outcome (n = 112, 96.6%, P = 0.01). Lethal outcome was confi rmed in patients with primary Gram-negative rod bacteremia (n = 55, 79.7%, P = 0.03), MDR strain (n = 74, 89.2%, P = 0.03), presence of shock (n = 120, 75.0%, P <0.001), mechanical ventilation (n = 133, 74.3%, P <0.001), cancer chemotherapy (n = 18, 90.0%, P = 0.03), and chronic obstructive pulmonary disease (n = 13, 100%, P = 0.03). Conclusion The carriage of MDRO in ICU-admitted patients is important, especially for ESBL-GN. Is carriage of multidrug-resistant organisms a risk factor for nosocomial infections in an infectious diseases ICU? Introduction The objective was to evaluate whether asymptomatic carriage of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and extended-spectrum beta- lactamase producing Gram-negative bacilli (ESBL-GN) on admittance to the ICU of the University Hospital of Infectious Diseases Cluj-Napoca, Romania is a risk factor for infection due to these multidrug-resistant organisms (MDRO) during hospitalization. fi Conclusion We conclude that infection is prevalent even in CICU, and that the microbiological profi le is quite diverse, as well as the antibiotics. This allows us to better understand the profi le of this kind of unit. Reference g g p Methods A prospective study during a 6-month period (June to November 2014), including all adult patients admitted to our ICU. All patients were screened on admittance for nasal MRSA, intestinal VRE and ESBL-GN carriage. Patients admitted with any localization of infections due to these organisms were excluded. Patients were monitored for developing nosocomial infections due to MDRO during hospitalization. We evaluated previous colonization as a risk factor for future infections. We used bioMerieux selective chromogenic media for MDRO for screening and Vitek2Compact for identifi cation. Statistical analysis was performed with chi-square test and univariate analysis. 1. Silva E, et al. Crit Care. 2004;8:R251-60. y p q y Results From 119 screened adult patients, 65 women (54.6%), average age 67 years, we had at screening on admittance into the ICU: 14 positive MRSA (11.8%), 63 positive ESBL-GN (52.9% – 41 strains of Escherichia coli, 26 strains of Klebsiella sp., 11 strains of Proteus mirabilis and one strain of Enterobacter cloacae) and 35 positive VRE (29.4% – 33 strains of Enterococcus faecium and two strains of Enterococcus faecalis) without concomitant infection with these MDRO. The average duration of ICU stay was 7.32 days. During hospitalization, 14 patients (11.8%) developed nosocomial infections due to MDRO. Colonization with MDRO preceded nosocomial infections in: one of four patients with MRSA-positive blood cultures (P = 0.96), seven of eight patients with ESBL-GN infections (P = 0.10) and three of four patients with VRE urinary tract infections (P = 0.14). Although not statistically signifi cant, owing to the low number, most patients who developed infections with ESBL-GN had previous intestinal colonization. 1. Silva E, et al. Crit Care. 2004;8:R251-60. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P93 Gram-positive bacteria (n = 24, 30%; Staphylococcus aureus (n = 16, 20%), Enterococcus faecalis (n = 4, 5%), Staphylococcus epidermidis (n = 3, 4%)), Gram-negative (n = 43, 53%; klebsiella sp. (n = 13, 16%), Pseudomonas aeruginosa (n = 7, 9%), Escherichia coli (n = 7, 9%)) and fungi (n = 5, 6%; candida sp. (n = 2, 3%), Candida albicans (n = 1, 1%), Candida dubliniensis (n = 1, 1%)). The commonly prescribed antimicrobials were piperacillin/tazobactam (n = 32, 40%), vancomycin (n = 30, 37%), polymyxin B (n = 23, 28%), cefepime (n = 16, 20%), meropenem (n = 12, 15%), cefuroxime (n = 8, 10%), ciprofl oxacin (n = 6, 7%), tigecycline (n = 6, 7%), ampicillin (n = 5, 6%), clindamycin (n = 4, 5%), chloramphenicol (n = 4, 5%), oxacillin (n = 4, 5%) and others (n = 32, 28%). There was 75% (n = 46) infection during hospitalization in the unit. Approximately 32% of infections were caused by multidrug-resistant pathogens, although there was effi ciency of 81% in the proper use of initial antimicrobials. Conclusion We conclude that infection is prevalent even in CICU, and that the microbiological profi le is quite diverse, as well as the antibiotics. This allows us to better understand the profi le of this kind of unit. Reference Is carriage of multidrug-resistant organisms a risk factor for nosocomial infections in an infectious diseases ICU? M Lupse1, M Flonta2, L Herbel2, A Petrovan2, A Binder2, N Todor3, A Cioara1 1University of Medicine and Pharmacy, Cluj-Napoca, Romania; 2Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania; 3‘Ion Chiricuta’ Institute of Oncology, Cluj-Napoca, Romania Critical Care 2015, 19(Suppl 1):P93 (doi: 10.1186/cc14173) p g References S32 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P96 admission; 4.8% required the extrarenal depuration technique. In total, 497 patients (44.1%) were coronary, 49.5% male, mean age 66.18 (SD ±12.6), CI (64.88 to 67.48); mean APACHE II 9.74 (SD ± 6.1), CI (9.1 to 10.3); and a mean time stay of 3.62 days (SD ±4.7), CI (3.1 to 4.1). Mortality in this group was 3.7%. In 61.9% of cases the diagnosis of admission was AMI, 16% arrhythmia and 11.6% unstable angina. Of patients, 629 were polyvalent (55.8%), 53.85% male, mean age 58.05 (SD ±17.2), CI (56.7 to 59.4); mean APACHE II 14.6 (SD ±9.1), CI (13.8 to 15.3); and a mean time stay of 4.64 days (SD ±7.7), CI (4 to 5.25). Mortality was 11.6%. In 33.2% the cause of income was digestive, 23.2% acute or chronic exacerbated respiratory failure, 12.4% severe sepsis/septic shock and 10.1% postoperative cardiovascular surgery. The incidence density (ID) of catheter-related bacteremia was 5.5, 92.8% from the fourth day of ICU admission; ID of ventilator-associated pneumonia (VAP) was 5.94, 88.9% since the fourth day; and ID of urinary tract infections (UTI) related to urinary catheter was 2.88, 80% of them since the fourth day. From all patients who developed intra-ICU infections, mean APACHE II in admission was 21.3 (SD ±9.6) with a mean time stay of 23.4 days (SD ±12.9) and a mortality percentage of 19.6%. 1. Rit K, et al. IJCP. 2013;24:451-5. P95 Emergence of isolates that are intrinsically resistant to colistin in critically ill patients: are we selecting them out? MN Sivakumar, M Hisham, V Nandakumar, T Gopinathan Kovai Medical Center and Hospital, Coimbatore, India Critical Care 2015, 19(Suppl 1):P95 (doi: 10.1186/cc14175) Introduction Poor infection control practices along with irrational usage of antibiotics lead to emergence of multidrug-resistant (MDR) organisms. Increasing use of colistin for treating MDR infections leads to selection of organisms that are intrinsically resistant to colistin. There are limited Indian literatures which evaluated the incidence of intrinsically resistant isolates to colistin in critically ill patients. Our study aimed to investigate the incidence of true pathogen or colonizer with the prior antibiotic exposure and patient’s clinical outcome. Conclusion Being a broad-spectrum bactericidal agent usable both orally and parenterally with low toxicity profi les and lesser prevalence of cross-resistance with other antimicrobials, fosfomycin can be an alternative to other broad-spectrum agents to treat uncomplicated infections as well as in the case of infections with MDR organisms where treatment options are very few. This study possibly reveals a much- needed solution for the rising carbapenem resistance and also for the treatment of infections with such MDR pathogens, thereby bringing down the length of stay in hospital, cost of therapy and suff ering on the part of the patients. Methods The prospective, cross-sectional study was carried out from March 2013 to April 2014. Clinical samples included culture positivity for isolates intrinsically resistant to colistin from patients who were admitted to the ICU or had a prior ICU stay in the same admission. Methods The prospective, cross-sectional study was carried out from March 2013 to April 2014. Clinical samples included culture positivity for isolates intrinsically resistant to colistin from patients who were admitted to the ICU or had a prior ICU stay in the same admission. Results A total of 93 unusual Gram-negative rods were isolated from 76 patients. This included 19.4% (n = 18) Serratia marcescens, 12.9% (n = 12) Stenotrophomonas maltophilia, 14% (n = 13) Burkholderia cepacia, 24.7% (n = 23) Proteus mirabilis, 17.2% (n = 16) Morganella morganii, 9.7% (n = 9) Elizebethkingia meningoseptica and 2.1% (n = 2) Providencia species. A total of 68.4% (n = 52) patients had prior exposure to either colistin or carbapenems or both. In total, 71% (n = 66) of the total isolates from patients had previous antibiotic exposure. 2. Garbati MA, et al. J Infect Dev Ctries. 2013;7:213-6. Analysis of Gram-negative rod bacteremia in the surgical and medical ICU The incidence of nosocomial infections with MDRO in the ICU is high. ESBL-GN intestinal colonization could be a risk factor for nosocomial infections but further studies are needed to confi rm this. Patient epidemiology in a level II hospital ICU and how main nosocomial infections aff ect morbidity and mortality M Muñoz, E Yuste, O Moreno, R Fernandez, R Ramirez Hospital Universitario San Cecilio, Granada, Spain Critical Care 2015, 19(Suppl 1):P94 (doi: 10.1186/cc14174) Introduction We describe the type of patient and the main nosocomial infections in a level II hospital ICU unit, 18 beds (12 polyvalent-general, six coronary). Introduction We describe the type of patient and the main nosocomial infections in a level II hospital ICU unit, 18 beds (12 polyvalent-general, six coronary). y Methods We used the ENVIN-HELICS database and made statistical calculations for all patients admitted to the ICU between 1 October 2012 and 30 September 2013 using SPSS v.15. g Results Patients admitted (1,126): 65.1% were male; mean age 61.72 (SD ±15.8), CI (60.7 to 62.7); mean APACHE II 12.6 (SD ±8.42), CI (12.12 to 13.11); and a mean time stay of 4.84 days (SD ±6.26). In total, 68.9% were provided from the community. A total of 44.1% were coronary, 2.84% trauma and 53.02% medical–surgical patients. A total of 29.8% had antibiotic therapy in the ICU, 20% had it before incoming. In total, 18.38% were treated with artifi cial airway (MV, tracheostomy). In total, 54.09% used a urinary catheter and 38.8% needed a central venous catheter. Fifteen percent of patients had some kind of surgery before Conclusion E. coli and Acinetobacter spp. – the most often pathogens of Gram-negative rod bacteremia – were mostly multidrug resistant. Multidrug-resistant bacteremia was related to age, length of stay less than 14 days, and lethal outcome. Predisposing factors for shorter length of stay: primary bacteremia, mechanical ventilation, lethal outcome, and for lethal outcome: primary bacteremia, multidrug resistance, presence of shock, mechanical ventilation, cancer chemotherapy, chronic obstructive pulmonary disease. S33 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P95 Among the total 93 intrinsically resistant isolates to colistin, 37.6% (n = 35) of isolates from all clinical sources (endotracheal, pus, urine and blood samples) were true pathogens and the remaining 62.3% (n = 58) were colonizers. There was a statistically signifi cant increase in length of ICU stay and duration of hospitalization in the presence of true pathogen. Conclusion Selection pressure due to extensive use of higher antibiotics may lead to emergence of intrinsically resistant isolates, which narrows the therapeutic options in the ICU. Our study emphasizes the paramount importance of establishing clinical relevance of these organisms before treating them as true pathogens. This calls for judicious use of higher antibiotics, implementation of an antibiotic stewardship program and strict infection control practices. f Kolkata A Chakraborty, S Roy, S Chakraborty, A Datta, A Kar Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P96 (doi: 10.1186/cc14176) Introduction In the era of rising prevalence of serious infections caused by multidrug-resistant (MDR) organisms and the paucity of in-fl ow of newer antimicrobial agents, the relatively older antibiotics that had been left out of clinical practice for various reasons are now being increasingly considered as the potential agents to combat such infections. Fosfomycin, known for almost four decades, has a broad spectrum of activity against several Gram-negative and Gram-positive bacteria. Methods This study, conducted in the Microbiology Department of Medica Superspecialty Hospital between July and November 2014, was aimed at testing the in vitro sensitivity of fosfomycin against isolates identifi ed from various clinical specimens from diff erent parts of Kolkata. After confi rming the identity and antibiogram by Microscan Autoscan 4, the isolates were tested for fosfomycin sensitivity by the Epsilometer test. MIC values were interpreted in accordance with the currently recommended Clinical and Laboratory Standards Institute (CLSI) criteria for urinary tract isolates of Escherichia coli and Enterococcus faecalis and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria for Enterobacteriaceae and Staphylococcus aureus. y Conclusion In our ICU the main cause of admission was the polyvalent patient, who is younger and has more severity with not much diff erence in mean time of stay compared with the coronary patient. The intra-ICU infections provide an increase of morbi-mortality risk and consumption of resources. p y Results Out of the 1,895 isolates tested, fosfomycin displayed an overall in vitro susceptibility against 90%, but only 64% against MDR strains. Among the MDR organisms nearly 78% of E. coli and 70% of Klebsiella spp. and 40% of MRSA isolates showed provisional MICs in the sensitive range while among the sensitive strains fosfomycin showed around 92% susceptibility. Our study results were comparable with the results obtained from an Indian study published from CMC Vellore in 2013 showing a fosfomycin susceptibility of around 75% among MDR uropathogenic E. coli. P97 Results A total of 93 unusual Gram-negative rods were isolated from 76 patients. This included 19.4% (n = 18) Serratia marcescens, 12.9% (n = 12) Stenotrophomonas maltophilia, 14% (n = 13) Burkholderia cepacia, 24.7% (n = 23) Proteus mirabilis, 17.2% (n = 16) Morganella morganii, 9.7% (n = 9) Elizebethkingia meningoseptica and 2.1% (n = 2) Providencia species. A total of 68.4% (n = 52) patients had prior exposure to either colistin or carbapenems or both. In total, 71% (n = 66) of the total isolates from patients had previous antibiotic exposure. Among the total 93 intrinsically resistant isolates to colistin, 37.6% (n = 35) of isolates from all clinical sources (endotracheal, pus, urine and blood samples) were true pathogens and the remaining 62.3% (n = 58) were colonizers. There was a statistically signifi cant increase in length of ICU stay and duration of hospitalization in the presence of true pathogen. Antibiotic synergy testing for multidrug-resistant Gram-negative pathogens in a Greek ICU E Douka, E Perivoliot, E Kraniotaki, M Nepka, C Routsi, K Fountoulis, A Skoutelis, S Zakynthinos Evangelismos General Hospital, Athens, Greece Critical Care 2015, 19(Suppl 1):P97 (doi: 10.1186/cc14177) Skewed antibiogram of community-acquired urinary isolates and the therapeutic dilemma Skewed antibiogram of community-acquired urinary isolates and the therapeutic dilemma p A Chakraborty, S Roy, A Datta, A Kar Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P99 (doi: 10.1186/cc14179) A Chakraborty, S Roy, A Datta, A Kar Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P99 (doi: 10.1186/cc14179) Introduction Urinary tract infection (UTI) is one of the most common bacterial infections in humans. Gram-negative organisms being the most common causative agent, the rising prevalence of resistance to a number of antibiotics and more importantly the production of extended spectrum beta-lactamase (ESBL) by these organisms is a growing concern worldwide. As the scenario is no better in community isolates, the choice of empirical antimicrobials for such infections becomes a great challenge for the clinicians. fi Results Against 59 MDR A. baumannii strains, the synergy eff ect of CRB/ COL was 55.9%, RIF/COL 38.9%, CRB/GEN 22%, CRB/AMK 20.3% and TG/COL 16.9%, respectively. Against 41 K. pneumoniae strains, synergy rates were: CRB/COL 43.9%, CRB/GEN 31.7%, PIP/TAZ/GEN 29.2% and TG/COL 24.4% respectively. Against 64 P. aeruginosa strains, synergy rates were: AMK/PIP/TAZ 64.6%, AMK/AZT 64.6%, AMK/CEF 58.3%, CRB/ COL 52%, AMK/CRB 25%. Conclusion The most eff ective combination for both the A. baumannii and K. pneumoniae strains tested was CRB/COL. The next most eff ective combination was RIF/COL and CRB/GEN respectively. No competitive eff ect was observed for RIF/COL combination in all cases tested. The most eff ective combinations for P. aeruginosa strains were AMK plus PIP/TAZ or AZT or CEF. The next most eff ective combination was CRB/ COL. We recommend implementation of an antibiotic synergy test for MDR pathogens as a routine antimicrobial test in the hospitals’ microbiology laboratories, especially for critically ill patients, since some combinations seem to excel. Further studies are needed for the correlation of these combinations with clinical effi cacy. Methods In this retrospective observational study we aimed at knowing the prevalence of ESBL production by organisms causing UTI in the community and to study the antibiogram of such isolates. Urine samples from patients with suspected UTI in the community were cultured for uropathogen by routine microbiological methods and susceptibility testing was done on Microscan Autoscan 4 (Siemens). y Results Out of 527 isolates of Enterobactereaceae, 314 (59.58%) were ESBL producers from the community samples compared with 315 (67.30%) from hospital samples, with Escherichia coli being the most commonly isolated pathogen. Enterobacter spp. P100 Is it possible to predict multidrug-resistant organism colonization and/or infection at ICU admission? F Callejo-Torre1, JM Eiros2, S Ossa-Echeverri1, P Olaechea3, F Alvarez-Lerma4, M Palomar5, Envin-Helics Study Group1 1Hospital Universitario de Burgos, Spain; 2Hospital Clínico Universitario de Valladolid, Spain; 3Hospital de Galdakao-Usansolo, Galdakao, Spain; 4Hospital del Mar, Barcelona, Spain; 5Hospital Arnau de Villanova, Lleida, Spain Critical Care 2015, 19(Suppl 1):P100 (doi: 10.1186/cc14180) y Methods We retrospectively assessed two hypothetical empirical antibiotic treatment algorithms for VAP on an 18-bed ICU. Data on consecutive episodes of microbiologically confi rmed VAP were collected over a period of 22 months and divided into a derivation (1 February 2013 to 30 November 2013) and validation (1 December 2013 until 15 November 2014) cohort. We constructed two algorithms in the derivation cohort. One is a local ecology-based algorithm (LEBA), according to clinical risk factors for MDR and susceptibility results in our hospital. The other is a Gram stain-based algorithm (GSBA). The selection of antibiotics on GSBA was directed against pathogens predicted from the results of bedside Gram staining of tracheal aspirates collected just before antibiotic therapy. Subsequently, LEBA and GSBA were retrospectively reviewed and compared with actually prescribed antibiotics in the validation cohort.i p Critical Care 2015, 19(Suppl 1):P100 (doi: 10.1186/cc14180) Introduction We tried to develop a predictive model for patients colonized/infected by any multidrug-resistant organism (MDRO-C/I) at ICU admission based on risk factors easy to obtain (not depending on complex clinical records), being aware that foreseeing MDRO-C/I at ICU admission is key for appropriate empirical treatment and infection control. Results The fi rst 50 VAP episodes made up the derivation cohort and the subsequent 50 VAP episodes the validation cohort. Antibiotic coverage rates by applying LEBA and GSBA were identical (96% vs. 96%). GSBA proposed more narrow spectrum therapy as compared with LEBA (P <0.001). GSBA recommended carbapenems in signifi cantly less episodes than LEBA (P <0.001) and the same episodes as actually prescribed initial therapy (P = 1). However, there was signifi cant increase of antibiotic coverage rates in GSBA compared with the actually prescribed initial therapy (96% vs. 78%, P = 0.015). Conclusion Antibiotic coverage rates on GSBA were comparable with LEBA. The use of GSBA would result in a signifi cant reduction of the administration of broad-spectrum antibiotics. Bedside Gram staining may be useful to guide appropriate initial antibiotic therapy for VAP. Skewed antibiogram of community-acquired urinary isolates and the therapeutic dilemma showed highest prevalence (80%) of ESBL production from the community samples. Among the ESBL producing strains from the community, the sensitivity to ciprofl oxacin, levofl oxacin and nitrofurantoin was 18%, 21% and 44% respectively while in the non-ESBL producers the sensitivity rates were 52%, 51% and 73% respectively. P98 Development of antibiotic treatment algorithms based on Gram stain to restrict use of broad-spectrum antibiotics in the treatment of ventilator-associated pneumonia: a retrospective analysis J Yoshimura, T Kiguchi, A Matsushima, S Fujimi Osaka General Medical Center, Osaka, Japan Critical Care 2015, 19(Suppl 1):P98 (doi: 10.1186/cc14178) P98 Development of antibiotic treatment algorithms based on Gram stain to restrict use of broad-spectrum antibiotics in the treatment of ventilator-associated pneumonia: a retrospective analysis J Yoshimura, T Kiguchi, A Matsushima, S Fujimi Osaka General Medical Center, Osaka, Japan Critical Care 2015, 19(Suppl 1):P98 (doi: 10.1186/cc14178) p y Conclusion Organisms producing the ESBL phenotype present with an added possibility of being resistant to other broad-spectrum antimicrobial agents which are commonly prescribed in the community to empirically treat such infections. This makes the choice of empirical antibiotic much more challenging in the community, drawing errors in judgment. A possibility of frequent overcorrection lies on the other side of the coin. This study also shows the possible need for empirical institution of class I carbapenems as one of the treatment options and outpatient parenteral antimicrobial therapy. Introduction Ventilator-associated pneumonia (VAP) is a common and serious problem in ICUs. Several studies have been conducted to determine the eff ectiveness of Gram stain of tracheal aspirates for diagnosing VAP. However, the eff ectiveness for predicting causative microorganisms and guiding appropriate initial antibiotic therapy has not been evaluated. The purpose of this study is to determine whether Gram stain of tracheal aspirates can guide appropriate initial antibiotic therapy for VAP. Antibiotic synergy testing for multidrug-resistant Gram-negative pathogens in a Greek ICU Introduction The emergence of multidrug-resistant (MDR) pathogens is a major cause of infection-related mortality among critically ill patients. The synergistic eff ect between commonly used antibiotics against diffi cult to treat nosocomial MDR Gram-negative strains, if present, could provide a viable option as an alternative therapy. The aim of this study was to investigate the potential of antibiotic synergy against MDR A. baumannii, K. pneumonia and P. aeruginosa strains, isolated from critically ill patients in a Greek ICU. y Methods We tested 59 A. baumannii, 41 K. pneumoniae and 64 P. aeruginosa strains, isolated during the period 2010 to 2013. All strains were resistant to carbapenems and showed reduced susceptibility or resistance to tigecycline or colistin (MIC >2), in accordance with CLSI guidelines. We evaluated double-drug combinations of carbapenem (CRB)/colistin (COL), tigecycline (TG)/COL, rifampicin (RIF)/COL, CRB/ gentamicin (GEN), CRB/amikacin (AMK) for A. baumannii, TG/COL, S34 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 CRB/COL, piperacillin–tazobactam (PIP/TAZ)/GEN, CRB/GEN for K. pneumoniae and AMK/(PIP/TAZ), AMK/aztreonam (AZT), AMK/cefepime (CEF), AMK/CRB and CRB/COL for P. aeruginosa strains. In order to perform synergy tests, the E-test methodology (BioMerieux, Marcy l’E’toile, France) was used. Synergy was defi ned as a fraction inhibitory concentration (FIC) index ≤0.5, additive eff ect 0.5 to 1, indiff erent or antagonistic eff ect >2 (Lorian defi nition). CRB/COL, piperacillin–tazobactam (PIP/TAZ)/GEN, CRB/GEN for K. pneumoniae and AMK/(PIP/TAZ), AMK/aztreonam (AZT), AMK/cefepime (CEF), AMK/CRB and CRB/COL for P. aeruginosa strains. In order to perform synergy tests, the E-test methodology (BioMerieux, Marcy l’E’toile, France) was used. Synergy was defi ned as a fraction inhibitory concentration (FIC) index ≤0.5, additive eff ect 0.5 to 1, indiff erent or antagonistic eff ect >2 (Lorian defi nition).f P103 Novel infl uenza A antibodies reduce severity of secondary pneumococcal pneumonia after infl uenza infection in mice KF Van der Sluijs, F Van Someren Greve, MD De Jong, MJ Schultz, NP Juff ermans Novel infl uenza A antibodies reduce severity of secondary pneumococcal pneumonia after infl uenza infection in mice KF Van der Sluijs, F Van Someren Greve, MD De Jong, MJ Schultz, NP Juff ermans Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P103 (doi: 10.1186/cc14183) y Methods Data were collected prospectively from 69,894 patients admitted consecutively (stay >24 hours) to 147 Spanish ICUs participating in the National Surveillance Study of Nosocomial Infections in ICU registry (ENVIN) during April to June 2006 to 2010. Univariable and multivariable analysis was performed for both objectives but we used only easy-to-obtain variables for the predictive model exclusively from those admitted in 2010 (n = 16,950, 2/3 for analysis and 1/3 for subsequent validation). Introduction Secondary bacterial pneumonia after infl uenza infection can cause severe disease with a high mortality. Recently, a new group 2 infl uenza A antibody (AT10_002) has been developed, which binds to multiple H3 and H7 subtypes. In a mouse model of primary infl uenza infection, treatment with AT10_002 as a fusion antibody protects against lethal infection, and reduces loss of bodyweight [1]. We hypothesized that treatment with AT10_002 reduces weight loss, lung injury and bacterial outgrowth, in a mouse model of viral infection followed by secondary pneumococcal infection. y q Results In the 2006 to 2010 period, 1,046 were C/I by MRSA (note that relative risks are not included due to space limitations). First objective: previous antibiotic, APACHE II score >18, skin-soft tissue or postsurgical superfi cial skin infections, trauma or medical patient, age >65 (especially >75), urinary catheter and admitted from a long- term care facility were independent risk factors for MRSA-C/I in ICU. Multicolonization increased signifi cantly the risk of MRSA-C/I, and immunodefi ciency and gender male emerged as protective factors. Second objective: independent risk factors on ICU admission were male gender, trauma critical patient, urgent surgery, admitted from other ICU, community or long-term facility, being immunosuppressed and skin-soft tissue infection. All confi gured the risk model for which, although showing good discrimination (AUC-ROC, 0.77; 95% CI, 0.72 to 0.82), sensitivity (67%) and specifi city (76.5%) were insuffi cient for the ICU setting. P101 P101 Methicillin-resistant Staphylococcus aureus in the ICU: risk factors and a predictive model to detect it at ICU admission F Callejo-Torre1, JM Eiros2, S Ossa-Echeverri1, P Olaechea3, M Palomar4, F Alvarez-Lerma5, Envin-Helics Study Group1 1Hospital Universitario de Burgos, Spain; 2Hospital Clínico Universitario de Valladolid, Spain; 3Hospital de Galdakao-Usansolo, Galdakao, Spain; 4Hospital Arnau de Villanova, Lleida, Spain; 5Hospital del Mar, Barcelona, Spain Critical Care 2015, 19(Suppl 1):P101 (doi: 10.1186/cc14181) g y p y Results Among 41 patients, 15 (37%) underwent FMS. There was no diff erence in age, sex, underlying disease, target temperature management, and prophylactic antibiotic use between two groups. Mean duration of ECMO was 4 days in both groups. The incidence of bacteremia was none in the group with FMS and fi ve (19%) in the group without FMS. Within fi ve cases of bacteremia, three were caused by enterobacterium. Introduction Being capable of predicting MRSA on ICU admission is crucial to enhance infection control and to avoid inappropriate empirical treatment. Two objectives were studied: to describe risk factors for MRSA colonization/infection (MRSA-C/I) once admitted to the ICU; and to develop a predictive model at ICU admission, based on easy-to-obtain admission factors. Conclusion FMS may be protective against bacteremia for OHCA patients undergoing ECMO. Protective eff ect of a fecal incontinence management system against bacteremia for out-of-hospital cardiac arrest patients undergoing extracorporeal membrane oxygenation S Kikuta, R Miki, S Ishihara, S Nakayama Hyogo Emergency Medical Center, Chuo, Kobe, Hyogo, Japan Critical Care 2015, 19(Suppl 1):P102 (doi: 10.1186/cc14182) Introduction Recently, extracorporeal cardiopulmonary resuscitation (ECPR) has become a common measure against cardiopulmonary arrest. In cases with ECPR, we usually insert cannulae for extracorporeal membrane oxygenation (ECMO) via the femoral artery and vein. However, the cannulation site is often contaminated by feces due to incontinence. Moreover, patients tend to be compromised by hypothermia due to the target temperature management, so we often experience central line-associated bloodstream infection of patients undergoing ECMO. We investigated the protective eff ect of a fecal incontinence management system (FMS) against bacteremia in patients undergoing ECMO. Conclusion MDRO prediction at ICU admission could not be based merely on clinical–demographic risk factors. Taking into account local particularities and combining risk factors with a rapid laboratory test might be the most eff ective way forward. g g Methods We studied 41 consecutive patients undergoing ECMO for out-of-hospital cardiac arrest (OHCA) between April 2010 and May 2014. Patients were divided into two groups according to the use or no use of FMS (Flexi-Seal™). Patients who died within 48 hours or from whom cannulae for ECMO were removed within 48 hours were excluded. Patients’ characteristics, underlying disease, target temperature management, prophylactic antibiotic use and incidence of bacteremia during admission were recorded and analyzed retrospectively. Results Among 41 patients, 15 (37%) underwent FMS. There was no diff erence in age, sex, underlying disease, target temperature management, and prophylactic antibiotic use between two groups. Mean duration of ECMO was 4 days in both groups. The incidence of bacteremia was none in the group with FMS and fi ve (19%) in the group without FMS. Within fi ve cases of bacteremia, three were caused by enterobacterium. g g Methods We studied 41 consecutive patients undergoing ECMO for out-of-hospital cardiac arrest (OHCA) between April 2010 and May 2014. Patients were divided into two groups according to the use or no use of FMS (Flexi-Seal™). Patients who died within 48 hours or from whom cannulae for ECMO were removed within 48 hours were excluded. Patients’ characteristics, underlying disease, target temperature management, prophylactic antibiotic use and incidence of bacteremia during admission were recorded and analyzed retrospectively. P102 (relative risk not shown due to space limitation): age 65 to 74, medical or surgical critical patient (especially urgent surgery), admitted from other ICU or long-term facility, immunosuppression and deep postsurgical skin or skin-soft tissue infections. Admitted from the community and female gender emerged as protective factors. Although the predictive model showed good discrimination (AUC-ROC = 0.775 (95% CI, 0.744 to 0.807)), sensitivity was only 67.4%. Validation with the remaining 4,952 patients (1/3) showed an AUC-ROC = 0.712 (95% CI, 0.665 to 0.759) and a P value on the Hosmer–Lemeshow goodness of fi t test of 0.855. Even creating a new model, including variables obtained after ICU admission (severity by APACHE score, mechanical ventilation, central venous, arterial or urinary catheter, immunodefi ciency, parenteral nutrition, ventricular derivation, extrarenal depuration, non-invasive ventilation, tracheotomy, enteral nutrition and nasogastric tube), prediction capability did not improve (AUC-ROC = 0.801 (95% CI, 0.774 to 0.828), sensitivity 71.4%). Protective eff ect of a fecal incontinence management system against bacteremia for out-of-hospital cardiac arrest patients undergoing extracorporeal membrane oxygenation S Kikuta, R Miki, S Ishihara, S Nakayama Hyogo Emergency Medical Center, Chuo, Kobe, Hyogo, Japan Critical Care 2015, 19(Suppl 1):P102 (doi: 10.1186/cc14182) P100 Results The fi rst 50 VAP episodes made up the derivation cohort and the subsequent 50 VAP episodes the validation cohort. Antibiotic coverage rates by applying LEBA and GSBA were identical (96% vs. 96%). GSBA proposed more narrow spectrum therapy as compared with LEBA (P <0.001). GSBA recommended carbapenems in signifi cantly less episodes than LEBA (P <0.001) and the same episodes as actually prescribed initial therapy (P = 1). However, there was signifi cant increase of antibiotic coverage rates in GSBA compared with the actually prescribed initial therapy (96% vs. 78%, P = 0.015). Methods Data were collected prospectively from admission to discharge of 16,950 patients admitted consecutively (at least >24 hours) to 147 Spanish ICUs of the ENVIN (National Surveillance Study of Nosocomial Infections in ICUs) registry, from April to June 2010. To create the predictive model, 11,998 (2/3) patients were used for univariable and multivariable logistic regression model and 4,952 (1/3) for subsequent validation. Results With a MDRO prevalence of 2.12% (359 MDROs at ICU admission were detected in 314 patients), 87.58% patients had only one MDRO, meanwhile 12.42% were MDRO-C/I by two or more simultaneously. Risk factors used in the development of the predictive model and independently associated with MDRO-C/I at ICU admission were Conclusion Antibiotic coverage rates on GSBA were comparable with LEBA. The use of GSBA would result in a signifi cant reduction of the administration of broad-spectrum antibiotics. Bedside Gram staining may be useful to guide appropriate initial antibiotic therapy for VAP. S35 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Source of MDR infections in an ICU: busting the myth R Agrawal Source of MDR infections in an ICU: busting the myth R Agrawal FEHI, New Delhi, India Critical Care 2015, 19(Suppl 1):P106 (doi: 10.1186/cc14186) Results In total, 1,499 patients were included, of whom 265 patients (18%) had a viral respiratory tract infection with at least one virus. In 17 patients, two viruses were found; two patients had an infection with three viruses. The most prevalent was parainfl uenzavirus-3 (5.7%); 17 patients (1.1%) had an infection with infl uenza. The lowest prevalence of viral infections occurred in September (12%), the highest in October and February (both 26%). Of the patients tested positive in TA, only 46% also tested positive in NP. The median cp values were not signifi cantly diff erent between TA and NP swabs (31.1 vs. 31.6, P = 0.75). Introduction MDR infections in the ICU are not nosocomial all the time, as perceived commonly. We performed a 2-year retrospective study to analyze the source of culture positivity in a medical ICU and to identify which types of infections are more prevalent. Methods The data of a 35-bed medical ICU were analyzed from November 2012 to October 2014. The source of culture positivity was divided into three groups: patients admitted from the ER to the ICU who were referred from other hospitals or direct admissions, the second group was patients admitted within the hospital but outside the ICU for the fi rst 48 hours, and the third group was ICU-acquired infections. We also analyzed the data for type of infections, whether Gram-negative, Gram-positive or fungal. Conclusion The prevalence of viral respiratory tract infections is high in unselected ICU patients. Testing tracheal aspirate in combination with nasopharynx greatly increased detection of viruses, and yields similar cp values. Whether these viral infections are associated with prolonged mechanical ventilation and worse outcomes remains to be determined. g p g Results There were 1,051 cultures positive in a 2-year period. In total, 46.8% (n = 492) of cultures were already positive on admission, which denotes community-acquired and referred patients from other hospitals. A total of 31.1% (n = 327) of cultures were positive from patients admitted to general wards for more than 48 hours and then transferred to the ICU. Twenty-two percent (n = 232) of cultures were ICU-acquired infections. The data show community-acquired and hospital-acquired infections are the bulk of the culture load in an ICU. P103 Afterwards validation with the remaining 4,952 (1/3) showed AUC-ROC = 0.72 (95% CI, 0.65 to 0.79) and P value on the Hosmer–Lemeshow goodness of fi t test = 0.539. The model did not improve even after including more complex variables (AUC-ROC = 0.82; 95% CI, 0.77 to 0.86, sensitivity 63.64%, specifi city 78.48%). y y p Methods Male C57Bl/6 mice were intranasally inoculated with 400 TCID50 Infl uenza A (H3N2). Two days after infection, mice were injected with either AT10_002 i.v. (n = 8) or a control antibody (n = 7). After 7 days, both groups were intranasally inoculated with 5 × 103 S. pneumoniae type 3 and were sacrifi ced 18 hours later. Outcome measures were weight loss, wet lung weight, cell count in bronchoalveolar lavage fl uid (BALF), and colony-forming units (CFUs) in lung homogenate. Data are represented as medians, and treatment groups are compared using nonparametric tests.i Results Mice receiving AT10_002 showed signifi cantly lower weight loss at the time of sacrifi ce compared with the control group (+1% vs. –12% change in weight; P = 0.0003). Also wet lung weight was lower (68 vs. 96 mg; P = 0.0003), cell counts in BALF were lower (4.9 × 105 vs. 7.0 × 105 cells/ml; P = 0.0037) and CFUs in lung homogenate were lower (33 vs. 25 × 104 CFUs/mg; P = 0.0003) compared with controls. Conclusion Early treatment with infl uenza antibody AT10_002 signifi cantly reduces weight loss, lung injury and bacterial outgrowth, i Conclusion Independent risk factors for MRSA-C/I in the ICU and at ICU admission are described. To predict MRSA-C/I at ICU admission we should not rely on clinical–demographic risk factors alone. Its combination with a rapid laboratory test could be the way to proceed in future studies. Conclusion Early treatment with infl uenza antibody AT10_002 signifi cantly reduces weight loss, lung injury and bacterial outgrowth, S36 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 hospitals – 17 high-volume care units) in the Czech Republic from 1 January 2011 to 5 November 2013. Patients were divided into two groups: survivors (n = 274) and nonsurvivors (n = 261). in a mouse model of infl uenza infection followed by secondary pneumococcal pneumonia. Reference in a mouse model of infl uenza infection followed by secondary pneumococcal pneumonia. P103 Reference g Results Survivors versus nonsurvivors were similar in: age 65.8 (64.2; 67.5) versus 66.5 (64.7; 68.3) P = 0.583, men 159 (58.0%) versus 160 (62.0%) P = 0.376, APACHE II score 27 (15 to 40) versus 28 (15 to 40) P = 0.737. Statistically signifi cant diff erences between survivors versus nonsurvivors were found in the parameter ‘Consensus initial antimicrobial therapy with microbial cultures’ 178 (79.5%) versus 128 (58.4%) P <0.001 and in the parameter ‘Administration antimicrobials within the fi rst hour’ 163 (59.9%) versus 171 (70.7%) P = 0.001. Administration of 30 ml/kg crystalloid for hypotension or lactate 4 mmol/l (3 hours) and application of vasopressors (6 hours) were in both groups without statistically signifi cant diff erences. 1. Wagner K, et al. Proc Natl Acad Sci U S A. 2014;111:16820-5. Adequate initial antimicrobial therapy as the factor assessing treatment effi cacy in human septic shock 1 l 1 Š 2 l 1 Š k1 Introduction The early identifi cation of severe sepsis and septic shock and early implementation of the SSC bundles were associated with reduced mortality [1]. The failure to initiate appropriate antimicrobial therapy increased mortality of septic shock patients [2]. We hypothesized that the parameter ‘Consensus initial antimicrobial therapy with microbial cultures’ correlates with outcome of septic shock patients. Conclusion Antibiotic stewardship and strict adherence to infection control protocols in hospitals and guidelines for general practitioners can signifi cantly reduce the load of resistant organisms in the ICU. This may eventually improve patient outcomes and help in preserving the antibiotics for future generations. Methods We analyzed 535 consecutive patients with septic shock (sepsis-induced hypotension persisting despite adequate fl uid resuscitation) from the EPOSS database (Data-based Evaluation and Prediction of Outcome in Severe Sepsis), which was developed to monitor and assess treatment effi cacy in patient with severe sepsis and septic shock. Patients were admitted to participating ICUs (12 Source of MDR infections in an ICU: busting the myth R Agrawal This could be attributed to increased surveillance and adherence to infection control practices in the ICU which may not be followed stringently in other parts of the hospital. Overuse of broad-spectrum antibiotics in community and primary care hospitals has resulted in a spurt in growth of resistant infections. This has reached an alarming level in developing countries. Out of total cultures positive 78.3% (n = 822) were Gram-negative infections which included community-based and non-ICU infections. P105 Adequate initial antimicrobial therapy as the factor assessing treatment effi cacy in human septic shock P Szturz1, P Folwarczny1, J Švancara2, R Kula1, P Ševèík1 1University Hospital and Faculty of Medicine Ostrava University, Ostrava, Czech Republic; 2Institute of Biostatistic and Analyses, Masaryk University, Brno, Czech Republic Critical Care 2015, 19(Suppl 1):P105 (doi: 10.1186/cc14185) P105 Adequate initial antimicrobial therapy as the factor assessing treatment effi cacy in human septic shock P Szturz1, P Folwarczny1, J Švancara2, R Kula1, P Ševèík1 1University Hospital and Faculty of Medicine Ostrava University, Ostrava, Czech Republic; 2Institute of Biostatistic and Analyses, Masaryk University, Brno, Czech Republic Critical Care 2015, 19(Suppl 1):P105 (doi: 10.1186/cc14185) Prevalence of viral respiratory tract infections in acutely admitted and ventilated ICU patients: a prospective multicenter observational study F Van Someren Greve1, KF Van der Sluijs1, R Molenkamp1, AM Spoelstra-de Man2, OL Cremer3, RB De Wilde4, PE Spronk5, MD De Jong1, MJ Schultz1, NP Juff ermans1 1Academic Medical Center, Amsterdam, the Netherlands; 2VU Medical Center, Amsterdam, the Netherlands; 3University Medical Center Utrecht, the Netherlands; 4Leiden University Medical Center, Leiden, the Netherlands; 5Gelre Hospitals, Apeldoorn, the Netherlands Critical Care 2015, 19(Suppl 1):P104 (doi: 10.1186/cc14184) g p y gif Conclusion We found that correct choice of antibiotics improves outcome of septic shock patients. The choice of empirical antimicrobial therapy depends on complex factors related to the underlying disease, susceptibility of pathogens, patient’s history and clinical syndrome. Adequate initial antimicrobial therapy as an important factor of survival along with suitable initial fl uid resuscitation and application of vasopressors should be a priority for healthcare in human septic shock. References p , p , Critical Care 2015, 19(Suppl 1):P104 (doi: 10.1186/cc14184) Introduction The prevalence of viral respiratory tract infections in critically ill patients is uncertain, as well as the optimal diagnostic method to detect these. The aim of this study was to assess the prevalence of viral respiratory tract infections in mechanically ventilated patients, in both the upper and lower respiratory tract.i Source of MDR infections in an ICU: busting the myth R Agrawal FEHI, New Delhi, India Critical Care 2015, 19(Suppl 1):P106 (doi: 10.1186/cc14186) Source of MDR infections in an ICU: busting the myth R Agrawal FEHI, New Delhi, India Critical Care 2015, 19(Suppl 1):P106 (doi: 10.1186/cc14186) References 1. Dellinger RP, et al. Crit Care Med. 2013;41:580-637. 2. Kumar A, et al. Crit Care Med. 2006;34:1589-96. 1. Dellinger RP, et al. Crit Care Med. 2013;41:580-637. 2. Kumar A, et al. Crit Care Med. 2006;34:1589-96. Methods A prospective observational study was performed in fi ve ICUs in the Netherlands. From September 2013 to April 2014, consecutive acutely admitted, mechanically ventilated patients were included, regardless of diagnosis at admission. Nasopharyngeal (NP) swabs and tracheal aspirates (TA) were collected at intubation, and were tested via multiplex RT-PCR for the following viruses: infl uenza A and B, parainfl uenzaviruses, RSV, human metapneumoviruses, bocaviruses, coronaviruses, rhinoviruses, enteroviruses, parechoviruses and adenoviruses. Viral DNA/RNA copies were expressed by crossing-point (cp) values. References Concordance between qPC in VAP patients Positive Agreement culture qPCR (%) S. aureus 28/20 31/25 96.7/89.7 (BAL/ETA) P. aeruginosa 23/20 20/23 97.6/93.5 (BAL/ETA) Enterobacteriaceae 27/7 36/18 90.3/85.0 (BAL/ETA) Conclusion Sensitivity and specifi city of the ne for these main bacteria found in VAP could en antibiotic therapy. In the future, the developme aim at obtaining a bedside diagnostic in only a P108 Use of Cepheid Xpert Carba-R® for rapid detec carbapenemase-producing bacteria in critica surgical patients: fi rst report of an observatio A Cortegiani, V Russotto, P Capuano, G Tricoli, DM L Saporito, G Graziano, A Giarratano University of Palermo, Italy Critical Care 2015, 19(Suppl 1):P108 (doi: 10.1186/ Introduction Xpert Carba-R® (Cepheid®, USA) i rapid (<1 hour) detection of bacteria carrying genes (KPC, NDM, VIM, OXA-48, IMP-1). The compare PCR with microbiological cultures in surgical patients. Methods We performed an observational study P107 P107 Concordance between a new molecular real-time approach and traditional culture in suspected VAP patients M Clavel1, O Barraud2, V Moucadel3, MC Ploy2, E Karam4, F Meynier3, B François for Valibi Study Group5 1Hopital Dupuytren, Limoges, France; 2UMRS-1092, Hopital Dupuytren, Limoges, France; 3bioMérieux SA, Grenoble, France; 4Service de Réanimation, Brive, France; 5Inserm, Limoges, France Critical Care 2015, 19(Suppl 1):P107 (doi: 10.1186/cc14187) the ICU stay. We obtained two rectal swab specimens and two drainage samples to perform PCR assay and classic culture tests. We used Cohen’s K to test concordance of results. We considered concordant those results of positive detection of carbapenemase-producing bacteria by both methods (even if a polymicrobial growth was observed by cultures) or negative results by both methods. Concordance was studied for rectal swab and drainage specimens. Antibiotic susceptibility testing was performed through a semiquantitative method. the ICU stay. We obtained two rectal swab specimens and two drainage samples to perform PCR assay and classic culture tests. We used Cohen’s K to test concordance of results. We considered concordant those results of positive detection of carbapenemase-producing bacteria by both methods (even if a polymicrobial growth was observed by cultures) or negative results by both methods. Concordance was studied for rectal swab and drainage specimens. Antibiotic susceptibility testing was performed through a semiquantitative method. Results Eight complete samples sets were collected from seven patients. Seven rectal swab specimens were negative for both PCR and cultures. In one patient a positive culture from carbapenem-resistant P. aeruginosa was detected from the rectal swab resulting negative to PCR. References In one patient a positive culture from carbapenem-resistant A. baumanii was detected by drainage culture resulting negative to PCR. In two cases a positive result was observed from both PCR and cultures of rectal swab and drainage specimens. Vim and KPC genes were detected in one case and A. baumanii and K. pneumoniae with carbapenem resistance were isolated from cultures. A KPC gene was detected by PCR in the other case, and K. pneumoniae with carbapenem resistance was isolated from cultures. In all other cases a negative result was observed by both PCR and cultures. Cohen’s K of 0.71 (95% CI = 0.21 to 1) was observed for rectal swab and drainage specimens. Introduction Early microbiological documentation may reduce attributable mortality and excessive use of broad-spectrum antibiotics in ventilator-associated pneumonia (VAP). Using bronchoalveolar lavage (BAL) and endotracheal aspirates (ETA), we studied a new molecular biology-based approach to detect and quantify bacteria in less than 3 hours. This prospective multicenter trial aimed at comparing the microbiological results obtained using this molecular protocol (easyMAG® system) and semiquantitative culture in suspected VAP. y y q p Methods ETA and BAL samples were consecutively collected during 10 months in adult patients in four ICUs of France. The molecular method includes a preprocessing liquefaction for ETA before DNA extraction. DNAs were extracted using the easyMAG® system. Real- time PCR (qPCR) was run using the ABI7500FastDx PCR instrument. The results presented here concern: Staphylococcus aureus, Pseudomonas aeruginosa and Enterobacteriaceae. Quantifi cation was performed using qPCR standard curves, by converting the cycle threshold to CFU/ ml. Conclusion We need more data to evaluate the performance of PCR for rapid detection of carbapenemase-producing bacteria from rectal swabs and drainage of critically ill surgical patients even though its concordance with cultures seems to be good. Results A total of 125 suspected VAP were included from 122 patients. In total, 125 BAL and 107 ETA were collected. Sex ratio (M/F) was 76%, and CPIS ≥6 was calculated in 74.6% of the suspected VAP patients. Mean ventilation duration before sampling was 6 days. Seventy-eight percent and 65% of the BAL and ETA culture were positive respectively. Correlations between molecular method and culture on BAL and ETA are reported in Table 1. 09 Use of an electronic medical record system to improve antimicrobial stewardship P Allan, M Newman, J Collinson, L Bond, W English Royal Cornwall Hospital NHS Trust, UK Critical Care 2015, 19(Suppl 1):P109 (doi: 10.1186/cc14189) Use of an electronic medical record system to improve antimicrobial stewardship P Allan, M Newman, J Collinson, L Bond, W English Royal Cornwall Hospital NHS Trust, UK Critical Care 2015, 19(Suppl 1):P109 (doi: 10.1186/cc14189) P Allan, M Newman, J Collinson, L Bond, W English Royal Cornwall Hospital NHS Trust, UK Table 1 (abstract P107). Concordance between qPCR and culture on BAL/ETA in VAP patients Positive Agreement Sensitivity Specifi city culture qPCR (%) (%) (%) S. aureus 28/20 31/25 96.7/89.7 96.6/76.9 96.8/93.8 (BAL/ETA) P. aeruginosa 23/20 20/23 97.6/93.5 100/100 97.1/92.4 (BAL/ETA) Enterobacteriaceae 27/7 36/18 90.3/85.0 90.0/58.3 90.4/88.4 (BAL/ETA) Table 1 (abstract P107). Concordance between qPCR and culture on BAL/ETA in VAP patients Introduction Antimicrobial resistance constitutes a growing global threat, driven in part by inappropriate antimicrobial prescribing [1]. Most hospitals implement antibiotic policies to promote antimicrobial stewardship. This audit examined the Royal Cornwall Hospital Trust (RCHT) Critical Care Department’s compliance with the current standard defi ned in our local antimicrobial policy. This states that all antimicrobial prescriptions are to have an indication and review date recorded [2]. Sequential strategies to improve compliance were introduced prior to re-auditing the eff ects. Methods The RCHT Critical Care Department utilizes the Phillips Care Vue electronic patient record. Data from this system were interrogated at three stages to assess our compliance with the trust’s antimicrobial policy. The fi rst data interrogation was performed prior to any intervention, and refl ected baseline antimicrobial prescribing habits. The second data interrogation was performed during a period of active antibiotic stewardship promotion. The third data interrogation was performed following the addition of a care bundle to the prescribing module of Care Vue. This daily tick-box prompt reminded clinicians to check that all antimicrobial prescriptions had an indication and review date recorded. The records of all of the patients admitted to the critical care department during the periods of data interrogations were assessed for antimicrobial indication and review date transcription.i References . Klevens, et al. Estimating healthcare associated infections. Public Health Rep. 2007;122:160-6. . Klevens, et al. Estimating healthcare associated infections. Public Health Rep. 2007;122:160-6. . Hecker, et al. Unnecessary use of antimicrobials. Arch Intern Med. 2003;163:972-8. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S37 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P107 Concordance between a new molecular real-time approach and traditional culture in suspected VAP patients M Clavel1, O Barraud2, V Moucadel3, MC Ploy2, E Karam4, F Meynier3, B François for Valibi Study Group5 1Hopital Dupuytren, Limoges, France; 2UMRS-1092, Hopital Dupuytren, Limoges, France; 3bioMérieux SA, Grenoble, France; 4Service de Réanimatio Brive, France; 5Inserm, Limoges, France Critical Care 2015, 19(Suppl 1):P107 (doi: 10.1186/cc14187) Introduction Early microbiological documentation may red attributable mortality and excessive use of broad-spectrum antibio in ventilator-associated pneumonia (VAP). Using bronchoalve lavage (BAL) and endotracheal aspirates (ETA), we studied a molecular biology-based approach to detect and quantify bacter less than 3 hours. This prospective multicenter trial aimed at compa the microbiological results obtained using this molecular prot (easyMAG® system) and semiquantitative culture in suspected VAP. Methods ETA and BAL samples were consecutively collected du 10 months in adult patients in four ICUs of France. The molec method includes a preprocessing liquefaction for ETA before D extraction. DNAs were extracted using the easyMAG® system. R time PCR (qPCR) was run using the ABI7500FastDx PCR instrument. results presented here concern: Staphylococcus aureus, Pseudomo aeruginosa and Enterobacteriaceae. Quantifi cation was perform using qPCR standard curves, by converting the cycle threshold to C ml. Results A total of 125 suspected VAP were included from 122 patie In total, 125 BAL and 107 ETA were collected. Sex ratio (M/F) was 7 and CPIS ≥6 was calculated in 74.6% of the suspected VAP patie Mean ventilation duration before sampling was 6 days. Seventy-e percent and 65% of the BAL and ETA culture were positive respectiv Correlations between molecular method and culture on BAL and are reported in Table 1. Table 1 (abstract P107). Concordance between qPCR and culture on BAL/ in VAP patients Positive Agreement Sensitivity Specif culture qPCR (%) (%) (%) S. aureus 28/20 31/25 96.7/89.7 96.6/76.9 96.8/9 (BAL/ETA) P. References aeruginosa 23/20 20/23 97.6/93.5 100/100 97.1/9 (BAL/ETA) Enterobacteriaceae 27/7 36/18 90.3/85.0 90.0/58.3 90.4/8 (BAL/ETA) Conclusion Sensitivity and specifi city of the new molecular appro for these main bacteria found in VAP could enable targeted fi rst- antibiotic therapy. In the future, the development of this approach aim at obtaining a bedside diagnostic in only a few hours. P108 Use of Cepheid Xpert Carba-R® for rapid detection of carbapenemase-producing bacteria in critically ill, abdominal surgical patients: fi rst report of an observational study A Cortegiani, V Russotto, P Capuano, G Tricoli, DM Geraci, A Ghodousi, L Saporito, G Graziano, A Giarratano University of Palermo, Italy Critical Care 2015, 19(Suppl 1):P108 (doi: 10.1186/cc14188) Introduction Xpert Carba-R® (Cepheid®, USA) is a PCR-based assay rapid (<1 hour) detection of bacteria carrying carbapenem-resista genes (KPC, NDM, VIM, OXA-48, IMP-1). The aim of the study i compare PCR with microbiological cultures in critically ill, abdom surgical patients. Methods We performed an observational study at University Hospit Giaccone’ Palermo. We enrolled abdominal surgical patients admi to the ICU with suspected abdominal sepsis or developing sepsis du P107 Concordance between a new molecular real-t traditional culture in suspected VAP patients M Clavel1, O Barraud2, V Moucadel3, MC Ploy2, E Ka B François for Valibi Study Group5 1Hopital Dupuytren, Limoges, France; 2UMRS-1092, H Limoges, France; 3bioMérieux SA, Grenoble, France; 4 Brive, France; 5Inserm, Limoges, France Critical Care 2015, 19(Suppl 1):P107 (doi: 10.1186/ Introduction Early microbiological docum attributable mortality and excessive use of bro in ventilator-associated pneumonia (VAP). lavage (BAL) and endotracheal aspirates (ET molecular biology-based approach to detect a less than 3 hours. This prospective multicenter t the microbiological results obtained using t (easyMAG® system) and semiquantitative cultu Methods ETA and BAL samples were consecu 10 months in adult patients in four ICUs of method includes a preprocessing liquefactio extraction. DNAs were extracted using the e time PCR (qPCR) was run using the ABI7500Fast results presented here concern: Staphylococcu aeruginosa and Enterobacteriaceae. Quantif using qPCR standard curves, by converting the ml. Results A total of 125 suspected VAP were inclu In total, 125 BAL and 107 ETA were collected. S and CPIS ≥6 was calculated in 74.6% of the s Mean ventilation duration before sampling wa percent and 65% of the BAL and ETA culture we Correlations between molecular method and c are reported in Table 1. Table 1 (abstract P107). Micafungin concentrations 100 mg daily in plasma and burn eschars in patients with severe burn injuries gi q Results A total of 102 mechanically ventilated patients, 75 men and 27 women, were included in the study. All patients showed VAP caused by MDR bacteria. They were stratifi ed by outcome into survivors and nonsurvivors. ICU mortality was 55%. Gender, cause of admission, the causative microbe, colonization of bronchial secretions and secondary bacteremia had no correlation with outcome. Age and APACHE II score were higher in nonsurvivors (P <0.01 and P <0.05 respectively). The time-onset of pneumonia after admission was longer in patients with VAP caused by Klebsiella or Pseudomonas than those with VAP caused by acinetobacter (P <0.01). Patients with Klebsiella or Pseudomonas pneumoniae needed more time on mechanical ventilation than those with pneumonia from acinetobacter (P <0.01). Introduction Micafungin (MCF) is an echinocandin agent with broad activity against Candida spp., which are frequently isolated in blood and eschar cultures of burned patients, who present diff erent pharmacokinetics (PK) characteristics. Due to the limited information about its PK, we investigate MCF levels in plasma and burn eschar tissues in this population. Methods A PK study of MCF at standard dosage (100 mg/day). Cmax (end of the infusion) and Cmin (before next dose) plasma levels of MCF were obtained after fi rst dose and at steady state (days 4 and 5 of therapy); and on day 5 in eschars (1 to 3 hours after infusion). They were measured by HPLC. Spearman’s rho test was used for bivariate correlations between MCF exposure and patient’s clinical factors. Conclusion VAP caused by MDR bacteria is a leading cause of ICU death. Age and APACHE II score are signifi cant risk factors of death. References 1. Golia S, et al. J Clin Diagn Res. 2013;7:2462-6. 1. Golia S, et al. J Clin Diagn Res. 2013;7:2462-6. 1. Golia S, et al. J Clin Diagn Res. 2013;7:2462-6. 2. Charles MP, et al. Australas Med J. 2013;6:430-4. 2. Charles MP, et al. Australas Med J. 2013;6:430-4. Results There were 10 patients (eight men; age: 18 to 77 years). Patients’ characteristics and PK are shown in Table 1. A high interindividual variability was observed in the concentrations of MCF. Peak plasma concentrations after the fi rst and repeated doses of MCF were inversely correlated with % burned TBSA (Spearman’s ρ = –0.695 and –0.750 (P <0.05), respectively), but not with the time from burn injury. P108 P108 Use of Cepheid Xpert Carba-R® for rapid detection of carbapenemase-producing bacteria in critically ill, abdominal surgical patients: fi rst report of an observational study A Cortegiani, V Russotto, P Capuano, G Tricoli, DM Geraci, A Ghodousi, L Saporito, G Graziano, A Giarratano University of Palermo, Italy Critical Care 2015, 19(Suppl 1):P108 (doi: 10.1186/cc14188) Results From the fi rst data interrogation, antimicrobial prescriptions had an indication and review date transcription in 57% and 60% of cases respectively. Following the awareness campaign, the indication and review date transcription rate increased to 78% and 85% respectively. A daily electronic prompt was then added to our care bundle list. The fi nal data interrogation, performed after this intervention, demonstrated that the transcription rates for both the indication and the review date had increased to 96%. Introduction Xpert Carba-R® (Cepheid®, USA) is a PCR-based assay for rapid (<1 hour) detection of bacteria carrying carbapenem-resistance genes (KPC, NDM, VIM, OXA-48, IMP-1). The aim of the study is to compare PCR with microbiological cultures in critically ill, abdominal surgical patients. Conclusion We have demonstrated that the use of a daily prompt within an electronic patient record can greatly improve compliance in recording the indication and review date for all antimicrobials. These data support the widespread implementation of an electronic prescribing system where daily reminders are integrated in an eff ort to improve compliance with antimicrobial stewardship. Methods We performed an observational study at University Hospital ‘P. Giaccone’ Palermo. We enrolled abdominal surgical patients admitted to the ICU with suspected abdominal sepsis or developing sepsis during Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S38 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Eventually, the IC was confi rmed for 403/835 patients (peritonitis: 177; candidaemia: 141; deep candidiasis: 61; mixed infection sites: 24). Candida albicans was the main pathogen (67%), then C. glabrata (16%). At inclusion, CIC were treated with caspofungin (Cas): 55%, and fl uconazole (Flu): 34%, whereas these antifungals were administered to 46% and 45% of SIC, respectively. Patients with SIC were more severe than those with CIC. The two main criteria for initiating empirically an AFT were a central venous catheter (79%) and severe septic shock (70%). The rate of change of the initial AFT was higher in the CIC group (49%) than in the SIC group (33%, P <0.0001). P111 Epidemiological cohort study of systemic antifungal therapy for suspected or confi rmed invasive candidiasis in the ICU: the Amarcand2 study J Constantin1, JF Timsit2, JP Gangneux3, JP Mira4, P Montravers2, H Dupont5, P Perrigault6, O Lortholary7, E Azoulay8, O Leroy9 1CHU Estaing, Clermont-Ferrand, France; 2Paris Diderot University/Bichat Hospital, Paris, France; 3Rennes University Hospital, Rennes, France; 4Cochin University Hospital, Paris, France; 5Amiens University Hospital, Amiens, France; 6Montpellier University Hospital, Montpellier, France; 7Necker University Hospital, Paris, France; 8Saint-Louis University Hospital, Paris, France; 9Tourcoing University Hospital, Tourcoing, France Critical Care 2015, 19(Suppl 1):P111 (doi: 10.1186/cc14191) P108 In the CIC group, it was mostly for changing the antifungal agent (de-escalation Cas  Flu in half of the patients) based on mycological tests results. In the SIC group, the AFT was modifi ed almost as often for changing the drugs (including 22% de-escalation Cas  Flu) as for stopping the AFT. The 28-day mortality of candidaemia was 42% in cases of C. glabrata, 40% in cases of C. albicans, and 20% in cases of C. parapsilosis. Among survivors, the median duration of treatment was 17 to 21 days according to the infection site in cases of CIC, and 10 days in cases of SIC. Epidemiological cohort study of systemic antifungal therapy for suspected or confi rmed invasive candidiasis in the ICU: the Amarcand2 study J Constantin1, JF Timsit2, JP Gangneux3, JP Mira4, P Montravers2, H Dupont5, P Perrigault6, O Lortholary7, E Azoulay8, O Leroy9 1CHU Estaing, Clermont-Ferrand, France; 2Paris Diderot University/Bichat Hospital, Paris, France; 3Rennes University Hospital, Rennes, France; 4Cochin University Hospital, Paris, France; 5Amiens University Hospital, Amiens, France; 6Montpellier University Hospital, Montpellier, France; 7Necker University Hospital, Paris, France; 8Saint-Louis University Hospital, Paris, France; 9Tourcoing University Hospital, Tourcoing, France l l d y Conclusion This is the largest PK study of 100 mg daily of MCF in severely burned critically ill patients. The inverse correlation between MCF exposure and % burned TBSA suggests that patients with large burned TBSA may need higher doses of MCF. Nevertheless, MCF levels in plasma and burn eschar tissues after the fi rst and multiple doses were above the MIC90 against most clinically important Candida species. g y p g Critical Care 2015, 19(Suppl 1):P111 (doi: 10.1186/cc14191) Introduction Prescription of antifungal treatments (AFT) in ICUs in case of suspected or confi rmed invasive candidiasis (SIC or CIC) has been challenged by diff erent guidelines. The study aimed to describe the epidemiology of the invasive candidiasis (IC), analyze the criteria for the AFT initiation, the AFT type, and its changes during patient follow-up. Methods A prospective observational multicenter cohort study. Consecutive adult patients with SIC or CIC and treated with systemic AFT were included between October 2012 and September 2013 in 104 French ICUs. References 1. World Health Organisation. Antimicrobial resistance: global report on surveillance. 2014. http://www.who.int/drugresistance/documents/ surveillancereport/en/. 1. World Health Organisation. Antimicrobial resistance: global report on surveillance. 2014. http://www.who.int/drugresistance/documents/ surveillancereport/en/. 2. Royal Cornwall Hospital Trust. Automatic stop/review date policy for antimicrobials. 2012. Micafungin concentrations 100 mg daily in plasma and burn eschars in patients with severe burn injuries MCF concentrations in burn eschars were not correlated with % burned TBSA. MCF was well tolerated. One patient had candidemia. The crude mortality was 40%. P112 Micafungin concentrations 100 mg daily in plasma and burn eschars in patients with severe burn injuries A Agrifoglio1, MJ Asensio1, M Sánchez1, B Galván1, E Herrero1, L Cachafeiro1, E Perales1, S Luque2, A García de Lorenzo1 1La Paz/IdiPAZ University Hospital, Madrid, Spain; 2Hospital del Mar, Barcelona, Spain Critical Care 2015, 19(Suppl 1):P112 (doi: 10.1186/cc14192) Micafungin concentrations 100 mg daily in plasma and burn eschars in patients with severe burn injuries A Agrifoglio1, MJ Asensio1, M Sánchez1, B Galván1, E Herrero1, L Cachafeiro1, E Perales1, S Luque2, A García de Lorenzo1 1La Paz/IdiPAZ University Hospital, Madrid, Spain; 2Hospital del Mar, Barcelona, Spain Critical Care 2015, 19(Suppl 1):P112 (doi: 10.1186/cc14192) P113 P113 Tedizolid clearance by in vitro continuous renal replacement therapy model SJ Lewis, L Switaj, BA Mueller University of Michigan, Ann Arbor, MI, USA Critical Care 2015, 19(Suppl 1):P113 (doi: 10.1186/cc14193) Factors associated with survival of ICU patients with pneumonia caused by multidrug-resistant Gram-negative bacteria M Georgiadou, E Pappa, E Papandreou, H Pavlou, M Eforakopoulou KAT-EKA General Hospital Kifi sia, Athens, Greece Critical Care 2015, 19(Suppl 1):P110 (doi: 10.1186/cc14190) Introduction Multidrug-resistant (MDR) bacterial pneumonia is associated with signifi cant morbidity and mortality in severely ill ICU patients. The assessment of factors associated with the onset and clinical course of MDR pneumonia may improve treatment eff ectiveness. The purpose of this study is to identify factors associated with outcome in mechanically ventilated patients with ventilator- associated pneumonia (VAP) caused by MDR bacteria. y Conclusion French ICU patients are treated with antifungal agents selected according to the candidiasis severity, contrary to ESCMID guidelines which recommend initiating with echinocandins regardless of severity. As recommended, the therapy was secondarily adapted to microbiological results. p y Methods We studied retrospectively all mechanically ventilated patients treated in the A’ ICU of KAT General Hospital in Athens from 1 January 2011 to 31 December 2013 and showed ventilator-associated pneumonia from MDR Gram-negative bacteria. Standard demographic and clinical data, the causative organisms and outcome were recorded. For statistical signifi cance, chi-square and Student t tests were used. P112 P114 Stability of crushed tedizolid phosphate tablets for nasogastric tube administration G Kennedy1, J Osborn1, S Flanagan2, N Alsayed3, S Bertolami1 1Cubist Pharmaceuticals, Lexington, MA, USA; 2Cubist Pharmaceuticals, San Diego, CA, USA; 3Cubist Pharmaceuticals, Zurich, Switzerland Critical Care 2015, 19(Suppl 1):P114 (doi: 10.1186/cc14194) Introduction Tedizolid phosphate, a novel oxazolidinone antibacterial prodrug recently approved by the US Food and Drug Administration for the treatment of acute bacterial skin and skin structure infections, is available as oral (that is, tablets) and intravenous formulations. The clinical pharmacokinetics of tedizolid, the active moiety of tedizolid phosphate, are similar when orally administered tedizolid phosphate is given as powder in a capsule or as tablets. This suggests that crushing tablets prior to administration is unlikely to alter tedizolid pharmacokinetics, provided no drug is lost during administration. To determine whether the expected dose of tedizolid phosphate can be delivered via nasogastric (NG) tube in critically ill patients who have diffi culty swallowing, this study evaluated the stability and recovery of tedizolid phosphate 200 mg tablets after crushing, dispersion in water, and passage through an NG tube. Introduction Tedizolid phosphate, a novel oxazolidinone antibacterial prodrug recently approved by the US Food and Drug Administration for the treatment of acute bacterial skin and skin structure infections, is available as oral (that is, tablets) and intravenous formulations. The clinical pharmacokinetics of tedizolid, the active moiety of tedizolid phosphate, are similar when orally administered tedizolid phosphate is given as powder in a capsule or as tablets. This suggests that crushing tablets prior to administration is unlikely to alter tedizolid pharmacokinetics, provided no drug is lost during administration. To determine whether the expected dose of tedizolid phosphate can be delivered via nasogastric (NG) tube in critically ill patients who have diffi culty swallowing, this study evaluated the stability and recovery of tedizolid phosphate 200 mg tablets after crushing, dispersion in water, and passage through an NG tube. for treatment of nosocomial pneumonia, common in critically ill patients with acute kidney injury. There are limited data on tedizolid disposition in continuous renal replacement therapy (CRRT). This study’s purpose was to assess continuous hemofi ltration (CHF) and continuous hemodialysis (CHD) infl uence on tedizolid clearance. Methods Validated, bovine blood-based, in vitro CHF and CHD models were used with six new HF 1400 (polysulfone) and six new Multifl ow 150 (AN 69) hemodiafi lters. P113 Tedizolid clearance by in vitro continuous renal replacement therapy model P113 Tedizolid clearance by in vitro continuous renal replacement therapy model SJ Lewis, L Switaj, BA Mueller University of Michigan, Ann Arbor, MI, USA Critical Care 2015, 19(Suppl 1):P113 (doi: 10.1186/cc14193) Introduction Tedizolid is an oxazolidinone antibiotic approved to treat acute bacterial skin and soft tissue infection and is under investigation Results In total, 870 patients were included and 835 evaluable, the IC was confi rmed at study inclusion for 291 and suspected for 544 patients. S39 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Table 1 (abstract P112). Clinical and pharmacokinetic characteristics of patients Table 1 (abstract P112). Clinical and pharmacokinetic characteristics of patients Plasma Plasma Days from SOFA MCF dose Cmax/Cmin Cmax/Cmin Burn eschar admission at the % burned (mg/kg after fi rst dose at steady state tissue on day 5 to the start beginning LOS in BICU Patient TBSA % FT ABSI body weight) (μg/ml) (μg/ml) (μg/g) of MCF of MCF (days) 1 35 20 9 1.3 8.6/0.8 7.4/1.0 2.3 38 1 75 2 40 35 8 2.0 8.5/1.1 9.4/1.8 <LQ 15 6 23 3 23 16 8 1.3 6.4/0.8 10.3/1.2 <LQ 12 2 17 4 70 40 12 1.1 3.9/0.5 4.5/0.8 0.4 8 6 43 5 23 12 7 1.3 7.5/1.8 8.0/1.4 0.6 10 5 19 6 70 60 11 1.2 3.4/0.5 5.0/0.9 1.5 12 5 70 7 80 70 12 1.1 3.8/0.4 4.0/0.4 0.2 34 2 61 8 60 50 10 1.4 4.8/0.5 4.3/1.0 0.2 34 2 90 9 44 34 10 1.3 4.5/1.1 9.1/2.3 0.2 8 6 34 10 34 28 9 1.3 4.1/0.7 5.4/1.0 0.7 10 5 35 Median 42 34.5 9.5 1.3 4.7/0.7 6.4/1.0 0.5 12 5.0 39 IQR 31.3 to 70.0 19.0 to 52.5 8 to 11.3 1.1 to 1.4 3.9 to 7.5/0.5 to 1.1 4.5 to 9.1/0.9 to 1.4 0.3 to 1.1 9.5 to 19.8 3.5 to 5.6 22.7 to 71.3 ABSI, Abbreviated Burn Severity Index; BICU, burn intensive care unit; FT, full thickness; IQR, interquartile range; LOS, length of hospital stay; LQ, limit of quantifi cation (<0.1 μg/ml); SOFA, Sequential Organ Failure Assessment; TBSA, total body surface area. CLTM appears modest relative to total body clearance and is unlikely to require dose adjustments. CRRT adsorption in the clinical setting is likely less than what we observed in this in vitro, continuously recirculating blood model. CLTM appears modest relative to total body clearance and is unlikely to require dose adjustments. P113 Tedizolid clearance by in vitro continuous renal replacement therapy model CRRT adsorption in the clinical setting is likely less than what we observed in this in vitro, continuously recirculating blood model. Figure 1 (abstract P113). P114 Stability of crushed tedizolid phosphate tablets for nasogastric tube administration G Kennedy1, J Osborn1, S Flanagan2, N Alsayed3, S Bertolami1 1Cubist Pharmaceuticals, Lexington, MA, USA; 2Cubist Pharmaceuticals, San Diego, CA, USA; 3Cubist Pharmaceuticals, Zurich, Switzerland Critical Care 2015, 19(Suppl 1):P114 (doi: 10.1186/cc14194) P114 Stability of crushed tedizolid phosphate tablets for nasogastric tube administration P115 P115 Antiviral prophylaxis inhibits cytomegalovirus reactivation in critical illness NJ Cowley1, A Owen1, J Millar1, SC Shiels1, RL Woolley2, NJ Ives2, H Osman1, P Moss2, JF Bion1 1University Hospital Birmingham, UK; 2University of Birmingham, UK Critical Care 2015, 19(Suppl 1):P115 (doi: 10.1186/cc14195) Introduction Reactivation of latent cytomegalovirus (CMV) can lead to viraemia or CMV disease and has been detected in up to 30% of critically ill patients without prior history of immune suppression. However, the clinical importance of this observation remains unclear. We report a proof-of-concept randomised controlled trial of two antiviral drugs in intensive care patients to determine their impact on CMV reactivation. Methods We conducted a single-centre randomised controlled study of high-dose valaciclovir or low-dose valganciclovir prophylaxis, as compared with standard care, in CMV seropositive patients in the ICU at Queen Elizabeth Hospital Birmingham, UK. Patients were excluded if CMV seronegative. Study participants randomised to a study drug received either 450 mg valganciclovir daily enterally (or ganciclovir intravenously) or 2 g valaciclovir four times daily enterally (or aciclovir intravenously) for a period of up to 28 days. Blood was collected for CMV viral load during the 28-day study period. The primary outcome measure was reactivation of CMV in blood above 20 copies.ml–1 (assay detection limit) by day 28. Methods DAP (6 mg/kg) was administered intravenously every 48 hours to CVVHDF patients in the ICU. Blood and fi ltrate samples were collected at 0, 1, 1.5, 2, 5, 12, 24, and 48 hours after infusion. All collected samples were analyzed using HPLC according to the method of Tobin and colleagues [3]. Maximum concentration (Cmax), elimination half- life (t1/2), area AUC, Cmin, volume of distribution (Vd), clearance (CL), fraction unbound, and sieving coeffi cient (Sc) were evaluated. Patient characteristics and CVVHDF parameters including blood, dialysate, and fi ltration fl ow rates were recorded. il Results Three patients were included in the study. Mean blood, dialysate, and fi ltration fl ow rates were 86.7 ± 11.5 ml/minute, 417 ± 29 ml/hour, and 417 ± 29 ml/hour, respectively, confi rming that CVVHDF was performed under low-fl ow setting. P115 Cmax was 50.1 ± 12.7 mg/l (31.9, 70.5, 49.7 mg/l); t1/2, 35.1 ± 34.8 hours (18.6, 11.5, 70.5 hours); AUC, 889 ± 399 mg hour/l (471, 967, 1,260 mg hour/l); Cmin, 16.0 ± 10.3 mg/l (2.3, 24.7, 14.0 mg/l); Vd, 26.0 ± 20.9 l (23.8, 6.34, 47.9 l); CL, 9.47 ± 4.56 ml/minute (14.7, 6.35, 7.37 ml/minute); and fraction unbound, 5.8% (5.7, 4.1, 7.6%). Sc and CL of dialyzer were 0.08 ± 0.03 (0.11, 0.04, 0.07) and 1.20 ± 0.39 ml/minute (1.70, 0.88, 0.96 ml/minute), respectively. Results A total of 124 patients were randomised; 44 control, 34 valaciclovir, and 46 valganciclovir. Recruitment to the valaciclovir arm was halted early because of an imbalance in mortality (44% mortality vs. 19% in other arms). Independent blinded review of all deaths did not reveal any deaths attributable to unexpected causes. Fourteen patients were excluded from the primary analysis because of baseline CMV reactivation. CMV reactivation occurred in 30% (12/40) of the control arm but only 3% (1/39) in the valganciclovir arm (RR: 0.09 (95% CI: 0.01, 0.6)). When the two treatment arms were considered together, reactivation was observed in only 4% (3/70) (RR: 0.1 (95% CI: 0.04, 0.5)). See Figure 1. Conclusion DAP (6 mg/kg daptomycin every 48 hours) in patients receiving low-fl ow CVVHDF resulted in showing variability of AUC and avoiding accumulation. Owing to small case numbers, it needs further study. g Conclusion This is the fi rst study in critical care to assess the feasibility of antiviral prophylaxis to prevent CMV reactivation in a mixed population of critically ill patients. Low-dose valganciclovir was shown to suppress CMV reactivation as eff ectively as higher-dose valaciclovir. P114 Stability of crushed tedizolid phosphate tablets for nasogastric tube administration Tedizolid’s transmembrane clearances (CLTM) during CHF and CHD were assessed by measuring sieving (SC) and saturation (SA) coeffi cients at various ultrafi ltrate (Quf) (1, 2, 3 l/ hour) and dialysate fl ow rates (Qd) (1, 2, 3 and 6 l/hour), using a blood fl ow rate (Qb) of 200 ml/minute. Tedizolid adsorption was tested in a 1 l recirculating CHF model at Quf of 2 l/hour and Qb of 200 ml/minute over 4 hours. Adsorption (%) was calculated after correcting for the dilution by CHF priming volume. Urea was added as a control in all experiments. Methods For each assay, run in triplicate, one 200 mg tablet of tedizolid phosphate was crushed, dispersed in water, drained under gravity through one of two types of NG tubes (type 1, Kangaroo Nasogastric Feeding Tube, 10 Fr 43" (109 cm); type 2, Salem Sump Dual Lumen Stomach Tube, 18 Fr/CH (6.0 m) 48" (122 cm)), and collected for recovery analysis by high-performance liquid chromatography with UV detection. To analyze the chemical stability of the crushed tablet dispersed in water, the aqueous preparation was assayed initially after dispersion and again after 4 hours at room temperature, without NG tube passage. The prespecifi ed limit for tedizolid phosphate in recovery samples was 90 to 110% of the dose. Limits were also specifi ed for levels of certain impurities. Results Urea SC and SA were ~1 in all experiments. In CHF, mean tedizolid SC ranged from 0.52 to 0.57 for HF1400 and from 0.50 to 0.54 for M150. CLTM did not diff er between fi lter types for Quf of 1, 2, and 3 l/hour. In CHD, mean tedizolid SA ranged from 0.46 to 0.56 for HF1400 and from 0.38 to 0.44 for M 150. Tedizolid CLTM with the HF1400 was higher than M150 values at Qd of 6 l/hours (P <0.02). Tedizolid exhibited irreversible adsorption within 10 minutes. See Figure 1. Results The average and individual recovery values of tedizolid phosphate were within 90 to 110% of the 200 mg dose when crushed tablets, dispersed in water at room temperature, were transferred through the 2 NG tubes (type 1: 95.8%; type 2: 93.6%). There was Conclusion Tedizolid’s CLTM is dependent on hemodiafi lter type and Qd for CHD and Quf in CHF. P114 Stability of crushed tedizolid phosphate tablets for nasogastric tube administration At conventional CRRT rates, tedizolid S40 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Acknowledgements Research funded by the NIHR under the RfPB Programme (PG 1010 23225). Views expressed are of the authors and not necessarily the NHS, NIHR, or DOH. no signifi cant change in recovery values after 4 hours of storage at room temperature (93.9% initially and 94.7% after 4 hours). Results for degradation products and impurities were also within specifi ed limits in NG recovery samples and in the 0-hour and 4-hour aqueous preparations. P116 p p Conclusion The stability and recovery of tedizolid phosphate were not infl uenced by crushing the tablets and passing through an NG tube. Therefore, administration of crushed tedizolid phosphate tablets to patients is unlikely to alter the pharmacokinetics of tedizolid compared with whole tablets. Pharmacokinetics of daptomycin in patients undergoing low-fl ow continuous venovenous hemodiafi ltration TI Ide1, Y Takesue1, K Ikawa2, S Nishi1 1Hyogo College of Medicine, Nishinomiya City, Japan; 2Hiroshima University, Hiroshima, Japan Critical Care 2015, 19(Suppl 1):P116 (doi: 10.1186/cc14196) Introduction In daptomycin (DAP), 1,061 mg hour/l of the area under the concentration–time curve (AUC)/MIC was required to obtain clinical success [1], and a trough serum concentration (Cmin) cutoff point of 24.3 g/ml was most signifi cantly associated with CPK elevation [2]. Reportedly, DAP at a recommended dosage of 8 mg/kg is removed in patients undergoing high-fl ow continuous venovenous hemodiafi ltration (CVVHDF) (blood fl ow and fi ltration rates were 150 ± 48 and 2 l/hour). In Japan, CVVHDF is preferentially performed with lower fl ow rates. Investigating eff ects of fl ow rate on DAP removal during continuous renal replacement therapy is essential to adjust therapeutic dosages. We aimed to investigate the pharmacokinetics of DAP in CVVHDF patients in this setting. PK/PD of single-dose amikacin in emergency department patients with severe sepsis/shock: should we apply the ICU-based higher loading dose? PK/PD of single-dose amikacin in emergency department patients with severe sepsis/shock: should we apply the ICU-based higher loading dose? S De Winter1, J Wauters1, E Van Wijngaerden1, W Peetermans1, P Annaert2, J Verhaegen1, JB Gillet1, D Knockaert1, I Spriet1 1University Hospitals Leuven, Belgium; 2Catholic University Leuven, Belgium Critical Care 2015, 19(Suppl 1):P118 (doi: 10.1186/cc14198) Methods A total of four colistin-resistant (MIC ≥4) GNB were isolated from ICU patients with nosocomial MDR infections. All four isolates were Klebsiella pneumonia. Among these isolates three were from blood and one from endotracheal aspirate and all four isolates were sensitive to fosfomycin in vitro. All of these patients had multiple comorbidities with recent history of colistin exposure. Intravenous fosfomycin sodium (inj Fosmicin; Meiji, Japan) was started as a combination therapy with carbapenem. Introduction Studies in the ICU showed that a single amikacin dose of ≥25 mg/kg should be used in conditions of increased distribution volume (Vd) such as severe sepsis/shock [1]. However, no data are available for emergency department (ED) patients in the early phase of sepsis/septic shock. The purpose of this study was to determine whether a single amikacin dose of 25 versus 15 mg/kg results in PK/PD target attainment for ED patients. Results Among the three bacteremic patients, two recovered completely from sepsis as well as the patient with ventilator-associated pneumonia. There was clinical as well as microbiological cure with normalization of sepsis markers. The only one bacteremic patient who died during the course of therapy was later diagnosed to have azole- resistant fungemia as a superinfection. g p Methods ED patients with severe sepsis/shock were randomly treated with a single amikacin dose of 25 versus 15 mg/kg. Blood samples were collected at +1 (peak), +6 hours and +24 hours (trough) after the start of infusion. Primary outcome was PK/PD target attainment defi ned as a peak/MIC >8, corresponding with both actual MIC values documented from isolated pathogens, as well as EUCAST susceptibility breakpoints for Enterobacteriaceae and P. aeruginosa; that is, 8 mg/l. Noncompartmental analysis was used to calculate PK parameters. g p Conclusion Based on the evidence of clinical experience and available studies, intravenous fosfomycin therapy may be considered as the last option for the treatment of MDR GNB infection where there is documented colistin resistance and where there is literally no other choice of antibiotic therapy. PK/PD of single-dose amikacin in emergency department patients with severe sepsis/shock: should we apply the ICU-based higher loading dose? Results During a study duration of 20 months, 50 patients were enrolled in each dosing regimen resulting in 100 peak concentrations, 92 and 88 +6 hours and +24 hours concentrations respectively. Target attainment using local MIC values (median 2 mg/l, documented in 56 isolated Gram-negative pathogens) was achieved in 95% in both groups (P = 0.98). Using EUCAST susceptibility breakpoints, the target Table 1 (abstract P118) Introduction In vitro studies suggest that there is signifi cant adsorption of amikacin, netilmicin, gentamicin and tobramycin to polyacrylonitrile haemofi lters. This occurs rapidly and has the potential to substantially reduce the peak aminoglycoside concentration, which will reduce effi cacy [1]. However, whether signifi cant adsorption occurs in vivo is unknown. We therefore carried out a controlled in vivo study of the eff ect of amikacin adsorption by polyacrylonitrile fi lters during haemofi ltration, using a porcine model of acute renal failure. l, clearance. aMann–Whitney U <0.05, 15 versus 25 mg/kg ED patients Conclusion The EUCAST-based PK/PD target was only attained in 76% of patients treated with 25 mg/kg. However, in contrast to ICU patients, the majority of ED patients are treated for community-acquired infections, so MIC values are signifi cantly lower than the EUCAST susceptibility breakpoints, warranting PK/PD target attainment in both 25 and 15 mg/kg dosing regimens when local epidemiology is taken into account. i g p Methods A porcine model of acute renal failure was created by bilateral ligation of the renal arteries and veins. Eight pigs underwent haemofi ltration using a 0.6 m2 polyacrylonitrile fi lter, blood fl ow 200 ml/ minute, ultrafi ltration rate 1,000 ml/hour. All ultrafi ltrate was returned to the pigs via a separate venous catheter so that any elimination of amikacin by haemofi ltration could only be due to adsorption. Another eight pigs underwent sham haemofi ltration in which blood was pumped around a haemofi ltration circuit without a haemofi lter and without ultrafi ltration. Both groups of pigs were given intravenous amikacin, 15 mg/kg body weight over 30 minutes, and blood samples were taken from the arterial limb of the haemofi lter circuit at 0, 5, 10, 15, 20, 25, 30, 40, 50, 60, 75, 90, 105, 120, 150, and 180 minutes after the start of the amikacin administration to assay amikacin concentrations. Results Post-distribution peak concentration of amikacin was slightly, but signifi cantly, lower in the CRRT group than that in sham group (55.0 ± 4.5 vs. 61.1 ± 5.9 mg/l, P <0.05).f Reference 1. Taccone et al. Crit Care. 2013;14:R53. Intravenous fosfomycin therapy in critically ill patients infected with colistin-resistant enterobacteriacae Conclusion This study shows that the eff ect of adsorption by polyacrylonitrile haemofi lters on in vivo amikacin peak concentrations is small, and less than would be expected from in vitro data. Introduction Carbapenem-resistant enterobacteriacae emerged in recent years as one of the most challenging groups of antibiotic- resistant pathogens. Polymyxins are considered as the last resort for the treatment of infections with carbapenem-resistant Gram-negative bacilli (GNB). Inadequate or extensive use of colistin leads to emergence of colistin resistance in GNB, jeopardizing treatment options in ICUs, potentially increasing mortality and morbidity and necessitating prudent use of alternative antibiotics. Fosfomycin, a phosponic acid derivative which acts primarily by disrupting bacterial cell wall synthesis, is a broad-spectrum antibiotic. Fosfomycin tromethamine is an oral formulation approved for the treatment of uncomplicated urinary tract infection caused by multidrug-resistant (MDR) bacteria. Recently fosfomycin is also available as a sodium/disodium formulation for intravenous use, which is showing promising result against MDR/ potentially drug-resistant pathogens. Acknowledgement This work was supported by a grant from the Hong Kong Research Grants Committee, CUHK 4644/08M. Reference 1. Tian Q, Gomersall CD, Ip M, Tan PE, Joynt GM, Choi GY. Adsorption of amikacin, a signifi cant mechanism of elimination by hemofi ltration. Antimicrob Agents Chemother. 2008;52:1009-13. References 1. Safdar N, et al. Antimicrob Agents Chemother. 2004;48:63-8. 2. Bhavnani SM, et al. Clin Infect Dis. 2010;50:1568-74. . Safdar N, et al. Antimicrob Agents Chemother. 2004;48:63-8. 3. Tobin CM, et al. J Antimicrob Chemother. 2008;62:1462-3. Figure 1 (abstract P115). CMV reactivation over time. Each line represents a single patient. Figure 1 (abstract P115). CMV reactivation over time. Each line represents a single patient. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S41 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 was attained in 76% versus 40% in the 25 versus 15 mg/kg group, respectively (P < 0.0001). Single-dose PK parameters are displayed in Table 1 and compared with the ones reported in the ICU [1]. P117 P117 Adsorption of amikacin during continuous venovenous haemofi ltration in a swine model of acute renal failure CD Gomersall, Q Tian, D Reynolds, M Ip, G Choi, G Joynt The Chinese University of Hong Kong, Shatin, Hong Kong Critical Care 2015, 19(Suppl 1):P117 (doi: 10.1186/cc14197) Table 1 (abstract P118) PK parameter 15 mg/kg ED 25 mg/kg ED 25 mg/kg ICU Peak (mg/l) 58 (47 to 70)a 91 (72 to 105)a 73 (62 to 90) Trough (mg/l) 6 (3 to 12) 5 (3 to 15) 7 (2 to 15) Vd (l/kg) 0.3 (0.3 to 0.5) 0.4 (0.2 to 0.6) 0.4 (0.3 to 0.5) Cl (ml/minute/kg) 1.6 (1 to 2.3)a 2.2 (1.4 to 3)a 1.9 (1.3 to 3.5) Cl, clearance. aMann–Whitney U <0.05, 15 versus 25 mg/kg ED patients. 1. Antoniadou A, Kontopidou F, Poulakou G, Koratzanis E, Galani I, Papadomichelakis E, et al. Colistin-resistant isolates of Klebsiella pneumoniae emerging in intensive care unit patients: fi rst report of a multiclonal cluster. J Antimicrob Chemother. 2007; 59:786-90. P120 Performance of amikacin inhale: impact of supplemental oxygen and device orientation Introduction Amikacin Inhale is an integrated drug–device combi- nation in development by Bayer HealthCare through a collaboration with Nektar Therapeutics, to improve clinical outcome in intubated and mechanically ventilated patients with Gram-negative pneumonia. It is available in two confi gurations: on-vent for intubated patients and hand-held for extubated patients to complete aerosolized antibiotic therapy. Amikacin Inhale is a smart system that consists of the pulmonary drug delivery system with a vibrating mesh nebulizer and the specially formulated Amikacin Inhalation Solution (400 mg every 12 hours for 10 days). The objectives of this study were to evaluate the performance of the Amikacin Inhale hand-held confi guration with supplemental O2 concentration supplied at diff erent fl ow rates and in diff erent orientations. We hypothesize that the delivered dose of amikacin will not signifi cantly change with increased O2 fl ow rate or varying orientation.i q Results Preventive administration of IT as an adjunct to systemic antibiotics was associated with a lower incidence of NP in group 1 (group 1 33.3%, group 2 66.7%, χ2 = 6,000; P = 0.014) and a shorter duration of ICU stay (group 1 8.0 ± 4.6 days vs. 17.1 ± 18.4 days, P = 0.03). The mortality did not diff er between groups: 11.1% in group 1 and 22.2% in group 2 (P ≥0.99). On day 3 Acinetobacter spp. (30.5%), K. pneumoniae (22.0%), B. cepacia (13.2%) and P. aeruginosa (34.3%) were detected in BAL, there were no diff erences between groups. In group 1 CPIS remained stable and APACHE II decreased. CPIS and APACHE II were lower in group 1 on day 5 (P = 0.0004). y Conclusion Early administration of IT as an adjunct to systemic antibiotics is eff ective in prevention of NP in multiple trauma patients: it promotes decrease of NP incidence and decrease of ICU stay. Methods In the hand-held confi guration of Amikacin Inhale, amikacin is aerosolized into a holding chamber. Amikacin aerosol is inhaled with ambient air entering the bottom of the chamber through the inhalation valve. Supplemental O2 may be supplied through the O2 port and mixes with ambient air entering through the inhalation valve. O2 concentration and delivered dose at the mouthpiece exit were characterized in vitro at various O2 fl ow rates (2 to 10 l/minute). O2 concentrations were measured every minute until the end of dosing. Early preventive administration of inhaled tobramycin in severe polytrauma Early preventive administration of inhaled tobramycin in severe polytrauma A Kuzovlev1, A Shabanov2, T Chernenkaya2, V Moroz1, A Goloubev1 1V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia; 2N.V. Sklifosofsky Research Institute, Moscow, Russia Critical Care 2015, 19(Suppl 1):P121 (doi: 10.1186/cc14201) y Results Overall, nine cases with CNS infection were recorded aged from 22 to 74, all males. LP was performed between the second and 17th day (average 8.3 days) and the CSF analysis showed 40 to 6,000 cells – mainly PMNs, protein 161 mg% to 287 mg% and glucose from 3 to 58 mg/dl. They were all colonized with Acinetobacter baumannii sensitive only to colistin. CSF cultures were negative for all patients besides one, who grew A. baumannii. Of those, seven (77%) were receiving i.v. colistin, eight (88%) carbapenems, and eight (88%) glycopeptides, all in combination with other antibiotics. Median i.t. administration time was 9.1 days. All patients responded to i.v. and i.t. antibiotics but there was one case in which fever relapsed and increased number of cells in subsequent LP was observed which was attributed to colistin, which was withdrawn. All these patients survived, and were discharged to the ward. p y A Kuzovlev1, A Shabanov2, T Chernenkaya2, V Moroz1, A Goloubev1 1V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia; 2N.V. Sklifosofsky Research Institute, Moscow, Russia Critical Care 2015, 19(Suppl 1):P121 (doi: 10.1186/cc14201) Introduction Nosocomial pneumonia (NP) occurs in 30 to 50% of multiple trauma patients. It is mostly caused by multiresistant Gram- negative bacteria. Use of inhaled antibiotics as adjuncts to systemic antibiotics presents a great outlook for the prevention of NP in multiple trauma patients. The aim of the study was to evaluate the effi cacy of early administration of inhaled tobtamycin (IT) as an adjunct to systemic antibiotics for the prevention of NP in polytrauma. Methods Fifty-four ICU mechanically ventilated patients with multiple trauma (ISS >30; car accident 55.6%; fall 29.6%; train accident 11.1%; domestic 3.7%) were enrolled in the single-center randomized trial. Groups were comparable in ISS, age, sex, type of trauma, and blood loss. Patients were randomized into two groups: Group 1 (n = 27), addition of IT to systemic antibiotics (ciprofl oxacin 800 mg/day; metronidazol 1,500 mg/day); Group 2 (n = 27), only systemic antibiotics (same regimen). Early preventive administration of inhaled tobramycin in severe polytrauma Inhaled tobramycin (300 mg twice daily via nebulizer) and systemic antibiotics were administered within the fi rst 24 hours Conclusion Patients treated with the abovementioned regime showed clinical and biochemical improvement. The above drug combination turned out to be successful in neurosurgical ICU patients with CNS infection. Intrathecal administration of colistin, vancomycin and amikacin for central nervous system infections in ICU neurosurgical patients P Alexandropoulos, S Georgiou, V Chantziara, A Tsimogianni, E Chinou, V Karagiannisa, G Michaloudis Introduction Central nervous system (CNS) infections in ICU patients after neurosurgery are a diffi cult and life-threatening complication demanding immediate action. In many cases intravenous (i.v.) administration of antibiotics is not suffi cient; thus, intrathecal (i.t.) administration is required. g pi pp 2 Results The mean O2 concentration ranged from 36 to 70% over 2 to 10 l/minute and was ≥40% at ≥3 l/minute. The delivered dose did not change substantially with increasing enriched O2 fl ow rate (72 to 82% of nominal dose). At 0° and 45° orientations, the delivered dose of amikacin was 74 to 80% and 73 to 76% of the nominal dose (400 mg), respectively. Methods From January 2013 to November 2014 all cases with CNS infections were recorded. Inclusion criteria were the presence of fever ≥38.5°C, increased infl ammatory markers, compatible lumbar puncture (LP) fi ndings (increased number of polymorphonuclear leukocytes, increased protein and low glucose compared with serum levels) and no evidence of other site of infection. All subjects were receiving appropriate i.v. antibiotic treatment based on cultures. Intrathecal administration of 300,000 iu colistin, 25 mg vancomycin and 25 mg amikacin was performed taking under consideration that neurosurgical patients in the ICU have CNS infection attributed to Gram-negative bacteria or/and to Staphylococcus species. Conclusion Amikacin Inhale was shown in vitro to be suitable for extubated patients who require supplemental O2. The delivered dose was independent of supplemental O2 and device orientation. P120 Performance of amikacin inhale: impact of supplemental oxygen and device orientation A ventilator was connected to the set up to simulate patient breathing. The delivered dose was measured at the exit of the mouthpiece. Drug distribution within the test setup compartments was analyzed using HPLC. The in vitro delivered amikacin dose was also measured at nebulizer orientations of 0° and 45° (n = 3 per orientation) using a simulated breathing profi le with no supplemental O2. P122 Intrathecal administration of colistin, vancomycin and amikacin for central nervous system infections in ICU neurosurgical patients P Alexandropoulos, S Georgiou, V Chantziara, A Tsimogianni, E Chinou, V Karagiannisa, G Michaloudis Saint Savvas Oncology Hospital, Athens, Greece Critical Care 2015, 19(Suppl 1):P122 (doi: 10.1186/cc14202) Reference 1. Antoniadou A, Kontopidou F, Poulakou G, Koratzanis E, Galani I, Papadomichelakis E, et al. Colistin-resistant isolates of Klebsiella pneumoniae emerging in intensive care unit patients: fi rst report of a multiclonal cluster. J Antimicrob Chemother. 2007; 59:786-90. 1. Antoniadou A, Kontopidou F, Poulakou G, Koratzanis E, Galani I, Papadomichelakis E, et al. Colistin-resistant isolates of Klebsiella pneumoniae emerging in intensive care unit patients: fi rst report of a multiclonal cluster. J Antimicrob Chemother. 2007; 59:786-90. S42 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P120 P120 Performance of amikacin inhale: impact of supplemental oxygen and device orientation N Kadrichu1, K Corkery1, T Dang1, P Challoner2 1Novartis Pharmaceuticals, San Carlos, CA, USA; 2Nektar Therapeutics, San Francisco, CA, USA Critical Care 2015, 19(Suppl 1):P120 (doi: 10.1186/cc14200) after ICU admission. After obtaining the results of bronchoalveolar lavage microbiology, the antibiotic regimen was switched according to the sensitivity. The primary outcome measure was new onset of NP and duration of ICU stay. Microbiological, X-ray, CPIS, signs of sepsis and oxygenation index were used as objective indicators of the clinical progress. The secondary outcome measure was 30-day mortality. Diagnosis of NP was made according to the standard clinical and CPIS criteria. The data were statistically analyzed by SPSS 11.5 (M, σ, Newman–Keuls test; chi-square-test P <0.05). after ICU admission. After obtaining the results of bronchoalveolar lavage microbiology, the antibiotic regimen was switched according to the sensitivity. The primary outcome measure was new onset of NP and duration of ICU stay. Microbiological, X-ray, CPIS, signs of sepsis and oxygenation index were used as objective indicators of the clinical progress. The secondary outcome measure was 30-day mortality. Diagnosis of NP was made according to the standard clinical and CPIS criteria. The data were statistically analyzed by SPSS 11.5 (M, σ, Newman–Keuls test; chi-square-test P <0.05). Adjunct prednisone therapy for patients with community-acquired pneumonia: a randomized, placebo-controlled multicenter trial CA Bl 1 N Ni 1 M B i l1 P S h 2 E Ull 3 I S Wid 1 Adjunct prednisone therapy for patients with community-acquired pneumonia: a randomized, placebo-controlled multicenter trial CA Blum1, N Nigro1, M Briel1, P Schuetz2, E Ullmer3, I Suter-Widmer1, B Winzeler1, R Bingisser1, H Elsaesser3, D Drozdov2, B Arici2, SA Urwyler1, J Refardt1, P Tarr4, S Wirz4, R Thomann5, C Baumgartner6, H Duplain7, D Burki8, W Zimmerli3, N Rodondi6, B Mueller2, M Christ-Crain1 1University Hospital Basel, Switzerland; 2Medical University Clinic, Kantonsspital Aarau, Switzerland; 3Kantonsspital Baselland/Liestal, Liestal, Switzerland; 4Kantonsspital Baselland/Bruderholz, Bruderholz, Switzerland; 5Bürgerspital, Solothurn, Switzerland; 6Inselspital, Bern University Hospital, Bern, Switzerland; 7Hôpital du Jura, Site de Delémont, Delémont, Switzerland; 8Viollier SA, Basel, Switzerland Results We included nine trials enrolling 2,637 patients. Eight trials were of unclear risk of bias and one was classifi ed as having low risk of bias. In trials comparing heparin with placebo or usual care, the risk ratio for death associated with heparin was 0.88 (95% CI = 0.77 to 1.00, I2 = 0%, 2477 patients, six trials). In trials comparing heparin with other anticoagulants, the risk ratio for death was 1.30 (95% CI = 0.78 to 2.18, I2 = 0%, 160 patients, three trials). In trials comparing heparin with placebo or usual care, major hemorrhage was not statistically signifi cantly increased (risk ratio 0.79, 95% CI = 0.53 to 1.17, I2 = 0%, 2,392 patients, three trials). In one small trial of heparin compared with other anticoagulants, the risk of major hemorrhage was signifi cantly increased (2.14, 95% CI = 1.07 to 4.30, 48 patients). Important secondary and safety outcomes, including minor bleeding, were sparsely reported. Critical Care 2015, 19(Suppl 1):P125 (doi: 10.1186/cc14205) Critical Care 2015, 19(Suppl 1):P125 (doi: 10.1186/cc14205) Introduction Clinical trials yielded confl icting data about the benefi t of adding systemic corticosteroids for community-acquired pneumonia (CAP). We evaluated whether short-term corticosteroid treatment reduces time to clinical stability in patients hospitalized for CAP. Methods This randomized, placebo-controlled multicenter trial compared prednisone 50 mg for 7 days with placebo in patients hospitalized with CAP. The primary endpoint was time to clinical stability. Results Overall, 802 patients were randomized in seven Swiss hospitals from December 2009 to May 2014. Time to clinical stability was shorter in the prednisone group compared with placebo (3.0 vs. 4.4 days, HR = 1.33, 95% CI = 1.15 to 1.50, P <0.001). The prednisone group as compared with the placebo group had a shorter time to hospital discharge (6 vs. i References 1. Alejandria MM, Lansang MD, Dans LF, Mantaring III JBlas. Intravenous immunoglobulin for treating sepsis, severe sepsis and septic shock. Cochrane Database Syst Rev. 2013;9:CD001090. doi:10.1002/14651858.CD001090.pub2. 2. Department of Health. Clinical guidelines for immunoglobulin use. London: Department of Health; 2011. y p 2. Department of Health. Clinical guidelines for immunoglobulin use. London: Department of Health; 2011. Methods We included randomized controlled trials from MEDLINE, EMBASE, CENTRAL, Global Health, Scopus, Web of Science, the International Clinical Trials Registry Platform (inception to April 2014), conference proceedings, and reference lists of relevant articles. Two reviewers independently identifi ed and extracted trial-level data from randomized trials investigating unfractionated or low molecular heparin administered to patients with sepsis, severe sepsis, septic shock or DIC associated with infection. Internal validity was assessed in duplicate using the Risk of Bias tool. Our primary outcome was mortality. Safety outcomes included hemorrhage, transfusion and thrombocytopenia. Effi cacy and safety of heparin in patients with sepsis: a systematic review and meta-analysis g Conclusion The use of IVIg does not appear to aff ect mortality in sepsis. There was also no statistical benefi t or harm demonstrated by using IVIg. This also holds true whether IVIg is given either according to the guidelines or not; however, stricter adherence to the guidelines does have fi nancial implications. Critical Care 2015, 19(Suppl 1):P123 (doi: 10.1186/cc14203) Introduction Septic shock is characterized by systemic infl ammation coupled with upregulation of coagulation. Heparin is an inexpensive and widely available anticoagulant with anti-infl ammatory properties. The objectives our study were to evaluate the effi cacy and safety of heparin in patients with sepsis, septic shock or disseminated intravascular coagulation (DIC) associated with infection. P123 Effi cacy and safety of heparin in patients with sepsis: a systematic review and meta-analysis P123 Effi cacy and safety of heparin in patients with sepsis: a systematic review and meta-analysis R Zarychanski1, AM Abou-Setta1, S Kanji2, AF Turgeon3, A Kumar1, DS Houston1, E Rimmer1, BL Houston4, L McIntyre2, AE Fox-Robichaud5, PC Hebert6, DJ Cook5, DA Fergusson2 1University of Manitoba, Winnipeg, MB, Canada; 2Ottawa Hospital Research Institute, Ottawa, ON, Canada; 3Université Laval, Québec City, QC, Canada; 4University of Toronto, ON, Canada; 5McMaster University, Hamilton, ON, Canada; 6Centre hospitalier de l’Université de Montreal (CHUM) – Hopital Notre-Dame, Montreal, QC, Canada Critical Care 2015, 19(Suppl 1):P123 (doi: 10.1186/cc14203) Adjunct prednisone therapy for patients with community-acquired pneumonia: a randomized, placebo-controlled multicenter trial CA Bl 1 N Ni 1 M B i l1 P S h 2 E Ull 3 I S Wid 1 7 days (HR = 1.19, 1.04 to 1.38), P = 0.012) and a shorter duration of intravenous antibiotic treatment (4 vs. 5 days (diff erence, –0.89 days, –0.20 to –1.57 days), P = 0.011). All-cause mortality, ICU stay, recurrent pneumonia and rehospitalization rate were similar in both groups. Incidence of pneumonia-associated complications until day 30 tended to be lower in the prednisone group (2.8% vs. 5.6%, OR = 0.49, 0.23 to 1.02, P = 0.06). The prednisone group had a higher rate of in-hospital hyperglycemia needing insulin treatment (19.4% vs. 10.9%, OR = 1.96, 1.31 to 2.93, P = 0.001). Other adverse events compatible with corticosteroid use were rare and similar in both groups. Conclusion Heparin in patients with sepsis, septic shock, and DIC associated with infection may be associated with decreased mortality; however, the overall impact remains uncertain. Safety outcomes have been under-reported and require further study. Large randomized trials are needed to evaluate the effi cacy and safety of heparin in patients with sepsis, severe sepsis, and septic shock. Reference 1. Karaiskos I, Galani L, Baziaka F, Giamarellou H. Intraventricular and intrathecal colistin as the last therapeutic resort for the treatment of multidrug-resistant and extensively drug-resistant Acinetobacter baumannii ventriculitis and meningitis: a literature review. Int J Antimicrob Agents. 2013;41:499-508. S43 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P123 Effi cacy and safety of heparin in patients with sepsis: a systematic review and meta-analysis R Zarychanski1, AM Abou-Setta1, S Kanji2, AF Turgeon3, A Kumar1, DS Houston1, E Rimmer1, BL Houston4, L McIntyre2, AE Fox-Robichaud5, PC Hebert6, DJ Cook5, DA Fergusson2 1University of Manitoba, Winnipeg, MB, Canada; 2Ottawa Hospital Research Institute, Ottawa, ON, Canada; 3Université Laval, Québec City, QC, Canada; 4University of Toronto, ON, Canada; 5McMaster University, Hamilton, ON, Canada; 6Centre hospitalier de l’Université de Montreal (CHUM) – Hopital Notre-Dame, Montreal, QC, Canada Critical Care 2015, 19(Suppl 1):P123 (doi: 10.1186/cc14203) guidelines for prescription, with a mortality rate of 25%. Nine patients did not meet the national guidelines for prescription, with a mortality rate of 44%. The diff erence in mortality rates between the two groups did not reach statistical signifi cance (P = 0.6). There was no signifi cant diff erence in APACHE II scores between the two groups. There was also no diff erence in mortality between those receiving IVIg and those who did not. We also found no diff erence in those receiving single or double doses of IVIg. P126 Pharmacokinetics, safety and tolerability of human recombinant alkaline phosphatase in healthy volunteers E Peters1, J Arend2, R Tiessen3, A Van Elsas2, R Masereeuw1, P Pickkers1 1Radboudumc, Nijmegen, the Netherlands; 2AM-Pharma, Bunnik, the Netherlands; 3PRA Health Sciences, Zuidlaren, the Netherlands Critical Care 2015, 19(Suppl 1):P126 (doi: 10.1186/cc14206) P124 P124 Use of intravenous immunoglobulin to treat sepsis in a general ICU Y Drakeford, J Kelly, P Morgan, J Melville, A Holland Surrey and Sussex Healthcare NHS Trust, Redhill, UK Critical Care 2015, 19(Suppl 1):P124 (doi: 10.1186/cc14204) Use of intravenous immunoglobulin to treat sepsis in a general ICU Y Drakeford, J Kelly, P Morgan, J Melville, A Holland Surrey and Sussex Healthcare NHS Trust, Redhill, UK Critical Care 2015, 19(Suppl 1):P124 (doi: 10.1186/cc14204) Introduction Sepsis is a major cause of admission to the ICU, and a leading cause of death for ICU patients. Intravenous immunoglobulin (IVIg) is indicated in the treatment of some patients with sepsis, although the evidence for this remains controversial. The use of IVIg is regulated due to its high cost, and prescription guidelines have been revised by the NHS, coordinated by the National Demand Management Programme for Immunoglobulin. Conclusion Prednisone treatment for 7 days in hospitalized patients with CAP shortens time to clinical stability, time to hospital discharge and duration of intravenous antibiotic treatment without an increase in complications. Pharmacokinetics, safety and tolerability of human recombinant alkaline phosphatase in healthy volunteers Pharmacokinetics, safety and tolerability of human recombinant alkaline phosphatase in healthy volunteers E Peters1, J Arend2, R Tiessen3, A Van Elsas2, R Masereeuw1, P Pickkers1 1Radboudumc, Nijmegen, the Netherlands; 2AM-Pharma, Bunnik, the Netherlands; 3PRA Health Sciences, Zuidlaren, the Netherlands Critical Care 2015, 19(Suppl 1):P126 (doi: 10.1186/cc14206) Rat polymyxin B hemoperfusion model: preventive eff ect on renal tubular cell death in a rat cecal ligation and puncture model Rat polymyxin B hemoperfusion model: preventive eff ect on renal tubular cell death in a rat cecal ligation and puncture model T Masuda1, C Mitaka2, M Khin Hnin Si2, K Kido2, Y Qi2, T Uchida2, S Abe2, T Miyasho3, M Tomita4 1Tokyo Medical and Dental University, Tokyo, Japan; 2Tokyo Medical and Dental University Graduate School, Tokyo, Japan; 3Rakuno Gakuen University, Hokkaido, Japan; 4Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P127 (doi: 10.1186/cc14207) g gi Results The mortality rate of 28 days in the L-group was 32.8%, and was 18.8% in the H-group. Mean arterial pressure increased signifi cantly (P <0.01) in the H-group compared with the L-group. WBC counts in the L-group increased and in the H-group decreased (P <0.01) during PMX- DHP treatment. Platelet counts in both groups decreased signifi cantly (P <0.01).There was no signifi cant diff erence between before and after PMX-DHP in IL-6 levels. On the other hand, IL-1ra decreased signifi cantly before and after PMX-DHP. Also, IL-6 and IL-1ra in the L-group were signifi cantly higher than those in the H-group at the start of PMX- DHP. PCT values in the L-group were increased compared with the H-group at the start of PMX-DHP (P <0.01). PCT in the L-group increased signifi cantly (P <0.01), but no signifi cant changes in the H-group. PAI- 1 showed no signifi cant changes before and after PMX-DHP and no changes in both groups at the start of PMX-DHP. Introduction Direct hemoperfusion with a polymyxin B immobilized column (PMX-DHP) adsorbs endotoxin and has been used for the treatment of septic shock [1]. However, the mechanisms of action behind PMX-DHP are not fully understood. Therefore, the purpose of this study was to elucidate mechanisms of action behind PMX-DHP in a rat model of cecal ligation and puncture. Introduction Direct hemoperfusion with a polymyxin B immobilized column (PMX-DHP) adsorbs endotoxin and has been used for the treatment of septic shock [1]. However, the mechanisms of action behind PMX-DHP are not fully understood. Therefore, the purpose of this study was to elucidate mechanisms of action behind PMX-DHP in a rat model of cecal ligation and puncture. Methods Sprague–Dawley rats were anesthetized and were mechanical ventilated after tracheostomy. The right internal carotid artery was cannulated with a catheter for continuous measurement of the arterial pressure and heart rate. P128 y p Results RecAP administration resulted in a terminal elimination half- life and plasma clearance of 49 to 58 hours and 2.8 to 3.4 l/hour after single ascending doses, respectively, and 63 to 66 hours and 3.1 to 3.8 l/hour after multiple ascending doses. Peak recAP concentrations and AP activity levels were reached at the end of the 1-hour infusion and showed a rapid decline with about 10% of the maximum concentration remaining at 4 hours and less than 5% at 24 hours post start. Although the maximal concentration and total systemic exposure of recAP and AP activity increased slightly more than dose proportionally this is of no signifi cance in the estimated therapeutic dose range. RecAP treatment was generally well tolerated and anti-drug antibodies could not be detected in serum. P129 Use of therapeutic plasma exchange in children with thrombocytopenia-associated multiple organ failure in the Turkish TAMOF network White blood cell counts have an impact on septic patient outcome followed by polymyxin-B immobilized fi ber with direct hemoperfusion p H Tanaka, T Ikeda, S Ono, S Suda, T Ueno Tokyo Medical University, Hachioji Medical Center, Hachioji, Japan Critical Care 2015, 19(Suppl 1):P128 (doi: 10.1186/cc14208) Introduction The mortality rate of severe sepsis and septic shock is varied and high (25 to 70%). In our institute, the indication for polymyxin-B immobilized fi ber with direct hemoperfusion (PMX-DHP) has been that circulatory failure (systolic blood pressure <90 mmHg or required catecholamines and high lactacidemia) continued despite following early goal-directed therapy by the Surviving Sepsis Campaign guidelines 2012. Conclusion RecAP is characterized by a long serum terminal half-life, by stable serum AP levels and did not exert any safety concerns when administered to healthy volunteers. These results pave the way to investigate the potential of recAP as a new treatment option for sepsis- associated AKI in a phase II clinical trial, which will start at the end of 2014 [Clinical Trial Register:NCT02182440]. g Methods This study included 80 patients with severe sepsis or septic shock due to abdominal infection retrospectively. These subjects were divided into two groups: those with WBC counts <4,000 (L-group: 64 patients) and those with WBC counts >12,000 (H-group: 16 patients). Mean arterial pressure, WBC counts, platelet counts, interleukin-6 (IL-6), and plasminogen activator inhibitor-1 (PAI-1) were measured immediately before the initiation and after the completion of PMX- DHP. Statistical analysis was performed using the chi-squared test for background factors, with Wilcoxon’s rank-sum test for comparison within a group, and Mann–Whitney’s U test for comparison between groups. The signifi cance level was set at P <0.05. Pharmacokinetics, safety and tolerability of h alkaline phosphatase in healthy volunteers 1 d2 3 l 2 Methods We conducted a retrospective audit of pharmacy records of IVIg prescriptions issued to ICU patients with severe sepsis and septic shock from 2009 to 2014 against national prescription guidelines. Microbiology results were examined to support prescriptions, and admission APACHE II scores and unit outcomes were examined. Results From 2009 to 2014, 644 patients were admitted to the ICU with severe sepsis and septic shock, with a mortality rate of 41%. Seventeen patients received IVIg. Of these, eight patients met the national Methods We conducted a retrospective audit of pharmacy records of IVIg prescriptions issued to ICU patients with severe sepsis and septic shock from 2009 to 2014 against national prescription guidelines. Microbiology results were examined to support prescriptions, and admission APACHE II scores and unit outcomes were examined. p p y E Peters1, J Arend2, R Tiessen3, A Van Elsas2, R Masereeuw1, P Pickkers1 1Radboudumc, Nijmegen, the Netherlands; 2AM-Pharma, Bunnik, the Netherlands; 3PRA Health Sciences, Zuidlaren, the Netherlands Critical Care 2015, 19(Suppl 1):P126 (doi: 10.1186/cc14206) Results From 2009 to 2014, 644 patients were admitted to the ICU with severe sepsis and septic shock, with a mortality rate of 41%. Seventeen patients received IVIg. Of these, eight patients met the national Introduction Clinical trials showed renal protective eff ects of bovine intestinal alkaline phosphatase in critically ill patients with S44 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion PMX-DHP improved hemodynamics, acid–base balance, and creatinine levels through reducing cytokines and renal tubular cell death in a rat model of cecal ligation and puncture. These fi ndings suggest the preventive role of PMX-DHP in the development of sepsis- related acute kidney injury. sepsis-associated acute kidney injury (AKI) [1,2]. Recently, human recombinant AP (recAP) was developed as a pharmacological attractive replacement. We conducted a phase I clinical trial to evaluate tolerability, safety and pharmacokinetics of recAP in healthy volunteers. Methods In a randomized, double-blind, placebo-controlled phase I trial, healthy volunteers received via a 1-hour i.v. infusion a single dose of recAP (200, 500, 1,000 or 2,000 U/kg; n = 33) or multiple doses of recAP (500 or 1,000 U/kg; n = 18) on three consecutive days (n = 18). Serum recAP concentrations, AP activity levels and anti-drug antibodies were measured, and safety parameters were monitored. References 1. Pickkers P, et al. Crit Care. 2012;16:R14. , ; 2. Heemskerk S, et al. Crit Care Med. 2009;37:417-23.e1. Reference 1. Ronco C, et al. Polymyxin B hemoperfusion: a mechanistic perspective. Crit. Care. 2014;18:309. 1. Ronco C, et al. Polymyxin B hemoperfusion: a mechanistic perspective. Crit. Care. 2014;18:309. Rat polymyxin B hemoperfusion model: preventive eff ect on renal tubular cell death in a rat cecal ligation and puncture model The right femoral vein was cannulated with a catheter for infusion of saline (10 ml/kg/hour) during the study period. The rats were randomized into three experimental groups: cecal ligation and puncture (CLP) + dummy column (Dummy- DHP) group (n = 10), CLP + PMX-DHP group (n = 10), and sham group (n = 4). Four hours after CLP, Dummy-DHP or PMX-DHP was performed for 1 hour. Blood was drawn from the right internal carotid artery, perfused through PMX column or dummy column, and returned to the right femoral vein. The heart rate, mean arterial pressure, arterial blood gases, and plasma concentrations of creatinine, lactate, potassium, and cytokines (IL-6 and IL-10) were measured at baseline and at 4, 5, and 8 hours after CLP. At the completion of the experiment, the rats were killed overdose of pentobarbital. The kidney, liver, and lung were harvested, and histopathologic examinations of these organs were performed. g g p Conclusion The mortality rate of the L-group tended to be higher than that of the H-group. Infl ammatory and anti-infl ammatory cytokines in the L-group were higher than those of the H-group. These results indicate that leukopenia (WBC <4,000) in severe sepsis patients leads to more severe outcome and hypercytokinemia than leukocytosis (WBC >12,000) in severe sepsis patients. P129 Use of therapeutic plasma exchange in children with thrombocytopenia-associated multiple organ failure in the Turkish TAMOF network E Sevketoglu1, D Yildizdas2, O Horoz2, H Kihtir1, T Kendirli3, S Bayraktar4, J Carcillo5 1Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey; 2Cukurova University Medical Faculty, Adana, Turkey; 3Ankara University Medical Faculty, Ankara, Turkey; 4Haseki Research and Training Hospital, Istanbul, Turkey; 5University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Results Hypotension and metabolic acidosis occurred in the CLP + Dummy-DHP group, whereas hemodynamics and acid–base balance were better maintained in the CLP + PMX-DHP group. Plasma concentrations of lactate, creatinine, potassium, and cytokines were signifi cantly higher in the CLP + Dummy-DHP group than in the CLP + PMX-DHP group at 8 hours. Renal tubular cell death was observed in the CLP + Dummy-DHP group, but not in the CLP + PMX-DHP group. Critical Care 2015, 19(Suppl 1):P129 (doi: 10.1186/cc14209) Introduction Thrombocytopenia-associated multiple organ failure (TAMOF) can lead to high mortality in critically ill children, possibly related to consequences of thrombotic microangiopathy. Plasma Introduction Thrombocytopenia-associated multiple organ failure (TAMOF) can lead to high mortality in critically ill children, possibly related to consequences of thrombotic microangiopathy. Plasma S45 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 APACHE scores before and after ECAC therapy were available for eight patients who died; APACHE score decreased >5 points in fi ve patients after single application of ECAC. exchange therapy may improve thrombotic microangiopathy [1]. The purpose of this observational cohort study is to describe whether there is an association between use of plasma exchange therapy and outcome in the Turkish TAMOF network. Conclusion ECAC can be used as adjuvant therapy in treatment of severe sepsis/septic shock/MOF. Our patients had high PM and four could be saved with use of ECAC. We could expect a better outcome if ECAC was used early (<24 hours) during treatment. However, future well-designed studies are needed to clarify the role of ECAC in patients with MOF/septic shock. Methods We performed a retrospective cohort analysis in patients with TAMOF at three diff erent pediatric ICUs comparing those who received plasma exchange (+) plus standard therapies with those who did not receive plasma exchange (–) and only received standard therapies. Results Among the 42 TAMOF patients enrolled, all had a primary or secondary sepsis diagnosis. P130 P130 Clinical experience of using a novel extracorporeal cytokine adsorption column for treatment of septic shock with multiorgan failure Methods We retrospectively evaluated 387 patients who received a broad-spectrum antimicrobial treatment for septic shock due to GNB between January 2009 and December 2012 in the ICU of 10 Japanese tertiary hospitals. After alignment of the treatment time phase for each patient, we divided the patients into two groups according to whether PMX treatment was performed within 24 hours after ICU admission (PMX group: n = 129 and non-PMX group: n = 258). The primary endpoint was 28-day mortality. Ruby Hall Clinic, Pune, India Introduction Severe sepsis and multiorgan failure (MOF) are major causes of death in the ICU. The extracorporeal cytokine adsorption column (ECAC; Cytosorb®, CytoSorbents Corporation, USA), a critical care focused therapeutic device, results in rapid in vitro and in vivo elimination of several key cytokines and prevents organ failure. Use of ECAC in patients with sepsis is a new area of research with insuffi cient data to promote large prospective RCTs. Studies published to date have shown promising results. We report our clinical experience with ECAC for severe sepsis/septic shock/MOF patients. Results The mean (SD) age and SOFA scores on ICU admission were 72.5 (12.5) years and 10.0 (3.4), respectively. The infection site was intra-abdominal (47.0%), pulmonary (17.6%), and urinary tract (27.8%). Two-thirds of all patients had bacteremia due to GNB. No diff erence in 28-day mortality was observed between the two groups (PMX: 33.9% vs. non-PMX: 33.1%, P = 0.87). In the Cox regression analysis adjusted for age, sex and facilities, the PMX treatment (hazard ratio = 0.87; 95% confi dence interval, 0.53 to 1.43) did not improve the outcome.f Methods A retrospective evaluation of ECAC in patients admitted to a tertiary ICU from November 13 to October 14 to analyze: clinical safety; selection of a subgroup of patients where it could be used; selection of timing for initiation; number of device fi lters required per patient; and selective markers to identify above initiation. Patients were managed with standard of care (SOC; antibiotics, vasopressors, i.v. fl uids, sepsis dosed steroids) and ECAC as adjuvant therapy. Vitals, APACHE II and SOFA scores were measured. i Conclusion No diff erence in mortality rate was observed after adjustment for the endotoxin adsorption therapy with PMX in the patients with septic shock due to GNB. Use of therapeutic plasma exchange in children with thrombocytopenia-associated multiple organ failure in the Turkish TAMOF network Fifteen received plasma exchange therapy (PE(+) group) and 27 received standard medical treatment without plasma exchange (PE(–) group). The mean age was 17.69 months (8.24 to 54.22) in the PE(+) group, and 13.46 months (6.47 to 20.55) in the PE(–) group. Age (P = 0.232), gender (P = 0.206), thrombocyte count (P = 0.09), OFI score (P = 0.111) and Pelod score (P = 0.177) on admission were not statistically diff erent between groups. The overall 28-day mortality was higher in the PE(–) group 70.37% compared with 26.67% in the PE(+) group (univariate P =0.006; multivariate controlling for Pelod, OFI, PRISM scores and neurological failure P = 0.048). Length of stay was increased in the PE(+) group (P = 0.004). Reference Introduction Mortality from septic shock in the ICU remains high, ranging from 30 to 50%. In particular, Gram-negative bacilli (GNB) account for 40% of the causative bacteria of severe sepsis, which progresses to multiorgan failure due to signifi cant infl ammation. Hemoperfusion with polymyxin B-immobilized fi ber (PMX) adsorbs endotoxin and can reduce the infl ammatory cascade of sepsis due to GNB. However, the clinical effi cacy of this treatment has not been demonstrated. We aimed to verify the effi cacy of endotoxin adsorption therapy by using PMX. Reference 1. Nguyen TC, Carcillo JA. Bench-to-bedside review: Thrombocytopenia- associated multiple organ failure – a newly appreciated syndrome in the critically ill. Crit Care. 2006;10: 235. Reference 1. Nguyen TC, Carcillo JA. Bench-to-bedside review: Thrombocytopenia- associated multiple organ failure – a newly appreciated syndrome in the critically ill. Crit Care. 2006;10: 235. Eff ectiveness of polymyxin B immobilized fi ber hemoperfusion in patients with septic shock due to Gram-negative bacillus infection: the PMXHP study N Saito1, K Sugiyama2, T Ohnuma3, T Kanemura4, M Nasu5, Y Yoshidomi6, H Adachi7, H Koami8, Y Tsujimoto9, A Tochiki10, Y Wagatsuma11, T Myumi12 1Chiba Hokusou Hospital, Nippon Medical School, Chiba, Japan; 2Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan; 3Saitma Medical Center, Jichi Medical University, Saitama, Japan; 4National Hospital Organization Disaster Medical Center, Tokyo, Japan; 5Urasoe General Hospita, Okinawa, Japan; 6Saga-ken Medical Center, Koseikan, Saga, Japan; 7Iizuka Hospital, Fukuoka, Japan; 8Saga University Hospital, Saga, Japan; 9Yamagata Prefectural Central Hospital, Yamagata, Japan; 10Tsukuba Medical Center Hospital, Ibaraki, Japan; 11University of Tsukuba, Ibaraki, Japan; 12University of Occupational and Environment Health, Fukuoka, Japan Conclusion The positive association found between use of plasma exchange therapy and improved survival supports the potential of this therapy in Turkish children with TAMOF. The positive, although less so, associated treatment eff ect observed after controlling for illness severity provides further rationale for performing a randomized controlled trial in the pediatric Turkish TAMOF network. Sample size calculations call for a 100-patient trial with a pre hoc interim analysis after enrollment of 50 TAMOF patients. p Critical Care 2015, 19(Suppl 1):P131 (doi: 10.1186/cc14211) Introduction Mortality from septic shock in the ICU remains high, ranging from 30 to 50%. In particular, Gram-negative bacilli (GNB) account for 40% of the causative bacteria of severe sepsis, which progresses to multiorgan failure due to signifi cant infl ammation. Hemoperfusion with polymyxin B-immobilized fi ber (PMX) adsorbs endotoxin and can reduce the infl ammatory cascade of sepsis due to GNB. However, the clinical effi cacy of this treatment has not been demonstrated. We aimed to verify the effi cacy of endotoxin adsorption therapy by using PMX. Impact of evolving cardiac catheterisation services on admissions to a regional ICU Results Nineteen ICU patients (14 men, fi ve women; 24 to 72 years; average ICU stay 10 days; average ventilator days 9) with APACHE II >17 (except one with dengue shock syndrome), SOFA score ≥11 (n = 16) and the majority having infection largely in the lung (n = 8; alone or with UTI and blood infection) followed by the abdomen (n = 4), UTI (n = 3) and others (n = 4) were given ECAC (total ECAC = 31). Predicted mortality (PM) was >40% in 16, >30% in two and <30% in two (tropical infections) patients. Duration of therapy was 6 hours (no. of ECAC = 18) and 8 hours (n = 4; no. of ECAC = 5) for the majority of patients. Overall, four patients (two with tropical infections and two with PM >40%) survived; three of them had were ECAC early (<24 hours of admission). The majority of patients (n = 11) who died could be given ECAC only once. Of patients who died, seven were given ECAC late (>24 hours). g EA Gorman, D Trainor Royal Victoria Hospital, Belfast, UK Critical Care 2015, 19(Suppl 1):P132 (doi: 10.1186/cc14212) EA Gorman, D Trainor Introduction National UK audit data demonstrate cardiac catheterisation services, including percutaneous coronary intervention and noncoronary interventions, are increasing [1-3]. National mortality rates post cardiac catheterisation are also increasing, refl ecting an increasing proportion of sicker patients undergoing interventional procedures [3]. National audit procedures do not evaluate patients admitted to intensive care post cardiac catheterisation. We aimed to Introduction National UK audit data demonstrate cardiac catheterisation services, including percutaneous coronary intervention and noncoronary interventions, are increasing [1-3]. National mortality rates post cardiac catheterisation are also increasing, refl ecting an increasing proportion of sicker patients undergoing interventional procedures [3]. National audit procedures do not evaluate patients admitted to intensive care post cardiac catheterisation. We aimed to S46 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P133). evaluate the impact of an evolving regional cardiac catheterisation service on a regional intensive care unit (RICU) serving a population of 1.8 million. Methods A retrospective review was carried out. Patients admitted from the regional cardiac catheterisation laboratory to the regional ICU, between September 2009 and September 2014, were identifi ed using validated RICU admission records. Clinical data were extracted from computerised patient records. Impact of the introduction of e-learning prior to a basic transthoracic echo course P Madhivathanan1, S Jain2, D Walker3 Introduction Deep venous thrombosis (DVT) is an increasing major cause of mortality and morbidity. There is a need for quick, easy, cheap, convenient and reliable diagnostic tools. The objectives were to ascertain the diagnostic concordance of emergency doctor- performed ultrasound (EDUS) of the lower extremities with specialist doctor-performed (radiologist or vascular surgeon) echo-Doppler (SDED), in the diagnosis of DVT, and to identify possible causes of nonconcordance. P Madhivathanan1, S Jain2, D Walker3 1Barts Health NHS Trust, London, UK; 2Homerton University Hospitals NHS Foundation Trust, London, UK; 3University College London Hospitals NHS Foundation Trust, London, UK Critical Care 2015, 19(Suppl 1):P133 (doi: 10.1186/cc14213) P Madhivathanan , S Jain , D Walker 1Barts Health NHS Trust, London, UK; 2Homerton University Hospitals NHS Foundation Trust, London, UK; 3University College London Hospitals NHS Foundation Trust, London, UK Critical Care 2015, 19(Suppl 1):P133 (doi: 10.1186/cc14213) Introduction Focused Intensive Care Echo accreditation is a nationally approved pathway for training and accreditation in basic transthoracic echocardiography (TTE) in the UK. Recently, an e-learning module, the Intensive Care Echo and Basic Lung Ultrasound (ICE-BLU), has been introduced to facilitate TTE learning [1]. Previous work from our group has shown that incorporating simulation-based teaching elements into a basic TTE course improves candidates’ satisfaction [2]. We assessed the impact of introducing the ICE-BLU e-learning programme prior to our simulation-based basic TTE course. Methods A prospective, multicentre study. Adult patients (>18 years old) with clinical suspicion of DVT, with high or moderate risk (on Wells scoring), or low risk with increased D-dimer levels, were eligible for the study. Emergency doctors performed two EDUS in femoral and popliteal areas (these results were blinded). After this, echo-Doppler was performed by specialist doctors. Both procedures were done within 24 hours of each other. The fi nal result was considered nonconcordant if one or both of the EDUS did not match with the SDED. These SDED were used as reference (as standard clinical practice). Methods Prior to the August 2014 course, all candidates were required to complete the ICE-BLU e-learning module. On the morning of the course, the candidates completed a questionnaire to assess the impact of the e-learning module. The survey included questions on the quality of content, user friendliness, whether the content was pitched at the right level and any problems faced whilst accessing the e-learning module. P133 p Critical Care 2015, 19(Suppl 1):P134 (doi: 10.1186/cc14214) References 1. http://www.e-lfh.org.uk/programmes/icu-echoultrasound. Accessed 1 Dec 2014. Accessed 1 Dec 2014. 2. Madhivathanan PR, et al. Simulation-based transthoracic echo teaching: a tertiary centre experience. Intensive Care Med. 2014;40 Suppl 1:S158-9. 2. Madhivathanan PR, et al. Simulation-based transthoracic echo teaching: a tertiary centre experience. Intensive Care Med. 2014;40 Suppl 1:S158-9. 1. British Cardiovascular Interventional Society. Audit returns for adult interventional procedures. January 2013–December 2013. http://www.bcis. org.uk/documents/BCIS_Audit_2013_for_web_Version_23-11-2014.pdf. Diagnostic concordance of emergency doctor-performed bedside ultrasonography versus specialist-performed echo-Doppler ultrasonography in the diagnosis of deep venous thrombosis of lower limbs 2. National Institute for Cardiovascular Outcomes. Myocardial ischaemia national audit project. Public report April 2012–March 2013. http://www.ucl.ac.uk/nicor/audits/minap/reports. 3. British Cardiovascular interventional society. National coronary interventional procedures. Public report. January 2012–December 2013. http://www.bcis.org.uk/resources/PCI_Audit_Report_2012_fi nal.pdf. DL Ly-Pen1, JP Penedo Alonso2, MS Sánchez Perez2, FR Roldán Moll2, MZ Zamorano Serrano2, LD Díaz Vidal2, SJ Justo3 1Southend University Hospital, Westcliff -on-Sea, UK; 2Hospital Universitario Ramón y Cajal, Madrid, Spain; 3Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain Critical Care 2015, 19(Suppl 1):P134 (doi: 10.1186/cc14214) DL Ly-Pen1, JP Penedo Alonso2, MS Sánchez Perez2, FR Roldán Moll2, MZ Zamorano Serrano2, LD Díaz Vidal2, SJ Justo3 1Southend University Hospital, Westcliff -on-Sea, UK; 2Hospital Universitario Ramón y Cajal, Madrid, Spain; 3Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain Critical Care 2015, 19(Suppl 1):P134 (doi: 10.1186/cc14214) Impact of evolving cardiac catheterisation services on admissions to a regional ICU p p Results A total of 170 patients were identifi ed (representing 2.9% of critical care admissions during this time). Baseline characteristics: 71.7% male, median age 66 (IQR 55 to 74), median APACHE score 18 (IQR 15 to 23). Seventy-one patients (41.7%) had an APACHE score >20. Fifteen patients (8.8%) were aged >80 years. Admissions increased yearly – 20 in 2010, 26 in 2011, 35 in 2012, 47 in 2013, 37 at the end of the third quarter of 2014 (projected 59 admissions by year end 2014). Median length of stay was 3.5 days (IQR 1.8 to 7.2). Average length of stay reduced yearly (9.14 days in 2010 to 5.01 days in 2014). ICU bed- days per year remained static over the 5-year period. Critical care and hospital mortality rates were 33% and 39% respectively. There was a trend towards increasing mortality yearly, and with increasing age and APACHE score. Conclusion Our survey has shown that the e-learning initiative was welcome by the candidates. We conclude that introduction of e-learning prior to a simulation-based basic TTE course enhances candidates’ satisfaction and feedback. Conclusion An evolving cardiac catheterisation service is having a signifi cant impact on intensive care services within a regional centre. Increasing mortality trends in this critical care population refl ects post- cardiac catheterisation mortality trends nationally. We suggest intensive care admissions post cardiac catheterisation should be included in the national audit, to allow forward planning of intensive care services and to promote quality improvement within this population. References Sepsis survivors present with higher values of cardiac index and velocity time integral in the emergency department T Santos, M Schweller, C Gontijo-Coutinho, D Franci, P Nocera, T Guerra-Grangeia, J Matos-Souza, M Carvalho-Filho Unicamp, Campinas, Brazil Critical Care 2015, 19(Suppl 1):P137 (doi: 10.1186/cc14217) Sepsis survivors present with higher values of cardiac index and velocity time integral in the emergency department T Santos, M Schweller, C Gontijo-Coutinho, D Franci, P Nocera, T Guerra-Grangeia, J Matos-Souza, M Carvalho-Filho Unicamp, Campinas, Brazil Critical Care 2015, 19(Suppl 1):P137 (doi: 10.1186/cc14217) y Results From January 2014 to December 2014, 32 patients with septic shock (study group) and 20 patients with sepsis but no septic shock (control group) were recruited. The baseline characteristics were similar. Conventional echocardiographic measurements, including LVEF (59.53% vs. 60.67% in the control group, P = 0.450) and fractional shortening (31.98% vs. 32.98%, P = 0.323), did not diff er between the two groups. The study group had a greater degree of myocardial dysfunction measured by left ventricular global longitudinal strain (–14.6 vs. –17.6, P = 0.005, with a less negative value implying worse myocardial contractility). The hemodynamic profi les (cardiac index 3.49 l/minute/m2 vs. 3.41 l/minute/ m2 respectively, P = 0.764) were not statistically diff erent.i Introduction Myocardial depression is common among septic patients [1]. The aim of this study was to assess whether the values of cardiac index (CI) and velocity–time integral (VTI) calculated by echocardiography diff er between survivors and nonsurvivors of sepsis. Methods This was a prospective observational study. We included adult newly admitted septic patients, regardless of disease severity. Exclusion criteria were concomitant pregnancy or obstetric/gyne- co logical sepsis and co-existing or terminal diseases that may limit life expectancy. At the moment of recruitment, additional exclusion criteria included: concomitant pulmonary embolism, trauma or acute ischemic coronary disease; pericardial tamponade; aortic valve disease; tachyarrhythmias and absence of adequate echocardiographic windows. Echocardiographic evaluations were made within the fi rst 10 minutes of initiation of fl uid therapy in the emergency room. All measurements and images were obtained with a 1.5 to 3.5 MHz phased array transducer using a standard cardiac preset. CI is the quotient of the cardiac output (CO) divided by the body surface area. The CO is the product of the stroke volume by the heart rate. Stroke volume is calculated as the product between aortic VTI (measured using pulsed- wave Doppler) and aortic cross-sectional area. The latter is calculated in the long axis parasternal window using the left ventricular outfl ow tract diameter measurement. Impact of the introduction of e-learning prior to a basic transthoracic echo course We also analysed candidates’ feedback from our January and August 2014 courses (Figure 1). Results From September 2013 to September 2014, a total of 328 patients were enrolled. Fifty-one investigators from seven hospitals performed the EDUS. Each patient had the EDUS (femoral and popliteal areas) and SDED (also in femoral and popliteal areas). Of 328 pairs of US studies, 37 were nonconcordant between EDUS and SDED. Two EDUS were incomplete, so the concordance analysis was performed with 326 US studies, with 35 discordant. The percentage of agreement between EDUS and SDED was 89.26%. The kappa index was 0.76 (95% CI = 0.69 to 0.84), and this means a substantial agreement. Results The response rate of the survey was 100%. Eighty per cent of candidates completed the e-learning module. The e-learning module was rated high by most candidates (80%). However, nearly one-half of the candidates faced problems accessing the module, online. Analysis of candidates’ feedback (from the January and August 2014 courses) revealed that candidates’ overall impression was better with the introduction of e-learning prior to the course. Conclusion There is substantial agreement between EDUS and SDED in the diagnosis of DVT, in routine clinical practice. This confi rms the results of previous papers. The largest nondiagnostic concordance in thrombus occurs in the early performances of emergency doctors, S47 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results Comparing group I versus group II, the mortality rate was 45%, and there was a statistically signifi cant diff erence for temperature (P = 0.001), HR (P = 0.001) and WBC count (P = 0.01) on admission. Upon comparing survivors versus nonsurvivors in group I there was a statistical diff erence in HR on day 7 (P = 0.02), successful vasopressor withdrawal (P = 0.02), P/F ratio (P = 0.02) and ScVO2 on day 7 (P = 0.03). Regarding IL-1α, IL-1β, TNFα and troponin I there was no statistical signifi cant diff erence between groups I and II but IL-6, IL-10 and CRP showed statistically signifi cant diff erence on admission PV and CS. Pro- BNP shows statistically signifi cant diff erence in all CS samples between septic and nonseptic groups. Regarding echo upon comparing the survivors versus nonsurvivors, E’d/t on day 0 shows a statistically signifi cant diff erence between both groups. Reference 1. Angus DC. Epidemiology of severe sepsis in USA. Crit Care Med. 2001;29:1303-10. Impact of the introduction of e-learning prior to a basic transthoracic echo course SAPS II and seventh-day SOFA are good predictive scores for mortality in sepsis. especially until the fi fth performance. After the sixth one, the incidence of mismatches falls dramatically. It seems advisable to mentor the training programmes with at least fi ve shadowed performances in order to lower the incidence of mistakes. P135 P135 Cardiac abnormalities in patients with septic shock detected by speckle tracking echocardiography PY Ng1, WC Sin1, AK Ng2, WM Chan1 1Queen Mary Hospital, Hong Kong; 2Grantham Hospital, Hong Kong Critical Care 2015, 19(Suppl 1):P135 (doi: 10.1186/cc14215) P135 Cardiac abnormalities in patients with septic shock detected by speckle tracking echocardiography PY Ng1, WC Sin1, AK Ng2, WM Chan1 1Queen Mary Hospital, Hong Kong; 2Grantham Hospital, Hong Kong Critical Care 2015, 19(Suppl 1):P135 (doi: 10.1186/cc14215) Introduction Sepsis-induced myocardial dysfunction is a well- recognized condition and confers worse outcomes in septic patients. However, the diagnostic criteria remain poorly described. Echocardiographic assessment by conventional parameters such as left ventricular ejection fraction (LVEF) is often aff ected by ongoing changes in preload and afterload conditions. Novel echocardiographic technologies such as speckle tracking imaging have evolved for direct assessment of the myocardial function. In this study, we investigate the measurement of myocardial strain by speckle tracking imaging for the diagnosis of sepsis-induced myocardial dysfunction. g p y p Conclusion Diastolic dysfunction was seen in 90% of patients. Fever, HR, and WBC counts are still good early indicators for diagnosis of sepsis. Vasopressor withdrawal on the seventh day was a good predictor for survival. Admission serum IL-6, IL-10 and CRP from PV were better indicators for sepsis than IL-1, pro-BNP and troponin I. Admission TNFα and seventh-day IL-6 levels were highly prognostic for mortality. CS samples proved that NT pro-BNP is a good indicator for sepsis diagnosis and a good predictor for survival. TNFα from CS samples was also a good predictor of mortality. SAPS II and a slower E’d/t on admission was a good predictor of mortality. R f Methods This is a prospective, case–control study at a university- affi liated tertiary care adult medical ICU. Consecutive patients admitted with a diagnosis of septic shock meeting the international consensus criteria were included. Patients with other causes of myocardial dysfunction were excluded. They are compared with age-matched, gender-matched, and cardiovascular risk factor-matched controls, who were admitted to hospital for sepsis but did not develop septic shock. Conventional echocardiographic parameters, as well as speckle tracking imaging of myocardial function, were obtained within 24 hours of diagnosis. Offl ine analyses of endocardial tracings were performed by two independent operators. Reference Sepsis survivors present with higher values of cardiac index and velocity time integral in the emergency department T Santos, M Schweller, C Gontijo-Coutinho, D Franci, P Nocera, T Guerra-Grangeia, J Matos-Souza, M Carvalho-Filho Unicamp, Campinas, Brazil Critical Care 2015, 19(Suppl 1):P137 (doi: 10.1186/cc14217) Conclusion This is a fi rst study in the adult population to show that the use of speckle tracking imaging can diagnose signifi cant sepsis- induced myocardial dysfunction, which was not otherwise detectable by conventional echocardiography. P138 Speckle tracking imaging for evaluation of eff ects of positive end-expiratory pressure level on right ventricular function M Türker, A Pirat, A Camkiran Firat, B Pirat, A Sezgin, G Arslan Baskent University, Ankara, Turkey Critical Care 2015, 19(Suppl 1):P138 (doi: 10.1186/cc14218) Introduction Positive end-expiratory pressure (PEEP) is commonly used to correct hypoxemia in the ICU. However, PEEP may impair right ventricular functions by increasing its afterload. Speckle tracking imaging (STI) is a new echocardiography strain analysis technique that provides direct assessment of myocardial contractility during systole and diastole. The aim of this study was to evaluate the eff ects of diff erent PEEP levels on right ventricular functions by using STI in patients undergoing coronary artery bypass grafting surgery. Methods After ethics committee approval and patients’ written consent, we prospectively analyzed 20 CABG surgery patients. After initiation of mechanical ventilation and before sternotomy, 5, 10, and 20 cmH2O PEEP were applied in 5-minute intervals consequently. After stabilization at each PEEP level, four-chamber and two-chamber images of the right ventricle were recorded using TEE. The right ventricle diameter, velocity, longitudinal strain, SR, and fractional area change (RVFAC) were calculated and evaluated from the recorded images. PEEP at which LS disappeared or reappeared were compared using the Wilcoxon signed-rank test to assess the infl uences of anatomical side and PEEP increase or decrease. The values of PEEP at disappearance of LS for the right lung were not statistically signifi cantly diff erent from the left lung (P = 0.844 for increases, P = 0.938 for decreases). The values of PEEP at which LS disappeared obtained during increases were not statistically signifi cantly diff erent from values obtained during decreases (P = 1.000 for left lung, P = 0.875 for right lung; Figure 1). From data pooled from both sides and protocols, the median value of PEEP at which LS disappeared as a false positive sign of pneumothorax was 25 cmH2O (interquartile range = 20 to 30 cmH2O). At PEEP = 10 cmH2O, no patient showed absence of LS, whereas at PEEP = 35 cmH2O, all patients showed absence of LS (Figure 2). g Results The mean age of study patients (85% male) was 59.7 ± 10.5 years. Intraoperative mean, systolic, and diastolic arterial blood pressures and heart rate were similar at the three PEEP levels. P136 Evaluating the eff ect of sepsis and septic shock on myocardial functions by echocardiography and serum biomarker level in peripheral veins and coronary sinus M Soliman1, A Alazab1, R El Hossainy1, M Nirmalan2, H Nagy1 1Cairo University, Cairo, Egypt; 2University of Manchester, UK Critical Care 2015, 19(Suppl 1):P136 (doi: 10.1186/cc14216) Introduction Sepsis is a leading cause of death in critically ill patients despite the use of modern antibiotics and resuscitation therapies. Biomarkers and cardiovascular changes have an important place in this process. Myocardial depression occurs in 40% of septic patients. Methods Twenty patients (group I) with sepsis or septic shock were included and 10 patients (group II) served as the nonseptic group. Group I morbidity and mortality at day 28 in the ICU were targeted as the endpoint. Laboratory investigations, APACHE IV, SAPS II and SOFA scores were calculated. Biomarkers IL-1α, IL-1β, IL-6, IL-10, TNFα, CRP, NT-proBNP and troponin level were estimated on admission and day 7 in the peripheral vein (PV) and coronary sinus (CS). Transthoracic echocardiography and tissue Doppler imaging was done on admission and on day 7. Results In 3 months, 58 patients were included. The average age was 46.6 years, and 36 were male. Overall mortality was 14%. We included 16 patients with sepsis syndrome, 27 patients with severe sepsis and 15 patients with septic shock. Severe sepsis patients presented with higher values of CI, when compared with sepsis syndrome and septic shock patients (3.46, 3.08 and 2.92 l/minute/m2, respectively, P = NS). The same occurred with VTI (19.27, 18.81 and 16.74 cm for severe sepsis, sepsis syndrome and septic shock, respectively; P = NS). Mean values of CI were lower in nonsurvivors of sepsis (2.51 vs. 3.35 l/minute/ m2, P = 0.018). Mean values of VTI were also lower in nonsurvivors (14.83 vs. 19.01 cm, P = 0.022). Conclusion In our study, nonsurvivors of sepsis presented with lower values of both CI and VTI in the emergency department. Therefore, CI S48 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P139). Absence of LS during increasing and decreasing PEEP. Figure 2 (abstract P139). Values of PEEP above which LS was not present. and VTI may be good markers of sepsis severity and mortality in newly admitted patients. In addition, further studies are warranted to assess the role of CI and VTI as therapeutic targets. P139 Absence of lung sliding is not a reliable indicator of pneumothorax in patients who require high PEEP J Golub1, A Markota1, A Stožer2, G Prosen3, A Bergauer1, F Svenšek1, A Sinkovič1 1University Medical Centre Maribor, Slovenia; 2University of Maribor, Slovenia; 3Community Health Centre, Maribor, Slovenia Critical Care 2015, 19(Suppl 1):P139 (doi: 10.1186/cc14219) P140 Lung ultrasound in quantifying lung water in septic shock patients L De Geer, A Oscarsson, M Gustafsson Linkoping University Hospital, Linkoping, Sweden Critical Care 2015, 19(Suppl 1):P140 (doi: 10.1186/cc14220) P136 Reference 1. Silva E, Pedro Mde A, Sogayar AC, et al. Brazilian Sepsis Epidemiological Study (BASES study). Crit Care. 2004;8:R251-60. P138 P138 Compared with 5 and 10 cmH2O PEEP, mean RVFAC signifi cantly decreased at 20 cmH2O PEEP (P = 0.001). Right ventricle velocity reduced with incremental PEEP increases (P <0.05). Mean SR values decreased at 20 cmH2O PEEP when compared with 5 cmH2O PEEP (P = 0.03). Mean right ventricle diameter measurements decreased with incremental PEEP increases; however, this decrease was signifi cantly diff erent between 20 cmH2O PEEP and other two PEEP levels (P = 0.01). The mean right ventricle strain value signifi cantly decreased at 20 cmH2O PEEP when compared with other two PEEP levels (P <0.001 for both). p g Conclusion According to this study, higher PEEP levels correlate with disappearance of LS without pneumothorax. Absence of LS in patients with high PEEP should be interpreted with caution and other signs of pneumothorax should be sought before therapeutic interventions are attempted. Conclusion Compared with 5 and 10 cmH2O PEEP levels, right ventricle functions in terms of strain, SR, right ventricle diameter, and RVFAC were signifi cantly impaired at 20 cmH2O PEEP level. P140 Variations in near-infrared spectroscopy-derived oxygen downslope during a vascular occlusion test in critically ill patients: relationship with outcome p A Donati, E Damiani, A Carsetti, V Monaldi, E Montesi, P Pelaia A Donati, E Damiani, A Carsetti, V Monaldi, E Montesi, P Pelaia Università Politecnica delle Marche, Ancona, Italy Critical Care 2015, 19(Suppl 1):P141 (doi: 10.1186/cc14221) Università Politecnica delle Marche, Ancona, Italy y Critical Care 2015, 19(Suppl 1):P141 (doi: 10.1186/cc14221) Results No changes in mean arterial pressure were observed. The perfused small vessel density tended to decrease at t1 and normalize at t2 (Figure 1) in the hyperoxia group. These variations appeared early after 2 minutes of FiO2 changes. A signifi cant increase in lactate levels over time (from 1.1 (0.9 to 1.7) at t0 to 1.4 (1.1 to 1.9) mmol/l at t2, P = 0.01) was seen in the hyperoxia group. Introduction Near-infrared spectroscopy (NIRS) with a vascular occlusion test (VOT) can be used to extrapolate information regarding the tissue oxygen extraction rate. We explored the meaning of variations in tissue oxygen saturation downslope (StO2down) during a VOT in critically ill patients. Conclusion Hyperoxia induces an early decrease in microvascular perfusion, which appears to go back to normality at return to normoxia. Figure 1 (abstract P142). y p Methods In this prospective observational study, NIRS (thenar eminence) was applied every day in 93 patients admitted to the ICU. A VOT was performed using a 40% StO2 target. The slope of the desaturation curve was assessed separately for the fi rst part (StO2 Down1) and the last part (StO2 Down2) of the curve and the diff erence between Down2 – Down1 was calculated.if Results No signifi cant diff erences were seen in StO2 Down1 or Down2 between ICU survivors (n = 76) and ICU nonsurvivors (n = 17) over Figure 1 (abstract P141). Figure 1 (abstract P142). Conclusion Hyperoxia induces an early decrease in microvascular perfusion, which appears to go back to normality at return to normoxia. Conclusion Hyperoxia induces an early decrease in microvascular perfusion, which appears to go back to normality at return to normoxia. Normobaric hyperoxia and the microcirculation in critically ill patients: a prospective observational study Normobaric hyperoxia and the microcirculation in critically ill patients: a prospective observational study S Zuccari, A Donati, E Damiani, E Montesi, S Ciucani, M Rogani, P Pelaia Università Politecnica delle Marche, Ancona, Italy Critical Care 2015, 19(Suppl 1):P142 (doi: 10.1186/cc14222) Conclusion LUS non-invasively and user-independently quantifi es lung water in concordance with, but does not replace, invasive measurements. Further studies are needed establish the role of LUS as a monitoring and diagnostic tool in septic shock patients. References Introduction It is well known that oxygen acts as a vasoconstrictor. We evaluated the impact of normobaric hyperoxia on the sublingual microcirculation in critically ill patients. Introduction It is well known that oxygen acts as a vasoconstrictor. We evaluated the impact of normobaric hyperoxia on the sublingual microcirculation in critically ill patients. 1. Frassi F, et al. J Card Fail. 2007;13:830-5. 1. Frassi F, et al. J Card Fail. 2007;13:830-5. 2. Prosen G, et al. Crit Care. 2011;15:R114. Methods Forty mechanically ventilated (FiO2 ≤50%) patients with hemodynamic stability were enrolled in a prospective observational study. The fi rst 20 patients underwent a 2-hour period of hyperoxia (FiO2 = 100%), and 20 patients were studied as controls (no FiO2 variations). The sublingual microcirculation (three sites) was evaluated with sidestream dark-fi eld imaging at baseline (t0), after 2 hours of hyperoxia (t1), and 2 hours after return to baseline (t2). Continuous video recording was also performed during FiO2 variations on one and the same area (2-minute video). 3. Dellinger RP, et al. Intensive Care Med. 2013;39:165-228. Absence of lung sliding is not a reliable indicator of pneumothorax in patients who require high PEEP Introduction Quantifi cation of lung ultrasound (LUS) artifacts (B-lines) is used to assess pulmonary congestion in emergency medicine and cardiology [1,2]. We investigated B-lines in relation to extravascular lung-water index (EVLWI) from invasive transpulmonary thermodilution in septic shock patients. Our aim was to evaluate the role of LUS in an intensive care setting. Methods Twenty-one patients admitted with septic shock to a general ICU underwent LUS of eight zones, four per hemithorax, within 24 hours after ICU admission. EVLWI was calculated simultaneously by transpulmonary thermodilution using a pulse-contour continuous cardiac output system, and NT-proBNP and clinical data were collected. Two physicians blinded to other data independently quantifi ed the number of B-lines. Spearman’s rho was used to test the correlation of B-lines to EVLWI and clinical data, and linear regression and Bland– Altman analysis were used to assess the agreement between B-lines and EVLWI. Interobserver variability was tested using Bland–Altman analysis and intraclass correlation coeffi cient (ICC). Introduction The objective of our study was to estimate correlation between PEEP and disappearance of lung sliding (LS) due to lung overdistension in the absence of pneumothorax. Methods We performed a prospective study from September 2013 to May 2014 in adult patients with respiratory failure who required mechanical ventilation, lung CT and recruitment manoeuvre. Lung CT was used as the gold standard to exclude pneumothorax. A staircase recruitment manoeuvre was used with 5 cmH2O increases of PEEP from baseline to 35 cmH2O and decreases in reverse order. The duration of each step was 1 minute. Lung ultrasound was performed to evaluate LS at each step in one intercostal window in the highest point of left and right hemithoraces by physicians trained in lung ultrasound and blinded to changes in PEEP.i Results Fourteen patients (67%) were male, the median age was 62 years (IQR 55 to 68) and eight (38%) patients had cardiac comorbidities. In median, SAPS 3 was 64 (IQR 60 to 74), ICU length of stay was 3 days (IQR 2 to 8) and seven patients (33%) died within 30 days of ICU admission. All patients were mechanically ventilated and treated according to Results In all, eight patients were included; fi ve (62.5%) males, mean age 70.1 ± 7.4 years. Mean auto-PEEP was 0.7 ± 0.4 cmH2O. Absence of lung sliding is not a reliable indicator of pneumothorax in patients who require high PEEP The values of S49 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 guidelines [3]. The median number of B-lines was 15 (IQR 10 to 30) and the median (IQR) NT-proBNP, EVLWI and oxygenation index (OI) were 7,800 ng/l (3,690 to 15,050), 11 ml/kg (IQR 8 to 18) and 9.2 (5.7 to 15.7), respectively. None of the characteristics diff ered signifi cantly between survivors and nonsurvivors. The number of B-lines correlated to EVLWI (ρ = 0.45, P = 0.04; r2 = 0.20, P = 0.04), but not to NT-proBNP (ρ = –0.42, P = 0.06), OI (ρ = 0.25, P = 0.31) or ICU length of stay (ρ = 0.14, P = 0.57). On Bland–Altman analysis, mean diff erences and 95% limits of agreements between B-lines and EVLWI was 4.9 (–14.5 to 24.5), and 5.9 (–3.5 to 15.3) when assessing observer agreement. The ICC between methods was 0.52 (95% CI = –0.17 to 0.81) and 0.90 (95% CI = 0.73 to 0.92) between observers. the fi rst 10 days in the ICU, while Down2 – Down1 was higher in ICU nonsurvivors (Figure 1). Patients in the upper quartile of mean Down2 – Down1 showed the highest 90-day mortality (P = 0.014).l Conclusion ICU nonsurvivors tended to show a fl attening in the last part of the desaturation curve during a VOT, suggesting a reduced tissue oxygen extraction. This may depend on microvascular dysfunction and/or cellular hypometabolic status. P142 P143 P143 Near-infrared spectroscopy for assessing the tissue oxygen extraction rate during sepsis: relationship with outcome A Donati, E Damiani, C Scorcella, S Tondi, S Ciucani, P Pelaia Università Politecnica delle Marche, Ancona, Italy Critical Care 2015, 19(Suppl 1):P143 (doi: 10.1186/cc14223) Prospective nonrandomized observational study of the use of an impedance threshold device in patients with spontaneous respiration and hemodynamic instability C Pantazopoulos1, I Floros1, N Archontoulis1, D Xanthis1, D Barouxis2, N Iacovidou2, T Xanthos2 1Laiko General Hospital of Athens, Greece; 2University of Athens, Medical School, Athens, Greece Critical Care 2015, 19(Suppl 1):P144 (doi: 10.1186/cc14224) Conclusion The length of time to lactate normalization in the severe burn patient is a marker of survival and a simple parameter to guide the endpoint of resuscitation; however, the percentage of lactate clarifi ed in the fi rst 24 hours is not valid. Introduction The use of an impedance threshold device (ITD) in cardiac arrest victims has been shown to increase the systolic arterial pressure (SAP) by increasing venous return [1]. There are limited studies concerning the use of ITD in patients with spontaneous respiration and hemodynamic instability. The purpose of this study is to evaluate changes of hemodynamic parameters with the use of ITD in patients with spontaneous respiration and hemodynamic instability. P144 P144 Prospective nonrandomized observational study of the use of an impedance threshold device in patients with spontaneous respiration and hemodynamic instability C Pantazopoulos1, I Floros1, N Archontoulis1, D Xanthis1, D Barouxis2, N Iacovidou2, T Xanthos2 1Laiko General Hospital of Athens, Greece; 2University of Athens, Medical School, Athens, Greece Critical Care 2015, 19(Suppl 1):P144 (doi: 10.1186/cc14224) Lactate in the burn patient This may refl ect a tissue hypometabolic status, which may be better elicited in the fi nal part of the ischemic challenge. Healthy volunteers (n = 27) were studied as controls. The slope of the desaturation curve was assessed separately for the fi rst (StO2 Down1) and the last part (StO2 Down2) of the curve and the diff erence between, Down2 – Down1, was calculated. Results StO2 Down1 was lower in healthy volunteers as compared with septic patients (P <0.05); no diff erence was seen between ICU survivors (n = 7) and nonsurvivors (n = 7). StO2 Down2 was similar between healthy volunteers and ICU survivors, while it was higher in nonsurvivors (P <0.01 vs. healthy). ICU nonsurvivors showed higher Down2 – Down1 as compared with ICU survivors (P <0.01, Figure 1). Results StO2 Down1 was lower in healthy volunteers as compared with septic patients (P <0.05); no diff erence was seen between ICU survivors (n = 7) and nonsurvivors (n = 7). StO2 Down2 was similar between healthy volunteers and ICU survivors, while it was higher in nonsurvivors (P <0.01 vs. healthy). ICU nonsurvivors showed higher Down2 – Down1 as compared with ICU survivors (P <0.01, Figure 1). Conclusion Tissue oxygen extraction was reduced in septic patients. Nonsurvivors showed a fl attening in the last part of the desaturation curve during a VOT, while the fi rst part of the StO2 downslope did not show any diff erence between survivors and nonsurvivors. This may refl ect a tissue hypometabolic status, which may be better elicited in the fi nal part of the ischemic challenge. y Results During a period of 2 years we studied 143 patients; their mean age was 46.98 ± 19.38 years, mean TBSA burn injury of the study population was 22.82 ± 20.25. The fl ame was the most frequent mechanism. A total of 83 patients were in mechanical ventilation and 13.6% of them developed ARDS. The mortality range in the study group was 17%. Serum lactate at admission ≥2 mmol/l was associated with 31.3% mortality versus 6% in patients with a serum lactate at admission <2 mmol/l (P <0.05). Length of time to lactate normalization variable is associated with mortality (P <0.02). The average lactate normalization time was 4.6 days in nonsurvivors while in survivors it was 2.02 days. A relation does not exist between the lactate clearance and mortality in all patients. P143 Near-infrared spectroscopy for assessing the tissue oxygen extraction rate during sepsis: relationship with outcome C S ll S d S C l Introduction Microcirculatory dysfunction impairs tissue oxygenation during sepsis. We applied near-infrared spectroscopy (NIRS) to evaluate the tissue oxygen extraction rate in sepsis and its relationship with outcome. Methods A prospective observational study; 14 septic patients underwent NIRS monitoring (thenar eminence) with a vascular occlusion test (using a 40% StO2 target) at admission to the ICU. Figure 1 (abstract P141). Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S50 Figure 1 (abstract P143). 10 minutes after the intervention. Endpoint of the study was a change of patient’s SAP after application of ITD. Results The SAP of patients that were included in the study increased 15 to 22 mmHg (P <0.05). Heart rate remained unchanged. Eighty percent of patients declared good to very good tolerance from ITD application. Conclusion In this observational study of patients with spontaneous respiration and hypotension, ITD increased the SAP, while it seems that it was well tolerated by patients. Additional and larger studies will be needed in the future in order to investigate the benefi ts of ITD when used to patients with spontaneous respiration and hemodynamic instability. Reference 1. Pirrallo RG, et al. Eff ect of an inspiratory impedance threshold device on hemodynamics during conventional manual cardiopulmonary resuscitation. Resuscitation. 2005;66:13-20. 1. Pirrallo RG, et al. Eff ect of an inspiratory impedance threshold device on hemodynamics during conventional manual cardiopulmonary resuscitation. Resuscitation. 2005;66:13-20. Lactate in the burn patient p EH Herrero, M Sánchez, L Cachafeiro, A Agrifoglio, B Galván, MJ Asensio, A García de Lorenzo Hospital La Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P145 (doi: 10.1186/cc14225) Introduction Severe burns result in rapid loss of intravascular volume due to development of a severe capillary leak and hypovolemic shock. It is widely accepted that traditional markers, such as blood pressure and urinary output, are useful but do not suffi ciently refl ect global perfusion, regional microcirculation or reversal shock. Blood lactate concentration is widely used in ICUs as a reliable prognostic marker of global tissue hypoxia. Our aim is to determine whether the percentage of lactate clarifi ed in the fi rst 24 hours is valid as a guide for resuscitation. Methods We prospectively studied 143 consecutive burn patients admitted to our Burn Unit. Sociodemographics and comorbidities data were recorded. Clinical data were collected to calculate the Acute Burn Severity Index. Resuscitation according to the Parkland formula was guided by a urinary output of 0.5 to 1 ml/hour and the results of monitoring the blood pressure. Crystalloid solution (Ringer´s acetate) was given exclusively during the fi rst 24 hours. Early surgical excision of burn eschar and early coverage of excised burn wounds with autografts was performed. Initial and subsequent serum lactate levels were measured to calculate lactate clearance according to the formula: lactate basal – lactate at 24 hours / lactate basal × 100. The primary outcome was mortality. Figure 1 (abstract P143). Healthy volunteers (n = 27) were studied as controls. The slope of the desaturation curve was assessed separately for the fi rst (StO2 Down1) and the last part (StO2 Down2) of the curve and the diff erence between, Down2 – Down1, was calculated. Results StO2 Down1 was lower in healthy volunteers as compared with septic patients (P <0.05); no diff erence was seen between ICU survivors (n = 7) and nonsurvivors (n = 7). StO2 Down2 was similar between healthy volunteers and ICU survivors, while it was higher in nonsurvivors (P <0.01 vs. healthy). ICU nonsurvivors showed higher Down2 – Down1 as compared with ICU survivors (P <0.01, Figure 1). Conclusion Tissue oxygen extraction was reduced in septic patients. Nonsurvivors showed a fl attening in the last part of the desaturation curve during a VOT, while the fi rst part of the StO2 downslope did not show any diff erence between survivors and nonsurvivors. Is the shock index a universal predictor in the emergency department? A cohort study Results Twenty-three patients underwent VA ECMO for refractory CS in the study period. Etiologies of CS were: 11 acute myocarditis, fi ve acute myocardial infarction and seven acute decompensation of chronic cardiomyopathy. The median time of ECMO was 10 days (4 to 15). Thirteen patients died during hospital stay and 10 survived. Three patients were bridged to LVAD and two to heart transplant; eight were bridged to recovery. The main cause of ICU death was multiple organ dysfunction (12/13). Nonsurvivors showed signifi cantly higher LAC0 (5 (2 to 6) vs. 8 (5 to 11), P = 0.021). Lactate clearance at 48 hours was not signifi cantly diff erent between survivors and nonsurvivors (79%, 95% CI = 67 to 86 vs. 60%, 95% CI = 32 to 72, P = 0.08). However, LAC48 was predictive for ICU mortality (AUC 0.82; 95% CI = 0.64 to 1.0; P = 0.011). ROC curve analysis identifi ed the accuracy was highest by setting the lactate <2 mmol/l. Patients that did not normalize lactate (LAC <2 mmol/l) after 48 hours despite hemodynamic restoration had poorer outcome at 30 days, as is shown in the Kaplan–Meier curve (log- rank P = 0.006) (Figure 1). Introduction The shock index (SI; heart rate/systolic blood pressure) is a widely reported tool to identify acutely ill patients at risk for circulatory collapse in the emergency department (ED). Because old age, diabetes, essential hypertension, and β-/Ca2+ channel-blockers might reduce the compensatory increase in heart rate and mask blood pressure reductions in shock or pre-shock states, we hypothesized that these factors weaken the association between SI and mortality, reducing the utility of SI to identify patients at risk. Methods This was a cohort study from Odense University Hospital of all fi rst-time visits to the ED between 1995 and 2011 (n = 111,019). The outcome was 30-day mortality. We examined whether age ≥65 years, diabetes, essential hypertension, and use of β-/Ca2+ channel-blockers modifi ed the association between SI and mortality. The prognostic value of SI ≥1 was evaluated with diagnostic likelihood ratios. Conclusion Failing to normalize patient’s LAC in the fi rst 48 hours of VA ECMO assistance for CS is a predictor of ICU mortality. Targeting LAC level <2 mmol/l at 48 hours post ECMO institution might be a reasonable goal for these patients. Results We observed a 30-day mortality of 3%. Blood lactate normalization following venoarterial ECMO institution for refractory cardiogenic shockfi Methods A 5-month prospective nonrandomized observational study that included 50 adult patients with spontaneous respiration and hypotension in the emergency room and the wards of multiple causes except trauma. After measurement of the SAP and verifi cation of hypotension (SAP ≤90 mmHg), a mask-style ITD was added. Hemodynamic parameters were evaluated every 1 minute and for M Bottiroli, D Decaria, T Maraffi , S Nonini, F Milazzo, R Paino Anestesia Rianimazione 3, A.O. Niguarda, Milan, Italy Critical Care 2015, 19(Suppl 1):P146 (doi: 10.1186/cc14226) Introduction Venoarterial (VA) ECMO is used to support patients with refractory cardiogenic shock (CS). Elevated lactate level (>2 mmol/l) Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S51 Figure 1 (abstract P146). an inotropic score as a predictor of mortality and morbidity among children who diagnosed septic shock. Figure 1 (abstract P146) Methods A multicenter retrospective chart review was performed in two pediatric ICUs. A total of 93 children with septic shock were recruited. Hourly doses of following inotropes were recorded for the fi rst 48 hours after admission: dopamine, dobutamine, adrenaline and noradrenaline. The inotrope score for every hour, minimum, maximum and mean values for the fi rst 24 hours, and subsequent 24 hours were calculated. In our analysis, the inotrope score was calculated as described by Wernovsky. We expanded this formula to include norephinephrine as follows: Wernovsky Inotrope Score = dopamine dose (μg/kg/minute) + dobutamine dose (μg/kg/minute) + 100 × epinephrine dose (μg/kg/ minute). Our adjusted inotrope score = Wernovsky Inotrope Score + 100 × norepinephrine dose (μg/kg/minute).f p p μg g Results Forty-two of 93 patients died. Age and sex were not diff erent between survivors and nonsurvivors. Signifi cantly higher mean and maximum inotropic score for the fi rst 24 hours and fi rst 48 hours were found in nonsurvivors than those of survivors (P <0.05). Using 15 as a cutoff point for predicting mortality, the sensitivity and specifi city were 69.76% and 50.98% respectively. The association between Prism scores and minimum, mean and maximum inotrope scores were statistically signifi cant for 0 to 24 hours, 25 to 48 hours and 0 to 48 hours. Mean 0 to 24 hours and maximum 0 to 48 hours inotrope scores were weakly associated with prolonged ICU stay (P = 0.047, P = 0.042 respectively). There were no signifi cant relationships between inotrope scores and receiving mechanical ventilation.i Figure 1 (abstract P146). Is the shock index a universal predictor in the emergency department? A cohort study With SI <0.7 as reference, a SI of 0.7 to 1 was associated with an adjusted OR of 2.9 (CI 2.7 to 3.2) for 30-day mortality while the adjusted OR for SI ≥1 was 10.3 (CI 9.2 to 11.5). ORs for SI ≥1 were reduced (but still signifi cant) in patients who were older, hypertensive, or on β-/Ca2+ channel-blockers, whereas diabetes had no eff ect. The OR for SI ≥1 in patients ≥65 years was 8.2 (CI 7.2 to 9.4) compared with 18.9 (CI 15.6 to 23.0) in younger patients. β-/Ca2+ channel-blocked patients had an OR of 6.4 (CI 4.9 to 8.3) versus 12.3 (CI 11.0 to 13.8) in nonusers, and the OR for hypertensive patients was 8.0 (CI 6.6 to 9.4) versus 12.9 (CI 11.1 to 14.9) in nonhypertensive patients. The OR for SI ≥1 of 9.3 (CI 6.7 to 12.9) in diabetics did not diff er from the OR of 10.8 (CI 9.6 to 12.0) in nondiabetic patients. A SI of 0.7 to 1 was associated with ORs signifi cantly greater than 1 (range: 2.2 to 3.1) with no evident diff erences within the subgroups. A SI measurement ≥1 was associated with lower positive likelihood ratios in patients ≥65 years, with hypertension, diabetes or using β-/Ca2+ channel-blockers (range 4.9 to 6.5) compared with patients not exposed to these factors (range 7.6 to 11.6). Blood lactate normalization following venoarterial ECMO institution for refractory cardiogenic shockfi is an indicator of end-organ hypoperfusion. We hypothesize that the lactate (LAC) normalization had prognostic value in this cohort of patients. Methods We performed a retrospective observational study on patients admitted to the ICU for refractory CS from January 2010 to November 2014. Patients with postcardiotomy and/or post-transplant CS were excluded. Demographics, clinical, hemodynamic and biochemical values were collected. LAC was measured on arterial blood before ECMO institution (LAC0) and after 48 hours (LAC48). Lactate clearance was calculated as follows: (LAC0 – LAC48) / LAC0 × 100. Data were analyzed by comparative statistic; sensibility and specifi city were tested with ROC. Conclusion The mean and maximum inotropic scores in the fi rst 24 hours and 0 to 48 hours are an independent predictor of mortality in critically ill children with septic shock. P148 Is the shock index a universal predictor in the emergency department? A cohort study AK Kristensen1, JG Holler1, J Hallas2, A Lassen1, N Shapiro3 1Odense University Hospital, Odense, Denmark; 2University of Southern Denmark, Odense, Denmark; 3Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P148 (doi: 10.1186/cc14228) P149 Risk factors for severe vasodilatory shock after cardiac surgery J Almeida, F Galas, J Fukushima, E Almeida, A Gerent, E Osawa, C Park, R Nakamura, A Leme, M Sundin, R Kalil Filho, F Jatene, L Hajjar Heart Institute, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P149 (doi: 10.1186/cc14229) Introduction Vasodilatory shock is a well-known complication in patients who undergo cardiac surgery with cardiopulmonary bypass (CPB) and its occurrence is associated with higher morbidity and mortality. Despite that, clinical characteristics of vasoplegic shock and its spectrum of severity are poorly described. The aim of this study was to compare patients who developed mild to moderate vasoplegic shock with patients who developed a severe form and to identify predictive factors for the severe form of vasoplegic shock. Results Heterogeneity of LS eff ects was registered in a number of values. The most signifi cant positive eff ect which allowed one to evaluate myocardial reserve was demonstrated by decrease of PPA (93.5% of patients) and increase of EF (77.6% of patients). The most signifi cant changes were also noted in decrease of TrI, PH and MI (in 53.2%, 36.6% and 36% of patients, respectively). In 69.2% of patients with noncoronarogenic dilated cardiomyopathy the eff ect of LS exposure was marked. In the majority of patients with ischemic cardiomyopathy the eff ect was moderate. In case of the absence of LS-positive eff ect, perioperative use of mechanical circulatory support was considered. Conclusion Preoperative use of LS allows one to evaluate myocardial reserves and prepare high-risk patients with CHF for surgery. Our fi ndings may serve as one of the additional criteria to choose the type of surgical treatment: reconstructive surgery (with or without perioperative mechanical circulatory support) or heart transplantation. Methods We performed an observational study in 300 patients who underwent cardiac surgery with CPB and presented within the fi rst 24 hours after surgery with refractory hypotension and used a vasopressor agent. Severe vasoplegic shock was defi ned as a requirement of norepinephrine higher than 1 μg/kg/minute or the use of two or more vasopressors. Baseline characteristics, laboratorial, clinical and intraoperative data, such as amount of fl uids, bleeding, blood transfusion, inotropes and length of CPB were collected at ICU admission. Logistic regression was performed using severe vasodilatory shock as the outcome. Results There were 46 (15%) patients who develop the severe form of vasodilatory shock within 24 hours after cardiac surgery. Reference Reference 1. Jochberger S, et al. Intensive Care Med. 2009;35:489-97. 1. Jochberger S, et al. Intensive Care Med. 2009;35:489-97. P149 In a univariate analysis, patients with the severe form were more likely to be older, to receive more blood transfusion and inotropic agents, to have higher levels of serum lactate, lower hemoglobin concentration and lower SvO2 at the end of the procedure, lower cardiac output index, higher heart rate and higher levels of reactive C protein at ICU admission. These patients also experienced more postoperative organ dysfunction, had a longer length of ICU stay and higher mortality. There were no diff erences between patients regarding amount of fl uids and length of CPB. In a multivariate analysis we identify age (OR = 1.04, 95% CI = 1.01 to 1.08, P = 0.016), intraoperative use of epinephrine (OR = 5.49, 95% CI = 2.42 to 12.43, P <0.001), higher serum lactate at the end of the procedure (OR = 1.04, 95% CI = 1.01 to 1.06, P = 0.001) and intraoperative blood transfusion (OR = 5.06, 95% CI = 2.19 to 11.69, P <0.001). P151 Levosimendan versus dobutamine in cardiac surgery MD Delgado-Amaya, EC Curiel-Balsera, CJ Joya-Montosa Hospital Regional de Málaga, Spain Critical Care 2015, 19(Suppl 1):P151 (doi: 10.1186/cc14231) Introduction Early studies suggested a signifi cant increase in survival in patients treated with levosimendan compared with dobutamine or placebo (LIDO, RUSSLAN and CASINO trials). However, two subsequent studies (SURVIVE and REVIVE II) have not confi rmed these fi ndings. Methods A prospective observational study of all patients undergoing cardiac surgery at Malaga’s Regional Hospital from March 2009 to March 2013. We analyzed patients who used levosimendan compared with those that used dobutamine in the fi rst hours after cardiac surgery, discarding patients in which neither of these two drugs were used or surgical cases that arrived at the ICU with both inotropics. We analyzed demographic variables as well as clinical complications in the ICU and overall perioperative mortality of patients. We performed a second analysis using the propensity score, obtaining the probability of patients being treated with either drug, pairing each patient who received levosimendan with its nearest neighbor receiving dobutamine. Results We collected 875 patients: 331 received one of the two drugs, 50 received both drugs and 494 did not receive any drug. ICU mortality was 7.2% (levosimendan group) and 12.5% (dobutamine group), P = 0.1. After adjustment for severity and type of surgery, the use of levosimendan in the postoperative period was not a protective factor for ICU mortality (P = 0.18, OR = 0.5, 95% CI = 0.18 to 1.3). In the matched sample, mortality was 7.4% (levosimendan group) and 5.9% (dobutamine), P = 0.73. After logistic regression adjusted for severity, measured with EuroSCORE and type of surgery, levosimendan was not a protective factor for ICU mortality (P = 0.8, OR = 1.2, 95% CI = 0.26 to 5.45).f Conclusion This study demonstrated that older patients, intraoperative blood transfusion and utilization of epinephrine were independently associated with a more severe form of vasodilatory shock after cardiac surgery with CPB. Also, we identifi ed that a higher lactate at the end of the procedure was an independent predictive factor for this severe form of shock. Is an inotrope score a predictor of mortality and morbidity in children with septic shock? E Sevketoglu1, A Anil2, S Kazanci1, O Yesilbas1, M Akyol1, S Bayraktar3, N Aksu4, S Hatipoglu1, M Karabocuoglu5 1Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Bakýrkoy, Turkey; 2Izmir Katip Celebi University Medicine Faculty, Izmir, Turkey; 3Haseki Research and Training Hospital, Istanbul, Turkey; 4Tepecik Research and Training Hospital, Izmir, Turkey; 5Sisli Memorial Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P147 (doi: 10.1186/cc14227) E Sevketoglu1, A Anil2, S Kazanci1, O Yesilbas1, M Akyol1, S Bayraktar3, N Aksu4, S Hatipoglu1, M Karabocuoglu5 1Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Bakýrkoy, Turkey; 2Izmir Katip Celebi University Medicine Faculty, Izmir, Turkey; 3Haseki Research and Training Hospital, Istanbul, Turkey; 4Tepecik Research and Training Hospital, Izmir, Turkey; 5Sisli Memorial Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P147 (doi: 10.1186/cc14227) Introduction Inotropes and vasoactive drugs in septic shock are commonly used to maintain cardiac output, tissue perfusion and oxygenation. We undertook this study with the purpose of evaluating S52 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion SI is independently associated with 30-day mortality in a broad population of ED patients. Old age, hypertension and β-/Ca2+ channel-blockers weaken this association, but the association remains prognostic. SI ≥1 suggests substantial risk of 30-day mortality in all ED patients. for the surgical intervention (2 to 4 days before surgery). In total, 44.9% of the patients had CHF caused by noncoronarogenic dilated cardiomyopathy and 55.1% by ischemic cardiomyopathy. Indication for LS therapy was left ventricular ejection fraction (EF) <35% (28 ± 6%). Seventy percent of patients had mitral insuffi ciency (MI), grades II to IV, 63% tricuspid insuffi ciency (TrI), grades II to III, 84% pulmonary hypertension (PH), 47% arterial hypertension, grades II to III, and 27% of the patients had left ventricular aneurysm. Mean level of BNP was 1,803 ± 124 pg/ml. LS was administered as i.v. infusion in doses of 0.025 to 0.1 μg/kg/minute without previous bolus injection. Mean duration of infusion was 27.5 ± 5.3 hours. After infusion all patients underwent control assessment of values. All patients were operated: 25 (23.3%) underwent reverse cardiac remodeling, 63 (58.9%) myocardium revascularization (MR) with mitral or aortic valve replacement, 17 (15.9%) MR and/or resection of left ventricular aneurism and two (1.9%) heart transplantation. Levosimendan in the emergency department: a useful tool to improve cellular perfusion Introduction Levosimendan was originally developed for the treat ment of decompensated heart failure in situations for which conventional therapy is not suffi cient. It is an eff ective calcium- sensitising drug with vasodilatory and inotropic eff ects and improves cardiac contractility. Trials have shown positive outcome benefi t with the use of levosimendan [1]. We reviewed the usage levosimendan at our institution and outcome of these patients. Introduction Levosimendan is an inotropic seldom used in emergency departments (EDs). It has shown improved mortality in patients with shock [1] with few adverse eff ects [2]. This work denotes the experience of levosimendan use in the ED of Hospital Universitario Mayor between 2012 and 2014. p Methods We reviewed the use of levosimendan at Harefi eld from January 2013 through December 2013. Patient demographics, logistic EuroSCORE (Figure 1), diagnosis, surgical or intervention details, inotropic support, dosage and duration of levosimendan use, length of stay in the ICU, cost (Table 1) and patient outcome were collected. Results Levosimendan was used in 30 patients, 23 (77%) male and seven (23%) female. Median age was 69 (59 to 72.8). Levosimendan was used post cardiac surgery, post angioplasty and in patients with ventricular assist devices (VAD) and extracorporeal membrane oxygenator (ECMO). Most of the patients received a standard regimen of 12.5 mg administered at a dose of 0.1 μg/kg/minute for 24 hours. Concurrent noradrenaline was used in most of the patients ranging from 0.02 to 0.2 μg/kg/minute. The median length of stay in the ICU was nine (6 to 14.5) days for survivors and 23.5 (7.5 to 36) days in nonsurvivors. Sixteen patients (55%) survived and were discharged from the hospital. Methods We reviewed the use of levosimendan at Harefi eld from January 2013 through December 2013. Patient demographics, logistic EuroSCORE (Figure 1), diagnosis, surgical or intervention details, inotropic support, dosage and duration of levosimendan use, length of stay in the ICU, cost (Table 1) and patient outcome were collected. Methods We present a retrospective study which analyzes the eff ect, after 24 hours, of levosimendan administration on perfusion parameters of 166 ED patients. Patients had to have shock diagnosis of any cause. Diff erences between the initial and fi nal mean value of the following parameters were evaluated: lactate, central venous oxygen saturation (ScvO2) and venoarterial diff erence of CO2 (DvaCO2). Data were stratifi ed according to levosimendan categories (initial or rescue). Reference Reference Preoperative treatment with levosimendan helps to evaluate myocardial reserves in cardiosurgical patients with chronic heart failure Conclusion In our environment, we have observed diff erences in the use of levosimendan compared with dobutamine (higher rate of men undergoing CABG, diabetes and worse EF). After homogenizing the sample of patients by propensity score, an eff ect on mortality is discarded and we observed a signifi cant need for use of norepinephrine and a nonsignifi cant trend for prolonged mechanical ventilation and renal failure requiring renal replacement therapy, both probably related with the greatest need for vasopressors observed. Introduction The aim of the study was to assess the possibility of preoperative levosimendan (LS) administration in myocardial reserve evaluation and choice of the method of surgical treatment in patients with chronic heart failure (CHF). Introduction The aim of the study was to assess the possibility of preoperative levosimendan (LS) administration in myocardial reserve evaluation and choice of the method of surgical treatment in patients with chronic heart failure (CHF). Methods LS was used in 107 (female and male) patients (mean age 53 ± 3 years) as a component of CHF therapy to prepare them S53 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P152 Reference 1. Follath F, et al. Lancet. 2002;360:196-202. Levosimendan in the emergency department: a useful tool to improve cellular perfusion In addition, association between diff erent variables with mortality was sought. Diff erences were considered statistically signifi cant at probability levels below 0.05.f y , ( ) p Results Levosimendan was used in 30 patients, 23 (77%) male and seven (23%) female. Median age was 69 (59 to 72.8). Levosimendan was used post cardiac surgery, post angioplasty and in patients with ventricular assist devices (VAD) and extracorporeal membrane oxygenator (ECMO). Most of the patients received a standard regimen of 12.5 mg administered at a dose of 0.1 μg/kg/minute for 24 hours. Concurrent noradrenaline was used in most of the patients ranging from 0.02 to 0.2 μg/kg/minute. The median length of stay in the ICU was nine (6 to 14.5) days for survivors and 23.5 (7.5 to 36) days in nonsurvivors. Sixteen patients (55%) survived and were discharged from the hospital. p y Results There were no diff erences in APACHE II values between patients who received levosimendan as initial therapy from those who received it as a rescue measure. A total of 41 patients fulfi lled lactate normalization requirements (lactate <2.0 or clearance >50%) (Table 1). Forty-four patients reached normal values of SvcO2 and 37 patients of DavCO2 after levosimendan initiation. There were no associations between the normalization of lactate, SvO2 and DvaCO2 and diff erent types of shock. Twenty-nine patients who received initial therapy with levosimendan normalized their lactate values and 12 who received it as a rescue therapy (P <0.05). Sixty-three patients developed hypotension, and none had adverse eff ects requiring discontinuation of the drug. Hospital mortality was 47.7%. Variables associated with mortality in the study group were lactate value at admission (OR = 1.3, 95% CI = 1.0 to 1.7), the use of vasopressin after start levosimendan (OR = 7.5, 95% CI = 1.9 to 28.6) and the use of norepinephrine before starting (OR = 10.8, 95% CI = 1.9 to 60.7). Figure 1 (abstract P152). Logistic EuroSCORE of all patients. Table 1 (abstract P153). Perfusion variables before and after levosimendan Variable Initial Final Lactate (mmol/l) 3.3 (0.5 to 18) 2.38 (0.4 to 17)* SvcO2 (%) 56.3 (23 to 85) 65.2 (37 to 91)* DvaCO2 (mmHg) 8.2 (–16 to 26) 7.3 (–2 to 21) P <0.01. McNemar test. Table 1 (abstract P153). Perfusion variables before and after levosimendan Variable Initial Final Figure 1 (abstract P152). Logistic EuroSCORE of all patients. Figure 1 (abstract P152). Levosimendan in the emergency department: a useful tool to improve cellular perfusion Logistic EuroSCORE of all patients. Conclusion Levosimendan use in the ED, as initial or rescue therapy, normalizes lactate values and improves the SvcO2 after 24 hours, without an increase in adverse eff ects. f Table 1 (abstract P152). Cost of levosimendan based on a 70 kg patient Levosimendan Adrenaline Milrinone Maximum dose (μg/kg/minute) 0.2 1 0.7 Cost per vial (£) 894 2.30 16 Cost per 24 hours (£) 894 7 112 Conclusion We have successfully used this drug in high-risk patients during the perioperative period with good results without major complications. Levosimendan seems to reduce catecholamine requirement, the need for mechanical circulatory support, and the duration of critical care, which can justify the cost of this drug. It can be also useful in weaning patients from short-term VAD and ECMO. Larger studies are required in this area. Table 1 (abstract P152). Cost of levosimendan based on a 70 kg patient Table 1 (abstract P152). Cost of levosimendan based on a 70 kg patient Levosimendan Adrenaline Milrinone P153 Levosimendan in the emergency department: a useful tool to improve cellular perfusion P153 Levosimendan in the emergency department: a useful tool to improve cellular perfusion G Devia, J Torres, S Lopez Hospital Universitario Mayor, Bogotá, Colombia Critical Care 2015, 19(Suppl 1):P153 (doi: 10.1186/cc14233) Levosimendan: use, cost-eff ectiveness and outcome in a tertiary cardiothoracic centre Levosimendan: use, cost-eff ectiveness and outcome in a tertiary cardiothoracic centre A Ranjan, N Bhudia, I McGovern, C Walker, L Kuppurao Royal Brompton & Harefi eld NHS Foundation Trust, Harefi eld, London, UK Critical Care 2015, 19(Suppl 1):P152 (doi: 10.1186/cc14232) A Ranjan, N Bhudia, I McGovern, C Walker, L Kuppurao Royal Brompton & Harefi eld NHS Foundation Trust, Harefi eld, London, UK Critical Care 2015, 19(Suppl 1):P152 (doi: 10.1186/cc14232) P153 References 1. Landoni G, et al. Minerva Anestesiol. 2010.76:276-86. 2. Mebazaa A, et al. JAMA. 2007.297:1883–91. Conclusion We have successfully used this drug in high-risk patients during the perioperative period with good results without major complications. Levosimendan seems to reduce catecholamine requirement, the need for mechanical circulatory support, and the duration of critical care, which can justify the cost of this drug. It can be also useful in weaning patients from short-term VAD and ECMO. Larger studies are required in this area. Introduction The inotropic agents used in the ICU are dobutamine and milrinone; unfortunately, they have shown signifi cant side eff ects when used for myocardial depression during septic shock. Our objective is to describe Mn behavior in septic shock. S54 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 adaptive threshold for low amplitude QRS detection; QRS fi lter with an extended frequency range; management of VT alarm priorities. Conclusion A majority of the FPs was linked to user settings and patient conditions. The algorithm changes resulted in a clear reduction of ECG algorithm-related FP alarms, while the magnitude of the reduction depends strongly on the settings at the bedside. References 1. ECRI Institute. 2013;42:354-9. 2 Drew BJ et al PLoS ONE 2014 9: e110274 Methods We reviewed 72 clinical records of patients with diagnosis of septic and mixed shock who received Mn through January to December 2013. Demographic, hemodynamic, metabolic and gasometric data were recorded before and after Mn infusion. The PiCCO monitoring system was used. Data were expressed as mean and standard deviation. The statistical analysis used Student’s t test. P <0.05 was considered signifi cant. adaptive threshold for low amplitude QRS detection; QRS fi lter with an extended frequency range; management of VT alarm priorities. Conclusion A majority of the FPs was linked to user settings and patient conditions. The algorithm changes resulted in a clear reduction of ECG algorithm-related FP alarms, while the magnitude of the reduction depends strongly on the settings at the bedside. References 1. ECRI Institute. 2013;42:354-9. 2. Drew BJ, et al. PLoS ONE. 2014.9: e110274. 1. ECRI Institute. 2013;42:354-9. P155 Admission to the ICU with cerebrovascular event (CVE) and trauma was related to arrhythmia (P = 0.021, P = 0.032, respectively). There was a signifi cant relationship between VIP and sepsis presence (P <0.001, P <0.001). Atrial fi brillation was the most frequent type of arrhythmia (53%), and the most frequently used medication was diltiazem (28.5%). The patients who had arrhythmias had a longer ICU stay (P = 0.021). The mortality rate for all patients was 48.1%. There was no statistically signifi cant relationship between arrhythmia and mortality (P >0.05). False arrhythmia alarms can be reduced by algorithm improvements while the magnitude of the reduction is aff ected by alarm settings False arrhythmia alarms can be reduced by algorithm improvements while the magnitude of the reduction is aff ected by alarm settings M Kaski1, J Vanhatalo1, S Treacy2, H Viertio-Oja1 1GE Healthcare, Helsinki, Finland; 2GE, Milwaukee, WI, USA Critical Care 2015, 19(Suppl 1):P155 (doi: 10.1186/cc14235) False arrhythmia alarms can be reduced by algorithm improvements while the magnitude of the reduction is aff ected by alarm settings M Kaski1, J Vanhatalo1, S Treacy2, H Viertio-Oja1 1GE Healthcare, Helsinki, Finland; 2GE, Milwaukee, WI, USA Critical Care 2015, 19(Suppl 1):P155 (doi: 10.1186/cc14235) M Kaski1, J Vanhatalo1, S Treacy2, H Viertio-Oja1 M Kaski1, J Vanhatalo1, S Treacy2, H Viertio-Oja1 y j 1GE Healthcare, Helsinki, Finland; 2GE, Milwaukee, WI, USA , , ; , , , Critical Care 2015, 19(Suppl 1):P155 (doi: 10.1186/cc14235) Critical Care 2015, 19(Suppl 1):P155 (doi: 10.1186/cc14235) Introduction The ECRI Institute has identifi ed alarm fatigue as the number one health technology hazard [1]. A recent study on 461 ICU patients investigated 2,558,760 alarms [2]. In total, 88.8% of the annotated 12,671 arrhythmia alarms were false positives (FPs). It was concluded that the excessive number of alarms is ‘a complex interplay of inappropriate user settings, patient conditions, and algorithm defi ciencies’. Nine conditions causing alarms, four of which were ECG algorithm related, were reported [2]. In this study, we investigated a new algorithm in which improvements targeting three of the reported four ECG-related conditions were implemented: low amplitude QRS; wide QRS; nonactionable ventricular tachycardia (VT). gi p y y Conclusion Older age, higher APACHE II scores, trauma, CVE, VIP and sepsis increases arrhythmia risk in critically ill patients. Atrial fi brillation is most common and the most preferred treatment for all arrhythmias is diltiazem. References Results Seventy-two patients were studied: 36.5% were women, mean and SD of age, APACHE II, mechanical ventilation days and long ICU stay were: 67 ± 16 years, 18.5 ± 5.9 points, 14.9 ± 12.9 and 24.5 ± 21.9 days, respectively. A total 20.3% of the patients received dobutamine. Thirty- nine percent presented mixed shock. Global mortality was 23%. After Mn infusion: cardiac index (CI) increased: 3.1 ± 1 to 3.3 ± 1.1, cardiac rate increased: 82.4 ± 14.4 to 88.3 ± 18 and ScvO2 increased: 71.1 ± 10.3 to 76.1 ± 7.3 (P <0.05). PaCO2 arteriovenous diff erence and lactate were reduced: 7.36 ± 3.3 to 6.04 ± 3.6 and 18.7 ± 14.9 to 13.1 ± 9.1 (P <0.05). CVP, MAP, RVSI, VSTI, EVLWI and base excess showed no signifi cant diff erence. Mn initial average dose was 0.35 ± 0.13. NE before and after Mn infusion showed no signifi cant diff erence: 0.11 ± 0.20 versus 0.12 ± 0.22. References 1. Kanji S, et al. Crit Care Med. 2008;36:1620-4 1. Kanji S, et al. Crit Care Med. 2008;36:1620-4. j , ; 2. Annane D, et al. Am J Respir Crit Care Med. 2008;178:20-5. 2. Annane D, et al. Am J Respir Crit Care Med. 2008;178:20-5. P156 Arrhythmia incidence and risk factors in critically ill patients G Tasdemir, N Kelebek Girgin, A Aydin Kaderli, E Cizmeci, R Iscimen, F Kahveci, A Aydinlar Uludag University Medical Faculty, Bursa, Turkey Critical Care 2015, 19(Suppl 1):P156 (doi: 10.1186/cc14236) Introduction Cardiac arrhythmias may be observed at any time during the ICU stay. The prognosis may suff er due to these arrhythmias. In our study, we aimed to evaluate incidence and risk factors of arrhythmias occurring in patients in the ICU. Introduction Cardiac arrhythmias may be observed at any time during the ICU stay. The prognosis may suff er due to these arrhythmias. In our study, we aimed to evaluate incidence and risk factors of arrhythmias occurring in patients in the ICU. Conclusion Mn optimizes cardiovascular performance in septic shock and mixed shock, without aff ecting hemodynamic variables and global tissue perfusion. In addition, we observed that the IC, ScvO2, PaCO2 arteriovenous diff erence and lactate are related variables. References Methods Patients treated in the ICU were included in the study if they fulfi lled the following: age >18, no cardiac valvular disease, no cardiac surgery in the recent 6-month period, no history of myocardial infarction (MI), need for mechanical ventilation, and one or more organ failure. Demographic, hemodynamic and laboratory parameters, APACHE II score, presence of sepsis, acute renal failure, MI, and VIP during the ICU stay were recorded. Therapies used for arrhythmia and response to therapies were also recorded. 1. Holmes CL, et al. Vasoactive drugs for vasodilatatory shcok in ICU. Curr Opin Crit Care. 2009;15:398-402. 2. Jentzer JC, et al. Pharmacotherapy update on the use of vasopressors and inotropes in the intensive care unit. J Cardiovasc Pharmacol Ther [Epub ahead of print].l p p Results Two hundred and fourteen patients were included in the study. Twenty-six percent (n = 56) of patients had arrhythmias. Incidence was higher in females (P = 0.045). Average age of arrhythmic patients was 69 (19 to 86), and they were older than nonarrhythmic patients (P <0.001). APACHE II scores were higher in arrhythmic patients (P = 0.001). 3. Deep A, et al. Evolution of haemodynamics and outcome of fl uid-refractory septic shock in children. Intensive Care Med. 2013;39:1602-9. 3. Deep A, et al. Evolution of haemodynamics and outcome of fl uid-refractory septic shock in children. Intensive Care Med. 2013;39:1602-9. High-sensitive cardiac troponins and CK-MB concentrations in patients undergoing cardiac surgery High-sensitive cardiac troponins and CK-MB concentrations in patients undergoing cardiac surgery N De Mey, I Brandt, C Van Mieghem, K De Decker, G Cammu, L Foubert OLV AALST, Aalst, Belgium Critical Care 2015, 19(Suppl 1):P158 (doi: 10.1186/cc14238) N De Mey, I Brandt, C Van Mieghem, K De Decker, G Cammu, L Foubert OLV AALST, Aalst, Belgium Introduction Hs-cTn is the new standard cardiac biomarker for the diagnosis of myocardial necrosis. We conducted a prospective study to compare the course and values of Hs-cTn and CK-MB after CABG and OPCAB. We also evaluated the relationship between values >10 × 99th percentile URL of CK-MB and Hs-cTn as a possible marker for perioperative myocardial infarction. g g Results The cTnI concentrations measured in the control group ranged from 0.4 to 17.2, mean 2.1 (95% CI: 1.6 to 2.6) ng/l, without age dependency. Men revealed higher levels than women, means (IQR) were 2.8 (1.2 to 2.6) and 1.1 (0.7 to 1.3) ng/l. The CLSI nonparametric method revealed a 99th percentile value of 16 ng/l. The quantifi cation of cTnI above the LoD (1.0 ng/l) and below the 99th percentile was possible in 79 of 120 individuals. The imprecision profi le according to NCCLS revealed 20%, 10% and 5% CVs at concentrations of 2, 3 and at 20 ng/l, respectively. The discharge diagnosis was NSTEMI in 71 patients. The cTnI median values at 0, 3 and 6 hours were 46, 166 and 399 ng/l, respectively. AUC values at 0, 3 and 6 hours were 0.923, 0.964 and 0.969 for hs-cTnT and 0.919, 0.962 and 0.958 for cTnI, respectively. cTnI revealed AUC values of absolute changes from admission to 3 hours and from admission to 6 hours were 0.920 and 0.931, respectively.i Methods All adult patients undergoing cardiac surgery between February and August 2014 were included. Exclusion criteria were urgent surgery, GFR <60 ml/minute/1.73 m2, CK-MB >4 μg/l and/or Hs-cTn >14 ng/l at baseline (BL). Hs-cTn and CK-MB were measured before induction (BL), upon arrival in the ICU and at fi xed times after arrival. Patients with perioperative AMI as defi ned by the third universal defi nition of AMI were excluded for post hoc analysis [1]. Results Of the 93 patients admissible for inclusion, 40 in the CABG and 14 in the OPCAB group met all inclusion criteria in this preliminary dataset. High-sensitive cardiac troponins and CK-MB concentrations in patients undergoing cardiac surgery CK-MB values are higher from ICU arrival up to T24 versus baseline in both CABG and OPCAB (P <0.0001) with a peak at T3. For Hs-cTn, ICU up to T48 values are higher (P <0.01) in CABG with a peak Conclusion The PATHFAST cTnI demonstrated complete fulfi llment of the analytical criteria for high-sensitive cTn assays: The imprecision (CV) at the manufacturer-recommended 99th percentile value was 5%. The quantifi cation of cTnI in was possible in 65.8% of healthy individuals. The examination of the diagnostic characteristics revealed complete concordance with the hscTnT assay for detection of NSTEMI and for assessment of absolute changes of cTn values (rise and/or fall) in NSTEMI patients. PATHFAST cTnI showed highly sensitive detection of NSTEMI with increasing sensitivity at admission and after 3 to 6 hours, not going along with decreased specifi city. The PATHFAST cTnI might be useful at the point-of-care setting for early rule-in and rule-out diagnosis of NSTEMI. Figure 1 (abstract P158). Figure 1 (abstract P158). Analytical and diagnostic characteristics of the high-sensitivity PATHFAST troponin I assay p y E Spanuth1, R Thomae2, E Giannitsis3 E Spanuth1, R Thomae2, E Giannitsis3 1DIAneering GmbH, Heidelberg, Germany; 2Mitsubishi Chemical Europe, Düsseldorf, Germany; 3University of Heidelberg, Germany Critical Care 2015, 19(Suppl 1):P159 (doi: 10.1186/cc14239) E Spanuth1, R Thomae2, E Giannitsis3 1DIAneering GmbH, Heidelberg, Germany; 2Mitsubishi Chemical Europe, Düsseldorf, Germany; 3University of Heidelberg, Germany Critical Care 2015, 19(Suppl 1):P159 (doi: 10.1186/cc14239) Conclusion Among ADHF patients, the coupling of pulmonary hypertension and RVD carries an incremental risk, having a portentous impact on the survival rate. Introduction The POC PATHFAST cTnI assay (Mitsubishi Medience, Japan) has shown promising analytical validity. We thought to evaluate whether the assay could be classifi ed ‘highly-sensitive’. P158 yi g y Methods cTnI was determined using PATHFAST in 120 healthy individuals (60 men and 59 women, 21 to 69 years old, median 42 years). Cardiac disorders were excluded by cardiac magnetic resonance imaging. The diagnostic characteristics were investigated by determination of cTnI and cTnT (Roche hs-cTnT) in 181 patients admitted to the chest pain unit at presentation, and 3 and 6 hours later. The results were related to the discharge diagnoses. Pulmonary hypertension, right ventricular dysfunction and acute heart failure: a portentous consortium y Methods The false alarm rate of the new algorithm (GE Carescape, 2012) was compared with that of the algorithm evaluated in the study (GE Solar, 2003) [2] on the collected ECG waveform data. User settings such as QRS detection sensitivity (high/normal) were not available. Therefore, normal sensitivity was assumed for both versions. With the old algorithm, 10 patients with low QRS amplitudes gave a signifi cantly higher number of FPs than were reported [2]. For those patients, both sensitivity modes were tested with the old algorithm. Sixty-six percent of patients with a pacemaker did not have the pacemaker mode selected [2]. Outlier patients in which false alarms were due to user settings (20 patients with a pacemaker) or patient condition (four patients with a bundle branch block) rather than algorithm defi ciency were excluded. HD Michalopoulou, HM Michalopoulou, P Stamatis, E Kostetsos, D Stamatis Metaxa Hospital, Athens, Greece Critical Care 2015, 19(Suppl 1):P157 (doi: 10.1186/cc14237) Introduction Pulmonary hypertension and right ventricular dysfunc- tion (RVD) are frequently encountered in patients with acute heart failure. We sought a better understanding of the coupling between RVD and pulmonary hypertension in the setting of acute decompensated heart failure (ADHF) as it might improve the prognostic stratifi cation and infl uence the survival rates. l Methods Echocardiography was performed in 329 patients with ADHF and right ventricular function was assessed by measuring the right ventricular fractional area, and a right ventricular ejection fraction (RVEF) <35% was taken as the cutoff value for RV systolic dysfunction. The systolic pulmonary pressure (PASP) was calculated from the tricuspid regurgitation signal applying the modifi ed Bernoulli equation, Results Improved algorithm resulted in 66% reduction of FP alarms. When using the high-sensitivity mode for the 10 patients with low QRS, FP reduction was 18%. No compromises regarding detection of true events were found. The 24 outlier patients contributed to 81.3% of FP alarms. The algorithm changes responsible for the reduced FPs were: S55 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 at T6, and from T3 to T48 in OPCAB (P <0.05) versus baseline (Figure 1). In CABG patients CK-MB levels are higher versus OPCAB from ICU up to T12 (P <0.03), and from ICU to T48 for Hs-cTn levels (P <0.02). Pulmonary hypertension, right ventricular dysfunction and acute heart failure: a portentous consortium In 39 CABG patients (97.5%) and 10 OPCAB patients (71.4%) all individual Hs-cTn values are above 140 ng/l (= 10 × 99th percentile of URL). at T6, and from T3 to T48 in OPCAB (P <0.05) versus baseline (Figure 1). In CABG patients CK-MB levels are higher versus OPCAB from ICU up to T12 (P <0.03), and from ICU to T48 for Hs-cTn levels (P <0.02). In 39 CABG patients (97.5%) and 10 OPCAB patients (71.4%) all individual Hs-cTn values are above 140 ng/l (= 10 × 99th percentile of URL).i and pulmonary hypertension was considered as PASP >35 mmHg. Based on the values of PASP and RVEF the study group was classifi ed into four subgroups: group 1, normal PASP/preserved RVEF; group 2, high PASP/preserved RVEF; group 3, normal PASP/ low RVEF; group 4, high PASP/low RVEF. The primary endpoint was all-cause mortality. The median follow-up was 18 months. Survival analysis was performed according to the Cox regression method, adjusted for age, gender, LV function, estimated glomerular fi ltration rate, troponin I, hemoglobin, serum sodium and BNP levels. Conclusion Both CK-MB and Hs-cTn levels increase signifi cantly after cardiac surgery. Postoperative Hs-cTn levels exceed the 10 × 99th percentile of URL in nearly all CABG patients. Our data show an important discrepancy between the 10 × 99th percentile for both biomarkers, and suggest that a diff erent defi nition for postoperative AMI may be needed when Hs-cTn is used. Results Pulmonary hypertension was found in 78% of the patients (median PASP: 53 mmHg). As compared with the patients with normal PASP the patients with pulmonary hypertension were more likely to be in New York Heart Association functional class (NYHA) III or IV (86% vs. 49%, P <0.001), had a lower RVEF (23 ± 9% vs. 32 ± 8%, P <0.001), and had signifi cantly higher BNP levels (280 ± 107 pg/ml vs. 540 ± 320 pg/ ml, P <0.001). In a Cox model, compared with patients with normal right ventricular function and without pulmonary hypertension (group 1), the adjusted hazard ratio for mortality was 3.1 (95% CI: 1.6 to 4.2, P <0.01) in group 2, 0.3 (95% CI: 0.2 to 1.9, P = 0.3) in group 3 and 4.2 (95% CI: 1.9 to 6.1, P <0.001) in group 4. y Reference y Reference 1. Thygesen et al. J Am Coll Cardiol. 2012;60:1581-98. P160 P160 Combining therapeutic hypothermia and primary coronary intervention in comatose survivors of ventricular fi brillation due to ST-elevation myocardial infarction R Knafelj, M Noc Universty Clincal Center, Ljubljana, Slovenia Critical Care 2015, 19(Suppl 1):P160 (doi: 10.1186/cc14240) Combining therapeutic hypothermia and primary coronary intervention in comatose survivors of ventricular fi brillation due to ST-elevation myocardial infarction R Knafelj, M Noc Universty Clincal Center, Ljubljana, Slovenia Critical Care 2015, 19(Suppl 1):P160 (doi: 10.1186/cc14240) y R Knafelj, M Noc Universty Clincal Center, Ljubljana, Slovenia Critical Care 2015, 19(Suppl 1):P160 (doi: 10.1186/cc14240) Introduction Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for ST-elevation acute myocardial infarction (STEMI). In comatose survivors of cardiac arrest, mild induced hypothermia (MIH) improves neurological recovery. Figure 1 (abstract P158). S56 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results Of the 3,835 nontraumatic patients treated in the ED, 3,196 were adults. In this adult population, 500 ECGs were performed in patients whose symptoms suggest ACS. The median age was 62.3 years and the sex ratio was 1.16. Clinical presentation was chest pain (31%), dyspnea (14%), palpitations (5%), disturbance of consciousness (3%) or others (47%). Fifty-six (11.2%) were diagnosed as ACS, including 20 ST-elevation myocardial infarction (STEMI), 28 non-STEMI and eight unstable angina. Of the 20 STEMI patients, eight (40%) and fi ve (25%) were diagnosed as STEMI complicated by right ventricular and posterior wall ischemia respectively, which means that these complications could have been missed by standard 12-lead ECG. Methods A total of 112 patients undergoing PPCI and MIH were compared with 32 comparable consecutive patients who underwent PPCI but no MIH. We hypothesized that combining both methods lead to better survival rate. MIH was induced (propofol, fentanyl, saline 4 ml/kg BW, 2°C) and maintained for 24 hours, targeting 32 to 34°C. Spontaneous rewarming was allowed (0.5°C).if g Results There were no signifi cant diff erences between the MIH and Control group in general characteristics, cardiac arrest circumstances and angiographic features. Except for decreases in heart rate during MIH, there was no diff erence between MIH and no MIH groups in arterial pressure, peak lactate (7.7 vs. 6.2 mmol/l; P = 0.36), need for vasopressors (57% vs. 41%; P = 0.09), aortic balloon counterpulsation (13% vs. 22%; P = 0.19), repeat cardioversion/defi brillation (17% vs. 25%; P = 0.30). P160 There was lower incidence of inotropic use (36% vs. 59%; P = 0.01) and use of antiarrhythmics (11% vs. 53%; P = 0.002). There was no diff erence in FiO2 during mechanical ventilation and in renal function. See Table 1. y Conclusion Eighteen-lead ECG with synthesized right-sided and posterior precordial leads was an effi cient method to diagnose ACS in a Caucasian population within 10 minutes of ED arrival. It is particularly performant to detect right ventricular ischemia early, which can modify acute therapeutic strategy. References 1. Thygesen K, et al. Circulation. 2007;116:2634-53. 2. Katoh T, et al. J Nippon Med Sch. 2011;78:22-9. 3. Tamura A, et al. Am J Cardiol. 2014;114:1187-91. References 1. Thygesen K, et al. Circulation. 2007;116:2634-53. 2. Katoh T, et al. J Nippon Med Sch. 2011;78:22-9. 3. Tamura A, et al. Am J Cardiol. 2014;114:1187-91. Table 1 (abstract P160). Survival after 12 months MIH Control P CPC 1/2 50 (45%) 5 (15%) 0.002 CPC 3/4 0 0 NS Cardio 20 (18%) 6 (19%) 0.95 CNS 18 (16%) 17 (53%) 0.00001 Table 1 (abstract P160). Survival after 12 months Conclusion Hospital survival with CPC 1/2 was signifi cantly better in the MIH group (45% vs. 15%; P = 0.01). Our study clearly demonstrates that PPCI and MIH are feasible and may be combined safely in comatose survivors of ventricular fi brillation in STEMI setting. Such strategy improves survival with good neurological recovery. References Introduction After an acute myocardial infarction with ST-segment elevation (STEMI) treated with percutaneous coronary intervention (PCI), the left ventricle (LV) can undergo negative remodeling (R–). We aimed to investigate whether global longitudinal strain (SGL) of the left ventricle (LV) predicts remodeling. e e e ces 1. HACA Study Group. Mild therapeutic hypothermia to improve the neurological outcome after cardiac arrest. N Engl J Med. 2002;346:549-56. 2. Knafelj R, Radsel P, Ploj T, Noc M. Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fi brillation with ST-elevation acute myocardial infarction. Resuscitation. 2007;74:227-34. g g ; 2. Knafelj R, Radsel P, Ploj T, Noc M. Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fi brillation with ST-elevation acute myocardial infarction. Resuscitation. 2007;74:227-34. Methods Transthoracic echocardiography with speckle tracking imaging (TTE-STI) was performed 2 to 3 days after primary PCI and 6 months later in patients with diagnosis of STEMI. P160 LV R– criteria were: LVEF increase ≤5% and end-diastolic volume increase ≥15%. Logistic regression and ROC curve analysis was used for the statistical analysis. Results Eighty-three patients (56 ± 11 years) with STEMI at any LV localization and subjected to primary PCI were studied during 2012: LV P165 Prognostic comparison of tissue Doppler indices of diastolic dysfunction and cardiac biomarkers in septic shock V Karali, V Voutsas, N Loridas, M Konoglou, M Papaioannou, A Alexiou, V Hatsiou, C Fitili, M Bitzani Papanikolaou Hospital, Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P165 (doi: 10.1186/cc14245) P165 Prognostic comparison of tissue Doppler indices of diastolic dysfunction and cardiac biomarkers in septic shock V Karali, V Voutsas, N Loridas, M Konoglou, M Papaioannou, A Alexiou, V Hatsiou, C Fitili, M Bitzani Papanikolaou Hospital, Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P165 (doi: 10.1186/cc14245) y y Methods A consecutive registry of patients seen in 2013 (January to October) in the ICU of a hospital without a HU. The total transfer time is considered from the call to the Emergency Coordination Center until arrival at the HU. In turn, this time is divided into activation time, arrival time of the relocation team, patient preparation time and transfer time. Methods A consecutive registry of patients seen in 2013 (January to October) in the ICU of a hospital without a HU. The total transfer time is considered from the call to the Emergency Coordination Center until arrival at the HU. In turn, this time is divided into activation time, arrival time of the relocation team, patient preparation time and transfer time. In the case of primary PCI, the door-to-balloon time was estimated by adding to the total transfer time the initial assessment and completion time of catheterization and balloon infl ation. The times are expressed in minutes, as the median and interquartile range. In the case of primary PCI, the door-to-balloon time was estimated by adding to the total transfer time the initial assessment and completion time of catheterization and balloon infl ation. The times are expressed in minutes, as the median and interquartile range. Introduction Diastolic dysfunction as evaluated by tissue Doppler imaging (TDI), particularly by E/E’ ratio (peak early diastolic transmitral velocity/peak early diastolic mitral annular velocity) and mitral annular E’-wave, is common and crucial in critical illness. Our prospective observational study assessed the prognostic signifi cance of TDI variables versus cardiac biomarkers, B-type natriuretic peptide (BNP), troponin-T (TnT) and investigated determinants of plasma BNP rise, in septic shock. g Results During 10 months of 2013, we treated 162 STEMI. Of these, 104 had evidence of reperfusion (64%). Primary PCI was performed in 24 patients (23%), of which 10 were transferred from the hospital to the HU. Fibrinolytic therapy was used in 62 patients (59%), of these 20 (32.2%) required rescue PCI. The transfer time for primary PCI was 0:39:44 (0:31:41 to 0:44:32) minutes. The transfer time for rescue PCI was 0:38:56 (0:37:25 to 0:51:29) minutes. Cerebrovascular haemodynamics in preeclamptic patients E Shifman, S Floka Cerebrovascular haemodynamics in preeclamptic patients E Shifman, S Floka The State Budgetary Healthcare Institution of Moscow Area ‘Moscow’s Regional Research Clinical Institute n.a. M.F. Vladimirsky’, Moscow, Russia Critical Care 2015, 19(Suppl 1):P164 (doi: 10.1186/cc14244) The State Budgetary Healthcare Institution of Moscow Area ‘Moscow’s Regional Research Clinical Institute n.a. M.F. Vladimirsky’, Moscow, Russia Critical Care 2015, 19(Suppl 1):P164 (doi: 10.1186/cc14244) p y gi Results Mean ± SD APACHE II score was 21.22 ± 7.28, mean ± SD admission SOFA score was 10.25 ± 2.76. Hospital mortality was 55%. Nonsurvivors had increased E/E’ (15.56 ± 1.48; P <<0.00001) and reduced E’ 6.32 ± 0.68 cm/second (P <<0.00001) compared with survivors, who exhibited inverse correlations with an E/E’ signifi cantly lower (9.30 ± 2.88) and higher E’ (9.01 ± 0.85 cm/second). In contrast, BNP and TnT levels displayed remarkably lower statistical signifi cance in nonsurvivors (P = 0.005, P = 0.007 respectively). The ROC curves had an area under the curve of 0.98 for the E’, and 0.92 for the E/E’. Vasopressor management (noradrenaline dose) (P = 0.0001), fl uid balance (P <0.001) and E/E’ (P = 0.00004) were independent predictors of plasma BNP concentration. Introduction The goal of the study was to analyse cerebral blood fl ow in pregnancy complicated by preeclampsia. Introduction The goal of the study was to analyse cerebral blood fl ow in pregnancy complicated by preeclampsia. Methods This was a prospective study. I group: 45 patients, 17 to 38 years (mean age 27.5 ± 5.3 years) with verifi ed diagnosis of severe preeclampsia; control group: 72 healthy women with normal pregnancy, third trimester, 19 to 34 years (mean age 24.5± 4.3 years). Exclusion criteria: potentially haemodynamically signifi cant stenosis; congestive heart disease; arrhythmia; large changes in haemorheology; diabetes mellitus; and craniospinal trauma and syncope. Study of cerebral fl ow was improved by the method of transcranial dopplerography (TCD). All patients underwent duplex scan of extracranial portions of brachiocephalic arteries and transcranial duplex scan in the area of middle cerebral artery (MCA) (segment M1). During duplex scan of brachiocephalic arteries lumen, the presence of extravasal causes for basic blood fl ow disturbances was estimated. We determined lumen of large basilar arteries and quantitative features of blood fl ow in MCA. Synthesized 18-lead electrocardiogram as routine myocardial ischemia detection in an emergency department: a preliminary evaluation in Europe Figure 1 (abstract P162). Clinique Notre-Dame de Grâce, Gosselies, Belgium q g Critical Care 2015, 19(Suppl 1):P161 (doi: 10.1186/cc14241) Introduction Standard 12-lead electrocardiogram (ECG) is, with biomarkers, the most accurate method in the diagnosis of acute coronary syndrome (ACS). However, posterior (V7-V8-V9) and right (V3R-V4R-V5R) derivations are not systematically performed due to the time-consuming procedure involved, despite major therapeutic implications (fl uid loading instead of nitrates use in right ventricular involvement) and published guidelines [1]. Recently, an 18-lead ECG system, standard 12-lead ECG and six additional synthesized leads (assessing posterior and right ventricular areas) in only one recording procedure has been developed. The reliability of this material (ECG 2550; Nihon Kohden Co. Ltd, Japan) was already validated in this indication in an Asian population [2,3]. Methods We conducted a prospective, observational study with patients admitted to our emergency department (ED), during a 6-month period. Requirement for ECG was guided by physician’s discretion according to patient’s history. All patients with chest pain, dyspnea, palpitations, disturbance of consciousness, malaise or abdominal complaint underwent synthesized 18-lead ECG within 10 minutes of ED arrival. The aim of the study was to evaluate the eff ectiveness of the synthesized 18-lead ECG as an ischemia triage tool in the ED, and particularly the ability to early detect a right ventricular involvement. Figure 1 (abstract P162). S57 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 R– patients (n = 35, 42%) and no LV R– patients (n = 48, 58%). Diabetes mellitus (41% vs. 19%; P <0.001) and TnI levels (1.2 ± 2.1 μg/l vs. 0.4 ±0.3 μg/l; P = 0.005) showed higher incidence in LV R– patients. SGL was –12.5 ± 5.6% in no LV R– patients and –6.5 ± 3.4 in LV R– patients. In the regression analysis just LV SGL and SL in left anterior descending territory remained signifi cant, OR: 1.85 (1.24 to 2.76) (P <0.001) and OR: 1.63 (1.15 to 2.31) (P <0.001), respectively. P165 Prognostic comparison of tissue Doppler indices of diastolic dysfunction and cardiac biomarkers in septic shock V Karali, V Voutsas, N Loridas, M Konoglou, M Papaioannou, A Alexiou, V Hatsiou, C Fitili, M Bitzani Papanikolaou Hospital, Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P165 (doi: 10.1186/cc14245) The door-to-balloon time estimated for primary PCI was 80 minutes. Methods Twenty-seven mechanically ventilated adult patients admitted to our ICU were evaluated within 72 hours of evolving septic shock. Patients underwent two transthoracic echocardiographies within 72 hours of the onset of septic shock: shortly after diagnosis and 24 hours later (confi rmatory), alongside relevant measurements of cardiac biomarkers. Peak mitral infl ow E and A velocity waves were recorded using pulsed-wave Doppler at the mitral valve tips from the apical four-chamber view, peak early (E’) and late (A’) diastolic myocardial velocities were obtained by TDI at the septal mitral annulus in the apical four-chamber view. E/E’ was calculated. P ≤0.01 was reported as statistically signifi cant. Conclusion Times for interhospital transfer of patients with STEMI who had undergone urgent catheterization are within the range considered optimal. In the case of primary PCI, times are lower than the 90 to 120 minutes recommended practice guidelines. Synthesized 18-lead electrocardiogram as routine myocardial ischemia detection in an emergency department: a preliminary evaluation in Europe The analysis of ROC curves revealed that at the cutoff level of –12.46%, SGL identifi es LV R– with a sensibility of 81% and a specifi city of 86% (AUC = 0.88: 95% CI: 0.79 to 0.96; P <0.001) (Figure 1).i fl ow velocity (Vps), maximal end-diastolic velocity (Ved), time-adjusted maximal velocity (TAMX), resistance index (RI), pulsative index (PI), and systolic/diastolic ratio (S/D) were determined. Signifi cance of mean value diff erences were calculated using the STATISTICA 6.0 program with determination of Student’s t criteria with normal spread in the group. g p Results All haemodynamic values in the M1 segment of MCA in preeclamptic patients were decreased in comparison with the same values in healthy pregnant women with diff erent signifi cance: PI (mean 0.77 vs. 0.84, P <0.01); RI (mean 0.52 vs. 0.54, P <0.05); Vps (mean 90.22 vs. 104.74 cm/second, P <0.001); Ved (mean 43.25 vs. 48.53 cm/second, P <0.001); TAMX (mean 61.48 vs. 67.30 cm/second, P <0.01); and S/D (mean 2.02 vs. 2.06, P <0.05). Found pathophysiological changes of cerebral haemodynamics were consistent with a dopplerographic pattern of diminished perfusion and are typical for vascular segments, which are located proximally to the zone of abnormally high haemodynamic resistance: prestenotic arterial segments, episodes of arterial hypertension and distal vasoconstriction. Conclusion SGL assessment in the fi rst days after primary PCI is useful in the prediction of LV R– independently of the myocardial infarction localization. P164 Cerebrovascular haemodynamics in preeclamptic patients E Shifman, S Floka The State Budgetary Healthcare Institution of Moscow Area ‘Moscow’s Regional Research Clinical Institute n.a. M.F. Vladimirsky’, Moscow, Russia Critical Care 2015, 19(Suppl 1):P164 (doi: 10.1186/cc14244) Analysis of the interhospital transfer times in patients with ST-elevation acute coronary syndrome for undergoing urgent coronariography Analysis of the interhospital transfer times in patients with ST-elevation acute coronary syndrome for undergoing urgent coronariography FM Acosta Diaz, O Moreno, M Muñoz, R Fernandez, J Soto, M Colmenero San Cecilio Universitary Hospital, Granada, Spain Critical Care 2015, 19(Suppl 1):P163 (doi: 10.1186/cc14243) y Conclusion With TCD we obtained a possibility to determine and estimate changes in cerebrovascular fl ow in pregnant patients with severe preeclampsia. This enhances diagnostic possibilities of some serious pregnancy complications, and gives us deep understanding of some components of pathogenesis and increased treatment effi cacy. y p p Critical Care 2015, 19(Suppl 1):P163 (doi: 10.1186/cc14243) Introduction The aim was to analyze the related assistance times to transfer patients with ST-elevation acute coronary syndrome (STEMI) referred to another hospital with a hemodynamics unit (HU) for performing emergency catheterization (primary or rescue PCI). P165 P168 Results A total of 207 male and 144 female patients, APACHE II score 21 ± 7, 62 ± 14 years old, one to 126 TPTDs per patient. Diagnosis: cirrhosis/liver failure n = 112 patients (31.9%), sepsis 55 (15.7%), ARDS 46 (13.1%), GI aff ection 21 (6.0%), cardiogenic shock 19 (5.4%), various 98 (27.9%). Patients with liver failure were slightly younger than the other patients (58 ± 11 vs. 64 ± 15 years; P <0.001). All other baseline characteristics were comparable including APACHE II (20 ± 7 vs. 21 ± 8; NS), SAPS (39 ± 12 vs. 41 ± 14; NS), height (172 ± 9 vs. 170 ± 9 cm; NS) and weight (76 ± 20 vs. 73 ± 17 kg; NS). Among haemodynamic parameters, preload markers GEDVI (753 ± 168 vs. 790 ± 226 ml/m2; P = 0.182) and CVP (14.4 ± 8.8 vs. 14.9 ± 7.1 mmHg; P = 0.250) were comparable. Despite comparable preload parameters, the following parameters were signifi cantly diff erent: patients with acute or chronic liver failure had signifi cantly higher cardiac index (4.3 ± 1.3 vs. 3.3 ± 1.3 l/minute/ m2; P <0.001), stroke volume index (50 ± 15 vs. 37 ± 15; P <0.001), pulse pressure (75 ± 19 vs. 65 ± 21 mmHg; P = 0.021) and cardiac power index (0.7 ± 0.24 vs. 0.60 ± 0.28 W/m2; P <0.001). By contrast, MAP (77 ± 15 vs. 80 ± 15 mmHg; P = 0.045), SVRI (1,305 ± 638 vs. 1,877 ± 898 dyns/ cm5m2; P <0.001) and heart rate (84 ± 19 vs. 92 ± 22/minute; P <0.001) were signifi cantly lower in patients with liver failure. P168 Room temperature transpulmonary thermodilution (TPTD) with increased indicator 20 ml TPTD bolus compared with standard TPTD with 15 ml iced saline: a prospective observational study W Huber1, E Maendl1, A Beitz1, M Messer1, T Lahmer1, B Henschel1, S Rasch1, C Schnappauf1, RM Schmid1, ML Malbrain2 1Klinikum rechts der Isar, Technical University of Munich, Germany; 2Ziekenhuis Netwerk, Antwerp, Belgium Critical Care 2015, 19(Suppl 1):P168 (doi: 10.1186/cc14248) Introduction Use of ice-cold saline is assumed to provide best accuracy of TPTD to obtain the cardiac index (CI), global end-diastolic volume (GEDVI) and extravascular lung-water (EVLWI). However, room- temperature injectate might facilitate TPTD outside the ICU. Accidental intra-arterial injection: an under-reported preventable never event femoral TPTD (Pulsion Medical Systems, Germany). Results Fifteen female and 16 male patients, APACHE II score 21 ± 7. Mean values of CI (4.02 ± 0.98 vs. 3.96 ± 0.91 l/minutem2; P <0.001), GEDVI (800 ± 166 vs. 796 ± 163 ml/m2; P = 0.011) and EVLWI (10.3 ± 3.7 vs. 9.7 ± 3.6 ml/kg; P <0.001) were slightly higher when measured at room temperature compared with cold saline. Mean bias and PE values were 0.06 ± 0.37 l/minutem2 and 18.6% for CI, 4 ± 81 ml/m2 and 20.2% for GEDVI and 0.5 ± 1.1 ml/kg and 22.7% for EVLWI. Bias values in case of femoral compared with jugular indicator injection were not signifi cantly diff erent for CI (0.04 ± 0.41 vs. 0.11 ± 0.30 l/minutem2; P = 0.161) and EVLWI (0.56 ± 1.19 vs. 0.42 ± 1.07 ml/kg; P = 0.492). Bias for GEDVI-room was signifi cantly lower for femoral CVC compared with jugular indicator injection (–6.0 ± 81.1 vs. 18.9 ± 78.3 ml/m2; P = 0.008). Conclusion Compared with previous data using 15 ml room- temperature injectate, our data with 20 ml room-temperature injectate in general provide acceptable bias and percentage error when compared with standard TPTD with 15 ml iced saline. This also applies for femoral CVC room-temperature TPTD which might also be related to a new PiCCO-2 algorithm correcting for femoral CVC site. Reference M Mariyaselvam, A Hutton, P Young Queen Elizabeth Hospital, King’s Lynn, UK Critical Care 2015, 19(Suppl 1):P166 (doi: 10.1186/cc14246) Introduction Depending upon the medication administered, accidental administration of medication into the arterial line can cause devastating complications. This wrong-route injection is a never event in the UK but may be under-reported especially when occurring in the unconscious patient who may not notice associated pain temporally. Under-reporting may occur because resultant complications may be delayed a number of hours and the accountable healthcare worker may not recognise or choose not to report the error. In 2008 the UK National Patient Safety Agency (NPSA) reported only 76 incidents related to poor sampling technique but few wrong route arterial injections. Of these 21% suff ered moderate to severe harm [1]. The NPSA suggests that training and the use of clear labelling alongside red arterial tubing and standard red lock caps be used to prevent arterial sampling errors. Cerebrovascular haemodynamics in preeclamptic patients E Shifman, S Floka By the transtemporal approach in the MCA M1 segment, peak systolic Conclusion Diastolic dysfunction as evaluated by E/E’ and E’ constitutes a major independent predictor of outcome in septic shock, compared with cardiac biomarkers, suggesting that echocardiographic techniques assessing diastolic dysfunction in sepsis may replace cardiac biomarkers for mortality prediction. Fluid balance, vasopressor management and diastolic dysfunction are independent predictors of BNP elevation in septic shock. Our fi ndings should be confi rmed by an extended prospective study. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S58 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P166 the PiCCO-2 device with the latest algorithm correcting GEDVI for femoral TPTD (Pulsion Medical Systems, Germany). Accidental intra-arterial injection: an under-reported preventable never event Methods In 2014, we conducted a national postal survey of ICUs in the UK to attempt to determine the rate of accidental intra-arterial injections. The survey was sent to the clinical director of every ICU and they were asked whether they were aware of any unintentional arterial line injection having occurred in their hospital in the last 5 years. 1. Huber W, et al. J Crit Care. 2014;29:1133. 1. Huber W, et al. J Crit Care. 2014;29:1133. y Results Of the 56 ICUs that responded, 16 (28.5%) reported that they had personally seen an accidental injection into the arterial line. P169 Transpulmonary thermodilution-derived haemodynamics in patients with liver failure: a prospective study in 351 patients W Huber, A Breitling, B Henschel, S Mair, S Goetz, J Tschirdewahn, J Frank, A Beitz, RM Schmid Klinikum rechts der Isar, Technical University of Munich, Germany Critical Care 2015, 19(Suppl 1):P169 (doi: 10.1186/cc14249) Conclusion Despite the arterial line safety recommendations made by the NPSA in 2008, we demonstrate that intra-arterial injection is still a problem and that it remains under-reported. Our incidence is likely to be an underestimate as it relies on the recollections of a single individual in each institution. Medical errors can be mitigated by consideration of human factors and system engineering to improve patient safety. A focus on clinical awareness, colour coding and training may lead to improvements; however, institutions and clinical directors also bear a responsibility to prevent never events and a number of engineered solutions are now available such as needle-free non-injectable arterial sampling devices to protect the healthcare environment and make this error impossible [2,3]. Introduction Patients with acute or chronic liver failure are considered to have an altered pattern of haemodynamics. Nevertheless, there is a lack of studies systematically investigating haemodynamics in patients with liver failure. Therefore, it was the aim of this study to compare transpulmonary thermodilution (TPTD)-derived haemodynamics of 112 patients with acute or chronic liver failure with 239 patients without liver failure. Acknowledgement Funding from Eastern Academic Health Science Network, UK. References Acknowledgement Funding from Eastern Academic Health Science Network, UK. Methods We analyzed a prospectively maintained database including 6,016 TPTD measurements in 351 patients. To account for diff erent numbers of TPTDs in diff erent patients, comparison of fi rst measurements of patients with and without liver failure was the primary endpoint. Statistics: Wilcoxon test for unpaired samples; IBM SPSS Statistics 22. 1. Rapid response alert 06. NPSA; 2008. 1. Rapid response alert 06. NPSA; 2008. 2. Mariyaselvam et al. Anaesthesia. 2014;70:51-5. 3. Mukhopadhyay et al. Crit Care. 2010;14:R7. Reference 1. Romano M, et al. Care Med. 2002;30:1834-41. Measurement of cardiac output in children: comparison between direct Fick method and pressure recording analytical method: preliminary report Measures were performed by a single trained operator, who was blind to CVP values. Methods Patients with a CVC placed as part of clinical management were evaluated. EJV and internal jugular vein (IJV) measurements were performed at the left cricoid level. IJV and EJV were visualized in short axis view; diameters, circumferences and areas were obtained at end expiration with simultaneous CVP measurement. Measures were performed by a single trained operator, who was blind to CVP values. Results Forty-eight patients were included. A poor correlation was found between CVP and IJV and EJV circumference and area in mechanically ventilated patients. A strong correlation was found between CVP and EJV circumference (r: 0.74; P = 0.0004; 95% CI: 0.421 to 0.897) and area (r: 0.702; P = 0.0012; 95% CI: 0.35 to 0.88) in spontaneously breathing patients. Conventional receiver-operating characteristic curves were generated to assess the utility of EJV circumference and area to predict low (≤8 mmHg) versus high (>8 mmHg) CVP values. AUC for EJV circumference and area was 0.935 (P <0.0001; 95% CI: 0.714 to 0.997) and 0.87 (P <0.0001; 95% CI: 0.63 to 0.98) respectively (Figure 1). Conclusion These results highlight a potentially evolving role of Measurement of cardiac output in children: comparison between direct Fick method and pressure recording analytical method: preliminary report Introduction There are few methods of cardiac output (CO) estimation validated in children. The aim of this study is to investigate the reliability of an uncalibrated pulse contour method of CO estimation, the pressure recording analytical method (PRAM), in pediatric patients scheduled for diagnostic right and left heart catheterization, compared with the oxygen-direct Fick method. yg Methods Cardiac index (CI) was simultaneously estimated by Fick, and PRAM applied to pressure signals recorded invasively from a femoral catheter. All measurements were performed in steady-state condition. PRAM CI measurements were obtained for 10 consecutive beats simultaneously during the Fick CI estimation. Agreement between Fick and PRAM was assessed using the Bland–Altman method. Correlation coeffi cient, bias, and percentage of error were calculated. fi Results Forty-three CI measurements were performed in 43 patients. The data showed good agreement between CIFick and CIPRAM: r2 = 0.98; bias –0.0074 l/minute/m2; limits of agreement from –0.22 to 0.22 l/minute/m2. The percentage error was 8%. Figure 1 shows the Bland–Altman plot. Figure 1 (abstract P171). Figure 1 (abstract P170). Bland–Altman plot of the cardiac index measured with Fick versus PRAM. Figure 1 (abstract P170). Bland–Altman plot of the cardiac index measured with Fick versus PRAM. Figure 1 (abstract P171). Nonetheless, the external jugular vein (EJV) circumference and area have not been evaluated. Considering the role of EJV visual assessment in the clinical estimation of CVP, we hypothesized that EJV ultrasound evaluation could be used to reliably estimate CVP. Conclusion PRAM provides reliable estimates of cardiac output in hemodynamically stable pediatric cardiac patients compared with the Fick method. Reference Conclusion PRAM provides reliable estimates of cardiac output in hemodynamically stable pediatric cardiac patients compared with the Fick method. f Methods Patients with a CVC placed as part of clinical management were evaluated. EJV and internal jugular vein (IJV) measurements were performed at the left cricoid level. IJV and EJV were visualized in short axis view; diameters, circumferences and areas were obtained at end expiration with simultaneous CVP measurement. Measures were performed by a single trained operator, who was blind to CVP values. Methods Patients with a CVC placed as part of clinical management were evaluated. EJV and internal jugular vein (IJV) measurements were performed at the left cricoid level. IJV and EJV were visualized in short axis view; diameters, circumferences and areas were obtained at end expiration with simultaneous CVP measurement. P168 A recent study [1] showed acceptable bias and percentage error (PE) for CI-room derived from TPTD with 15 ml room temperature saline compared with CI-cold using 15 ml iced saline for TPTD. However, GEDVI-room and EVLWI-room had borderline PE values close to 30%, and the bias of GEDVI-room markedly increased with higher values of GEDVI and in case of femoral CVC. Since imprecision of TPTD-room might be reduced by a larger volume of injectate, it was the aim of our study to compare CI, GEDVI and EVLWI derived from TPDT using 20 ml room temperature injectate with standard TPTD with 15 ml iced saline. Conclusion Our data derived from a large TPTD database demonstrate markedly diff erent haemodynamics in patients with cirrhosis or acute liver failure with the only exception of static preload markers GEDVI and CVP. These fi ndings should be considered in instable patients with liver failure. Methods In 31 patients 236 sets with two 20 ml TPTDs with 21°C and subsequently two standard TPTDs with 4°C saline were obtained using Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S59 Figure 1 (abstract P171). P170 P170 Measurement of cardiac output in children: comparison between direct Fick method and pressure recording analytical method: preliminary report J Alonso Iñigo1, F Escribá1, J Carrasco1, J Encarnación1, M Fas2, M Barberá1 1Hospital Universitario y Politécnico La Fe, Valencia, Spain; 2Hospital Universitario de la Ribera, Alzira, Spain Critical Care 2015, 19(Suppl 1):P170 (doi: 10.1186/cc14250) P172 Do intravascular hypovolaemia and hypervolaemia result in changes in pulmonary blood volume? g p y JJ Vos1, TW Scheeren1, SA Loer2, A Hoeft3, JK Wietasch1 1University of Groningen, University Medical Center Groningen, the Netherlands; 2Institute for Cardiovascular Research, VU University Medical Centre, Amsterdam, the Netherlands; 3University of Bonn, Germany Critical Care 2015, 19(Suppl 1):P172 (doi: 10.1186/cc14252) Introduction Hypovolaemia is generally believed to induce centrali sa- tion of blood volume. Therefore, we evaluated whether hypovolaemia and hypervolaemia result in a change in central blood volume (that is, pulmonary blood volume (PBV)) and we explored the eff ects on the distribution between PBV and circulating blood volume (Vd circ). Introduction Hypovolaemia is generally believed to induce centrali sa- tion of blood volume. Therefore, we evaluated whether hypovolaemia and hypervolaemia result in a change in central blood volume (that is, pulmonary blood volume (PBV)) and we explored the eff ects on the distribution between PBV and circulating blood volume (Vd circ). Methods Twenty anesthetized Landrace/Large-White pigs (19 ± 2 kg, 10 to 15 weeks) were subjected to a fi xed hemorrhage (50% over 30 minutes). The pigs were randomly allocated into two groups (n = 10 per group). In group A, ITD was the only treatment for hypotension, while in group B, an intravenous administration of 1 l Ringer lactate was applied for treatment of hypotension. Hemodynamic parameters were continuously assessed for the fi rst 30 minutes after blood loss. Methods After local District Governmental Animal Investigation Committee approval, blood volume was altered in both directions randomly in steps of 150 ml (mild) to 450 ml (moderate) either by haemorrhage, retransfusion of blood, or infusion of colloids in six Foxhound dogs. The anaesthetised dogs were allowed to breathe spontaneously. Blood volumes were measured using the dye dilution technique: PBV was measured as the volume of blood between the pulmonary and aortic valve, and Vd circ by two-compartmental curve fi tting [1,2]. The PBV/Vd circ ratio was used as a measure of blood volume distribution. A linear mixed model was used for analysing the infl uence of blood volume alterations on the measured haemodynamic variables and blood volumes. yi Results Mean systolic arterial pressures (SAPs) 30 minutes after the intervention in each group were as follows: group A 80 ± 5 mmHg and group B 90 ± 4 mmHg. Maximum SAPs during the assessment period were: group A 89 ± 2 mmHg and group B 128 ± 5 mmHg. p P Balsorano, S Romagnoli, A De Gaudio P Balsorano, S Romagnoli, A De Gaudio AOUC Careggi, Florence, Italy AOUC Careggi, Florence, Italy Critical Care 2015, 19(Suppl 1):P171 (doi: 10.1186/cc14251) AOUC Careggi, Florence, Italy Critical Care 2015, 19(Suppl 1):P171 (doi: 10.1186/cc14251) Introduction Although recognized as a questionable indicator of the intravascular volume, central venous pressure (CVP) is integrated in many therapeutic algorithms for hemodynamic resuscitation of critically ill patients [1]. In an attempt to simplify CVP estimation, several clinical and ultrasonographic approaches have been suggested [2-5]. p y g Conclusion These results highlight a potentially evolving role of EJV circumference and area in the hemodynamic management S60 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 of spontaneously breathing patients. An important aspect of the suggested approach is its simplicity, requiring basic technical skills and making it suitable in any scenario where an ultrasound machine is available. P175 Relation between global end-diastolic volume and left ventricular end-diastolic volume A Pironet1, P Morimont1, S Kamoi2, N Janssen1, PC Dauby1, JG Chase2, B Lambermont1, T Desaive1 1University of Liège, Belgium; 2University of Canterbury, Christchurch, New Zealand Critical Care 2015, 19(Suppl 1):P175 (doi: 10.1186/cc14255) (Figure 1). Conclusion Mild to moderate alterations of blood volume result in changes of PBV and Vd circ. However, against the traditional belief of centralisation we could show that the cardiovascular system preserves the distribution of blood between central and circulating blood volume in anaesthetised dogs. References 1. Anesthesiology. 1994;81:76-86. 2. Intensive Care Med. 2001;27:767-74. Figure 1 (abstract P172). Figure 1 (abstract P172). 1University of Liège, Belgium; 2University of Canterbury, Christchurch, New Zealand Critical Care 2015, 19(Suppl 1):P175 (doi: 10.1186/cc14255) Introduction Measurement of global end-diastolic volume (GEDV) is provided by cardiovascular monitoring devices using thermodilution procedures. The aim of this study was to assess the relation between this clinically available index and left ventricular end-diastolic volume (LVEDV), which is typically not available at the patient bedside. Methods Measurements were performed on six anaesthetised and mechanically ventilated pigs. Volume loading via successive infusions of saline solution was fi rst performed and was followed by dobutamine infusion. These two procedures provided a wide range of LVEDV values. During these experiments, GEDV was intermittently measured using the PiCCO monitor (Pulsion AG, Germany) during thermodilutions and LVEDV was continuously measured using an admittance catheter (Transonic, NY, USA) inserted in the left ventricle. Results Table 1 presents the linear correlations obtained between LVEDV and GEDV. These correlations are good to excellent, with r2 values from 0.59 to 0.85. However, the coeffi cients of the linear regressions present a large intersubject variability, which prevents the precise estimation of LVEDV using GEDV. Nevertheless, variations in LVEDV are well reproduced by the GEDV index. The variations in LVEDV actually equal 21 to 48% of those in GEDV. The coeffi cient b is always nonzero, indicating that some proportion of the GEDV index is actually not linked to LVEDV. Conclusion Mild to moderate alterations of blood volume result in changes of PBV and Vd circ. However, against the traditional belief of centralisation we could show that the cardiovascular system preserves the distribution of blood between central and circulating blood volume in anaesthetised dogs. R f Conclusion Mild to moderate alterations of blood volume result in changes of PBV and Vd circ. Comparative study between fl uidless resuscitation with permissive hypotension using the impedance threshold device versus aggressive fl uid resuscitation with Ringer lactate in a swine model of hemorrhagic shock C Pantazopoulos1, I Floros1, N Archontoulis1, D Xanthis1, D Barouxis2, N Iacovidou2, T Xanthos2 1Laiko General Hospital of Athens, Greece; 2University of Athens, Medical School, Athens, Greece Critical Care 2015, 19(Suppl 1):P174 (doi: 10.1186/cc14254) References 1. Dellinger RP, et al. Intensive Care Med. 2013;39:165-228. 2. Cook DJ. Am J Med Sci. 1990;299:175-8. 3. Donahue SP, et al. Am J Emerg Med. 2009;27:851-5. 4. Beigel R, et al. J Am Soc Echocardiogr. 2013;26:1033-42. 5. Rudski LG, et al. J Am Soc Echocardiogr. 2010;23:685-713. References 1. Dellinger RP, et al. Intensive Care Med. 2013;39:165-228. 2. Cook DJ. Am J Med Sci. 1990;299:175-8. 3. Donahue SP, et al. Am J Emerg Med. 2009;27:851-5. 4. Beigel R, et al. J Am Soc Echocardiogr. 2013;26:1033-42. 5. Rudski LG, et al. J Am Soc Echocardiogr. 2010;23:685-713. References 1. Dellinger RP, et al. Intensive Care Med. 2013;39:165-228. 2. Cook DJ. Am J Med Sci. 1990;299:175-8. 3. Donahue SP, et al. Am J Emerg Med. 2009;27:851-5. 4. Beigel R, et al. J Am Soc Echocardiogr. 2013;26:1033-42. 5. Rudski LG, et al. J Am Soc Echocardiogr. 2010;23:685-713. References 1. Dellinger RP, et al. Intensive Care Med. 2013;39:165-228. 2. Cook DJ. Am J Med Sci. 1990;299:175-8. 3. Donahue SP, et al. Am J Emerg Med. 2009;27:851-5. 4. Beigel R, et al. J Am Soc Echocardiogr. 2013;26:1033-42. 5. Rudski LG, et al. J Am Soc Echocardiogr. 2010;23:685-713. Introduction Permissive hypotension, which results in avoidance of intravascular overpressure and thereby avoidance of platelet plug dislodgement early in the clotting mechanism, improves the results after trauma and hemorrhage. The research hypothesis is that augmentation of negative intrathoracic pressure with the use of an impedance threshold device (ITD) will improve hemodynamic parameters, without aff ecting permissive hypotension or causing hemodilution. On the other hand, aggressive resuscitation with Ringer lactate will cause hemodilution and intravascular pressures that are very high for permissive hypotension, capable of platelet plug dislodgement. 2. Intensive Care Med. 2001;27:767-74. P172 Do intravascular hypovolaemia and hypervolaemia result in changes in pulmonary blood volume? Mean pulse pressure was higher in the ITD group versus the fl uid resuscitation group (P <0.05). After the assessment period, mean hematocrit in group A was 24 ± 2%, while in group B it was 18 ± 1% (P <0.001). Conclusion In our study, the ITD increased SAP and pulse pressure without overcompensation. On the other hand, aggressive fl uid resuscitation led to a signifi cant increase of SAP >100 mmHg capable of clot dislodgement and in addition led to hemodilution. Results A total of 68 alterations in blood volume resulted in changes in Vd circ ranging from –33 to +31% (Figure 1). PBV decreased during mild and moderate haemorrhage, while during retransfusion PBV increased during moderate hypervolaemia only. The PBV/Vd circ ratio remained constant during all stages of hypovolaemia and hypervolaemia (Figure 1). P175 R l i 1. Anesthesiology. 1994;81:76-86. P175 However, against the traditional belief of centralisation we could show that the cardiovascular system preserves the distribution of blood between central and circulating blood volume in anaesthetised dogs. P176 Volume assessment in critically ill patients: echocardiography, bioreactance and pulse contour thermodilution S Hutchings1, P Hopkins1, A Campanile2 1King’s College Hospital, London, UK; 2Papworth Hospital, Cambridge, UK Critical Care 2015, 19(Suppl 1):P176 (doi: 10.1186/cc14256) p S Hutchings1, P Hopkins1, A Campanile2 pp Methods This prospective, single-center study included 80 patients with sepsis from the Department of Critical Care Medicine of Zhejiang Hospital. Patients were randomly assigned to either Group A or Group B, with patients of in Group A fi rst taking the passive leg raising test and then taking the fl uid infusion test, while patients in Group B followed the opposite protocol. NICOM was used to continuously record hemodynamic parameters such as cardiac output (CO), heart rate (HR) and central venous pressure (CVP), at baseline1, PLR, baseline2, and volume expansion (VE). Fluid responsiveness was defi ned as the change in CO (ΔCO) ≥10% after VE. Introduction We performed an evaluation of three devices used for assessment of volume status in critically ill patients in our institution: transthoracic echocardiography (TTE) (CX50; Philips Ultrasound), bio reactance (NICOM; Cheetah Medical) and pulse contour-based thermodilution (PiCCO; Pulsion Medical). Methods Ten mechanically ventilated critically ill patients with PiCCO monitoring in situ and a good quality of images on transthoracic view were included. All study measurements were made in triplicate. A single trained cardiologist, blinded to the results from the other monitors, performed the TTE study. Diff erences among the three methods were assessed for signifi cance using one-way ANOVA, Spearman’s coeffi cient and Bland–Altman analysis. All statistical analyses were performed using Graph-pad Prism 5 and P <0.05 was taken as signifi cant. g ( ) Results CO increased during PLR (from 5.21 ± 2.34 to 6.03 ± 2.73 l/ minute, P <0.05); and after VE (from 5.09 ± 1.99 to 5.60 ± 2.11 l/minute, P <0.05). The PLR-induced change in CO (ΔCOPLR) and the VE-induced change in CO (ΔCOVE) were highly correlated (r = 0.80 (0.64 to 0.90)), while the CVP and ΔCOVE were uncorrelated (r = 0.12 (–0.16 to 0.32)). The areas under the ROC curves of ΔCOPLR and ΔCVP for predicting fl uid responsiveness were 0.868 and 0.514 respectively. ΔCOPLR ≥10% was found to predict fl uid responsiveness with a sensitivity of 86% and a specifi city of 79%.l g p p gi Results Ninety measurements were obtained. NICOM and TTE-derived stroke volume appeared well matched but PICCO-derived values showed signifi cant variation (F = 2.4, P = 0.09). References Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S61 Table 1 (abstract P175). Linear regressions between LVEDV and GEDV Subject a b (ml) r2 1 0.26 7.64 0.82 2 0.43 –47.10 0.66 3 0.21 –12.99 0.75 4 0.25 –11.42 0.59 5 0.41 –65.42 0.85 6 0.48 –65.75 0.68 LVEDV = a × GEDV + b. regards fl uid administration between PiCCO and echocardiography. NICOM appeared unreliable in this setting. regards fl uid administration between PiCCO and echocardiography. NICOM appeared unreliable in this setting. Conclusion The results show that GEDV and LVEDV are generally well correlated, but the correlation coeffi cients are subject specifi c. A preliminary calibration step (for instance using echocardiography) is thus necessary to infer LVEDV from GEDV. Introduction Fluid administration is always important and diffi cult during the therapy of patients with sepsis. Accurately predicting fl uid responsiveness and thus estimating whether the patient will benefi t from fl uid therapy seems particularly important. The present study intended to predict fl uid responsiveness in patients with sepsis using a bioreactance-based passive leg raising test, and to compare this approach with the commonly used central venous pressure (CVP) approach. P176 Volume assessment in critically ill patients: echocardiography, bioreactance and pulse contour thermodilution S Hutchings1, P Hopkins1, A Campanile2 1King’s College Hospital, London, UK; 2Papworth Hospital, Cambridge, UK Critical Care 2015, 19(Suppl 1):P176 (doi: 10.1186/cc14256) There was no correlation between TTE velocity time integer (VTI) and NICOM stroke volume variation (SVV) (r = 0.24, P = 0.20; Figure 1A) but a good correlation and small bias between TTE-VTI and PiCCO-SVV (r = 0.76, P <0.0001; Figure 1B). Applying the following indications for volume expansion (PiCCO and NICOM SVV >15% and TTE VTI variability >15%) we found an agreement in 71% of cases between TTE and PiCCO and in 42% of cases between echocardiography and NICOM. i Conclusion Bioreactance-based PLR could predict fl uid responsiveness in patients with sepsis, while CVP could not. P176 P176 Volume assessment in critically ill patients: echocardiography, bioreactance and pulse contour thermodilution S Hutchings1, P Hopkins1, A Campanile2 1King’s College Hospital, London, UK; 2Papworth Hospital, Cambridge, UK Critical Care 2015, 19(Suppl 1):P176 (doi: 10.1186/cc14256) Predicting fl uid responsiveness in ICU patients: comparison of diff erent parameters and cutoff limits using pulse power analysis assessment H Barrasa, J Maynar, S Castaño, Y Poveda, P Garcia Domelo, A Tejero, G Baziskueta, A Quintano, B Fernández Miret, M Iturbe, S Cabañes, F Fonseca Alava University Hospital-Santiago, Vitoria, Spain Critical Care 2015, 19(Suppl 1):P180 (doi: 10.1186/cc14260) Introduction Dynamic parameters are becoming standard for fl uid responsiveness assessment. Cutoff values are diff erent in the literature. The aim was to assess the accuracy of diff erent preload parameters to predict fl uid responsiveness using pulse power analysis and to compare diff erent levels of hemodynamic response due to passive leg raising (PLR) against the eff ect of a fl uid challenge (FC). y Results We evaluated 27 patients, age 68 (95% CI: 61 to 74) and APACHE II score 22 (95% CI: 18 to 26). Seven patients were high responders, eight patients were moderate responders and 12 were nonresponders. DO2 was signifi cantly increased in high responders (37 ± 35%, P <0.01) as compared with moderate responders or nonresponders. Furthermore, nonresponders had a decrease in their DO2 (–10 ± 7%, P <0.01), while moderate responders showed no change in their DO2 (1.6% ± 10, P = 0.73) after fl uid challenge. We found no diff erences in changes in lactate levels and central venous oxygen saturation (ScvO2) between high responders, moderate responders and nonresponders. No diff erences in the changes of VCO2 or VO2/VCO2 ratio were found between high responders, mild responders and nonresponders too. Changes in DO2/VCO2 ratio were found to be signifi cantly increased only in high responders (47 ± 73% vs. –14 ± 31%, P = 0.02) and not in mild responders (15 ± 54% vs. –14 ± 31%, P = 0.15) as compared with nonresponders. g gfl g Methods A prospective study in a 17-bed mixed ICU. Patients were fully ventilated and CO monitored with LiDCOplus® and underwent a FC due to hypotension and/or hypoperfusion and preload dependence (SVV and/or PPV >10%). PLR was performed before FC. Hemodynamic data were recorded prePLR, postPLR and postFC with 0.5 l crystalloids. We compared diff erent cutoff values of increase in CO and SV (10 to 15%) to assess the ability of PLR, SVV, PPV and CVP to predict the response to FC. Statistical analysis: continuous variables expressed as mean ± SD. P180 P180 Predicting fl uid responsiveness in ICU patients: comparison of diff erent parameters and cutoff limits using pulse power analysis assessment H Barrasa, J Maynar, S Castaño, Y Poveda, P Garcia Domelo, A Tejero, G Baziskueta, A Quintano, B Fernández Miret, M Iturbe, S Cabañes, F Fonseca Alava University Hospital-Santiago, Vitoria, Spain Critical Care 2015, 19(Suppl 1):P180 (doi: 10.1186/cc14260) Global end-diastolic volume: a better indicator of cardiac preload in patients with septic shock L Mirea, R Ungureanu, D Pavelescu, I Grintescu g Clinical Emergency Hospital of Bucharest, Romania g y p , Critical Care 2015, 19(Suppl 1):P179 (doi: 10.1186/cc14259) g y p , Critical Care 2015, 19(Suppl 1):P179 (doi: 10.1186/cc14259) Introduction The aim of the study was to assess the value of the global end-diastolic volume (GEDV) evaluated by transpulmonary thermodilution as an indicator of cardiac preload comparing with stroke volume variation (SVV) in patients with septic shock. g p p Conclusion Our results support the idea that a reversible FC (PLR; CO cutoff 12.6%) is best at identifying responder patients to a FC. Dynamic parameters (SVV/PPV) are also eff ective when appropriate. Beat-to- beat SV and CO using pulse power analysis is a valid tool for these tests. Methods A prospective, observational study performed in an interdisciplinary ICU including 91 patients with septic shock. Hemodynamic monitoring was performed with a new calibrated pulse wave analysis method (VolumeView/EV1000; Edwards Lifesciences) in 37 patients (group EV1000) or with an uncalibrated method (FloTrac/ Vigileo; Edwards Lifesciences) in 54 patients (group Vigileo) during the fi rst 72 hours. All patients were receiving mechanical ventilation and vasopressors. Measurements were performed before and immediately after volume loading using 500 ml Ringer solution over a short period (<30 minutes).l p References p p Referencesl 1. De Backer D. Can passive leg raising be used to guide fl uid administration? Crit Care. 2006;10:170. 2. Pinsky MR. Functional haemodynamic monitoring. Curr Opin Crit Care. 2014;20:288-93. 3. Teboul JL, Monnet X. Pulse pressure variation and ARDS. Minerva Anestesiol. 2013;79:398-407. Conclusion Stroke volume produced by bioreactance appeared to be comparable with that measured by echocardiography but not with PiCCO. There was a good agreement between decision-making as 4. Monnet X, Teboul JL. Volume responsiveness. Curr Opin Crit Care. 2007;13:549-53. Figure 1 (abstract P176). Figure 1 (abstract P176). t P176) S62 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P178 Conclusion The transpulmonary thermodilution GEDV is a better indicator of cardiac preload than SVV in patients with septic shock. Acknowledgements This paper was cofi nanced from the European Social Fund, through the Sectorial Operational Programme Human Resources Development 2007–2013, project number POSDRU/159/1.5/S/138907 ‘Excellence in scientifi c interdisciplinary research, doctoral and postdoctoral, in the economic, social and medical fi elds – EXCELIS’; coordinator, The Bucharest University of Economic Studies. References P178 Acute changes of metabolic parameters after fl uid challenge T Nguyen, D De Bels, M Pustetto, P Cottignies, J Devriendt, C Pierrakos Brugmann Hospital, Brussels, Belgium Critical Care 2015, 19(Suppl 1):P178 (doi: 10.1186/cc14258) Introduction The detection of heart response to fl uid administration is still a challenge in clinical practice. Changes in metabolic parameters may be useful to detect changes in cardiac output (CO) after fl uid expansion. 1. Michard F, et al. Chest. 2003;124:1900-8. 2. Bendjelid K, et al. Br J Anaesth. 2013;111:573-9. Methods This is a prospective observational study in adult critically ill patients. CO was measured either by echocardiography or by a thermodilution method (PiCCO, Swan–Ganz catheter). Hemodynamic measurements and blood gas analysis were obtained before and after a fl uid challenge with either 1,000 ml crystalloid or 500 ml colloid. Arterial and central venous blood gas samples were taken simultaneously. Oxygen delivery (DO2), oxygen consumption (VO2) and carbon dioxide production (VCO2) were calculated according to well-known formulas. Patients were divided into three groups (high responders, mild responders and nonresponders) according to their change in CO (>20%, 10 to 20%, <10%, respectively). P181 P181 Respiratory variations in aortic blood fl ow velocity and inferior vena cava diameter as predictors of fl uid responsiveness in mechanically ventilated children using transthoracic echocardiography in a pediatric PICU K El Halimi, M Negadi, H Bouguetof, L Zemour, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P181 (doi: 10.1186/cc14261) Respiratory variations in aortic blood fl ow velocity and inferior vena cava diameter as predictors of fl uid responsiveness in mechanically ventilated children using transthoracic echocardiography in a pediatric PICU K El Halimi, M Negadi, H Bouguetof, L Zemour, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P181 (doi: 10.1186/cc14261) Respiratory variations in aortic blood fl ow velocity and inferior vena cava diameter as predictors of fl uid responsiveness in mechanically ventilated children using transthoracic echocardiography in a pediatric PICU Respiratory variations in aortic blood fl ow velocity and inferior vena cava diameter as predictors of fl uid responsiveness in mechanically ventilated children using transthoracic echocardiography in a pediatric PICU Predicting fl uid responsiveness in ICU patients: comparison of diff erent parameters and cutoff limits using pulse power analysis assessment Comparison before and after was done using a paired Student’s t test, and receiver operating characteristic (ROC) curves were generated by varying the discriminating threshold of each variable. p Conclusion Only signifi cant increases of CO (>20%), after fl uid administration, lead to improved oxygen delivery; DO2 may be decreased in nonresponders. The changes of ScvO2 and lactate levels do not track the changes of CO after fl uid challenge. The DO2/VCO2 ratio may be a useful index to identify signifi cant increases of CO after fl uid challenge in cases where CO measurement is not feasible. Results Thirty-one patients were included. Baseline parameters: MAP 70.5 mmHg (SD 13.3) 87% under catecholamine, SV 55.32 ml (SD 20.2), CO 5.2 l (SD 2), SVV 16.8% (SD 12), PPV 19.1% (SD 14), HR 96 bpm (SD 18) and CVP 9.2 mmHg (SD 2.5). In total, 41.9% of patients increased 15% CO after FC (selected as responders), 38.7% after the PLR. Diff erences in responders versus nonresponder patients were: baseline SVV (23.9 vs. 11.6; P = 0.02) and PPV (28.4 vs. 12.4; P = 0.01). Diff erences in SV and CO were not statistically signifi cant. The best parameter to predict positive response to FC was PLR with cutoff 12.6% for CO increase: sensitivity 84.6% (95% CI = 65 to 104), specifi city 94.4% (95% CI = 84 to 105) and AU ROC 0.94 (95% CI = 0.86 to 1.0). ROC was also good for SVV 0.835 (95% CI = 0.66 to 1.0; P = 0.002) and PPV 0.833 (95% CI = 0.681 to 0.985; P = 0.002) in this cutoff value. In SV increase, PLR, SVV and PPV had P <0.05, but with worse ROC. In addition, SVV <13% identifi ed patients who will not increase MAP with FC: sensitivity 91.7% (95% CI = 76 to 107.3%), negative predictive value 93.5 (95% CI = 80.7 to 106). CVP failed to distinguish responders from nonresponders. References volume status. In this way, dynamic echocardiographic parameters have been proposed in mechanically ventilated children [1,2], using the heart–lung interactions. This study aimed to investigate whether respiratory variations of aortic blood fl ow velocity (DELTA Vpeak ao) and inferior vena cava diameter (DELTA IVC) by transthoracic echocardiography (TTE) could accurately predict fl uid responsiveness in ventilated children. volume status. In this way, dynamic echocardiographic parameters have been proposed in mechanically ventilated children [1,2], using the heart–lung interactions. This study aimed to investigate whether respiratory variations of aortic blood fl ow velocity (DELTA Vpeak ao) and inferior vena cava diameter (DELTA IVC) by transthoracic echocardiography (TTE) could accurately predict fl uid responsiveness in ventilated children. 1. Monnet X, et al. Esophageal Doppler monitoring predicts fl uid responsiveness in critically ill ventilated patients. Intensive Care Med. 2005;31:1195-201. 2. Tibby SM, et al. Are transoesophageal Doppler parameters a reliable guide to paediatric haemodynamic status and fl uid management? Intensive Care Med. 2001;27:201-5. 2. Tibby SM, et al. Are transoesophageal Doppler parameters a reliable guide to paediatric haemodynamic status and fl uid management? Intensive Care Med. 2001;27:201-5. Methods A prospective observational and interventional study conducted in a pediatric ICU investigated 40 mechanically ventilated children with preserved left ventricular (LV) function using TTE. Each patient had tachycardia, hypotension, oliguria, delayed capillary refi lling or hemodynamic instability despite vasopressor drugs. Intervention: standardized volume expansion (VE). P183 Fluid management in mechanically ventilated children with acute circulatory failure based on the pleth variability index in a pediatric ICU H Bouguetof, M Negadi, K El Halimi, L Zemour, D Boumendil, Z Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P183 (doi: 10.1186/cc14263) Results The VE-induced increase in LV stroke volume was ≥10% in 28 patients (responders) and <10% in 12 patients (nonresponders). Before VE, the DELTA Vpeak ao and DELTA IVC in responders was respectively higher than that in nonresponders (18.75% (12 to 32) vs. 13.5% (6 to 16) and 31% (18 to 57) vs. 17.5% (14 to 25)). The prediction of fl uid responsiveness was higher with DELTA Vpeak ao (ROC curve area 0.894 (95% CI = 0.756 to 0.969), P = 0.0001) and DELTA IVC (ROC curve area 0.869 (95% CI = 0.717 to 0.957), P = 0.0001). P184 Collapsibility of jugular veins, subclavian veins and inferior vena cava as predictors of fl uid responsiveness in patients on pressure support ventilation: a prospective cohort study Y Iizuka1, M Sanui1, T Nomura2 1Jichi Medical University Saitama Medical Center, Saitama, Japan; 2Shonan Kamakura General Hospital, Kamakura, Japan Critical Care 2015, 19(Suppl 1):P184 (doi: 10.1186/cc14264) Collapsibility of jugular veins, subclavian veins and inferior vena cava as predictors of fl uid responsiveness in patients on pressure support ventilation: a prospective cohort study Y Iizuka1, M Sanui1, T Nomura2 1Jichi Medical University Saitama Medical Center, Saitama, Japan; 2Shonan Kamakura General Hospital, Kamakura, Japan Critical Care 2015, 19(Suppl 1):P184 (doi: 10.1186/cc14264) Introduction Prediction of fl uid responsiveness is defi ned by an increase in stroke volume (SV) of at least 10% after volume expansion. Dynamic [1] and static [2] esophageal Doppler (OD) parameters have been proposed in mechanically ventilated children to guide fl uid therapy. This study aimed to compare dynamic parameters using the respiratory variation in aortic blood fl ow with static parameters using Doppler corrected fl ow times (FTc) obtained by OD. Introduction The accuracy of predicting fl uid responsiveness (FR) using IVC collapsibility is high in patients on controlled mechanical ventilation, but remains unknown in spontaneously breathing patients with mechanical ventilation. Also, adequate ultrasound images of IVC are diffi cult to obtain in a substantial number of patients. The aim of the current study is to evaluate utility of collapsibility of jugular veins (IJV) and subclavian veins (SCV) in comparison with collapsibility of IVC in patients on pressure support ventilation. ppl y Methods A prospective, observational and interventional study was conducted in our pediatric ICU from March 2012 to September 2014. We investigated 18 mechanically ventilated children with acute circulatory failure (ACF) – tachycardia, hypotension, oliguria, delayed capillary refi lling or hemodynamic instability despite vasopressor drugs – using OD for each patient. Intervention: standardized volume expansion (VE). Results The VE-induced increase in stroke volume was ≥10% in 14 patients (responders) and <10% in four patients (nonresponders). Before VE, the DELTA Vpeak ao in responders was higher than in nonresponders (19.5% (12 to 29) vs. 11.5% (7 to 13)), whereas FTc was lower in responders than in nonresponders (262.5 milliseconds (180 to 340) vs. 285 milliseconds (205 to 300)). The prediction of fl uid responsiveness was higher with DELTA Vpeak ao (ROC curve area 0.964 (95% CI = 0.756 to 1.000); P = 0.0001) than with FTc (ROC curve area 0.562 (95% CI = 0.314 to 0.790); P = 0.7203). pediatric PICU pediatric PICU K El Halimi, M Negadi, H Bouguetof, L Zemour, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P181 (doi: 10.1186/cc14261) Results A total of 211 fl uid challenges were studied in 91 patients. We observed a signifi cant relationship between the GEDV index before volume loading and the percentage increase in GEDV index in the EV1000 group and changes in GEDV index were signifi cantly correlated with changes in stroke volume index (r = 0.75, P <0.001), but an insignifi cant relationship between SVV variation and cardiac index variation (P >0.05) in the Vigileo group. Introduction Volume expansion remains the fi rst treatment step for most children with acute circulatory failure in order to assess blood Introduction Volume expansion remains the fi rst treatment step for most children with acute circulatory failure in order to assess blood S63 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Prediction of fl uid responsiveness in mechanically ventilated children using dynamic and static parameters by esophageal Doppler in a pediatric ICU Prediction of fl uid responsiveness in mechanically ventilated children using dynamic and static parameters by esophageal Doppler in a pediatric ICU K El Halimi, M Negadi, H Bouguetof, L Zemour, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P182 (doi: 10.1186/cc14262) Conclusion In this study, PVI seems to predict fl uid responsiveness in ventilated children with ACF. pp p K El Halimi, M Negadi, H Bouguetof, L Zemour, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P182 (doi: 10.1186/cc14262) References The best cutoff value for DELTA Vpeak ao was 16% with sensitivity and specifi city predictive values of 71.6% and 83.3%, respectively, and DELTA IVC was 20% with sensitivity and specifi city predictive values of 88.5% and 90.9%, respectively. Introduction The pleth variability index (PVI) is a new dynamic index obtained by automatic estimation of respiratory variations in the pulse oximeter waveform amplitude. This noninvasive and continuous hemodynamic monitoring has been recently proposed in mechanically ventilated patients to guide fl uid therapy. We recently acquired a PVI monitor in 2014. PVI is calculated by measuring changes in perfusion index (PI) during the respiratory cycle as follows: PVI = ((PImax – Pimin) / PImax) × 100. This study aimed to investigate whether PVI at baseline can predict fl uid responsiveness. pl p Methods In our pediatric ICU we started a prospective and observational study. Between January and November 2014, nine mechanically ventilated children were investigated using PVI and transthoracic echocardiography for each patient with acute circulatory failure (ACF): tachycardia, hypotension, oliguria, delayed capillary refi lling or hemodynamic instability despite vasopressor drugs. Intervention: standardized volume expansion. Conclusion In this study, DELTA Vpeak and DELTA IVC were appropriate variables to predict fl uid responsiveness by TTE in ventilated children. References 1. Durand P, et al. Respiratory variations in aortic blood fl ow predict fl uid responsiveness in ventilated children. Intensive Care Med. 2008;34:888-94. 1. Durand P, et al. Respiratory variations in aortic blood fl ow predict fl uid responsiveness in ventilated children. Intensive Care Med. 2008;34:888-94.l 2. Choi DY, et al. Respiratory variation in aortic blood fl ow velocity as a predictor of fl uid responsiveness in children after repair of ventricular septal defect. Pediatr Cardiol. 2010;31:1166-70. 2. Choi DY, et al. Respiratory variation in aortic blood fl ow velocity as a predictor of fl uid responsiveness in children after repair of ventricular septal defect. Pediatr Cardiol. 2010;31:1166-70. Results Signifi cant changes in stroke volume were observed after volume loading (VL) ≥10% in eight patients (responders (R)) and <10% in one patient (nonresponder (NR)). Before VL, PVI was signifi cantly higher in R than NR at baseline ((19.75 ± 3.15%) vs. (9% ± 0.00%), P <0.0001), and decreased signifi cantly in R from baseline to after VL ((19.75% ± 3.15) vs. (12.5% ± 2.828), P <0.0001). P187 Assessing fl uid status with the vascular pedicle width: relationship to IVC diameter, IVC variability and lung comets N Salahuddin, I Hussain, Q Shaikh, M Joseph, H Alsaidi, K Maghrabi King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Critical Care 2015, 19(Suppl 1):P187 (doi: 10.1186/cc14267) Assessing fl uid status with the vascular pedicle width: relationship to IVC diameter, IVC variability and lung comets Methods Mechanically ventilated patients having cardiac arrhythmia who have been considered for volume expansion were recruited in this prospective study. Each patient was sedated, paralyzed and monitored with a central venous catheter and a thermistor-tipped femoral arterial VolumeView catheter connected to the EV1000 monitor. We assessed hemodynamic changes after PLRT via a pulse wave contour analysis method. Then we compared it with hemodynamic changes after volume expansion (NSS 500 ml in 15 minutes) via the transpulmonary thermodilution (TPTD) method. N Salahuddin, I Hussain, Q Shaikh, M Joseph, H Alsaidi, K Maghrabi King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Critical Care 2015, 19(Suppl 1):P187 (doi: 10.1186/cc14267) Introduction This study attempts to determine a vascular pedicle width (VPW) cutoff value that identifi es a fl uid replete state defi ned as an IVC diameter ≥2 cm and ≤15% respiratory variation. p y Methods In a cross-sectional design, consecutive, critically ill patients underwent simultaneous chest radiographs and ultrasounds. The Research Ethics Committee approved the study. Results A total of 17 patients were included in this study. Six patients were volume responders (TPTD cardiac index change ≥15%). A PLRT change cardiac index ≥10% from the pulse wave contour analysis method had predicted VR with a sensitivity of 50%, a specifi city of 72.7% and an area under the ROC curve of 0.591 (P = 0.546). Results Eighty-four data points on 43 patients were collected. VPW correlated with IVC diameter (r = 0.64, P ≤0.001) and IVC variation (r = –0.55, P ≤0.001). No correlation was observed between VPW and number of lung comets (r = 0.12, P = 0.26) or positive fl uid balance (r = 0.3, P = 0.058). On multivariate linear regression, standardized coeffi cients demonstrated that a 1 mm increase in IVC diameter corresponded to a 0.28 mm (Beta) increase in VPW. P184 Collapsibility of jugular veins, subclavian veins and inferior vena cava as predictors of fl uid responsiveness in patients on pressure support ventilation: a prospective cohort study Y Iizuka1, M Sanui1, T Nomura2 1Jichi Medical University Saitama Medical Center, Saitama, Japan; 2Shonan Kamakura General Hospital, Kamakura, Japan Critical Care 2015, 19(Suppl 1):P184 (doi: 10.1186/cc14264) Results A total of 204,680 patients met the search criteria, and 76,807 patients developed one or more postsurgical complications (morbidity rate 37.5%). In patients with and without complications, hospital costs (including 30 days readmission costs) were $27,607 ± 32.788 and $15.783 ± 12,282 (P <0.0001), median (interquartile range) hospital lengths of stay (fi rst stay) were 7 (4 to 10) days and 4 (3 to 5) days (P <0.0001), and 30-day readmission rates were 17.2% and 11.9% (P <0.0001), respectively. With PGDT, the morbidity rate was anticipated to decrease from 26.6 to 31.1%, yielding gross cost savings of $153 million to 263 million for the study period, $61 million to 105 million per year, or $754 to 1,286 per patient. used to estimate the expected reduction in postsurgical morbidity with PGDT. Potential cost-savings were calculated from the actual and anticipated morbidity rates using the mean difference in total costs volume was 9.8 ml/predicted body weight. The area under the ROC curve of IVC collapsibility was 0.576 (95% confi dence interval (CI): 0.38 to 0.77), while the area under the ROC curves of right IJV, left IJV, right SCV and left SCV collapsibility were 0.870 (95% CI: 074 to 1.0), 0.54 (95% CI: 0.34 to 0.74), 0.62 (95% CI: 0.43 to 0.81) and 0.54 (95% CI: 0.34 to 0.74), respectively. Greater than 11% of right jugular vein collapsibility predicted fl uid responsiveness with a sensitivity of 79% and a specifi city of 94%. volume was 9.8 ml/predicted body weight. The area under the ROC curve of IVC collapsibility was 0.576 (95% confi dence interval (CI): 0.38 to 0.77), while the area under the ROC curves of right IJV, left IJV, right SCV and left SCV collapsibility were 0.870 (95% CI: 074 to 1.0), 0.54 (95% CI: 0.34 to 0.74), 0.62 (95% CI: 0.43 to 0.81) and 0.54 (95% CI: 0.34 to 0.74), respectively. Greater than 11% of right jugular vein collapsibility predicted fl uid responsiveness with a sensitivity of 79% and a specifi city of 94%. pi y Conclusion Our results suggest collapsibility of the right jugular vein can be a useful predictor of fl uid responsiveness in patients on pressure support ventilation, compared with other central large veins. Collapsibility of IVC does not predict FR in those patients. P185 Passive leg raising cannot predict volume responsiveness in septic shock patients having cardiac arrhythmia P Ratanawatkul1, A Wattanathum2 1Srinagarind Hospital, Khon Kaen, Thailand; 2Phramongkutklao Hospital, Bangkok, Thailand Critical Care 2015, 19(Suppl 1):P185 (doi: 10.1186/cc14265) Reference 1. Pearse et al. Eff ect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014;311:2181-90. Introduction The passive leg raising test (PLRT) is a self-volume challenge used in order to predict volume responsiveness (VR) in both spontaneous and mechanically ventilated critically ill patients. However, there were small numbers of arrhythmic patients included in previous studies. Therefore, the accuracy of the PLRT for prediction of VR in arrhythmic patient is still inconclusive. We hypothesized that the PLRT can predict VR in mechanically ventilated patients having cardiac arrhythmia. P187 P187 ROC curve analysis yielded an AUC of 0.843 (95% CI = 0.75 to 0.93), P ≤0.001 and provided the best accuracy with a cutoff VPW value of 64 mm (sensitivity 81%, specifi city 78%, PPV = 88.5%, NPV = 66%, correct classifi cation rate = 79.6%). See Figure 1. Conclusion The PLRT may not be used for prediction of VR in mechanically ventilated patients having cardiac arrhythmia; however, further and larger studies are needed to confi rm this fi nding. References 1. Monnet X, et al. Crit Care Med. 2006;34:1402-7. 1. Monnet X, et al. Crit Care Med. 2006;34:1402-7. 2. Cavallaro F, et al. Intensive Care Med. 2010;36:1475-83. 2. Cavallaro F, et al. Intensive Care Med. 2010;36:1475-83. Figure 1 (abstract P187). ROC curve for VPW discriminating fl uid repletion by IVC ultrasound. P184 Collapsibility of jugular veins, subclavian veins and inferior vena cava as predictors of fl uid responsiveness in patients on pressure support ventilation: a prospective cohort study Y Iizuka1, M Sanui1, T Nomura2 1Jichi Medical University Saitama Medical Center, Saitama, Japan; 2Shonan Kamakura General Hospital, Kamakura, Japan Critical Care 2015, 19(Suppl 1):P184 (doi: 10.1186/cc14264) p y p p Conclusion Postsurgical complications occurred in more than one- third of our study population and had a dramatic impact on hospital costs, length of stay, and readmission rates. Potential cost savings with PGDT were $754 to 1,286 per patient. These projections should help hospitals estimate the return on investment for implementation of PGDT. P184 Collapsibility of jugular veins, subclavian veins and inferior vena cava as predictors of fl uid responsiveness in patients on pressure support ventilation: a prospective cohort study Y Iizuka1, M Sanui1, T Nomura2 1Jichi Medical University Saitama Medical Center, Saitama, Japan; 2Shonan Kamakura General Hospital, Kamakura, Japan Critical Care 2015, 19(Suppl 1):P184 (doi: 10.1186/cc14264) The best cutoff value for DELTA Vpeak ao was 13% with sensitivity and specifi city predictive values of 85.7% and 100%, respectively; and the best cutoff value for FTc was 265 milliseconds with sensitivity and specifi city predictive values of 57.1% and 75%, respectively. Methods Patients on pressure support ventilation were prospectively included when fl uid challenges were clinically indicated. Bilateral IJV were examined at the level of cricoid cartilage. Bilateral SCV were measured where the veins crossed the clavicle. Anteroposterior diameter, cross-sectional area (CSA) of IJV and SCV were measured using frame by frame analysis. IVC was measured 2 cm from the right atrial border in a long axis view. Fluid responsiveness was defi ned as 8% increase of stroke volume calculated by the Vigileo monitor (Vigileo, FloTrac; Edwards Lifesciences) after passive leg raising (started from supine position). Receiver operating characteristic (ROC) curves were generated using EZR. Results Twenty-nine patients (35 measurements) were included. Nineteen measurements had fl uid responsiveness. The mean tidal Conclusion In our study, DELTA Vpeak was the most appropriate variable to predict fl uid responsiveness by OD in ventilated children with ACF. S64 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 used to estimate the expected reduction in postsurgical morbidity with PGDT. Potential cost-savings were calculated from the actual and anticipated morbidity rates using the mean diff erence in total costs. Results A total of 204,680 patients met the search criteria, and 76,807 patients developed one or more postsurgical complications (morbidity rate 37.5%). In patients with and without complications, hospital costs (including 30 days readmission costs) were $27,607 ± 32.788 and $15.783 ± 12,282 (P <0.0001), median (interquartile range) hospital lengths of stay (fi rst stay) were 7 (4 to 10) days and 4 (3 to 5) days (P <0.0001), and 30-day readmission rates were 17.2% and 11.9% (P <0.0001), respectively. With PGDT, the morbidity rate was anticipated to decrease from 26.6 to 31.1%, yielding gross cost savings of $153 million to 263 million for the study period, $61 million to 105 million per year, or $754 to 1,286 per patient. used to estimate the expected reduction in postsurgical morbidity with PGDT. Potential cost-savings were calculated from the actual and anticipated morbidity rates using the mean diff erence in total costs. Bioimpedance as a measure of fl uid overload in patients recently admitted to intensive care Bioimpedance as a measure of fl uid overload in patients recentl admitted to intensive care M O’Connor, E Galtrey, CJ Kirwan, JR Prowle Barts Health NHS Trust, London, UK Critical Care 2015, 19(Suppl 1):P188 (doi: 10.1186/cc14268) y Barts Health NHS Trust, London, UK Critical Care 2015, 19(Suppl 1):P188 (doi: 10.1186/cc14268) Critical Care 2015, 19(Suppl 1):P188 (doi: 10.1186/cc14268) Introduction Fluid overload is associated with adverse outcomes in critical illness; however, better methodology is required for its quantifi cation. Bioelectrical impedance analysis (BIA) represents a non- invasive method for quantifi cation of fl uid overload [1], but has not been widely taken up in the ICU. Results Fifty patients were included, 40.8% of them were responders. The proportion of responders increases with the increase of dose of fl uids (Table 1). The regression equation was: change of Pmsf (%) = 4.4 (dose of fl uids ml/kg, 95% CI 2.3 to 6.5) – 1.6 (95% CI 7.4 to 4.3, R2 = 0.28, F(1.47) = 17.8, P <0.001). The predicted dose of fl uids required to achieve a change in Pmsf of 15% is 3.7 ml/kg crystalloids. y p Methods We assessed changes in fl uid balance and performed daily BIA (using a Maltron BioScan 920-II; Maltron International Ltd, UK) over 3 days in consecutive ICU admissions with LOS >72 hours. Table 1 (abstract P189). Change of Pmsf-arm and CO Table 1 (abstract P189). Change of Pmsf-arm and CO 1 ml/kg 2 ml/kg 3 ml/kg 4 ml/kg (n = 12) (n = 12) (n = 13) (n = 13) P ΔPmsf-arm (%) 0.0 6.5 9.0 18 0.05 (–4 to 9) (3 to 21) (8 to 16) (9 to 21) ΔCO (%) 3.9 6 9.9 12.9 0.1 (0.4 to 10) (2.1 to 9.1) (–1.6 to 14.3) (2.6 to 23.5) Responders (%) 25.0 18.2 46.2 69.2 0.04 Values are median (interquartile range). Results Of 24 patients 71% were male, median age was 65 years and APACHE II score was 15. Eleven patients had a medical diagnosis and 13 a surgical or trauma reason for admission. Seventy-one percent were mechanically ventilated and 67% were on vasopressors or inotropes. Median BIA-estimated extracellular water was 25.2 l (IQR 22 to 28) on day 1, equating to excess fl uid of 7.2 l (IQR 5 to 13.9). Median right body resistance normalized to height at 50 kHz (R50/h) on day 1 was 214 Ω/m (IQR 187 to 256). Return on investment for implementation of perioperative goal-directed therapy in major surgery: a nationwide database study Introduction Preventable postsurgical complications are increasingly recognized as a major healthcare burden. A recent meta-analysis showed a 17 to 29% decrease in complications after major surgery with perioperative goal-directed therapy (PGDT) [1]. We assessed the fi nancial consequences of postsurgical complications in a large population from 541 US hospitals in order to predict potential savings with PGDT. Introduction Preventable postsurgical complications are increasingly recognized as a major healthcare burden. A recent meta-analysis showed a 17 to 29% decrease in complications after major surgery with perioperative goal-directed therapy (PGDT) [1]. We assessed the fi nancial consequences of postsurgical complications in a large population from 541 US hospitals in order to predict potential savings with PGDT. Methods Data from adults who had any one of 10 major noncardiac surgical procedures between January 2011 and June 2013 were selected from the Premier research database. Twenty-six postsurgical complications were tabulated. Hospital costs, length of stay, and readmission rates were compared in patients with and without complications. Risk ratios reported by Pearse’s meta-analysis were Figure 1 (abstract P187). ROC curve for VPW discriminating fl uid repletion by IVC ultrasound. Figure 1 (abstract P187). ROC curve for VPW discriminating fl uid repletion by IVC ultrasound. S65 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 The objective of this study was to determine the minimum volume of intravenous fl uid required to signifi cantly increase the Pmsf. Conclusion A VPW value of 64 mm accurately identifi es a fl uid replete state. Increased extravascular lung water, however, was not relatable to the VPW measurements. The VPW can be confi dently used to discriminate fl uid repletion from fl uid responsiveness. li Methods Patients following cardiac surgery were randomly allocated to receive 1, 2, 3 or 4 ml/kg (body weight) of crystalloid over 5 minutes using a 60 ml syringe. Pmsf was measured using the arterial pressure after stopping blood fl ow in the arm with a pneumatic tourniquet infl ated for 1 minute. Cardiac output (CO) was also recorded at baseline and immediately after the fl uid infusion. CO was measured with LiDCO or pulmonary artery catheter, and a positive response was considered an increase of 10% from baseline. From previous data, the least signifi cant change for Pmsf was 15%. Return on investment for implementation of perioperative goal-directed therapy in major surgery: a nationwide database study Medians were compared using the independent samples media test, and proportions were compared using a chi-square test. Statistical signifi cance was considered when P <0.05. P188 Bioimpedance as a measure of fl uid overload in patients recently admitted to intensive care Daily change in ECW and R50/h correlated with daily fl uid balance between BIA measurements (R2 = 0.48 and 0.37 respectively) (Figure 1).i y Conclusion BIA suggests many patients already have signifi cant fl uid overload on the fi rst day of ICU admission. Overall, changes in device-specifi c algorithms for ECW estimation and measured resistances correlated with recorded fl uid balance; however, there were inconsistencies in the number of individual patients. Prospective assessment is required to establish whether BIA measurements can be used to assist fl uid management in the ICU. Conclusion The minimum volume required to perform an eff ective fl uid challenge is 4 ml/kg infused in 5 minutes. However, only 30% of the variation of change in Pmsf can be explained by the dose of i.v. fl uid given. The proportion of responders increases with the volume of fl uids. 1. Earthman C, et al. Bioimpedance spectroscopy for clinical assessment of fl uid distribution and body cell mass. Nutr Clin Pract. 2007;22:389. P189 P189 Minimal volume for a fl uid challenge in postoperative patients H Aya, A Rhodes, RM Grounds, M Cecconi St George’s Healthcare NHS Trust, London, UK Critical Care 2015, 19(Suppl 1):P189 (doi: 10.1186/cc14269) Positive fl uid balance as a risk factor for mortality and acute kidney injury in vasoplegic shock after cardiac surgery 1ICESP, São Paulo, Brazil; 2Heart Institute, University of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P191 (doi: 10.1186/cc14271) Introduction After cardiac surgery, about 15% of patients develop vasoplegic shock, characterized by systemic vasodilation, increased capillary permeability and edema. We hypothesized that large-volume resuscitation, resulting in positive fl uid balances in the fi rst 24 hours of ICU admission, would be associated with mortality and would not be protective against AKI in this subset of patients. Conclusion Postsurgical complications have a signifi cant impact on hospital margins. Enhanced Recovery Programs have the potential not only to improve quality of care but also to improve hospital margins. References g Methods This is a retrospective analysis of 362 patients submitted to cardiac surgery at the Heart Institute of University of São Paulo in a period of 2 years. Of a total of 2,383 patients, we enrolled 362 patients. Vasoplegic shock was diagnosed if in the 24 hours of ICU admission patients had hypotension, need of vasoactive drugs after fl uid replacement and cardiac index ≥2.2 l/minute/m2. Data were analyzed in logistic regression models for 30-day mortality and acute kidney injury through Acute Kidney Injury Network (AKIN) score as outcomes. Results The mean age of patients was 57 years. Of 362 patients, 53 died at 30 days (14.6%). Nonsurvivors as compared with survivors were slightly older (59 ± 12 vs. 55 ± 13, P = 0.063), had a higher prevalence of AKI through AKIN score ((0) 6.9%, (1) 11.1%, (2) 28.9%, (3) 31.9%, P <0.001), a higher 24-hour fl uid balance (421 ml (–55 to 695) vs. 2,686 ml (1,321 to 2,856), P <0.001), and higher lactate levels at the intraoperative and at 48 hours (5 mmol/l (4.0 to 7.6) vs. 4.4 (3.33 to 6.55), P <0.001; and 8.11 (5.49 to 12.3) vs. 1.5 (1.33 to 1.88), P <0.001). In the multivariate analysis, positive fl uid balance in the fi rst 24 hours (OR = 1.006, 95% CI = 1.003 to 1.008, P <0.001) and higher lactate after 48 hours (OR = 1.204, 95% CI = 1.072 to 1.353, P = 0.002) were predictors of 30-day mortality. Forty-three percent of patients developed AKI during 30 days. P192 Impact of postsurgical complications on hospital costs and margins R Lavender1, M Mythen2, J Bao3, RH Chapman3, F Michard1 1Edwards Lifesciences, Irvine, CA, USA; 2UCLH National Institute of Health Research, London, UK; 3Avalere Health, Washington, DC, USA Critical Care 2015, 19(Suppl 1):P192 (doi: 10.1186/cc14272) y Results Three hundred and thirty-nine patients were included; mean age was 51 ± 20.4 years, 167 (49%) patients were male. Mean APACHE II score was 22 ± 12.8 and SAPS II score was 35.4 ± 18.9. Severe sepsis/ septic shock was the admitting diagnosis in 129 (38%) patients, 108 (32%) patients were postoperative. AKI developed in 148 (44%) patients; Risk 29 (9%); Injury 26 (8%); Failure 89 (26%) by the RIFLE criteria. On univariate regression analysis; positive fl uid balance >2 l on the fi rst ICU admission day, OR 2 (95% CI = 1.3, 3.3, P = 0.002); age, OR 2.7 (95% CI = 1.7, 4.2, P = 0.000); CHF, OR 3.1 (95% CI = 1.2, 7.9, P = 0.013); APACHE II score, OR 1.02 (95% CI = 1.0, 1.04, P = 0.006); SAPS II score, OR 1.04 (95% CI = 1.02, 1.05, P = 0.000); mean MAP on admission, OR 0.98 (95% CI = 0.96, 0.99, P = 0.033); need for vasopressors on admission, OR 2.7 (95% CI = 1.7, 4.2, P <0.001) and for >24 hours, OR 2.7 (95% CI = 1.7, 2.5, P <0.001); and vancomycin use, OR 1.5 (95% CI = 1.02, 2.53, P = 0.04) signifi cantly predicted the development of AKI. On multivariate regression, CHF, OR 3.8 (95% CI = 1.4, 10, P = 0.007); age, OR 1.02 (95% CI = 1.01, 1.03, P = 0.001); vasopressors for >24 hours, OR 2.6 (95% CI = 1.6, 4.2, P <0.001) and a >2 l positive fl uid balance on the fi rst ICU day, OR 1.6 (95% CI = 1.02, 2.7, P = 0.04) remained signifi cant predictors. Introduction The impact of postsurgical complications (PSC) on hospital cost has been studied but the impact on margins remains controversial [1]. We assessed economic consequences of PSC in US Medicare patients, and benefi ts expected from reducing PSC by 14% to 40% with Enhanced Recovery Programs [2]. y Methods Data from patients with ≥1 comorbidity and major cardiac, vascular, gastrointestinal and orthopedic surgeries in 2011 were extracted from Medicare Standard Analytic Files. Hospital margin was calculated as payment minus cost. Positive fl uid balance as a risk factor for mortality and acute kidney injury in vasoplegic shock after cardiac surgery In the multivariate analysis, positive fl uid balance in the fi rst 24 hours (OR = 1.001, 95% CI = 1.000 to1.001, P <0.001) and higher lactate at 48 hours (OR = 1.011, 95% CI = 1.000 to 1.021, P = 0.0043) were predictors of 30-day AKI. 1. Eappen S, et al. JAMA. 2013;309:1599-606. P192 Patients with and without PSC were compared, and the economic impact of a 14 to 40% relative reduction in PSC was calculated. Results Of 303,432 patients, 37% had ≥1 PSC. Median length of stay was 10 days for patients with ≥1 PSC and 6 days without (P <0.0001 with vs. without PSC), with readmissions for 21% and 16%, respectively (P <0.0001 with vs. without PSC). Average margins for cases with PSC converted into without PSC would be $1,870 higher. A 14 to 40% reduction in patients with PSC (from 37% to 32% to 22%) would result in saving $153 million to $438 million, and increase hospital margins overall by $28 million to $79 million. See Table 1. i Conclusion Fluid overload, defi ned as a >2 l positive fl uid balance on the fi rst day of ICU admission, is an independent risk factor for the development of AKI in the general ICU population. Table 1 (abstract P192) With PSC Without PSC Mean 2011 US$/patient Cost ($) Margin ($) Cost ($) Margin ($) Cardiac 46,535 –2,286 32,887* –778* Gastrointestinal 33,280 –3,088 18,942* –752* Orthopedic 20,798 –3,567 15,194* –1,872* Vascular 31,042 –4,782 17,667* –2,267* P <0.0001 with versus without PSC. Table 1 (abstract P192) P191 Positive fl uid balance as a risk factor for mortality and acute kidney injury in vasoplegic shock after cardiac surgery A Rezende1, L Camara2, A Leme2, J Ribeiro2, I Bispo2, S Zeferino2, J Jardim2, C Park1, E Osawa2, J Almeida2, A Gerent1, F Galas2, D Fonseca2, J Fukushima1, L Hajjar2 1ICESP, São Paulo, Brazil; 2Heart Institute, University of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P191 (doi: 10.1186/cc14271) Minimal volume for a fl uid challenge in postoperative patients H A A Rh d RM G d M C i H Aya, A Rhodes, RM Grounds, M Cecconi St George’s Healthcare NHS Trust, London, UK g Critical Care 2015, 19(Suppl 1):P189 (doi: 10.1186/cc14269) Introduction In critical illness, fl uid overload may predispose to acute renal dysfunction by a number of mechanisms. Once acute kidney Introduction An eff ective fl uid challenge should increase the mean systemic fi lling pressure (Pmsf) in order to increase the venous return. Figure 1 (abstract P188). Change in BIA-measured ECW (a) or R/h at 50 kHz (b) versus daily fl uid balance. Hz (b) versus daily fl uid balance. Figure 1 (abstract P188). Change in BIA-measured ECW (a) or R/h at 50 kHz (b) versus daily fl uid balance. S66 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion Positive fl uid balance after cardiac surgery is an independent risk factor for mortality and for acute kidney injury in patients presenting vasoplegic shock. injury (AKI) develops, positive fl uid balance has been described as a risk factor for overall mortality and delayed renal recovery. We hypothesized that fl uid overload may be an independent risk factor for AKI in the critically ill. injury (AKI) develops, positive fl uid balance has been described as a risk factor for overall mortality and delayed renal recovery. We hypothesized that fl uid overload may be an independent risk factor for AKI in the critically ill. Methods In a cross-sectional design, we collected data on consecutive, critically ill, adult patients admitted over a 5-month period to the medical and surgical ICUs of a single center. AKI was defi ned according to the RIFLE Classifi cation. Logistic regression analysis was performed to determine the predictive ability of variables for AKI. The institutional Research Ethics Committee approved the study. P195 Team-based extubation protocol in cardiac surgical patients reduces ventilation time and reduces length of stay in the ICU JM Taculod, MJ Dajac, A Del Rosario, J Gammad, S Mahaju, O Siow Eng, P Oh, R Kollengode, G Maclaren, ME Cove National University Hospital, Singapore Critical Care 2015, 19(Suppl 1):P195 (doi: 10.1186/cc14275) Team-based extubation protocol in cardiac surgical patients reduces ventilation time and reduces length of stay in the ICU JM Taculod, MJ Dajac, A Del Rosario, J Gammad, S Mahaju, O Siow Eng, P Oh, R Kollengode, G Maclaren, ME Cove National University Hospital, Singapore Critical Care 2015, 19(Suppl 1):P195 (doi: 10.1186/cc14275) Results We included a total of 1,267 patients. The median age was 68 (quartiles: 59, 76), 32% were female, 68% underwent coronary artery bypass grafting and 59% underwent valve surgery. Median length of hospital stay was 6 days (quartiles: 5, 9). Median length of stay in the normal, elevated and high lactate groups were 5 days (quartiles: 4, 7), 6 days (quartiles: 5, 9) and 9 days (quartiles: 6, 17), P <0.001 for comparison. In multivariable analysis, patients with an elevated lactate had a 1.12 times (95% CI: 1.02 to 1.23, P = 0.02) longer length of stay compared with those with normal lactate. Patients with a high lactate had a 1.30 times (95% CI: 1.10 to 1.53, P = 0.002) longer length of stay compared with those with normal lactate. Introduction National University Hospital, Singapore, recently formed a Division of Critical Care – Respiratory Therapy. This service rapidly expanded to provide 24/7 Respiratory Therapy Services in the cardiothoracic intensive care unit (CTICU). One goal of service expansion was a reduction in duration of mechanical ventilation after cardiac surgery. We hypothesized that introduction of a team- based extubation protocol would reduce the duration of mechanical ventilation and ultimately aff ect ICU length of stay. Conclusion Postoperative lactate levels are associated with increased length of hospital stay in patients undergoing major cardiac surgery. Interventions aimed at decreasing postoperative lactate levels may decrease hospital length of stay. f Methods A multidisciplinary group created a team-based extubation protocol. The protocol was applied to all elective postoperative cardiac surgery patients. To assess the protocol’s impact, data were collected in a registry 3 months before and 3 months after protocol initiation. Data collection included cardiopulmonary bypass time, McCormack airway assessment, ICU admission time, initial pH, lactate, inotropes upon arrival at the CTICU, blood gas analysis prior to extubation, time of extubation and length of stay. Patients were excluded from data analysis if they experienced events which contraindicated application of the protocol, such as signifi cant intraoperative or postoperative complications. These events were explicitly stated in the extubation protocol. Lactate levels after major cardiac surgery are associated with hospital length of stay Introduction The objective of the study was to evaluate whether postoperative lactate values are associated with hospital length of stay in patients undergoing major cardiac surgery. Previous studies have shown an association between postoperative lactate levels and increased morbidity and mortality after major cardiac surgery. However, the association between lactate and hospital length of stay has not been adequately characterized. Methods We performed a retrospective analysis of all patients presenting for coronary artery bypass grafting and/or valve surgery between 2002 and 2014 at a tertiary care center in Boston, who had a lactate level measured within 3 hours of skin closure. Lactate values S67 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 were categorized into clinical meaningful categories: 0 to 2 mmol/l (normal), 2 to 4 mmol/l (elevated) and ≥4 mmol/l (high) to allow for nonlinear eff ects. The unadjusted association between lactate group and length of stay was assessed with the Kruskal–Wallis test and post hoc Wilcoxon rank-sum tests. To assess the association between postoperative lactate levels and hospital length of stay we performed multivariable Poisson regression with robust variance estimates. We adjusted for more than 30 variables including patient demographics, comorbidities, cardiac characteristics (for example, New York Heart Association class and ejection fraction), and surgical characteristics (for example, year, status (elective, urgent, emergent), type of procedure, perfusion time, and cross clamp time). severe hypotension (MAP <65 mmHg) and the study was not stopped in any case. The length of the hospital stay was shorter among patients in the intensive group (10.9 (9.9 to 11.9) vs. 12.4 days (11.3 to 13.6); P = 0.045). severe hypotension (MAP <65 mmHg) and the study was not stopped in any case. The length of the hospital stay was shorter among patients in the intensive group (10.9 (9.9 to 11.9) vs. 12.4 days (11.3 to 13.6); P = 0.045). Conclusion An intensive alveolar recruitment protocol did not result in hemodynamic instability in hypoxemic patients after cardiac surgery (NCT01502332). P195 P195 Team-based extubation protocol in cardiac surgical patients reduces ventilation time and reduces length of stay in the ICU JM Taculod, MJ Dajac, A Del Rosario, J Gammad, S Mahaju, O Siow Eng, P Oh, R Kollengode, G Maclaren, ME Cove National University Hospital, Singapore Critical Care 2015, 19(Suppl 1):P195 (doi: 10.1186/cc14275) Singapore’s Domain-specifi c review board granted waiver of patient consent to analyze and present these data. Hemodynamic behavior in a randomized trial of intensive alveolar recruitment after cardiac surgery recruitment after cardiac surgery A Leme, M Amato, E Osawa, J Fukushima, M Feltrim, E Nozawa, J Almeida L Hajjar, F Galas Heart Institute, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P194 (doi: 10.1186/cc14274) A Leme, M Amato, E Osawa, J Fukushima, M Feltrim, E Nozawa, J Almeida, L Hajjar, F Galas jj Heart Institute, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P194 (doi: 10.1186/cc14274) Introduction The potential benefi ts of a protocol of intensive alveolar recruitment may be outweighed by its detrimental eff ects in hemodynamic stability after cardiac surgery. The aim of this study was to analyze the hemodynamic behavior of patients included in a trial of intensive alveolar recruitment after cardiac surgery. p y p Results A total of 201 patients undergoing elective open cardiac surgery were included; 99 patients before protocol implementation (pre-protocol) and 102 patients after implementation (post-protocol). There was no signifi cant diff erence in mean age (60 vs. 61 P = 0.823), gender (79.8% vs. 79.4% P = 1.00), EuroSCORE (26 vs. 32 P = 0.576) and proportion receiving bypass surgery (72% vs. 80% P = 0.206) or valve surgery (21% vs. 19% P = 0.722) between the two groups. Median extubation time was reduced by 3.5 hours (620 minutes vs. 408 minutes P <0.001). ICU length of stay was also reduced following introduction of the pre-protocol 48 hours versus 24 hours post protocol (P <0.05).i Methods In this randomized trial, we assigned adult patients with PaO2/ FIO2 <250 at a PEEP of 5 cmH2O to either intensive alveolar recruitment or a standard protocol, both using low-tidal volume ventilation (6 ml/ kg/ibw) after adequate volemia status. Our hypothesis was that an intensive alveolar recruitment protocol with controlled pressure of 15 cmH2O and PEEP of 30 cmH2O during 1 minute, repeated three times at 1-minute intervals between each maneuver, would not cause hemodynamic instability. Conclusion A team-based extubation protocol signifi cantly reduced the duration of mechanical ventilation and this translated to reduced ICU length of stay in patients undergoing elective open-heart surgery. Results In total, 163 patients were included in the standard and 157 in the intensive group. Patients of the intensive group had a signifi cant reduction of the MAP at T1, T2 and T3 (1 hour, 2 hours and 3 hours of the protocol), returning to baseline after T4 (Figure 1). No patients had P196 Impact of patient frailty on outcome in cardiothoracic surgery J Brohan, P Delaney, B O’Brien Cork University Hospital, Cork, Ireland Critical Care 2015, 19(Suppl 1):P196 (doi: 10.1186/cc14276) Vasoplegic syndrome in cardiac surgery: role of synergism between polymorphism of tumor necrosis factor beta and plasminogen activator inhibitor type 1 JL Iribarren, J Jiménez, N Perez, M Brouard, R Perez, E Hurtado, S Diosdado, M Buitrago, A Arbesu, R Martinez, M Mora Hospital Universitario de Canarias, La Laguna, Spain Critical Care 2015, 19(Suppl 1):P199 (doi: 10.1186/cc14279) Introduction Cardiopulmonary bypass can lead to postoperative hemodynamic disorders. Several genetic polymorphisms have been studied in this setting. We investigated the possible existence of a synergism between polymorphisms of plasminogen activator inhibitor type 1 (PAI-1) and tumoral necrosis factor beta (TNF-B) on hemodynamic response after cardiac surgery. Introduction Cardiopulmonary bypass can lead to postoperative hemodynamic disorders. Several genetic polymorphisms have been studied in this setting. We investigated the possible existence of a synergism between polymorphisms of plasminogen activator inhibitor type 1 (PAI-1) and tumoral necrosis factor beta (TNF-B) on hemodynamic response after cardiac surgery. g Results A total of 8,026 were recorded, in 77 of them an IABP was inserted before the surgery. We performed a propensity score analysis by pairing 72 patients with and without BCIAO based on epidemiological factors and type of surgery. In the analysis of all-cause 30-day mortality, 27% of patients in whom IABP was inserted prior surgery died versus 13.1% of patients without IABP preoperative implantation (P = 0.043). A combined endpoint that included need for prolonged mechanical ventilation over 24 hours or reoperation or mediastinitis or stroke after surgery or 30-day mortality was performed and occurred in 58.3% of patients with preoperative IABP versus 41.7% without it (P = 0.046). When stratifi ed by preoperative risk (analyzed with EuroSCORE), no diff erence between groups was observed (P = 0.62, OR 0.75 (0.23 to 2.35)) for mortality rate and (P = 0.11, OR 0.47 (0.19 to 1.18)) for the combined endpoint. The patients with preoperative IABP implantation had a higher ICU length of stay (10.6 ± 7.7 vs. 4.6 ± 6.7, P = 0.046) with no diff erences in terms of overall hospital stay (21.8 ± 18.7 vs. 18.9 ± 22.08, NS). y y Methods We prospectively studied the association between hemodynamic response and polymorphisms of TNF-B and PAI-1 in 563 patients undergoing elective cardiac surgery during the years 2008 to 2011. We tested the Hardy–Weinberg equilibrium in the sample. V18 SPSS was used.if Results We studied 563 patients. We found signifi cant diff erences in TNF-B polymorphisms regarding norepinephrine requirements at 4 hours (F: 15.9; P <0.001), post hoc Scheff é (GG vs. P198 Intraortic balloon pump use in cardiac surgery: analysis of data from the ARIAM Registry of Cardiac Surgery Intraortic balloon pump use in cardiac surgery: analysis of data from the ARIAM Registry of Cardiac Surgery J Muñoz-Bono, MD Delgado-Amaya, E Curiel-Balsera, C Joya-Montosa, G Quesada-García Hospital Regional de Málaga, Spain Critical Care 2015, 19(Suppl 1):P198 (doi: 10.1186/cc14278) Results A total of 120 patients were included in this study, including 100 patients who underwent cardiac surgery and 20 patients who underwent thoracic surgery. Eighty-fi ve patients (70.8%) were male. The mean age was 65.4 years (range 25 to 89 years). The mean baseline frailty score also varied widely within our cohort. Four patients died in the ICU following their surgery (3% ICU mortality rate). Mean length of ICU stay was 2.7 days (range 0 to 20 days), with a mean duration of ventilation of 20 hours (range 0 to 264 hours). Follow-up of these patients at 6 months following their surgery is currently underway. Introduction The aim of the study is to analyze IABP use in patients undergoing cardiac surgery included in the ARIAM Registry of Cardiac Surgery. Introduction The aim of the study is to analyze IABP use in patients undergoing cardiac surgery included in the ARIAM Registry of Cardiac Surgery. g y Methods An observational, retrospective, multicenter study of all patients undergoing cardiac surgery included in the ARIAM- ANDALUCIA database of Cardiac Surgery from March 2008 to July 2012. We used the chi-square test and Student t test as needed, establishing the level of statistical signifi cance at 95%. y y y Conclusion Owing to advances in life expectancy, health and perioperative medicine, it has become more diffi cult to determine fi tness for major surgery. Our data suggest that frailty may be a useful prognostic measure to help inform such decisions. R f gi Results Of the 8,026 patients who underwent cardiac surgery during the study period, BCIAO was implemented in 358 (4.5%) of them. In total, 65.4% were male. Surgical times in those patients where IABP was implanted were 146 ± 81 minutes and 90 ± 66 minutes (cardiopulmonary and aortic clamping times, respectively). The in- surgery room mortality was 4.7%, 30-day mortality in these patients was 40.2%. Patients in whom IABP was implanted had a mortality rate eight times higher than those who did not require it during surgery or postoperatively (40.2% vs. 8.4%, P = 0.0001. OR 8.1, 95% CI (6.4 to 10.3)). Impact of patient frailty on outcome in cardiothoracic surgery J Brohan, P Delaney, B O’Brien Cork University Hospital, Cork, Ireland Critical Care 2015, 19(Suppl 1):P196 (doi: 10.1186/cc14276) Figure 1 (abstract P194). J Brohan, P Delaney, B O’Brien , y, Cork University Hospital, Cork, Ireland Cork University Hospital, Cork, Ireland Critical Care 2015, 19(Suppl 1):P196 (doi: 10.1186/cc14276) y p , , Critical Care 2015, 19(Suppl 1):P196 (doi: 10.1186/cc142 Introduction Frailty is defi ned as a multidimensional syndrome involving loss of physical and cognitive reserve leading to greater vulnerability to adverse events [1]. Such events include susceptibility to unplanned hospital admissions, and death [1-3]. Frailty is associated with increased ICU and 6-month mortality, and reduced quality of life [4]. The aim of this study is to investigate the impact of baseline frailty on postoperative quality of life indicators and postoperative frailty following cardiothoracic surgery. Methods Adult patients undergoing cardiac surgery or thoracic surgery (involving thoracotomy) were included in this study. Baseline measures of frailty [4] and performance status were prospectively recorded using validated tools. Informed consent was obtained prior to inclusion. Outcome measures of APACHE II scores, duration of ventilation, length S68 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P198 Intraortic balloon pump use in cardiac surgery: analysis of data from the ARIAM Registry of Cardiac Surgery Besides mortality was higher, the later IABP was implanted the higher the mortality rate was (29.6% of the preoperative, 44.2% of surgical and 54.4% of those starting in ICU, P = 0.015). The ICU length of stay was 9 ± 22 days while the hospital length of stay was 21 ± 28 days. In patients who needed IABP, the ICU stay was higher than for those who did not need it (9 ± 22 vs. 5 ± 10 days, P = 0.002) whereas there was no diff erence in hospital stay (21 ± 28 vs. 20 ± 24 days, P = 0.054). 1. Rockwood K, et al. A global clinical measure of fi tness and frailty in elderly people. CMAJ. 2005;173:489-95. 2. Rockwood K, et al. Changes in relative fi tness and frailty across the adult lifespan: evidence from the Canadian National Population Health Survey. CMAJ. 2011;183:E487-94. 3. Makary MA, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210:901-8. 4. Le Maguet P, et al. Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective, multicentre observational study. Intensive Care Med. 2014;40:674-82. P198 of ICU stay and mortality were recorded. Follow-up at 6 months was conducted by telephone to assess recovery patterns. of ICU stay and mortality were recorded. Follow-up at 6 months was conducted by telephone to assess recovery patterns. Registry of Cardiac Surgery MD Delgado-Amaya, C Joya-Montosa, J Muñoz-Bono, E Curiel-Balsera Hospital Regional de Málaga, Spain MD Delgado-Amaya, C Joya-Montosa, J Muñoz-Bono, E Curiel-Balsera Hospital Regional de Málaga, Spain f p y y Conclusion The intra-aortic balloon pump was used by 4.5% of surgeries performed during the study period and in patients with an increased risk of perioperative complications, estimated by EuroSCORE. ICU length of stay was higher in patients requiring IABP, with no diff erences in overall hospital stay. Mortality rate was 40% higher, and increases with the delay in the implantation. p g g p Critical Care 2015, 19(Suppl 1):P197 (doi: 10.1186/cc14277) g g Critical Care 2015, 19(Suppl 1):P197 (doi: 10.1186/cc14277) Introduction The aim of our study was to assess whether the preoperative use of IABP is benefi cial in patients undergoing cardiac surgery of any kind. Introduction The aim of our study was to assess whether the preoperative use of IABP is benefi cial in patients undergoing cardiac surgery of any kind. Methods An observational, retrospective, multicenter study of all patients undergoing cardiac surgery and included in the ARIAM- ANDALUCIA Registry of Cardiac Surgery from March 2008 to July 2012. The probability of placing IABP in the preoperative period has been calculated, making a propensity analysis to obtain two homogeneous groups treated with or without the IABP, based on personal history, functional status and type of surgery. Seventy-seven patients with preoperative IABP were matched with 77 patients without BCIAO with the nearest propensity score. We used the chi-square test or Student t test as needed and binary logistic regression for multivariate analysis so we can rule out possible confounding variables. We used the statistical package R v2.12 for MAC. P199 Vasoplegic syndrome in cardiac surgery: role of synergism between polymorphism of tumor necrosis factor beta and plasminogen activator inhibitor type 1 JL Iribarren, J Jiménez, N Perez, M Brouard, R Perez, E Hurtado, S Diosdado, M Buitrago, A Arbesu, R Martinez, M Mora Hospital Universitario de Canarias, La Laguna, Spain Critical Care 2015, 19(Suppl 1):P199 (doi: 10.1186/cc14279) P200 Pharyngeal oxygenation during apnoea following conventional pre-oxygenation and high-fl ow nasal oxygenation D Stolady, M Mariyaselvam, H Young, E Fawzy, M Blunt, P Young Queen Elizabeth Hospital, King’s Lynn, UK Critical Care 2015, 19(Suppl 1):P200 (doi: 10.1186/cc14280) y Methods We performed a prospective randomized cross-over study on hypoxemic non-intubated patients (PaO2/FiO2 ≤300 mmHg) admitted to the ICU of the San Gerardo Hospital and prescribed to receive oxygen by facial mask. We delivered the same air/oxygen mix by HFNC (Optifl ow; Fisher & Paykel Healthcare, Auckland, New Zealand) and facial mask (20 minutes per step). Continuous recordings of regional lung volumes by EIT (Pulmovista 500; Drager Medical GmbH, Lubeck, Germany) and of inspiratory eff ort by esophageal pressure (Pes) were obtained and analyzed offl ine by dedicated software. Introduction We hypothesised that pharyngeal oxygen concentrations would be maintained higher and for longer with transnasal humidifi ed rapid insuffl ation ventilatory exchange (THRIVE) than conventional bag-mask pre-oxygenation (CPO). CPO requires the mask to be removed during laryngoscopy; this means that air may enter the mouth so subsequent apnoeic oxygenation will be less eff ective. Oral suctioning could exacerbate this process. However, if high pharyngeal oxygen concentrations and an open airway are maintained, apnoeic oxygenation could be substantially improved. Methods used have included NO-DESAT [1] and recently THRIVE [2], which has been shown to extend apnoea times for up to 1 hour. yfl y Results We enrolled 15 patients (10 male), age 57 ± 16 years. Compared with standard facial mask, HFNC signifi cantly improved PaO2/FiO2 (199 ± 60 vs. 150 ± 46, P <0.001) and end-expiratory lung impedance (corresponding to aeration) (866 ± 568 au vs. baseline, P <0.001). Moreover, HFNC decreased the respiratory rate (22 ± 5 bpm vs. 20 ± 5 bpm, P <0.001), as well as negative Pes swings (ΔPes 8.3 ± 5 mmHg vs. 6.6 ± 1 mmHg, P <0.01) and corrected minute ventilation (that is, actual MV × actual PaCO2 / 40 mmHg) (49,887 ± 16,176 au vs. 41,811 ± 14,042 au, P <0.001). Finally, central venous pressure increased (6 ± 5 mmHg vs. 4 ± 5 mmHg, P <0.01), possibly indicating positive end-expiratory pressure eff ect. Methods A volunteer with a nasopharyngeal sampling catheter underwent simulated emergency airway management (EAM), using both CPO and THRIVE, with and without suction. Reference 1. Sotello D, Rivas M, Mulkey Z, Nugent K. High-fl ow nasal cannula oxygen in adult patients: a narrative review. Am J Med Sci. 2015;349:179-85. Results Pharyngeal oxygen concentrations (mean and SEM) are shown in Figure 1 (all points are signifi cant P <0.05). Vasoplegic syndrome in cardiac surgery: role of synergism between polymorphism of tumor necrosis factor beta and plasminogen activator inhibitor type 1 AA, 0.32 (0.11 to 0.65) vs. 0.06 (0.04 to 0.09) μg/kg/minute, P <0.001; GG vs. AG, 0.32 (0.11 to 0.65) vs. 0.06 (0.03 to 0.08), P <0.001)) and at 24 hours (F: 8; P = 0.005), post hoc Scheff é (GG vs. AA, 0.27 (0.01 to 0.52) vs. 0.10 (0.06 to 0.14), P = 0.019; GG vs. AG, 0.27 (0.01 to 0.52) vs. 0.07 (0.04 to 0.09), P = 0.003)). Unfavorable TNF-B (G homozygous vs. allele A) and PAI-1 unfavorable (4G homozygous vs. allele 5G) were grouped, after adjusting for perioperative signifi cant variables. The homozygous GG and 4G alleles were signifi cant for NA 4 hours (F: 5.5; P = 0.02 and F: 4.1; P = 0.04, respectively) and GG–4G allele interaction (F: 6; P = 0.01) (Figure 1), Conclusion The use of IABP prior to cardiac surgery in patients at high risk does not reduce the mortality rate nor the combined endpoint described above. ICU length of stay was greater in those patients in whom IABP was implanted prior to surgery; there were no diff erences in overall hospital stay. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S69 THRIVE. Assessment of NO-DESAT (15 l/minute) was abandoned due to discomfort. R f Figure 1 (abstract P199). THRIVE. Assessment of NO-DESAT (15 l/minute) was abandoned due to discomfort. Figure 1 (abstract P199). P200 Following 3 minutes of pre-oxygenation with CPO (FiO2 = 1, FEO2 >0.8) or THRIVE (60 l/minute; Optifl ow, Fisher and Paykel), EAM was simulated by voluntary apnoea and pharyngoscopy with the laryngoscope blade tip placed 2 cm from the posterior pharyngeal wall. Capnography at the laryngoscope tip confi rmed apnoea. Pharyngeal gas samples (20 ml) were collected during apnoea, and after 5 seconds of oropharyngeal suctioning. Pre- oxygenation was repeated between sampling. Samples (n = 100) were analysed using calibrated fuel cells. f Conclusion In non-intubated hypoxemic critically ill patients, HFNC improves oxygenation and end-expiratory aeration; moreover, HFNC reduces the inspiratory eff ort and the minute ventilation needed to maintain normal arterial CO2 tension. 0 Eff ects of high-fl ow nasal cannula therapy on oxygenation, lung volumes and CO2 removal in critically ill hypoxemic patients: preliminary results p y T Mauri1, N Eronia2, G Bellani2, G Grasselli2, R Marcolin2, S Marocco Arrigoni2, A Pesenti2 1IRCC Ca’ Granda Maggiore Policlinico Hospital, Milan, Italy; 2San Gerardo Hospital, Monza, Italy Critical Care 2015, 19(Suppl 1):P201 (doi: 10.1186/cc14281) Figure 1 (abstract P199). Figure 1 (abstract P199). while for NA at 24 hours statistics showed GG (F: 3.2; P = 0.07), 4G allele (F: 2; P = 0.15) and interaction (F: 3.6, P = 0.05). Conclusion GG homozygous polymorphism TNF-B is associated with an increased dependence on norepinephrine after cardiopulmonary bypass, showing a synergistic action with the 4G allele of PAI-1. while for NA at 24 hours statistics showed GG (F: 3.2; P = 0.07), 4G allele (F: 2; P = 0.15) and interaction (F: 3.6, P = 0.05). Introduction High-fl ow nasal cannula (HFNC) is increasingly proposed as respiratory support for hypoxemic non-intubated acute respiratory failure patients. Clinically, HFNC therapy decreases dyspnea, improves patient’s comfort, improves oxygenation and enhances clearance of upper airway secretions [1]. We present preliminary results from a clinical study aimed at measuring the eff ects of HFNC on gas exchange, lung volumes and inspiratory eff ort in hypoxemic non-intubated critically ill patients. Conclusion GG homozygous polymorphism TNF-B is associated with an increased dependence on norepinephrine after cardiopulmonary bypass, showing a synergistic action with the 4G allele of PAI-1. New assembled video laryngoscope: a study on effi cacy and cost-eff ectiveness A similar pattern was seen was seen in the vast majority of ICUs: a single institution reported no capnography available. However, in 141 (66.8%) of the hospitals surveyed, no facility to measure ETCO2 was present on the general wards. Where available, 86.7% used capnography to confi rm ETT placement. Less than 50% used ETCO2 to determine CPR eff ectiveness and 8% to prognosticate.i is located in the same position as the light source on the standard Macintosh blade thus providing a view angle of up to 290° and the USB camera is connected to a laptop. A total of the fi rst 50 patients who presented to the emergency department over a period of 6 months in need of intubation were included in the study and every alternate patient participated in the evaluation of the assembled video laryngoscope (VAL). Information about patient demographics and airway characteristics, Cormack-Lehane (C/L) views and the ease of intubation using the VAL was collected. Failure was defi ned as more than one attempt at intubation. given the option to decline participation. All data were anonymised. Results A total of 211 hospitals met the inclusion criteria. The response rate was 100%. Arrest calls were mainly attended by anaesthesia (47.8%) and ICU doctors (38.3%) with around 2% physicians only. Most were a registrar grade (56.3%). The ability to measure ETCO2 was available in all but four EDs; most used waveform capnography. A similar pattern was seen was seen in the vast majority of ICUs: a single institution reported no capnography available. However, in 141 (66.8%) of the hospitals surveyed, no facility to measure ETCO2 was present on the general wards. Where available, 86.7% used capnography to confi rm ETT placement. Less than 50% used ETCO2 to determine CPR eff ectiveness and 8% to prognosticate. Results Excellent (C/L1) or good (C/L2) laryngeal exposure was obtained in 92% and 8% of patients respectively. In 25 patients in whom VAL was performed, there was a comparable or superior view. Intubation with direct laryngoscopy was successful in 95.2% of patients and VAL was successful in 95.4% of patients. Three patients from the VAL group and four patients from the direct laryngoscopy group were excluded. See Figure 1. Conclusion We believe this is the fi rst study of its kind to follow NAP4 and investigate the availability of capnography throughout for use during cardiac arrest. New assembled video laryngoscope: a study on effi cacy and cost-eff ectiveness Whilst equipment levels appear adequate (albeit not perfect) in resuscitation areas, there appears a lack of availability of suitable devices on general wards. Figure 1 (abstract P202). New video laryngoscope connected to laptop. New assembled video laryngoscope: a study on effi cacy and cost-eff ectiveness i Conclusion Pharyngeal oxygen concentration rapidly falls following CPO. This may be detrimental for apnoeic oxygenation during con ven- tional laryngoscopy. Conversely, THRIVE maintains high pharyngeal oxygen concentrations over time. Suction has an immediate negative eff ect on pharyngeal oxygen concentration that is attenuated by f SM Ayyan, Z Ali Figure 1 (abstract P200). Pharyngeal oxygen concentration. Introduction Video laryngoscopes have been introduced in recent years as an alternative choice to facilitate tracheal intubation. Diffi culties with tracheal intubation are mostly caused by diffi cult direct laryngoscopy with impaired view to the vocal cords. Many endoscopic intubation laryngoscopes have been designed to visualize the vocal cords around the corner looking through a proximal viewfi nder. Although they are useful devices, they have limitations for doing direct laryngoscopy and are very expensive, hence they are not used for routine tracheal intubation.i Methods A Macintosh intubating laryngoscope has been modifi ed by attaching a waterproof USB camera with a inbuilt light source, which S70 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 is located in the same position as the light source on the standard Macintosh blade thus providing a view angle of up to 290° and the USB camera is connected to a laptop. A total of the fi rst 50 patients who presented to the emergency department over a period of 6 months in need of intubation were included in the study and every alternate patient participated in the evaluation of the assembled video laryngoscope (VAL). Information about patient demographics and airway characteristics, Cormack-Lehane (C/L) views and the ease of intubation using the VAL was collected. Failure was defi ned as more than one attempt at intubation. examining practice regarding intubation for cardiac arrest and the availability and utilisation of capnography within the ED, ICU and general wards. Questions were directed at the anaesthetist or intensive care doctor ‘responding to cardiac arrest calls’. The respondent was given the option to decline participation. All data were anonymised. Results A total of 211 hospitals met the inclusion criteria. The response rate was 100%. Arrest calls were mainly attended by anaesthesia (47.8%) and ICU doctors (38.3%) with around 2% physicians only. Most were a registrar grade (56.3%). The ability to measure ETCO2 was available in all but four EDs; most used waveform capnography. P203 P203 Availability of appropriate airway monitoring at UK in-hospital cardiac arrest S Turle1, PB Sherren1, T Callaghan1, S Nicholson2, SJ Shepherd1 1Pan-Thames Intensive Care Training Scheme, London, UK; 2KSS Intensive Care Training Scheme, London, UK Critical Care 2015, 19(Suppl 1):P203 (doi: 10.1186/cc14283) Using a laryngoscope and endotracheal tube succeeds in a diffi cult case of nasogastric tube insertion J P k Y L Using a laryngoscope and endotracheal tube succeeds in a diffi cult case of nasogastric tube insertion J Park, Y Lee Ewha Womans Unversity Hospital, Seoul, South Korea Critical Care 2015, 19(Suppl 1):P204 (doi: 10.1186/cc14284) , Ewha Womans Unversity Hospital, Seoul, South Korea Critical Care 2015, 19(Suppl 1):P204 (doi: 10.1186/cc14284) Introduction Nasogastric (NG) tube insertion is necessary in a variety of critically ill patients for intra-abdominal decompression, prevention of aspiration, route of medication administration and nutrition. However, it often fails in patients who showed sedated or comatose mentality with poor cooperation during the procedure. Although there are many reports inserting a NG tube in diffi cult cases, most methods need a special guide wire, tube or nasoendoscope. We report a case of NG tube insertion in a comatose patient using a laryngoscope and endotracheal tube which are easily available. Figure 1 (abstract P202). New video laryngoscope connected to laptop. Conclusion This new assembled VAL is the cheapest video-assisted laryngoscope available costing around $60, which can even be introduced into primary healthcare setup in developing countries. VAL consistently yielded a comparable or superior glottic view compared with direct laryngoscopy despite the limited or lack of prior experience with the device. Because the device can be used for both routine as well diffi cult tracheal intubation, it may be a helpful tool to intubate trauma cases where C-spine immobilization is unavoidable. The presented video-assisted laryngoscope is a useful tool for documentation, teaching and monitoring tracheal intubation. Figure 1 (abstract P204). Insertion of a nasogastric tube through an endotracheal tube in the esophagus. References 1. Grmec S. Intensive Care Med. 2002;28:701-4. 2. Deakin CD, et al. Resuscitation. 2010;81:1305-52. 3. Cook TM, et al. Br J Anaesth. 2011;106:617-31. 1. Grmec S. Intensive Care Med. 2002;28:701-4. Admissions with airway emergencies in the ICU at a tertiary referral centre Results Forty-fi ve patients (31 male) were included with a mean age of 67 ± 15 years. The commonest admission diagnoses were sepsis (10), cardiogenic shock (10), primary respiratory failure (nine) and intracranial haemorrhage (eight). The median transfer delay time was 47 minutes. Only 27 (60%) patients were actually transferred and they were signifi cantly younger than nontransferred patients (62 vs. 73 years, P = 0.02). In-transit mortality was zero. Mean length of stay in the critical care centre was 14.8 ± 16.8 days. Survival to discharge was signifi cantly higher in transferred (14/27) compared with nontransferred (3/18) patients (52% vs. 17%, P = 0.017). Overall mortality rates were 62% and 69% at 1 and 6 months respectively and were signifi cantly lower in the transferred group (P = 0.02). M Gresoiu, M Singer M Gresoiu, M Singer University College London Hospital, London, UK Critical Care 2015, 19(Suppl 1):P205 (doi: 10.1186/cc14285) Introduction As a tertiary referral centre for ENT and maxillo-facial surgery, our ICU receives complex elective and emergency cases. The frequency, aetiology and outcomes of airway emergencies are poorly described. Understanding these factors is key to improving management. g Methods We conducted a retrospective review of the ICU electronic patient database examining unplanned admissions with airway emergencies between December 13 and November 14. Data on demographics, aetiology of airway obstruction (including postprocedural), APACHE II score, therapeutic intervention(s) administered, and outcomes were collected. Conclusion Overall mortality rates of medical patients intubated urgently at BGH were high. Forty per cent of intubated patients were not transferred, indicating signifi cant modifi cation of the protocol over time. Patients transferred to the critical care centre were younger and had signifi cantly better outcomes than patients remaining in BGH, probably due to decisions not to transfer patients with poor prognoses. Most patients who survived to discharge were still alive 6 months later. Reference Results Of 1,516 unplanned admissions, airway emergencies represented 6.3% (96 patients) of whom 40 (41.7%) had malignancy (26 maxillo-facial/trachea, three pulmonary, four haematological, seven other) and 24 infection (abscesses, epiglottitis, Ludwig’s angina). Referring specialties were maxillo-facial surgery (n = 34), internal medicine (n = 25), ENT (n = 21) and other surgical specialties (n = 16). Thirteen patients had complications post bronchoscopy (vocal cord palsy, need for NIV or intubation), one post microlaryngoscopy, and 20 were admitted after diffi cult intubation. Outcomes of medical patients requiring emergency intubation in a rural Irish hospital Outcomes of medical patients requiring emergency intubation in a rural Irish hospital Results A 15-year-old male patient admitted due to abrupt mental change and brain imaging showed severe subdural hemorrhage. NG tube insertion was done for enteral feeding but failed several times though changing position. As we had no guide wire and no nasoendoscope, an endotracheal tube was used as guidance for the NG tube. After making a longitudinal midline cut on the endotracheal tube, it was inserted into the esophagus under a laryngoscope. The NG tube was pushed into the endotracheal tube, and then the endotracheal tube was removed through the cut, reserving the NG tube. We checked the position of the NG tube by air sound and X-ray, and started enteral feeding without complication, such as nasal bleeding, emphysema, and gastric perforation. See Figure 1. p A O’ Connor, MP D’Alton, B Carey Bantry General Hospital, Co. Cork, Ireland Critical Care 2015, 19(Suppl 1):P206 (doi: 10.1186/cc14286) Introduction Bantry General Hospital (BGH) is a small rural hospital serving a large, geographically isolated part of southwest Ireland. Following an infl uential national review of adult critical care services [1], a protocol was introduced in late 2010 mandating the immediate transfer of all medical patients intubated on an emergency basis to a large critical care centre 100 km away. Similar mandatory transfer protocols were introduced at the same time throughout the island of Ireland but few data are available regarding patient outcomes. We designed a study to look at the outcomes of all patients encompassed by the protocol at BGH. Conclusion We report a new method of NG tube insertion using a laryngoscope and endotracheal tube. y Methods We retrospectively reviewed the charts and electronic data of medical patients requiring emergency intubation at BGH from November 2010 to December 2013. We recorded the following data: age, sex, admission diagnosis, comorbidities, time delay to transfer, in- transit mortality, length of stay, survival to discharge and 1-month and 6-month mortality.i p Reference 1. Towards Excellence in Critical Care. Review of adult critical care services in the Republic of Ireland fi nal report. Submitted to the Health Service Executive; September 2009. Admissions with airway emergencies in the ICU at a tertiary referral centre Eighteen were admitted post drainage of abscess (dental, retropharyngeal) and seven for observation for epiglottitis. Thirteen patients had stridor (three tracheal stenosis, one vocal cord cyst, one post CVA, four post vocal cord palsy, one post oesophagoscopy, one post thyroidectomy, two post decannulation). Seven were admitted after emergency tracheostomy, one after blocked tracheostomy, one after emergency laryngectomy, six post bleeding (epistaxis, haemoptysis, bleed form laryngectomy site), and four post evacuation haematoma. Three were admitted following anaphylaxis/ angioedema and one after laryngospasm. Twenty-nine patients required medical management only (for example, steroids, nebulisers, and so forth), 25 were extubated post diffi cult intubation and six needed haemostasis control. Ten (nine surgical) tracheostomies were performed during their ICU stay. Sixteen patients died in hospital, of whom fi ve were in the ICU at the time; 14 of these had an underlying malignancy. Twenty-three patients deteriorated during their ICU stay including HAP (n = 3), bleeding from airway (n = 3), PEA arrest (n = 1), airway swelling (n = 2), blocked laryngectomy (n = 1), and tracheostomy dislodgement (n = 1). 03 Availability of appropriate airway monitoring at UK in-hospital cardiac arrest S Turle1, PB Sherren1, T Callaghan1, S Nicholson2, SJ Shepherd1 1Pan-Thames Intensive Care Training Scheme, London, UK; 2KSS Intensive Care Training Scheme, London, UK Critical Care 2015, 19(Suppl 1):P203 (doi: 10.1186/cc14283) Introduction Airway complications are more common outside the operating theatre and in emergency situations. Capnography remains the gold standard of confi rming correct endotracheal tube (ETT) placement, retaining high sensitivity and specifi city in cardiac arrest [1]. The 2010 European Resuscitation Council guidelines for adult advanced life support recommended waveform capnography in this setting [2]. Failure to use capnography was also identifi ed as a major contributor to airway-related morbidity and mortality in a national UK audit [3]. We sought to investigate current practice relating to the availability and use of capnography equipment cardiac arrest within UK hospitals. Methods Between June and November 2014, a telephone survey was conducted of all UK acute hospitals with adult level 3 ICUs and an emergency department (ED). Hospitals were identifi ed using nationally available data. A standardised telephone questionnaire was developed Figure 1 (abstract P204). Insertion of a nasogastric tube through an endotracheal tube in the esophagus. S71 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 http://ccforum.com/supplements/19/S1 Methods A NG tube was inserted using a laryngoscope and endotracheal tube. Airway hygiene in the ICU: can ipratropium plus salbutamol help? N Magalhaes Airway hygiene in the ICU: can ipratropium plus salbutamol help? N Magalhaes Centro Hospitalar Tâmega e Sousa, Penafi el, Portugal Critical Care 2015, 19(Suppl 1):P209 (doi: 10.1186/cc14289) Airway hygiene in the ICU: can ipratropium plus salbutamol help? N Magalhaes g Centro Hospitalar Tâmega e Sousa, Penafi el, Portugal Critical Care 2015, 19(Suppl 1):P209 (doi: 10.1186/cc14289) g g j p Results A total of 348 patients were included. VL attained better glottic visualization than DL (92.3% vs. 82.6%, respectively: P <0.001). In total, 299 patients with good glottic visualization were included in the analysis. Of these patients, 185 (61.9%) were male, median age and body mass index were 69 (interquartile range (IQR), 51 to 77) and 22 (IQR, 20 to 24) respectively. In univariate analysis, VL group had less respiratory failure (18.3% vs. 46.8%: P <0.001) and included more trauma patients (21.1% vs. 7.9%: P <0.001). The fi rst-attempt success rates were similar between two groups (82.6% vs. 77.4%: P = 0.286). Multivariable logistic regression analysis adjusted for potential confounders showed that the success rate of VL was similar to that of DL (odds ratio, 1.17; 95% confi dence interval, 0.57 to 2.39).i Introduction β-Adrenergic agonists increase the ciliary beat frequency in experimental models, raising the possibility that they may be useful for airway hygiene [1]. Salbutamol increases large airway mucociliary clearance [2], although this may not be true for smaller airways [3]. There are no data from ICU patients, so we decided to test the eff ectiveness of transtracheal instillation of a mixture of ipratropium and salbutamol, assessing the reduction of the number of aspirations and hours of ventilation. Methods An open randomized prospective study was held during 2014. All admitted patients were alternately selected as the study or control group and included if submitted to invasive ventilation for at least for 24 hours. Four patients who had secondary cardiac rhythm eff ects attributable to β-adrenergic agonists were excluded. In the study group, 3 ml of a dilution of 2.5 ml ipratropium (0.52 mg) plus salbutamol (2.5 mg) with 2.5 ml distilled water was instilled after the aspiration of secretions. During the ventilation period we noted for both groups, in addition to the demographic data, the number of tracheal aspirations by day and hours of ventilation. The statistical analysis was done with XLSTAT 2014 and we used the Kolmogorov– Smirnov test to compare the normal distribution of the groups. P210 Simultaneous use of a heat and moisture exchanger and a heated humidifi er causes critical airway occlusion in less than 24 hours M Mariyaselvam, A Doyle, G Wijewardena, N English, P Young Queen Elizabeth Hospital, King’s Lynn, UK Critical Care 2015, 19(Suppl 1):P210 (doi: 10.1186/cc14290) p , g y , Critical Care 2015, 19(Suppl 1):P210 (doi: 10.1186/cc14290) q Results There were 62 RSI intubations using THRIVE (ICU and ED = 30; OR = 33). Diffi cult airway equipment used in 36 cases (videolaryngoscopy in 23). Mean apnoea time was 118 seconds (30 to 480 seconds), with a median SpO2 fall of 1% (0 to 33%). There was no correlation between arterial desaturation and apnoeic time. OR cases had a mean apnoea of 113 seconds with a median SpO2 fall of 0% (0 to 13%). ICU and ED cases had a mean apnoea time of 119 seconds and median SpO2 fall of 1% (0 to 33%). THRIVE was universally readily accepted. Reasons cited included: simplifi cation of pre-oxygenation (hands free) and increased confi dence. Six outlying arterial desaturation events suggested poor airway maintenance at induction or use in particularly high-risk patients. Many anaesthetists reinstituted THRIVE following extubation in selected patients (for example, obesity). No complications occurred during implementation. Introduction We hypothesised that the simultaneous use of a heat and moisture exchanger (HME) and a heated humidifi er (HH) would increase the incidence of airway occlusion over a 24-hour period in comparison with each device in isolation. This bench study compares the incidence of airway occlusion when using (group 1) no airway humidifi cation, (group 2) a HME alone, (group 3) a HH alone and (group 4) both a HME and a HH in combination. Tracheal intubation requires the use of artifi cial humidifi cation systems. HMEs are less effi cient but convenient especially for a short period of intubation and HHs are commonly more expensive. Both devices are often used in close proximity on the ICU depending on the particular clinical scenario and/ or clinical practitioner. Following a critical incident of HME obstruction due to waterlogging on our ICU we realised that HH and HME may be used together inadvertently. This airway obstruction was only resolved by the removal of the HME from the patient’s breathing circuit. Transnasal humidifi ed rapid insuffl ation ventilatory exchange for pre-oxygenation and apnoeic oxygenation during rapid sequence induction Transnasal humidifi ed rapid insuffl ation ventilatory exchange for pre-oxygenation and apnoeic oxygenation during rapid sequence induction Transnasal humidifi ed rapid insuffl ation ventilatory exchange for pre-oxygenation and apnoeic oxygenation during rapid sequence induction M Mariyaselvam, D Stolady, G Wijewardena, M Blunt, P Young Queen Elizabeth Hospital, King’s Lynn, UK Critical Care 2015, 19(Suppl 1):P208 (doi: 10.1186/cc14288) Results These preliminary results included 107 patients. The only normal distribution, according to the Kolmogorov–Smirnov test, was for the number of hours of ventilation: 76.3 ± 100 (24; 478) in the study group versus 111 ± 167 (24; 780) in the control group.i Conclusion The preliminary analysis, referring to the fi rst 6 months of study, showed a tendency in the reduction of both ventilation hours and length of stay in the study group. No signifi cant diff erence was found in the number of aspirations, which may be explained by ICU nursing routines. Further studies will try to fi nd whether signifi cant diff erences in the incidence of VAP exist, allowing this procedure to be implemented in ICU routines. Introduction Rapid sequence induction (RSI) in the ICU, emergency department (ED) and operating room (OR) carries the risk of hypoxemia if laryngoscopy is prolonged especially in high-risk patients. Bag and mask pre-oxygenation is normally used to extend the apnoea time; however, arterial desaturation may still rapidly occur. Transnasal humidifi ed rapid insuffl ation ventilatory exchange (THRIVE) is a new technique that provides modest CPAP during pre-oxygenation and crucially also continuous oxygenation of the pharyngeal space throughout the apnoeic period. In elective surgery, THRIVE provides apnoea times as long as 60 minutes due to apnoeic oxygenation [1]. We report the fi rst implementation of THRIVE with emergency patients into the ICU, ED and OR. References 1. Frohock JI, Wijkstrom-Frei C, Salathe M. Eff ects of albuterolenantiomers on ciliary beat frequency in ovine trachealepithelial cells. J Appl Physiol. 2002;92:2396-402. 1. Frohock JI, Wijkstrom-Frei C, Salathe M. Eff ects of albuterolenantiomers on ciliary beat frequency in ovine trachealepithelial cells. J Appl Physiol. 2002;92:2396-402. 2. Lafortuna CL, Fazio F. Acute eff ect of inhaled salbutamol onmucociliary clearance in health and chronic bronchitis. Respiration. 1984;45:111-23. 2. Lafortuna CL, Fazio F. Acute eff ect of inhaled salbutamol onmucociliary clearance in health and chronic bronchitis. Respiration. 1984;45:111-23. 3. Svartengren K, Philipson K, Svartengren M, Camner P. Eff ect ofadrenergic stimulation on clearance from small ciliatedairways in healthy subjects. Exp Lung Res. 1998;24:149-58. Methods Following training a THRIVE system was installed in each location either as a fi xed system on the anaesthetic machine (OR) or a mobile solution on a wheeled stand (ICU, ER). This was a simplifi ed Optifl ow system (Fisher and Paykel, New Zealand) consisting of a high-fl ow rotameter, a reusable humidifi er, a reusable circuit and a disposable nasal interface. Anaesthetists of all grades were encouraged to use THRIVE (60 l/minute) prior to and during all high-risk intubations. Prospective data of pre and post intubation SpO2 and time to intubate were collected. Anaesthetists were interviewed on acceptability of the technique. 1. Patel A, et al. Anaesthesia. 2014 [Epub ahead of print]. Airway hygiene in the ICU: can ipratropium plus salbutamol help? N Magalhaes i Conclusion Despite the possible poor alignment of airway, the fi rst- attempt success rate of VL is similar to that of DL among patients with good glottic visualization. P210 Methods A lung simulator underwent pressure controlled ventilation Conclusion We conclude that THRIVE provides a convenient, safe and easy to implement technique for pre-oxygenation and apnoeic oxygenation during laryngoscopy. y p g Methods A lung simulator underwent pressure-controlled ventilation (Pinsp = 25 cmH2O; PEEP = 5 cmH2O; Vt = 500 ml) for 24 hours for seven P209 The primary exposure was use of VL. Potential confounders of success rate examined were age, sex, primary indication of intubation, methods of intubation, and operator level of training and specialty. Among patients with good glottic visualization, we conducted a multivariable logistic regression adjusted for potential confounders. Comparison of video laryngoscopy with direct laryngoscopy in patients with good glottic visualization: an observational study of 348 emergency intubations g y Y Kato, H Okamoto, H Uchino, T Fukuoka Kurashiki Central Hospital, Kurashiki Okayama, Japan Critical Care 2015, 19(Suppl 1):P207 (doi: 10.1186/cc14287) g y Y Kato, H Okamoto, H Uchino, T Fukuoka Introduction Video laryngoscopy (VL) is known to improve glottic visualization and the fi rst-attempt success rate compared with direct laryngoscopy (DL) in emergency tracheal intubations (ETIs). Since VL does not align the oral, pharyngeal, and laryngeal axes of the upper airway, it sometimes leads to failed intubation despite good glottic visualization. We tested the hypothesis that VL has a lower fi rst- attempt success rate of ETI than DL among patients with good glottic visualization. Methods We performed a prospective observational study examining ETIs at our tertiary care institution from July 2012 to June 2014. All consecutive patients who underwent ETIs in the emergency department and ICU were included. Patients under 18 years of age, intubated with VL not using C-MAC, were excluded. After each ETI eff ort, the operator completed a standardized data collection form. We classifi ed glottic visualization as good (C-L grade 1 or 2), and poor (C-L grade 3 or 4). The primary outcome was the fi rst-attempt success rate. Conclusion Marked variation was seen in the type and aetiology of airway emergencies admitted to the ICU. A broad training programme is thus required to off er wide-ranging awareness of potential problems, communication (including an emergency airway plan), and acute management. S72 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P211 P211 Endobronchial streptokinase for airway thrombus: a case series D Lloyd, J Bomford, M Barry, W Berry, N Barrett, L Camporota, N Ioannou, B Lams, C Langrish, C Meadows, A Retter, D Wyncoll, G Glover Guys and St Thomas’ NHS Trust, London, UK Critical Care 2015, 19(Suppl 1):P211 (doi: 10.1186/cc14291) Introduction Pulmonary haemorrhage (PH) is common in patients receiving mechanical ventilation and especially during ECMO, due to severe lung pathology and systemic anticoagulation. Whilst PH manifests as worsening ventilation and gas exchange, in ECMO patients who already have low tidal volume and who do not rely on pulmonary gas exchange, deterioration may not be evident until extensive airway thrombus (AT) has developed. Management of AT is challenging, with lavage, suctioning, mechanical disruption and extraction of limited effi cacy in severe cases. Limited reports suggest that topical thrombolytics may have a role in the management of AT [1]. We report the safety and effi cacy of endobronchial streptokinase (EBSK) in patients with extensive AT. Results Control group: 100 patients who received standard intubation and treatment in 2009 to 2010. Of these, four dropped out due screening failure of pneumonia on the day of enrollment. Study group: in 2011 to 2014, 192 patients were screened. Of these, 49 were found eligible and were enrolled. Of these, 14 dropped out (four screening failures with pneumonia on day of enrollment and 10 withdrawals with MV of less than 24 hours). Mean age was 51 (control) and 49 (study). Males were 75% of both groups and mean weight was 81 kg in both. VAP was diagnosed in 26 (27%) of controls and only three (8.5%) of the study group (P = 0.03). Mean time from admission to VAP diagnosis was 4.7 days in controls versus 5.12 in the study group (NS). No serious adverse events occurred. Methods A retrospective case series in a UK ECMO centre. Patients who received EBSK between 2010 and 2014 were identifi ed from pharmacy records. Conclusion Patients connected to the AnapnoGuard system demonstrated a statistically signifi cant lower VAP rate compared with the control group (8.5% vs. 27% respectively, P = 0.03). The estimated relative risk of VAP occurring in the control group was more than three times higher than the study group. Rinsing and aspiration of subglottic secretions combined with cuff pressure and seal management may be an eff ective method to prevent VAP. P211 Results Five patients were identifi ed, 80% were male. Median age was 40 years, APACHE II score 36.5 and Murray score 3.75. Four were on ECMO with systemic heparin. All had ARDS secondary to lung infections (community-acquired pneumonia (two), lung abscess (one), TB (one) and PJP (one)). All had extensive AT, diagnosed on bronchoscopy, causing occlusion of the trachea or major bronchi, refractory to physiotherapy, lavage, suctioning ± rigid bronchoscopy. Patients received up to three administrations of EBSK, 1,000 u/ml in saline 0.9% under bronchoscopic guidance. Dose per administration was 30,000 to 80,000 u and total dose was 30,000 to 150,000 u (375 to 1,500 u/kg), with interval bronchoscopy after several hours for lavage and suctioning of lysed clot. In all cases EBSK was well tolerated with no immediate complications and no clinically signifi cant change in systemic laboratory coagulation parameters at 12 or 24 hours compared with pretreatment baseline. In all cases, signifi cant clearance of airway thrombus was achieved. Median tidal volume increased from 60 ml pre treatment to 170 ml at 24 hours. Median PaO2 during the ‘FiO2 1.0 test’ improved from 9.0 to 17.6 kPa at 24 hours. No major bleeding, intracerebral haemorrhage or ECMO cannulae bleeding was seen up to 7 days post treatment.i P213 Risk factors for bleeding complications after percutaneous dilatational tracheostomy: a 10-year institutional analysis K Pilarczyk1, G Marggraf1, M Dudasova1, E Demircioglu1, D Wendt1, B Huschens2, H Jakob1, F Dusse1 1West German Heart Center Essen, University Hospital Essen, Germany; 2University Hospital Essen, Germany Critical Care 2015, 19(Suppl 1):P213 (doi: 10.1186/cc14293) Introduction Percutaneous dilatational tracheotomy (PDT) is the standard airway access in critically ill patients who require prolonged mechanical ventilation. Bleeding complications after PDT are infrequently observed but have a tremendous impact on further clinical course CFA risk stratifi cation for patients scheduled for PDT. Introduction Percutaneous dilatational tracheotomy (PDT) is the standard airway access in critically ill patients who require prolonged mechanical ventilation. Bleeding complications after PDT are infrequently observed but have a tremendous impact on further clinical course CFA risk stratifi cation for patients scheduled for PDT. Conclusion In this series, the largest reported to date, and the fi rst on ECMO, EBSK was highly eff ective in achieving clearance of AT with subsequent improvements in pulmonary mechanics and gas exchange. No major disturbance of systemic coagulation parameters or major haemorrhagic complications occurred. P212 test periods for each group (n = 24). A HME (Filta-Therm; Intersurgical, Berkshire, UK) was placed between the breathing circuit and catheter mount or the HH (MR850; Fisher & Paykel, Auckland, New Zealand) was used, or both in combination. Circuit manipulation was performed 4-hourly to simulate patient movement. Hourly Vt was recorded to determine airway occlusion. Critical airway occlusion (defi ned as a drop on the TV to <50 ml) was assessed using a Fisher’s exact test. 1. Keane et al. Chest. 1999;115:293-300. P211 The use of EBSK may be considered for refractory AT. Methods We retrospectively reviewed the records of all patients who underwent PDT (using the Ciaglia technique with bronchoscopic guidance) on our cardiothoracic ICU between 2003 and 2013. Patients were stratifi ed into two groups: patients suff ering from acute moderate, severe or major bleeding (Group A) and patients who presented none or only mild bleeding (Group B). y Reference S73 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Reduction of ventilator-associated pneumonia using the AnapnoGuard system Reduction of ventilator-associated pneumonia using the AnapnoGuard system p y Y Bar-Lavie Rambam Medical Center, Haifa, Israel Critical Care 2015, 19(Suppl 1):P212 (doi: 10.1186/cc14292) Introduction Ventilator-associated pneumonia (VAP) is a common complication in mechanically ventilated patients. Frequently the pathogens responsible derive from aspirated secretions of the upper respiratory tract or the stomach. In order to prevent aspiration, two missions should be attained: a good tracheal cuff seal with a well- tolerated pressure, together with continuous evacuation of secretions from the subglottic space. These two goals can be achieved using the AnapnoGuard system and its related endotracheal tube (ETT). Results In all seven of the breathing circuits in group 4 (both a HME and a HH in combination), critical airway occlusion occurred suddenly between 19 and23 hours. No episodes occurred in the other three groups (P <0.0001). g p Conclusion The combination of the use of HME and HH within a single ICU risks inadvertent dual use in a single patient and if uncorrected this is likely to result in a ventilator circuit obstruction. Medical errors can be mitigated by consideration of human factors and system engineering to improve patient safety. A focus on clinical awareness and training may lead to improvements; however, the numbers, experience and turnover of critical care staffi ng would indicate that a systems approach is appropriate and either HME or HH should be used exclusively in an ICU. y Methods A single-center, open-label study in a general ICU. Control group: (retrospective data) mechanically ventilated patients on standard of care regular ETT, manual suction of the trachea and oral– pharyngeal space by nursing staff . Study group: (prospective data) connected at all times to the AnapnoGuard system: an ETT with two above-the-cuff suction ports and a third port and lumen for rinsing and CO2 measurement. A triple lumen harness is connected to a control system designed to measure CO2 levels above the cuff (to identify leaks), infl ate the cuff accordingly, rinse and suction secretions above the cuff . To be included in the study patients had to have no pneumonia on admission and at least 3 days of mechanical ventilation. VAP was diagnosed for a new chest X-ray infi ltrate accompanied by fever, leucocytosis and positive sputum culture. The study was approved by the hospital IRB. Reference Study groups showed signifi cant diff erences in Simplifi ed Acute Physiology Score (SAPS) on the day of PDT (Group A: 47.0 ± 13.1, Group B: 32.9 ± 11.2, P = 0.042), renal replacement therapy on the day of PDT (Group A: 53 (60.2%), Group B: 439 (48.1%), P = 0.026), presence of coagulopathy (Group A: 48 (54.5%), Group B: 393 (43.0%), P = 0.043), platelet count (Group A: 91.6 ± 59.2, Group B: 111.5 ± 79.8 × 1,000/μl, P = 0.037), fi brinogen levels (Group A: 373.6 ± 159.1, Group B: 450.6 ± 259.0 mg/dl, P = 0.012), proportion of PDTs performed by residents (Group A: 72 (81.8%), Group B: 632 (69.2%), P = 0.034) and moderately to very diffi cult PDT (Group A: 31 (35.2%), Group B: 141 (15.4%), P = 0.001). Using logistic regression analyses, diffi cult PDT, low-experienced operator, SAPS >40 and low fi brinogen were independent predictors of relevant bleedings after PDT. Methods The study was conducted in a Danish eight-bed, non- university ICU. Since 2007, all patients admitted to the ICU have been registered on an electronic patient record system, in which daily vital values, diagnoses, procedures and healthcare providers’ notes are entered. When searching for ‘percutaneous dilatation tracheostomy’ in the electronic system, we found all patients who had undergone this specifi c procedure. Afterwards we analyzed each of these patients’ hospital records, looking for any periprocedure or postprocedure complications noted within 7 days. In addition we registered patients’ age, sex, BMI, SOFA score, methods used in procedures and experience of operators. p Results A total of 136 patients admitted to the UCI had undergone a PDT between 2007 and 2014. Of these, two were excluded due to the PDT being performed in another hospital before admission to our ICU. All 134 PDTs were performed with the Ciaglia Blue Rhino Method. No PDTs were performed with bronchoscopic guidance. In 12 cases some kind of complication due to the PDT was registered: six cases with need of surgical hemostasis, three cases of bleeding with need of transfusion of blood products, one case of PDT displacement, one case of ventilation-related problems during procedure and, fi nally, one case of tracheal cartilage fracture. There were no incidents of pneumothorax. No PDTs had a lethal outcome due to the procedure itself. The total complication rate was 9.0%. Reference Results A total of 1,001 patients (46% male, mean age 68.1 years) that underwent PDT were analyzed. In the majority of patients, no or S74 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 of PDT are described in the literature, each with disadvantages and benefi ts. The aim of this study was to analyze complications due to PDTs performed without the use of bronchoscopic assistance. only mild bleeding during PDT occurred (none: 425 (42.5%), mild: 488 (48.8%)). In 84 patients (8.4%), bleeding was classifi ed as moderate. Three patients suff ered from severe bleeding, only one major bleeding with need for emergency surgery was observed. Study groups showed signifi cant diff erences in Simplifi ed Acute Physiology Score (SAPS) on the day of PDT (Group A: 47.0 ± 13.1, Group B: 32.9 ± 11.2, P = 0.042), renal replacement therapy on the day of PDT (Group A: 53 (60.2%), Group B: 439 (48.1%), P = 0.026), presence of coagulopathy (Group A: 48 (54.5%), Group B: 393 (43.0%), P = 0.043), platelet count (Group A: 91.6 ± 59.2, Group B: 111.5 ± 79.8 × 1,000/μl, P = 0.037), fi brinogen levels (Group A: 373.6 ± 159.1, Group B: 450.6 ± 259.0 mg/dl, P = 0.012), proportion of PDTs performed by residents (Group A: 72 (81.8%), Group B: 632 (69.2%), P = 0.034) and moderately to very diffi cult PDT (Group A: 31 (35.2%), Group B: 141 (15.4%), P = 0.001). Using logistic regression analyses, diffi cult PDT, low-experienced operator, SAPS >40 and low fi brinogen were independent predictors of relevant bleedings after PDT. only mild bleeding during PDT occurred (none: 425 (42.5%), mild: 488 (48.8%)). In 84 patients (8.4%), bleeding was classifi ed as moderate. Three patients suff ered from severe bleeding, only one major bleeding with need for emergency surgery was observed. Percutaneous dilatational tracheostomy: complications and safety without the use of bronchoscopic guidance Sygehus Lillebælt, Vejle, Denmark Sygehus Lillebælt, Vejle, Denmark yg j Critical Care 2015, 19(Suppl 1):P214 (doi: 10.1186/cc14294) Reference Of the 12 cases, four (33%) complications occurred during the procedure, the rest (66%) occurred after the procedure. The overall periprocedure complication rate was 3%. Conclusion In this study, PDTs without the use of bronchoscopic guidance were performed safely with a low rate of complications. Conclusion Periprocedural bleeding complications during PDT are rare. However, low fi brinogen levels as well as diffi cult PDT, low-experienced operator and SAPS >40 are associated with an increased risk for bleeding complications. Therefore, preprocedural risk evaluation for bleeding complications should include these factors and further studies are necessary to prove whether modifi cation of risk factors – for example, substitution of fi brinogen prior to PDT – is able to reduce incidence of bleeding complications. P215 Introduction Since the introduction and development of percu- taneous dilatational tracheostomy (PDT), this procedure is accepted and incorporated in ICUs worldwide. In spite of obvious benefi ts for the patients, who obtain more comfort and mobility and less use of sedatives, the procedure also implies the risk of several complications, some of which may be lethal. Severe complications include hemorrhage, displacement and pneumothorax. Diff erent methods P216 Impact of antibiotic therapy during a bedside percutaneous tracheotomy procedure in an ICU E Brotfain1, A Borer1, L Koyfman1, A Frenkel1, S Gruenbaum2, A Smolikov1, A Zlotnik1, M Klein1 1Ben Gurion University of The Negev, Soroka Medical Center, Beer Sheva, Israel; 2Yale University School of Medicine, New Haven, CT, USA Critical Care 2015, 19(Suppl 1):P216 (doi: 10.1186/cc14296) Results In total 12,839 records of patients discharged from the ICU were analyzed. Tracheostomy was present in 133 patients. Two groups were defi ned: (1) TCU (n = 56) and (2) GW (n = 77). Patients of the TCU group were older (60.1 ± 13.1 vs. 54.9 ± 15.8 years; P <0.05) with higher APACHE II score (23 (CI: 21.5 to 25.6) vs. 18.5 (CI: 17.1 to 19.9); P <0.001), and had longer stay in the ICU (45.8 (CI: 38.2 to 53.3) vs. 28.4 (CI: 24.2 to 32.6) days; P <0.001) and on the ward (71.1 (CI: 57.4 to 84.8) vs. 46.1 (CI: 33.7 to 58.2) days; P <0.001) than those of the GW group. The GW group had category 1 of Sabadell score more frequently than the TCU group (25.9% vs. 8.9%; P = 0.019). Rates of nosocomial infections were similar in both groups. No signifi cant diff erences on vasoactive use (50% vs. 40.2%), renal failure (23.2% vs. 20.7%), blood transfusions (25% vs. 23.2%), parenteral nutrition (10.7% vs. 12.9%), in-hospital deaths (14.3% vs. 24.6%), decannulation (55% vs. 50%), or discharge to home (53.6% vs. 37.7%) were found between groups 1 and 2, respectively. Introduction Percutaneous bedside tracheostomy (PBT) is a frequently done procedure in the ICU. PBT is a clean-contaminated procedure, and the duration of the procedure is 15 to 20 minutes depending on the physician’s procedural skills. The rate of infectious complications and effi cacy of perioperative therapy in reducing infections after PBT is currently unknown. Currently there have been no defi nitive recommendations for prophylactic antibiotic therapy before PBT in the ICU. Methods All clinical and microbiological data were retrospectively collected and analyzed during the ICU stay before PBT performance and 72 hours after the PBT procedure from 110 patients in our ICU. Controls were defi ned as patients in whom the PBT procedure was performed in the ICU, with antibiotics administered 72 hours prior to and during the procedure (Group 1, n = 82). P216 Cases were defi ned as patients in whom the PBT procedure was performed in the ICU without antibiotics administered 72 hours prior to and during the procedure (Group 2, n = 28). Secondary bacteremia, line sepsis and VAP during the 72 hours after PBT were considered infectious complications. Two- tailed P <0.05 was considered to be signifi cant.f Conclusion In our setting the TCU helps to care more safely for severe tracheostomized patients after ICU discharge, and furthermore facilitates discharge home. References 1. Martinez GH, et al: Respir Care. 2009;54:1644-52. 1. Martinez GH, et al: Respir Care. 2009;54:1644-52. 2. Fernandez R, et al: Crit Care Med. 2011;39:2240-5. 2. Fernandez R, et al: Crit Care Med. 2011;39:2240-5. i Results No diff erences were found in age, gender, admission diagnoses, length of ICU stay and in-hospital mortality rate between the two study groups. Overall Gram-negative, Gram-positive and fungal fl ora were Reference Reference Methods We retrospectively reviewed medical records of ICU adults patients who had TQ when discharged to a new TCU and to a GW. The study was carried out in two tertiary care university hospitals from January 2007 to November 2014. Study variables were age, sex, APACHE II score, principal diagnosis, associated major procedures, length of stay in ICU and out in hospital, TCU and GW, Sabadell score, in-hospital mortality, types of tracheotomy procedure, decision to decannulate and discharge to home or long-care facilities. 1. Kollig E, et al. Injury. 2000;31:663-8. 1. Kollig E, et al. Injury. 2000;31:663-8. 1. Kollig E, et al. Injury. 2000;31:663-8. Decision-making algorithm for TS in the ICU Second University of Naples, Italy Critical Care 2015, 19(Suppl 1):P215 (doi: 10.1186/cc14295) Introduction Nowadays more percutaneous dilatational tracheostomy (PDT) methods are in use, but there is no ideal risk-free technique. We Figure 1 (abstract P215). Figure 1 (abstract P215). Figure 1 (abstract P215). S75 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 similar in both groups before and after PBT. Patients who received antibiotic therapy had a lower incidence of new ventilator-associated pneumonia (VAP) episodes (15/82 (18.2%) in Group 1 vs. 14/28 (50%) in Group 2, P <0.001 (0.23, 0.87 to 0.13)) (Table 1). There were no diff erences in the incidence of bacteremia or line sepsis (Table 1). Conclusion Our fi ndings highlight the importance of conducting a prospective randomized control trial to better understand the role of antibiotic prophylaxis in PBT. have outlined a decisional algorithm to choose the most appropriate technique in each case to reduce the incidence of complications. have outlined a decisional algorithm to choose the most appropriate technique in each case to reduce the incidence of complications. Methods A retrospective review was performed using data from the last 14 years. Two hundred patients were selected. Patients were divided into two groups: one including the fi rst 100 PDTs treated without the algorithm (nA-group) and the other including the last 100 patients treated with the algorithm (A-group). Valuation of clinical and anatomical features of the patients, neck ultrasound and fi brobronchoscopy came before the procedure [1]. The algorithm was formulated by our experience with PDT techniques, comparing the specifi c characteristics of each one with the physiopathological characteristics of each patient. Conclusion Our fi ndings highlight the importance of conducting a prospective randomized control trial to better understand the role of antibiotic prophylaxis in PBT. P217 P217 Outcomes of patients with tracheostomy discharged from ICU to Transitional Care Unit and general wards J Rubio1, JA Rubio2, E Palma2, R Sierra1, F Carmona1, F Fuentes2 1Hospital Universitario Puerta del Mar, Cadiz, Spain; 2Hospital Infanta Cristina, Badajoz, Spain Critical Care 2015, 19(Suppl 1):P217 (doi: 10.1186/cc14297) Outcomes of patients with tracheostomy discharged from ICU to Transitional Care Unit and general wards Outcomes of patients with tracheostomy discharged from ICU to Transitional Care Unit and general wards Results We recorded complications (bleeding, tracheoesophageal fi stula, subglottic stenosis, tracheal rings’ fracture, diffi culty of placement, change of procedure) related to PDTs performed with and without applying the algorithm. We considered complications that occurred in our experience and we changed our modality in technique choice (Figure 1). Compared with the complications reported in the nA-group, use of the algorithm as a guide to choose the kind of PDT technique seems to reduce the incidence of complications (37% vs. 19%; P = 0.001 chi-square test). Introduction Patients with a tracheostomy (TQ) tube in place discharged from the ICU to a general ward (GW) are a fragile group and the TQ may be a risk factor for morbidity and mortality [1,2]. For this reason they need closer monitoring and more airway care. The Transitional Care Unit (TCU) assists patients with serious medical conditions and bridges the gap between the ICU and home or long-term care facilities providing the necessary medical, nursing, psychological and rehabilitative care. The purpose of this study was to evaluate the impact of the TCU on outcomes of tracheostomized patients discharged from the ICU. Conclusion In our experience the application of the proposed algorithm may reduce the incidence of complications related to PDT in the ICU. However, a randomized controlled multicenter study would be necessary in order to confi rm the effi ciency and validity of the proposed algorithm. P218 Rapid amelioration of respiratory parameters in severely obese patients after percutaneous dilatational tracheotomy S Kaese, M Zander, J Waltenberger, P Lebiedz University Hospital of Muenster, Münster, Germany Critical Care 2015, 19(Suppl 1):P218 (doi: 10.1186/cc14298) Rapid amelioration of respiratory parameters in severely obese patients after percutaneous dilatational tracheotomy S Kaese, M Zander, J Waltenberger, P Lebiedz University Hospital of Muenster, Münster, Germany Critical Care 2015, 19(Suppl 1):P218 (doi: 10.1186/cc14298) Table 1 (abstract P216). Clinical data of new infections 72 hours after the PBT procedure Infection Group 1 Group 2 P value OR Bacteremia 21/82(25.6%) 11/28(39.3%) 0.149 Colonization 67/82(82.7%) 23/28(82.1%) 0.718 Line sepsis 10/82 (12%) 4/28 (14.3%) 0.39 New VAP (%) 15/82(18.2%) 14/28 (50%) 0.001 Table 1 (abstract P216). Clinical data of new infections 72 hours after the PBT procedure Table 1 (abstract P216). Clinical data of new infections 72 hours after the PBT d Introduction Incidence of obesity in developed countries is rising. Currently, Europe has a prevalence of 9 to 30% with signifi cant impact on public health systems. Obese patients in the ICU require special management and treatment. Altered anatomy in obese patients complicates procedures such as mechanical ventilation. Obesity aff ects cardiopulmonary physiology and requires elevated ventilation pressures. In our retrospective study, we determined the eff ect of early S76 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion There is a clear reduction in the need for unplanned IPPV in both patient groups. An audit in 2013 showed incomplete protocol adherence in the ITU, therefore benefi ts may be underestimated. Conclusion There is a clear reduction in the need for unplanned IPPV in both patient groups. An audit in 2013 showed incomplete protocol adherence in the ITU, therefore benefi ts may be underestimated. percutaneous dilatational tracheotomy (PDT) and cessation of sedation on respiratory parameters in severely obese patients. percutaneous dilatational tracheotomy (PDT) and cessation of sedation on respiratory parameters in severely obese patients. p y p y p Methods From June 2010 to July 2014, we included all patients with a body weight of >130 kg, respiratory failure and PDT who were admitted to the ICU of the University Hospital of Muenster. We compared respirator parameters and blood gas analysis before and after PDT. Parameters were recorded on days –1, 0, 1, 3, 5, and 10, with day 0 describing the day of PDT. P220 P220 Is the gastric tube a burden for noninvasive ventilation? I Minev, C Stefanov University Hospital ‘St. Early postoperative use of CPAP reduces need for unplanned IPPV in elective vascular patients H K d J N i J S id l Early postoperative use of CPAP reduces need for unplanned IPPV in elective vascular patients H Kennedy, J Navein, J Seidel Doncaster Royal Infi rmary, Sheffi eld, UK Critical Care 2015, 19(Suppl 1):P219 (doi: 10.1186/cc14299) H Kennedy, J Navein, J Seidelifi y Doncaster Royal Infi rmary, Sheffi eld, UK Methods In this study, six of the COPD patients admitted to our ICU, who required NGT placement, were ventilated with the Draeger Evita 2 dura through a modifi ed reusable silicone face mask (UMDNS code: 12-453 with 22 mm ID connection; sizes 4 and 5) with silicone headgear and a hook ring. All of them had a NGT during their stay in the ICU. We evaluated the effi cacy of our modifi cation comparing the achieved Vt with modifi ed and unmodifi ed face mask, during two periods of 10 minutes. The mode and parameters of ventilation were not changed. We assessed patient comfort with a visual analogue scale. Introduction Respiratory failure is a well-known complication of aortic aneurysm surgery. We describe the impact of a protocol, using CPAP after elective surgery to reduce the need for unplanned invasive ventilation. Methods In 2012 we introduced a CPAP protocol for patients undergoing elective aortic aneurysm surgery, either open (AAA) or as an endovascular repair (EVAR). According to pre-existing risk factors (see Table 1) and arterial blood gas analysis in the anaesthetic room, they were assigned to two alternative options on the ITU: prophylactic CPAP for 9 hours in each of the fi rst two postoperative nights or oxygen via face mask. CPAP was applied at any time in the patients stay, if their P/F ratio dropped below 40. Criteria to stop CPAP were also predefi ned. Previously, CPAP was initiated at the discretion of nursing staff , P/F ratios were not utilised. p g Results The average duration of NIV was 3.5 days (SD = 1.6). We examined two sets of 10 consequent breathing cycles for every patient. The mean Vt was 472 ml (SD = 76 ml) with standard face mask and 460 ml (SD = 86 ml) with the modifi ed one. There was statistically signifi cant correlation between the two datasets (P <0.05). No additional leaks were detected. According to the VAS evaluation, fi ve of the patients (83%) had comfort improvement with the modifi ed mask. Table 1 (abstract P219). Criteria for the use of prophylactic CPAP FEV1: <1.5 l/minute Poor exercise tolerance (<100 yards) due to chest problems Poor exercise tolerance (<100 yards) due to chest problems SpO2 <92% on FiO2 >0.4 in theatre SpO2 <92% on FiO2 >0.4 in theatre Early postoperative use of CPAP reduces need for unplanned IPPV in elective vascular patients H K d J N i J S id l Conclusion With this modifi cation of the face mask we achieved adequate drainage of the stomach and/or the enteral nutrition of the patients and improvement in their comfort during NIV, compared with the ventilation with a standard mask, without additional air leaks and at a low cost. Table 1 (abstract P219). Criteria for the use of prophylactic CPAP P218 Rapid amelioration of respiratory parameters in severely obese patients after percutaneous dilatational tracheotomy S Kaese, M Zander, J Waltenberger, P Lebiedz University Hospital of Muenster, Münster, Germany Critical Care 2015, 19(Suppl 1):P218 (doi: 10.1186/cc14298) George’, Plovdiv, Bulgaria Critical Care 2015, 19(Suppl 1):P220 (doi: 10.1186/cc14300) y g y Results Twenty-one patients were included in the study. Mean age was 56 ± 10.3 years and 14 (66.7%) of the patients were male. Body weight was 164.5 ± 39.4 kg, body height accounted for 176.8 ± 8.7 cm (n = 20) and body mass index was 49.7 ± 16.9 kg/m2. Patients stayed in the ICU for 18.4 ± 13.8 days. Mean time of mechanical ventilation by endotracheal tube was 2.4 ± 1.5 days (n = 20) and via tracheostomy 9.8 ± 7.0 days. After PDT, peak inspiratory pressure (P <0.0001), positive end-expiratory pressure (P <0.0001) and insuffl ated oxygen concentration (P <0.0001) could signifi cantly and rapidly be reduced. Respiratory minute volume increased signifi cantly (P = 0.004). PDT was not associated with relevant complications. Introduction The application of noninvasive ventilation (NIV) in ICUs has spread widely during the years. It is used in the treatment of diff erent forms of acute respiratory failure and COPD exacerbations. Although NIV is thought to be more comfortable for patients than invasive mechanical ventilation, its failure rates in the ICUs range between 10 and 40%. Except for the interface-related problems, there are some specifi c considerations for the patient–ventilator interaction and the applied mechanical forces. During NIV there is a predisposition for the stomach to be infl ated with gas, which could cause severe respiratory complications, especially in COPD patients, and thus prolong the mechanical ventilation and the weaning process. This remains one of the major causes for NIV failure. Although a lot of face masks with diff erent interfaces are available on the market, just a few have additional ports for a NGT. They are characterized by higher price and a complex setup. In order to perform NIV in patients, requiring NGT placement, without additional air leaks and to be able to ensure their enteral nutrition and/or stomach drainage, we installed a port for a NGT on a standard face mask. Conclusion Early PDT rapidly improves respiratory distress in severely obese patients due enabling of spontaneous breathing and reduction of dead space ventilation. Lung ultrasound aeration assessment: comparison of two techniques S Mongodi1, F Mojoli1, A Stella1, I Godi1, G Via1, G Tavazzi1, A Orlando1, B Bouhemad2 S Mongodi1, F Mojoli1, A Stella1, I Godi1, G Via1, G Tavazzi1, A Orlando1, B Bouhemad2 S Mongodi1, F Mojoli1, A Stella1, I Godi1, G Via1, G Tavazzi1, A Orlando1, B Bouhemad2 1Fondazione IRCCS Policlinico S. Matteo Hospital – University of Pavia, Italy; 2Centre Hospitalier Universitaire Dijon, France Critical Care 2015, 19(Suppl 1):P222 (doi: 10.1186/cc14302) 1Fondazione IRCCS Policlinico S. Matteo Hospital – University of Pavia, Italy; 2Centre Hospitalier Universitaire Dijon, France 1Fondazione IRCCS Policlinico S. Matteo Hospital – University of Pavia, Italy; 2Centre Hospitalier Universitaire Dijon, France Critical Care 2015, 19(Suppl 1):P222 (doi: 10.1186/cc14302) Critical Care 2015, 19(Suppl 1):P222 (doi: 10.1186/cc14302) p p Methods The authors prospectively enrolled 17 patients with septic shock who were admitted to the medical ICU, Phramongkutklao Hospital between September 2013 and June 2014. EVLWI was measured by TPTD (VolumeView Set, EV1000; Edwards Lifesciences) method. According to international evidence-based recommendations for point-of-care lung ultrasound 2012, three methods of LUS (LOGIQ e ultrasound; GE Healthcare) were compared to assess EVLW daily in each patient until no indication for invasive blood pressure monitoring [1]. Firstly, B-lines were measured in 28 lung zones. The total numbers of B-lines seen in each patient were counted as total B-line scores (TBS). Secondly, upper and lower BLUE points were anterior two-region scans each side marked by physician hands. Pulmonary edema was diagnosed if three or more B-lines were presented in all regions. Lastly, scanning eight regions, two anterior and two laterals per side, was considered abnormal if more than one scan per side had three or more B-lines.i Introduction Lung ultrasound (LUS) allows semiquantifi cation of lung aeration in PEEP trials [1], pneumonia [2] and weaning [3]. LUS score is based on number/coalescence of vertical artifacts (B-lines) in longitudinal scan (LONG) [4]: the pleura is identifi ed between two ribs and its visualization limited by intercostal space (ICS) width. We hypothesized that a transversal scan (TRANSV) aligned with ICS would visualize longer pleura and a higher number of artifacts, with better assessment of loss of aeration (LoA). Methods LONG and TRANSV were performed in six areas per lung (anterior, lateral and posterior, each divided into superior and inferior). Once LONG was performed, TRANSV was obtained by a probe rotation until the ribs disappeared. We considered pleural length, B-line number/coalescence, and subpleural/lobar consolidations. P221 P221 Lung ultrasonography as a marker of pulmonary edema in cardiac surgery patients: visual versus quantitative evaluation F Corradi1, C Brusasco2, T Manca3, F Nicolini3, F Nicosia1, T Gherli3, V Brusasco2, A Vezzani3 1Ente Ospedaliero Ospedali Galliera Genova, Italy; 2Università degli Studi di Genova, Italy; 3Azienda Ospedaliero-Universitaria di Parma, Italy Critical Care 2015, 19(Suppl 1):P221 (doi: 10.1186/cc14301) Results We compare patient cohorts in the years 2010 and 2011 (pre protocol) with 2013 and 2014 (post protocol). Results are reported as the split between open surgery and endovascular repair. Table 2 presents requirements for invasive ventilation (IPPV) and length of stay (LOS) for both patient groups. Table 2 (abstract P219). IPPV requirements and length of stay data Table 2 (abstract P219). IPPV requirements and length of stay data 2010 to 2011 2013 to 2014 LOS LOS LOS LOS ITU hospital ITU hospital IPPV (days) (days) IPPV (days) (days) EVAR 2/67 (3%) 2 6 1/77 (1.3%) 2 5 AAA 10/46 (21.7%) 5 9 6/37 (16.2%) 5 12 Introduction Lung ultrasonography (LUS) has been used for non- invasive detection of pulmonary edema. LUS visual scores (V-LUS) based on B-lines are poorly correlated with either pulmonary capillary wedge pressure (PCWP) or extravascular lung water (EVLW). A new quantitative LUS analysis (Q-LUS) has been recently proposed [1,2]. The aim of the study was to investigate whether Q-LUS is better correlated with PCWP and EVLW than V-LUS, and to what extent positive end- expiratory pressure (PEEP) aff ects the assessment of pulmonary edema by Q-LUS and V-LUS. S77 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods Thirty-nine patients mechanically ventilated with PEEP of 5 cmH2O (n = 47) or 10 cmH2O (n = 30) and PCWP (n = 77) or EVLW (n = 38) monitored were studied.i Methods Thirty-nine patients mechanically ventilated with PEEP of 5 cmH2O (n = 47) or 10 cmH2O (n = 30) and PCWP (n = 77) or EVLW (n = 38) monitored were studied.i versus 3.9 ± 0.1 cm (range 3.0 to 4.3; variance 0.1) (P <0.0001), B-lines per scan were 1.1 ± 1.6 versus 1.8 ± 2.5 (P <0.0001), coalescent B-lines were detected in 24 versus 30% (P <0.05) and subpleural consolidations in 16 versus 22% (P <0.05), respectively. LUS scores’ prevalence signifi cantly diff ered in LONG versus TRANSV (Figure 1). P221 Results PCWP was signifi cantly and strongly correlated with Q-LUS Grey Unit value (r2 = 0.64) but weakly with V-LUS B-line score (r2 = 0.19). EVLW was signifi cantly and strongly correlated with QLUS Grey Unit mean value (r2 = 0.65) more than with V-LUS B-line score (r2 = 0.42). Q-LUS showed a better diagnostic accuracy than V-LUS for the detection of PCWP >15 mmHg or EVLW >10 ml/kg. With a PEEP of 5 cmH2O, the correlations with PCWP or EVLW were stronger with Q-LUS than V-LUS. With a PEEP of 10 cmH2O, the correlations with PCWP or EVLW were still signifi cant for Q-LUS but insignifi cant for V-LUS. Intraobserver repeatability and interobserver reproducibility were much better for Q-LUS than V-LUS. f Conclusion TRANSV visualizes signifi cantly longer pleura and greater number of artifacts useful for lung disease assessment. References f Conclusion TRANSV visualizes signifi cantly longer pleura and greater number of artifacts useful for lung disease assessment. References 1. Bouhemad B, et al. Am J Resp Crit Care Med. 2011;183:341-7. 2. Bouhemad B, et al. Crit Care Med. 2010;38:84-92. 3. Soummer A. et al. Crit Care Med. 2012;40:264-72. 4. Volpicelli G. et al. Int Care Med. 2012;38:577-91. Lung ultrasound aeration assessment: comparison of two techniques LUS score was assigned: 0 normal lung, 1 moderate LoA (≥3 well-spaced B-lines), 2 severe LoA (coalescent B-lines), 3 complete LoA (tissue-like pattern). Results We enrolled 38 patients (21 males, age 60 ± 16 years, BMI 24.7 ± 4.7 kg/m2) corresponding to 456 ICSs. In 63 ICSs, a tissue-like pattern was visualized in both techniques. In the other 393, LONG versus TRANSV pleural length was 2.0 ± 0.6 cm (range 0.8 to 3.8; variance 0.31) Results A total of 40 comparisons were obtained. Signifi cant positive linear correlations were found between TBS and EVLWI determined by TPTD (r = 0.637, P <0.001). The TBS ≥39 has sensitivity of 91.7% and specifi city of 75.0% to defi ne EVLWI >10 ml/kg. There was low sensitivity (33.3% and 50.0% respectively) but high specifi city (100% and 96.0% respectively) of the positive BLUE points and eight regions to defi ne EVLWI >10 ml/kg. Figure 1 (abstract P222). LUS scores. P <0.01 TRANSV versus LONG. i Conclusion TBS is the best method for assessing EVLW compared with BLUE points and eight regions. These data support the benefi t of LUS with summation of B-line scores of 28 rib interspaces for assessment of the increment of EVLW in septic shock patients. f Reference Reference 1. Volpicelli G, et al. Intensive Care Med. 2012;38:577-91. 1. Volpicelli G, et al. Intensive Care Med. 2012;38:577-91. Ultrasound assessment for extravascular lung water in patients with septic shock Conclusion Both V-LUS and Q-LUS are acceptable indicators of pulmonary edema in patients mechanically ventilated with low PEEP but at high PEEP only Q-LUS provides data that are signifi cantly correlated. Computer-aided Q-LUS has the advantages of being not only independent of operator perception but also of PEEP. References P Pirompanich1, A Wattanathum2 1Thammasat University, Pathumthani, Thailand; 2Phramongkutklao Hospital, Bangkok, Thailand Critical Care 2015, 19(Suppl 1):P223 (doi: 10.1186/cc14303) 1. Corradi F, Ball L, Brusasco C, Riccio AM, Baroffi o M, Bovio G, et al. Assessment of extravascular lung water by quantitative ultrasound and CT in isolated bovine lung. Respir Physiol Neurobiol. 2013;187:244-9. Introduction Extravascular lung water (EVLW) refers to fl uid within the lung but outside the vascular compartment. Increment of EVLW was associated with mortality in critically ill patients. Extravascular lung water index (EVLWI) >10 ml/kg was found in patients with cardiogenic pulmonary edema and correlated with pulmonary capillary wedge pressure >20 mmHg. Measurement of EVLW needs sophisticated tools and an invasive method by transpulmonary thermodilution (TPTD) technique. In contrast, multiple B-lines by lung ultrasound (LUS) have been recently proposed to correlate with increased EVLW in patients with pulmonary edema. This study aims to compare three methods of LUS and EVLWI measured by TPTD to assess pulmonary edema in patients with septic shock. bovine lung. Respir Physiol Neurobiol. 2013;187:244-9. 2. Quanta Imaging Technology. www.quanta.camelotbio.com. Eff ect of lung recruitment on oxygenation in patients with acute lung injury ventilated in CPAP/pressure support mode A Lovas, D Trasy, M Nemeth, I Laszlo, Z Molnar University of Szeged, Hungary Critical Care 2015, 19(Suppl 1):P226 (doi: 10.1186/cc14306) Introduction One of the aims of lung recruitment is to improve oxygenation [1], but it has not yet been investigated in spontaneously breathing patients. Our objective was to evaluate the eff ects of recruitment maneuvers on oxygenation in patients ventilated in CPAP/ pressure support (CPAP/PS) mode. p pp Methods In a prospective, observational study, 30 patients with a Lung Injury Score ≥2 were recruited. Following baseline measurements (t0) PEEP was increased by 5 cmH2O (t1). Recruitment maneuver was applied for 40 seconds with 40 cmH2O PS. Measurements were taken immediately after recruitment (t2) then 15 minutes (t3) and 30 minutes later (t4).f 2 3 4 Results According to the diff erence of PaO2/FiO2 between t2 and t0, three groups were defi ned: nonresponders (NR: diff erence of PaO2/FiO2 ≤0%, n = 8), low responders (LR: diff erence of PaO2/FiO2 = 0 to 50%, n = 11) and high responders (HR: diff erence of PaO2/FiO2 >50%, n = 11). In the NR-group, PaO2/FiO2 decreased signifi cantly: median (interquartile), PaO2/FiO2 = 178 (159 to 240) versus 165 (118 to 210) mmHg; in the LR- group and in the HR-group there was signifi cant improvement: 119 (98 to 164) versus 161 (123 to 182) mmHg and 141 (130 to 183) versus 239 (224 to 369) mmHg, P <0.05, respectively. Dynamic compliance (Cdyn) signifi cantly dropped at t2 as compared with t0 in the NR-group, Cdyn = 62 (48 to 87) versus 53 (43 to 78) ml/cmH2O, while there was no signifi cant change in the LR- and HR-groups, P <0.05. At the same time points the dead space to tidal volume ratio (Vds/Vte) signifi cantly increased in the NR-group, Vds/Vte = 30 (23 to 37) versus 37 (26 to 42)%, but not in the LR- and HR-groups, P <0.05. Figure 1 (abstract P224). Sample ultrasound recording. Lines 1 and 2 are diaphragm thickness measurements. Results We were successfully able to record the diaphragm thickness in all included patients. Median time on the ventilator was 9 days (IQR 4 to 15 days). Mean baseline thickness was 1.9 mm (SD ±0.4 mm), and mean nadir was 1.3 mm (SD ±0.4 mm), corresponding with a mean change in thickness of 32% (SD ±18%). As early as after only 72 hours of MV, we already noted an average drop of diaphragm thickness of 20%, illustrating the rapid progression of the atrophy in VIDD. P226f Eff ect of lung recruitment on oxygenation in patients with acute lung injury ventilated in CPAP/pressure support mode A Lovas, D Trasy, M Nemeth, I Laszlo, Z Molnar University of Szeged, Hungary Critical Care 2015, 19(Suppl 1):P226 (doi: 10.1186/cc14306) References 1. Grosu H, et al. Chest. 2012;142:1455-60. Conclusion Recruitment maneuvers improved PaO2/FiO2 in the majority of patients (73%) without aff ecting Cdyn or Vds/Vte; therefore it may be a safe approach to improve oxygenation in patients ventilated in CPAP/PS mode. 1. Grosu H, et al. Chest. 2012;142:1455-60. 2. McCool F, et al. Am J Resp Crit Care Med. 1997;155:1323-28. 2. McCool F, et al. Am J Resp Crit Care Med. 1997;155:1323-28. 2. McCool F, et al. Am J Resp Crit Care Med. 1997;155:1323-28. Eff ect of lung recruitment on oxygenation in patients with acute lung injury ventilated in CPAP/pressure support mode A Lovas, D Trasy, M Nemeth, I Laszlo, Z Molnar University of Szeged, Hungary Critical Care 2015, 19(Suppl 1):P226 (doi: 10.1186/cc14306) Conclusion On average, diaphragm thickness decreased 32% in our cohort. The decrease occurred rapidly, with two-thirds of the maximal thinning already present after 72 hours of MV. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods Thirty-two spontaneously breathing patients with suspected community-acquired pneumonia undergoing computed tomography examination were consecutively enrolled. Each hemithorax was evaluated for the presence or absence of abnormalities by chest X-ray and quantitative or visual ultrasonography. Methods Thirty-two spontaneously breathing patients with suspected community-acquired pneumonia undergoing computed tomography examination were consecutively enrolled. Each hemithorax was evaluated for the presence or absence of abnormalities by chest X-ray and quantitative or visual ultrasonography. diaphragmatic atrophy can be assessed using ultrasound, the biggest trial in humans published so far included seven patients and only measuring the thickness at two moments during the disease process [1]. We aimed to assess the time course of diaphragm atrophy in a larger cohort of MV patients using ultrasound. y Results Quantitative ultrasonography showed higher sensitivity (93%), specifi city (95%), and diagnostic accuracy (94%) than chest X-ray (64%, 80%, and 69%, respectively), or visual ultrasonography (68%, 95%, and 77%, respectively), or their combination (77%, 75%, and 77%, respectively). Methods A total of 54 patients from an adult ICU were included in this prospective single-centre cohort trial. Patients who needed <72 hours of MV or had been recently admitted to an ICU were excluded. Patients were ventilated in a controlled, assisted, and/or hybrid ventilation mode. The thickness of the diaphragm was assessed daily; the fi rst recording was within 24 hours after the start of mechanical ventilation and we continued the measurements until the patients were extubated or tracheotomised. We measured the diaphragm at the zone of apposition, as described by McCool and colleagues [2] using a linear 13 MHz ultrasound probe. Figure 1 shows a sample measurement. y Conclusion Quantitative lung ultrasonography was considerably more accurate than either chest X-ray or visual ultrasonography in the diagnosis of community-acquired pneumonia and it may represent a useful fi rst-line approach for confi rmation of clinical diagnosis in emergency settings. Quantitative ultrasonography for pneumonia F C di1 C B 2 T M 3 F Ni i 1 A V 1. Lachman B. Intensive Care Med. 1992;18:319-21. y F Corradi1, C Brusasco2, T Manca3, F Nicosia1, A Vezzani3, V Brusasco2 1Ente Ospedaliero Ospedali Galliera Genova, Italy; 2Università degli Studi di Genova, Italy; 3Azienda Ospedaliero-Universitaria, Parma, Italy Critical Care 2015, 19(Suppl 1):P225 (doi: 10.1186/cc14305) F Corradi1, C Brusasco2, T Manca3, F Nicosia1, A Vezzani3, V Brusasco2 1Ente Ospedaliero Ospedali Galliera Genova, Italy; 2Università degli Studi di Genova, Italy; 3Azienda Ospedaliero-Universitaria, Parma, Italy Critical Care 2015, 19(Suppl 1):P225 (doi: 10.1186/cc14305) References Figure 1 (abstract P224). Sample ultrasound recording. Lines 1 and 2 are diaphragm thickness measurements. 1. Corradi F, Ball L, Brusasco C, Riccio AM, Baroffi o M, Bovio G, et al. Assessment of extravascular lung water by quantitative ultrasound and CT in isolated bovine lung. Respir Physiol Neurobiol. 2013;187:244-9. 2. Quanta Imaging Technology. www.quanta.camelotbio.com. 1. Corradi F, Ball L, Brusasco C, Riccio AM, Baroffi o M, Bovio G, et al. Assessment of extravascular lung water by quantitative ultrasound and CT in isolated bovine lung. Respir Physiol Neurobiol. 2013;187:244-9. 2. Quanta Imaging Technology. www.quanta.camelotbio.com. 1. Corradi F, Ball L, Brusasco C, Riccio AM, Baroffi o M, Bovio G, et al. Assessment of extravascular lung water by quantitative ultrasound and CT in isolated bovine lung. Respir Physiol Neurobiol. 2013;187:244-9. 1. Corradi F, Ball L, Brusasco C, Riccio AM, Baroffi o M, Bovio G, et al. Assessment of extravascular lung water by quantitative ultrasound and CT in isolated bovine lung. Respir Physiol Neurobiol. 2013;187:244-9. g p y 2. Quanta Imaging Technology. www.quanta.camelotbio.com. A better way to determine sample size to detect changes in length of mechanical ventilation? A better way to determine sample size to detect changes in length of mechanical ventilation? YS Chiew1, C Pretty1, D Redmond1, GM Shaw2, T Desaive3, JG Chase1 1University of Canterbury, Christchurch, New Zealand; 2Christchurch Hospital, Christchurch, New Zealand; 3University of Liege, Belgium Critical Care 2015, 19(Suppl 1):P227 (doi: 10.1186/cc14307) Atrophy of diaphragm muscle visualized with ultrasound in mechanically ventilated patients T Schepens, M Mergeay, W Verbrugghe, P Parizel, M Vercauteren, PG Jorens Antwerp University Hospital, Edegem, Belgium p y p , g , g Critical Care 2015, 19(Suppl 1):P224 (doi: 10.1186/cc14304) Introduction Mechanical ventilation (MV) induces diaphragmatic muscle atrophy and contractile fi bre dysfunction, the so-called ventilator-induced diaphragm dysfunction (VIDD). Although Figure 1 (abstract P222). LUS scores. P <0.01 TRANSV versus LONG. S78 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 A better way to determine s of mechanical ventilation? Introduction Chest-X-ray is recommended for routine use in patients with suspected pneumonia, but its use in emergency settings is limited. In this study, the diagnostic performance of a new method for quantitative analysis of lung ultrasonography was compared with bedside chest X-ray and visual lung ultrasonography for detection of community-acquired pneumonia, using thoracic computed tomography as a gold standard. YS Chiew1, C Pretty1, D Redmond1, GM Shaw2, T Desaive3, JG Chase1 1University of Canterbury, Christchurch, New Zealand; 2Christchurch Hospital, Christchurch, New Zealand; 3University of Liege, Belgium Critical Care 2015, 19(Suppl 1):P227 (doi: 10.1186/cc14307) Introduction Estimation of eff ective sample size (N/arm) is important to ensure power to detect signifi cant treatment eff ects. However, S79 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 monitoring of the eff ect of benzodiazepines on respiratory status in non-intubated patients has been diffi cult, putting patient safety at risk. A non-invasive respiratory volume monitor (RVM) that provides continuous measurement of minute ventilation (MV), tidal volume (TV) and respiratory rate (RR) was used to quantify the eff ects of midazolam on respiratory status in spontaneously breathing patients. traditional parametric sample size estimations depend upon restrictive assumptions that often do not hold in real data. This study estimates N to detect changes in length of mechanical ventilation (LoMV) using Monte-Carlo simulation (MCS) and mechanical ventilation (MV) data to better simulate the cohort. Methods Data from 2,534 MV patients admitted to Christchurch Hospital ICU from 2011 to 2013 were used. N was estimated using MCS to determine a sample size with power of 80%, and compared with the Altman’s nomogram for two patients groups, (1) all patients and (2) targeted patients with 1 <LoMV ≤15 days. MCS allows any range of intervention eff ect to be simulated, where this study tested a 10 and 25% diff erence in LoMV (0.5 to 1.25 days for mean LoMV of 5 days). The simulated LoMV for the intervention group is compared with the LoMV in a control group using the one-sided Wilcoxon rank-sum test, Student t test, and Kolmogorov– Smirnov test to assess central tendency and variation. Methods An impedance-based RVM (ExSpiron; Respiratory Motion Inc., Waltham, MA, USA) was used in 30 patients who received 2 mg midazolam prior to induction of anesthesia and were sedated but spontaneously breathing. A better way to determine s of mechanical ventilation? Further studies are ongoing to quantify hypoventilation after administration of other anesthetic medications. Conclusion Continuous monitoring with RVM provides a valuable depiction of hypoventilation from benzodiazepines, not demonstrated by other methodologies such as pulse oximetry and RR alone. RVM monitoring can help uncover potentially life-threatening hypoventilation in older patients. Further studies are ongoing to quantify hypoventilation after administration of other anesthetic medications. Conclusion Traditional parametric sample size estimation may overestimate the required patients. MCS can estimate eff ective N/arm and evaluate specifi c patient groups objectively, capturing local clinical practice and its impact on LoMV. It is important to consider targeting specifi c patient groups by applying patient selection criteria that can be easily translated into trial design. Conclusion Traditional parametric sample size estimation may overestimate the required patients. MCS can estimate eff ective N/arm and evaluate specifi c patient groups objectively, capturing local clinical practice and its impact on LoMV. It is important to consider targeting specifi c patient groups by applying patient selection criteria that can be easily translated into trial design. A better way to determine s of mechanical ventilation? Eleven of these patients (58 ± 19 years, average BMI 27.7) received midazolam at least 20 minutes prior to induction. Digital RVM data were collected and MV, TV and RR calculated and evaluated from 30-second segments 10 minutes before and after the fi rst dose of midazolam. Ten patients were analyzed as a group and one patient was analyzed separately (due to idiosyncratic reaction). y Results The distribution of LoMV is heavily skewed. Altman’s nomogram assumes a normal distribution and found N >1,000 to detect a 25% LoMV change. Figure 1 panels (1) and (2) show N for 80% power if all patients were included, and panels (3) and (4) for the targeted patient group. Panels (1) and (3) show that it is impossible to achieve 80% power for a 10% intervention eff ect. For 25% eff ect, MSC found N = 400/arm (all patients) and N = 150/arm (targeted cohort). Results Following administration of midazolam, the group MV and TV decreased an average of 19 ± 7% and 16 ± 5%, respectively (mean ± SEM, P <0.01, both) while RR remained essentially unchanged (decrease of 3 ± 8%, P >0.3). In the younger half of the cohort (45 ± 16 years), the decreases in MV and TV were not signifi cant, only 6 ± 3% and 8 ± 5%, respectively. The older half of the cohort (72 ± 8 years) displayed fourfold greater MV and TV decreases (32 ± 11%, P <0.05 and 25 ± 6%, P <0.05), when compared with the younger cohort, P <0.01, Figure 1). Figure 1 (abstract P227). Conclusion Traditional parametric sample size estimation may overestimate the required patients. MCS can estimate eff ective N/arm and evaluate specifi c patient groups objectively, capturing local clinical practice and its impact on LoMV. It is important to consider targeting specifi c patient groups by applying patient selection criteria that can be easily translated into trial design. P228 Non-invasive respiratory volume monitoring for quantifi cation of respiratory depression after benzodiazepine administration G M ll 1 D L dd2 Figure 1 (abstract P227). Figure 1 (abstract P228). Figure 1 (abstract P228). Figure 1 (abstract P227). Conclusion Continuous monitoring with RVM provides a valuable depiction of hypoventilation from benzodiazepines, not demonstrated by other methodologies such as pulse oximetry and RR alone. RVM monitoring can help uncover potentially life-threatening hypoventilation in older patients. P229 P229 Nebulized heparin for patients under mechanical ventilation: a conventional data meta-analysis GJ Glas1, A Serpa Neto2, J Horn1, MJ Schultz1 1Academic Medical Center, Amsterdam, the Netherlands; 2Hospital Israelita Albert Einstein, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P229 (doi: 10.1186/cc14309) Nebulized heparin for patients under mechanical ventilation: a conventional data meta-analysis y GJ Glas1, A Serpa Neto2, J Horn1, MJ Schultz1 1Academic Medical Center, Amsterdam, the Netherlands; 2Hospital Israelita Albert Einstein, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P229 (doi: 10.1186/cc14309) Non-invasive respiratory volume monitoring for quantifi cation of respiratory depression after benzodiazepine administration G Mullen1, D Ladd2 1Vidant Medical Center, Greenville, NC, USA; 2Respiratory Motion, Inc., Waltham, MA, USA Critical Care 2015, 19(Suppl 1):P228 (doi: 10.1186/cc14308) Non-invasive respiratory volume monitoring for quantifi cation of respiratory depression after benzodiazepine administration G Mullen1, D Ladd2 1Vidant Medical Center, Greenville, NC, USA; 2Respiratory Motion, Inc., Waltham, MA, USA Critical Care 2015, 19(Suppl 1):P228 (doi: 10.1186/cc14308) Non-invasive respiratory volume monitoring for quantifi cation of respiratory depression after benzodiazepine administration G Mullen1 D Ladd2 Introduction Mechanical ventilation has the potential to induce pulmonary coagulopathy. Local treatment by nebulization of heparin could be benefi cial in ventilated patients. The aim of this data meta- analysis is to determine the association between nebulization of heparin and outcome of mechanically ventilated critically ill patients. Methods PubMed, Scopus, EMBASE, and Web of Science were searched for relevant articles. Articles were selected if they compared Critical Care 2015, 19(Suppl 1):P228 (doi: 10.1186/cc14308) Introduction Benzodiazepines are used in many of settings to induce sedation, but can cause a reduction in respiratory drive. Objective Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S80 Figure 1 (abstract P229). Eff ect of heparin nebulization on mortality. Figure 1 (abstract P229). Eff ect of heparin nebulization on mortality. nebulization of heparin with standard care. The primary endpoint was overall mortality. Secondary endpoints included occurrence of pneumonia and number of ventilator-free days and alive at day 28.i pulse oximetry with derived heart rate; snoring and nasal airfl ow with nasal pressure transducer and nasal thermistor; rib cage, abdominal motion and body position with abdominal and thoracic belts. American Academy of Sleep Medicine 2014 recommendations were used for the diagnosis of OSA and OHS. Because of the diagnostic diffi culties of hypopnea in hypoxemic patients, we evaluated only the obstructive apnea index (OAI) instead of the apnea hypopnea index (AHI). pulse oximetry with derived heart rate; snoring and nasal airfl ow with nasal pressure transducer and nasal thermistor; rib cage, abdominal motion and body position with abdominal and thoracic belts. American Academy of Sleep Medicine 2014 recommendations were used for the diagnosis of OSA and OHS. Because of the diagnostic diffi culties of hypopnea in hypoxemic patients, we evaluated only the obstructive apnea index (OAI) instead of the apnea hypopnea index (AHI). Results Thirty-one patients with the mean age of 67 ± 9 years were included in the study. Their mean APACHE II score was 16 ± 5 and BMI was 33 ± 9 kg/m2. Admission arterial blood gases were as follows (mean ± SD); pH: 7.33 ± 0.07, PaO2: 74 ± 12 mmHg, PaCO2: 69 ± 11 mmHg, HCO3 –: 31 ± 5, O2Sat%: 92 ± 4. Admission diagnoses of the patients were OHS (36%) and COPD (68%). Mean OAI was 13 ± 6 in patients with OAI >5. Diagnosis of obstructive sleep apnea with respiratory polygraph in hypercapnic ICU patients P231 G Gursel, A Zerman, M Aydogdu, B Basarik Aydogan, K Gonderen, S Memmedova, N Sevimli, I Koroglu, Z Isikdogan, M Badoglu, O Ozdedeoglu Gazi University Medical Faculty, Ankara, Turkey Critical Care 2015, 19(Suppl 1):P230 (doi: 10.1186/cc14310) Non-invasive respiratory volume monitoring for quantifi cation of respiratory depression after benzodiazepine administration G Mullen1 D Ladd2 Diagnosis of obstructive sleep apnea with respiratory polygraph in hypercapnic ICU patients G Gursel, A Zerman, M Aydogdu, B Basarik Aydogan, K Gonderen, S Memmedova, N Sevimli, I Koroglu, Z Isikdogan, M Badoglu, O Ozdedeoglu Gazi University Medical Faculty, Ankara, Turkey Critical Care 2015, 19(Suppl 1):P230 (doi: 10.1186/cc14310) Non-invasive respiratory volume monitoring for quantifi cation of respiratory depression after benzodiazepine administration G Mullen1 D Ladd2 Eighty-one percent (n = 25) of the recordings were interpretable and clinical and RPLG data supported a new diagnosis of OSA in 14 (56%) patients, and EPAP levels were increased. Laboratory sleep study was recommended to 19% of the patients. At the end of the study 56% of the COPD and 72% of the OHS patients were identifi ed to have OSA. Conclusion Although it underestimates AHI, RPLG is important and technically feasible in ICU patients in suggesting the presence of OSA and in providing information for appropriate NIV management. Results Six articles were found: fi ve retrospective cohorts with historical controls, one randomized controlled trial, covering 423 patients. Dosages of nebulized heparin varied from 30,000 to 150,000 IU/day. Fifty out of 222 patients (22.5%) receiving nebulized heparin and 48 out of 201 patients (23.9%) receiving standard care died (risk ratio (RR) 0.79 (95% CI 0.47 to 1.35)) (see Figure 1). Occurrence of pneumonia (RR 1.36 (95% CI 0.54 to 3.45); I2 = 59%), and number of ventilator-free days and alive at day 28 (standardized mean diff erence 0.11 (95% CI –0.14 to 35); I2 = 0%), were not diff erent between the two groups. Results Thirty-one patients with the mean age of 67 ± 9 years were included in the study. Their mean APACHE II score was 16 ± 5 and BMI was 33 ± 9 kg/m2. Admission arterial blood gases were as follows (mean ± SD); pH: 7.33 ± 0.07, PaO2: 74 ± 12 mmHg, PaCO2: 69 ± 11 mmHg, HCO3 –: 31 ± 5, O2Sat%: 92 ± 4. Admission diagnoses of the patients were OHS (36%) and COPD (68%). Mean OAI was 13 ± 6 in patients with OAI >5. Eighty-one percent (n = 25) of the recordings were interpretable and clinical and RPLG data supported a new diagnosis of OSA in 14 (56%) patients, and EPAP levels were increased. Laboratory sleep study was recommended to 19% of the patients. At the end of the study 56% of the COPD and 72% of the OHS patients were identifi ed to have OSA. Conclusion Nebulization of heparin is not associated with improved outcome in mechanically ventilated critically ill patients. This meta- analysis is limited by methodological problems in most included studies. Only one randomized controlled trial could be included. Also, most patients in the meta-analyzed studies suff ered from inhalation trauma, and heparin dosages diff ered widely. Prospective assessment of the ability of rapid shallow breathing index computed during a pressure support spontaneous breathing trial to predict extubation failure in ICU Prospective assessment of the ability of rapid shallow breathing index computed during a pressure support spontaneous breathing trial to predict extubation failure in ICU Prospective assessment of the ability of rapid shallow breathing index computed during a pressure support spontaneous breathing trial to predict extubation failure in ICU G Besch1, J Revelly2, P Jolliet2, L Piquilloud-Imboden2 1CHRU Besançon, France; 2CHUV, Lausanne, Switzerland Critical Care 2015, 19(Suppl 1):P232 (doi: 10.1186/cc14312) G Besch1, J Revelly2, P Jolliet2, L Piquilloud-Imboden2 1CHRU Besançon, France; 2CHUV, Lausanne, Switzerland Critical Care 2015, 19(Suppl 1):P232 (doi: 10.1186/cc14312) y 2 2 Results The study group was comprised of four men and three women. Median age was 69 (IQR: 61.0 to 72.5) years old. The reason for admission was ARDS (n = 5) and acute exacerbation of idiopathic pulmonary fi brosis (n = 2). The reasons for ARDS are bacterial pneumonia (n = 3), necrotizing fasciitis (n = 1) and extensive burn (n = 1). We identifi ed NETs in the bronchial aspirates of all the patients. NET formation had persisted in four cases during the study period, their P/F ratio did not improve and all patients were dead due to respiratory failure. On the other hand, NETs decreased and vanished in three cases, their P/F ratio improved and all patients recovered from ARDS. Introduction As the objective clinical criteria [1] are imperfect to assess patients before extubation, simple physiological parameters are used to try to improve extubation failure (EF) prediction. The rapid shallow breathing index (RSBI) (respiratory rate (RR) over tidal volume (VT) ratio) recorded during a T-piece spontaneous breathing trial (SBT) is known as the most reliable physiologic predictor. However, RSBI is nowadays usually computed during a pressure support (PS) SBT using the values displayed on the ventilator screen and not based on spirometry measurements without any assist as initially published. The aim of the present study was to prospectively assess the ability of currently measured RSBI to predict EF. Conclusion NET formation was observed in bronchial aspirates of all the patients diagnosed with ARDS or acute exacerbation of idiopathic pulmonary fi brosis. It may be one of the prognostic factors of ARDS or acute exacerbation of idiopathic pulmonary fi brosis. Methods Retrospective analysis of prospectively collected data from patients intubated for more than 48 hours admitted in the medico- surgical ICU of Lausanne, Switzerland, from January 2007 to December 2008. Respiratory muscle training during mechanical ventilation: a systematic reviewfi a systematic review D Brace, M Parrotto, C Urrea, A Goffi , A Murray, E Fan, L Brochard, N Ferguson, E Goligher UHN, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P231 (doi: 10.1186/cc14311) Introduction The most frequent reasons for hypercapnic respiratory failure (HRF) in ICUs are COPD and in recent years obesity hypoventilation syndrome (OHS) and obstructive sleep apnea (OSA). Even 15 to 30% of COPD patients also have accompanying OSA. Due to increased upper airway resistance, those patients require higher expiratory pressures (EPAP) during noninvasive ventilation (NIV). In order to prescribe optimal mode and pressures during the ICU stay and at discharge, the intensivist should diagnose the underlying OSA. Portable recording devices have been developed and they were approved at least for the diagnosis in high pretest probability patients with results equal to in-laboratory polysomnography. The aim of this study is to assess whether respiratory polygraph (RPLG) can be used for obtaining diagnostic information of OSA in hypercapnic ICU patients. Methods Patients, with HRF requiring NIV, were included in the study. RPLG studies were conducted under nasal oxygen before NIV, using the Philips Respironics Alice PDx® device, which provides the records of Introduction Respiratory muscle weakness is common in mechanically ventilated patients and impairs liberation from ventilation. Inspiratory muscle training (IMT) might accelerate liberation from mechanical ventilation. We undertook to summarize previously published IMT protocols and the impact of IMT on respiratory muscle function and clinical outcomes. Methods We searched multiple databases using a sensitive search strategy combining MeSH headings and keywords for studies of IMT during MV. Studies were adjudicated for inclusion and data were abstracted independently and in duplicate. Methodological quality was assessed using the GRADE system. Results Eleven studies met the inclusion criteria; of these, six were randomized controlled trials and fi ve were observational studies. Figure 1 (abstract P231). Eff ect of IMT on the rate of successful weaning from mechanical ventilation. S81 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 A variety of IMT techniques were employed including inspiratory threshold loading (eight studies), biofeedback to increase inspiratory eff ort (one study), chair-sitting (one study) and diaphragmatic breathing pattern training (one study). Threshold loading was achieved by application of an external device (six studies) or increases in the inspiratory pressure trigger setting (two studies). University of Turku, Finland Critical Care 2015, 19(Suppl 1):P234 (doi: 10.1186/cc14314) University of Turku, Finland Critical Care 2015, 19(Suppl 1):P234 (doi: 10.1186/cc14314) University of Turku, Finland Critical Care 2015, 19(Suppl 1):P234 (doi: 10.1186/cc14314) Introduction Acute lung injury (ALI) and its hypoxemic form, acute respiratory distress syndrome (ARDS), has no approved pharma co- logical treatment and is a condition with high mortality. Vascular leakage is one of the early events of ALI/ARDS. CD73 activity (ecto- 5’-nucleotidase) maintains the endothelial barrier function of lung capillaries via its enzymatic endproduct adenosine. Interferon-beta (IFNβ) increases synthesis of CD73 and has been eff ective in a mouse model of ALI [1]. Results A total of 478 extubated patients were included, 25 of whom (5.2%) were reintubated. ICU mortality (ICU-m) and in-hospital mortality (H-m) were higher in reintubated patients: ICU-m = 6 (24) versus 22 (5), P = 0.002 and H-m = 9 (36) versus 63 (15), P = 0.009. The reasons for EF were: acute lung failure (n = 15), congestive heart failure (n = 4) and aspiration/bronchial congestion (n = 6). Demographic data were similar between patients successfully and nonsuccessfully extubated: age: 58 ± 17 versus 58 ± 19 years, P = 0.85; male gender: 15 (60) versus 263 (61), P = 0.99. SAPS II score was higher in the EF group: 30 ± 22 versus 42 ± 27, P = 0.04. RSBI were signifi cantly higher in patients who experienced EF: RSBI=59 ± 44 versus 43 ± 26, P = 0.04. The area under the ROC curve for currently measured RSBI was: 0.617 (95% CI = 0.571 to 0.662), P = 0.035. Methods Therefore we conducted a phase I/II trial [2], in which intravenously administered human recombinant IFNβ1a (FP-1201) was used in the study, which consisted of dose escalation (phase I) and expansion (phase II) parts to test the FP-1201 safety, tolerability and effi cacy in ALI/ARDS patients. CD73, MxA (a marker for IFN β response) and other biomarkers were measured to follow pharmacokinetics/ dynamics of the intravenously administered FP-1201 and therapeutic effi cacy. Conclusion In a cohort of 458 medico-surgical ICU patients, RSBI measured during a pressure support SBT was higher in patients experiencing EF but very imperfect to predict EF. Reference fi y Results The optimal tolerated dose of FP-1201 (10 μg/day for 6 days) resulted in maximal MxA stimulation. Also soluble CD73 values increased, while IL-6 decreased in sera of the FP-1201-treated ALI/ARDS patients. Prospective assessment of the ability of rapid shallow breathing index computed during a pressure support spontaneous breathing trial to predict extubation failure in ICU EF was defi ned as the need for reintubation within 48 hours after extubation. Reintubations for a procedure requiring general anesthesia were not considered as EFs. RR and VT during the PS SBT were recorded from the ventilator and RSBI was computed accordingly. Baseline characteristics and currently measured RSBI were compared between patients who experienced EF versus success (t test or chi-square test as appropriate). The ability of currently measured RSBI to predict EF was assessed using ROC curve analysis. P234 1. MacIntyre NR, et al. Chest. 2001;120:375S. Respiratory muscle training during mechanical ventilation: a systematic reviewfi Most studies implemented IMT in the weaning phase (n = 5) or after diffi cult weaning (n = 5); one study implemented IMT within 24 hours of intubation. IMT was associated with greater increases in maximal inspiratory pressure compared with control (six studies, mean diff erence 7.6 cmH2O (95% CI 5.8, 9.3), I2 = 0%). There were no signifi cant diff erences in the duration of MV (six studies, mean diff erence –1.1 days (95% CI –2.5, 0.3), I2 = 71%) or the rate of successful weaning (Figure 1; fi ve studies, risk ratio 1.13 (95% CI 0.92, 1.40), I2 = 58%). The GRADE quality of evidence was low for all these outcomes; risk of bias was high for most studies and summary eff ects were imprecise and inconsistent. No serious adverse events related to IMT were reported. P233 Presence of neutrophil extracellular traps in bronchial aspirate of patients diagnosed with acute respiratory distress syndrome or acute exacerbation of idiopathic pulmonary fi brosis M Ojima1, N Yamamoto1, T Hirose1, S Hamaguchi1, N Matsumoto1, R Takegawa1, M Seki1, O Tasaki2, K Tomono1, T Shimazu1 1Osaka University Graduate School of Medicine, Suita, Japan; 2Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan Critical Care 2015, 19(Suppl 1):P233 (doi: 10.1186/cc14313) Introduction Neutrophil extracellular traps (NETs) are fi brous structures that are produced extracellularly from activated neutrophil. They can trap and kill various pathogens, and their release is one of the fi rst lines of immune system. Meanwhile, recently it was reported that NETs also exert adverse eff ects in infl ammatory diseases. Acute respiratory distress syndrome (ARDS) and acute exacerbation of idiopathic pulmonary fi brosis is acute-onset respiratory failure. It is characterized by excessive neutrophil infi ltration into the alveolus, and great amounts of neutrophil elastase are released. The purpose of this study is to evaluate whether NETs are produced in bronchial aspirate of patients with ARDS or acute exacerbation of idiopathic pulmonary fi brosis, and to identify correlations with the respiratory function. p Conclusion IMT in mechanically ventilated patients appears safe and well tolerated and improves respiratory muscle function. IMT was not associated with accelerated liberation from mechanical ventilation. However, because the included studies had important methodological limitations and employed varying methods of IMT, we cannot draw fi rm conclusions about the eff ect of IMT on clinical outcomes. i y y Methods This was a prospective observational study of seven patients admitted to the ICU of a large urban tertiary referral hospital. All patients were mechanically ventilated at the time of admission. The bronchial aspirates were collected serially from the patients by suction through a tracheal tube. To identify NETs, extracellular components including DNA, histone H3, and citrullinated histone H3 were simultaneously detected using immunohistochemistry. The respiratory function was evaluated by PaO2/FiO2 ratio (P/F ratio). New molecules controlling endothelial barrier S Jalkanen New molecules controlling endothelial barrier S Jalkanen New molecules controlling endothelial barrier S Jalkanen University of Turku, Finland Critical Care 2015, 19(Suppl 1):P234 (doi: 10.1186/cc14314 References 1. Crit Care Med. 2006;34:532-7. 2. J Crit Care. 2012;27:522.e11-7. 3. Crit Care. 2013;17:R132. Methods Forty-one CD-1 mice were divided into two groups: an HCl group underwent orotracheal instillation of hydrochloric acid on day 0, and a group control. Mice were evaluated on days 0, 1, 2 and 4 after a 30-minute period of mechanical ventilation. Blood and lung edema fl uid (EF) were sampled. Before initiation of MV, all mice received a tracheal instillation of bovine serum albumin (5%) to detect changes in alveolar protein levels over 30 minutes. Plasma levels of sRAGE and total protein levels were measured. AFC rate values were corrected after measurement of mouse serum albumin in EF. P235 P235 Endocan can be a predictive marker of severity of sepsis but cannot be a marker of acute respiratory distress syndrome in ICU patients M Mizunuma, H Ishikura, Y Nakamura, K Muranishi, S Morimoto, H Kaneyama, Y Izutani, T Nishida, A Murai Fukuoka University Hospital, Fukuoka, Japan Critical Care 2015, 19(Suppl 1):P235 (doi: 10.1186/cc14315) f References 1. Kiss et al. Eur J Immunol. 2007;37:3334-8. 2. Bellingan G, et al. Lancet Respir Med. 2014; 2:98-107. 1. Kiss et al. Eur J Immunol. 2007;37:3334-8. 2. Bellingan G, et al. Lancet Respir Med. 2014; 2:98-107. P237 Elevated levels of soluble RAGE predict impaired alveolar fl uid clearance in a translational mouse model of acute respiratory distress syndrome R Blondonnet1, M Jabaudon1, G Clairefond2, J Audard1, D Bouvier2, G Marceau1, P Blanc2, P Dechelotte1, V Sapin2, JM Constantin1 1CHU Clermont-Ferrand, France; 2Laroratoire R2D2-EA7281, Clermont-Ferrand, France Critical Care 2015, 19(Suppl 1):P237 (doi: 10.1186/cc14317) Results We enrolled 70 ARDS patients during the investigation periods. We met six patients with nonsepsis, 27 with severe sepsis and 37 with septic shock. The serum Endocan levels were signifi cantly higher in patients with septic shock (3.7 to 3.9 ng/ml) than in patients with severe sepsis (1.7 to 2.3 ng/ml, P <0.05), nonsepsis (0.6 to 0.3 ng/ml, P <0.05) and healthy donors (0.4 to 0.1 ng/ml, P <0.05). However, there was no signifi cant correlation between the Endocan level and the severity of ARDS. In addition, signifi cant correlation between the Endocan level and EVLWi and PVPI was not observed. Introduction Receptor for advanced glycation endproducts (RAGE) is a transmembrane receptor expressed in the lung and primarily located on alveolar type I cells. RAGE is implicated in acute respiratory distress syndrome to alveolar infl ammation and, when its soluble form sRAGE is assayed in plasma or pulmonary edema fl uid, as a marker of AT I cell injury. Functional activity of AT 1 cells can be assessed by the measurement of the alveolar fl uid clearance (AFC) rate [1], but the relationship between sRAGE plasma levels of sRAGE and AFC rates has never been investigated. Our objectives were to report plasma levels of sRAGE in a mouse model of direct acid-induced epithelial injury, and to test their correlation with AFC rates. Conclusion These results suggested that there was good relationship between the Endocan level and the severity of sepsis. But unlike the trauma patients, correlation between the severity of ARDS and Endocan value was not recognized. P236 Mesenchymal stem cell and endothelial cell interaction restores endothelial permeability via paracrine hepatocyte growth factor in vitro Mesenchymal stem cell and endothelial cell interaction restores endothelial permeability via paracrine hepatocyte growth factor in vitro Q Chen, A Liu, H Qiu, Y Yang Southeast University, Nanjing, China Critical Care 2015, 19(Suppl 1):P236 (doi: 10.1186/cc14316) Endocan can be a predictive marker of severity of sepsis but cannot be a marker of acute respiratory distress syndrome in ICU patients M Mizunuma, H Ishikura, Y Nakamura, K Muranishi, S Morimoto, H Kaneyama, Y Izutani, T Nishida, A Murai Fukuoka University Hospital, Fukuoka, Japan Critical Care 2015, 19(Suppl 1):P235 (doi: 10.1186/cc14315) l Results The permeability signifi cantly increased after LPS stimulation in a dose-dependent and time-dependent manner (P <0.01). Mean- while, MSC-EC interaction more signifi cantly decreased endothelial permeability induced by LPS (P <0.05 or P <0.01). Moreover, HGF levels in the MSC-EC interaction group were much higher than those of the MSC group (P <0.01). However, neutralizing HGF with anti- HGF antibody inhibited the role of MSC-EC interaction in improving endothelial permeability (P <0.05). Compared with the MSC group, MSC-EC interaction increased VE-cadherin protein expression (P <0.01), and restored remodeling of F-actin and junctional localization of VE- cadherin. However, the MSC eff ect was signifi cantly blocked by anti- HGF antibody (P <0.05 or P <0.01). Introduction Endocan (endothelial cell specifi c molecule-1), a 50 kDa dermatan sulfate proteoglycan, is expressed by endothelial cells in the lung and kidney. It was reported that the serum Endocan level is related to the severity of sepsis and positive correlation with the mortality rate. On the other hand, it was also reported that lower levels of serum Endocan are associated with subsequent development of chronic kidney disease, and chronic liver disease acute lung injury (ALI) in trauma patients. The aim of this study is confi rmation of the relationship between serum Endocan level and the severity of sepsis, and also the severity of acute respiratory distress syndrome (ARDS) in septic patients. y Conclusion These data suggest that MSC-EC interaction decreased endothelial permeability induced by LPS, which was mainly attributed to HGF secreted by hMSCs. The main mechanisms of HGF restoring the integrity of EC monolayers are remodeling of endothelial intercellular AJs and decreasing caveolin-1 protein expression. p p Methods This study was conducted as a single-center, retrospective, observational study in the emergency department of Fukuoka University Hospital from April 2010 to August 2013. Blood samples were collected within 2 hours when the patients were diagnosed with ARDS. In this time we adopted the Berlin defi nition as the categorized of ARDS severity. Furthermore, we evaluated the extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) as a condition of ARDS using the transpulmonary thermodilution method. Additionally, 10 healthy donors were entered as a control. The patients were divided into nonsepsis, severe sepsis and septic shock using the ACCP/SCCM guidelines. University of Turku, Finland Critical Care 2015, 19(Suppl 1):P234 (doi: 10.1186/cc14314) The overall mortality of the 37 patients treated with FP-1201 S82 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 permeability in lung injury via paracrine hepatocyte growth factor (HGF). Recently, it has been indicated that MSCs secreted more factors by MSC–endothelial cell (MSC-EC) interaction. We hypothesized that MSC-EC interaction restored endothelial permeability induced by lipopolysaccharide (LPS) via paracrine HGF. was only 8.1%, fourfold to fi vefold less than the expected rate based on APACHE II score values of 21.9. The control group (n = 59), which was eligible for the trial but not possible to recruit, had mortality of 32.2% (P = 0.01) and APACHE II score 23.0. Conclusion Restriction of vascular leakage with FP-1201 seems to signifi cantly benefi t ALI/ARDS patients. Our results suggest that FP- 1201 could be the fi rst eff ective, mechanistically targeted, disease- specifi c pharmacotherapy for patients with ARDS. However, these fi ndings warrant conduction of a large multicenter study to establish safe and eff ective FP-1201 treatment of ARDS. f p p y p Methods We investigated the endothelial permeability induced by LPS under two co-culture conditions in transwells. HPMECs were added into the upper chambers of cell-culture inserts, while there two diff erent co-culture conditions in the lower side of transwells as follows: MSC-EC interaction group: MSCs and HPMEC contact co- culture in the lower chambers; and MSC groups: MSCs only in the lower chambers. The endothelial permeability in the upper side of transwells was detected. Then the concentration of HGF was measured in the culture medium using an enzyme-linked immunosorbent assay kit, following by neutralizing HGF with anti-HGF antibody in the co-culture medium. In addition, VE-cadherin protein expression were measured under the co-culture conditions by western blot, adherens junctions (AJs) protein including F-actin and VE-cadherin were detected by immunofl uorescence technique as well.i P240 y Results Of those 4,652 patients, there were 2,947 nonsmokers, 1,148 exsmokers, and 557 active smokers. There was no diff erence of APACHE II score between three groups of patients. The active smokers exhibited the highest incidence of ARDS (active smokers 5.4%, exsmokers 4.8%, and nonsmokers 3%, P = 0.003). There was no diff erence of 28-day mortality between the three groups of patients. Active smokers had the highest incidence of SIRS (active smokers 41%, exsmokers 37%, and nonsmokers 34%, P = 0.006). Compared with nonsmokers and exsmokers, active smokers had a longer SICU LOS (P <0.01) and higher total SICU cost (P = 0.02). Patients who smoked more than 15 pack- years were 2.5 times more likely to develop ARDS than patients who smoked ≤15 pack-years (95% CI: 1.65 to 3.66, P <0.001). In multivariate analysis we found that every 1 pack-year of cigarette smoking before References 1. Hoshino Y, et al. Am J Physiol Lung Cell Mol Physiol. 2001;281:L509-16. 2. Chittawatanarat K, et al. J Med Assoc Thai. 2014;97 (Suppl 1):S45-54. P238 Smoking increased risk of ARDS in surgical critically ill patients: results from the multicenter THAI-SICU study P Wacharasint1, P Fuengfoo1, N Sukcharoen1, R Rangsin2, THAI-SICU Trial Group3 1Phramongkutklao Hospital, Bangkok, Thailand; 2Phramongkutklao College of Medicine, Bangkok, Thailand; 3THAI-SICU Collaborating Centre, Bangkok, Thailand Critical Care 2015, 19(Suppl 1):P238 (doi: 10.1186/cc14318) 2 Results A total of 101 ARDS patients was enrolled; 44 (43.6%) patients were normal weight, 36 (35.6%) overweight and 21 (20.8%) obese. Lung and chest wall elastance were not diff erent between groups, both at PEEP levels of 5 cmH2O and 15 cmH2O (P = 0.580 and P = 0.113, respectively), and the end-inspiratory transpulmonary pressure was also similar. We did not observe any diff erence between groups regarding PaO2/FiO2 ratio (P = 0.178 at PEEP 5 cmH2O; P = 0.073 at PEEP 15 cmH2O) and PaCO2 (P = 0.491 at PEEP 5 cmH2O; P = 0.237 at PEEP 15 cmH2O). Introduction Cigarette smoking slowly and progressively damages the respiratory system [1]. In surgical critically ill patients, whether active cigarette smoking until admission to the surgical intensive care unit (SICU) is associated with increased risk of acute respiratory distress syndrome (ARDS) is not clearly identifi ed. 2 Conclusion In ARDS obese patients the chest wall elastance and the end-inspiratory transpulmonary pressure are not aff ected by the body weight, suggesting that normal weight and obese patients present similar risks for lung stress and VILI onset. The severity of hypoxemia was not diff erent between groups. y yi Methods We conducted a cohort study using the THAI-Surgical Intensive Care Unit (THAI-SICU) study databases [2], which recruited 4,652 Thai patients admitted to the SICUs from nine university-based hospitals in Thailand (April 2011 to November 2012). The enrolled patients were divided into three groups (active smokers, exsmokers, and nonsmokers). Primary outcome was the incidence of patients diagnosed with ARDS and the secondary outcomes included 28-day mortality, incidence of systemic infl ammatory response syndrome (SIRS), SICU length of stay (LOS), and total SICU cost. f References 1. Pelosi et al. Chest. 1996;109:144-51. 1. Pelosi et al. Chest. 1996;109:144-51. . Suratt et al. J Appl Physiol Respir Environ Exerc Physiol. 1984;57:403 2. Suratt et al. J Appl Physiol Respir Environ Exerc Physiol. 1984;57:403-7. P239l P239 Infl uence of body weight on lung mechanics and respiratory function in ARDS patients I Algieri1, D Chiumello2, C Mietto1, E Carlesso1, A Colombo1, G Babini1, M Cressoni1 1Università degli Studi di Milano, Milan, Italy; 2Fondazione IRCCS, ‘Ospedale Maggiore Policlinico Mangiagalli Regina Elena’ di Milano, Milan, Italy Critical Care 2015, 19(Suppl 1):P239 (doi: 10.1186/cc14319) Figure 1 (abstract P237). Relation between AFC rates and sRAGE plasma levels. (P = 0.03) and day 2 (P = 0.02). The rate of AFC was inversely correlated with sRAGE levels in the plasma (Spearman’s ρ = –0.73, P <0.001). See Figure 1. Introduction Traditionally, ARDS obese patients are ventilated with higher tidal volumes and higher PEEP due to expected increased in pleural pressure. However, data from the literature regarding the infl uence of body mass on lung mechanics and, particularly, on chest wall elastance are not univocal [1,2]. Failure to account for how the increase in body weight could aff ect the respiratory function can result in injurious mechanical ventilation and in the onset of VILI. The aim of this study was to evaluate the role of the body weight on respiratory mechanics in ARDS patients. g Conclusion The highest impairment in AFC is reported on day 1. sRAGE levels are also higher in injured mice and may be a good surrogate marker of AT I cell injury. This is a newly described relationship between AFC rates and sRAGE plasma level in a mouse model of direct epithelial injury. Our results support further translational investigation on the role of RAGE in alveolar injury and recovery. 1. Eur Respir J. 2012;39:1162-70. Methods A group of deeply sedated and paralyzed ARDS patients was divided into three classes according to the body mass index: normal weight (between 18.5 and 24.9 kg/m2), overweight (between 25.0 and 29.9 kg/m2) and obese (between 30.0 and 39.9 kg/m2). They were mechanically ventilated in volume-controlled mode with a tidal volume of 6 to 8 ml/kg according to predicted body weight. Respiratory mechanics and gas exchange were assessed at PEEP levels of 5 and 15 cmH2O. Mesenchymal stem cell and endothelial cell interaction restores endothelial permeability via paracrine hepatocyte growth factor in vitro Q Chen, A Liu, H Qiu, Y Yang Results Basal AFC rate was 35% over 30 minutes in HCl-injured mice, but it was signifi cantly depressed on day 1 (16% over 30 minutes; P = 0.02). Over time, AFC reached basal levels again. Plasma levels of sRAGE were higher in HCl-treated animals than in control animals on day 1 Introduction Mesenchymal stem cells (MSCs) have potent stabilizing eff ects on the vascular endothelium injury, inhibiting endothelial Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S83 Figure 1 (abstract P237). Relation between AFC rates and sRAGE plasma levels. admission to the SICU is associated with increased risk of new ARDS with a hazard ratio of 1.02 (95% CI: 1.01 to 1.02, P = 0.001) after adjustment for APACHE II score, age, gender, and chronic obstructive pulmonary disease. Conclusion In surgical critically ill patients, active smokers are associated with increased risk of new ARDS, longer SICU LOS, and higher total ICU cost, compared with exsmokers and nonsmokers. Our fi ndings emphasize the essential need for a smoking cessation program. f Complex approach for diagnosing acute respiratory distress syndrome in nosocomial pneumonia Complex approach for diagnosing acute respiratory distress syndrome in nosocomial pneumonia A Kuzovlev, V Moroz, A Goloubev, S Polovnikov, V Stec V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Critical Care 2015, 19(Suppl 1):P240 (doi: 10.1186/cc14320) Complex approach for diagnosing acute respiratory distress syndrome in nosocomial pneumonia A Kuzovlev, V Moroz, A Goloubev, S Polovnikov, V Stec V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Critical Care 2015, 19(Suppl 1):P240 (doi: 10.1186/cc14320) A Kuzovlev, V Moroz, A Goloubev, S Polovnikov, V Stec V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Critical Care 2015, 19(Suppl 1):P240 (doi: 10.1186/cc14320) A Kuzovlev, V Moroz, A Goloubev, S Polovnikov, V Stec V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Critical Care 2015, 19(Suppl 1):P240 (doi: 10.1186/cc14320) Introduction Acute respiratory distress syndrome (ARDS) develops on the basis of nosocomial pneumonia (NP) in 30 to 35% of cases. A complex clinical approach is required for diagnosing it. The aim of this study was to investigate into the role of the PaO2/FiO2 ratio (P/F), extravascular lung water index (EVLWI) and surfactant protein D (SPD) as a complex diagnostic tool for ARDS in NP. S84 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods The observational study in ICU ventilated septic patients with peritonitis (70%), pancreonecrosis (25%) and mediastinitis (5%) was done in 2010 and 2014. ARDS was diagnosed and staged according to the V.A. Negovsky Research Institute criteria and the Berlin defi nition. Plasma SPD was measured on ARDS diagnosis (day 0) and days 3 and 5 by the immunoenzyme essay (BioVendor, USA). Patients were treated according to the international guidelines. Data were statistically analyzed by STATISTICA 7.0, ANOVA and presented as median and 25 to 75th percentiles (ng/ml); P <0.05 was considered statistically signifi cant. Areas under the receiver operating curves were calculated. Results Sixty-fi ve patients (out of 450 screened) were enrolled in the study according to the inclusion/exclusion criteria. Patients were assigned into groups: NP + ARDS (n = 43, 43 ± 4.9 years old, M/F 39/4, mortality 23%) and NP (n = 22, 40 ± 5.1 years old, M/F 20/2, mortality 18%). Groups were comparable in APACHE II and SOFA scores on the baseline. In the NP + ARDS group SPD was higher at all points than in the NP group. Plasma SPD on day 0 >111.2 ng/ml yielded a sensitivity of 68.2% and specifi city of 92.3% (AUC 0.85; 95% CI 0.684 to 0.945; P <0.0001) for diagnosing ARDS in NP. Complex approach for diagnosing acute respiratory distress syndrome in nosocomial pneumonia A Kuzovlev, V Moroz, A Goloubev, S Polovnikov, V Stec V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Critical Care 2015, 19(Suppl 1):P240 (doi: 10.1186/cc14320) Results Forty-fi ve oesophageal balloon pressure–volume curves were obtained in 31 patients undergoing controlled mechanical ventilation (PEEP 12 ± 5 cmH2O, FiO2 0.7 ± 0.2, tidal volume/ideal body weight 8.0 ± 1.6 ml/kg). According to the graphically detected minimum slope section of the curve, the minimum and maximum appropriate balloon volumes were 1.5 ± 0.6 ml and 5.3 ± 0.9 ml, respectively. Between these two volumes, the slope of the curve was 1.1 ± 0.5 cmH2O/ml, ranging from 0.3 to 3.1 cmH2O/ml. Eff ects of a recruitment maneuver on plasma soluble rage in patients with diff use ARDS: a prospective randomized crossover study M Jabaudon, N Hamroun, L Roszyk, R Blondonnet, R Guerin, JE Bazin, V Sapin, B Pereira, JM Constantin CHU Clermont-Ferrand, France Critical Care 2015, 19(Suppl 1):P241 (doi: 10.1186/cc14321) y M Jabaudon, N Hamroun, L Roszyk, R Blondonnet, R Guerin, JE Bazin, V Sapin, B Pereira, JM Constantin CHU Clermont-Ferrand, France Critical Care 2015, 19(Suppl 1):P241 (doi: 10.1186/cc14321) Introduction The soluble form of the receptor for advanced glycation endproducts (sRAGE) is a promising marker for epithelial dysfunction, but it has not been fully characterized as a biomarker during ARDS. Whether sRAGE could inform on the response to ventilator settings has been poorly investigated, and whether recruitment maneuver (RM) may infl uence plasma sRAGE remains unknown. p p gl Results Forty-fi ve oesophageal balloon pressure–volume curves were obtained in 31 patients undergoing controlled mechanical ventilation (PEEP 12 ± 5 cmH2O, FiO2 0.7 ± 0.2, tidal volume/ideal body weight 8.0 ± 1.6 ml/kg). According to the graphically detected minimum slope section of the curve, the minimum and maximum appropriate balloon volumes were 1.5 ± 0.6 ml and 5.3 ± 0.9 ml, respectively. Between these two volumes, the slope of the curve was 1.1 ± 0.5 cmH2O/ml, ranging from 0.3 to 3.1 cmH2O/ml. l Methods Twenty-four patients with moderate/severe, nonfocal ARDS were enrolled in this prospective monocentric crossover study and randomized into a ‘RM-SHAM’ group when a 6-hour-long RM sequence preceded a 6-hour-long sham evaluation period, or a ‘SHAM-RM’ Figure 1 (abstract P241). Evolution of plasma levels of sRAGE (pg/ml) in both randomization sequences. 2 Conclusion The oesophageal artefact – that is, the reaction of the oesophageal wall to balloon infl ation – may be clinically signifi cant, being on average 1 cmH2O for each millilitre of volume injected in the catheter, but reaching values as high as 3 cmH2O/ml. Complex approach for diagnosing acute respiratory distress syndrome in nosocomial pneumonia A Kuzovlev, V Moroz, A Goloubev, S Polovnikov, V Stec V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Critical Care 2015, 19(Suppl 1):P240 (doi: 10.1186/cc14320) Our fi ndings could help to design future studies of sRAGE as a marker of response to therapeutic interventions during ARDS. P242 Oesophageal artefact may signifi cantly aff ect oesophageal pressure measurement in mechanically ventilated patients F Mojoli, F Torriglia, M Pozzi, S Bianzina, G Tavazzi, A Orlando, A Braschi Fondazione IRCCS Policlinico S. Matteo Hospital – University of Pavia, Italy Critical Care 2015, 19(Suppl 1):P242 (doi: 10.1186/cc14322) Introduction Oesophageal pressure is increasingly used to monitor and manage mechanically ventilated patients. Even if the oesophageal balloon catheter is correctly positioned, the measurement can be aff ected by inappropriate balloon fi lling and/or oesophageal reaction to balloon infl ation. We aimed to assess the oesophageal reaction to oesophageal balloon fi lling in mechanically ventilated patients. i Methods An oesophageal balloon catheter (NutriVent; Sidam, Mirandola, Italy) was introduced in mid/distal thoracic position in 31 patients under invasive mechanical ventilation for acute respiratory failure. At ambient pressure, the balloon of the NutriVent catheter can be infl ated up to 6 ml without generation of recoil pressure. The balloon was progressively infl ated in 0.5 ml steps up to 9 ml and end-expiratory values of balloon pressure were used to assemble the balloon pressure–volume curve. The minimum slope section of the curve was graphically detected and infl ation volumes corresponding to this part of the curve were considered appropriate. Overdistension of the balloon being excluded by defi nition in this section of the curve, its slope was attributed to the oesophageal reaction to balloon infl ation.i Methods An oesophageal balloon catheter (NutriVent; Sidam, Mirandola, Italy) was introduced in mid/distal thoracic position in 31 patients under invasive mechanical ventilation for acute respiratory failure. At ambient pressure, the balloon of the NutriVent catheter can be infl ated up to 6 ml without generation of recoil pressure. The balloon was progressively infl ated in 0.5 ml steps up to 9 ml and end-expiratory values of balloon pressure were used to assemble the balloon pressure–volume curve. The minimum slope section of the curve was graphically detected and infl ation volumes corresponding to this part of the curve were considered appropriate. Overdistension of the balloon being excluded by defi nition in this section of the curve, its slope was attributed to the oesophageal reaction to balloon infl ation. Complex approach for diagnosing acute respiratory distress syndrome in nosocomial pneumonia A Kuzovlev, V Moroz, A Goloubev, S Polovnikov, V Stec V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Critical Care 2015, 19(Suppl 1):P240 (doi: 10.1186/cc14320) The pressure generated by the oesophageal reaction leads to overestimation of pleural pressure. Therefore, the oesophageal artefact may signifi cantly aff ect clinical decision-making based on absolute values of oesophageal pressure. Complex approach for diagnosing acute respiratory distress syndrome in nosocomial pneumonia A Kuzovlev, V Moroz, A Goloubev, S Polovnikov, V Stec V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia Critical Care 2015, 19(Suppl 1):P240 (doi: 10.1186/cc14320) P/F ratio on day 0 <280 yielded a sensitivity of 94.1% and specifi city of 76.9% (AUC 0.89; 95% CI 0.744 to 0.952; P <0.0001) and EVLWI on day 0 >8.3 ml/kg yielded a sensitivity of 94.1% and specifi city of 92.3% (AUC 0.92; 95% CI 0.810 to 0.982; P <0.0001) for the diagnosis of ARDS in NP. A complex ROC analysis (for SPD in the group of patients with P/F <280 and EVLWI >8.3) yielded a much better diagnostic accuracy of SPD: cutoff >93.7 ng/ml, sensitivity 81.0%, specifi city 100.0% (AUC 0.96; 95% CI 0.817 to 0.998; P <0.0001). Conclusion A complex approach (P/F <280, EVLWI >8.3, SPD >93.7) presents as a sensitive and highly specifi c method for diagnosing ARDS in NP patients. group (inverted sequences). Protective ventilation was applied, and RM consisted of the application of 40 cmH2O airway pressure for 40 seconds. Arterial blood was sampled for gas analyses and sRAGE measurements, 5 minutes pre RM (or 40-second-long sham period), 5 minutes, 30 minutes, 1 hour, 4 hours and 6 hours after the RM (or 40-second-long sham period). g p ) Results Mean PaO2/FiO2, tidal volume, PEEP and plateau pressure were 125 mmHg, 6.8 ml/kg (ideal body weight), 13 and 26 cmH2O, respectively. Median baseline plasma sRAGE levels were 3,232 pg/ml. RM induced a signifi cant decrease in sRAGE (–1,598 ± 859 pg/ml) in 1 hour (P = 0.043). At 4 and 6 hours post RM, sRAGE levels increased back toward baseline values. Pre-RM sRAGE was associated with RM- induced oxygenation improvement (AUC 0.87). See Figure 1. Conclusion We report the fi rst kinetics study of plasma sRAGE after RM in ARDS. Our fi ndings could help to design future studies of sRAGE as a marker of response to therapeutic interventions during ARDS. Results Mean PaO2/FiO2, tidal volume, PEEP and plateau pressure were 125 mmHg, 6.8 ml/kg (ideal body weight), 13 and 26 cmH2O, respectively. Median baseline plasma sRAGE levels were 3,232 pg/ml. RM induced a signifi cant decrease in sRAGE (–1,598 ± 859 pg/ml) in 1 hour (P = 0.043). At 4 and 6 hours post RM, sRAGE levels increased back toward baseline values. Pre-RM sRAGE was associated with RM- induced oxygenation improvement (AUC 0.87). See Figure 1. Conclusion We report the fi rst kinetics study of plasma sRAGE after RM in ARDS. P244 P245 Functional respiratory imaging of airways in ventilated ARDS patients: revealing the regional relation between PEEP-induced airway opening and airway dilatation T Schepens1, C Vanholsbeke2, W Vos2, J De Backer2, P Parizel1, PG Jorens1 1Antwerp University Hospital, Edegem, Belgium; 2FLUIDDA, Kontich, Belgium Critical Care 2015, 19(Suppl 1):P245 (doi: 10.1186/cc14325) P245 Functional respiratory imaging of airways in ventilated ARDS patients: revealing the regional relation between PEEP-induced airway opening and airway dilatation Regional distribution of excess tissue mass in ARDS lung I Algieri1, D Massari1, A Colombo1, G Babini1, F Crimella1, M Brioni1, A Cammaroto1, K Nikolla1, C Montaruli1, M Guanziroli1, M Gotti1, C Chiurazzi1, M Amini1, M Chiodi1, M Cressoni1, D Chiumello2, L Gattinoni1 1Università degli Studi di Milano, Milan, Italy; 2Fondazione IRCCS, ‘Ospedale Maggiore Policlinico Mangiagalli Regina Elena’ di Milano, Milan, Italy Critical Care 2015, 19(Suppl 1):P244 (doi: 10.1186/cc14324) Functional respiratory imaging of airways in ventilated ARDS patients: revealing the regional relation between PEEP-induced airway opening and airway dilatation y p g y T Schepens1, C Vanholsbeke2, W Vos2, J De Backer2, P Parizel1, PG Jorens1 1Antwerp University Hospital, Edegem, Belgium; 2FLUIDDA, Kontich, Belgium Critical Care 2015, 19(Suppl 1):P245 (doi: 10.1186/cc14325) Introduction ARDS has a wide variability of lung morphological charac- teristics. Both alveolar collapse and airway narrowing or closing are present, often heterogeneously. Despite advances in ARDS imaging, we have thus far been unable to distinguish regional airway opening from airway dilatation in PEEP-induced lung recruitment. We demonstrate the technique of functional respiratory imaging (FRI) to diff erentiate these two entities. Introduction ARDS is characterized by edema diff use to all lung fi elds. Distribution of excess tissue mass had been studied with CT scan in a few patients on a single slice, comparing with data obtained in healthy controls. Methods ARDS patients underwent CT scan imaging during their ICU stay at 45 cmH2O end-inspiratory pressure. After hospital discharge, patients underwent a follow-up CT scan performed at end inspiration. Each lung was divided into three sections along the apex–base axis and into three sections along the sternum–vertebral axis (nine regions per lung). Excess tissue mass in each lung region was defi ned as the diff erence in lung tissue (grams) between the CT scan performed during ARDS course and the follow-up CT scan. Results are presented as mean ± SD. Methods Six patients with early-stage ARDS were included in this prospective single-centre cohort trial. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P245 Functional respiratory imaging of airways in ventilated ARDS patients: revealing the regional relation between PEEP-induced airway opening and airway dilatation T Schepens1, C Vanholsbeke2, W Vos2, J De Backer2, P Parizel1, PG Jorens1 1Antwerp University Hospital, Edegem, Belgium; 2FLUIDDA, Kontich, Belgium Critical Care 2015, 19(Suppl 1):P245 (doi: 10.1186/cc14325) Figure 1 (abstract P244). Figure 1 (abstract P244). demonstrated recently its eff ectiveness on prognosis. Extrapulmonary etiologies of ARDS include abdominal emergencies. In cases of severe hypoxemia in the early postoperative period, intensivists discuss prone positioning based on the risk/benefi t ratio. demonstrated recently its eff ectiveness on prognosis. Extrapulmonary etiologies of ARDS include abdominal emergencies. In cases of severe hypoxemia in the early postoperative period, intensivists discuss prone positioning based on the risk/benefi t ratio. p gi Methods We conducted a retrospective two-center study of 5 years. The aim was to compare the prevalence of surgical complication potentially related to prone positioning between patients who had at least one prone positioning session and patients that remained in a supine position after abdominal surgery. Patients with ARDS in a context of recent (<7 days) abdominal surgery (except laparoscopy) were included. The primary outcome was the number of patients who had at least one surgical complication potentially related to prone positioning. We defi ned a priori these complications: scar dehiscence, abdominal compartment syndrome, stoma leakage, stoma necrosis, scar necrosis, wound infection, displacing of a drainage system, removal of gastro- or jejunostomy feeding, digestive fi stula, evisceration.i g j j y g gi Results We identifi ed 43 patients with postoperative ARDS (62 ± 8 years, SAPS II 50 ± 13), among whom 34 (79%) had emergent surgery. Fifteen patients had at least one stoma after surgery. Nineteen patients (44%) had at least one prone positioning session (number of sessions: 2 (1 to 3)). At baseline, prone group patients had minimum PaO2/FiO2 ratio lower than the supine group (77 ± 23 vs. 110 ± 46 mmHg, P = 0.005). Plateau pressure was higher in the prone group (28 ± 4 vs. 23 ± 5 cmH2O, P = 0.002). The fi rst prone positioning session signifi cantly increased the PaO2/FiO2 ratio: 106 ± 52 vs. 192 ± 90 mmHg (P = 0.001). Mean duration of the fi rst prone positioning session was 20 ± 10 hours. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 In the prone group, 11 patients (58%) had at least one surgical complication, in comparison with nine (38%) in the supine group (P = 0.2). These complications resulted in revision surgery for two (10%) patients in the prone group and two (8%) in the supine group (P = 0.8). Mortality in the ICU was respectively 42% and 38% in prone group and supine group (P = 0.8).if Conclusion These preliminary results confi rm the eff ectiveness of prone positioning in terms of oxygenation in ARDS after abdominal surgery without signifi cant increase in surgical complications and no eff ect on the need for surgical revisions. Hence, if necessary, clinicians should not refrain from proning patients with postabdominal surgery ARDS. P243 P243 Prone positioning in acute respiratory distress syndrome after abdominal surgery S Gaudry1, S Tuff et1, AC Anne-Claire2, N Zucman1, S Msika1, M Pocard2, D Payen2, D Dreyfuss1, JD Ricard1 1Hôpital Louis Mourier, Colombes, France; 2Hôpital Lariboisière, Paris, France Critical Care 2015, 19(Suppl 1):P243 (doi: 10.1186/cc14323) Introduction Prone positioning has been used for many years as an alveolar recruitment strategy in acute respiratory distress syndrome (ARDS). Prone positioning in ARDS improves oxygenation and Introduction Prone positioning has been used for many years as an alveolar recruitment strategy in acute respiratory distress syndrome (ARDS). Prone positioning in ARDS improves oxygenation and Figure 1 (abstract P241). Evolution of plasma levels of sRAGE (pg/ml) in both randomization sequences. S85 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Effi cacy and safety of open lung ventilation in patients with impaired peripheral chemorefl ex sensitivity N Trembach, I Zabolotskikh Kuban State Medical University, Krasnodar, Russia Kuban State Medical University, Krasnodar, Russia Critical Care 2015, 19(Suppl 1):P246 (doi: 10.1186/cc14326) g Results Piglets ventilated with higher energy loads (RR 15 and 12) developed ventilator-induced lung injury (VILI), while piglets ventilated with lower energy loads (RR 9, 6 and 3) did not. The energy dissipated in the lung parenchyma at each breath was 0.56 J (0.52 to 0.62). Dissipated energy increased with time in piglets that developed VILI, while it remained near-constant in all the other piglets. Recruitability was 6% (3 to 8) of lung parenchyma, strain was 3.1 (2.6 to 3.5) and lung inhomogeneity extent (that is, the percentage of lung parenchyma that is inhomogeneous) was 10% (9 to 11). The energy dissipated in the lung parenchyma was well related to lung recruitability (r2 = 0.50, P <0.0001), strain (r2 = 0.57, P <0.0001) and lung inhomogeneity extent (r2 = 0.42, P <0.0001). Multiple linear regression showed that dissipated energy was independently related to all of the three determinants of energy dissipation: lung opening and closing (P = 0.025), strain (P <0.0001) and lung inhomogeneities (P <0.01). Introduction Mechanical ventilation during anesthesia leads to the development of atelectasis, poor oxygenation and postoperative pulmonary complications. Application of PEEP and recruitment maneuver (RM) can signifi cantly reduce the severity of atelectasis and improve lung function. But the application of this strategy often leads to hemodynamic instability, which may be associated with impaired reactivity of the cardiovascular system. The purpose of this study was to evaluate the effi cacy and safety of RM in patients with increased sensitivity of peripheral chemoreceptors (SPCR), which refl ects the decreasing reactivity of the cardiovascular system. g y y Methods We conducted a prospective study in 116 patients with high SPCR, evaluated using the breath-holding test. The test was performed by measuring of voluntary breath-holding duration (BHD) after two- thirds of maximal inspiration. The end of breath-hold was determined by a palpation of contraction of the diaphragm. BHD <38 seconds was the marker of high SPCR [1]. All patients received a major abdominal surgery and were randomized into an open lung ventilation group or a PEEP group. P244 The lower infl iction point on a pressure–volume curve was considered as the clinically acceptable minimal PEEP value. Subsequently, four distinct PEEP levels were chosen to perform CT scans: at 20 cmH2O; median value between 1 and 3; clinically acceptable minimal; and 0 cmH2O. FRI methods as described by De Backer and colleagues [1] were used to evaluate airway opening and airway dilatation. Results We studied eight ARDS patients (55 ± 18 years) with a BMI of 27 ± 6 kg/m2. At ICU admission, patients had the following clinical parameters: PaO2/FiO2 106 ± 33 with PEEP 15 ± 5 cmH2O; PaCO2 43 ± 10 mmHg; pH 7.35 ± 0.05. The average increase in lung weight during ARDS compared with follow-up CT scan was 68 ± 40% (680 ± 320 g). Figure 1 presents the tissue volume during ARDS (white bars) and after ARDS resolution (black bars) and compares the ratio between the two (P <0.01 vs. dependent region). Results Airway stretching (that is, bronchodilatation) could be quantifi ed and distinguished from airway recruitment with this technique. Higher PEEP pressures not only recruit, but also expand the bronchi. The ratio of dilation/recruitment of bronchi was higher in the upper lobes than in the lower lobes, as illustrated in Figure 1. We were able to phenotype each patient, allowing a prediction on when an increase in PEEP further recruits atelectasis/bronchi or distends certain airway regions. Conclusion The excess tissue mass was not diff erent between apex, hilum and base, but was increased in the dependent lung regions at apex and hilum, being uniformly distributed at the lung base. y g Conclusion The novel technique of FRI can be used to visualise the airway structures in ARDS and distinguish airway stretching from Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S86 more pronounced. So CI on average decreased by 34% (from 3.7 to 2.5 l/minute/m2) compared with 10% with no RM (P <0.05), and SVR decreased by 19% (from 1,310 to 1,150 dyn × sec–1 × cm–5, P <0.05), while in the PEEP group it did not change. No signifi cant diff erences between groups in the incidence of complications, length of stay in the ICU and in the hospital were noted. Figure 1 (abstract P245). Bronchodilation and bronchial recruitment split per lobe for one patient. Effi cacy and safety of open lung ventilation in patients with impaired peripheral chemorefl ex sensitivity The concept of open lung ventilation was performed as follows: PEEP was increased from 4 to 10 cmH2O for three breaths, from 10 to 15 cmH2O for three breaths, and from 15 to 20 cmH2O for 10 breaths [2]. Then PEEP was reduced to 12 cmH2O. This RM was repeated every hour. In the PEEP group PEEP was maintained at 12 cmH2O during the whole anesthesia. Hemodynamics, blood gases and dynamic compliance were evaluated. Conclusion Energy dissipation was largely dependent on strain, obtained with very high tidal volumes, but also lung inhomogeneities and lung opening and closing played a signifi cant role. Reference 1. Cressoni M. et al. Am J Respir Crit Care Med. 2014;189:149-58. P244 Conclusion RM patients with high SPCR and with reduced reactivity of the cardiovascular system improve lung function, but this is associated with the risk of hemodynamic instability. References 1. Zabolotskikh I, et al. Eur J Anesth. 2014;31:62. 2. Weingarten TN, et al. Br J Anesth. 2010;104:16-22. Determinants of energy dissipation in the respiratory system during mechanical ventilation Università degli Studi di Milano, Milan, Italy Critical Care 2015, 19(Suppl 1):P247 (doi: 10.1186/cc14327) Introduction Mechanical ventilation performs at each breath mechanical work on the lung parenchyma. Part of this energy is recovered and part is dissipated into the respiratory system. The purpose of this study is to assess the respective role of three known determinants of energy dissipation: lung opening and closing, strain and lung inhomogeneities [1]. Figure 1 (abstract P245). Bronchodilation and bronchial recruitment split per lobe for one patient. g g Methods Thirteen female piglets (21 ± 2 kg) were ventilated with a strain (VT/FRC) greater than 2.5 (VT ~ 38 ± 3 ml/kg) for 54 hours or until massive lung edema developed. Piglets were divided into fi ve groups characterized by diff erent energy loads obtained varying the respiratory rate: 15 breaths/minute (n = 3), 12 (n = 3), 9 (n = 3), 6 (n = 2) and 3 (n = 2). Every 6 hours two CT scans were performed (end-expiration and end- inspiration) and a static pressure–volume curve was obtained. A total of 51 CT scan couples and 51 corresponding pressure–volume curves was analyzed. The energy dissipated in the lung parenchyma at each breath was determined as the hysteresis area of the pressure–volume curve. CT scans were quantitatively analyzed with dedicated software. Data are presented as median (interquartile range). airway recruitment. This pilot study shows that, in ARDS, the upper lung regions are subject to airway dilation, whereas the lower (atelectatic) lung lobes have more airway opening with higher PEEP levels. Reference 1. De Backer et al. Radiology. 2010;257:854-62. P246fi P248 P248 Immune response after prolonged hyperoxic mechanical ventilation HJ Helmerhorst1, LR Schouten2, NP Juff ermans2, MJ Schultz2, E De Jonge1, DJ Van Westerloo1 1Leiden University Medical Center, Leiden, the Netherlands; 2Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P248 (doi: 10.1186/cc14328) P248 Immune response after prolonged hyperoxic mechanical ventilation HJ Helmerhorst1, LR Schouten2, NP Juff ermans2, MJ Schultz2, E De Jonge1, DJ Van Westerloo1 1Leiden University Medical Center, Leiden, the Netherlands; 2Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P248 (doi: 10.1186/cc14328) P248 Immune response after prolonged hyperoxic mechanical ventilation HJ Helmerhorst1, LR Schouten2, NP Juff ermans2, MJ Schultz2, E De Jonge1, DJ Van Westerloo1 1Leiden University Medical Center, Leiden, the Netherlands; 2Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P248 (doi: 10.1186/cc14328) 1Leiden University Medical Center, Leiden, the Netherlands; 2Academic Medical Center, Amsterdam, the Netherlands Results RM improved oxygenation compared with the PEEP group. The mean increase in the oxygenation index at the end of surgery was 31% (from 340 to 445 mmHg, P <0.05), in the PEEP group the increase was less signifi cant and amounted to 12% (from 330 to 370 mmHg, P <0.05). Dynamic compliance increased by 35% in the RM group and did not change in the PEEP group. Hemodynamic changes at RM were Critical Care 2015, 19(Suppl 1):P248 (doi: 10.1186/cc14328) Introduction Mechanical ventilation and hyperoxia independently promote pulmonary injury and infl ammation. However, the time course of the immune response following concurrent exposure is unclear. The Introduction Mechanical ventilation and hyperoxia independently promote pulmonary injury and infl ammation. However, the time course of the immune response following concurrent exposure is unclear. The Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S87 lungs. We used EIT with increased signal quality and spatial resolution to describe and quantify the regional changes in aeration caused by body position, both during spontaneous breathing and mechanical ventilation in pulmonary healthy patients undergoing laparoscopic prostatectomy. lungs. We used EIT with increased signal quality and spatial resolution to describe and quantify the regional changes in aeration caused by body position, both during spontaneous breathing and mechanical ventilation in pulmonary healthy patients undergoing laparoscopic prostatectomy. Figure 1 (abstract P248). Infl ammatory mediators independent of tidal volumes after 12 hours of MV. Methods In 40 patients we performed EIT measurements at fi ve points of time (Table 1) with the Swisstom BB2 prototype. Structural and functional eff ects of mechanical ventilation and aging on single rat diaphragm muscle fi bers N Cacciani, H Ogilvie, L Larsson Karolinska Institutet, Solna – Stockholm, Sweden Critical Care 2015, 19(Suppl 1):P250 (doi: 10.1186/cc14330) p g g Methods Healthy male C57Bl/6J mice, aged 9 to 10 weeks, were randomly assigned to experimental groups (n = 8), in which the applied fractions of oxygen (FiO2) were 30%, 50% or 90% and tidal volumes were either 7.5 or 15 ml/kg. Anesthetized mice were tracheotomized and ventilated for 8 or 12 hours. Infl ammatory cells and mediators were measured in bronchoalveolar lavage fl uid (BALf).i Introduction The still unclear mechanisms causing ventilator- induced diaphragm dysfunction (VIDD) are considered intrinsic to the diaphragm muscle fi bers. VIDD delays and complicates weaning from mechanical ventilation (MV) and accordingly contributes to prolonged ICU stay by 50%, with older patients being more aff ected than the young. The main aim of this study was to measure the eff ects of aging and 5 days of MV on rat diaphragm muscle fi ber structure and function. We also aimed to investigate the biological age of the old rats to obtain data useful to design future experimental studies focusing on the eff ects of age in an ICU setting. Results Mice exposed to higher FiO2 had signifi cantly higher PaO2 levels at the end of the experiment. The total number of infl ammatory cell in the BALf was not signifi cantly diff erent between the experimental groups (P = 0.28), yet an increasing trend in the percentage of neutrophils was observed with increasing FiO2 (P = 0.03). Cytokine and chemokine levels did not diff er between FiO2 groups at 8 hours of ventilation. In mice ventilated for 12 hours, a signifi cantly increasing trend in IFNγ, IL-1β, IL- 10, MCP-1 and TNFα (Fig. 1, P <0.01) was measured with increasing FiO2, whereas IL-6, KC, MIP-2, GM-CSF and VEGF remained virtually unchanged. Diff erences between the tidal volume groups were small and did not markedly infl uence the eff ects of hyperoxia. See Figure 1.f Methods We used a unique ICU rat model, which allows us to maintain the vital parameters stable under deep sedation and MV for long durations (several weeks). Diaphragm fi ber cross-sectional area (CSA) and force-generating capacity (specifi c force = absolute force / CSA) were measured in young (6 months) and old (28 to 32 months) F344/ BN hybrid rats in response to 5 days of deep sedation and volume- controlled MV. P250 Structural and functional eff ects of mechanical ventilation and aging on single rat diaphragm muscle fi bers N Cacciani, H Ogilvie, L Larsson Karolinska Institutet, Solna – Stockholm, Sweden Critical Care 2015, 19(Suppl 1):P250 (doi: 10.1186/cc14330) Structural and functional eff ects of mechanical ventilation and aging on single rat diaphragm muscle fi bers N Cacciani, H Ogilvie, L Larsson Karolinska Institutet, Solna – Stockholm, Sweden Critical Care 2015, 19(Suppl 1):P250 (doi: 10.1186/cc14330) To investigate the biological age of the old rats, we performed a second set of experiments, comparing muscle fi ber CSA and specifi c force in fast and slow-twitch distal hind limb muscles in three diff erent age groups: young adults (6 months), middle aged (18 months) and old rats (28 months). ylf yp g Conclusion Hyperoxia induced a time-dependent and diff erentiated immune response that was independent of tidal volumes in a model of mechanically ventilated mice. The presence of cytokines and chemokines in the pulmonary compartment was more pronounced with prolonged and severe hyperoxia. P248 Thirty-two electrodes were used to apply weak alternating currents to the thorax and to measure the resulting voltages, from which tomographic images of the changes in regional impedance caused by ventilation were created. We describe the ventilation distribution using a novel EIT lung function parameter called Silent Spaces that provides information about areas that do not receive much or any air during tidal breathing and are divided into nondependent (NSS) and dependent Silent Spaces (DSS) using a reference line that runs perpendicular to the gravity vector right through the centre of ventilation. NSS and DSS are expressed as a percentage of the total lung area. Results Perioperative changes of NSS and DSS are shown in Table 1 as mean ± SD. Statistically signifi cant diff erences marked by § when compared with 1 or by * when compared with 3 (P <0.05). Conclusion We describe for the fi rst time the mapping of Silent Spaces during spontaneous breathing and changing ventilation conditions and body positions in patients with healthy lungs using EIT. This mapping of Silent Spaces might prove useful for developing perioperative protective ventilation strategies. Figure 1 (abstract P248). Infl ammatory mediators independent of tidal volumes after 12 hours of MV. aim of this preclinical study was to study both time-dependent and dose-dependent eff ects of supplemental oxygen during prolonged ventilatory support on pulmonary infl ammation in a well-established murine model of ventilation comparing low and high tidal volumes. aim of this preclinical study was to study both time-dependent and dose-dependent eff ects of supplemental oxygen during prolonged ventilatory support on pulmonary infl ammation in a well-established murine model of ventilation comparing low and high tidal volumes. Methods Healthy male C57Bl/6J mice, aged 9 to 10 weeks, were randomly assigned to experimental groups (n = 8), in which the applied fractions of oxygen (FiO2) were 30%, 50% or 90% and tidal volumes were either 7.5 or 15 ml/kg. Anesthetized mice were tracheotomized and ventilated for 8 or 12 hours. Infl ammatory cells and mediators were measured in bronchoalveolar lavage fl uid (BALf).i Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods All 89 inpatients on the CCU who received mechanical ventilation continuously for 7 days or more between October 2012 and December 2013 were initially included. Forty patients who were intubated prior to arrival at RCHT, had incomplete notes, or were extubated during end-of-life care were excluded. Patients were divided into groups by fi rst airway intervention; 31 TOE, 18 TR. fi bers from young, middle aged and old animals confi rmed the 28 to 32 month rats to be senescent from a skeletal muscle point of view. p Conclusion These results demonstrate intrinsic changes in diaphragm muscle fi bers of signifi cant importance for the prolonged and complicated weaning from MV. Moreover, the increased number of frail diaphragm muscle fi bers observed after MV in old age, both controls and mechanically ventilated, off ers a further age-related possible mechanism which may be of signifi cant clinical importance. These results also provided useful information to design future experimental studies focused on the eff ect of age in an ICU setting, pharmacological intervention strategies as well as mechanisms underlying rat strain diff erences. g p yi y ; , Results A total 52% (16/31) of patients had TOE, required no other airway intervention and survived to discharge from hospital, compared with 72% (13/18) of TR patients. Four patients from each group failed the fi rst intervention and died prior to a second intervention. In total, 8/11 patients who had a second intervention after failed TOE survived to discharge from hospital. One patient had a second TR but died before discharge. This gave an in-hospital mortality rate of 19% for the TOE group and 28% for the TR group. TOE was performed earlier, all 31 on days 7 to 15. TR was performed later; 14/18 on days 7 to 15, and 4/18 on days 17 to 23. Early TR was more successful; 11/11 survived to discharge without a second intervention who had TR on days 7 to 12, compared with 29% (2/7) after day 12. TOE was more successful when performed later; 64% (7/11) survived to discharge without a second airway intervention when TOE was after day 10, 45% (9/20) between days 7 and 10. Initial pH and mortality in patients with exacerbations of COPD and pneumonia treated with NIV in a teaching hospital critical care unit IM Goodhart, MC Faulds, S Lobaz, AJ Glossop Sheffi eld Teaching Hospitals NHS FT, Sheffi eld, UK Critical Care 2015, 19(Suppl 1):P253 (doi: 10.1186/cc14333) Results Twenty-eight patients were included in G1 and 22 patients in G2. There was no signifi cant diff erence between the patients’ admission parameters and daily NIV usage times. PaCO2 decreased >5 mmHg in 93% of G1 patients and in 60% of G2 patients in the fi rst 6 hours (P = 0.044). A 10 mmHg reduction in PaCO2 occurred in more patients (93% vs. 60%, P = 0.004) and in a shorter time (1.8 ± 1.2 vs. 3 ± 3 days, P = 0.044) in G1. At the time of discharge, PaCO2 levels were <50 mmHg in 79% of G1 and 41% of G2 patients (P = 0.006). Both groups showed similar and signifi cant improvements in PaO2, PaCO2 and HCO3 – levels within the fi rst 4 days but only in G1 patients were HCO3 – levels decreased more rapidly than G2 patients (P = 0.007). Duration of NIV (6 ± 2 vs. 8 ± 3 days, P = 0.002) and the number of mode and pressures changes (0.3 ± 1.8 vs. 2 ± 2 times, P >0.0001) were signifi cantly less in G1. While mean IPAP was similar in both groups, maximum and minimum EPAP titrated automatically in G1 were signifi cantly diff erent from G2. Mean tidal volume and amount of leakage were also signifi cantly higher in G1. fi g pfi Critical Care 2015, 19(Suppl 1):P253 (doi: 10.1186/cc14333) fi g pfi Critical Care 2015, 19(Suppl 1):P253 (doi: 10.1186/cc14333) Introduction Bilevel non-invasive ventilation (NIV) is an established therapy in chronic obstructive pulmonary disease (COPD) but confl icting evidence exists for its use in patients with pneumonia. Initial arterial pH <7.25 is used as a marker of severity and need for admission to critical care (CC) [1]. We examined the impact of pH and condition on outcome in patients with acute respiratory failure (ARF) of mixed aetiology treated with NIV. Methods Data were collected retrospectively for a 5-year period from 2008 to 2013 using the Metavision electronic patient record. We identifi ed all patients admitted with ARF treated with bilevel NIV. Patients who received continuous positive airway pressure or had a primary surgical problem were excluded. Initial pH and mortality in patients with exacerbations of COPD and pneumonia treated with NIV in a teaching hospital critical care unit IM Goodhart, MC Faulds, S Lobaz, AJ Glossop Sheffi eld Teaching Hospitals NHS FT, Sheffi eld, UK Critical Care 2015, 19(Suppl 1):P253 (doi: 10.1186/cc14333) We recorded primary cause of respiratory failure, arterial blood gas values and mortality.i g gi y g Conclusion These results suggest that the AVAPS-AE mode may provide some advantages in hypercapnic ICU patients such as rapid PaCO2 reduction, less NIV duration and workload. Results A total of 145 patients were identifi ed. Mean age was 64 and 51% were male. The primary diagnosis was pneumonia in 69 patients and exacerbation of COPD in 57. The overall mortality was 19% on CC and 39% at 1 year. In patients with COPD, infective exacerbations had a higher CC mortality (17%) compared with non-infective (0%). However, by 1 year the mortality was 28% in infective and 29% in non-infective. Patients with pneumonia had a higher mortality on CC (25%) and at 1 year (48%). Patients with an initial pH <7.25 were less likely to survive. The mortality at discharge from CC was 16% (pH ≥7.25) and 26% (pH <7.25) but narrowed to 38% and 39% by 1 year. When subdivided, it was found that patients with infective COPD and pH <7.25 had the lowest 1-year mortality (17%) while those with pneumonia and pH <7.25 had the highest mortality (67%). P251 P251 Does it make a diff erence to add automatic EPAP titration to the volume-targeted pressure support mode in noninvasive ventilation of hypercapnic ICU patients? G Gursel, A Zerman, B Basarik, K Gonderen, M Aydogdu, S Memmedova Gazi University Medical Faculty, Ankara, Turkey Critical Care 2015, 19(Suppl 1):P251 (doi: 10.1186/cc14331) Introduction Obese patients are increasing in number in ICUs and more than 90% of them also have sleep apnea syndrome. Variability in upper airway resistance during sleep and awakening periods makes it diffi cult to set EPAP in these patients. A new mode that automatically titrates EPAP according to upper airway resistance and IPAP according to target tidal volume may be more eff ective. The aim of this study is to evaluate whether adding automatic EPAP titration to the volume-targeted pressure support mode will provide any therapeutic advantages in hypercapnic ICU patients. Conclusion TOE is more common and is associated with shorter time spent ventilated, in the CCU and in hospital than TR. It is also associated with a lower in-hospital mortality rate. TOE is more successful when performed after day 10; TR is more successful when performed before day 13. After failed TOE, a second TOE is associated with longer time in hospital but a better mortality rate than secondary tracheostomy. y Methods The hypercapnic patients treated with average volume- assured pressure support-automatic EPAP (AVAPS-AE) mode (Group1 (G1)) were compared with those treated with AVAPS mode (Group 2 (G2)). G2 was recruited retrospectively and matched with G1 according to diagnoses, demographic characteristics, arterial blood gas values and daily noninvasive ventilation (NIV) usage times. Trilogy 100® devices and their software Directview® (Philips Respironics) were used to reveal the respiratory data such as pressures, volumes, and daily usage times. For statistical analyses, t test, chi-square test and repeated measures of ANOVA were used. P253 Initial pH and mortality in patients with exacerbations of COPD and pneumonia treated with NIV in a teaching hospital critical care unit IM Goodhart, MC Faulds, S Lobaz, AJ Glossop Sheffi eld Teaching Hospitals NHS FT, Sheffi eld, UK Critical Care 2015, 19(Suppl 1):P253 (doi: 10.1186/cc14333) P249 Perioperative assessment of regional ventilation during changing body positions and ventilation conditions by electrical impedance tomography with increased spatial resolution and signal quality A März1, A Ukere1, K Wodack1, C Trepte1, A Waldmann2, S Böhm2, D Reuter1 1University Medical Center Hamburg-Eppendor, University Hamburg, Germany; 2Swisstom AG, Landquart, Switzerland Critical Care 2015, 19(Suppl 1):P249 (doi: 10.1186/cc14329) Perioperative assessment of regional ventilation during changing body positions and ventilation conditions by electrical impedance tomography with increased spatial resolution and signal quality A März1, A Ukere1, K Wodack1, C Trepte1, A Waldmann2, S Böhm2, D Reuter1 1University Medical Center Hamburg-Eppendor, University Hamburg, Germany; 2Swisstom AG, Landquart, Switzerland Critical Care 2015, 19(Suppl 1):P249 (doi: 10.1186/cc14329) Results This study demonstrated an unexpected increase in CSA (P <0.001) of the diaphragm fi bers in response to 5 days of MV in both young and old animals. Maximum force decreased 39.8 to 45.2% (P <0.001) in both young and old animals compared with controls, resulting in a dramatic loss of specifi c force. This increase in CSA and the concomitant decrease in specifi c force observed in both young and old diaphragm fi bers are compatible with an ineff ective compensatory hypertrophy in response to the MV. The comparison of the limb muscles Introduction Electrical impedance tomography (EIT) is a functional imaging technology allowing one to regionally monitor aeration of the Table 1 (abstract P249) 1 2 3 4 5 (sitting, (supine, (ventilated, (ventilated, (ventilated, spontaneous breathing) spontaneous breathing) supine position) 30° head down position) supine position) NSS (%) 5.25 ± 2.9 4.12 ± 1.89§ 3.05 ± 1.9§ 2.8 ± 2.7§ 2.67 ± 1.9§ DSS (%) 0.07 ± 0.3 2.29 ± 2.3§ 9.23 ± 6.3§ 11.5 ± 8.9§* 8.5 ± 5.8§ Table 1 (abstract P249) 1 2 3 4 5 (sitting, (supine, (ventilated, (ventilated, (ventilated, spontaneous breathing) spontaneous breathing) supine position) 30° head down position) supine position) NSS (%) 5.25 ± 2.9 4.12 ± 1.89§ 3.05 ± 1.9§ 2.8 ± 2.7§ 2.67 ± 1.9§ DSS (%) 0.07 ± 0.3 2.29 ± 2.3§ 9.23 ± 6.3§ 11.5 ± 8.9§* 8.5 ± 5.8§ S88 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 After fi rst failed TOE, four patients had a successful second TOE; all four survived to discharge resulting in a median CCU stay of 29 days and median hospital stay of 39 days (excluding prior to CCU admission). Seven patients had TR after the fi rst failed TOE, fi ve survived to discharge from the CCU and four to discharge from the hospital. This group had shorter median stays in both the CCU (27 days) and hospital (32 days). Overall, the median duration of time ventilated, in the CCU, and in hospital was shorter for the TOE group; 13, 17 and 24 days respectively, compared with 22, 27.5 and 34 days for the TR group. P252 Retrospective study of patients receiving long-term mechanical ventilation I D d B H d R Si l i I Dunwoody, B Hopwood, R Sinclair Royal Cornwall Hospital, Truro, UK Critical Care 2015, 19(Suppl 1):P252 (doi: 10.1186/cc14332) Introduction This study analysed the practice of clinicians managing patients requiring long-term mechanical ventilation in the critical care unit (CCU) of the Royal Cornwall Hospital, Truro (RCHT), comparing outcomes of primary tracheostomy (TR) with trial of extubation (TOE). Conclusion NIV is used in our unit with comparable success rates to published series [2,3]. COPD patients responded well to NIV, while Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S89 patients with pneumonia treated with NIV have the highest mortality. A low presenting pH is associated with a higher mortality in patients with pneumonia treated with NIV. However, in COPD patients, pH <7.25 is not associated with higher mortality in CC or at 1 year. Further work defi ning the precise role of pH as a prognostic indicator is warranted. References patients with pneumonia treated with NIV have the highest mortality. A low presenting pH is associated with a higher mortality in patients with pneumonia treated with NIV. However, in COPD patients, pH <7.25 is not associated with higher mortality in CC or at 1 year. Further work defi ning the precise role of pH as a prognostic indicator is warranted. References care units within the NoECCN. Patient data collected included patient demographics, admission diagnosis and speciality, hospital length of stay (LOS) pre and post critical care admission, severity of illness scores, critical care LOS and status at hospital discharge. p g Results During the study period 134 patients met the criteria for PMV representing 1% of annual admissions and 6.9% NoECCN bed- days. The majority of patients receiving PMV were medical (50.7%), followed by emergency surgery (20.1%), elective surgery (16.4%) and specialist services such as spinal cord injury (8.2%) and cardiothoracic transplant (4.5%). The commonest admission diagnosis in the medical population was pulmonary infection followed by acute neurological disorders, while 89.4% of surgical patients were admitted to critical care during the perioperative period. At the end of the study period the highest hospital mortality was observed in the nonspecialist surgical population (26.5%). In contrast, the medical population had one of the lowest hospital mortality rates (11.8%), lower than predicted using the intensive care national audit research network illness severity score. P254 Lung protective ventilation with lower tidal volumes and development of pulmonary complications in critically ill patients without ARDS FD Simonis1, A Serpa Neto2, M Gama de Abreu3, P Pelosi4, MJ Schultz1 1Academic Medical Center, Amsterdam, the Netherlands; 2Hospital Isrealita Albert Einstein, São Paulo, Brazil; 3University Hospital Carl Gustav Carus, Dresden, Germany; 4IRCCS San Martino IST, Genoa, Italy Critical Care 2015, 19(Suppl 1):P254 (doi: 10.1186/cc14334) Reference 1. Pilcher DV, et al. Outcomes, cost and long term survival of patients referred to a regional weaning unit. Thorax. 2005;60:187-92. Methods An individual patient data meta-analysis of studies of ventilation in ICU patients without ARDS. Corresponding authors of retrieved studies provided individual patient data. The primary outcome, pulmonary complications, was a composite of development of ARDS or pneumonia during hospital stay. Secondary outcomes included ICU and hospital length of stay, and in-hospital mortality. Patients were assigned to three groups based on tidal volume size (≤7 ml/kg predicted body weight (PBW), 7 to 10 ml/kg PBW, or ≥10 ml/ kg PBW). P252 Retrospective study of patients receiving long-term mechanical ventilation I D d B H d R Si l i Comparable rates of hospital discharge were found in both medical (85%) and nonspecialist surgical patients (88.9%). 1. 2013 BTS NIV audit. https://www.brit-thoracic.org.uk/document-library/ audit-and-quality-improvement/audit-reports/ bts-adult-niv-audit-report-2013/ 2. Carillo et al. ICM. 2012;38:458-66. 3. Lightowler et al. BMJ. 2003;326:185-9. Lung protective ventilation with lower tidal volumes and development of pulmonary complications in critically ill patients without ARDS FD Simonis1, A Serpa Neto2, M Gama de Abreu3, P Pelosi4, MJ Schultz1 1Academic Medical Center, Amsterdam, the Netherlands; 2Hospital Isrealita Albert Einstein, São Paulo, Brazil; 3University Hospital Carl Gustav Carus, Dresden, Germany; 4IRCCS San Martino IST, Genoa, Italy Critical Care 2015, 19(Suppl 1):P254 (doi: 10.1186/cc14334) g Conclusion The results of this study highlight an expanding proportion of NoECCN critical care bed-days occupied by stable patients undergoing PMV. In keeping with published UK data, elevated hospital mortality was observed in the nonspecialist surgical subpopulation. Although the literature suggests the medical cohort of patients has poorer prognosis, within our region all were liberated from mechanical ventilation and over 80% were discharged from hospital. R f Introduction A large meta-analysis suggests that use of low tidal volumes benefi ts patients without ARDS [1] but most studies in this meta-analysis included patients receiving ventilation during general anesthesia for surgery. The aim of the present meta-analysis is to determine the association between tidal volume size and development of pulmonary complications in ICU patients. Eff ects of positive end-expiratory pressure on lung ventilation/ perfusion matching: a clinical study N Eronia1, T Mauri2, G Bellani1, R Marcolin1, S Marocco Arrigoni1, G Grasselli1, A Pesenti1 , 1San Gerardo Hospital, Monza, Italy; 2IRCC Ca’ Granda Maggiore Policlinico Hospital, Milan, Italy Critical Care 2015, 19(Suppl 1):P256 (doi: 10.1186/cc14336) Results Seven investigations (2,184 patients) were meta-analyzed. Pulmonary complications occurred in 23%, 28% and 31% respectively in the ≤7 ml/kg PBW, 7 to 10 ml/kg PBW and ≥10 ml/kg PBW group (adjusted RR, 0.72; 95% CI, 0.52 to 0.98; P = 0.042). Occurrence of pulmonary complications was associated with a lower number of ICU- free days and alive at day 28, a lower number of hospital-free days and alive at day 28 and increased in-hospital mortality. Introduction Positive end-expiratory pressure (PEEP) exerts multiple protective eff ects in hypoxemic critically ill patients: PEEP can increase end-expiratory lung volume (EELV) and induce recruitment, thus reducing lung strain and opening and closing of alveoli and potentially improving the ventilation/perfusion matching. In particular, estimation of PEEP-induced ventilation/perfusion matching might help identify the optimal PEEP setting, but bedside non-invasive methods are few and complex to be applied in daily clinical practice. Electrical impedance tomography (EIT) is a non-invasive bedside technique that claims to track global and regional changes in perfusion and ventilation over time. In the present study we aimed at verifying the eff ects of PEEP on ventilation/perfusion matching, as assessed by EIT, in acute respiratory failure patients. Conclusion Ventilation with low tidal volumes is associated with a lower risk of development of pulmonary complications. Occurrence of pulmonary complications is associated with an increased ICU and hospital length of stay and in-hospital mortality in ICU patients without ARDS. Reference Reference 1. Serpa Neto A, et al. JAMA. 2012;308:1651-9. Reference 1. Serpa Neto A, et al. JAMA. 2012;308:1651-9. 1. Serpa Neto A, et al. JAMA. 2012;308:1651-9. p y p Methods We enrolled 20 intubated critically ill patients undergoing controlled mechanical ventilation, sedated, paralyzed and with PaO2/FiO2 ≤300 at PEEP ≥5 cmH2O. We started EIT monitoring (Pulmovista500®; Dräger Medical GmbH, Lübeck, Germany) and applied two PEEP levels (clinical and clinical + 5 cmH2O) for 20 minutes each. We collected ventilatory and EIT parameters and, by offl ine analysis, we calculated the increase of EELV at higher PEEP and the EIT- based indexes of ventilation heterogeneity (VtHetend-insp) and of the regional homogeneity of ventilation/perfusion matching (HA/P). P255 Factors associated with survival and hospital discharge amongst critically ill patients undergoing prolonged mechanical ventilation in the North of England Critical Care Network L O’Connor1, I Gonzalez2, L Garcia2 1Sunderland Royal Hospital, Sunderland, UK; 2James Cook University Hospital, Middleborough, UK Critical Care 2015, 19(Suppl 1):P255 (doi: 10.1186/cc14335) Factors associated with survival and hospital discharge amongst critically ill patients undergoing prolonged mechanical ventilation in the North of England Critical Care Network L O’Connor1, I Gonzalez2, L Garcia2 1Sunderland Royal Hospital, Sunderland, UK; 2James Cook University Hospital, Middleborough, UK Critical Care 2015, 19(Suppl 1):P255 (doi: 10.1186/cc14335) Pressure reconstruction method for spontaneous breathing eff ort monitoring Pressure reconstruction method for spontaneous breathing eff ort monitoring N Damanhuri1, YS Chiew1, NA Othman1, PD Docherty1, GM Shaw2, JG Chase1 1University of Canterbury, Christchurch, New Zealand; 2Christchurch Hospital, Christchurch, New Zealand Critical Care 2015, 19(Suppl 1):P259 (doi: 10.1186/cc14339) N Damanhuri1, YS Chiew1, NA Othman1, PD Docherty1, GM Shaw2, JG Chase1 1University of Canterbury, Christchurch, New Zealand; 2Christchurch Hospital, Christchurch, New Zealand Critical Care 2015, 19(Suppl 1):P259 (doi: 10.1186/cc14339) Introduction Estimating respiratory mechanics of mechanically venti lated patients is unreliable when patients exhibit spontaneous breathing (SB) eff orts on top of ventilator support. This reverse triggering eff ect [1] results in an M-wave shaped pressure wave. A model-based method to reconstruct the aff ected airway pressure curve is presented to enable estimation of the true underlying respiratory mechanics of these patients. Table 1 (abstract P257) Ki <27.8 ml/ Ki ≥27.8 ml/ minute/ml minute/ml × 104 (n = 7) × 104 (n = 8) P value PaO2/FiO2 280 (261 to 346) 239 (212 to 271) 0.31 pH 7.46 (7.43 to 7.48) 7.41 (7.39 to 7.44) 0.15 PaCO2 (mmHg) 37 (34 to 44) 50 (46 to 53) 0.01 WBCs (103 cell/mm3) 8 (8 to 9) 9 (9 to 16) 0.34 Total lung volume (ml) 1,298 (1,092 to 1,494) 1,516 (1,408 to 1,665) 0.18 Total lung weight (g) 592 (488 to 741) 732 (597 to 774) 0.39 Total lung gas (ml) 706 (551 to 843) 804 (755 to 1,080) 0.15 Not-infl ated lung tissue (%) 25 (12 to 30) 23 (17 to 30) 0.95 Poorly infl ated lung tissue (%) 34 (42 to 42) 31 (29 to 34) 0.39 Well-infl ated lung tissue (%) 36 (27 to 47) 47 (35 to 52) 0.53 Conclusion Patients clinically defi ned as having primary graft dysfunction did not have an increased rate of 18-FDG uptake. 18-FDG uptake was not diff erent in single-lung versus bilateral transplantation and, in single-lung procedures, the native lung showed elevated infl ammatory activity. Methods Airway pressure and fl ow data from 72 breaths of a pneu- monia patient were used for proof of concept. A pressure wave reconstruction method fi lls parts of the missing area caused by SB eff orts and reverse triggering by connecting the peak pressure and end-inspiration slope (Figure 1). A time-varying elastance model [2] was then used to identify underlying respiratory elastance (AUCEdrs). P258 4.8) vs. 1.9 (1.5 to 2.1), P <0.01) and lower compliance of dependent lung regions (Crsdep, 13 ± 3 ml/cmH2O vs. 18 ± 6 ml/cmH2O, P <0.05), as compared with patients with smaller improvement. 4.8) vs. 1.9 (1.5 to 2.1), P <0.01) and lower compliance of dependent lung regions (Crsdep, 13 ± 3 ml/cmH2O vs. 18 ± 6 ml/cmH2O, P <0.05), as compared with patients with smaller improvement. P257 18-FDG PET in lung transplantation I Al 1 F V l 1 M G l 1 B S f P257 18-FDG PET in lung transplantation I Al 1 F V l 1 M G l 1 B S f 18-FDG PET in lung transplantation I Algieri1, F Valenza1, M Guanziroli1, B Safaee Fakhr1, M Cressoni1, M Brioni1, A Colombo1, G Babini1, F Crimella1, D Massari1, K Nikolla1, G Crisafulli1, S Paladini1, L Rosso2, A Palleschi2, F Zito2, D Chiumello1, L Gattinoni1 1Università degli Studi di Milano, Milan, Italy; 2Fondazione IRCCS Ca’ Granda- Ospedale Maggiore Policlinico, Milan, Italy Critical Care 2015, 19(Suppl 1):P257 (doi: 10.1186/cc14337) p g p g p g p g p Results The median value of LU comets was signifi cantly lower in Group A compared with Group B. There was a signifi cant increase in hypoxic index in Group A compared with Group B. There was no signifi cant diff erence between both groups as regards PIP, while Pplat showed a signifi cant increase in Group B compared with Group A and Cs showed a signifi cant decrease in Group B. Introduction Lung transplantation is associated with an infl ammatory reaction known as primary graft dysfunction. This clinical syndrome occurs within the fi rst 72 hours after transplantation and is characterized by hypoxemia (PaO2/FiO2 <300) and bilateral infi ltrates not secondary to cardiac dysfunction, viral or bacterial pneumonia and venous anastomotic obstruction. gi p Conclusion LU is a useful to quantify EVLW; it is a good predictor of weaning. References Methods 18-FDG PET scan was used to study 15 lung transplantation patients. The rate of 18-FDG uptake (Ki) was computed voxel by voxel with the Patlak method. Patients were divided according to the median Ki (27.8 (20.3 to 34.6) ml/minute/ml × 104). Data are reported as median and interquartile range. 1. Nektaria X, Eumorfi a K, George P, et al. Impact of lung ultrasound on clinical decision making in critically ill patients. Intensive Care Med. 2014;40:57-65. 2. Jambrik Z, Monti S, Coppola V, et al. Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. Am J Cardiol. 2004;93:1265-70. 2. Jambrik Z, Monti S, Coppola V, et al. Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. Am J Cardiol. 2004;93:1265-70. Results Five patients developed primary graft dysfunction; median Ki in these patients was not diff erent from patients who did not (24.5 (18.2 to 33.6) ml/minute/ml × 104 vs. 29.1 (23 to 35.4) ml/minute/ ml × 104 respectively, P = 0.64). Bilateral lung transplantation patients were characterized by a median Ki of 30.5 (22.9 to 34.5) ml/minute/ ml × 104, while patients undergoing single-lung transplantation presented a median Ki of 24.4 (21 to 34.1) ml/minute/ml × 104 (P = 0.61). Considering single-lung transplantation, graft and native lung had similar Ki: 24.4 (21 to 34.1) ml/minute/ml × 104 versus 24.2 (17.7 to 30.1) ml/minute/ml × 104 respectively (P = 0.64). When patients were divided according to the median Ki value, higher Ki was associated with higher PaCO2 values (50 (46 to 53) mmHg vs. 37 (34 to 44) mmHg, P = 0.01). See Table 1. Usefulness of extravascular lung water assessment as a predictor of weaning from mechanical ventilation Usefulness of extravascular lung water assessment as a predictor of weaning from mechanical ventilation Conclusion EIT might represent a feasible, bedside method to estimate PEEP-induced improvement in ventilation/perfusion matching. Assessing regional ventilation and mechanical lung properties might help identify patients who would benefi t more from higher PEEP. g Alexandria University Hospital, Alexandria, Egypt Critical Care 2015, 19(Suppl 1):P258 (doi: 10.1186/cc14338) Introduction Quantitative measurement of extravascular lung water (EVLW) would be extremely useful for clinical management, both as an index of severity and to guide treatment lung ultrasonography (LU) as a tool to quantify EVLW. q y Methods Forty mechanically ventilated patients were examined for 5 successive days after being eligible for weaning; counting B-lines (comets) in both lung fi elds by LU, peak airway pressure, plateau airway pressure, static compliance and ABG analysis every 6 hours. Patients were divided into two groups according to success of the weaning process: group A (weaned group), and group B (nonweaned group). Results The median value of LU comets was signifi cantly lower in Group A compared with Group B. There was a signifi cant increase in hypoxic index in Group A compared with Group B. There was no signifi cant diff erence between both groups as regards PIP, while Pplat showed a signifi cant increase in Group B compared with Group A and Cs showed a signifi cant decrease in Group B. Pressure reconstruction method for spontaneous breathing eff ort monitoring The area of the unreconstructed M-wave has less pressure, resulting in a lower overall AUCEdrs without reconstruction. The missing area of the airway pressure or AUCEdrs is hypothesized to be a surrogate of patient- specifi c inspiratory to assess the strength of SB eff orts. AUCEdrs and missing area A2 are compared with/without reconstruction.if 2 Results Median AUCEdrs and breath-specifi c eff ort using reconstruction were 24.99 (IQR: 22.90 to 25.98) cmH2O/l and 3.64 (IQR: 0.00 to 3.87)% versus AUCEdrs of 20.87 (IQR: 15.24 to 27.48) cmH2O/l for unreconstructed M-wave data, indicating signifi cant patient and breath-specifi c SB eff ort, and the expected higher elastance (P <0.05). Conclusion A simple reconstruction method enables the real-time measurement of respiratory system properties of a SB patient and measures the surrogate of the SB eff ort, that latter of which has clinical use in deciding whether to extubate or re-sedate the patient. Conclusion Patients clinically defi ned as having primary graft dysfunction did not have an increased rate of 18-FDG uptake. 18-FDG uptake was not diff erent in single-lung versus bilateral transplantation and, in single-lung procedures, the native lung showed elevated infl ammatory activity. Factors associated with survival and hospital discharge amongst critically ill patients undergoing prolonged mechanical ventilation in the North of England Critical Care Network L O’Connor1, I Gonzalez2, L Garcia2 Critical Care 2015, 19(Suppl 1):P255 (doi: 10.1186/cc14335) g g y p g Results Patients were 62 ± 12 years old, mean PaO2/FiO2 was 197 ± 52, lower PEEP level was 7 (7 to 9) cmH2O, while higher PEEP was 12 (12 to 14) cmH2O (P <0.001). At higher PEEP, EELV increased (391 (334 to 555) ml vs. PEEP low, considered as baseline, P <0.001); VtHetend- insp was reduced (1.8 (1.5 to 2.4) vs. 2.2 (1.8 to 2.6), P <0.001) and HA/P increased (0.29 ± 0.19 vs. 0.2 ± 0.15, P <0.05). Interestingly, the increase of HA/P was signifi cantly correlated with the decrease of VtHetend- insp (r = –0.48, P <0.05). Moreover, patients with higher potential for improvement of ventilation/perfusion matching (that is, patients with increase of HA/P >16%) had higher baseline VtHetend-insp (2.6 (2.3 to Introduction The combination of a global demographic shift and increased survival following critical illness has led to an increasing number of patients requiring prolonged mechanical ventilation (PMV) and longer critical care stay. This is a prospective observational study evaluating the characteristics and speciality-based outcome of critically ill patients undergoing prolonged mechanical ventilation in the North of England Critical Care Network (NoECCN). Methods A weekly survey was conducted over a 1-year period screening patients older than 16 years of age requiring PMV in all 18 adult critical S90 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P257 q y Methods Forty mechanically ventilated patients were examined for 5 successive days after being eligible for weaning; counting B-lines (comets) in both lung fi elds by LU, peak airway pressure, plateau airway pressure, static compliance and ABG analysis every 6 hours. Patients were divided into two groups according to success of the weaning process: group A (weaned group), and group B (nonweaned group).i Breath-to-breath respiratory mechanics variation: how much variation should we expect? Each patient was sedated to prevent spontaneous breathing eff ort, and ventilated using the volume control mode with a square fl ow profi le. Varied PEEP levels were maintained for 30 minutes before 1 minute of data were collected for analysis. This dataset provides a wide range of respiratory mechanics values, and the clinical protocol detail is in [1]. A clinically proven, single compartment model respiratory system elastance (Ers) is identifi ed from data for every breathing cycle at each PEEP level using a linear regression method. The dynamic elastance (Edynamic = (peak airway pressure – positive end-expiratory pressure) / tidal volume) of the corresponding breathing cycle is calculated for comparison.fii p g g y p Results The coeffi cient of variation (CV) of identifi ed Ers across all patients was low (<0.005), as expected, as the 30-minute period allows time-dependent alveolar recruitment to fully occur and stabilise. However, even with substantial stabilisation periods, there remains a diff erence between the minimum and maximum estimated Ers within each 1-minute period of analysed data. The diff erences were median 2.8% (interquartile range (IQR): 1.5 to 4.6%, 90% range (90R): 0.8 to 13.4) for Ers and 3.6% (IQR: 2.3 to 5.2, 90R: 0.9 to 10.8) for Edynamic, and in extreme cases, can be up to 16%. Results Over 275 paired samples were analysed over the following concentration ranges: pH 7.249 to 7.545; pCO2 3.32 to 11.01 kPa; pO2 5.59 to 21.80 kPa; Hct 23.6 to 41.4%; K+ 3.3 to 4.79 mM. The imprecision for each sensor was calculated to be: pH –0.00 ± 0.03; pCO2 –0.48 ± 0.34 kPa; pO2 –0.85 ± 0.96 kPa; Hct –4.49 ± 3.42%; K+ 0.08 ± 0.15 mM, respectively. The data collected on the new analyser for Hct showed relative imprecision of 3.42%. The pooled SD was calculated to be 1.21% and the mean SD of each of the novel devices used was 1.14%. This indicates that scatter observed on the Hct sensor was largely due to inter-device rather than intra-device factors. Conclusion This study quantifi ed the variability (over short periods) of identifi ed and estimated respiratory mechanics properties used to (potentially) guide ventilation care in sedated patients. It is also important to note that this minimum level of variability occurs even when stabilisation is achieved. Breath-to-breath respiratory mechanics variation: how much variation should we expect? 1Sphere Medical, Cambridge, UK; 2University of Birmingham, UK Critical Care 2015, 19(Suppl 1):P261 (doi: 10.1186/cc14341) 1Sphere Medical, Cambridge, UK; 2University of Birmingham, UK Critical Care 2015, 19(Suppl 1):P261 (doi: 10.1186/cc14341) p KT Kim1, YS Chiew1, C Pretty1, GM Shaw2, T Desaive3, JG Chase1 1University of Canterbury, Christchurch, New Zealand; 2Christchurch Hospital, Christchurch, New Zealand; 3University of Liege, Belgium Critical Care 2015, 19(Suppl 1):P260 (doi: 10.1186/cc14340) KT Kim1, YS Chiew1, C Pretty1, GM Shaw2, T Desaive3, JG Chase1 1University of Canterbury, Christchurch, New Zealand; 2Christchurch Hospital, Christchurch, New Zealand; 3University of Liege, Belgium Critical Care 2015, 19(Suppl 1):P260 (doi: 10.1186/cc14340) Introduction Patient-dedicated arterial blood analysers off er the potential to allow close monitoring of critically ill patients without leaving the patient’s bedside or net loss of blood for the patient. A new patient-attached blood gas analyser was evaluated in a clinical environment to compare the results against the reference bench-top analyser. Introduction Model-based respiratory mechanics can be used to guide mechanical ventilation therapy. However, identifi ed mechanical properties vary breath to breath, leading to potential treatment errors when using model-based care that requires accuracy. This study investigates and quantifi es this variability to improve its application in guiding clinical interventions. Methods Twenty ICU patients with a range of clinical conditions, including trauma, head injury, post-surgical recovery and sepsis, were included in the study. The new analyser was operated by clinical staff at the Queen Elizabeth Hospital, Birmingham, who each underwent a 90-minute training programme. Patients were monitored using the patient-dedicated analyser (Proxima; Sphere Medical) for up to 3 days. Each time a sample was tested on the patient-dedicated analyser, a concurrent sample was drawn and tested on the hospital’s bench- top analyser (Cobas b221; Roche Diagnostics). Samples were assessed using methods described by Bland and Altman for repeated measures. Performance of the novel device was analysed by calculating bias as the mean diff erence between the new analyser and the comparator device, imprecision as ±1 standard deviation (SD) from the mean and limits of agreement as ±1.96 SD from the mean. Percentage values for bias and precision were calculated from analysis of the percentage diff erence between the two methods of analysis. Intra-device imprecision for the haematocrit (Hct) sensor was calculated using a pooled variance calculation. Methods Retrospective data from 12 acute respiratory distress syndrome (ARDS) patients were used [1]. 1. Bersten. Eur Respir J. 1998;12:526-32. References 1. Akoumianaki E, et al. Chest. 2013;143:927-38. 2. Chiew YS, et al. Biomed Eng Online. 2011;10:111. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 S91 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P259). Edrs for M-wave and reconstructed airway pressure at PEEP = 15 cmH2O. t PEEP = 15 cmH O Figure 1 (abstract P259). Edrs for M-wave and reconstructed airway pressure at PEEP = 15 cmH2O. P261 P261 Evaluation of a patient-dedicated blood gas analyser JJ Fox1, TH Clutton-Brock2 1Sphere Medical, Cambridge, UK; 2University of Birmingham, UK Critical Care 2015, 19(Suppl 1):P261 (doi: 10.1186/cc14341) Breath-to-breath respiratory mechanics variation: how much variation should we expect? Thus, clinically, if this information was to be used to guide ventilation in real time, such as titrating PEEP to minimal elastance, larger errors, at least up to 15% variation in Ers, could be expected, which could well aff ect care. Such levels thus also begin to defi ne the minimum levels of change necessary to be larger than natural variation. Conclusion The patient-dedicated blood gas analysers demonstrated excellent agreement with the bench-top analyser for pH, pCO2, pO2 and K+, while Hct provides a reasonable trend monitor with variable bias. Proxima is well suited to enable staff to more closely manage unstable and critically ill patients. This device may be of signifi cant benefi t to patients at risk of iatrogenic anaemia or those being treated in side rooms/isolation rooms. Tidal volume accuracy during non-invasive ventilation with modern neonatal mechanical ventilators K Moon, S Mizuguchi, K Tachibana, M Takeuchi Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi City, Osaka, Japan Critical Care 2015, 19(Suppl 1):P262 (doi: 10.1186/cc14342) K Moon, S Mizuguchi, K Tachibana, M Takeuchi Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi City, Osaka, Japan Critical Care 2015, 19(Suppl 1):P262 (doi: 10.1186/cc14342) Introduction Maintaining the appropriate tidal volume (VT) is important for success of lung protective ventilation. However, in neonates, the presence of airway leaks may increase the errors in the delivery of tiny VT, which raises a concern of ventilator-induced lung injury. This study is to investigate the accuracy of VT delivery during non-invasive ventilation (NIV) with modern neonatal ventilators. Results There was a signifi cant correlation between the indexed EE and indexed VE in both groups (R = 0.51, P <0.0001 in the control group; R = 0.63, P <0.0001 in the MV group). The VR was signifi cantly suppressed in the MV group compared with the control group (0.041 ± 0.003/minute/ BEE vs. 0.069 ± 0.003/minute/BEE, P = 0.012; respectively). Although the indexed VE was comparable in the MV and control groups (0.19 ± 0.07 l/ kg vs. 0.17 ± 0.04 l/kg, P = 0.23; respectively), the indexed EE was shifted to a higher range in the MV group than in the control group (maximal indexed EE; 2.26 ± 0.68 vs. 1.74 ± 0.20, P = 0.008; respectively). The TV was smaller (maximal TV; 985 ± 592 ml vs. 1,410 ± 299 ml, P = 0.018; respectively) and the RR was more frequent (maximal RR; 30 ± 8/minute vs. 16 ± 4/minute, P <0.0001; respectively) in the MV group than in the control group. Methods Using a lung simulator for a patient body weight of 3 kg, we measured the actual delivered VT in the lung and compared it with the value displayed on the ventilator in six ventilators. We tested 18 conditions with various combinations of respiratory mechanics (normal, restrictive, obstructive), leak levels (0, 1.0, 1.5 l/minute), and PEEP settings (5, 10 cmH2O). All conditions were tested in NIV mode. The pressure level was set to achieve VT to the lung at 6 to 7 ml/kg. All other settings were: FIO2 0.21, Itime 0.6 seconds, f 25/minute, and default rise time. We calculated the mean errors of the ventilator-displayed VT at various levels of airway leak. Eff ective capnography training in the ICU using the ‘hats and caps’ training tool Eff ective capnography training in the ICU using the ‘hats and caps training tool CA Lobo, FE Kelly, S Steynberg, G Thomas, C Pope, M Eveleigh, M Charlton, TM Cook Royal United Hospital, Bath, UK Critical Care 2015, 19(Suppl 1):P264 (doi: 10.1186/cc14344) Reference Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S92 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P262 The VE was indexed by body weight and the EE was also indexed by the basal energy expenditure (BEE) estimated by the Harris–Benedict formula. VR was defi ned as the slope in the indexed VE–indexed EE plot with an assumption of those relationship in the linear manner. We examined the correlation between indexed EE and indexed VE in both groups, and the diff erences of the maximal indexed EE, the maximal indexed MV, and the others between both groups were investigated using the unpaired t test. For all the data, signifi cance was accepted at values of P <0.05. P262 Tidal volume accuracy during non-invasive ventilation with modern neonatal mechanical ventilators K Moon, S Mizuguchi, K Tachibana, M Takeuchi Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi City, Osaka, Japan Critical Care 2015, 19(Suppl 1):P262 (doi: 10.1186/cc14342) Table 1 (abstract P262) Leak amount Hamilton Hamilton (l/minute) C3 G5 Servo i PB840 PB980 VN500 0 26 (15) 4 (6) 3 (2) 2 (7) –4 (2) 2 (2) 1.0 –9 (5) 9 (5) –2 (2) –5 (4) –2 (4) 20 (5) 1.5 16 (8) –14 (8) –2 (2) –6 (4) –2 (3) 33 (6)a Data presented as mean (SD), %. aUnable to measure in one case. Introduction Failure to use or correctly interpret capnography in patients dependent on an artifi cial airway in ICUs was thought to have contributed to 74% of ICU airway-related deaths in the NAP4 study [1]. However, capnography is only of value if those using it can interpret it correctly, with recommendations for training all ICU staff in capnography [1,2]. A recent UK survey identifi ed that only 48% of ICUs have trained all staff in capnography interpretation (TM Cook, personal communication). In this study, we used a capnography teaching aid (‘hats and caps’) to educate all ICU staff during a 1-month period, and evaluated its eff ectiveness. Conclusion Tidal volume accuracy during neonatal NIV varies greatly among diff erent ventilators and leak conditions. This must be considered in neonatal ventilation management to avoid over- ventilation or underventilation. Figure 1 (abstract P264). ‘Hats and caps’ capnography training guide. Tidal volume accuracy during non-invasive ventilation with modern neonatal mechanical ventilators Conclusion The VR to external stress with mechanical ventilation is more suppressed than in healthy volunteers. The VE in the mechanical ventilation was earned by a higher RR rather than by increased TV. Careful monitoring of VE or RR would be benefi cial in early rehabilitation with mechanical ventilation. y Results The VT mean error values are presented in Table 1. When no leak existed, the mean error was less than 5% in all ventilators except one (C3) which showed a mean error of 26%. As the leak level increased, three ventilators (C3, G5, and VN500) showed marked diff erences between the delivered and displayed VT. In particular, the VN500 could not operate in the large leak condition. The other three ventilators (PB840, PB980, Servo i) showed acceptable VT accuracy across all conditions tested. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods ‘Hats and caps’ was devised on our ICU [3] and used for the training: this teaches that capnography traces on the left signify the airway is functional, in contrast to the traces on the right which indicate immediate attention is required (Figure 1). This was presented to staff working on the ICU in individual bedside teaching sessions with feedback obtained and evaluated. percentage variation –1.4040 ± 4.73 (–2.15 to –0.67); r = 0.996 and r2 = 0.992 (P <0.000). Flow variation (l/minute) 3.82 ± 3.85 (3.04 to 4.69); fl ow percentage variation 9.76 ± 8.08 (8.11 to 11.41); r = 0.969 and r2 = 0.939 (P <0.000). (3) FiO2 variation –0.005 ± 0.26 (–0001 to 0009); FiO2 percentage variation –0.72 ± 5.2 (–1.5 to 0.1); r = 0.996 and r2 = 0.992 (P <0.000). Flow variation (l/minute) 3.91 ± 1.26 (3.69 to 4.13); fl ow percentage variation 12.77 ± 5.33 (11.84 to 13.7); r = 0.996 and r2 = 0.992 (P <0.000). See Figure 1. percentage variation –1.4040 ± 4.73 (–2.15 to –0.67); r = 0.996 and r2 = 0.992 (P <0.000). Flow variation (l/minute) 3.82 ± 3.85 (3.04 to 4.69); fl ow percentage variation 9.76 ± 8.08 (8.11 to 11.41); r = 0.969 and r2 = 0.939 (P <0.000). (3) FiO2 variation –0.005 ± 0.26 (–0001 to 0009); FiO2 percentage variation –0.72 ± 5.2 (–1.5 to 0.1); r = 0.996 and r2 = 0.992 (P <0.000). Flow variation (l/minute) 3.91 ± 1.26 (3.69 to 4.13); fl ow percentage variation 12.77 ± 5.33 (11.84 to 13.7); r = 0.996 and r2 = 0.992 (P <0.000). See Figure 1. Results We delivered teaching sessions to 100% (9/9) of junior doctors, 100% (71/71) of nursing staff and other health professionals. We obtained feedback from 90% (76/84), showing an improvement in understanding of capnography from 73% of respondents to 100%, with 87% reporting that the teaching aid made capnography interpretation much easier. All felt the training would improve patient safety, and 97% felt it would be worthwhile training in other ICUs. g Conclusion The FiO2 percentage variation in the Airvo® is higher than the other two devices, with no clinical relevance. The fl ow percentage variation of Evita XL® is superior to the other two devices; this may have some clinical relevance. Comparison of three methods of applying high fl ow nasal oxygen: in vitro study yl y in vitro study M Muñoz Garach1, O Olga1, ME Yuste Osorio1, R Fernandez Fernandez2, R Ramirez Puerta1, F Acosta Díaz1, AM Perez Bailón1, S Narbona Galdó1, L Peñas Maldonado1 1Hospital Universitario San Cecilio, Granada, Spain; 2Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain Critical Care 2015, 19(Suppl 1):P265 (doi: 10.1186/cc14345) Methods Twenty-one adult and clinically stable patients undergoing assisted mechanical ventilation for more than 48 hours were investigated during pressure support (baseline) and during a 2-hour CPAP trial. sEMG of diaphragm (costmar), intercostal and sternocleidal (accessory muscles) was recorded with a dedicated device (Dipha16; Inbiolab, Groningen, the Netherlands) simultaneously with airway waveforms and expressed as the ratio of the signal during baseline. Diaphragmatic electrical activity from a nasogastric tube (EAdi) of 14 of those patients was also measured. 1Hospital Universitario San Cecilio, Granada, Spain; 2Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain Critical Care 2015, 19(Suppl 1):P265 (doi: 10.1186/cc14345) Introduction High fl ow nasal (HNF) requires precise control of the fraction of inspired oxygen (FiO2) and fl ow contributed as well as an adequate adjustment of temperature and humidity of the gas provided. There are several equipments for HNF. We evaluated the FiO2 and fl ow supplied with three diff erent systems Results The rapid shallow breathing index was lower than 105 in all patients and only one patient failed the trial. We observed that the mean inspiratory value of costmar increased immediately after switch to CPAP but did not signifi cantly vary during the CPAP trial (ANOVA, P = 0.7). On the other hand, the activation of accessory muscles increased signifi cantly during the same period (P = 0.01) and was strongly correlated with respiratory rate (r = 0.41, P <0.001) and inversely with f y Methods There have been analyzed: (1) ‘Oxygen Therapy’ from Dräger Evita-XL®; (2) Fisher & Paykel Airvo® option; and (3) pack of fl owmeters Debson®. Measurements were made in the distal part of the circuit that is used in clinical practice. Variables: programmed and measured FiO2, programmed and measured fl ow. We used the Oxygen Monitor Ohmeda 5120® and Flow Meter® Fisher-Porter. Before each measurement we checked and/or calibrated each of them. All measurements were performed at room temperature in the ICU of our hospital (23 to 26º).The data were processed using SPSS v.15.0.1, accepting a signifi cance level of 95%. Figure 1 (abstract P266). Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion Use of ‘hats and caps’ enabled delivery of short bedside teaching sessions to clinical staff in ICU during everyday work. Feedback shows a marked improvement in confi dence around capnography interpretation. It may have value in other ICUs to improve staff understanding of capnography and improve patient safety. References P266 Surface electromyography of respiratory muscles during a CPAP trial for weaning g S Arrigoni Marocco, G Bellani, A Bronco, M Pozzi, F Rabboni, G Villa, N Eronia, A Pesenti San Gerardo Hospital, Monza, Italy Critical Care 2015, 19(Suppl 1):P266 (doi: 10.1186/cc14346) 1. Cook TM, et al. BJA. 2011;106:617-31. 2. McGrath BA. BJA. 2014;113:521. 3. Cook TM, et al. Anaesthesia. 2013;68:421. Introduction Weaning from mechanical ventilation is an important concern in ICU clinical practice. Surface electromyography (sEMG) [1] is a non-invasive tool to assess activity of diff erent muscles. We describe sEMG patterns of respiratory muscles during a CPAP trial [2] in patients undergoing pressure support ventilation. Surface electromyography of respiratory muscles during a CPAP trial for weaning S Arrigoni Marocco, G Bellani, A Bronco, M Pozzi, F Rabboni, G Villa, N Eronia, A Pesenti San Gerardo Hospital, Monza, Italy Critical Care 2015, 19(Suppl 1):P266 (doi: 10.1186/cc14346) Surface electromyography of respiratory muscles during a CPAP trial for weaning S Arrigoni Marocco, G Bellani, A Bronco, M Pozzi, F Rabboni, G Villa, N Eronia, A Pesenti San Gerardo Hospital, Monza, Italy Critical Care 2015, 19(Suppl 1):P266 (doi: 10.1186/cc14346) Ventilatory response during intentional early rehabilitation in patients with mechanical ventilation K Obata1, N Shiba2, T Takahashi3, S Ichiba2, Y Ujike2 1 d C Ok l Ok , , , , j 1Japanese Red Cross Okayama Hospital, Okayama, Japan; 2Okayama University Graduate School of Medicine, Okayama, Japan; 3Tokyo University of Technology, Tokyo, Japan Critical Care 2015, 19(Suppl 1):P263 (doi: 10.1186/cc14343) Introduction Intentional early rehabilitation with mechanical ventilation in ICUs is performed in clinical settings. However, strict indexes for safe rehabilitation have not been fully elucidated. The purpose of this study is to analyze ventilator response (VR) between healthy volunteers and patients with mechanical ventilation. Methods Sixteen healthy volunteers (Control group) and 13 patients on mechanical ventilation (MV group) were enrolled in this study. Both groups were positioned in a variety of postures (baseline in a supine position, settled back 30°, settled back 60°, and sitting position) and measured with an indirect calorimeter. The instantaneous energy expenditure (EE), tidal volume (TV), respiratory rate (RR) and minute expiratory volume (VE) were non-invasively measured in each posture. Figure 1 (abstract P264). ‘Hats and caps’ capnography training guide. S93 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Systematic procedures including non-invasive ventilation improve morbidity in sleeve gastrectomy I Auriant, N Devos, S Rossi I Auriant, N Devos, S Rossi Critical Care 2015, 19(Suppl 1):P269 (doi: 10.1186/cc14349) Table 1 (abstract P267). Mean ventilator-days/reintubation rates Table 1 (abstract P267). Mean ventilator-days/reintubation rates 2009 2010 2011 2012 2013 2014 MICU mean ventilator-days 7.71 6.81 5.90 5.88 5.50 5.50* MICU reintubation rates 14.5% 9.8% 9.7% 9.8% 13.9% 8.3% SICU mean ventilator-days 5.91 5.93 5.68 5.93 4.93** 5.20* SICU reintubation rates 5.2% 3.0% 4.1% 4.3% 4.7% 7.5% , Signifi cance as described in Results. Introduction Postoperative morbidity after sleeve gastrectomy is decreasing, but remains signifi cant. Bleeding and surgical fi stules remain the leading causes of morbidity and mortality. In several studies in postoperative care of obese patients, non-invasive positive pressure ventilation (NPPV) reduced the risk of lower respiratory tract infection and pneumonia [1], thereby reducing in-hospital morbidity. The aim of study was to describe whether systematic use of NPPV improves morbidity in the postoperative care of sleeve gastrectomy. Methods A 4-year before–after study was conducted in a 19-bed intermediate care unit of a private hospital. Before period: standard treatment – all patients received oxygen supplementation to achieve SaO2 above 90%. After period: standard treatment plus NPPV – all patients were submitted to a systematic postoperative protocol: NPPV was provided using an oxygen CIPAP system with 5 cmH2O. Statistical analysis: complication rates were compared using the chi-square test. P <0.05 was considered statistically signifi cant. Conclusion Initiatives to reduce ventilator-days per patient realized signifi cant reductions from 2009 to 2014 while reintubation rates were unaff ected. One component of the bundle, early mobilization, introduced in the SICU in 2013 was associated with an additional reduction in mean ventilator-days. y gi Results A total of 857 patients were included. Inclusion characteristics were similar in the two groups: Before group – noNPPV: 352 patients, 2010 to 2011. Age: 40.58 ± 10.94, BMI: 42.79 ± 5.51, sex ratio F/M: 0.81. After group – NPPV: 504 patients, 2012 to 2013. Age: 40.81 ± 11.24, BMI: 42.92 ± 5.09, sex ratio F/M: 0.77. There is a signifi cant between- group diff erence in the complication rate: Before group – noNPPV: 10 surgical fi stula (2.84%) and six postoperative bleeding (1.70%); After group – NPPV: seven surgical fi stula (1.39%) and three postoperative bleeding (0.6%). The overall complication rate fell from 4.54% to 1.98%. The chi-square statistic = 4.58. The number of degrees of freedom is 1. References 1. Chittawatanarat K, Thongchai C. Spontaneous breathing trial with low pressure support protocol for weaning respirator in surgical ICU. J Med Assoc Thai. 2009;92:1306-12. 1. Chittawatanarat K, Thongchai C. Spontaneous breathing trial with low pressure support protocol for weaning respirator in surgical ICU. J Med Assoc Thai. 2009;92:1306-12. Methods Ventilator-day data were compiled from 2009 to 2014 for MICU and SICU in our facility. Reintubation rates were calculated when intubations were required >1 day after an extubation. 2. Esteban A, Alia I, Gordo F, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156:459-65. 2. Esteban A, Alia I, Gordo F, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156:459-65. Results Ventilator volume ranged from 639 to 766 distinct patients/ year in the MICU and from 555 to 687 for the SICU. Ventilator-day reduction was signifi cant (P <0.01) for the MICU (7.7 to 5.5, –29%) and the SICU* (5.91 to 5.20, –12%). Reduction patterns diff ered between the units as the SICU had a distinct reduction (*P = 0.007) between 2012 and 2013 coinciding with implementation of an early mobilization program. Reintubation rates diff ered between the units and rates did not increase with decreasing mean patient ventilator- days. See Table 1. Comparison of three methods of applying high fl ow nasal oxygen: in vitro study p g gi Results (1) FiO2 variation –0.001 ± 0.09 (–0.01 to 0.002); FiO2 percentage variation –0.012 ± 1.88 (–0.27 to 0.25); r2 = 0.999 and r = 0.998 (P <0.000). Flow variation (l/minute) 5.45 ± 3.23 (4.94 to 5.96); fl ow percentage variation 19.59 ± 11.63 (17.75 to 21.43); r = 0. 997 and r2 = 0.994 (P <0.000). (2) FiO2 variation –0.007 ± 0.26 (–0.011/–0.003); FiO2 Figure 1 (abstract P265). Programmed and measured fl ow. Figure 1 (abstract P265) Programmed and measured flow Figure 1 (abstract P266). Figure 1 (abstract P265). Programmed and measured fl ow. S94 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 before discontinue mechanical ventilation and extubation in the surgical intensive care unit (SICU). tidal volume (r = –0.16, P = 0.02). In patients with EAdi we confi rmed a tight correlation between costmar and EAdi (r = 0.62, P <0.001). See Figure 1. tidal volume (r = –0.16, P = 0.02). In patients with EAdi we confi rmed a tight correlation between costmar and EAdi (r = 0.62, P <0.001). See Figure 1. Methods We performed a prospective open-label randomized control study (non-inferiority trial) in SICU patients who were intubated and used mechanical ventilation, and appropriated discontinuation of the ventilator between June 2011 and November 2013. All patients underwent the same weaning protocol. The appropriated patients for discontinuation of MV were randomized into low pressure support up to 7 cmH2O and T-piece method. Reintubation within 72 hours, pneumonia after extubation, and hospital mortality were recorded. The statistical signifi cant diff erence was considered when P <0.05. Conclusion sEMG indicated that while diaphragm activation remains constant during the CPAP period, accessory muscles were progressively recruited and particularly in the conditions of increased respiratory rate and lower tidal volumes. Ventilator-day reductions not associated with reintubations and further reduced by an early mobilization program Ventilator-day reductions not associated with reintubations and further reduced by an early mobilization program M Palmquist-Tess, A Adams, J Mangan, D Owen, M LeClaire HCMC, Minneapolis, MN, USA Critical Care 2015, 19(Suppl 1):P267 (doi: 10.1186/cc14347) y y p g M Palmquist-Tess, A Adams, J Mangan, D Owen, M LeClaire HCMC, Minneapolis, MN, USA Introduction Mechanical ventilation is associated with increased risk of pneumonia, barotrauma, VILI, VAP, ARDS and mortality. From 2009 to 2014 in the MICU/SICU of our facility, eff orts to reduce ventilator-days included: noninvasive ventilation, sedation reduction, daily sedation vacations and weaning protocols. In 2013, an early mobilization of ventilated patients in the SICU was initiated. Aggressive ventilator-day reduction eff orts may be expected to lead to premature extubations and reintubations. Conclusion The outcomes after discontinuation of the mechanical ventilator between low pressure support and T-piece was not diff erence in term of reintubation, pneumonia after extubation and hospital mortality. Systematic procedures including non-invasive ventilation improve morbidity in sleeve gastrectomy The value returned from the chi-square statistic is P <5%.i References 1. Yokoba M, et al. Respir Physiol Neurobiol. 2003;137:51-60. 2. Girard TD, et al. Lancet. 2008;371:126-34. 1. Yokoba M, et al. Respir Physiol Neurobiol. 2003;137:51-60. 2. Girard TD, et al. Lancet. 2008;371:126-34. 1. Yokoba M, et al. Respir Physiol Neurobiol. 2003;137:51-60. 2. Girard TD, et al. Lancet. 2008;371:126-34. gif Results A total of 520 patients were randomized into two groups: low pressure support group (260 patients) and T-piece group (260 patients). There was no diff erence in age, gender, body mass index, comorbidity, site of surgery, Charlson Comorbidity Index and Acute Physiologic and Chronic Health II score between groups (P >0.05). Regarding the intention to treat analysis, there were no diff erences between groups in reintubation rate (PSV 10% vs. T 14.6%; P = 0.109), pneumonia after extubation (PSV 14.2% vs. T 11.9%; P = 0.435) and hospital mortality rate (PSV 3.1% vs. T 3.5%; P = 0.805). Chiumello D, et al. Non-invasive ventilation in postoperative patients: a sytematic review. Intensive Care Med. 2011;37:918-29. P271 Systematic alveolar recruitment after cardiac surgery AL Lafarge, CK Kerneis, F Scalbert, LL Larnier, AB Brusset, PE Estagnasie, PS Squara Clinique Ambroise Paré, Neuilly-sur-Seine, France Critical Care 2015, 19(Suppl 1):P271 (doi: 10.1186/cc14351) Introduction The aim of our study was to investigate the value of C-reactive protein (CRP) and procalcitonin (PCT) in identifi cation of the systemic infl ammatory response syndrome (SIRS) and other complications in the early postoperative period after cardiac surgery with cardiopulmonary bypass (CPB) [1]. Methods In 93 patients undergoing coronary artery bypass graft surgery with CPB, after Ethical Committee approval in a prospective study, serum PCT and CRP values were collected before operation and daily until postoperative day 5. All patients were divided post hoc into patients with SIRS (n = 42) and patients without SIRS (n = 51). Student’s t test, the Mann–Whitney U test and receiver operating characteristic (ROC) curves were used. Introduction We designed a pilot study to evaluate the interest of an early systematic acute recruitment maneuver (ARM) in postcardiac surgery hypoxemic patients in order to properly design a larger trial. Methods This randomized controlled trial included consecutive patients operated on in our institution. Three hours after surgery, hypoxemic patients (PaO2 <300 mmHg, FIO2 = 1) were randomly assigned to ARM or control (H0). ARM was performed by applying once a positive end-expiratory pressure of 35 cmH2O during 45 seconds. Blood gases and hemodynamic variables were collected at H1, H8, H24 and H48. The primary endpoint was the duration of mechanical ventilation (MV). Secondary endpoints were survival rate, ICU length of stay and the occurrence of pneumonia. Results The comparison of serum CRP values in patients with or without SIRS on postoperative day 1 until postoperative day 5 demonstrated an increase in both groups without signifi cant diff erences (P >0.05). The PCT levels increased more signifi cantly in SIRS patients (5.78 ± 3.21 ng/ml vs. 1.23 ± 0.31 ng/ml) compared with patients without SIRS (P = 0.0001) on postoperative day 1. In patients with postoperative complications (21/93, 22%) (circulatory failure = 10, pneumonia = 2, respiratory insuffi ciency = 9, sepsis = 0), PCT levels remained elevated until postoperative day 5 (6.11 ± 2.87 ng/ml) but diminished in patients with SIRS (0.96 ± 0.23 ng/ml) (P <0.0001). Early postoperative pulmonary complications following heart transplantation A Camkiran Firat, Ö Kömürcü, P Zeyneloglu, M Türker, A Sezgin, A Pirat Baskent University, Ankara, Turkey Critical Care 2015, 19(Suppl 1):P270 (doi: 10.1186/cc14350) Introduction The aim of this study was to determine the types, incidence, and risk factors for early postoperative pulmonary complications in heart transplantation recipients. Methods We retrospectively collected data from the records of consecutive heart transplantations from January 2003 to December 2013. A total of 83 patients underwent heart transplantation. Those patients younger than 10 years (n = 9) and the patients who died intraoperatively (n = 1) or during the fi rst postoperative day (n = 1) were not included in the analyses. The data collected for each case were demographic features, duration of mechanical ventilation, respiratory problems that developed during the ICU stay, and early postoperative mortality (<30 days). The respiratory complications that we sought were pleural eff usion, pneumonia, pulmonary atelectasis, pulmonary edema, pneumothorax, and acute respiratory failure. Figure 1 (abstract P271). p p y Results Of the 72 patients considered, 52 (72.2%) were male. The mean age at the time of transplantation was 32.1 ± 16.6 years. The mean duration of postoperative mechanical ventilation was 71.8 ± 126.6 hours. The mean length of ICU stay was 13.5 ± 18.0 days. Two patients (2.8%) and one patient (1.4%) required extracorporeal membrane oxygenation support and intra-aortic balloon pump support, respectively, due to low cardiac output or primary graft failure postoperatively. Twenty-fi ve patients (34.7%) developed early postoperative respiratory complications. The most frequent problem was pleural eff usion (n = 19, 26.4%) followed by atelectasis (n = 6, 8.3%), acute respiratory distress syndrome (n = 5, 6.9%), pulmonary edema (n = 4, 5.6%), and pneumonia (n = 3, 4.2%). Postoperative duration of mechanical ventilation (44.2 ± 59.2 hours vs. 123.8 ± 190.8 hours, P = 0.005) and the length of ICU stay postoperatively (10.1 ± 5.8 hours vs. 19.8 ± 28.9 hours, P = 0.03) were longer among patients who had respiratory problems. Postoperative length of stay in the hospital (22.3 ± 12.5 days vs. 30.3 ± 38.3 days, P = 0.75) was similar in the two groups. The overall mortality rate was 12.5% (n = 9 patients). The patients who had respiratory problems did not show higher mortality than those who did not have respiratory problems (16.0% vs. 10.6%, P = 0.71). the two groups. Early postoperative pulmonary complications following heart transplantation At H1, PaO2/FIO2 was 367 ± 15 in the recruited group versus 299 ± 15 mmHg in the control group, P = 0.002. At H8 and 24 the diff erence was not signifi cant. At H48, the PaO2/FIO2 was lower in the recruited group (296 ± 10 vs. 343 ± 11 mmHg, P = 0.003) (Figure 1). The duration of mechanical ventilation (invasive + non-invasive) was lower in the recruited group (total 6.4 ± 1.4 vs. 8.4 ± 1.4 hours, P = 0.02). The survival rate, the length of stay in the ICU and the occurrence of pneumonia were similar in the two groups (P >0.2). Conclusion We can speculate that the inverse evolution of the blood oxygenation between the ARM group versus control may be due to: barotraumatism of normal alveoli during the ARM and/or a higher de- recruitment rate after ARM due to the shorter mechanical ventilation support. This pilot study shows that a unique ARM decreased the duration of MV in cardiac surgery patients but this may have subsequent detrimental eff ects on blood oxygenation. P272 Open-label randomized control trial between low pressure support and T-piece method for discontinuation from mechanical ventilator and extubation in general surgical ICUs g g K Chittawatanarat, S Orrapin, S Orrapin Chiang Mai University, Chiang Mai, Thailand Chiang Mai University, Chiang Mai, Thailand g y g Critical Care 2015, 19(Suppl 1):P268 (doi: 10.1186/cc14348) g y g Critical Care 2015, 19(Suppl 1):P268 (doi: 10.1186/cc14348) g y g Critical Care 2015, 19(Suppl 1):P268 (doi: 10.1186/cc14348) Introduction In routine practice for most surgical patients in Thailand, all appropriated patients with planned discontinuation of mechanical ventilator (MV) are routinely changed to T-piece before extubation. However, this method needs to alter the instrument for testing tolerability of the patient. The objective of this study was to compare continuous low pressure support (PSV) and the T-piece method (T) Conclusion Systematic use of NPPV signifi cantly improves morbidity in the postoperative care of sleeve gastrectomy. Reference Conclusion Systematic use of NPPV signifi cantly improves morbidity in the postoperative care of sleeve gastrectomy. Chiumello D, et al. Non-invasive ventilation in postoperative patients: a sytematic review. Intensive Care Med. 2011;37:918-29. S95 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P271). P270 Figure 1 (abstract P271). P270 Early postoperative pulmonary complications following heart transplantation A Camkiran Firat, Ö Kömürcü, P Zeyneloglu, M Türker, A Sezgin, A Pirat Baskent University, Ankara, Turkey Critical Care 2015, 19(Suppl 1):P270 (doi: 10.1186/cc14350) Is procalcitonin a valuable marker for identifi cation of postoperative complications after coronary artery bypass graft surgery with cardiopulmonary bypass? y y A Baysal1, M Dogukan2, H Toman3 1Kartal Kouyolu Research and Training Hospital, Istanbul, Turkey; 2Adiyaman University Research and Training Hospital, Adiyaman, Turkey; 3Canakkale 18 Mart University Hospital, Canakkale, Turkey Critical Care 2015, 19(Suppl 1):P272 (doi: 10.1186/cc14352) A Baysal1, M Dogukan2, H Toman3 1Kartal Kouyolu Research and Training Hospital, Istanbul, Turkey; 2Adiyaman University Research and Training Hospital, Adiyaman, Turkey; 3Canakkale 18 Mart University Hospital, Canakkale, Turkey Critical Care 2015, 19(Suppl 1):P272 (doi: 10.1186/cc14352) Conclusion Respiratory complications were relatively common in our cohort of heart transplant recipients. However, these complications were mostly self-limiting and did not result in increased mortality. Prediction of risk factors related to the development of hepatic dysfunction following open heart surgery Prediction of risk factors related to the development of hepatic dysfunction following open heart surgery A Baysal1, I Ozkaynak2, M Dogukan3 1Kartal Kouyolu Research and Training Hospital, Istanbul, Turkey; 2Kahramanmaraþ Sütçü Ýmam University Hospital, Kahramanmaraþ, Turkey; 3Adiyaman University Research and Training Hospital, Adiyaman, Turkey Critical Care 2015, 19(Suppl 1):P273 (doi: 10.1186/cc14353) A Baysal1, I Ozkaynak2, M Dogukan3 A Baysal , I Ozkaynak , M Dogukan 1Kartal Kouyolu Research and Training Hospital, Istanbul, Turkey; 1Kartal Kouyolu Research and Training Hospital, Istanbul, Turkey; 2Kahramanmaraþ Sütçü Ýmam University Hospital, Kahramanmaraþ, Turkey; 3Adiyaman University Research and Training Hospital, Adiyaman, Turkey Critical Care 2015, 19(Suppl 1):P273 (doi: 10.1186/cc14353) Conclusion Increasing sweep gas fl ow results in eff ective CO2 removal which can be further reinforced by raising blood fl ow. The clinically relevant oxygenation eff ect even in this setting of low invasivity could broaden the range of indications towards hypercapnic lung failure with mild to moderate hypoxia. Figure 1 (abstract P274). PaO2 with increasing blood fl ow (P <0.0001). Introduction Our goal was to investigate the incidence of postoperative jaundice in open heart surgery patients and to determine the risk factors associated with hepatic dysfunction. Methods A total of 292 patients were included in a prospective study design. Patients undergoing on-pump coronary artery bypass graft surgery (CABG) (n = 154) and valve repair surgery (mitral, mitral and aortic valve and/or tricuspid valve) (n = 138) were included. Postoperative hyperbilirubinemia was defi ned as occurrence of a plasma total bilirubin concentration of more than 34 μmol/l (2 mg/ dl) in any measurement during the postoperative period. All patients were divided into groups with or without hyperbilirubinemia. Liver enzymes were collected on postoperative days 1, 7, 14 and 30. The risk factors including age, cardiopulmonary bypass time, number of blood transfusions, inotropic support, use of intra-aortic balloon pump and ICU stay were evaluated with logistic regression. Figure 1 (abstract P274). PaO2 with increasing blood fl ow (P <0.0001). y g g Results Postoperative hyperbilirubinemia was observed in 27 of 292 patients (9.3%). The numbers of valves replaced, preoperative total bilirubin concentration, increased cardiopulmonary bypass time, higher number of inotropic support agents, and use of intra-aortic balloon pump correlate with hyperbilirubinemia on postoperative day 7 (P <0.05). P271 A PCT threshold value of 2.79 ng/ml was able to discriminate between postoperative complications in patients with or without SIRS with a sensitivity of y Results We included 124 patients, age 67.5 ± 10.6 years, M/F sex ratio 95/29, left ventricle ejection fraction 58.8 ± 10.6%, forced expiratory volume 94 ± 23% of the predicted value, bypass/valve ratio 82/53. The preoperative and postoperative PaO2/FIO2 were 401 ± 66 and 204 ± 66 mmHg, respectively (P <0.0001). The hemodynamic and ventilation status as well as the fl uid and inotrope supports were comparable in S96 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 developed miniaturized device consisting of a centrifugal pump and a membrane ventilator (iLA Activve®; Novalung, Germany) allows eff ective decarboxylation via a jugular double lumen cannula. So far no data on gas exchange in this setting exist to date. 82.5% and a specifi city of 70% (area under the curve: 0.76 ± 0.05; P <0.01) on postoperative day 1. Conclusion After cardiac surgery with CPB, PCT values increased signifi cantly in the SIRS group of patients compared with patients without SIRS on postoperative day 1 and remained elevated until postoperative day 5. In the early postoperative period, early rise of PCT values may help to discriminate the development of postoperative complications in patients with or without SIRS. Methods We included 10 patients receiving iLA Activve® due to hypercapnic respiratory failure as bridge-to-transplant or obstructive lung disease. Sweep gas fl ow was increased in steps from 1 to 14 l/ minute at constant blood fl ow (phase 1). Similarly, blood fl ow was gradually increased at constant sweep gas fl ow (phase 2). At each step, gas transfer via the membrane as well as arterial blood gas samples were obtained. 1. Delannoy B, Guye ML, Slaiman DH, Lehot JJ, Cannesson M. Eff ect of cardiopulmonary bypass on activated partial thromboplastin time waveform analysis, serum procalcitonin and C-reactive protein concentrations. Crit Care. 2009;13:R180. 1. Delannoy B, Guye ML, Slaiman DH, Lehot JJ, Cannesson M. Eff ect of cardiopulmonary bypass on activated partial thromboplastin time waveform analysis, serum procalcitonin and C-reactive protein concentrations. Crit Care. 2009;13:R180. P275 P275 Safety and effi cacy of extracorporeal CO2 removal combined with continuous renal replacement therapy in patients presenting both acute respiratory distress syndrome and acute kidney injury J Allardet-Servent, M Castanier, T Signouret, A Lepidi, R Soundaravelou, J Seghboyan Hopital Européen Marseille, France Critical Care 2015, 19(Suppl 1):P275 (doi: 10.1186/cc14355) P271 Results During phase 1, we observed a signifi cant increase in CO2 transfer together with a decrease in PaCO2 levels from a median of 66 mmHg (range 46 to 85) to 49 (31 to 65) mmHg from 1 to 14 l/ minute sweep gas fl ow, while arterial oxygenation deteriorated with high sweep gas fl ow rates. During phase 2, oxygen transfer signifi cantly increased leading to an increase in PaO2 from 67 (49 to 87) at 0.5 l/ minute to 117 (66 to 305) mmHg at 2.0 l/minute. Higher blood fl ow rates also signifi cantly enhanced decarboxylation. Increasing blood fl ow to 2.0 l/minute led to negative suction pressures of more than –100 mmHg and signs of hemolysis. See Figure 1. Prediction of risk factors related to the development of hepatic dysfunction following open heart surgery Independent risk factors of early postoperative jaundice are; multiple valve replacement surgery, ejection fraction and use of intraaortic balloon pump (R = 0.58, R2 = 0.33, F = 26.44, P <0.001). The ICU stay was signifi cantly longer in group 2 (11.52 ± 3.76 days) as compared with group 1 (2.79 ± 1.36 days) (P <0.001). g y Conclusion Patients undergoing multiple valve replacement procedures are at greater risk for the development of postoperative hyperbilirubinemia and an association with prolonged ICU stay was observed. Other risk factors including ejection fraction, increased cardiopulmonary bypass time and use of intra-aortic balloon pump are also important as they have been reported to increase postoperative complications [1]. Conclusion Increasing sweep gas fl ow results in eff ective CO2 removal which can be further reinforced by raising blood fl ow. The clinically relevant oxygenation eff ect even in this setting of low invasivity could broaden the range of indications towards hypercapnic lung failure with mild to moderate hypoxia. p Reference 1. Nishi H, Sakaguchi T, Miyagawa S, et al. Frequency, risk factors and prognosis of postoperative hyperbilirubinemia after heart valve surgery. Cardiology. 2012;122:12-9. Interhospital transfer of patients in extracorporeal membrane oxygenation F Socci, S Di Valvasone, M Ciapetti, A Franci, M Bonizzoli, G Cianchi, S Batacchi, A Peris Careggi Hospital, Firenze, Italy Critical Care 2015 19(Suppl 1):P276 (doi: 10 1186/cc14356) gg y Critical Care 2015, 19(Suppl 1):P276 (doi: 10.1186/cc14356) gg y Critical Care 2015, 19(Suppl 1):P276 (doi: 10.1186/cc14356) Introduction The transfer of patients in extracorporeal membrane oxygenation (ECMO) from a peripheral hospital to a tertiary center represents a high-risk situation of adverse events [1]. The aim of this retrospective study is to determine the feasibility and safety of interhospital transfer for critically ill patients with ECMO support. Methods We collected data for the ECMO Regional Reference Centre Careggi Hospital activity from September 2009 to June 2014. In this study, 57 transfers were examined. The ECMO service is activated by a telephone call from a peripheral hospital. The team is represented by an intensivist, a heart surgeon, a cardiologist, a perfusionist and an intensive care nurse, all previously trained in the management of patients with ECMO. Medical personnel and the necessary equipment are transported by an ambulance and a van, specially designed and equipped for the transfer of patients with ECMO. Methods Retrospectively, we examined 20 patients with cerebral MRI (including SWI) who had suff ered from severe ARDS and received ECMO therapy. The MRI slides were anonymized and analyzed by two experienced neuroradiologists. Based on the distribution pattern and characteristic, a modifi ed HACE score (mHCS) was surveyed [2]. i y Results Six of 20 patients (30%) showed multiple MH with emphasis in the splenium of the corpus callosum. Eight patients had sporadic MH in the parenchyma of the brain but not in the corpus callosum. The remaining six patients had no intracerebral alterations. The distribution of MH with involvement of the splenium resembled that seen in HACE survivors. Results In this study, 57 patients transferred from the peripheral hospital to the ECMO center were examined; in all cases the ECMO system was implanted in the peripheral hospital (54 venovenous ECMO and three venoarterious ECMO). On average, trails were 271 km ± 304 (round trip) (minimum 14 km to maximum 939 km). The activation time from the call to the ambulance departure from our hospital was an average of 2 hours 27 minutes 13 seconds ± 1 hour 25 minutes 35 seconds. Determinants of gas exchange during extracorporeal CO2 removal using a novel pump-driven venovenous gas exchange system in a minimally invasive setting y g A Hermann, K Riss, P Schellongowski, A Bojic, P Wohlfarth, O Robak, W Sperr, T Staudinger Medical University of Vienna, Austria Critical Care 2015, 19(Suppl 1):P274 (doi: 10.1186/cc14354) A Hermann, K Riss, P Schellongowski, A Bojic, P Wohlfarth, O Robak, W Sperr, T Staudinger Medical University of Vienna, Austria Critical Care 2015, 19(Suppl 1):P274 (doi: 10.1186/cc14354) Introduction Pump-driven venovenous extracorporeal CO2 removal (ECCO2-R) increasingly takes root in hypercapnic lung failure to minimize ventilation invasiveness or to avoid intubation. A recently Introduction Pulmonary overdistension has been observed in 33% of patients with acute respiratory distress syndrome (ARDS) despite low tidal volume (6 ml/kg ideal body weight) ventilation [1]. Tidal volume S97 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 (VT) reduction from 6 to 4 ml/kg attenuates overdistension but is associated with hypercarbia [2]. We thought to combine extracorporeal CO2 removal (ECCO2R) with continuous renal replacement therapy (CRRT) through the insertion of an oxygenator membrane within the hemofi ltration circuit in patients presenting both ARDS and acute kidney injury (AKI).i the devices during transport were not recorded; in some cases it was necessary to manage minor complications (circuit cavitation, minor vascula accesses bleeding). Conclusion Some studies have found several complications during transfer of patients in ECMO [2]. In our experience, there were no complications during the transfer of ECMO patients, even for longer trips. A wide and thorough clinical evaluation and multidisciplinary ECMO team allowed the optimization of clinical parameters before transport and a safely transfer. The start of ECMO treatment at peripheral hospitals and the transfer of patients in ECMO may be a viable option compared with conventional ventilation. Our data suggest that ECMO can be set up safely in peripheral hospitals by a multidisciplinary highly specialized ECMO team [3]. y j y Methods A fi rst set of measurement was performed at 6 ml/kg before and after ECCO2R. Twenty minutes later, VT was reduced to 4 ml/kg for the remainder of the study period (72 hours). Ventilator settings were those of the ARMA trial. The CRRT mode was hemofi ltration with 33% of predilution. Ultrafi ltration was adjusted to achieve a fi ltration fraction of 15%. Sweep gas fl ow was constant at 8 l/minute. The primary endpoint was a 20% reduction of PaCO2 at 20 minutes after initiation of ECCO2R. P276 h Introduction Cerebral microhemorrhages (MH) are diminutive focal bleedings which can be detected best by MRI using susceptibility- weighted imaging sequences (SWI). They can be found in a variety of neurologic diseases. The pattern of distribution can lead to the underlying pathomechanism [1]. Survivors of high-altitude cerebral edema (HACE) showed multiple MH, predominantly in the splenium of the corpus callosum. Mountaineers with a lack of acclimatization to high altitudes tend to suff er from HACE. Hypoxemia in great heights is discussed to be the main trigger of HACE [2]. Acute respiratory distress syndrome (ADRS) is characterized by oxygenation failure in mechanically ventilated patients. The severity is classifi ed by the ratio of arterial oxygen tension to fraction of inspired oxygen [3]. In some patients suff ering from severe ARDS, refractory to conventional therapy, venovenous extracorporeal membrane oxygenation therapy is the therapeutic option to ensure oxygenation. References 2 2 Results Eight patients were studied. Age was 69 ± 11 years, SAPS II was 68 ± 9 and SOFA score was 13 ± 4 at inclusion. Blood fl ow, at the inlet of the oxygenator membrane, was 400 ± 4 ml/minute. CO2 removal rate was 84 ± 4 ml/minute. Initiating ECCO2R, at 6 ml/kg, induced a mean PaCO2 reduction of 17% (41 ± 5.5 to 33.9 ± 5.6 mmHg, P <0.001). Then, lowering the VT to 4 ml/kg induced a mean PaCO2 increase of 25% (33.9 ± 5.6 to 42.6 ± 8 mmHg) and a mean PaO2/FIO2 ratio increase of 8% (176 ± 63 to 190 ± 61). Minute ventilation decrease from 7.4 ± 1.6 to 5 ± 1.2 l/minute. Respiratory system compliance did not vary. No major complications were observed. 1. Lindén V, Palmér K, Reinhard J, Westman R, Ehrén H, Granholm T, et al. Inter- hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation-national and international experience. Intensive Care Med. 2001;27:1643-8. 2. Haneya A, Philipp A, Foltan M, Mueller T, Camboni D, Rupprecht L, et al. Extracorporeal circulatory systems in the interhospital transfer of critically ill patients: experience of a single institution. Ann Saudi Med. 2009;29:110-4. 3. Ciapetti M, Cianchi G, Zagli G, Greco C, Pasquini A, Spina R, et al. Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients aff ected by severe swine-fl u(H1N1)-related ARDS. Scand J Trauma Resusc Emerg Med. 2011;19:32. 1. Lindén V, Palmér K, Reinhard J, Westman R, Ehrén H, Granholm T, et al. Inter- hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation-national and international experience. Intensive Care Med. 2001;27:1643-8. 1. Lindén V, Palmér K, Reinhard J, Westman R, Ehrén H, Granholm T, et al. Inter- hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation-national and international experience. Intensive Care Med. 2001;27:1643-8. 2. Haneya A, Philipp A, Foltan M, Mueller T, Camboni D, Rupprecht L, et al. Extracorporeal circulatory systems in the interhospital transfer of critically ill patients: experience of a single institution. Ann Saudi Med. 2009;29:110-4. p p g 3. Ciapetti M, Cianchi G, Zagli G, Greco C, Pasquini A, Spina R, et al. Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients aff ected by severe swine-fl u(H1N1)-related ARDS. Scand J Trauma Resusc Emerg Med. 2011;19:32. p p g 3. Determinants of gas exchange during extracorporeal CO2 removal using a novel pump-driven venovenous gas exchange system in a minimally invasive setting Results Eight patients were studied. Age was 69 ± 11 years, SAPS II was 68 ± 9 and SOFA score was 13 ± 4 at inclusion. Blood fl ow, at the inlet of the oxygenator membrane, was 400 ± 4 ml/minute. CO2 removal rate was 84 ± 4 ml/minute. Initiating ECCO2R, at 6 ml/kg, induced a mean PaCO2 reduction of 17% (41 ± 5.5 to 33.9 ± 5.6 mmHg, P <0.001). Then, lowering the VT to 4 ml/kg induced a mean PaCO2 increase of 25% (33.9 ± 5.6 to 42.6 ± 8 mmHg) and a mean PaO2/FIO2 ratio increase of 8% (176 ± 63 to 190 ± 61). Minute ventilation decrease from 7.4 ± 1.6 to 5 ± 1.2 l/minute. Respiratory system compliance did not vary. No major complications were observed. y j y Methods A fi rst set of measurement was performed at 6 ml/kg before and after ECCO2R. Twenty minutes later, VT was reduced to 4 ml/kg for the remainder of the study period (72 hours). Ventilator settings were those of the ARMA trial. The CRRT mode was hemofi ltration with 33% of predilution. Ultrafi ltration was adjusted to achieve a fi ltration fraction of 15%. Sweep gas fl ow was constant at 8 l/minute. The primary endpoint was a 20% reduction of PaCO2 at 20 minutes after initiation of ECCO2R. Interhospital transfer of patients in extracorporeal membrane oxygenation Transfer duration (from activation to return to the ECMO center) was an average of 8 hours 25 minutes 6 seconds ± 3 hours 27 minutes 58 seconds (minimum 3 hours to maximum 16 hours 55 minutes). The stop time (necessary for evaluation of the patient and for placement of the ECMO system) was an average of 3 hours 53 minutes 40 seconds ± 1 hour 6 minutes 35 seconds (minimum 2 hours 5 minutes to maximum 7 hours 30 minutes). Major complications related to malfunctions of Conclusion Based on these results, we postulate that hypoxemia is one of the main players in the development of splenium-associated MH, not only in HACE but also in severe ARDS and other diseases accompanied with severe hypoxemia. Further investigations have to examine potential triggers and special circumstances concerning ARDS treatment which lead to MH in this distinctive pattern. 1. Renard D, et al. J Neurol Neurosurg Psychiatry. 2014;85:1041-8. 2. Schommer K, et al. Neurology. 2013;81:1776-9. 3. Force ADT, et al. JAMA. 2012;307:2526-33. References Ciapetti M, Cianchi G, Zagli G, Greco C, Pasquini A, Spina R, et al. Feasibility of inter-hospital transportation using extra-corporeal membrane oxygenation (ECMO) support of patients aff ected by severe swine-fl u(H1N1)-related ARDS. Scand J Trauma Resusc Emerg Med. 2011;19:32. Conclusion Combining ECCO2R and CRRT in patients with ARDS and AKI is safe and feasible through the insertion of an oxygenator membrane within a RRT circuit. References 1. Terragni PP, Rosboch G, Tealdi A, et al. Tidal hyperinfl ation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2007;175:160-6. P277 Microhemorrhages in the corpus callosum after treatment with extracorporeal membrane oxygenation S Riech, P Hellen, O Moerer, K Kallenberg, M Müller, M Quintel, M Knauth University Medical Center Goettingen, Germany Critical Care 2015, 19(Suppl 1):P277 (doi: 10.1186/cc14357) 2. Terragni PP, Del Sorbo L, Mascia L, et al. Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal CO2 removal. Anesthesiology. 2009;111:826-35. 2. Terragni PP, Del Sorbo L, Mascia L, et al. Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal CO2 removal. Anesthesiology. 2009;111:826-35. P279 Introduction Diff erential hypoxia is a pivotal problem in cardio- pulmonary failure patients with femoral venoarterial extracorporeal membrane oxygenation (VA ECMO) support. Although there was some attempt to deliver more oxygenated blood to the upper body, the mechanism of diff erential hypoxia has not been well investigated. Successful approach for emergent consent for ECMO research J Board1, S Vallance1, C Aubron2, D Pilcher1, V Pellegrino1, DJ Cooper1 1The Alfred Hospital, Melbourne, Australia; 2Monash University, Melbourne, Australia Critical Care 2015, 19(Suppl 1):P279 (doi: 10.1186/cc14359) f y Methods We used a sheep model of acute respiratory failure that was supported with femoral VA ECMO (from inferior vena cava to femoral artery (IVC-FA)), ECMO from superior vena cava to FA (SVC-FA), ECMO from IVC to carotid artery (IVC-CA) and ECMO adding an additional return cannula to internal jugular vein based on femoral VA ECMO (FA- IJV). Angiography and blood gas analysis were performed. Introduction The HELP-ECMO pilot study (Heparin low dose protocol versus standard care in critically ill patients undergoing ECMO; ACTRN12613001324707) is a randomised controlled phase II study evaluating two levels of heparin anticoagulation in patients with no requirement for full anticoagulation. This work is a substudy of the HELP-ECMO trial and describes the consent process of the parent study. At our site, consent for research is often obtained by the research coordinator with little involvement from investigators. However, the nature of the ECMO population required a modifi ed consent approach to be implemented given that ECMO is often inserted emergently. It required a model that would be successful out of hours and could be delivered by any member of the treating team. g g p y g y p Results Blood oxygen saturation (SO2) of IVC (83.6 ± 0.8%) was higher than that of SVC (40.3 ± 1.0%) in sheep with IVC-FA. Oxygen-rich blood was drained back to the ECMO circuit and poorly oxygenated blood in the SVC entered the right atrium (RA). SVC-FA achieved the oxygen-rich blood return from IVC to RA without shifting the arterial cannulation. SO2 of SVC and pulmonary artery increased (70.4 ± 1.0% and 73.4 ± 1.1%, respectively) subsequently. Compared with IVC-FA, Figure 1 (abstract P278). SO2 values from blood gas analysis and vena cava angiography. Figure 1 (abstract P278). SO2 values from blood gas analysis and vena cava angiography. e 1 (abstract P278). SO2 values from blood gas analysis and vena cava angiography. References 1. Renard D, et al. J Neurol Neurosurg Psychiatry. 2014;85:1041-8. 2. Schommer K, et al. Neurology. 2013;81:1776-9. 3. Force ADT, et al. JAMA. 2012;307:2526-33. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S98 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P278f less diff erences of venous oxygen return and attenuated diff erential hypoxia were also observed in IVC-CA and FA-IJV. See Figure 1.f P278 Diff erential venous oxygen return: a key factor of diff erential hypoxia in venoarterial extracorporeal membrane oxygenation X Hou1, X Yang1, Z Du1, J Xing1, C Jiang1, J Wang1, Z Xing1, H Wang1, H Zeng2 1Beijing Anzhen Hospital, Beijing, China; 2Beijing Key Laboratory of Emerging Infectious Diseases, Beijing, China Critical Care 2015, 19(Suppl 1):P278 (doi: 10.1186/cc14358) Conclusion Diff erential venous oxygen return is a key factor of diff erential hypoxia in VA ECMO. We can take advantage of the notion of diff erential venous oxygen return to choose better cannula confi guration in clinical practice. In-hospital and long-term mortality after venoarterial ECMO for refractory cardiogenic shock In-hospital and long-term mortality after venoarterial ECMO for refractory cardiogenic shock M Bottiroli, T Maraffi , D Decaria, S Nonini, E Montrasio, K Gervasio, F Milazzo, R Paino Anestesia Rianimazione 3, A.O. Niguarda, Milan, Italy Critical Care 2015, 19(Suppl 1):P281 (doi: 10.1186/cc14361) y g M Bottiroli, T Maraffi , D Decaria, S Nonini, E Montrasio, K Gervasio, F Milazzo, R Paino Anestesia Rianimazione 3, A.O. Niguarda, Milan, Italy Critical Care 2015, 19(Suppl 1):P281 (doi: 10.1186/cc14361) Introduction Venoarterial (VA) ECMO is used for mechanical support in patients with cardiogenic shock (CS) unresponsive to medical therapy. Long-term survival and quality of life after hospital discharge have not yet been well analyzed. Methods We performed a retrospective observational study of patients admitted to the ICU for refractory CS from January 2010 to November 2014. Patients with postcardiotomy and/or post-transplant CS were excluded. Demographic, clinical and biochemical variables were collected. Continuous variables are presented as mean (standard deviation) and categorical variables as percentage. Long-term outcome and quality of life were assessed during scheduled follow-up evaluations or telephonic interviews. g p Results From April to December 2014, 30 patients were screened. Fourteen met the eligibility criteria and were approached for consent. Twelve patients were enrolled and randomised to receive either standard anticoagulation or low-dose heparin as per the study protocol. Consent was provided by the person responsible for 10 patients. One patient was competent to consent for themselves and one was enrolled under legislation allowing enrolment into research in the absence of a person responsible. There were two refusals. Seventy- one per cent of participants were approached out of hours. Eighty-six per cent were consented by clinicians. Twenty-one per cent of patients were consented by a non-investigator. Results We analyzed 23 consecutive patients undergoing VA ECMO for refractory CS. Etiologies of cardiac collapse were: 11 acute myocarditis, fi ve acute myocardial infarctions and seven acute decompensation of chronic cardiomyopathies (CCM). Thirteen patients died during the hospital stay and 10 survived. The main cause of ICU death was progressive multiple organ dysfunction (12/13). Baseline variables are presented in Table 1. All patients discharged from the hospital are still alive at follow-up (median 27 months, range 4 to 56) with a median NYHA class of 1 (range 1 to 2). All patients except one returned to an active style of life. Extracorporeal membrane oxygenator and ventricular assist device activity of a tertiary cardiothoracic centre: survival rates and length of ITU stay y D Sarridou1, CP Walker1, N Rashid1, D Heaton1, I McGovern1, N Marczin2, J Mitchell1 1The Royal Brompton & Harefi eld NHS Foundation Trust, London, UK; 2Imperial College, London, UK Critical Care 2015, 19(Suppl 1):P280 (doi: 10.1186/cc14360) Introduction Harefi eld Hospital accepts patients as a tertiary centre for end-stage heart and respiratory failure for the south of England. Interventions include VA-ECMO, VV-ECMO as a bridge to lung transplantation, left ventricular assist devices (LVAD) as a bridge for heart transplantation, right ventricular assist devices (RVAD) and BIVADs. The aim of this review was to identify the total number of such patients, analyse the individual length of ITU stay and calculate survival and mortality rates for each intervention. Conclusion VA-ECMO is an eff ective treatment tool for refractory CS in patients with acute life-threatening heart failure. Patients aff ected by acute decompensation of CCM had poorer outcomes characterized by multiple organ dysfunction, as already known in the literature. y Methods Patients consisted of six groups: Group 1: VA ECMO, Group 2: VV-ECMO, Group 3: LVAD, Group 4: RVAD, Group 5: BIVAD, Group 6: combination of devices. Data were extracted from the Perfusion Department records and the intensive care dataset from 2011 to 2013. Data included length of ITU stay, outcome, indication for device insertion and device-related major complications.i P280 P280 Extracorporeal membrane oxygenator and ventricular assist device activity of a tertiary cardiothoracic centre: survival rates and length of ITU stay D Sarridou1, CP Walker1, N Rashid1, D Heaton1, I McGovern1, N Marczin2, J Mitchell1 1The Royal Brompton & Harefi eld NHS Foundation Trust, London, UK; 2Imperial College, London, UK Critical Care 2015, 19(Suppl 1):P280 (doi: 10.1186/cc14360) P282 h P282 Characteristics of trauma patients with creatine kinase elevation N Assanangkornchai, O Akaraborworn, C Kongkamol, K Kaewsaengrueang Prince of Songkla University, Hatyai, Thailand Critical Care 2015, 19(Suppl 1):P282 (doi: 10.1186/cc14362) j p Results Forty patients were identifi ed. Twenty-nine were male and 11 female. Group 1 included 22 patients, Group 2: two patients, Group 3: four patients, Group 4: four patients, Group 5: zero, Group 6: eight patients treated with various combinations of ECMO or ventricular assist devices. ITU stay varied from 1 day to a maximum of 6 months intermittently for one patient. Duration of ITU stay for all 40 patients was 1,052 days with an average of 26.3 days per patient. Sixteen patients survived and were discharged to the Transplant Unit. Twenty- four patients died, putting the survival rate at 40% for this group. Conclusion This review demonstrates that the majority of these patients occupied intensive care beds for a prolonged period of time and despite the use of advanced support devices survival rates were signifi cantly lower than mortality rates. Results Forty patients were identifi ed. Twenty-nine were male and 11 female. Group 1 included 22 patients, Group 2: two patients, Group 3: four patients, Group 4: four patients, Group 5: zero, Group 6: eight patients treated with various combinations of ECMO or ventricular assist devices. ITU stay varied from 1 day to a maximum of 6 months intermittently for one patient. Duration of ITU stay for all 40 patients was 1,052 days with an average of 26.3 days per patient. Sixteen patients survived and were discharged to the Transplant Unit. Twenty- four patients died, putting the survival rate at 40% for this group. Introduction Rhabdomyolysis is a condition that results in the release of mainly creatine kinase (CK) and myoglobin from the breakdown of myocytes. Myoglobin has been known to cause renal failure (RF) and the CK level is routinely used as an indicator. A CK level >5,000 U/l was found to be associated with the risk of RF [1]. However, data are lacking on the level of CK to predict RF, especially in general trauma patients. The purpose of this study was to determine the initial CK level that predicts markedly elevated CK and the characteristics of trauma patients with elevated CK. Introduction Rhabdomyolysis is a condition that results in the release of mainly creatine kinase (CK) and myoglobin from the breakdown of myocytes. P279 Figure 1 (abstract P278). SO2 values from blood gas analysis and vena cava angiography. S99 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods The HELP-ECMO pilot study is enrolling patients admitted to a large metropolitan ICU who require ECMO. Education on eligibility criteria and study processes was given to all ICU senior medical staff . Consent must be performed prior to the commencement of anticoagulation, often only a short time after ECMO cannulation. To facilitate recruitment at all hours, a HELP-ECMO study box is located in the ICU. Within the box is an instruction page outlining the screening, consent and randomisation process, as well as administrative tasks. Plain language statements, randomisation envelopes and consent documentation stickers are provided. A consent script is provided to ensure consistency across consenting personnel. The process is reviewed by the research coordinator the following day to confi rm local governance compliance. In-hospital and long-term mortality after venoarterial ECMO for refractory cardiogenic shock Multivariate analysis (Cox) revealed pre-ECMO SOFA score (HR = 2.18, 95% CI = 1.016 to 4.6) and history of CCM (HR = 19, 95% CI = 2 to 178) and pre-ECMO lactate (HR = 1.2, 95% CI = 1.02 to 1.4) as independent risk factors for hospital mortality. Conclusion The model of consent described has proven to be successful in this challenging patient population. The ability of all staff to perform consent for the study has been a signifi cant factor in the success of the pilot. The review of study processes by research coordinators has supported this model. Table 1 (abstract P281) Alive Dead P value Age (years) 30 ± 18 43 ± 14 0.012 CCM 0 (0%) 7 (100%) 0.014 SOFA 8 ± 1.4 10 ± 1.9 0.002 Creatinine (mg/dl) 1.1 ± 0.3 2.2 ± 0.7 0.001 Bilirubin (mg/dl) 1 ± 0.4 2 ± 1.8 0.09 Lactate (mmol/l) 5 ± 2.1 8 ± 5.3 0.021 Platelets (103/μl) 257 ± 79 162 ± 99 0.03 Conclusion VA-ECMO is an eff ective treatment tool for refractory CS in patients with acute life-threatening heart failure. Patients aff ected by acute decompensation of CCM had poorer outcomes characterized by multiple organ dysfunction as already known in the literature References 1. Cartin Ceba R, et al. Risk factors for development of acute kidney injury in critically ill patients: a systematic review and meta-analysis of observational studies. Crit Care Res Pract. 2012:691013. Methods A retrospective observational study of adults with confi rmed rhabdomyolysis admitted to the Neurosciences Critical Care Unit between 2002 and 2012. Data collection included APACHE score, daily CK (with PEAK CK defi ned as the maximum CK recorded throughout ICU stay), creatinine, calcium, phosphate and bicarbonate levels, AKI, RRT, ICU length of stay and mortality. 1. Cartin Ceba R, et al. Risk factors for development of acute kidney injury in critically ill patients: a systematic review and meta-analysis of observational studies. Crit Care Res Pract. 2012:691013. 2. Suh SH, et al. Acute kidney injury in patients with sepsis and septic shock: risk factors and clinical outcomes. Yonsei Med J. 2013;54:965-72. 2. Suh SH, et al. Acute kidney injury in patients with sepsis and septic shock: risk factors and clinical outcomes. Yonsei Med J. 2013;54:965-72. g y y Results A total of 232 patients met the inclusion criteria. Rhabdo- myolysis was associated with trauma (76%), medical (15%) and surgical (9%) admission diagnoses. Forty-fi ve (19%) patients developed AKI, with 29 (12.5%) requiring RRT. Mortality was signifi cantly higher in patients who developed AKI (62% vs. 18%, P <0.001). Average CK on admission was 5,009 IU/l (SD 12,403 IU/l). CK values remained greater than 2,000 IU/l for an average of 3.3 days (range 1 to 10 days). Although PEAK CK was greater in patients requiring RRT compared with those that did not (PEAK CK: 32,354 IU/l vs. 7,353 IU/l, P = 0.001), receiver operator characteristic curves revealed that a threshold for PEAK CK >5,000 IU/l is only 55% specifi c and 83% sensitive for the prediction of need for RRT. CK peaks on the day of admission in 46% of patients, on day 2 in 37%, and on day 3 or later in 17% of cases. A McMahon Score >6 calculated on admission is 68% specifi c and 86% sensitive for RRT. P284 Methods Data from the Songklanagarind Hospital trauma registry were reviewed over 1 year (January 2013 to December 2013). Patients with at least two records of CK and creatinine (Cr) levels were included. Creatine kinase levels were analyzed during the fi rst 3 days of hospital admission. RF was defi ned as a Cr increment >0.3 mg/dl within 48 hours. Results Of the 1,491 patients admitted to the trauma service, 47 patients had CK levels drawn twice. These patients had a mean age of 32 years and a median Injury Severity Score (ISS) of 14. The predominant mechanism of injury was motorcycle crash. Only three patients developed RF. The median CK during the fi rst 3 days after admission was 3,088 (IQR 1,327, 6,072) U/l. The CK peaked at 11 hours after admission at a mean value of 16,114.167 (SD 34,010.80) U/l. There were no signifi cant diff erences in demographic data, ISS scores and fl uid balance between the groups of CK level over or below 5,000 U/l. A mean positive fl uid balance observed; however, initial CK was signifi cantly diff erent between the two groups. None of the patients with initial CK of <900 U/l had a peak of CK >5,000 U/l. Risk factors for acute kidney injury in patients with complicated intra-abdominal infection A Suarez de la Rica, E Maseda, V Anillo, C Hernandez-Gancedo, A Lopez-Tofi ño, M Villagran, F Gilsanz Hospital Universitario La Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P284 (doi: 10.1186/cc14364) P283 Rhabdomyolysis: early prognostication of renal failure and other adverse outcomes J Simpson1, A Taylor2, DK Menon2, N Sudhan2, A Lavinio2 1University of Cambridge, UK 2Cambridge University Hospitals, Cambridge, UK Critical Care 2015, 19(Suppl 1):P283 (doi: 10.1186/cc14363) Rhabdomyolysis: early prognostication of renal failure and other adverse outcomes J Simpson1, A Taylor2, DK Menon2, N Sudhan2, A Lavinio2 1University of Cambridge, UK 2Cambridge University Hospitals, Cambridge, UK Critical Care 2015, 19(Suppl 1):P283 (doi: 10.1186/cc14363) J Simpson1, A Taylor2, DK Menon2, N Sudhan2, A Lavinio2 1University of Cambridge, UK 2Cambridge University Hospitals, Cambridge, UK Critical Care 2015, 19(Suppl 1):P283 (doi: 10.1186/cc14363) Introduction The clinical diagnosis of rhabdomyolysis is confi rmed by creatine kinase (CK) levels >1,000 IU/l [1]. A local therapeutic protocol triggers aggressive renoprotective treatment in all patients with CK >2,000 IU/l. To evaluate local practice and refi ne CK thresholds for the instigation of renoprotective treatment, we studied the correlation between CK time trends and adverse outcomes such as acute kidney injury (AKI), the need for emergency renal replacement therapy (RRT) and mortality. We also evaluated the McMahon Score, a risk prediction model based on demographic, clinical, and laboratory variables available on admission [2].i p y Conclusion Severe AKI with RRT need is highly associated with previous HTN. The number of previous medications is related to severe AKI too. HTN has been described as a risk factor for developing AKI in critically ill patients [1]. ACEI and ARB use has been associated with AKI development in septic patients [2]. To our knowledge, this is the fi rst study that investigates risk factors associated with AKI in surgical septic patients with CIAI. 2. McMahon GM, et al. JAMA Intern Med. 2013;73:1821-8. 1. Khan FY. Neth J Med. 2009;67:272-83. Risk factors for acute kidney injury in patients with complicated intra-abdominal infection Risk factors for acute kidney injury in patients with complicated intra-abdominal infection A Suarez de la Rica, E Maseda, V Anillo, C Hernandez-Gancedo, A Lopez-Tofi ño, M Villagran, F Gilsanz Hospital Universitario La Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P284 (doi: 10.1186/cc14364) A Suarez de la Rica, E Maseda, V Anillo, C Hernandez-Gancedo, A Lopez-Tofi ño, M Villagran, F Gilsanz Hospital Universitario La Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P284 (doi: 10.1186/cc14364) Introduction AKI has been poorly studied in surgical septic patients. The aim of our study was to determine the factors related to AKI in surgical septic patients with complicated intra-abdominal infection (CIAI) and mortality associated with AKI in this setting. Methods An observational study was performed of all adult patients with CIAI requiring surgery and ICU admission from June 2011 to June 2013. We recorded demographic data, SAPS II, SOFA score at admission, presence of septic shock, history of pre-existing comorbidities, angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), NSAIDs, statins or diuretics consumption, baseline creatinine and at admission, and standard biomarkers. Factors associated with developing AKI and renal replacement therapy (RRT) were studied using a multivariate analysis. Association between mortality and AKI and RRT need was also analyzed. Conclusion Trauma patients had varying levels of elevated CK. Initial CK shows a promising result as a predictor of high peak CK levels. A larger sample size is needed to demonstrate the predictors of RF in trauma patients with elevated CK levels. Reference 1. Brown CVR, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a diff erence? J Trauma. 2004;56:1191-6. 1. Brown CVR, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a diff erence? J Trauma. 2004;56:1191-6. 1. Brown CVR, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a diff erence? J Trauma. 2004;56:1191-6. Results A total of 114 patients were included, with a mean SAPS II of 42.14. Sixty-seven patients (58.8%) developed AKI and 33 (28.9%) required RRT. Development of AKI (R2 = 0.498; P <0.0001; AUC = 0.926) was independently associated with SOFA (OR = 1.57; 95% CI = 1.29, 2.02) and creatinine at admission (OR for 0.1 units = 1.56; 95% CI = 1.30, 1.99). RRT need (R2 = 0.382; P <0.0001; AUC = 0.892) was independently associated with arterial hypertension (HTN) (OR = 4.90; 95% CI = 1.50, 15.97) and SOFA score (OR = 1.71). In another model with more predictive capacity (R2 = 0.433; P <0.0001; AUC = 0.918) the number of previous medications (OR = 3.73; 95% CI = 1.92, 8.38) and SOFA score (OR = 1.86; 95% CI = 1.47, 2.54) were related to RRT need. Both AKI and RRT need were related to ICU (RR = 8.41, 95% CI = 1.14, 62.5; and RR = 8, 95% CI = 2.40, 27.85 respectively) and 28-day mortality (RR = 2.8, 95% CI = 1.00, 7.86; and RR = 4.65, 95% CI =1.99, 10.40 respectively). P282 h Myoglobin has been known to cause renal failure (RF) and the CK level is routinely used as an indicator. A CK level >5,000 U/l was found to be associated with the risk of RF [1]. However, data are lacking on the level of CK to predict RF, especially in general trauma patients. The purpose of this study was to determine the initial CK level that predicts markedly elevated CK and the characteristics of trauma patients with elevated CK. Conclusion This review demonstrates that the majority of these patients occupied intensive care beds for a prolonged period of time and despite the use of advanced support devices survival rates were signifi cantly lower than mortality rates. S100 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Early detection of acute kidney injury during the fi rst week of the ICU M Flechet, F Güiza, M Schetz, P Wouters, I Vanhorebeek, I Derese, J Gunst, G Van den Berghe, G Meyfroidt KU Leuven, Belgium Critical Care 2015, 19(Suppl 1):P285 (doi: 10.1186/cc14365) Early detection of acute kidney injury during the fi rst week of the ICU M Flechet, F Güiza, M Schetz, P Wouters, I Vanhorebeek, I Derese, J Gunst, G Van den Berghe, G Meyfroidt KU Leuven, Belgium Critical Care 2015, 19(Suppl 1):P285 (doi: 10.1186/cc14365) Introduction Acute kidney injury (AKI) is associated with increased morbidity and mortality in critically ill patients [1]. Early detection and treatment may improve outcome. Introduction Acute kidney injury (AKI) is associated with increased morbidity and mortality in critically ill patients [1]. Early detection and treatment may improve outcome. y Methods A retrospective analysis of prospectively collected data from 2,158 patients without end-stage renal disease from the EPaNIC trial [2]. For early detection of AKI, defi ned according to the creatinine-based KDIGO guidelines [3], three multivariate logistic regression models (LR) were developed using data available at baseline (LR_B), upon ICU admission (LR_BA), and at the end of the fi rst day in the ICU (LR_BAD1). In a subpopulation (n = 580) where plasma neutrophil gelatinase- associated lipocalin (pNGAL), an early biomarker of AKI, was measured at ICU admission, the value of adding pNGAL to LR_BA and LR_BAD1 was assessed. The models were evaluated via bootstrapping, by comparing receiver operator characteristic (ROC) and decision curves. pi Conclusion Although higher CK levels are associated with adverse outcomes, instigation of renoprotective treatment should not be based solely on CK levels. A McMahon Score >6 on admission allows for a more sensitive, specifi c and timely identifi cation of patients at risk of renal failure requiring RRT. S101 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Table 1 (abstract P285). Area under ROC curves for the diff erent models LR_BA + pNGAL on LR_BA on pNGAL on subpopulation subpopulation subpopulation LR_B LR_BA LR_BAD1 with pNGAL with pNGAL with pNGAL (n = 2,158) (n = 2,067) (n = 1,808) (n = 528) (n = 528) (n = 528) 0.73 0.76 0.82 0.64 0.70 0.76 with the AMPK activator AICAR (100 mg/kg intraperitoneal, 24 hours before CLP), and sacrifi ced 24 hours after CLP. Blood and tissue samples were collected for all animals. AMPK activation (pThr172), B-ENaC, and mitophagy (LC3 II/I) were examined by western blot of kidney lysates. Plasma creatinine (Scr) was assessed using ELISA. Results Table 1 presents the performance of the models and admission pNGAL. References 1. De Geus H, et al. Am J Respir Crit Care Med. 2011;183:907-14. 2. Casaer M, et al. N Engl J Med. 2011;365:506-17. 3. Acute Kidney Injury Work Group. Kidney Int. 2012;2:1-138. 1. De Geus H, et al. Am J Respir Crit Care Med. 2011;183:907-14. 2. Casaer M, et al. N Engl J Med. 2011;365:506-17. 3. Acute Kidney Injury Work Group. Kidney Int. 2012;2:1-138. P286 Is acute kidney injury in the early phase of sepsis a sign of metabolic downregulation in tubular epithelial cells? K Jin, H Li, J Volpe, D Emlet, N Pastor-Soler, MR Pinsky, BS Zuckerbraun, K Hallows, JA Kellum, H Gomez University of Pittsburgh, PA, USA Critical Care 2015, 19(Suppl 1):P286 (doi: 10.1186/cc14366) Early detection of acute kidney injury during the fi rst week of the ICU M Flechet, F Güiza, M Schetz, P Wouters, I Vanhorebeek, I Derese, J Gunst, G Van den Berghe, G Meyfroidt KU Leuven, Belgium Critical Care 2015, 19(Suppl 1):P285 (doi: 10.1186/cc14365) Performance improved when predictions were made at a later time point, and was highest for LR_BAD1. Similar results were obtained in subgroups of septic and cardiac surgery patients. As an independent predictor, pNGAL alone did not perform better than a model using routine clinical data available upon admission. However, when combining pNGAL with LR_BA, predictive performance improved. The performance of LR_BAD1 was not improved by including pNGAL. with the AMPK activator AICAR (100 mg/kg intraperitoneal, 24 hours before CLP), and sacrifi ced 24 hours after CLP. Blood and tissue samples were collected for all animals. AMPK activation (pThr172), B-ENaC, and mitophagy (LC3 II/I) were examined by western blot of kidney lysates. Plasma creatinine (Scr) was assessed using ELISA. g Results The acute response to sepsis was characterized by early activation of AMPK which increased from 6 to 18 hours, peaked at 24 hours, and decreased by 48 hours (Figure 1A). This activation was associated with a consistent decrease in B-ENaC expression. In AICAR pretreated animals, AMPK was only activated in WT mice, which was associated with a decrease in the expression of B-ENaC as compared with AMPK KO mice (Figure 1B). p p y g p Conclusion This study shows the potential of data-driven models based on routinely collected patient information for early detection of AKI during the fi rst week of ICU stay. Although adding admission pNGAL to admission data improved early detection of AKI, this added value is lost upon inclusion of data from the fi rst day of ICU. R f Conclusion AMPK was activated early after induction of sepsis, and was associated with a consistent decrease in Beta-ENaC expression in the apical membrane of tubular epithelial cells. In addition, absence of AMPK activation in KO animals was associated with increased expression of Beta-ENaC at 24 hours after CLP. These data support the hypothesis that early activation of AMPK decreases energy consumption through ion channel downregulation. Is acute kidney injury in the early phase of sepsis a sign of metabolic downregulation in tubular epithelial cells? S102 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 AKI as per the AKIN KDIGO defi nition, as well as their worst level of TIMP2IGFBP7 during their fi rst 2-day stay. Values of mean and 25th to 75th percentile for the worst value of TIMP2IGFBP7 were 0.24 (0.11 to 0.46), 0.50 (0.28 to 1.24), 0.94 (0.34 to 3.28) and 3.34 (1.47 to 6.22) for no AKI, AKIN I, II and II respectively (P <0.0001). The worst values for no AKI/no sepsis, no AKI/sepsis, AKI/no sepsis and AKI/sepsis were 0.21 (0.10 to 0.4), 0.32 (0.15 to 0.63), 1.05 (0.41 to 2.31) and 0.98 (0.36 to 3.94) respectively, with P <0.05 for AKI and P = NS for sepsis. The AUC ROC curve for prediction of AKI of the worst value was 0.80 with sensitivity of 73.5% and specifi city of 71.4% (P <0.0001). In contrast to the Sapphire study, in our population cutoff values of 0.4 and 0.8 (ng/ml)2/1,000 predict AKI and AKIN ≥II respectively, regardless of the presence of sepsis. See Figure 1. Results There were 101 patients without AKI, 95 patients with KDIGO 1 AKI, and 42 patients with KDIGO 2 to 3 AKI within 48 hours of the start of surgery. In patients without AKI, median TIMP-2·IGFBP7 values were less than 0.3 (ng/ml)2/1,000 (dashed line in Figure 1) for all time points. In patients with KDIGO 1 AKI, median [TIMP-2·IGFBP7] signifi cantly exceeded this cutoff at 24 and 36 hours following the start of surgery (one-sided P <0.025). Median [TIMP-2·IGFBP7] increased earlier in KDIGO 2 to 3 AKI patients, remaining signifi cantly elevated relative to the cutoff from 12 to 60 hours after the start of surgery. The highest median [TIMP-2·IGFBP7] was observed at 24 hours for KDIGO 2 to 3 AKI patients and was nearly fi ve times the 0.3 (ng/ml)2/1,000 cutoff .i p yi gf Conclusion Urinary [TIMP-2·IGFBP7] was signifi cantly elevated as early as 12 to 24 hours from the start of surgery in patients who developed AKI within 48 hours. Monitoring of these biomarkers in the immediate postsurgical period might enable improved management of patients at risk for AKI. Conclusion TIMP-2 and IGFBP-7 can predict AKI in both septic and nonseptic critically ill patients. Further pragmatic randomised controlled trials are needed to prove their role on clinical basis. Is acute kidney injury in the early phase of sepsis a sign of metabolic downregulation in tubular epithelial cells? P287 Urinary TIMP-2 and IGFBP7 elevate early in critically ill postoperative patients that develop AKI P Honore1, LS Chauwla2, A Bihorac3, AD Shaw4, J Shi5, JA Kellum6 1VUB, Brussels, Belgium; 2VAMC, Washington, DC, USA; 3UF, Gainesville, FL, USA; 4VUSM, Nashville, TN, USA; 5WB, Carlsbad, CA, USA; 6PiU, Pittsburgh, PA, USA Critical Care 2015, 19(Suppl 1):P287 (doi: 10.1186/cc14367) Introduction This study tested the hypothesis that the cellular response in the kidney to sepsis is characterized by early activation of AMP activated protein kinase (AMPK), and that such activation is temporally associated with downregulation of the epithelial sodium channel (B-ENaC). Introduction Little is known about temporal changes in [TIMP- 2·IGFBP7] relative to injury in patients who develop AKI. In this analysis, we examined [TIMP-2·IGFBP7] in serial urine collections from the subset of Sapphire patients who were admitted to the ICU after major surgery. Methods We stratifi ed 238 Sapphire patients into three groups by their maximum AKI stage within 48 hours of the start of surgery using KDIGO criteria (No AKI, KDIGO 1, and KDIGO 2 to 3). Median TIMP-2·IGFBP7 values were calculated from all samples collected at 12 (±6)-hour intervals for 4 days following the start of surgery. Methods Fifteen C57BL/6 wildtype (WT) mice were subjected to cecal ligation and puncture (CLP), and sacrifi ced at 2, 6, 18, 24, or 48 hours. In addition, we pretreated three WT and three AMPK Beta 1 knockout mice Figure 1 (abstract P286). (A) AMPK activation (p-Thr172) and Beta-ENAC expression during early CLP. (B) Diff erence in Beta-ENAC expression between AICAR pretreated WT versus KO at 24 hours after CLP. intervals for 4 days following the start of surgery. Figure 1 (abstract P286). (A) AMPK activation (p-Thr172) and Beta-ENAC expression during early CLP. (B) Diff erence in Beta-ENAC expression between AICAR pretreated WT versus KO at 24 hours after CLP. Figure 1 (abstract P287). Figure 1 (abstract P287). Figure 1 (abstract P287). Figure 1 (abstract P286). (A) AMPK activation (p-Thr172) and Beta-ENAC expression during early CLP. (B) Diff erence in Beta-ENAC expression between AICAR pretreated WT versus KO at 24 hours after CLP. Figure 1 (abstract P286). (A) AMPK activation (p-Thr172) and Beta-ENAC expression during early CLP. (B) Diff erence in Beta-ENAC expression between AICAR pretreated WT versus KO at 24 hours after CLP. Is acute kidney injury in the early phase of sepsis a sign of metabolic downregulation in tubular epithelial cells? Reference 1. Kashani et al. Crit Care. 2013;17:R25. 1. Kashani et al. Crit Care. 2013;17:R25. Single point measurement of cystatin C has similar performance as serum creatinine for assessment of kidney function in critically ill patients J Houthoofd1, M Carlier2, J De Waele2, R Vanholder2, J Delanghe2, J Decruyenaere2, E Hoste2 Introduction Sepsis and acute kidney injury (AKI) have a high prevalence in the ICU population. The aim of this study is to describe the composite of tissue inhibitor of metalloproteinases-2 (TIMP2) and insulin-like growth factor-binding protein-7 (IGFBP7) as novel urinary renal biomarkers in both septic and nonseptic patients. Introduction The gold standard for routine evaluation of kidney function is measurement of serum creatinine concentration (Scr). In ICU patients, muscle loss and dilution leads to decreased Scr. Scr is distributed in total body water, resulting in delay of Scr changes when the glomerular fi ltration rate (GFR) changes (lag time). Cystatin C (CysC) is a protein produced by all cells with a nucleus and therefore less aff ected by muscle mass. Also, the lag time may be shorter as the volume of distribution is only extracellular fl uid. The objective of this study was to evaluate whether single point measurement of CysC is more adequate than Scr for monitoring of kidney function in ICU patients. Methods We conducted a prospective, observational study in two university hospitals. Patients were admitted in ICU either from the emergency department or after undergoing an acute surgery at hospital admission. Two months prior to the admission, recruited patients had not been admitted to hospital. We collected epidemiological, clinical and laboratory data at admission, 24 and 48 hours. TIMP2IGFBP7 was analysed in urine samples by a point-of-care device (Nephrocheck®; Astute Medical). Results The sample included 98 patients (65 men) with mean age 55 ± 17.3 years, length of ICU stay 11.1 ± 14.6 days. In total, 41.4% had sepsis at ICU admission; 59.2% were diagnosed of sepsis within the fi rst 48 hours of stay. We stratifi ed patients based on the presence of Methods Data were collected in two prospective single-center studies on a convenience sample of ICU patients. During the 24-hour study period, we measured CysC, Scr, and urinary inulin clearance (Cinu) as a Figure 1 (abstract P288). ROC curve and area under the curve (AUC) for the worst [TIMP2][IGFBP7] value within the fi rst 48 hours of ICU admission to predict (a) AKI and (b) AKIN KDIGO ≥2. Figure 1 (abstract P288). ROC curve and area under the curve (AUC) for the worst [TIMP2][IGFBP7] value within the fi rst 48 h predict (a) AKI and (b) AKIN KDIGO ≥2. P288 Urinary TIMP2 and IGFBP7 as early biomarkers of acute kidney injury in septic and nonseptic critically ill patients M Cuartero 1, A Betbesé 1, J Sabater2, J Ballús2, J Ordóñez1 1Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; 2Hospital Universitari Bellvitge, Hospitalet Llobregat, Barcelona, Spain Critical Care 2015, 19(Suppl 1):P288 (doi: 10.1186/cc14368) P291 gold standard for assessment of GFR. We compared Scr and CysC, with Cinu. Also, we assessed Cinu in patients who had CysC and Scr within the normal sex and age corrected limits. Finally, we determined the ability of CysC and Scr to detect normal range and decreased GFR (80 to 120 ml/minute/1.73m2 resp. <60). Association between urinary TIMP-2 and IGFBP7 as early biomarkers of AKI and oliguria during liver surgery: a prospective pilot study F Desmet1, M D’Hondt1, H Pottel2, S Carlier1, E Hoste3, J Kellum4, W De Corte1 Association between urinary TIMP-2 and IGFBP7 as early biomarkers of AKI and oliguria during liver surgery: a prospective pilot study F Desmet1, M D’Hondt1, H Pottel2, S Carlier1, E Hoste3, J Kellum4, W De Corte1 1AZ Groeninge, Kortrijk, Belgium; 2Catholic University Leuven, Kortrijk, Belgium; 3Ghent University Hospital, Ghent University, Ghent, Belgium; 4University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Critical Care 2015, 19(Suppl 1):P291 (doi: 10.1186/cc14371) 1AZ Groeninge, Kortrijk, Belgium; 2Catholic University Leuven, Kortrijk, Belgium; 3Ghent University Hospital, Ghent University, Ghent, Belgium; 4University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Critical Care 2015, 19(Suppl 1):P291 (doi: 10.1186/cc14371) p Results We included 68 patients, with median age 58 years (IQR 29 years), length of stay in the hospital before study 11 days (IQR 16), and APACHE II score 19 (IQR 9). Scr was 1.12 (IQR 1.55), CysC 0.64 (IQR 0.73), and Cinu 80 ml/minute/1.73 m2 (IQR 82). Cinu was markedly decreased in patients with Scr in normal range (n = 12) compared with patients with CysC in normal range (n = 22) (55 ml/minute/1.73 m2 (IQR 57.4) vs. 100 (IQR 42.2), P <0.001). Patients with normal range Scr had similar proportion of patients with Cinu in the normal range compared with normal range CysC patients (33.3% vs. 45.5%, P = 0.23). ROC analysis showed that Scr and CysC had similar performance for detection of normal range Cinu (AUC: 0.66; 95% CI = 0.53 to 0.77 vs. 0.77; 95% CI = 0.65 to 0.87; P = 0.118), and decreased Cinu (AUC: 0.86; 95% CI = 0.76 to 0.97 vs. 0.94; 95% CI = 0.88 to 1; P = 0.113). Introduction Patients undergoing elective liver surgery have an increased risk for developing AKI [1]. This study was intended to assess [TIMP-2][IGFBP7] and its possible association with urine output (UO) in this population. References 1. Slankamenac et al. Development and validation of a prediction score for postoperative ARF following liver resection. Ann Surg. 2009;250:720-8. 2. Hoste et al. Derivation and validation cutoff s for clinical use of cell cycle arrest biomarkers. Nephrol Dial Transplant. 2014;29:2054-61. 2. Hoste et al. Derivation and validation cutoff s for clinical use of cell cycle arrest biomarkers. Nephrol Dial Transplant. 2014;29:2054-61. g Results Mean age was 81 ± 5.6 years (16 male, 40.0%). Thirty-fi ve patients underwent TA-TAVI and fi ve patients TAo-TAVI. AKI developed in 17 patients (42.5%); seven patients (17.5%) suff ered from AKI 3 and required renal replacement therapy (RRT). Mean maximum value of UTI within 24 hours after TAVI was signifi cantly higher in patients with AKI compared with patients without renal impairment (2.19 ± 3.11 vs. 0.67 ± 0.816, P = 0.037) and higher in patients with AKI 3 compared with patients with AKI 2 (4.73 ± 3.58 vs. 0.59 ± 0.71, P = 0.022). In contrast, preoperative creatinine (AKI (mg/dl) 1.22 ± 0.41 vs. no AKI 1.30 ± 0.59; AKI 3 1.32 ± 0.49 vs. AKI 2 1.26 ± 0.53, P = NS) and early postoperative serum creatinine levels (maximum within 24 hours after TAVI: AKI 1.41 ± 0.50 vs. no AKI 1.34 ± 0.60; AKI 3 1.69 ± 0.56 vs. AKI 2 1.32 ± 0.54, P = NS) did not show any association with the development of AKI. ROC analyses revealed a very good predictive value of early UTI levels for the development of AKI 3 within the next 72 hours after TAVI with a sensitivity of 100% and a specifi city of 80% for a cutoff value of 0.815 (AUC = 0.919, 95% CI = 0.824 to 1.0, SE 0.048, P = 0.001). Single point measurement of cystatin C has similar performance as serum creatinine for assessment of kidney function in critically ill patients Figure 1 (abstract P288). ROC curve and area under the curve (AUC) for the worst [TIMP2][IGFBP7] value within the fi rst 48 hours of ICU admission to predict (a) AKI and (b) AKIN KDIGO ≥2. S103 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P290 Early prediction of acute kidney injury after transcatheter aortic valve implantation with urinary G1 cell cycle arrest biomarkers F Dusse, M Dudásová, D Wendt, M Thielmann, E Demircioglu, HG Jakob, K Pilarczyk University Hospital Essen, Germany Critical Care 2015, 19(Suppl 1):P290 (doi: 10.1186/cc14370) Introduction Acute kidney injury (AKI) is a common complication following transcatheter aortic valve implantation (TAVI) and has been shown to increase mortality. The concentration of the G1 cell cycle arrest proteins TIMP-2 and IGFBP7 in the urine have recently been suggested as sensitive biomarkers for early detection of AKI in critically ill patients. Whether postoperatively elevated levels of urinary [TIMP-2][IGFBP7] (UTI) predict the development of an AKI in patients undergoing TAVI is currently unknown. Conclusion This pilot study demonstrated the association between [TIMP-2][IGFBP7] increase and oliguria and may therefore indicate kidney damage during liver surgery. As Scr could not diff erentiate for these changes, patients did not meet the classical biomarker criteria for AKI. y Methods In a prospective cohort study, 40 patients undergoing TAVI, either trans-apical (TA) or trans-aortic (TAo), were enrolled. Serial measurements of UTI were performed every 12 hours in the postoperative course. Results were calculated for their multiplication and presented as arbitrary values. Urinary output and serum creatinine were recorded simultaneously. The primary clinical endpoint was the occurrence of AKI according to the AKI Network. P291 Secondly we sought to compare [TIMP-2][IGFBP7] with serum creatinine concentration (Scr). Methods A prospective single-center pilot study performed on 12 patients undergoing elective liver surgery. Serial urine samples were analyzed for [TIMP-2][IGFBP7] measured with the Nephrocheck device (Astute Medical, San Diego, CA, USA). Serial Scr was analyzed, UO, blood losses, and mean arterial pressure (MAP) were recorded. Fluid management was standardized, oliguria defi ned as a UO <0.5 ml/kg/ hour. [TIMP-2][IGFBP7] values of >0.3 identify patients at high risk and >2 at highest risk for AKI [2]. Conclusion Single point measurement of Scr and CysC has similar performance for detection of normal and decreased GFR in this cohort of ICU patients. Performance was weak for detection of normal GFR, but both biomarkers had moderate good performance for detection of decreased GFR. g [ ] Results Males comprised 66.7%, median age was 72 years. Median surgical time was 195 minutes. Peroperative median MAP was 71 mmHg (IQR 69; 77). Baseline median GFR was normal in eight patients and decreased in four patients (eGFR >90 and 66.5 ml/ minute/1.73 m2 respectively). Median baseline Scr was 0.75 mg/dl (IQR 0.61; 1.10), 0.74 mg/dl (IQR 0.64; 1.04) at ICU admission and 0.74 mg/ dl (0.64; 1.04) on day 1 postoperatively. No diff erence in Scr and eGFR was seen between these time points (P = 0.457 and P = 0.517 respectively; repeated-measures ANOVA). Median peroperative and postoperative UO was 0.18 ml/kg/hour (IQR 0.13; 0.23) and 0.93 ml/kg/ hour (IQR 0.79; 1.49) respectively. Median baseline [TIMP-2][IGFBP7] was 0.10 (IQR 0.04; 0.34), 2.02 (1.44; 6.23) during surgery, 0.61 (IQR 0.27; 1.22) at ICU admission and 0.74 (0.67; 0.97) on day 1 postoperatively. [TIMP-2][IGFBP7] diff ered at these time points (P <0.0001; repeated- measures ANOVA). Peroperative oliguria was associated with increased [TIMP-2][IGFBP7] (P = 0.018, chi-squared test). Continuous infusion of low-dose iohexol confi rms 1-hour creatinine clearance is more accurate in acute kidney injury than 4-hour creatinine clearance: preliminary data y J Dixon1, K Lane1, R Dalton2, I MacPhee1, B Philips1 J Dixon1, K Lane1, R Dalton2, I MacPhee1, B Philips1 p 1St George’s Hospital and University of London, UK; 2King’s College, London, UK Critical Care 2015, 19(Suppl 1):P292 (doi: 10.1186/cc14372) 1St George’s Hospital and University of London, UK; 2King’s College, London, UK Critical Care 2015, 19(Suppl 1):P292 (doi: 10.1186/cc14372) Introduction There is currently no accurate method of measuring the glomerular fi ltration rate (GFR) during acute kidney injury (AKI). Four- hour creatinine clearance (4-CrCl) is often used. We have previously validated a method of measuring the GFR using a continuous infusion of low-dose iohexol (CILDI) in patients with stable renal function (GFR from normal to <30 ml/minute/1.73 m2). Steady state was achieved in <10 hours in all subjects and we calculate that variations >10.3% suggest an AKI. In this study we compare GFR measured by CILDI with 4-CrCl and 1-hour creatinine clearance (1-CrCl). Conclusion Early elevation of urinary [TIMP-2][IGFBP7] after TAVI is associated with the development of postoperative AKI. These biomarkers have an excellent diagnostic accuracy in the prediction of severe AKI requiring RRT that is superior to that of serum creatinine. Further studies are necessary to prove whether UTI-guided therapy of patients with AKI can reduce morbidity and mortality. Methods Critically ill patients with evolving AKI and patients following nephrectomy were recruited. Demographics were compared using the t test. CIDLI was connected for up to 72 hours. Plasma and renal iohexol and creatinine concentrations were measured by tandem mass spectrometry four times daily. Iohexol renal clearance (IRC) and S104 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 1-CrCl and 4-CrCl were calculated and compared using Bland–Altman analysis. P294 Impact of kidney injury on fl uid overload and impaired oxygenation A Akcan Arikan, LL Loftis, MA Arnold, CE Kennedy Baylor College of Medicine, Houston, TX, USA Critical Care 2015, 19(Suppl 1):P294 (doi: 10.1186/cc14374) y Results Baseline estimated GFR was similar in the postnephrectomy (88 ± 28) to the evolving AKI group (92 ± 23), P = 0.70. The evolving AKI group had a higher APACHE score (17.8 ± 5.1 vs. 10.6 ± 3.9; P <0.001). Continuous infusion of low-dose iohexol confi rms 1-hour creatinine clearance is more accurate in acute kidney injury than 4-hour creatinine clearance: preliminary data When 1-CrCl was compared with IRC, a bias of 0.8% (SD 26%, limits of agreement –52 to 50%; Pearson’s r = 0.90) was observed in the evolving AKI group, whereas bias was –3.3% (SD 16, limits of agreement –35 to 29%; Pearson’s r = 0.95) in the postnephrectomy group. When 4-CrCl was compared with IRC, bias was 5.1% (SD 54, limits of agreement –102 to 112%, Pearson’s r = 0.45) in the established AKI group and bias was –4.5% (SD 38, limits of agreement –79 to 70%; Pearson’s r = 0.78) in the postnephrectomy group. Introduction Severity of acute kidney injury (AKI) and fl uid overload (FO) are not incorporated into current severity of illness measures and are invisible to the practitioner. The causal relationship and timing between AKI and FO and oxygenation is not clear. The Fluid Overload Kidney Injury Score (FOKIS) is a daily score incorporating subscores for AKI (pRIFLE (creatinine (Cr) and urine output (UOP))), FO (total fl uid (in – out) / ICU admission weight) >15% in fi ve percentile increments, and exposure to nephrotoxic medications. We previously reported that FOKIS outperforms PRISM in mortality prediction in our pediatric intensive care unit (PICU). We hypothesized that patients with AKI on admission to the PICU developed worse fl uid overload and in turn worse oxygenation. y g Conclusion Our data suggest that 4-CrCl is not as accurate and precise as 1-CrCl in patients with AKI and following nephrectomy. IRC appears to be more accurate and precise in patients with a predicted AKI risk and outcome (post nephrectomy) than in patients with evolving AKI. We hypothesise that IRC will be useful alternative to creatinine-based measures of AKI. Methods We prospectively calculated daily FOKIS scores and subscores (Cr, UOP, FO) in PICU patients. We excluded patients with <7 day stays in order to properly explore the association between timing of AKI and FO and oxygenation by oxygenation index (OI). y y y Results Over 18 months, there were 2,830 patients, 436 patients with PICU stay >7 days, 361 patients had complete data for all 7 days. Mortality was 4.5% overall and 11% cohort. A total of 246 patients (68%) had AKI (by FOKISCr or FOKISuop); 205 patients (57%) on day 1, 85 patients (24%) on day 3. Admission or day 3 AKI by either FOKIS subscore (FOKISCr or FOKISuop) did not predict maxFO or mortality. P295 P295 Acute kidney injury biomarkers off er the opportunity to reduce exposure to nephrotoxic drugs M Ostermann1, L Forni2, K Kashani3, M Joannidis4, A Shaw5, M Chawla6, JA Kellum7, on Behalf of Sapphire Investigators7 1Guy’s & St Thomas Foundation Hospital, London, UK; 2Royal Surrey County Hospital, Guilford, UK; 3Mayo Clinic, Rochester, MN, USA; 4University Hospital Innsbruck, Austria; 5Vanderbilt University Hospital, Nashville, TN, USA; 6George Washington University Medical Center, Washington, DC, USA; 7University of Pittsburgh, PA, USA Critical Care 2015, 19(Suppl 1):P295 (doi: 10.1186/cc14375) FOKIS f Methods Retrospective data from all nondialysed patients undergoing isolated CABG at our institution were collected for the year 2013. Propensity scoring using the software platform MatchIt® was used to match subjects from ONCAB and OPCAB groups with regard to preoperative variables: logistic EuroSCORE, creatinine clearance (CrCl), gender and operative urgency. Postoperative AKI was defi ned as a rise of 50% or more in baseline serum creatinine [2]. Chi-square analysis was used to determine statistically signifi cant diff erences. Conclusion In PICU patients, admission or day 3 AKI alone did not predict maxFO. A composite score that includes both AKI and FO parameters correlated with OI and discriminated survivors from nonsurvivors. FO seems to result from combination of increased fl uid exposure with underlying AKI but cannot fully be explained by oliguria in pediatric patients. yif Results From 500 cases (369 OPCAB, 131 ONCAB), 262 subjects were included in the fi nal analysis, with 131 in each group. There was a higher incidence of AKI and renal replacement therapy (RRT) in the ONCAB group, although this was not signifi cantly greater than in the OPCAB group (Table 1). The mortality rate was identical with three deaths in each group. The average length of ICU stay for the OPCAB group was 1.96 days versus 2.49 days for the ONCAB group. 2. Acute Kidney Injury Network criterion. http://www.akinet.org. 1. Lamy A, et al. N Engl J Med. 2012;366:1489-97. Continuous infusion of low-dose iohexol confi rms 1-hour creatinine clearance is more accurate in acute kidney injury than 4-hour creatinine clearance: preliminary data Increasing total FOKIS score was associated with increasing mortality and increasing OI (Table 1). FOKIS, controlled for PRISM, was an independent predictor of OI (P = 0.03). Does cardiopulmonary bypass increase the risk of postoperative acute kidney injury after coronary artery bypass grafting? A Karmali, C Walker, L Kuppurao Harefi eld Hospital, London, UK Critical Care 2015, 19(Suppl 1):P293 (doi: 10.1186/cc14373) Does cardiopulmonary bypass increase the risk of postoperative acute kidney injury after coronary artery bypass grafting? A Karmali, C Walker, L Kuppurao Harefi eld Hospital, London, UK Critical Care 2015, 19(Suppl 1):P293 (doi: 10.1186/cc14373) Introduction Acute kidney injury (AKI) following coronary artery bypass grafting (CABG) results in signifi cant morbidity, mortality and prolonged stay on the cardiothoracic ICU. We sought to determine the incidence of AKI in our cardiothoracic centre, hypothesizing a higher occurrence in patients undergoing CABG using cardiopulmonary bypass (ONCAB) compared with off -pump (OPCAB) surgery [1]. Table 1 (abstract P294) P FOKIS 0 <4 4 to 7 >7 value maxOI, median (IQR) 7.4 11.1 16.4 14.2 0.03 (5.9 to 16.4) (6.2 to 23.6) (7.3 to 29.6) (10 to 38.7) Mortality, % 3.6 7.7 13 38 <0.001 Conclusion In PICU patients, admission or day 3 AKI alone did not predict maxFO. A composite score that includes both AKI and FO parameters correlated with OI and discriminated survivors from nonsurvivors. FO seems to result from combination of increased fl uid exposure with underlying AKI but cannot fully be explained by oliguria in pediatric patients. Table 1 (abstract P294) P FOKIS 0 <4 4 to 7 >7 value maxOI, median (IQR) 7.4 11.1 16.4 14.2 0.03 (5.9 to 16.4) (6.2 to 23.6) (7.3 to 29.6) (10 to 38.7) Mortality, % 3.6 7.7 13 38 <0.001 Conclusion In PICU patients, admission or day 3 AKI alone did not predict maxFO. A composite score that includes both AKI and FO parameters correlated with OI and discriminated survivors from nonsurvivors. FO seems to result from combination of increased fl uid exposure with underlying AKI but cannot fully be explained by oliguria in pediatric patients. Table 1 (abstract P294) Table 1 (abstract P294) Retrospective analysis of the effi cacy of radio-contrast-induced nephropathy prophylaxis J Wood, N Shields, KV Wood Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK Critical Care 2015, 19(Suppl 1):P296 (doi: 10.1186/cc14376) Retrospective analysis of the effi cacy of radio-contrast-induced nephropathy prophylaxis J Wood, N Shields, KV Wood Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK Critical Care 2015, 19(Suppl 1):P296 (doi: 10.1186/cc14376) Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK g Critical Care 2015, 19(Suppl 1):P296 (doi: 10.1186/cc14376) Introduction This study investigated renal outcomes following radio- contrast (RC) administration in patients from two intensive care units (ITUs), where one gave RC-induced nephropathy (RCIN) prophylaxis, while the other did not. Acute kidney injury (AKI) during critical illness increases morbidity and mortality. ITU patients, who already suff er a variety of renal insults, often require RC, increasing their risk of developing AKI, and requiring renal replacement therapy (RRT). Evidence suggests that hydration alone is inadequate for the prevention of RCIN in ITU patients, and is contraindicated in some disease states [1]. The European Society of Intensive Care Medicine (ESICM) provides recommendations for prophylaxis [2]. The current study aimed to establish the effi cacy of the ESICM recommended prophylaxis. p p y Conclusion Both SOFA score and BD may be used to predict AKI in surgical oncology patients at ICU admission. These variables allow physicians to recognize early patients who might be under risk, and anticipate measures to avoid further renal impairment. References 1. Rocktaeschel J, Morimatsu H, Uchino S, Goldsmith D, Poustie S, Story D, et al. Acid–base status of critically ill patients with acute renal failure: analysis based on Stewart–Figge methodology. Crit Care. 2003;7:R60. 1. Rocktaeschel J, Morimatsu H, Uchino S, Goldsmith D, Poustie S, Story D, et al. Acid–base status of critically ill patients with acute renal failure: analysis based on Stewart–Figge methodology. Crit Care. 2003;7:R60. gg gy 2. Smith I, Kumar P, Molloy S, Rhodes A, Newman PJ, Grounds RM, et al. Base excess and lactate as prognostic indicators for patients admitted to intensive care. Intensive Care Med. 2001;27:74-83. fi Methods Retrospective data from 140 Maidstone (M) ITU patients (men 101, women 39, mean age 63.5, mean APACHE 15.3) and 73 Tunbridge Wells (T) ITU patients (men 41, women 32, mean age 60.2, mean APACHE 20.2) admitted between 22 September 2011 and 22 September 2013, who underwent RC-enhanced CT, were collected. Patients on MITU received ESICM-recommended RCIN prophylaxis: 200 mg aminophylline i.v. over 30 minutes prior to RC, 1.26% sodium bicarbonate 3 ml/kg/hour for 1 hour prior to RC and 1 ml/kg/hour for 6 hours post RC. Acute kidney injury biomarkers off er the opportunity to reduce exposure to nephrotoxic drugs 1 2 h 3 d 4 h 5 h l 6 Table 1 (abstract P293) OPCAB ONCAB P value AKI 14 (10.69%) 19 (14.50%) 0.35 RRT 6 (4.58%) 9 (6.87%) 0.43 Table 1 (abstract P293) g Critical Care 2015, 19(Suppl 1):P295 (doi: 10.1186/cc14375) Conclusion Our study is limited by its size and the use of logistic EuroSCORE as a composite measure of risk factors. However, it has demonstrated that in our predominantly off -pump cardiac unit, OPCAB conferred no statistically signifi cant advantage over ONCAB with regard to postoperative AKI. Studies to date have standardised patient-specifi c variables, but not the conduct of the procedure itself; for example, minimising renal hypoperfusion during OPCAB. This may be a reason for the lack of clear superiority in the continuing debate over choice of CABG procedure and reducing the risk of AKI. References Introduction Tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) are specifi c urinary biomarkers which can predict acute kidney injury (AKI) in critically ill patients within 12 hours [1]. A [TIMP-2]·[IGFBP7] result >0.3 (ng/ml)2/1,000 is associated with seven times the risk of AKI compared with a test result ≤0.3 [2]. The aim of our study was to explore the use of potentially nephrotoxic medications within the window between a positive biomarker test and the diagnosis of AKI stage 2 or 3.i Introduction Tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) are specifi c urinary biomarkers which can predict acute kidney injury (AKI) in critically ill patients within 12 hours [1]. A [TIMP-2]·[IGFBP7] result >0.3 (ng/ml)2/1,000 is associated with seven times the risk of AKI compared with a test result ≤0.3 [2]. The aim of our study was to explore the use of potentially nephrotoxic medications within the window between a positive biomarker test and the diagnosis of AKI stage 2 or 3. Methods We identifi ed all patients enrolled into the Sapphire study [1] who received at least one potentially nephrotoxic drug on the day of AKI (defi ned by stage 2 or 3 as per KDIGO classifi cation). We subsequently Methods We identifi ed all patients enrolled into the Sapphire study [1] who received at least one potentially nephrotoxic drug on the day of AKI (defi ned by stage 2 or 3 as per KDIGO classifi cation). We subsequently 2. Acute Kidney Injury Network criterion. http://www.akinet.org. pp References 1. Kashani K, et al. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care. 2013;17:R25. 2. Bihorac A, et al. Validation of cell-cycle arrest biomarkers for acute kidney injury: using clinical adjudication. Am J Resp Crit Care Med. 2014;189:932-9. 2. Bihorac A, et al. Validation of cell-cycle arrest biomarkers for acute kidney injury: using clinical adjudication. Am J Resp Crit Care Med. 2014;189:932-9. Results There were 76 (26.7%) patients who developed AKI within the fi rst 48 hours after ICU admission. In a univariate analysis, patients with AKI were more likely to be male, had higher Sequential Organ Failure Assessment (SOFA) score, higher baseline serum creatinine and urea levels, higher serum lactate levels and had more metabolic academia at admission. These patients also had a higher 24-hour Simplifi ed Acute Physiology III score and higher length of mechanical ventilation as compared with non-AKI patients. There were no diff erences between patients regarding intraoperative vasopressors, type and amount of fl uids, diuresis and blood transfusion. In a multivariate analysis we identifi ed admission base defi cit (BD) (OR = 1.13, 95% CI = 1.02 to 1.24, P = 0.017) and SOFA score (OR = 1.35, 95% CI = 1.2 to 1.51, P <0.001) as independent predictive factors of early AKI. 2. Joannidis M, et al. Intensive Care Med. 2010;36:392-411. 1. Huber W, et al. Radiology. 2006;239:793-804. Acute kidney injury biomarkers off er the opportunity to reduce exposure to nephrotoxic drugs 1 2 h 3 d 4 h 5 h l 6 S105 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 determined the proportion of patients who had a [TIMP-2]·[IGFBP7] result >0.3 (ng/ml)2/1,000 before meeting the criteria for AKI. determined the proportion of patients who had a [TIMP-2]·[IGFBP7] result >0.3 (ng/ml)2/1,000 before meeting the criteria for AKI. Predictors of renal recovery in critically ill patients with AKI: observations from the ongoing FBI clinical trial f S Robinson, U Larsen, A Zincuk, S Zwisler, P Toft , , , , Odense University Hospital, Odense, Denmark , , , , Odense University Hospital, Odense, Denmark y p Critical Care 2015, 19(Suppl 1):P298 (doi: 10.1186/cc14378) y Critical Care 2015, 19(Suppl 1):P298 (doi: 10.1186/cc14378) Introduction The predictive value of NGAL for renal recovery is not established. Base defi cit and SOFA score are predictive factors of early acute kidney injury in oncologic surgical patients Base defi cit and SOFA score are predictive factors of early acute kidney injury in oncologic surgical patients Results Of 184 patients who developed AKI, 58% received one or more potentially nephrotoxic drug on the day of AKI. Eighty-nine percent of these patients had a positive biomarker test ≥12 hours earlier. In 41% of patients receiving one or more nephrotoxic drug on the day of AKI, at least one nephrotoxic medication was stopped within 1 day of AKI, and in 24% of patients all nephrotoxic drugs were stopped within 1 day of AKI, which implies that these medications were not absolutely necessary. Introduction Patients who undergo major oncology surgery are under high risk to develop postoperative acute kidney injury (AKI), mainly due to infl ammatory and ischemic insults. This complication results in worse outcomes. The aim of this study is to identify predictive factors of AKI in this population. Conclusion Nephrotoxic medications are commonly used in patients who develop moderate or severe AKI. The [TIMP-2]·[IGFBP7] test could have identifi ed many of these patients earlier and would have off ered an opportunity to reduce exposure to non-essential nephrotoxic drugs. References Methods We performed an observational study in 285 consecutive patients admitted to a surgical ICU after major abdominal oncology surgery. Baseline characteristics, laboratorial, clinical and intraoperative data, such as type of fl uids, blood transfusion, bleeding and use of vasopressor, were collected at ICU admission. Early acute kidney injury was defi ned according to the Acute Kidney Injury Network classifi cation at 48 hours of ICU admission. Logistic regression model was performed using AKI as the outcome. P297 Base defi cit and SOFA score are predictive factors of early acute kidney injury in oncologic surgical patients A Gerent, J Almeida, E Almeida, A Lousada, C Park, J Ribeiro, J Fukushima, A Leme, E Osawa, A Rezende, I Bispo, F Galas, L Hajjar Instituto do Cancer do Estado de São Paulo – ICESP, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P297 (doi: 10.1186/cc14377) Introduction The predictive value of NGAL for renal recovery is not established. Methods Data from the fi rst 19 patients were assessed during a multicentre low molecular weight heparin trial (FBI, EudraCT Number: 2012-004368-23). Critically ill patients with AKI are randomly assigned into either a treatment arm (1 mg/kg enoxaparin) or a control arm (40 mg enoxaparin) upon commencement of CRRT. The primary outcome is the occurrence of venous thromboembolism. NGAL was measured at baseline and during CRRT-free intervals. Results The total number of patients developing renal injury falling into any RIFLE category for MITU at 24, 28 and 72 hours was eight (0.06%), 12 (0.09%) and 14 (0.1%), while for TITU it was fi ve (0.07%), six (0.08%), and four (0.05%) respectively. A repeated-measures ANOVA revealed no signifi cant diff erences in outcomes between the two groups overall (F = 2.35, P = 0.127) or at each time point (F = 1.93, P = 0.123). Results Patients were comparable at baseline with respects to demographics, APACHE II, creatinine, NGAL, start of dialysis, and the duration of dialysis. The main cause of AKI was sepsis (42%). In 63% of the patients, the reason for starting dialysis was a combination of anuria and electrolyte disturbances. Twenty-six percent of patients were dialysis dependent after the fi rst CRRT-free interval. Plasma NGAL levels were higher in nonrenal recovery patients (1,074 (±694) ng/ml) compared with renal recovery patients (296 (±197) ng/ml; P = 0.01). Urine NGAL levels were higher in nonrenal recovery patients (3,885 Conclusion While RCIN is a recognised problem within the critical care population, there is little clear evidence for any prophylactic strategy to reduce this risk. This study suggests that a RCIN prophylaxis protocol based on the ESICM recommendations has no eff ect on the incidence of RCIN. However, further studies are needed. Retrospective analysis of the effi cacy of radio-contrast-induced nephropathy prophylaxis J Wood, N Shields, KV Wood Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK Critical Care 2015, 19(Suppl 1):P296 (doi: 10.1186/cc14376) TITU patients received standard critical care alone. Exclusion criteria were: those undergoing RRT prior to CT, >1 CT in 48 hours, no creatinine (Cr) data available post scan. The Cr prior to CT (baseline), at 24, 48 and 72 hours post CT scan were identifi ed. The RIFLE criteria was used to classify the changes of Cr from baseline into low risk (% change >1.25), risk (% change >1.5), injury (% change >2) or failure (% change >3, or Cr>355 and increase of >44). P299 Comparison of two strategies for initiating renal replacement therapy in the ICU: study protocol plan for a multicenter, randomized, controlled trial from the AKIKI research group S Gaudry1, D Hajage2, F Schortgen3, L Martin-Lefevre4, J Ricard1, D Dreyfuss1 1Hôpital Louis Mourier, Colombes, France; 2Hôpital Bichat, Paris, France; 3Hôpital Henri Mondor, Créteil, France; 4CHD La Roche sur Yon, France Critical Care 2015, 19(Suppl 1):P299 (doi: 10.1186/cc14379) Results The total baseline plasma concentration of all standard amino acids was similar between IHD versus SLEDf groups (1,812 ± 517 vs. 2,675 ± 527 μmol/l, respectively) but were higher in the CVVH group (3,194 ± 564 μmol/l). RRT reduced the plasma concentration of amino acids in the SLEDf group (to 1,732 ± 529 μmol/l; P = 0.02), but had no eff ect in the IHD or CVVH groups (IHD; 1,853 ± 523, CVVH; 2,845 ± 512 μmol/l). The average, unadjusted loss of amino acids was signifi cantly infl uenced by mode of RRT (IHD, 5.13 ± 3.1 vs. SLEDf, 8.21 ± 4.07 vs. CVVH, 18.69 ± 3.04 g; P <0.01). The total baseline plasma concentration of trace elements was similar in the IHD, SLEDf and CVVH groups (3,797 ± 827, 3,667 ± 791, 3,642 ± 481 μg/l, respectively). By the end of the RRT session, the plasma concentration of trace elements had reduced (IHD, to 3,103 ± 827; SLEDf, to 2,805 ± 797; CVVH, to 3,433 ± 481 μg/l; P = 0.01). By the end of each RRT session, total losses of trace elements were estimated at IHD, 5,051 ± 2,312; SLEDf, 8,751 ± 2,421; CVVH, 11,258 ± 2,547 μg/l; P = 0.02 for treatment. Introduction There is currently no validated strategy for the timing of renal replacement therapy (RRT) for acute kidney injury (AKI) in the ICU when short-term life-threatening metabolic abnormalities are absent. No adequately powered prospective randomized study has to date addressed this issue. As a result, signifi cant practice heterogeneity exists and may expose patients either to unnecessary hazardous procedures or to undue delay in RRT. Methods This is a multicenter, prospective, randomized, open- label parallel-group clinical trial that compares the eff ect of two RRT initiation strategies on overall survival of critically ill patients receiving intravenous catecholamines and/or invasive mechanical ventilation and presenting with RIFLE F stage of AKI. In the early strategy, RRT is initiated immediately. References S106 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 (±2,722) ng/ml) compared with renal recovery patients (597 (±565) ng/ml; P = 0.006). See Figures 1 and 2. Infl ammatory parameters (WBCs, CRP, and procalcitonin) did not diff er signifi cantly between the groups. Conclusion NGAL may be able to predict renal recovery, and allow proper utilization of resources. Figure 2 (abstract P298). Urine neutrophil gelatinase-associated lipocalin concentration by recovery. Figure 1 (abstract P298). Plasma neutrophil gelatinase-associated lipocalin concentration by recovery. Figure 1 (abstract P298). Plasma neutrophil gelatinase-associated lipocalin concentration by recovery. more than 72 hours after randomization, serum urea concentration >40 mmol/l, serum potassium concentration >6 mmol/l, serum potassium concentration >5.5 mmol/l persisting despite medical treatment, arterial blood pH <7.15 in a context of pure metabolic acidosis (PaCO2 <35 mmHg) or in a context of mixed acidosis with a PaCO2 >50 mmHg without possibility of increasing alveolar ventilation, acute pulmonary edema due to fl uid overload despite diuretic therapy leading to severe hypoxemia requiring oxygen fl ow rate >5 l/minute to maintain SpO2 >95% or FiO2 >50% under invasive or non-invasive mechanical ventilation. The primary endpoint is overall survival, measured from randomization (D0) until death, regardless of the cause. The minimum follow-up duration for each patient will be 60 days. To demonstrate a 14% decrease in mortality, a total of 546 subjects (273 per group) should be randomized.i p g p Results Enrollment is ongoing. After the fi rst interim analysis, the DSMB recommended to continue the study. On 5 December 2014, 318 patients were included in the trial. Figure 1 (abstract P298). Plasma neutrophil gelatinase-associated lipocalin concentration by recovery. Conclusion The AKIKI study will be one of the very few large randomized controlled trials evaluating mortality according to the timing of RRT in critically ill patients with RIFLE F stage of AKI. Results should help clinicians better decide when to initiate RRT. Figure 2 (abstract P298). Urine neutrophil gelatinase-associated lipocalin concentration by recovery. P300 Micronutrient loss in renal replacement therapy for acute kidney injury W Oh1, M Devonald1, D Gardner2, R Mahajan3, D Harvey3, A Sharman3, B Mafrici1, M Rigby1, S Welham2 1Nottingham University Hospitals NHS Trust, Nottingham, UK; 2University of Nottingham, Sutton Bonington, UK; 3University of Nottingham, UK Critical Care 2015, 19(Suppl 1):P300 (doi: 10.1186/cc14380) Micronutrient loss in renal replacement therapy for acute kidney injury j y W Oh1, M Devonald1, D Gardner2, R Mahajan3, D Harvey3, A Sharman3, B Mafrici1, M Rigby1, S Welham2 1Nottingham University Hospitals NHS Trust, Nottingham, UK; 2University of Nottingham, Sutton Bonington, UK; 3University of Nottingham, UK Critical Care 2015, 19(Suppl 1):P300 (doi: 10.1186/cc14380) Introduction The prevalence of malnutrition in acute kidney injury (AKI) is high. Patients with AKI may require renal replacement therapy (RRT), which could result in loss of water-soluble micronutrients. Little is known about these losses in RRT and whether they diff er between types of RRT. This study aims to quantify micronutrient losses during RRT in patients with AKI and to compare them in three diff erent RRT modalities: continuous venovenous haemofi ltration (CVVH), intermittent haemodialysis (IHD) and sustained low-effi ciency diafi ltration (SLEDf). (±2,722) ng/ml) compared with renal recovery patients (597 (±565) ng/ml; P = 0.006). See Figures 1 and 2. Infl ammatory parameters (WBCs, CRP, and procalcitonin) did not diff er signifi cantly between the groups. Conclusion NGAL may be able to predict renal recovery, and allow proper utilization of resources. Methods A prospective observational study is being conducted at NUH. Thirty-three adult patients with AKI requiring RRT (13 IHD, 10 SLEDf, 10 CVVH) have been recruited. Samples of blood and RRT effl uent were obtained at baseline, mid and end-session from each participant during their fi rst RRT treatment. Samples were processed and stored at –80°C for subsequent analysis of amino acids by high- performance liquid chromatography and trace elements by inductively coupled mass spectrometry after derivatization from physiological fl uids. Micronutrient losses were calculated by multiplying mass- corrected concentrations by total volume of RRT effl uent, adjusted for baseline plasma concentrations and RRT dose. Data were analysed by restricted maximum likelihood estimating equations. P299 In the delayed strategy, clinical and metabolic conditions are closely monitored and RRT is initiated only when one or more events (severity criteria) occur, including: oliguria or anuria for Conclusion Micronutrients are lost during RRT in AKI. The degree of micronutrient loss is infl uenced by the type of RRT used. S107 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P301 Methods A comparison of patients receiving CVVHDF on the 11-bed critical care unit at Conquest Hospital, Hastings was undertaken, before and after the implementation of new CVVHDF protocols. All patients receiving CVVHDF were identifi ed from the electronic patient record system between March 2012 to 2013 and September 2013 to 2014. Patient demographics, the duration of CVVHDF and sodium bicarbonate supplementation were analysed between the groups to assess the impact of the new protocols. P301 Super high-fl ux CVVHD using regional citrate anticoagulation: long-term stability of middle molecule clearance M Siebeck, D Kindgen-Milles University Hospital, Düsseldorf, Germany Critical Care 2015, 19(Suppl 1):P301 (doi: 10.1186/cc14381) Introduction Conventional membranes used for CRRT have a limited middle molecule clearance. New membranes called super high-fl ux (SHF) or high cutoff membranes have been investigated. The loss of albumin with hemofi ltration is a major drawback, but these membranes can be used in CVVHD with regional citrate anticoagulation (Ci-Ca® CVVHD), which may limit albumin loss, and contribute to a prolonged fi lter patency and an improved and stable middle molecule clearance. We evaluated saturation coeffi cients (SC), plasma clearances (PCL) and serum levels of eight small and middle molecules during 72 hours of Ci-Ca® CVVHD with a SHF membrane (Ultrafl ux®EMiC®2). p p Results Sixty-four patients received CVVHDF in 2012 to 2013, 61 receiving citrate and three receiving unfractionated heparin due to fulminant liver failure. Forty-seven patients received CVVHDF in 2013 to 2014, two receiving no anticoagulation due to severe coagulopathy and one receiving unfractionated heparin. The two patient cohorts assessed were similar in age (median 65.5 for March 2012 to 2013 cohort vs. 66 for September 2013 to 2014 cohort), gender mix (64% male vs. 57% male) and severity of illness as assessed by APACHE II score (23 vs. 24). Mean duration of CVVHDF was also similar (71.5 hours vs. 75 hours). P299 A total 30/64 of 2012 to 2013 patients did not require a fi lter change prior to completion of RRT, compared with 23/47 of 2013 to 2014 patients. Sodium bicarbonate was added to the dialysate fl uid in 29/64 2012 to 2013 patients, compared with just 2/47 2013 to 2014 patients.i l Methods After approval of the local committee of medical ethics and written informed consent we enrolled patients on a surgical ICU with AKI RIFLE-F who were treated with a Ci-Ca® CVVHD with a SHF membrane for 72 hours. We measured urea (0.006 kDa), creatinine (0.113 kDa), osteocalcin (5.8 kDa), B2MG (12 kDa), myoglobin (17.2 kDa), FreeLightChains (FLC) kappa (25 kDa) and lambda (50 kDa) and albumin (66 kDa) at 0 hours, 1 hour, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours. PCL, SC and serum levels during 72 hours were compared, using the Wilcoxon signed-rank test with P <0.05. Conclusion Changing protocols resulted in a signifi cant reduction in off -license addition of sodium bicarbonate to dialysate bags without impacting on fi lter life, thus reducing nursing workload and removing a potential source of adverse events in this high-risk group of patients. Results Four females and 10 males (mean age 68.1 ±15.1 years; mean APACHE II score 13.7 ± 14.7; mean SAPS II 38.7 ± 12.7) were included. The SC and the PCL (ml/minute) of small solutes like creatinine at 1 hour (1.0 ± 0.0/23.72 ± 1.04) and 72 hours (0.95 ± 0.16/22.19 ± 3.99) were not statistically signifi cantly diff erent (P = 0.5/P = 0.42), the PCL was slightly reduced by 6%. The creatinine serum level was reduced by 42%. The SC and PCL of B2MG from 1 hour (0.61 ± 0.09/14.49 ± 2.5) to 72 hours (0.48 ± 0.13/11.6 ± 2.96) were signifi cantly decreased (P = 0.0024/P = 0.0061). The reduction was 23% only; the overall clearance still was high. There was almost no reduction in SC or PCL for FLC kappa from 1 hour (0.176 ± 0.047/4.14 ± 1.08) to 72 hours (0.164 ± 0.078/3.854 ± 1.87), not reaching statistical signifi cance (P = 0.94/P = 0.81). The serum levels of B2MG and FLC kappa were decreased by 39% and 23%. The SC of albumin was low (1 hour: 0.0009 ± 0.0004) and clearance decreased rapidly within the fi rst 6 hours from 0.021 ± 0.01 to 0.011 ± 0.009. Descriptive study of the haematological management of adult patients with severe respiratory failure receiving venovenous extracorporeal membrane oxygenation p yg O Tavabie, R Pocock, N Barrett, A Retter Introduction Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a novel therapy for severe respiratory failure (SRF). Its introduction has reduced mortality; however, patients require substantial blood product support and between 10 and 20% of cases develop a life-threatening haemorrhage. p g g Methods We contacted 336 practitioners at 135 centres, examining their haematological management. Conclusion This study shows high middle molecular clearances using a SHF membrane with Ci-Ca® CVVHD for 72 hours with no loss of albumin. This set-up may improve blood purifi cation in critically ill patients with acute kidney injury. Results In total 25% of practitioners contacted responded; 85% were attending physicians, predominantly based in North America and Europe, 41 and 32% respectively. Ninety-six per cent of units used a polymethylpentene membrane oxygenator and all used a centrifugal pump. Thirty-four per cent of responders managed <10 cases a year and 60% worked in units handling <20 annually, 6% saw >50 patients. One centre did not use unfractionated heparin. Monitoring of anticoagulation varied; 52% used the APTT, 43% the ACT and 5% the APTTr. Sixty per cent did not routinely measure antithrombin. Results In total 25% of practitioners contacted responded; 85% were attending physicians, predominantly based in North America and Europe, 41 and 32% respectively. Ninety-six per cent of units used a polymethylpentene membrane oxygenator and all used a centrifugal pump. Thirty-four per cent of responders managed <10 cases a year and 60% worked in units handling <20 annually, 6% saw >50 patients. One centre did not use unfractionated heparin. Monitoring of anticoagulation varied; 52% used the APTT, 43% the ACT and 5% the APTTr. Sixty per cent did not routinely measure antithrombin. Scenario 1 was based on a patient with H1N1. Practitioners targeted a haemoglobin (Hb) of 80 to 100 g/l; however, 20% targeted a Hb outside this range; 38% favouring a transfusion threshold of <80 g/l when the patient was improving compared with 32% when the patient had just started on ECMO. Seventeen per cent of practitioners transfused platelets when the count was <30 × 109/l whilst 21% maintained the platelet count >100 × 109/l. Scenario 2 described a patient with SRF secondary to a hospital-acquired pneumonia. The patient developed a haemothorax, with persistent blood loss of 200 ml/hour. Descriptive study of the haematological management of adult patients with severe respiratory failure receiving venovenous extracorporeal membrane oxygenation Practitioners targeted a higher haemoglobin concentration of 100 g/l and targeted a higher platelet count of >100 × 109/l when compared with the patient in scenario 1, neither of these diff erences was statistically signifi cant. Seventy-one per cent stated they would manage the patient off anticoagulation. There was no agreement as to the length of time off anticoagulation; 26% restarted anticoagulation in <12 hours, compared with 22% who advised no anticoagulation for >5 days. Scenario 3 examined the management of an incidental intracranial haemorrhage. There was a lack of consensus regarding the duration off anticoagulation; 14% of responders held anticoagulation for less than P299 Serum levels of albumin did not decrease (1 hour: 2.64 ± 0.51; 72 hours: 2.63 ± 0.25). P302 P302 Citrate anticoagulation for continuous venovenous haemodiafi ltration: the impact of a novel protocol on patients receiving therapy in one regional hospital J Highgate1, G Escott2, A Lowe2, F Stedman2, N McNeillis2 1Worthing Hospital, Worthing, UK; 2Conquest Hospital, Hastings, UK Critical Care 2015, 19(Suppl 1):P302 (doi: 10.1186/cc14382) Introduction Citrate has been used to anticoagulate extracorporeal haemofi ltration circuits since the 1960s, and has been used as the fi rst-line anticoagulant for continuous venovenous haemodiafi ltration (CVVHDF) at Conquest Hospital since 2009. Benefi ts of citrate demonstrated in clinical trials include increased fi lter life and increased bicarbonate formation from metabolism of the citrate complex; citrate also lacks the increased bleeding risk associated with unfractionated heparin use. One of the main issues with new renal replacement therapies is the development of ideal dialysate fl uids. During the initial period of citrate use at Conquest, hyponatraemia was identifi ed as an issue, with off -license supplementation of dialysate fl uid with sodium bicarbonate often necessary to prevent this. New protocols were therefore developed, designed to maximise the fi ltration dose and maintain normal electrolyte balance. S108 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods Data were collected from our computerised information system on all AKI patients receiving RRT on our ICU, between October 2008 and October 2013. This included demographics, APACHE II and SOFA scores, modality and dose of RRT and ICU length of stay (LOS). Renal and patient survival at ICU discharge was collected, in addition to outcome data at 28 and 90 days and 12 months. Data were examined 12 hours whilst 37% held anticoagulation for >5 days and tranexamic was considered useful by 25%. y Conclusion There was wide variation in the use of blood products and the intensity of anticoagulation. This is not surprising given the current lack of evidence. Further work is required to provide a standardised approach. using Cox proportional hazard multivariate analysis, with Stata 10.1. Results A total of 620 patients with AKI received RRT on our ICU between October 2008 and October 2013. Sixty-one per cent were males. Median age was 65 years (IQR 54 to 74). Median APACHE II score was 23 (IQR 18 to 27). Median SOFA score was 11 (IQR 8 to 13). Fifty-fi ve per cent were mechanically ventilated. Comparison between nafamostat mesilate and unfractionated heparin as anticoagulant during continuous renal replacement therapy Comparison between nafamostat mesilate and unfractionated heparin as anticoagulant during continuous renal replacement therapy S Makino, H Kita, Y Miyatake, T Yokoyama, K Kubota, N Obata, M Egi, T Misumi, S Izuta, S Mizobuchi Kobe University Hospital, Kobe, Japan Critical Care 2015, 19(Suppl 1):P304 (doi: 10.1186/cc14384) Introduction For continuous renal replacement therapy (CRRT), continuous administration of anticoagulant would be necessary to prevent the circuit clotting. Nafamostat mesilate (NM) is commonly used as its anticoagulant in Japan, although unfractionated heparin (UFH) is the most frequently used anticoagulant internationally. There is little study to compare the risk and benefi t of NM with UFH as an anticoagulant during CRRT. Methods We conducted a single-center retrospective observational study to compare NM with UFH as anticoagulant during CRRT. We screened subsequent critically ill patients requiring CRRT in our ICU from January 2011 to December 2013. We excluded patients who required any other extracorporeal circuit including extracorporeal membrane oxygenation, who used both NM and UFH simultaneously, or who were administered any other anticoagulant including gabexate mesilate or urokinase. The primary outcome of this analysis was fi lter life, and the secondary outcome was the incidence of bleeding complications during CRRT. As an initial dose, NM and UFH were given pre fi lter at 15 to 25 mg/hour and 1,500 to 3,000 IU/hour, respectively. The dose of both drugs was adjusted to maintain activated clotting time at post fi lter between 150 and 200 seconds. Filter life was assessed using the Kaplan–Meier method and the incident of bleeding complications was compared using the chi-square test. P <0.05 was considered to be statically signifi cant. Conclusion Results from our cohort suggest that, in patients with AKI presenting to ICU for RRT, long-term patient survival is signifi cantly impaired. Renal outcomes are poor with 35% being either dialysis dependent or having severe chronic kidney disease (eGFR <15 ml/ minute), at 1 year from ICU discharge. Our data do not suggest a benefi t of using HVHF in AKI patients presenting to ICU for RRT. P306 Plasma antioxidant capacity in critical traumatized patients: severity and anatomical location y G Papakitsos1, A Kapsali1, T Papakitsou2, A Roimba3 1GHA, Arta, Greece; 2GHM, Messologi, Greece; 3General Practitioner, Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P306 (doi: 10.1186/cc14386) i Results We included 101 patients in this study. Among them, 76 patients were with NM and 25 patients were with UFH. They used 239 fi lters in total; 173 with NM, 66 with UFH. There were signifi cantly more post- surgical patients in the NM group (P = 0.001). There was no diff erence in age, APACHE II score, days from ICU admission to commencement of CRRT, length of ICU stay and mortality between two groups. There was no diff erence in median number of fi lters used by one patient (NM vs. heparin; median of 1.5 (IQR) vs. 2 (IQR), P = 0.27). Filter life in the UFH group was signifi cantly longer than those in the NM group (NM vs. UFH; median of 24 hours vs. 36 hours; P = 0.01). The incidence of bleeding complications was not signifi cantly diff erent between two groups (P = 0.15). Introduction Oxidative stress (OS) has been invoked as a relevant factor in the evolution and outcome of critical care patients. Indeed, antioxidant therapies have been used in critical care patients, but with controversial results. This may be explained by assuming OS as a homeostatically regulated parameter and both its excess and its defi cit infl uencing severity progression. Nonetheless, antioxidant agents could mask an OS signaling role, blocking otherwise physiological responses aimed at recovery of homeostasis. We have evaluated plasma total antioxidant capacity (TAC) in traumatized patients in the emergency department (ED) and we determined its potential relationship with severity and trauma location. Conclusion In our retrospective analysis with 101 patients, fi lter life with UFH was signifi cantly longer than those with NM. The incidence of bleeding complications was not signifi cantly diff ered between patients with NM and UFH. y Methods In a prospective observational study of ED polytraumatized patients (n = 23, mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 11 ± 6) we measured (in the fi rst 24 hours) plasma TAC by the ferric reducing activity/antioxidant power (FRAP). For control subjects, we used age-matched and gender-matched volunteers (n = 32). We also evaluated the contribution of antioxidant molecules (uric acid, bilirubin, and albumin) to these values. P302 A total of 96.7% received CVVH as the principal RRT modality. Twenty-one per cent received a period of high-volume haemofi ltration (HVHF) (80 ml/kg/hour), median LOS was 6 days (IQR 3 to 14). In total, 331 (53.4%) patients recovered their renal function at ICU discharge, whilst 237 (38.2%), 220 (35.4%), and 220 (35.4%) patients did not at 28 and 90 days and 12 months respectively. A total of 414 (66.7%) patients survived to ICU discharge, with 368 (59.3%), 341 (55%) and 308 (49.6%) patients being alive at 28 and 90 days and 12 months respectively. Overall patient survival at the end of follow-up was 43%. Adjusting for age and sex; APACHE II score, SOFA score and use of HVHF were associated with worse patient survival at ICU discharge (HR: 1.07, 95% CI: 1.03 to 1.11, P <0.001, HR: 1.11, 95% CI: 1.03 to 1.19, P = 0.006 and HR: 2.27, 95% CI: 1.4 to 3.66, P = 0.001, respectively). Adjusting for age and sex; APACHE II score and use of HVHF were associated with worse renal recovery at ICU discharge (HR: 1.06, 95% CI: 1.03 to 1.09, P <0.001 and HR: 1.55, 95% CI: 1.03 to 2.3, P = 0.032 respectively). SOFA score did not appear to signifi cantly impact renal recovery (HR: 0.99, 95% CI: 0.94 to 1.04, P = 0.81). Features and treatment of surviving casualties in the Kunshan ‘August 2’ Explosion Accident: 40 case reports and literature review J Liu, WU Wu Suzhou Municipal Hospital, Nanjing Medical University, Suzhou, China Critical Care 2015, 19(Suppl 1):P309 (doi: 10.1186/cc14389) Introduction The aim was to analyze the injury features and treatment strategies of surviving casualties in the explosion accident on 2 August 2014 in Kunshan city (Kunshan ‘August 2’ Explosion Accident). Methods We retrospectively studied 40 cases of surviving casualties in the Kunshan ‘August 2’ Explosion Accident, and systemically reviewed the relevant literature. Introduction The aim was to analyze the injury features and treatment strategies of surviving casualties in the explosion accident on 2 August 2014 in Kunshan city (Kunshan ‘August 2’ Explosion Accident). Methods We retrospectively studied 40 cases of surviving casualties in the Kunshan ‘August 2’ Explosion Accident, and systemically reviewed the relevant literature. p p p p Results In total, 722 trauma patients were included, of which 300 patients were hypothermic. The mortality in the hypothermia group was signifi cantly higher than in normotherm patients (OR = 3.73, 95% CI = 2.02 to 7.13, P <0.001). A cutoff point of 36°C was observed as the best threshold for hypothermia (sensitivity 74%, specifi city 56%). Besides hypothermia, other predictors found for 28-day mortality were APACHE II score corrected for temperature, minimum thrombocytes in fi rst 24 hours and urea and included in the fi nal model with an AUC of 0.89 (95% CI = 0.85 to 0.92). External validation of the model was associated with a predicted probability of an AUC of 0.64 (95% CI = 0.51 to 0.77).i Methods We retrospectively studied 40 cases of surviving casualties in the Kunshan ‘August 2’ Explosion Accident, and systemically reviewed the relevant literature. Results A total of 40 cases were admitted to our hospital within 6.3 ± 0.8 hours after the explosion accident on 2 August 2014 in Kunshan city, including 28 males and 12 females. The major injury types included burn injury, inhalation injury, blast injury (lung, eye, eardrum, and so forth), traumatic brain injury and bone fractures. All cases suff ered from burn injury caused by the explosion. The mean burned area in the surviving casualties accounted for 92 ± 14% total body surface area (TBSA) and those with third-degree burns for 77 ± 19% TBSA. Additionally, incidence rate of inhalation injuries was 97.5%. There were 34 cases complicated by multiple organ dysfunction syndrome, which accounted for 85.0%. Features and treatment of surviving casualties in the Kunshan ‘August 2’ Explosion Accident: 40 case reports and literature review J Liu, WU Wu The common organ dysfunction of surviving casualties included the lungs, circulation, liver, gastrointestinal tract, kidney, brain, and coagulation. During hospitalization, the most common infectious site in surviving casualties was a burn wound, followed by blood and lung. The most common infectious strain of bacteria was Gram- negative bacteria, which accounted for 91.3%. Further analysis showed that Proteus mirabilis ranked fi rst in occurrence, followed by Acinetobacter baumannii and Pesudomonas aeruginosa, and Klebsiella pneumonia and Enterobacter cloacae ranked fourth and fi fth. After intensive treatment, the mean 28-day mortality was 20.0% and 90- day mortality was 62.5%, mainly due to septic shock and multiple organ dysfunction syndrome. Conclusion Hypothermia, defi ned as <36°C, is associated with an increased 28-day mortality. The discriminative ability of the developed model for predicting mortality in a new patient population is moderate. P309 Methods A retrospective cohort study was performed in adult trauma patients admitted to a level 1 trauma center and who were transferred to the ICU between 2007 and 2012. Diff erent cutoff points for hypothermia were compared to fi nd the best defi nition for hypothermia. Logistic regression analysis was performed to quantify the net eff ect of hypothermia on admission to the ICU on 28-day mortality and to develop a model with predictors. The developed model was externally validated in data from another level 1 trauma center with a comparable patient population. Features and treatment of surviving casualties in the Kunshan ‘August 2’ Explosion Accident: 40 case reports and literature review J Liu, WU Wu Suzhou Municipal Hospital, Nanjing Medical University, Suzhou, China Critical Care 2015, 19(Suppl 1):P309 (doi: 10.1186/cc14389) P305 Long-term renal and survival outcomes in acute kidney injury patients receiving renal replacement therapy in intensive care I Elsayed1, N Pawley1, J Rosser1, MJ Heap1, GH Mills1, A Tridente2, AH Raithatha1 1Sheffi eld Teaching Hospitals, Sheffi eld, UK; 2Whiston Hospital, St Helens & Knowsley, UK Critical Care 2015, 19(Suppl 1):P305 (doi: 10.1186/cc14385) Results Polytraumatized patients show diff erences in TAC with reference to control subjects. ED polytraumatized patients show high FRAP values. We found that FRAP values were inversely correlated with APACHE II score (r = –0.266, P <0.01) suggesting that, in trauma patients, increased antioxidant response, as measured by FRAP assay, could be a pathophysiological response to stress. Albumin and uric acid concentrations reproduced the FRAP trend with severity. Introduction Acute kidney injury (AKI) aff ects 40% of critically ill patients, with UK data reporting 5% needing renal replacement therapy (RRT). Hospital mortality is reported as being up to 60%. We sought to evaluate renal and long-term patient survival outcomes in AKI patients receiving RRT on our ICU. Conclusion FRAP values in trauma ED patients are independently infl uenced by age (β = 0.271, P <0.021), APACHE II score (β = –0.356, S109 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion An increase in StO2 and lower tissue oxygen extraction rates were associated with H-survival in polytrauma patients. Figure 1 (abstract P308). Figure 1 (abstract P308). P <0.002) and head trauma (β = –0.219, P <0.045). These results accentuate the infl uence of trauma location and severity in TAC changes. TAC response in ED patients reinforces the need for an adequate tailoring of treatments aimed at their recovery, such as antioxidant therapies. P <0.002) and head trauma (β = –0.219, P <0.045). These results accentuate the infl uence of trauma location and severity in TAC changes. TAC response in ED patients reinforces the need for an adequate tailoring of treatments aimed at their recovery, such as antioxidant therapies. P307 Hypothermia as a predictor for mortality in trauma patients K Balvers1, JM Binnekade1, C Boer2, JC Goslings1, NP Juff ermans1 1Academic Medical Center, Amsterdam, the Netherlands; 2VU University Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P307 (doi: 10.1186/cc14387) Introduction Previous studies reported hypothermia as an independent predictor for mortality. However, diff erent cutoff points were used in these studies and external validation has never been applied. The aim of this study was to quantify the net eff ect of hypothermia on admission to the ICU on the 28-day mortality and to test the predictors from the developed model in another level 1 trauma center with a comparable patient population to validate the model. Figure 1 (abstract P308). Conclusion An increase in StO2 and lower tissue oxygen extraction rates were associated with H-survival in polytrauma patients. Near-infrared spectroscopy to assess tissue oxygenation in patients with polytrauma: relationship with outcome A Donati, E Damiani, R Domizi, S Pierantozzi, S Calcinaro, P Pelaia Università Politecnica delle Marche, Ancona, Italy Critical Care 2015, 19(Suppl 1):P308 (doi: 10.1186/cc14388) Università Politecnica delle Marche, Ancona, Italy , , y Critical Care 2015, 19(Suppl 1):P308 (doi: 10.1186/cc14388) y Critical Care 2015, 19(Suppl 1):P308 (doi: 10.1186/cc14388) Introduction We evaluated tissue oxygenation by means of near- infrared spectroscopy (NIRS) and explored its relationship with outcome in polytrauma patients. Methods A prospective observational study; 37 polytrauma patients underwent NIRS monitoring (thenar eminence) every day during their stay in the ICU. A VOT was performed with a 40% tissue oxygen saturation (StO2) target. Healthy volunteers (n = 27) were studied as controls. y y Conclusion During the Kunshan ‘August 2’ Explosion Accident, burn injury was the leading cause of injuries. Most surviving casualties are accompanied by multiple organ dysfunction syndrome and infection. Results StO2 increased over the fi rst 7 days only in hospital survivors (n = 29), who showed higher values as compared with healthy volunteers at days 5 and 7 (Figure 1). StO2 downslope and upslope tended to be lower in H-nonsurvivors (n = 8) (P <0.05 at days 2 and 4) as compared with H-survivors. Tissue hemoglobin index was lower in H-no survivors over the fi rst 7 days and tended to normalize only in H-survivors (P >0.05 vs. healthy at day 7). Five patients were discharged from the ICU but did not survive until H-discharge. At discharge from the ICU, these patients were similar to H-survivors in SOFA score, heart rate, mean arterial pressure and lactate, but showed lower StO2 downslope (–13 (–16.5, –11.7)%/minute vs. –8.6 (–11.7, –6.5)%/minute, P = 0.01). P310 In-depth study of road accidents in Florence: understanding the biomechanical eff ects in major trauma involving vulnerable road users In-depth study of road accidents in Florence: understanding the biomechanical eff ects in major trauma involving vulnerable road users In-depth study of road accidents in Florence: understanding the biomechanical eff ects in major trauma involving vulnerable road users A Franci1, S Piantini2, M Pierini2, A Peris1, M Mangini1 1A.O.U. Careggi, Firenze, Italy; 2University of Florence, Italy Critical Care 2015, 19(Suppl 1):P311 (doi: 10.1186/cc14391) Introduction The purpose of this study is to analyze anatomic distributions, diagnostic methods, and prognosis of missed fractures in patients with severe injury. Introduction The purpose of this study is to analyze anatomic distributions, diagnostic methods, and prognosis of missed fractures in patients with severe injury. gg y y y Critical Care 2015, 19(Suppl 1):P311 (doi: 10.1186/cc14391) Methods A review of single-institutional medical records between January 2001 and May 2012 identifi ed 58 patients with 62 delayed diagnoses of fractures among 4,643 severely injured patients older than 20 years with Injury Severity Scores higher than 16. We evaluated combined injuries, location of fractures, diagnostic methods, and reasons for missed diagnosis at initial examination. Introduction Road accidents are the leading cause of death for young people, 50% being represented by vulnerable road users (VRU) (pedestrians, cyclists). In-depth accident studies assess the consequences of lack of use of safety devices and the need to develop new ones. Since 2009 a permanent team (physicians and engineers) has performed in-depth studies on road trauma admitted to our ICU [1]. Results Among 62 missed fractures, there were eight cases of spine fracture, 10 cases of peri-shoulder joint fracture, eight cases of upper extremity fracture, 10 cases of pelvis of acetabulum fracture, and 26 cases of lower extremity fracture. Head injury was the most common concomitant injury (23 cases). Initially missed fractures were most commonly discovered by offi cial reading by radiologists. The most common reasons for misdiagnosis were the use of improper radiologic study and missed-reading of proper radiologic studies. Methods The team studied 52 VRU crashes that occurred in an urban area. The clinical data included an injury assessment using total body CT scan, Injury Severity Score (ISS), Abbreviated Injury Score (AIS), ICU and hospital length of stay and outcome score. Engineers collect data onsite with the partnership of the police, and assess the dynamics of the vehicles with the most advanced reconstruction techniques. Medical and engineering data were cross-matched during the correlation process. Duration of mechanical ventilation in trauma patients: risk factor for VAP? I Turriziani, A Cecchi, A Giugni, L Copertino Ospedale Maggiore, Bologna, Italy Critical Care 2015, 19(Suppl 1):P310 (doi: 10.1186/cc14390) Duration of mechanical ventilation in trauma patients: risk factor for VAP? I Turriziani, A Cecchi, A Giugni, L Copertino Ospedale Maggiore, Bologna, Italy Critical Care 2015, 19(Suppl 1):P310 (doi: 10.1186/cc14390) I Turriziani, A Cecchi, A Giugni, L Copertino Introduction In the literature, duration of mechanical ventilation (DMV) is often considered an important risk factor (RF) [1] for VAP [2] in critical patients; generally the whole duration of MV is taken into S110 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P311). Frequency of lesions. account, including days before and after infection onset. We tried to assess whether, counting only MV days prior to VAP development (MVp), something would change. Methods We considered, in a 10-year period, data prospectively collected in our database (4D solution, V11) on trauma patients admitted to the ICU directly from the emergency department. Inclusion criteria were: age ≥16 years, ICU length of stay (ICUlos) ≥4 days, DMV ≥48 hours; we excluded patients who received antibiotics before VAP (or during the whole stay, for patients without VAP) and with incomplete data. Data were: age, sex, prehospital GCS <9, prehospital intubation (preHTI), admission base excess (BE), Injury Severity Score (ISS), surgery, massive transfusion, feeding, antacids, nursing, DMV, ICUlos and MVp. MVp was calculated as the diff erence between the fi rst day of VAP and the fi rst day of MV in patients who developed VAP (vapY) and whole DMV in patients that did not (vapN). We only considered the fi rst infectious episode. The outcome was VAP onset. Group comparison was made with Fisher’s exact test and Student’s t test. Signifi cant variables were evaluated in a logistic regression (LR) model; the Hosmer–Lemeshow test (HL) was used as the post-estimation test. Odds ratio (OR) and 95% confi dence interval (95% CI) were calculated. Statistical signifi cance for P <0.05. We used Stata/IC 10.1 for analysis. Figure 1 (abstract P311). Frequency of lesions. Table 1 (abstract P311). Accident dynamics: medium speed (km/hour) Dynamic N injured Speed (SD) Table 1 (abstract P311). Accident dynamics: medium speed (km/hour) Table 1 (abstract P311). Accident dynamics: medium speed (km/hour) Dynamic N injured Speed (SD) Car vs. pedestrian 29 41.1 (13.9) Motorcycle vs. pedestrian 7 40.6 (4.3) Car vs. ferences Richmond J, Egol KA, Koval KJ. Management of orthopaedic injuries in polytrauma patients. Bull Hosp Jt Dis. 2001-2002;60:162-7. Duration of mechanical ventilation in trauma patients: risk factor for VAP? I Turriziani, A Cecchi, A Giugni, L Copertino Ospedale Maggiore, Bologna, Italy Critical Care 2015, 19(Suppl 1):P310 (doi: 10.1186/cc14390) cyclist 10 40.7 (15.9) Other 6 49.0 (5.4) y Results A total of 541 patients met the inclusion criteria, 378 (69.9%) developed VAP. MVp does not seem to be a RF for VAP because they are longer in vapN than in vapY (mean MVp 5.5 vs. 4.41, P = 0.001). PreHTI (vapY/N: 49.74%/38.65%; OR: 1.57; 95% CI: 1.08 to 2.28), ISS (mean vapY/N: 28.4/25.55; P = 0.0018), BE (mean vapY/N: –3.76/–3.04; P = 0.03) were signifi cantly diff erent between the two groups. In LR only preHTI (OR: 1.47; 95% CI: 1.01 to 2.15) and ISS (OR: 1.03; 95% CI: 1.01 to 1.05) are RF for VAP (HL: P = 0.133). Conclusion In our study MVp are not a RF for VAP in trauma patients, although the whole DMV is longer in patients with VAP (mean DMV vapY/N: 13.57/6.09; P = 0.0001). Further studies could confi rm whether the whole DMV in trauma patients with VAP is a consequence of infection. Conclusion The head is still the most frequently and severely injured region. The severity of injuries increases in the most rigid part of the car. Improving VRUs’ safety devices (active and passive) to reduce impact speed and severity of the primary impact has to be the next step. Reference References 1. Charles MP, et al. Ventilator-associated pneumonia. Australas Med J. 1. Charles MP, et al. Ventilator-associated pneumonia. Australas Med J. 2014;7:334-44. 1. Charles MP, et al. Ventilator associated pneumonia. Australas Med J. 2014;7:334-44. 1. Piantini et al. BMC Emerg Med. 2013;13:3. 2. CDC ventilator-associated event (January 2014). www.cdc.gov. 2. CDC ventilator-associated event (January 2014). www.cdc.gov. P311 Dankook University Hospital, Cheonan City, South Korea Critical Care 2015, 19(Suppl 1):P312 (doi: 10.1186/cc14392) Endogenous microparticles drive the proinfl ammatory host immune response in severely injured trauma patients Critical Care 2015, 19(Suppl 1):P313 (doi: 10.1186/cc14393) Introduction Severe trauma aff ects the immune system, which in its turn is associated with poor outcome. The mediators driving the immune responses in trauma are largely unknown. The aim of this study was to investigate the role of endogenous microparticles (MPs) in mediating the immune response following severe trauma. Figure 1 (abstract P314). sRAGE kinetics (days). on days 1, 3 and 5. sRAGE was measured by ELISA and cfDNA was measured by UV absorbance after plasma isolation. g p g Methods A prospective, observational substudy of the Acute Coagulopathy and Infl ammation in Trauma (ACIT) II study was performed at our academic level 1 trauma center. Adult multiple trauma patients with an Injury Severity Score of 15 or higher were included between May 2012 and June 2013. Ex vivo whole blood stimulation with lipopolysaccharide was performed on aseptically collected patient plasma containing MPs and in plasma depleted of MPs. Flow cytometry and transmission electronic microscopy were performed on plasma samples to investigate the numbers and cellular origin of MPs. Healthy individuals served as a control group. Results Median ISS was 39 and mortality was 21% (8/38). During the fi rst 5 days after trauma, the median concentration of sRAGE (Figure 1) decreased signifi cantly over time (P <0.0001) while median levels of DNA did not (P = 0.73), and remained elevated compared with normal control. No correlation was found with ISS. Patients initially in shock had lower levels of sRAGE or cfDNA (P <0.05) and had received more fl uid (10.6 l vs. 5.25 l) or blood (6 l vs. 0.5 l). Day 3 and day 5 sRAGE levels were inversely correlated with PRBC received. Medians of sRAGE on days 0 (1,301 vs. 730 pg/ml) and day 1 (925 vs. 760 pg/ml) were signifi cantly higher in nonsurvivors (P <0.01). Finally, day 0 sRAGE was correlated with the maximal (r = 0.44; P = 0.007) and the cumulative renal failure component of the MODS, over the 10 days (r = 0.48; P = 0.005).f Results Ten trauma patients and 10 healthy individuals were included. Trauma patients were signifi cantly injured with a median ISS of 19 (17 to 45). On admission to the hospital, the host response to bacterial stimulation was blunted in trauma patients compared with healthy individuals, as refl ected by decreased production of IL-6, IL-10 and TNFα (P <0.001). In-depth study of road accidents in Florence: understanding the biomechanical eff ects in major trauma involving vulnerable road users Injuries suff ered by each person were related to specifi c impact objects. y g p p g Conclusion In order to prevent misdiagnosis of fractures in patients with severe injury, meticulous physical examination with suspicion of fractures should come fi rst. In addition, obtaining proper radiologic study and thorough evaluation of radiologic images are important to decreasing the rates of missed fracture diagnoses. In addition, thorough surveillance for ipsilateral fractures is important in extremities with identifi ed fractures. i Results The average ISS is 21.5 (SD 10.9). Cars are the most involved in serious urban VRU crashes. Car-to-pedestrian crashes are the most frequent (50%). The impact speed is always over 40 km/hour (Table 1). The head and face are the most frequently injured part (48% of the 571 injuries collected), followed by lower extremities (15%). In terms of maximum AIS (MAIS), the head is the most severely injured region with 42% of MAIS 3+ (Figure 1). i References S111 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P314). sRAGE kinetics (days). 2. Houshian S, Larsen MS, Holm C. Missed injuries in a level I trauma center. J Trauma. 2002;52:715-9. 3. Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of tertiary trauma Survey. J Trauma. 1998;44:1000-6; discussion 1006-7. 3. Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of tertiary trauma Survey. J Trauma. 1998;44:1000-6; discussion 1006-7. 4. Kalemoglu M, Demirbas S, Akin ML, et al. Missed injuries in military patients with major trauma: original study. Mil Med. 2006;171:598-602. 4. Kalemoglu M, Demirbas S, Akin ML, et al. Missed injuries in military patients with major trauma: original study. Mil Med. 2006;171:598-602. 4. Kalemoglu M, Demirbas S, Akin ML, et al. Missed injuries in military patients with major trauma: original study. Mil Med. 2006;171:598-602. Endogenous microparticles drive the proinfl ammatory host immune response in severely injured trauma patients In trauma patients, MP-positive plasma was associated with a signifi cantly higher synthesis of IL-6 and TNFα compared with plasma depleted from MPs (P = 0.047 and 0.002 respectively). Compared with healthy individuals the number of circulating MPs was signifi cantly decreased in trauma patients (P = 0.009). Most MPs originated from platelets. Multiple cellular protrusions, which result in MP formation, were observed in plasma from trauma patients, but not in healthy controls. Conclusion DNA and sRAGE kinetics diff er following trauma. Early elevation of sRAGE predicts mortality in univariate analysis and correlates with subsequent renal failure. P313 P313 Endogenous microparticles drive the proinfl ammatory host immune response in severely injured trauma patients N Curry1, K Balvers2, DJ Kleinveld2, AN Boïng2, R Nieuwland2, JC Goslings2, NP Juff ermans2 1John Radcliff e Hospital, Oxford, UK; 2Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P313 (doi: 10.1186/cc14393) P313 Endogenous microparticles drive the proinfl ammatory host immune response in severely injured trauma patients N Curry1, K Balvers2, DJ Kleinveld2, AN Boïng2, R Nieuwland2, JC Goslings2, NP Juff ermans2 1John Radcliff e Hospital, Oxford, UK; 2Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P313 (doi: 10.1186/cc14393) References 1. Cohen MJ. J Trauma. 2010;68:1273-8. 1. Cohen MJ. J Trauma. 2010;68:1273-8. . Cohen MJ. J Trauma. 2010;68:1273-8. 1. Cohen MJ. J Trauma. 2010;68:1273 8. 2. Simmons JD. Ann Surg. 2013;258:591-6. 2. Simmons JD. Ann Surg. 2013;258:591-6. 2. Simmons JD. Ann Surg. 2013;258:591-6. Clinical decision rule for cervical magnetic resonance imaging in suspected cervical spinal cord injury without bony injury is useful in predicting severity of cervical stenosis T Inagaki1, A Kimura1, A Hagiwara1, R Sasaki1, K Kobayashi1, A Inaka1, G Makishi2 1National Center for Global Health and Medicine Hospital, Tokyo, Japan; 2Seirei Hamamatsu General Hospital, Shizuoka, Japan Critical Care 2015, 19(Suppl 1):P315 (doi: 10.1186/cc14395) Clinical decision rule for cervical magnetic resonance imaging in suspected cervical spinal cord injury without bony injury is useful in predicting severity of cervical stenosis p g y T Inagaki1, A Kimura1, A Hagiwara1, R Sasaki1, K Kobayashi1, A Inaka1, G Makishi2 Conclusion On admission, trauma patients have a reduced immune response towards endotoxin challenge which is, at least in part, mediated by MPs, which circulate in low numbers and in early stages. Most MPs originate from platelets, which indicates that these cells may be the most important source of MPs involved in initiating an infl ammatory host response post injury. g y T Inagaki1, A Kimura1, A Hagiwara1, R Sasaki1, K Kobayashi1, A Inaka1, G Makishi2 1National Center for Global Health and Medicine Hospital, Tokyo, Japan; 2Seirei Hamamatsu General Hospital, Shizuoka, Japan Critical Care 2015, 19(Suppl 1):P315 (doi: 10.1186/cc14395) Introduction Cervical spinal cord injury (CCI) without bony injury (CCIWOBI) is more frequent among Asian than among Caucasian populations and shows various extents of severity. Cervical magnetic resonance imaging (MRI) is useful for detecting intramedullary lesions, ligament injuries and intervertebral disk hernias, but some patients with mild CCIWOBI do not show clinically signifi cant abnormalities on MRI. To date, the cost–benefi t ratio of performing MRI in addition to computed tomography (CT) is unclear. We have developed a clinical decision rule for cervical MRI (MR-CDR), indicating MRI for patients >70 years old with ossifi cation of the posterior longitudinal ligament on CT or injury in a ground-level fall or a fall down stairs. The objective of the present study was to prospectively validate this MR-CDR for cervical MRI in patients with suspected mild CCIWOBI. P314 DNA and sRAGE circulation in the early phase after polytrauma P Joly1, C Massé2, D Dwivedi2, P Liaw2, J Marshall3, Y Berthiaume2, E Charbonney4 1University of Montreal, QC, Canada; 2McMaster University, Hamilton, ON, Canada; 3University of Toronto, ON, Canada; 4CRHSCM-University of Montreal, QC, Canada Critical Care 2015, 19(Suppl 1):P314 (doi: 10.1186/cc14394) Introduction Various DAMPS, alarmins are released after trauma. The soluble receptor for advanced glycation endproducts (sRAGE) was reported to be associated with acute renal failure and duration of ventilation [1]. Cell-free DNA (cfDNA) has been associated with prognosis in trauma patients [2]. We studied the kinetics of these two biomarkers over the fi rst 5 days, in a cohort of severely ill trauma patients. Methods We have been conducting a prospective observational study in two institutions in Japan since September 2012, enrolling patients with CCIWOBI among head or neck trauma patients >16 years old brought in by ambulance. We collect data about patient characteristics, injury profi les, neurological fi ndings, results of radiological examinations, and medical courses. We then analyze the sensitivity and specifi city of MR-CDR for detecting intramedullary lesions on MRI and conduct further analysis. Methods Patients who had sustained serious traumatic injury, within 24 hours of trauma, were recruited in a level I trauma center. We collected ISS, baseline demographic characteristics, resuscitation information and daily organ dysfunction (MOD) scores, over 10 days. Blood samples were collected within 24 hours of trauma (day 0) and S112 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results During the study period, 63 patients were brought in with CCIWOBI. Mean age was 60.6 years (standard deviation, 17.9 years) and 76% were male. Forty-fi ve patients presented with mild symptoms (Frankel Grade D). Cervical MRI was performed for 23 patients. Sensitivity and specifi city of MR-CDR in detecting intramedullary lesions on T2- weighted imaging among cases of suspected mild CCIWOBI were 85.7% (95% confi dence interval (CI), 60.1 to 96.0%) and 33.3% (95% CI, 12.1 to 35.4%). Further analysis showed a signifi cant diff erence in minimal spinal canal diameter as measured on sagittal T2-weighted imaging between the MR-CDR-positive and MR-CDR-negative groups (5.0 mm vs. 8.3 mm, P = 0.0003). One patient underwent surgery during hospitalization and no patients experienced exacerbated neurological fi ndings. P316 Accuracy of targeted wire-guided tube thoracostomy in comparison with classical surgical chest tube placement: a clinical study A Protic, I Barkovic, A Sustic University Hospital Rijeka, Croatia Critical Care 2015, 19(Suppl 1):P316 (doi: 10.1186/cc14396) Introduction Chest tube malfunction, after the tube thoracostomy, is often the result of an inappropriate chest tube tip position. The aim of this study was to analyze the precision of chest tube placement using the targeted wire guide technique (TWG technique) with a curve dilator and to compare it with the classical surgical technique (CS technique). Methods In this clinical study 80 patients with an indication for thoracic drainage due to pneumothorax or pleural eff usion were included. The experimental group contained 39 patients whose chest tube was placed using the TWG technique. The control group contained 41 patients whose chest tube was placed using the CS technique. Introduction Chest tube malfunction, after the tube thoracostomy, is often the result of an inappropriate chest tube tip position. The aim of this study was to analyze the precision of chest tube placement using the targeted wire guide technique (TWG technique) with a curve dilator and to compare it with the classical surgical technique (CS technique). Results There is positive signifi cant correlation between T day and LOS of injured patients (P <0.001, Spearman coeffi cient = 0.1672). Statistical analysis by Mann–Whitney test, between groups A and B, showed signifi cant diff erences in ICU LOS (P <0.001); no signifi cant diff erences (P <0.05) were found for age, ISS and outcome (Table 1). p g q q Methods In this clinical study 80 patients with an indication for thoracic drainage due to pneumothorax or pleural eff usion were included. The experimental group contained 39 patients whose chest tube was placed using the TWG technique. The control group contained 41 patients whose chest tube was placed using the CS technique. Conclusion The optimum and early time point of tracheostomy seems to be directly related with LOS in the ICU, independently of the rate of ISS, patient’s age and outcome. These results could account for ICU cost-eff ectiveness, as diminished LOS decreased the overall cost. Reference Results The comparison of the outcomes of the two techniques applied suggests that the TWG technique was signifi cantly more successful, irrespective of patient diagnosis (TWG vs. CS in all patients, 78.4% vs. 36.6%, P <0.001). See Table 1. 1. Alali et al. P317 Evaluating trauma care: comparison of early versus late tracheostomy ICU data outcome on injured patients V Kaldis1, N Mourelatos1, D Markopoulou1, K Venetsanou2, E Diogou1, E Papadaki1, D Chroni1, I Alamanos1 1General Hospital KAT-EKA, Kifi sia Athens, Greece; 2ICU Research Unit KAT, Kifi ssia Athens, Greece Critical Care 2015, 19(Suppl 1):P317 (doi: 10.1186/cc14397) Introduction In the surgical ICU, bedside tracheostomy (T) is one of the most frequently applied surgical techniques for multi-injured patients mainly with TBI [1]. The optimum surgical time decision for T still remains a contradiction in trauma. This retrospective study was designed to register all trauma patients who underwent T, during 60 months of observation (2009 to 2013), in order to identify factors associated with their ICU outcome on the basis of the T day (A <10th day >B) after tracheal intubation. g Conclusion MR-CDR was not validated for predicting the existence of intramedullary lesions on cervical MRI. MR-CDR is useful in predicting the severity of cervical stenosis. Methods Seventy-eight injured patients in the SICU underwent T, from a total of 403 issues; 58 male and 20 female, with mean age 59.3 and 74.7 years respectively. The total length of ICU stay recorded was 2,098 days, nursing time 26.55 (4/93), whereas the T time was adjusted between the 6th and 16th day (mean 11th). Mean ISS score was 22.59 (9 to 50). Classifi cation according to trauma type was TBI (n = 44) followed by thoracic trauma. Thirty-one male survivors were discharged from the ICU, to the ward. The mortality rate amounts to 47 cases due to infectious/non-infectious nosocomial complications and multiorgan dysfunction syndrome. Clinical ISS, the type of injury, ICU length of stay (LOS), T day, demographic (gender, age) data and ICU outcome were registered. Statistical analysis was performed with GraphPad 5.0.i Factors related to sepsis and outcome in multiple trauma patients H Pavlou, E Pappa, M Eforakopoulou KAT-EKA General Hospital, Kifi sia, Athens, Greece Critical Care 2015, 19(Suppl 1):P318 (doi: 10.1186/cc14398) pi Critical Care 2015, 19(Suppl 1):P318 (doi: 10.1186/cc14398) Introduction The outcome of multiple trauma patients is related to a number of diagnostic and therapeutic interventions during hospitali- zation. ICU patients with severe trauma are susceptible to sepsis leading to poor outcome. Factors associated with the occurrence of sepsis and the outcome of these patients were investigated. Conclusion Using a curved dilator and the TWG technique for the thoracic drainage procedure we found statistically signifi cant advantage to the TWG technique in comparison with the CS technique regarding precise chest tube placement within the pleural cavity. References Methods We studied retrospectively all trauma patients admitted to the A’ ICU of KAT General Hospital in Athens during the last 3 years and were treated for more than 5 days. Age, gender, the type of injury, the severity of injury (Injury Severity Score), the length of ICU stay, severe sepsis, coexisting diseases, the outcome and the cause of death were recorded. Logistic regression and chi-square tests were used for statistical analysis. 1. Chen F, Yamada T, Aoyama A, et al. Position of a chest tube at video-assisted thoracoscopic surgery for spontaneous pneumothorax. Respiration. 2006;73:329-33. 2. Protic A, Barkovic I, Bralic M, et al. Targeted wire-guided chest tube placement: a cadaver study. Eur J Emerg Med. 2010;17:146-9. P314 No signifi cant diff erences were evident between groups in discharge status, duration of hospitalization, or neurological fi ndings at discharge. P316 Tracheostomy timing in traumatic brain injury: a propensity- matched cohort study. J Trauma Acute Care Surg. 2014;76:70-8. Table 1 (abstract P316) CS technique TWG technique Diagnosis N (% of success) (% of success) P value Pleural eff usion 47 37.5 78.2 0.005 Pneumothorax 31 35.3 78.6 0.029 Total 78 36.6 78.4 <0.001 P318 Factors related to sepsis and outcome in multiple trauma patients H Pavlou, E Pappa, M Eforakopoulou KAT-EKA General Hospital, Kifi sia, Athens, Greece Critical Care 2015, 19(Suppl 1):P318 (doi: 10.1186/cc14398) Ventilator-associated pneumonia in a trauma ICU M Raja, A Ely, P Zolfaghari Royal London Hospital, London, UK Critical Care 2015, 19(Suppl 1):P319 (doi: 10.1186/cc14399 Figure 1 (abstract P320). M Raja, A Ely, P Zolfaghari Royal London Hospital, London, UK Royal London Hospital, London, UK normoxia will create a condition of relative hypoxia, which acts in turn as a stimulus for erythropoietin (EPO) production [1]. Variations in GSH and oxygen free radical (ROS) levels may be involved in this process. We tested the NOP in critically ill patients. y p Critical Care 2015, 19(Suppl 1):P319 (doi: 10.1186/cc14399) Introduction Ventilator-associated pneumonia (VAP) is associated with increased length of ventilation, ICU stay, mortality, cost and antibiotic burden [1]. There is a large variation in reported rates of VAP, partly as a result of inconsistencies in defi nition [2]. We explored a more pragmatic defi nition to describe the VAP rate, antibiotic burden and outcome of VAP in a 44-bed adult critical care unit in a level 1 trauma centre. Methods A prospective observational study on 38 mechanically ventilated (FiO2 <50%) patients with no active bleeding, no blood transfusion needed, and no kidney failure. Eighteen patients underwent a 2-hour period of normobaric hyperoxia (FiO2 = 100%), 20 patients were evaluated as controls (no FiO2 variations). EPO was assayed at baseline (t0), 24 hours (D1) and 48 hours (D2). Serum GSH and ROS were assayed at t0 (baseline), t1 (2-hour FiO2 100%) and t2 (2- hour return to normoxia) in 12 patients in the hyperoxia group. Methods A retrospective review of all adult patients admitted to the ICU at The Royal London Hospital over a 6-month period (February to August 2014). The diagnosis of VAP was based on the Clinical Pulmonary Infection Score. Patients were identifi ed with VAP if they were started on antibiotics for chest sepsis 48 hours after start of mechanical ventilation. Demographic, clinical, microbiological and radiological data were collected to identify risk factors, and compare VAP and non- VAP groups. Chi-squared and ANOVA tests were performed using the SOFA statistics package. Results EPO tended to increase in the hyperoxia group over time (P = 0.05), while it remained stable in the control group (P = 0.53) (Figure 1). ROS levels increased at t1 and decreased at t2, GSH tended to decrease at t1 and increased at t2 in the hyperoxia group. Conclusion Relative hypoxia after a transient period of normobaric hyperoxia induces an increase in GSH levels, thus enhancing ROS scavenging. This may act as a stimulus for EPO production. Table 1 (abstract P317). SICU data Table 1 (abstract P317). SICU data Table 1 (abstract P317). SICU data Outcome ICU data ISS Age ICU LOS (days) Tracheostomy day Survival Mortality A <10 16 ± 87 (16/45) 66 ± 94 (28/87) 602 17.2 ± 21.5 (4/47) 5.5 ± 6.5 (1/10) n = 13 (43.3%) n = 17 (57.7%) B >10 16 ± 25 (9/50) 64 ± 87 (23/93) 1,496 25 ± 34 (9/95) 15 ± 26 (11/23) n = 18 (40%) n = 27 (60%) t test NS NS <0.001 <0.001 NS NS Data presented as median ± IQR S113 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results A total of 106 multiple trauma patients, 85 men and 21 women, met the inclusion criteria. Depending on their age, patients were divided into two groups: <60 years old and >60 years old. In both groups, gender, the type and severity of injuries and the length of ICU stay were not associated with outcome. The length of ICU stay was correlated with severe sepsis and coexisting diseases (P <0.01) in both groups. Mortality was not diff erent in the two groups. The presence of at least one coexisting disease was signifi cantly associated with mortality (P <0.007). Sepsis was signifi cant cause of death in trauma patients >60 years (P <0.05). Figure 1 (abstract P320). Figure 1 (abstract P320). y Conclusion In multiple trauma patients, the length of ICU stay and comorbidities infl uence the occurrence of severe sepsis, comorbidities increase mortality, and sepsis is the leading cause of death in trauma patients >60 years old. Ventilator-associated pneumonia in a trauma ICU M Raja, A Ely, P Zolfaghari Royal London Hospital, London, UK Critical Care 2015, 19(Suppl 1):P319 (doi: 10.1186/cc14399 Reference Results A total of 535 mechanically ventilated patients were admitted in the study period, with 281 ventilated for more than 48 hours. The incidence of VAP was 11% in all ventilated patients and 19.6% in those ventilated more than 48 hours. VAP rates were 31% in polytrauma, 25% in neurotrauma and 18% in the neuromedical/surgical cohort. Early and late onset VAP were equal in number. Patients with VAP spent longer on mechanical ventilation (9 ± 9 in no VAP vs. 18 ± 18 days in VAP patients; P <0.001), and had longer ICU and hospital LOS (11 ± 10 vs. 22 ± 20 days; P <0.001). However, APACHE II scores and hospital mortality were unaff ected (VAP 33.3% vs. no VAP 37.6%; P = 0.173). Despite rising infl ammatory markers and secretion load, many patients did not exhibit oxygenation defi cits. Sputum microbiology showed S. aureus, H. Infl uenza, Klebsiella and Enterobacter as predominant pathogens with low rates of Pseudomonas, Acinectobacter and other resistant organisms. Average length of antibiotic use was 6 (3 to 18) days. Conclusion Chest sepsis after 48 hours of mechanical ventilation commonly complicates neurocritical illness and polytrauma requiring signifi cant ICU resources and antibiotic burden. However, it does not aff ect mortality. Further research should focus on pathophysiology and new preventative measures to reduce VAP in the at-risk population. R f 1. Balestra et al. J Appl Physiol. 2006;100:512-8. p References 1. Taylor MD, et al. J Trauma. 2002;53:407-14. 2. Osborn TM, et al. Crit Care Med. 2004;32:2234-40. References References 1. Safdar N, et al. Crit Care Med. 2005;33:2184-93. 2. Nair GB, et al. Intensive Care Med. 2014 [Epub ahead of print]. 1. Safdar N, et al. Crit Care Med. 2005;33:2184-93. 2. Nair GB, et al. Intensive Care Med. 2014 [Epub ahead of print]. Results Mean D-dimer concentration of the control group and of the patient group with PE was 0.28 (95% CI: 0.25 to 0.31) mg/l and 1.45 (95% CI: 1.23 to 1.72) mg/l, respectively. Receiver operator characteristics analysis revealed an optimized cutoff value of 0.466 mg/l for the PATHFAST D-dimer assay (AUC = 0.975 (95% CI: 0.938 to 0.993); sensitivity: 95% (95% CI: 86 to 99%); specifi city: 89% (95% CI: 82 to 95%)). Therefore we used a rounded up cutoff value of 0.5 mg/l to examine the diagnostic accuracy of PATHFAST D-dimer to exclude PE. The correlation between PATHFAST and VIDAS results was particularly close for concentrations at or around the critical cutoff value of P320 Normobaric oxygen paradox and erythropoietin production in critically ill patients: a prospective observational study S Zuccari, A Donati, E Damiani, R Castagnani, N Mininno, P Pelaia Università Politecnica delle Marche, Ancona, Italy Critical Care 2015, 19(Suppl 1):P320 (doi: 10.1186/cc14400) P320 Normobaric oxygen paradox and erythropoietin production in critically ill patients: a prospective observational study S Zuccari, A Donati, E Damiani, R Castagnani, N Mininno, P Pelaia Università Politecnica delle Marche, Ancona, Italy Critical Care 2015, 19(Suppl 1):P320 (doi: 10.1186/cc14400) P321 Comparison of the PATHFAST D-dimer assay with two POC D-dimer assays E Spanuth1, B Ivandic1, R Thomae2, E Giannitsis3 1DIAneering GmbH, Heidelberg, Germany; 2Mitsubishi Chemical Europe, Düsseldorf, Germany; 3University of Heidelberg, Germany Critical Care 2015, 19(Suppl 1):P321 (doi: 10.1186/cc14401) Comparison of the PATHFAST D-dimer assay with two POC D-dimer assays E Spanuth1, B Ivandic1, R Thomae2, E Giannitsis3 1DIAneering GmbH, Heidelberg, Germany; 2Mitsubishi Chemical Europe, Düsseldorf, Germany; 3University of Heidelberg, Germany Critical Care 2015, 19(Suppl 1):P321 (doi: 10.1186/cc14401) E Spanuth1, B Ivandic1, R Thomae2, E Giannitsis3 1DIAneering GmbH, Heidelberg, Germany; 2Mitsubishi Chemical Europe, Düsseldorf, Germany; 3University of Heidelberg, Germany Critical Care 2015, 19(Suppl 1):P321 (doi: 10.1186/cc14401) Introduction The early exclusion of PE is a major precondition for goal- oriented diagnostic and therapeutic measures. The aim of the study was to evaluate the new point-of-care assay PATHFAST D-dimer in comparison with VIDAS D-Dimer Exclusion and STRATUS CS D-dimer. Methods A total of 272 patients with symptoms of PE and VTE were included. The diagnoses of VTE and PE were established by duplex ultrasound, venography and spiral CT. D-dimer values were determined in the patients and in plasma samples obtained from 102 healthy individuals who served as the control group. Introduction The early exclusion of PE is a major precondition for goal- oriented diagnostic and therapeutic measures. The aim of the study was to evaluate the new point-of-care assay PATHFAST D-dimer in comparison with VIDAS D-Dimer Exclusion and STRATUS CS D-dimer. Introduction The early exclusion of PE is a major precondition for goal- oriented diagnostic and therapeutic measures. The aim of the study was to evaluate the new point-of-care assay PATHFAST D-dimer in comparison with VIDAS D-Dimer Exclusion and STRATUS CS D-dimer. Methods A total of 272 patients with symptoms of PE and VTE were included. The diagnoses of VTE and PE were established by duplex ultrasound, venography and spiral CT. D-dimer values were determined in the patients and in plasma samples obtained from 102 healthy individuals who served as the control group. Impact of introducing guidelines for thrombolysis of submassive pulmonary embolism at a large UK teaching hospital GP Misselbrook g p p Results The peak action of enoxaparin and rivaroxaban was observed at 4 hours post administration. LPTEG indicators that determine the coagulation state after 4 hours in the fi rst group: CTA was decreased by 72.12% (P <0.05), ICD was decreased by 68.44% (P <0.05), GP was increased by 17.9%; in the second group: CTA was decreased by 76.24% (P <0.05), ICD was decreased by 74.52% (P <0.05), GP was increased by 23.34%. After 12 hours, CTA in the fi rst group decreased by 22.41%, ICD decreased by 5.3%, GP increased by 8.12%, indicating reduction of hypocoagulation eff ect; in the second group, CTA decreased by 39.35% (P <0.05), ICD decreased by 40.24% (P <0.05), GP increased by 18.25%. After 24 hours in the fi rst group LPTEG indicators returned to the original value, and in the second group of patients CTA was decreased by 15.14%, ICD was decreased by 6.62%, GP increased by 14.22%.f University Hospitals Southampton NHS Foundation Trust, Southampton, UK Critical Care 2015, 19(Suppl 1):P324 (doi: 10.1186/cc14404) Introduction Pulmonary embolism (PE) is a signifi cant cause of death with 10% of patients dying within 3 months [1]. Multiple studies now advocate the use of thrombolysis (TPA) in both massive and submassive PE [1,2]. This audit assessed the impact of introducing a guideline allowing for thrombolysis of submassive and massive PE at a large UK teaching hospital. g p Methods Retrospective data collection using notes and imaging to risk-stratify patients. First audit ran from January to June 2012. New guidance was introduced in March 2013 (Figure 1) after which a second cycle ran for a further 6 months. y y y Conclusion Using LPTEG showed the hypocoagulation eff ect of continuous rivaroxaban 24 hours after oral administration compared with enoxaparin, which retains less hypocoagulation eff ect 12 hours after administration. LPTEG indicators in the second group were bigger than in the fi rst group after 12 hours: CTA 43.07%, ICD 69.72%, GP 54.12%. Results Re-audit revealed 46 patients with radiological evidence of massive or submassive PE on CTPA (32% of all PEs). Ten patients had clinical features of submassive PE and nine presented as massive PE. Previous guidelines suggested consideration of TPA in only seven patients in 6 months. TPA was given to two patients; however, six patients had no contraindications to treatment (Table 1). P320 Normobaric oxygen paradox and erythropoietin production in critically ill patients: a prospective observational study Introduction The normobaric oxygen paradox (NOP) postulates that a period of normobaric hyperoxia followed by a rapid return to S114 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 0.5 mg/l. The correlation between PATHFAST and STRATUS results was particularly close in the patient group with VTE (r = 0.9694), whereas slightly lower results were obtained with STRATUS in the control group. With the widely used cutoff value 0.5 mg/l, PATHFAST demonstrated suitable sensitivity but not STRATUS. ROC analysis indicated that optimal cutoff values could be set at either 0.5 or 0.6 mg/l and at 0.3 or 0.4 mg/l for PATHFAST and STRATUS, respectively. clinical guidelines recommend the administration of pharmacological thromboprophylaxis (PTP) to reduce the risk of developing TEC [2]. However, it is unknown whether delayed PTP initiation increases risk of TEC. We hypothesize that delayed PTP initiation is associated with increased TEC rates. Methods A retrospective chart review (2010 to 2013) was conducted on adult trauma patients that were admitted into a level 1 trauma centre in Toronto. Demographics, date of PTP initiation, date of TEC diagnosis (CT-PE/US Doppler), injury type and severity were collected. A comparison between early and late PTP initiation has been made with regards to TEC development. Student’s t test, univariate and multivariate logistic regression analyses were performed. y Conclusion By use of the PATHFAST D-dimer assay only six of diagnoses were missed at the time of fi rst presentation compared with 10 diagnoses missed by the VIDAS D-dimer Exclusion assay, yielding higher sensitivity of the PATHFAST D-dimer assay compared with the VIDAS assay (90% vs. 83%). The STRATUS assays showed comparable performance and appeared to be suitable for the exclusion of VTE in the emergency room setting, whereas PATHFAST demonstrated superior sensitivity. Moreover, the PATHFAST analyzer allows simultaneous determination of D-dimer and cardiac troponin I within 16 minutes from whole blood samples. Therefore, this method might be useful at the point of care for early diagnostic assessment of patients with symptoms of PE or chest pain admitted to the ER or to the chest pain unit. g g y p Results A total of 1,312 patients received PTP, 821 (62.5%) initiated early PTP (within 48 hours) while 491 (37.5%) initiated after 48 hours. The group that initiated early prophylaxis was younger (mean: 46 vs. Using rivaroxoban in patients with venous thromboembolism I Tyutrin, O Tarabrin, B Todurov, S Shcherbakov, D Gavrychenko, G Mazurenko Odessa National Medical University, Odessa, Ukraine Odessa National Medical University, Odessa, Ukraine Critical Care 2015, 19(Suppl 1):P322 (doi: 10.1186/cc14402) Critical Care 2015, 19(Suppl 1):P322 (doi: 10.1186/cc14402) Conclusion Mortality rates in patients with delayed PTP are higher. Our study shows LOS as the only independent predictor for TEC. However, this might not necessarily refl ect causation. Delayed PTP appears not to be an independent predictor to TEC events in trauma patients, which favours current clinical trends when it comes to contraindicating early PTP initiation. Introduction A prospective study was conducted in patients for treatment of venous thromboembolism (VTE) to compare the eff ect of enoxaparin and rivaroxaban using the method of low-frequency piezoelectric thromboelastography (LPTEG) for checking coagulation activation markers. P320 Normobaric oxygen paradox and erythropoietin production in critically ill patients: a prospective observational study 55, P <0.0005), had lower ISS (mean: 17 vs. 24, P <0.0005), shorter length of stay (LOS) (mean: 11 vs. 23, P <0.0005), more pelvic fractures (19% vs. 13%, P = 0.0058), more head injury (AIS Head ≥3, P <0.0005), less blunt trauma (85% vs. 95%, P <0.0005), lower incidence of TEC (5.3% (44) vs. 8.5% (42), P = 0.023), and lower mortality rate (1.5% vs. 7.5%). Univariate analysis showed LOS (P <0.0005), ISS (P <0.0005), time to PTP initiation (P = 0.0018) and blunt MOI (P = 0.0099) signifi cantly associated with TEC events. Multivariate analysis, however, showed TEC events correlated only to LOS (P = 0.0001). Stepwise multiple logistic regression confi rmed LOS as independently associated with TEC events (95% CI = 0.003, 0.006, P <0.0005). P323 P323 Is delaying pharmacological thromboprophylaxis associated with thromboembolic complications? P Padim1, A Alshafai2, S Canestrini3, S Rizoli2, J De Rezende Neto2, A McFarlan2 1Universidade de São Paulo, Ribeirao Preto, Brazil; 2St Michael’s Hospital, Toronto, ON, Canada; 3St George’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P323 (doi: 10.1186/cc14403) Is delaying pharmacological thromboprophylaxis associated with thromboembolic complications? P Padim1, A Alshafai2, S Canestrini3, S Rizoli2, J De Rezende Neto2, A McFarlan2 1Universidade de São Paulo, Ribeirao Preto, Brazil; 2St Michael’s Hospital, Toronto, ON, Canada; 3St George’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P323 (doi: 10.1186/cc14403) q g g g Conclusion Delivering a service that off ers TPA to patients with submassive PE signifi cantly increases the need to consider this therapy. Introducing this service is only eff ective if doctors initially assessing these patients are aware of recent changes to guidelines for PE. R f References Methods A total of 60 patients entered the Odessa Clinical Regional Hospital for treatment venous thromboembolism. Patients were divided into two groups. The fi rst group (n = 30) were receiving enoxaparin in dosage 1.5 mg/kg subcutaneously per day. The second group (n = 30) were receiving rivaroxaban orally 15 mg/day. For checking the coagulation state we were using such indicators of LPTEG as constant thrombin activity (CTA), intensity of coagulation drive (ICD) and gel point (GP). We performed LPTEG three times per day: 4, 12 and 24 hours after taking the drug to check for changes in the coagulation state in both groups of patients. 1. Geerts W, Code K, Jay R, Chen E, Szalai J. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994. 331;1601-6. 1. Geerts W, Code K, Jay R, Chen E, Szalai J. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994. 331;1601-6. 2. Rogers FB, Cipolle MD, Velmahos G, et al. Practice management guidelines for the prevention of venous thromboembolism: the EAST Practice Management Guidelines Work Group. J Trauma. 2002;53:142-64. Impact of introducing guidelines for thrombolysis of submassive pulmonary embolism at a large UK teaching hospital GP Misselbrook Limitations to TPA administration were late recognition of submassive PE and inadequate knowledge of changes to guidelines.f p References Introduction Thromboembolic complications (TEC) are very common and lethal in patients suff ering from traumatic injury [1]. The trauma Introduction Thromboembolic complications (TEC) are very common and lethal in patients suff ering from traumatic injury [1]. The trauma Meyer G, et al. N Engl J Med. 2014;370:1402-11. Kearon C, et al. Chest. 2012;141:419-96S. S115 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 (P <0.001). The type of thrombosis was directly associated with poor outcome, especially one that resulted from central catheters (P <0.001) and pulmonary embolism (P <0.001). However, no correlations were found with temperature, white blood cells and platelet counts on admission (P > 0.05). (P <0.001). The type of thrombosis was directly associated with poor outcome, especially one that resulted from central catheters (P <0.001) and pulmonary embolism (P <0.001). However, no correlations were found with temperature, white blood cells and platelet counts on admission (P > 0.05). Figure 1 (abstract P324). New local guidelines. Conclusion Thrombosis aff ects the ICU patient’s fi nal outcome. The type of thrombosis contributes to a poor outcome and mainly the occurrence of pulmonary embolism signifi cantly increases the mortality rate. P325 Results A total of 51 patients were included. The median age and BMI were 73 years and 23 kg/m2, respectively; 31% were female and 69% were surgical critical care patients. The median APACHE II and SOFA scores were 20 and 8, respectively. Risk factors associated with DVT were presence of central venous catheter 63%, malignancy 9% and hemodialysis 14%. The rate of DVT was 18.6% and the rate of CRT was 13.7%. All of these were asymptomatic and seen in neck and upper extremities. There was no DVT-associated adverse event (pulmonary embolism, bleeding) during hospital stay. The 28-day all-cause mortality rate was 3.4%. Introduction Despite preventive anticoagulation therapy measures, venous thromboembolic disease is a major cause of morbidity and mortality among patients hospitalized in ICUs. In fact, pulmonary embolism is not only the most serious manifestation of the disease, but also one of the primary causes of sudden death. The aim of this study is to investigate the frequency of thromboembolism and pulmonary embolism in ICU hospitalized trauma and neurosurgical patients. Conclusion While incidence of asymptomatic DVT is relatively high in adult critically ill patients, they were found only in the neck and upper extremities without any adverse event. Further research is needed to evaluate the clinical signifi cance of this type of DVT. Methods One hundred ICU patients, 51 postoperative neurosurgical and 49 trauma, were included in the study. Patients’ demographic data as well as medical history, temperature, white blood cells and platelets counts were recorded on admission, the day of thrombosis diagnosis and the fi nal outcome of their treatment. Statistics were performed with SPSS-19. P <0.05 was considered signifi cant. P326 P326 Incidence and outcome of asymptomatic deep vein thrombosis in critically ill patients: a prospective cohort study R Echigoya, H Okamoto, H Uchino, A Kuriyama, N Tamura, K Sato, T Fukuoka Kurashiki Central Hospital, Okayama, Japan Critical Care 2015, 19(Suppl 1):P326 (doi: 10.1186/cc14406) Figure 1 (abstract P324). New local guidelines. Figure 1 (abstract P324). New local guidelines. Introduction Asymptomatic deep vein thrombosis (DVT) including catheter-related thrombosis (CRT) is an increasingly recognized disease entity in critically ill patients. However, the reported rate and outcome of DVT vary widely depending on study design, patient background and detecting method. The objective of this study is to evaluate the incidence and outcome of DVT in adult critically ill patients. Table 1 (abstract P324). TPA decisions High Intermediate Total risk risk Considered TPA and given 2 2 0 Considered TPA but contraindications 1 1 0 Considered TPA and not given on balance 3 0 3 Considered TPA and not given but fi t 3 2 1 criteria Not considered TPA but contraindicated 4 1 3 anyway Not considered TPA and on balance 5 1 4 would not be given Not considered TPA but fi t criteria 1 0 1 Table 1 (abstract P324). TPA decisions y p Methods This study is a prospective cohort study of patients admitted to a medical and surgical ICU from 1 July 2014 to 15 October 2014. All consecutive patients over 18 years of age and with expected ICU stay over 72 hours were included. Patients who had previous history of DVTs were excluded. We examined internal jugular vein, subclavian vein, axillary vein, brachial vein, femoral vein, superfi cial femoral vein, and popliteal vein, on ICU admission and within 48 hours after ICU discharge. The DVT was diagnosed using compression ultrasonography with color Doppler. Images were interpreted by two independent investigators trained in ultrasonography. All patients received intermittent pneumatic compression and unfractionated heparin twice daily during their IUC stay. Once the DVT was detected, therapeutic anticoagulation was initiated. Contrast-enhanced CT was performed when the patients were suspected to have pulmonary embolism. The primary outcome was the incidence of DVT during the ICU stay. Patients were followed until their hospital discharge. P327 P327 Computed tomographic pulmonary angiographic fi ndings to predict adverse outcomes in acute pulmonary embolism P Tajarernmuang, J Euathrongchit, C Liwsrisakun, A Deesomchok, T Theerakittikul, C Bumroongkit, C Pothirat, A Limsukon Chiang Mai University, Chiang Mai, Thailand Critical Care 2015, 19(Suppl 1):P327 (doi: 10.1186/cc14407) gi Results Thirty-eight out of 100 patients presented thrombosis, 14 trauma and 24 neurosurgical. We examined the correlation of thrombosis development during hospitalization with diagnosis, treatment allocated time and overall patient outcome. It was found that neurosurgical patients developed thrombosis more frequently than trauma patients (P <0.05). In relation to diagnosis, thrombosis was prevalent among patients with brain lesions (P = 0.018). Regarding the type of thrombosis, pulmonary embolism was also commonly apparent among individuals with brain lesion (P = 0.020). In addition, there was a statistically signifi cant correlation in thrombosis occurrence between hospitalization day (P <0.01) and patients’ outcome on discharge Introduction Computed tomographic pulmonary angiography (CTPA) has been used as a standard tool for diagnosing an acute pulmonary embolism (APE). The right ventricular (RV) strain signs may be used to predict adverse outcomes. However, the results are still controversial. The primary objective of our study was to evaluate the relationship between the RV strain signs and respiratory failure requiring mechanical ventilation or death in APE. The secondary objective was to identify clinical factors which related to those outcomes. Introduction Computed tomographic pulmonary angiography (CTPA) has been used as a standard tool for diagnosing an acute pulmonary embolism (APE). The right ventricular (RV) strain signs may be used to predict adverse outcomes. However, the results are still controversial. The primary objective of our study was to evaluate the relationship between the RV strain signs and respiratory failure requiring mechanical ventilation or death in APE. The secondary objective was to identify clinical factors which related to those outcomes. S116 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P329). Kaplan–Meier analysis of ESRD progression for SC and Ecu treatment for all patients. Methods CTPA and the medical records of patients with suspected APE on admission from June 2011 to March 2013 were reviewed. Mean platelet volume and mean platelet volume/platelet count ratio in risk stratifi cation of pulmonary embolism T Yardan1, M Meric1, C Kati1, Y Celenk2, A Atici1 1Ondokuz Mayis University School of Medicine, Samsun, Turkey; 2Ministry of Health Van Education & Research Hospital, Van, Turkey Critical Care 2015, 19(Suppl 1):P328 (doi: 10.1186/cc14408) T Yardan , M Meric , C Kati , Y Celenk , A Atici 1Ondokuz Mayis University School of Medicine, Samsun, Turkey; 2Ministry of Health Van Education & Research Hospital, Van, Turkey Critical Care 2015, 19(Suppl 1):P328 (doi: 10.1186/cc14408) Introduction Recently, mean platelet volume (MPV) was reported to predict early death in acute pulmonary embolism (PE). The aim of this study was to investigate the role of MPV and MPV/platelet count ratio (MPV/P) in risk stratifi cation of patients with acute PE. Conclusion Ecu treatment reduces the number of ESRD events and the rate of progression to ESRD; thus initiation of Ecu early after aHUS diagnosis may prevent cumulative kidney damage and progression to ESRD. i p Methods We retrospectively reviewed the medical records of patients with acute PE admitted to the emergency department. In addition to the clinical evaluation, platelet count and MPV were measured on admission. P328 Mean platelet volume and mean platelet volume/platelet count ratio in risk stratifi cation of pulmonary embolism T Yardan1, M Meric1, C Kati1, Y Celenk2, A Atici1 1Ondokuz Mayis University School of Medicine, Samsun, Turkey; 2Ministry of Health Van Education & Research Hospital, Van, Turkey Critical Care 2015, 19(Suppl 1):P328 (doi: 10.1186/cc14408) p Reference 1. Ghuysen A, Ghaye B, Willems V, Lambermont B, Gerard P, Dondelinger RF, et al. Computed tomographic pulmonary angiography and prognostic signifi cance in patients with acute pulmonary embolism. Thorax. 2005;60:956-61. p p Results The SC and Ecu treatment phases included 32 and 33 patients, respectively. With SC, during a median (range) of 211 (7 to 745) days, 13 (41%) patients had a total of 16 ESRD events. On Ecu treatment, during a median (range) of 924 (73 to 1,254) days, three (9%) patients had a total of fi ve ESRD events. The ESRD event rate was 92% lower during Ecu treatment versus the SC phase (0.36 vs. 0.07; P = 0.001); the incidence rate ratio was 0.08 (95% CI = 0.02 to 0.37; P = 0.001). HR for progression to ESRD for patients on Ecu versus SC was 0.03 (95% CI <0.01 to 0.34), a 97% reduction (Figure 1). Stratifi cation by baseline CKD stage showed no patients with CKD stage 2 or 3 at baseline progressed to ESRD over 3 years of Ecu treatment. Early initiation of eculizumab treatment in patients with atypical haemolytic uraemic syndrome improves long-term outcomes: a pooled analysis of clinical trials p y J Vande Walle1, Y Delmas2, G Ardissino J Vande Walle1, Y Delmas2, G Ardissino3, J Wang4, J Kincaid4, H Haller5 1University Hospital Ghent, Belgium; 2Centre Hospitalier Universitaire de Bordeaux, France; 3Ospedale Maggiore Policlinico, Milan, Italy; 4Alexion Pharmaceuticals, Cheshire, CT, USA; 5Medical School Hannover, Germany Critical Care 2015, 19(Suppl 1):P330 (doi: 10.1186/cc14410) Introduction Atypical haemolytic uraemic syndrome (aHUS) is a severe, life-threatening disease requiring rapid treatment to inhibit complement-mediated thrombotic microangiopathy (TMA) and avoid irreversible organ damage. Four prospective clinical trials have reported the safety and effi cacy of eculizumab (Ecu) in the treatment of aHUS [1,2]. We report data from a pooled analysis of these trials on renal function in patients starting Ecu within ≤7 days or >7 days after the current aHUS manifestation. Introduction Atypical haemolytic uraemic syndrome (aHUS) is a severe, life-threatening disease requiring rapid treatment to inhibit complement-mediated thrombotic microangiopathy (TMA) and avoid irreversible organ damage. Four prospective clinical trials have reported the safety and effi cacy of eculizumab (Ecu) in the treatment of aHUS [1,2]. We report data from a pooled analysis of these trials on renal function in patients starting Ecu within ≤7 days or >7 days after the current aHUS manifestation. P327 RV dysfunction signs included right ventricular to left ventricular (RV/LV) diameter ratio, interventricular septal shift, main pulmonary artery to ascending aorta (mPA/AA) diameter ratio, IVC contrast refl ux, SVC diameter, IVC diameter, PA diameter and azygos vein diameter. Clinical factors included cardiovascular, respiratory parameter and also time to diagnosis and treatment. g Results There were total of 36 cases with suspected APE on admission. Ten patients required mechanical ventilation (27.8%) and seven patients died (19.4%). Interventricular septal (IVS) shift was a signifi cant risk factor of in-hospital death (85.7% vs. 27.6%, P = 0.008) and respiratory failure (70% vs. 26.9%, P = 0.026). The sensitivity, specifi city, positive predictive and negative predictive values of IVS shift to predict in-hospital death were 85.7%, 70%, 42.8% and 95.5%, respectively. The sensitivity, specifi city, positive predictive and negative predictive values of IVS shift to predict respiratory failure were 70%, 73.1%, 50% and 86.4%, respectively. The ratios of RV to LV diameter and the ratio of main pulmonary artery to ascending aorta diameter tended to be higher in the nonsurvivor group. The clinical factor that predicted mortality was the PaO2 to FiO2 ratio (P/F ratio). Mean P/F ratio in survivor and nonsurvivor groups was 246.1 ± 94.1 vs. 132.2 ± 78.1, respectively (P = 0.011). P/F ratio ≤150 was the best predictor of mortality (66.7% vs. 8.7%, P = 0.008). Figure 1 (abstract P329). Kaplan–Meier analysis of ESRD progression for SC and Ecu treatment for all patients. with aHUS progress to end-stage renal disease (ESRD) after the fi rst episode [1]. Two prospective clinical trials have assessed the effi cacy of eculizumab (Ecu) in patients with aHUS [2]. We now evaluate data on progression to ESRD before and during Ecu treatment. Methods Patients with chronic kidney disease (CKD) stage 1 to 4 were analysed for progression to an ESRD event (two consecutive glomerular fi ltration rate measurements <15 ml/minute/1.73m2 (CKD stage 5)). ESRD incidence rate ratios during supportive care (SC) and Ecu treatment phases were calculated using a negative binomial regression analysis. Kaplan–Meier analyses were calculated for all patients and stratifi ed by CKD stages 2 to 4 at baseline. Hazard ratios (HR) were calculated from Cox proportional hazard models. Conclusion The IVS shifting from CTPA and P/F ratio ≤150 helps predict poor outcomes in APE. References 1. Fremeaux-Bacchi V, et al. CJASN. 2013;8:554-62. Results One hundred and fi fty-two patients were included. Patients with right ventricular (RV) dysfunction had signifi cantly higher MPV levels and MPV/P than patients without RV dysfunction. Receiver operating characteristic analysis revealed that a MPV cutoff of 7.85 fl provided 53.3% sensitivity and 68.5% specifi city, and a MPV/P cutoff of 0.0339 fl /(109/l) provided 69.6% sensitivity and 65% specifi city for prediction of RV dysfunction. There was a positive correlation between MPV and systolic pulmonary artery pressure (SPAP) and between MPV and RV diameter. There was a positive correlation between MPV/P and SPAP and between MPV/P and RV diameter. The low-risk PE group had lower MPV and MPV/P than the massive PE and submassive PE groups. Conclusion MPV and MPV/P are associated with RV dysfunction and clinical severity in acute PE. Low MPV and MPV/P levels may be an indicator of low risk in patients with acute PE. 2. Legendre C, et al. N Engl J Med. 2013;368:2169-81. Evaluation of the quotient of the venoarterial carbon dioxide gradient and the arteriovenous oxygen content diff erence as a transfusion trigger parameter in hemodynamically stable patients with signifi cant anemiai Evaluation of the quotient of the venoarterial carbon dioxide gradient and the arteriovenous oxygen content diff erence as a transfusion trigger parameter in hemodynamically stable patients with signifi cant anemia A Taha, A Shafi e, M Mostafa, N Syed, H Hon, R Marktanner Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Critical Care 2015, 19(Suppl 1):P331 (doi: 10.1186/cc14411) Results We identifi ed 21 eligible studies (16,951 patients). After pooling data from the 20 included cohort studies (16,884 patients), at least around 33% (95% CI: 27 to 39; I2: 97.8%) of patients with TBI in published reports received transfusions at some point during their hospital stay. In a post hoc analysis of one RCT comparing transfusion strategies, 82% of patients were transfused RBCs. Thresholds for transfusion were rarely available and varied from 6 to 10 g/dl. From raw data, Glasgow Coma Scale scores were lower in patients who were transfused than those who were not (three cohort studies; n = 1,371; mean diff erence of 1.38 points (95% CI: 0.86 to 1.89); I2 = 12%). Mortality was not signifi cantly diff erent among transfused and nontransfused patients both in univariate and multivariate analyses. Hospital length of stay was longer among patients who were transfused (three studies; n = 455; mean diff erence 9.58 days (95% CI: 3.94 to 15.22); I2 = 74%). Due to the observational nature of included studies, results should be considered cautiously due to the high risk of confounding. i A Taha, A Shafi e, M Mostafa, N Syed, H Hon, R Marktanner Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Critical Care 2015, 19(Suppl 1):P331 (doi: 10.1186/cc14411) Introduction Hemoglobin as the main trigger parameter for blood transfusion usually gives diminutive information about oxygen delivery and consumption. Although central venous oxygen saturation (ScvO2) is an alternative parameter, its changes are unable to detect regional hypoxia. Our aim was to evaluate the quotient of the central venous-to- arterial carbon dioxide gradient (δPCO2) and the arteriovenous oxygen content diff erence (Ca-cvO2) as a valid transfusion trigger parameter in hemodynamically stable anemic patients to reduce the amount of potentially counterproductive erythrocyte transfusions [1].i Methods Forty-fi ve postoperative patients admitted to our cardiac ICU were enrolled between January 2013 and September 2014. Three groups were defi ned according to the trend of blood loss over the surgical drains in the fi rst 24 postoperative hours. Red blood cell transfusion in patients with traumatic brain injury: a systematic review Red blood cell transfusion in patients with traumatic brain injury: a systematic review A Boutin1, M Chasse1, M Shemilt1, F Lauzier1, L Moore1, R Zarychanski2, J Lacroix3, DA Fergusson4, D Griesdale5, P Desjardins1, AF Turgeon1 1Université Laval, Quebec, QC, Canada; 2University of Manitoba, Winnipeg, MB, Canada; 3Université de Montreal, QC, Canada; 4Ottawa Hospital Research Institute, Ottawa, ON, Canada; 5University of British Columbia, Vancouver, BC, Canada Critical Care 2015, 19(Suppl 1):P332 (doi: 10.1186/cc14412) minute/1.73 m2 were included. Changes from baseline in eGFR were analysed at study visits using a one-sample t test. y A Boutin1, M Chasse1, M Shemilt1, F Lauzier1, L Moore1, R Zarychanski2, J Lacroix3, DA Fergusson4, D Griesdale5, P Desjardins1, AF Turgeon1 1Université Laval, Quebec, QC, Canada; 2University of Manitoba, Winnipeg, MB, Canada; 3Université de Montreal, QC, Canada; 4Ottawa Hospital Research Institute, Ottawa, ON, Canada; 5University of British Columbia, Vancouver, BC, Canada A Boutin1, M Chasse1, M Shemilt1, F Lauzier1, L Moore1, R Zarychanski2, J Lacroix3, DA Fergusson4, D Griesdale5, P Desjardins1, AF Turgeon1 1Université Laval, Quebec, QC, Canada; 2University of Manitoba, Winnipeg, MB, Canada; 3Université de Montreal, QC, Canada; 4Ottawa Hospital Research Institute, Ottawa, ON, Canada; 5University of British Columbia, Vancouver, BC, Canada Critical Care 2015 19(Suppl 1):P332 (doi: 10 1186/cc14412) Results Data from 97 patients were analysed: median (range) age at enrolment was 29 (0 to 80) years; 62% of patients were females; median (range) duration of current manifestation to start of Ecu treatment was 23 (1 to 1,447) days; median (range) baseline eGFR was 15.9 (5.6 to 76.1) ml/minute/1.73 m2. Ecu treatment was started in 21 patients in ≤7 days and 76 patients in >7 days after presentation with TMA. Median eGFR was 11 ml/minute/1.73 m2 for the patients started within 7 days and 16 ml/minute/1.73 m2 for those initiating >7 days. The mean change from baseline in eGFR for patients starting Ecu in ≤7 days and in >7 days after presentation with TMA were 57 and 23 ml/minute/1.73 m2 at 1 year, respectively (Figure 1). Critical Care 2015, 19(Suppl 1):P332 (doi: 10.1186/cc14412) Introduction We aimed to evaluate the frequency of red blood cell (RBC) transfusion in patients with traumatic brain injury (TBI) as well as determinants and outcomes associated with RBC transfusion in this population. Methods We conducted a systematic review of cohort studies and trials of patients with TBI. Evaluation of the quotient of the venoarterial carbon dioxide gradient and the arteriovenous oxygen content diff erence as a transfusion trigger parameter in hemodynamically stable patients with signifi cant anemiai Mild blood loss was defi ned as 500 to 1,000 ml/24 hours, moderate (1,000 to 1,500/24 hours) and severe (>1,500 ml/24 hours). In addition to the δPCO2 the following parameters were monitored: CI, CO, SVR, serum lactate, ScvO2 and hemoglobin. Ca-cvO2 was calculated and the δPCO2/ Ca-cvO2 quotient was assessed for a total of 400 paired blood samples. All enrolled patients were hemodynamically stable. A retrospective analysis of this data was performed.i Conclusion RBC transfusion is frequent in patients with TBI, but practices varied widely in cohort studies in this population. The paucity of data precludes defi nitive conclusions and highlights the lack of clinical evidence guiding transfusion strategies in TBI. P329 Progression to end-stage renal disease is reduced with eculizumab in patients with atypical haemolytic uraemic syndrome J Vande Walle1, S Johnson2, E Harvey3, J Kincaid3 1University Hospital Ghent, Belgium; 2Medicus Economics, LLC, Boston, MA, USA; 3Alexion Pharmaceuticals, Cheshire, CT, USA Critical Care 2015, 19(Suppl 1):P329 (doi: 10.1186/cc14409) Methods Data from four phase 2, open-label, single-arm trials including both paediatric and adult patients with aHUS were pooled. Patients with a documented date of onset of current TMA manifestation and a baseline estimated glomerular fi ltration rate (eGFR) of <90 ml/ Introduction Atypical haemolytic uraemic syndrome (aHUS) is associated with severe kidney damage; almost one-half of adults S117 Critical Care 2015, Volume 19 Suppl 1 http://ccforum com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P330). Mean change in eGFR from baseline over 1 year (standard error). hemoglobin capacity decline and signifi cantly improved after erythrocyte transfusions (P <0.005). Figure 1 (abstract P330). Mean change in eGFR from baseline over 1 year (standard error). Conclusion Blood transfusions carry risks of adverse eff ects and should be carried out responsibly. Our fi ndings suggest an additive and easy detectable transfusion trigger parameter (δPCO2/Ca-cvO2) providing physiological information on anemia-related altered oxygen extraction conditions and hence the indication for erythrocyte transfusions. However, additional studies are warranted to confi rm these fi ndings. Reference 1. Mekontso-Dessap A, Castelain V, Anguel N, Bahloul M, Schauvliege F, et al. Combination of venoarterial PCO2 diff erence with arteriovenous O2 content diff erence to detect anaerobic metabolism in patients. Intensive Care Med. 2002;28:272-7. 1. Mekontso-Dessap A, Castelain V, Anguel N, Bahloul M, Schauvliege F, et al. Combination of venoarterial PCO2 diff erence with arteriovenous O2 content diff erence to detect anaerobic metabolism in patients. Intensive Care Med. 2002;28:272-7. y References 1. Legendre C, et al. N Engl J Med. 2013;368:2169-81. 2. Keating GM. Drugs. 2013;73:2053-66. 1. Legendre C, et al. N Engl J Med. 2013;368:2169-81. 2. Keating GM. Drugs. 2013;73:2053-66. 1. Legendre C, et al. N Engl J Med. 2013;368:2169-81. 2. Keating GM. Drugs. 2013;73:2053-66. Red blood cell transfusion in patients with traumatic brain injury: a systematic review We searched Medline, Embase, The Cochrane Library and BIOSIS databases from their inception up to 30 June 2014. We selected cohort studies and RCTs of adult patients with TBI reporting data on RBC transfusions. We extracted data related to demographics, baseline characteristics, blood product use and any relevant clinical patient-oriented outcome. Cumulative incidences of transfusion were pooled through random eff ect models with a DerSimonian approach, after a Freeman–Tukey transformation to stabilize variances. To evaluate the association between RBC transfusion and potential determinants as well as outcomes, we pooled risk ratios or mean diff erences with random eff ect models and the Mantel–Haenszel method. Sensitivity and subgroup analysis were planned a priori.i y p y g Conclusion This pooled analysis indicates that patients treated with Ecu within 7 days of a TMA manifestation had a greater improvement in eGFR over time than patients in whom treatment was delayed. These data show the importance of rapid diagnosis and treatment of aHUS for recovery of renal function. Red blood cell transfusion is associated with an increased mortality in critically ill surgical patients y A Piriyapatsom, O Chaiwat, S Kongsayreepong Siriraj Hospital, Bangkok, Thailand Critical Care 2015, 19(Suppl 1):P334 (doi: 10.1186/cc14414) Results δPCO2/Ca-cvO2 showed signifi cant correlation with the moderate and severe blood loss groups (P <0.01), while no signifi cant correlation was detected in the mild blood loss group. The abnormality of the δPCO2/Ca-cvO2 was easy detectable and refl ected intracapillary Introduction The aim of this study is to explore the association between red blood cell transfusion (RBCT) and mortality in Thai critically ill surgical patients. Introduction The aim of this study is to explore the association between red blood cell transfusion (RBCT) and mortality in Thai critically ill surgical patients. S118 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods This study was a part of the multicenter, prospective, observational study performed in nine surgical intensive care units (SICUs) across the nation between April 2011 and November 2012 [1]. This study included adult patients admitted to the SICUs after surgery. Patients were categorized into transfusion and no transfusion groups according to whether or not they received RBCT at any time during SICU stay. Demographic data, clinical outcomes as well as SICU and hospital length of stay (LOS) and SICU and hospital mortality were collected. Patients were followed for up to 28 days or until discharge from the SICUs. The primary endpoint was hospital mortality. Data were compared between groups and logistic regression analysis was performed to determine whether RBCT was an independent risk factor of hospital mortality. In addition, patients were matched between groups based on the propensity score of the requirement of RBCT and were then compared. confounders, a Hb level of ≤9 g/dl was associated with a poor neurologic outcome (OR = 2.572, 95% CI = 1.058 to 6.250), whereas an Hb level of ≤10 g/dl was not. A Hb level of ≤10.3 g/dl had a sensitivity of 82% and a specifi city of 62% to predict poor neurologic outcome in TBI patients. Conclusion In TBI patients a Hb level of ≤9 g/dl is associated with poor neurologic outcome. Red blood cell transfusion is associated with an increased mortality in critically ill surgical patients A transfusion threshold of ≤10.3 g/dl may be a reasonable target to be tested in future transfusion trials aimed at improving neurologic outcome of TBI patients.fi Acknowledgements All of the author institutes are affi liated members of the International Trauma Research Network (INTRN) and as such this work represents a combined output resulting from this Network. Microparticles from red blood cell transfusion products induce a strong infl ammatory host response y p q g Results Supernatant from blood bags containing MPs strongly induced production of all cytokines compared with supernatant without MPs, a reaction which equaled that of LPS stimulation. MPs from stored RBC bags induced higher production of TNF (868 (263 to 1,625) vs. 2,596 (407 to 3,040) pg/ml, P = 0.049), IL-6 (1,088 (234 to 3,716) vs. 6,952 (1,507 to 21,990), P = 0.042) and IL-8 (1,333 (535 to 3,569) vs. 5,562 (833 to 13,904), P = 0.081) compared with MPs from fresh RBC bags. There was no diff erence in IL-10 responses between groups (8.0 (3.9 to 32.1) vs. 3.9 (3.9 to 22.2), P = 0.390). The host response was dose dependent both for fresh and stored MPs. In addition, the same amount of older MPs induced a stronger host response compared with fresh MPs. Conclusion MPs from RBC transfusion bags induce a strong proinfl ammatory response, which is largely negated when MPs are removed. This MP-mediated response depends both on the amount of MPs as well as on alterations in MPs as a result of storage. Reference Reference Reference 1. Chittawatanarat K, et al. J Med Assoc Thai. 2014;97 Suppl 1:S45-54. 1. Chittawatanarat K, et al. J Med Assoc Thai. 2014;97 Suppl 1:S45-54. Microparticles from red blood cell transfusion products induce a strong infl ammatory host response Results Overall, 968 of 2,374 (40.8%) patients received RBCT. Trans- fused patients, when compared with those without RBCT, had more frequency of admission after emergency surgery, higher APACHE II score, higher SOFA score, higher number of organ dysfunctions and lower hemoglobin level at admission. When compared with patients without RBCT, those with RBCT had more frequency of all adverse events including infection, AKI, ALI/ARDS and MI, and longer SICU and hospital LOS. Both SICU and hospital mortality were also higher in the transfusion group compared with the no transfusion group (9.4% vs. 1.6% and 13.7% vs. 3.6%, both P <0.001, respectively). The logistic regression analysis showed that RBCT was an independent risk factor of hospital mortality with odds ratio of 1.60 (95% CI 1.05 to 2.45). In the propensity-score matched cohort of 852 patients, when compared with patients without RBCT, transfused patients had more frequency of adverse events including infection and AKI, longer SICU and hospital LOS and higher hospital mortality (7.5% vs. 4.0%, P = 0.027). l M Straat1, M Van Hezel1, A Boing1, R Nieuwland1, R Van Bruggen2, N Juff ermans1 f 1Academic Medical Center, Amsterdam, the Netherlands; 2Sanquin Blood Cell Research, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P336 (doi: 10.1186/cc14416) Introduction Red blood cell (RBC) transfusion is associated with increased morbidity and mortality in the critically ill. Adverse eff ects of transfusion may be mediated by red blood cell storage lesion. In this study, we hypothesized that MPs from stored RBC bags would induce a more pronounced host response than MPs from fresh RBC bags and that this response is dose dependent. p p Methods MPs were isolated by high-speed centrifugation from red blood cell transfusion bags stored for 2 to 7 (fresh) or 25 to 35 (stored) days. Whole blood from healthy volunteers was incubated with supernatant from the bags either containing MPs or depleted from MPs (n = 12 bags per group). Controls were incubated with PBS as a negative and LPS (10 ng/ml) as a positive control. Cytokines in supernatant were measured by ELISA. Data are expressed as medians and interquartile ranges. g y Conclusion This study showed that RBCT was associated with increased morbidity and mortality in critically ill surgical patients. These results supported the restrictive strategy of RBCT suggested by more recent studies. Eff ect of the haemoglobin level on neurologic outcome in patients with severe traumatic brain injury Eff ect of the haemoglobin level on neurologic outcome in patients with severe traumatic brain injury K Balvers1, MR Wirtz1, C Rourke2, S Eaglestone2, K Brohi2, S Stanworth3, C Gaarder4, JC Goslings1, NP Juff ermans1 1Academic Medical Center, Amsterdam, the Netherlands; 2Blizard Institute, Queen Mary University of London, UK; 3John Radcliff e Hospital, Oxford, UK; 4Oslo University Hospital, Oslo, Norway Critical Care 2015, 19(Suppl 1):P335 (doi: 10.1186/cc14415) Introduction Anaemia in patients with severe traumatic brain injury (TBI) may worsen neurologic outcome. The aim of this study was to determine the association of haemoglobin level (Hb) with neurologic outcome and to determine a transfusion threshold which may be used in future transfusion trials aimed at improving neurologic outcome in TBI patients. Value of thromboelastography in managing hypercoagulopathy in intensive care Methods A retrospective audit over 2 months of all blood transfusion forms at St Francis Hospital, Eastern Province, Zambia. Respective patients’ notes were reviewed for: record of observations during transfusion; patient demographics; and length of stay. We surveyed nurses’ attitudes, confi dence and knowledge in relation to blood transfusion standards. J Aron, A Gibbon, C Ward, J Ball St George’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P340 (doi: 10.1186/cc14420) J Aron, A Gibbon, C Ward, J Ball St George’s Hospital, London, UK g p , , Critical Care 2015, 19(Suppl 1):P340 (doi: 10.1186/cc14420 Introduction This aim of this analysis is to explore the use of thromboelastography (TEG) in the management of hypercoagulation in the ICU. TEG allows the assessment of whole blood coagulation and fi brinolysis and hence can identify patients who are hypercoagulable. Methods A prospective audit of TEG tests performed on patients being treated on a general surgical and medical ICU was conducted over a 2-month period. Results In May and June 2014, 457 requests were made for blood, of which 157 (34%) received blood transfusion, of which 108 (69%) had records of observations available. The audit demonstrated that requests were mostly complete (90%), but urgency was indicated in only 32%. The matching of blood to patient by more than one nurse was recorded amongst 66% of cases. Only 2% of transfusions met minimal requirements for transfusion reaction monitoring. Of nurses surveyed (n = 20), most were experienced in their post (mean 7.3 years, range 2 weeks to 20 years). Nurses rated themselves as highly confi dent in handling blood transfusions and identifying and dealing with transfusion reactions. However, 90% believed they could identify all transfusion reactions by measuring temperature alone, and 25% would measure temperature only as a parameter to monitor the transfusion, even in ideal settings. Most knew to check observations before, 15 minutes after the start of transfusion and then hourly thereafter (88%); but only 10% would check at the start, at completion and 4 hours after completing transfusion. The most frequently reported reason for not doing observations was time pressure on the ward (85%). Results Twenty-one out of 78 patients (26.9%) had one or more TEG criteria consistent with hypercoagulopathy. Admission diagnoses included trauma (37%), haemorrhage (23%), postoperative (23%) and sepsis (14.3%). Sixty-two per cent of patients with a primary diagnosis of trauma were in a hypercoaguable state. P337 Improving blood transfusion safety in a low-resource setting: an audit of 1,163 transfusion requests S Kudsk-Iversen1, R Colhoun1, D Chama2, J Mulenga2, MD Bould1, J Kinnear1, D Snell1 1Zambia Anaesthesia Development Project, Lusaka, Zambia; 2Zambia National Blood Transfusion Service, Lusaka, Zambia Critical Care 2015, 19(Suppl 1):P337 (doi: 10.1186/cc14417) Methods A substudy of the prospective multicentre Activation of Coagulation and Infl ammation in Trauma (ACIT) II study was performed on subjects recruited between January 2008 and December 2014. All adult trauma patients admitted to a level 1 trauma centre with severe traumatic brain injury (AIS head ≥3), ICU admission and available Hb levels on admission were selected for analysis. The primary outcome was the cognitive functioning of patients as determined by an estimated Glasgow Outcome Scale (GOS) on discharge. Anaemia was defi ned as a Hb level of ≤9 g/dl (severe anaemia) or ≤10 g/dl (moderate anaemia) within the fi rst 24 hours post injury. Multivariate logistic regression models were used to determine the association between anaemia and neurologic outcome. The receiver operating characteristic curve and the Youden Index were used to determine an optimal transfusion threshold. Introduction Sub-Saharan Africa suff ers from more acute life- threatening indications for blood transfusion compared with high- income countries [1]. The commonest ‘systems failure’ contributing to perioperative death in low-resource settings is the timely availability of correctly cross-matched blood products [2]. Often this is not the result of an absolute shortage of blood products, but failure in the chain of supply and distribution. We audited an early step in this chain, the quality of blood requests, at the University Teaching Hospital (UTH) in Lusaka, Zambia. UTH does not have a formal blood request form, and only the cancer diseases hospital (CDH) has a blood request form developed by the blood bank. Results Of a total of 261 TBI patients, 61 patients (23%) fell below the threshold for severe anaemia and 101 patients (39%) had moderate anaemia within the fi rst 24 hours. In a model adjusted for all relevant S119 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods We performed a 1-day retrospective review in June of blood request forms submitted to the cross-match laboratory, followed by a 14-day prospective review in September 2014. Group and save requests were excluded. Inadequate monitoring risks safety of blood transfusion in rural Zambia Results The mean age was 43.5 ± 5.7 years. Of 58 patients (38 male/20 female), 25 (43.1%) had iron defi ciency with outcomes of blood samples used at ICU admission. The overall transfusion rate was 32.8%, being higher in iron-defi ciency patients than in normal iron profi le patients (42.3 vs. 14.9%, P = 0.001). After adjusting for severity of illness and hemoglobin level, iron-defi ciency patients remained signifi cantly associated with transfusion, with a hazard ratio of 4.2 (95% CI, 1.3 to 12.9; P = 0.001). Zambia O Todd1, K Sikwewa1, J Kamp1, I Hodt Rasmussen1, K Mortensen1, S Kudsk-Iversen2 1St Francis Hospital Katete, Zambia; 2Unversity College Hospital, London, UK Critical Care 2015, 19(Suppl 1):P338 (doi: 10.1186/cc14418) O Todd1, K Sikwewa1, J Kamp1, I Hodt Rasmussen1, K Mortensen1, S Kudsk-Iversen2 1St Francis Hospital Katete, Zambia; 2Unversity College Hospital, London, UK Critical Care 2015, 19(Suppl 1):P338 (doi: 10.1186/cc14418) 1St Francis Hospital Katete, Zambia; 2Unversity College Hospital, London, UK Critical Care 2015, 19(Suppl 1):P338 (doi: 10.1186/cc14418) Introduction In Zambia, supply of blood is insuffi cient to meet clinical need, on a national level. Paradoxically, blood is also more often transfused unnecessarily in this setting. The Zambian National Blood Transfusion Service is currently scaling up voluntary blood donation and supply systems, and requires hospitals to improve blood transfusion safety. At a rural district hospital in Zambia, we audited practice and surveyed knowledge amongst staff using standards established in national guidelines. Conclusion Iron defi ciency is common at ICU admission and is associated with higher transfusion requirements. These fi ndings have important implications for transfusion practices in ICU patients. P340 P339 Eff ects of iron defi ciency on transfusion requirements in critically ill patients: a preliminary observational study M Aydogan, M Ucar, A Yücel, B Karakas, A Gok, T Togal Inonu University, Malatya, Turkey Critical Care 2015, 19(Suppl 1):P339 (doi: 10.1186/cc14419) P339 Eff ects of iron defi ciency on transfusion requirements in critically ill patients: a preliminary observational study M Aydogan, M Ucar, A Yücel, B Karakas, A Gok, T Togal Inonu University, Malatya, Turkey Critical Care 2015, 19(Suppl 1):P339 (doi: 10.1186/cc14419) M Aydogan, M Ucar, A Yücel, B Karakas, A Gok, T Togal Inonu University, Malatya, Turkey Critical Care 2015, 19(Suppl 1):P339 (doi: 10.1186/cc14419) Introduction Critically ill patients often need blood transfusion, but no reliable predictors of transfusion requirements are available at ICU admission. We hypothesized that ICU patients admitted with iron defi ciency may be at higher risk for developing anemia, requiring blood transfusion. The aims of this study were to determine the frequency of iron defi ciency in ICU patients at admission and to investigate its relationship with transfusion requirements in ICU patients. p Conclusion The audit revealed an important system failure impacting on effi cacy and safety of transfusion practice at UTH. Full patient identifi ers, as well as vital information such as the indication and urgency, were rarely fi lled in, which are crucial for the blood bank to prioritise the release of blood products. The audit shows that practice may be signifi cantly improved by a cheap intervention such as a standardised blood request form meeting international standards. Acknowledgements UK aid, THET. References 1 L d l T f A h S i 2013 49 416 21 Methods Eighty-fi ve patients admitted to the general ICU were enrolled in the prospective observational study. We studied 58 patients, after excluding those transfused on or before ICU admission. The patients’ age, gender, APACHE II score, diagnosis, severity score, presence of sepsis, ICU complications, ICU treatments, and transfusion-free interval were recorded. Iron defi ciency was assessed on the basis of several parameters, including hemoglobin, hematocrit, levels of serum iron, iron-binding capacity, transferrin saturation, levels of ferritin, soluble transferrin receptor, hepcidin, C-reactive protein, and peripheral blood smear. 1. Lund et al. Transfus Apher Sci. 2013;49:416-21. 2. Ohanaka et al. Turk J Med Sci. 2007;37:219-22. P337 Each form was audited against the American Association of Blood Banks (AABB) minimum standards for content of a blood request form. Analysis was performed with Fisher’s exact test for nominal data and t test for continuous data. Conclusion In this setting, current practice is evidently inadequate to identify and prevent blood transfusion reactions. The survey revealed high confi dence but patchy knowledge amongst nurses of the requirements for safe blood transfusion. Better timing to transfuse at times when nursing staff numbers are higher, alongside compulsory training, may together represent potential low-cost interventions to improve blood transfusion safety. Results A total of 1,163 blood requests were reviewed, 51 from CDH and 1,112 from other wards. Eighteen forms from CDH (35%) and 22 from other wards (2%) met all minimum AABB standards (P <0.0001). The mean number of standards met on the requests from CDH and the rest were 11.25 (SD 0.93) and 8.87 (SD 1.75) respectively (P <0.0001). Considering all blood requests, the standards met in order from least to most were: signature of requesting doctor (36%), urgency of request (43%), hospital number (59%), indication for transfusion (62%), type of product requested (72%), requesting doctor’s name (78%), age or date of birth of patient (84%), gender of patient (89%), quantity of products requested (90%), date form was completed (90%), patient’s ward (95%), and patient’s full name (100%). P339f P342 P342 In trauma, when used in the emergency department, do viscoelastic hemostatic tests decrease mortality? A systematic review J Cousineau, R Daoust, K Doyon, M Marquis, É Piette, JM Chauny, M Clar, D Rose, É Notebaert Hôpital du Sacré Coeur de Montréal, Montreal, QC, Canada Critical Care 2015, 19(Suppl 1):P342 (doi: 10.1186/cc14422) Introduction This systematic review done in March and updated in November 2014 has been conducted in accordance with the STARD, PRISMA and STROBE recommendations. Retrospective and prospective studies with a comparison group published in English were kept. Methods Two reviewers (JC and ÉN) and two librarians (MC and DR) independently conducted a systematic review and identifi ed abstracts. Full texts were read by two authors (ÉN and ÉP), and data were extracted. The following databases were searched: Cochrane CENTRAL, Medline, Embase, LILACS, Web of Science, Science.gov, SciFinder Scholar, WorldCat, the Transf Evid Lib Database, and proceedings of the congresses of the International Society on Thrombosis and Haemostosis and the American Society of Hematology. Figure 1 (abstract P340). Coagulation modifi cation prior to TEG analysis in hypercoagulable patients. as a result of performing TEG was documented in 14 of these 21 patients. No further blood products were administered in all cases and anticoagulation was commenced or increased in four cases. Conclusion Hypercoagulopathy was present in 27% of patients. One- third of these patients had recently received prothrombotic therapy indicating a possible iatrogenic aetiology. TEG analysis resulted in cessation of prothrombotic drug and blood product administration in all cases. Further research is required to determine whether titrated anticoagulation treatment to normalise the TEG profi le in these patients would be benefi cial. f y y Results We initially kept 2,870 references. In total, 453 articles had mortality in their keywords. After reading the abstracts, 37 papers were analysed, and three articles evaluating mortality in two groups of patients (using and not using a VHT) were identifi ed. Among these three studies, only one had raw data available. We did not succeed in getting this information from the two other authors. We asked the main authors of the 37 selected papers, and renowned authors in the fi eld, if they had studies with new data that could be included in our review. The answers were negative. Thromboelastography may detect hypercoagulation in early sepsis and improve anticoagulation during extracorporeal treatments F T S B R B h AB B ll S M M F l Aurelia and European Hospital, Rome, Italy p p y Critical Care 2015, 19(Suppl 1):P341 (doi: 10.1186/cc14421) Introduction During early sepsis, activation of the infl ammatory response and coagulation occurs. Extracorporeal therapies are used to adsorb mediators, but the coagulation of fi lters is a drawback [1,2]. The aim of this study is to evaluate whether thromboelastography (TEG) may detect hypercoagulation and may improve anticoagulation during extracorporeal treatments. Conclusion With the studies available as of the end of 2014, it is impossible to conclude whether the use of a VHT in the emergency department decreases mortality. Other studies are needed. References 1. Johansson PI, Stensballe J. Eff ect of haemostatic control resuscitation on mortality in massively bleeding patients: a before and after study. Vox Sang. 2009;96:111-8. p Methods Twenty-four patients with early severe sepsis had a TEG monitoring at basal time (T0) and during three diff erent extracorporeal treatments (T1): coupled plasma fi ltration (CPFA) with heparin infusion (Group A), CPFA with citrate infusion (Group B) and RRT with oXiris fi lter – heparin coated – and no heparin infusion (Group C). ANOVA test was used for the statistical analysis. 2. Messenger BM, et al. TEG-guided massive transfusion in trauma patients. Anesth Analg. 2011;112:S-9. 3. Kashuk K, et al. Initial experiences with POC rapid TEG for management of life-threatening postinjuty coagulopathy.Transfusion. 2012;52:23-33. 3. Kashuk K, et al. Initial experiences with POC rapid TEG for management of life-threatening postinjuty coagulopathy.Transfusion. 2012;52:23-33. y Results Table 1 presents the TEG values in early septic patients at T0. At T1, angle and MA decreased and r increased in Group A at diff erence with Group B and Group C (P <0.01). In group C, LY 30 was higher than in Group A and B (P <0.01). Reference 1. Kashuk JL, et al. r-TEG identifi es hypercoagulability and predicts thromboembolic events in surgical patients. Surgery. 2009;146:764-72. 1. Kashuk JL, et al. r-TEG identifi es hypercoagulability and predicts thromboembolic events in surgical patients. Surgery. 2009;146:764-72. P341 Thromboelastography may detect hypercoagulation in early sepsis and improve anticoagulation during extracorporeal treatments F Turani, S Busatti, R Barchetta, AB Belli, S Martini, M Falco Aurelia and European Hospital, Rome, Italy Critical Care 2015, 19(Suppl 1):P341 (doi: 10.1186/cc14421) References Figure 1 (abstract P340). Coagulation modifi cation prior to TEG analysis in hypercoagulable patients. 1. Livigni S, Bertolini G, Rossi C, et al. BMJ Open. 2014;4:e003536. 2. Ronco C, et al. Crit Care. 2014, 18:309. Value of thromboelastography in managing hypercoagulopathy in intensive care Hypercoagulopathy was suggested by an abnormally short R time in 16 patients (76%), an abnormal alpha angle in 17 cases (81%), a maximum amplitude >74 mm in nine cases (43%) and a high LY30 in one case. Procoagulant treatment was given to seven patients and fi ve patients had received no coagulation modifi cation prior to testing (Figure 1). Eight patients were receiving prophylactic anticoagulation and only one was receiving treatment-dose anticoagulation. A change in management S120 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P342 The three studies were: Johansson and Stensballe, total 832 cases, 121 traumas, raw data unavailable for trauma [1]; Messenger and colleagues, prospective study, 50 cases, mortality similar, raw data unavailable [2]; and Kashuk and colleagues, prospective study, 68 cases, mortality 59% control group, 28% VHT group [3]. Role of thromboelastography in the management of haemorrhage: an observational analysis y C Ward, J Aron, A Gibbon, J Ball C Ward, J Aron, A Gibbon, J Ball Table 1 (abstract P341) Control Sepsis r 8 ± 2 6 ± 3 k 4 ± 2 1.7 ± 0.5* Angle 47 ± 15 67 ± 7* MA 55 ± 8 72 ± 5* LYS 30 1.8 ± 1 0.95 ± 0.9 P <0.01. St George’s Hospital, London, UK g p Critical Care 2015, 19(Suppl 1):P343 (doi: 10.1186/cc14423) Introduction The aim of this analysis is to explore and evaluate the role of thromboelastography (TEG) in aiding the management of patients admitted with haemorrhage to the ICU. TEG has been shown to rationalise and reduce transfusion requirements [1] but the precise role of TEG in the assessment and management of haemostasis in the bleeding patient is uncertain and has not been previously demonstrated. Methods A prospective audit of TEG analyses performed on patients in the general medical and surgical ICU was recorded over a 2-month period. Operators documented the reason for admission, demographic data, indication for TEG, laboratory results, blood gas analysis, TEG results, diagnosis and subsequent action from the TEG result. Only patients who had been admitted with haemorrhage were included in this analysis. Conclusion In early sepsis, TEG monitoring may detect hyper coagu la- bility. CPFA with heparin, but not CPFA with citrate and oXiris, is able to reverse hypercoagulability. OXiris may induce fi brinolysis. TEG detects alterations of coagulation during early sepsis and extracorporeal treatments. S121 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 TEG analysis Both TEG normal/ Standard normal/ abnormal standard abnormal TEG abnormal Clot factor defi cit 9 (11.5) 20 (25.6) 3 (3.8) Platelet defi cit 11 (14.1) 13 (16.6) 2 (2.6) Fibrinogen defi cit 5 (6.4) 4 (5.1) 5 (6.4) Data presented as n (%). Results Seventy-eight audit sheets were completed, of which 31 identifi ed haemorrhage as the reason for admission. The mean age was 59.3 (range 21 to 90) and the mean APACHE II score was 18.23 (range 11 to 37). The main indications for TEG analysis included coagulopathy (64%) and ongoing haemorrhage (45%). As a result of performing TEG analysis, 23 (74%) patients had a documented change in their management. Utilisation review of thromboelastography in intensive care J Aron, A Gibbon, C Ward, J Ball St George’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P344 (doi: 10.1186/cc14424) Utilisation review of thromboelastography in intensive care J Aron, A Gibbon, C Ward, J Ball St George’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P344 (doi: 10.1186/cc14424) M Popescu, D Tomescu M Popescu, D Tomescu Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Critical Care 2015, 19(Suppl 1):P345 (doi: 10.1186/cc14425) Introduction Our aim was to assess hemostasis, using ROTEM, in patients with end-stage liver disease (ESLD) undergoing liver transplantation (LT) and to develop a predictive model for patients prone to high intraoperative blood loss. Introduction This review aims to assess the value of thrombo- elastography (TEG) on the general ICU, which has not been previously demonstrated. TEG is a near-patient assessment of whole blood coagulation and fi brinolysis, which reduces transfusion requirements during cardiothoracic surgery and liver transplantation. Methods We retrospectively analyzed 122 patients who underwent LT between January and December 2013 in a single national center. Patients with acute liver failure or incomplete data were excluded. Demographic data, severity of liver disease assessed by MELD score (model for ESLD), presence of portal vein thrombosis, and laboratory data were recorded preoperatively. We performed concomitant ROTEM assay and standard coagulation tests (prothrombin time (PT), International Normalized Ratio (INR), fi brinogen) 1 hour before surgery and 15 minutes after the neohepatic phase. Intraoperative blood loss was recorded. High blood loss was defi ned as loss of one blood volume during surgery. Correlation between recorded data standard ROTEM parameters and derived thrombodynamic ROTEM parameters (potential index (TPI), maximum velocity of clot formation (MaxV), time to MaxV (MaxVt), AUC) were analyzed using SPSS 19.0. Methods A prospective audit of TEG tests performed on patients being treated on a general ICU was conducted over 2 months. Results A total of 332 TEG tests were performed with a failure rate of 29.8%. Seventy-eight audit sheets were collected. Mean patient age was 68.9 years and mean APACHE II score was 18.1. Admissions included trauma (33.0%), perioperative (43.6%), haemorrhage (42.3%) and sepsis (21%). Standard tests of coagulation demonstrated 22 defi cits in coagulation which were not identifi ed as functionally signifi cant with TEG. Of these, 20 had abnormal clotting factor activity as measured by the INR/APTTr and 13 patients were thrombocytopenic. In total, 52.6% documented that the TEG result changed the management of the patient. In 46.8% of these cases no further blood products were required. In 41% there was no documentation. Role of thromboelastography in the management of haemorrhage: an observational analysis Ten patients did not require any further administration of blood products, which they would have received based on conventional laboratory results. The information gained from TEG also resulted in the omission of anticoagulation in three patients, and with a further two patients anticoagulation increased. Conclusion TEG analysis suggested that 22 patients who were identifi ed as coagulopathic with traditional measures of coagulation did not have a functional defi ciency. Over one-half of TEG studies resulted in a change in management and in 46.8% no further transfusions were required. There was a high technical failure rate and a low audit return rate, which may indicate the need for further training. Reference p g Conclusion TEG aids prompt rationalisation of blood products and titration of anticoagulation in the bleeding patient. TEG identifi es a number of patients who required administration of platelets and other procoagulants which would not have been identifi ed by conventional methods. Several patients would have also received inappropriate transfusions which has both cost and resource implications, alongside the potential adverse eff ects on patients. We recognise that further research is needed to clarify the overall effi cacy of TEG in the bleeding patient. f 1. Da Luz et al. Eff ect of TEG and ROTEM on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care. 2014;18:518. 1. Da Luz et al. Eff ect of TEG and ROTEM on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care. 2014;18:518. Decreased coagulation kinetics is associated with high blood loss in patients with end-stage liver disease undergoing liver transplantation Decreased coagulation kinetics is associated with high blood loss in patients with end-stage liver disease undergoing liver transplantation M Popescu, D Tomescu Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Critical Care 2015, 19(Suppl 1):P345 (doi: 10.1186/cc14425) Reference 1. Bollinger D, et al. Principles and practice of thromboelastography in clinical coagulation management and transfusion practice. Transfusion Med Rev. 2012;26:1-13. Utilisation review of thromboelastography in intensive care J Aron, A Gibbon, C Ward, J Ball St George’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P344 (doi: 10.1186/cc14424) See Table 1 and Figure 1. Table 1 (abstract P344). Summary of concordance with standard tests versus y g Results After applying exclusion criteria, 72 patients were analyzed with mean age of 54.5 years (SD 11.6) and a median MELD score of 17.4 (7 to 34). Preoperative MCE correlated with age (P = 0.044, 95% CI (–7.50, –0.12)) and MELD score (P = 0.009, 95% CI (–37.21, –6.69)), but not with PT (P = 0.557) or INR (P = 0.623). MaxV correlated with fi brinogen level (P = 0.005, 95% CI (0.01, 0.05)) and AUC correlated with age (P = 0.034, 95% CI (–257.74, –11.91)) and MELD score (P = 0.01, 95% CI (–1,233.14, –215.33)). Patients with portal vein thrombosis had an increase in InTEM CFT (P = 0.002, 95% CI (77.98, 317.97)) and MaxVt (P = 0.03, 95% CI (5.53, 105.63)). No correlation was found between preoperative ROTEM parameters and intraoperative blood loss. We calculated ΔMaxV, ΔMaxVt and ΔAUC as the mathematical diff erence between preoperative and intraoperative MaxV, MaxVt and AUC. High blood loss correlated with ΔAUC (P = 0.005, 95% CI (15.69, 61.03)), ΔMaxV (P = 9=0.002, 95% CI (–20,413, 6,392)) and ΔMaxVt (P = 0.008, 95% CI (15.69, 61.07)). Figure 1 (abstract P344). Change in management due to TEG results. Conclusion MELD score correlated with a decrease in MaxV and AUC on preoperative ROTEM but not with INR. Patients with portal vein thrombosis have increased InTEM CFT and MaxVt. High blood loss was associated with a decrease in thrombodynamic parameters, but no correlations were found between blood loss and standard ROTEM parameters. Figure 1 (abstract P344). Change in management due to TEG results. S122 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P346 time (aPTT), and prothrombin time (PT). In addition, the plasma levels of vitamin K-dependent coagulation factors were determined. P346 Evaluation of fi xed dose four-factor prothrombin complex concentrate for warfarin reversal at a level 1 trauma center H Drone, J Jancik, J Gorlin, M McCarthy Hennepin County Medical Center, Minneapolis, MN, USA Critical Care 2015, 19(Suppl 1):P346 (doi: 10.1186/cc14426) p g Results Acute coumarin anticoagulation of rats induced a rise in median bleeding time by ≥2-fold from an average of 823 to 1,800 seconds (maximum observation period) compared with untreated animals. Four-factor prothrombin complex concentrate (Beriplex® P/N) is superior to three-factor prothrombin complex concentrate for reversal of coumarin anticoagulation Four-factor prothrombin complex concentrate (Beriplex® P/N) is superior to three-factor prothrombin complex concentrate for reversal of coumarin anticoagulation E Herzog, F Kaspereit, W Krege, P Niebl, G Dickneite g p g CSL Behring GmbH, Marburg, Germany g g y Critical Care 2015, 19(Suppl 1):P347 (doi: 10.1186/cc14427) Introduction The study was conducted as a head-to-head comparison of a four-factor prothrombin complex concentrate (4F-PCC) and two diff erent three-factor PCCs (3F-PCC) for eff ective reversal of vitamin K antagonist (VKA)-induced anticoagulation using an established rat model of acute bleeding [1]. The 4F-PCC (containing the human coagulation factors II, VII, IX and X) is indicated for the urgent reversal of acquired coagulation factor defi ciency induced by VKA therapy in adult patients with acute major bleeding. In contrast, the 3F-PCCs (containing factors II, IX, X and only minimal VII) are indicated for the prevention and control of hemorrhagic episodes in hemophilia B patients. Nevertheless, the use of 3F-PCC for correcting hemostasis following warfarin overdose has been discussed but the lack of factor VII in these 3F-PCC products has raised questions about effi cacy. Conclusion In conclusion, 4F-PCC treatment eff ectively decreased apixaban-induced hemorrhage at a clinically relevant dose range. References . Herzog et al. Anesthesiology. Forthcoming 2014. 1. Herzog et al. Anesthesiology. Forthcoming 2014. 1. Herzog et al. Anesthesiology. Forthcoming 2014. 2. Pragst et al. J Thromb Haemost. 2012;10:1841-8. 2. Pragst et al. J Thromb Haemost. 2012;10:1841-8. 2. Pragst et al. J Thromb Haemost. 2012;10:1841-8. References 1. Varga C, et al. Transfusion. 2013;53:1451-8. 2. Junagade P, et al. Hematology. 2007;12:439-40. g g p Results Dose-dependent increases in time to hemostasis and total blood loss were observed post apixaban administration with maximum bleeding signals seen at 1,200 μg/kg. Treatment with 4F-PCC resulted in a statistically signifi cant reversal in apixaban-induced bleeding time (all doses) and volume (doses ≥12.5 IU/kg). Of the coagulation parameters measured, thrombin generation initiated using phospholipids only was the in vitro coagulation parameter most sensitive to 4F-PCC-mediated bleeding reversal, although statistically signifi cant 4F-PCC-mediated reductions in the prothrombin time and whole blood clotting time were also observed.f P347 Four-factor prothrombin complex concentrate (Beriplex® P/N) is superior to three-factor prothrombin complex concentrate for reversal of coumarin anticoagulation E Herzog, F Kaspereit, W Krege, P Niebl, G Dickneite CSL Behring GmbH, Marburg, Germany Critical Care 2015, 19(Suppl 1):P347 (doi: 10.1186/cc14427) p Reference 1. Dickneite. Thromb Res. 2007;119:643-51. f Results The INR was reduced to <2 in 100% of patients in the 4F-PCC group versus 84.6% of patients in the factor IX group (P <0.05). The INR was reduced to <1.6 in 90.8% of patients in the 4F-PCC group versus 50% in the factor IX group (P <0.05). Mean pre-reversal INRs were 3.5 and 4 and ranged from 1.1 to 10 and from 1.3 to 10 in the 4F-PCC and factor IX group respectively (P = 0.29). On average, a medication cost savings of US$802.63 dollars per patient was calculated from using a fi xed 1,500 unit dose over traditional dosing of 4F-PCC. There was a trend toward a shorter mean ICU LOS in the PCC group when compared with the factor IX group (5.8 vs. 2.8 days) and shorter mean hospital LOS (10.7 vs. 5.7 days), although neither outcome was statistically signifi cant. No diff erence in adverse event rates was observed.ii P348 Four-factor prothrombin complex concentrate (Beriplex® P/N) mediated reversal of apixaban-induced bleeding in a rabbit model E Herzog, F Kaspereit, W Krege, J Mueller-Cohrs, B Doerr, P Niebl, G Dickneite CSL Behring GmbH, Marburg, Germany Critical Care 2015, 19(Suppl 1):P348 (doi: 10.1186/cc14428) Introduction This study assessed whether a four-factor prothrombin complex concentrate (4F-PCC; Beriplex®/Kcentra®; CSL Behring) can eff ectively reverse bleeding associated with the direct oral factor Xa inhibitor apixaban in an established in vivo rabbit model [1,2].i Introduction This study assessed whether a four-factor prothrombin complex concentrate (4F-PCC; Beriplex®/Kcentra®; CSL Behring) can eff ectively reverse bleeding associated with the direct oral factor Xa inhibitor apixaban in an established in vivo rabbit model [1,2].i gif Conclusion A fi xed dose of 1,500 units of 4F-PCC was signifi cantly more eff ective at lowering the INR to a threshold of less than either 2 or 1.6 when compared with a combination of factor IX complex and vitamin K with or without FFP. Further research is needed to investigate clinical outcomes and a possible reduction in ICU and hospital LOS. References Methods For dose-fi nding purposes, anesthetized rabbits were treated with a single intravenous dose of apixaban (800 to 1,600 μg/kg). In a subsequent study phase, anesthetized rabbits were treated with apixaban (1,200 μg/kg) followed by 4F-PCC (6.25 to 100 IU/kg). Bleeding signals were quantifi ed following a standardized kidney incision by measurement of the volume of blood loss and time to hemostasis over an observation period of 30 minutes. Blood samples were collected for monitoring of coagulation parameters. Utilisation review of thromboelastography in intensive care J Aron, A Gibbon, C Ward, J Ball St George’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P344 (doi: 10.1186/cc14424) In parallel, PT and aPTT were prolonged from 8.9 to 29.9 seconds and from 14.5 to 25.5 seconds, respectively. Treatment with 4F-PCC was able to fully and statistically signifi cantly reverse bleeding, achieving average bleeding times of 676 seconds. In parallel, the elevation in PT was reduced to 15.1 seconds. In contrast, the two 3F-PCC products were not or only partially able to reduce coumarin-induced bleeding with average bleeding times of 1,398 and 1,708 seconds post treatment, respectively. This also correlated with inferior reductions in PT which achieved minimum levels of 23.8 and 29.5 seconds, respectively. There was no reduction in aPTT seen for any treatment option.i Introduction FDA-approved dosing of four-factor prothrombin complex concentrate (4F-PCC) in the USA is based on an INR and weight; however, there are data suggesting that a fi xed dose of 4F-PCC may be suffi cient for INR reversal and hemostasis [1,2]. The objective of this study was to assess the effi cacy and safety of a fi xed dose of 1,500 units of 4F-PCC. Historically, warfarin reversal included a combination of factor IX complex, vitamin K, and fresh frozen plasma (FFP). Using a fi xed dose of 4F-PCC may also provide signifi cant cost savings when compared with traditional dosing. y p Conclusion In conclusion, this fi rst direct comparison of 4F-PCC and 3F-PCCs for the reversal of VKA anticoagulation in a rat model of acute bleeding suggests that replenishment of all four vitamin K-dependent coagulation factors including factor VII as achieved using a 4F-PCC may result in superior effi cacy compared with the use of 3F-PCCs. R f Methods This retrospective chart review compared 26 admitted adults who received a fi xed dose of 1,500 units 4F-PCC with 26 patients who received a combination of factor IX complex and vitamin K, with or without FFP, for warfarin reversal from 1 January 2012 to 1 November 2014. Primary outcomes included reversal to an INR of <2 and reversal to an INR of <1.6. Secondary outcomes included ICU and hospital length of stay (LOS), change in INR, INR nadir, potential cost savings from 4F-PCC versus traditional dosing, and major adverse eff ects. Effi cacy of idarucizumab, prothrombin complex concentrate (PCC) and activated PCC to reverse the anticoagulatory potential of dabigatran in a porcine polytrauma model Effi cacy of idarucizumab, prothrombin complex concentrate (PCC) and activated PCC to reverse the anticoagulatory potential of dabigatran in a porcine polytrauma model M Honickel1, T Braunschweig1, J Van Ryn2, R Rossaint1, O Grottke1 1RWTH Aachen University Hospital, Aachen, Germany; 2CardioMetabolic Diseases Research, Boehringer Ingelheim GmbH & Co KG, Biberach, Germany Critical Care 2015, 19(Suppl 1):P351 (doi: 10.1186/cc14431) Results In the ShBl injury strand there was a signifi cant reduction in ATC in Early compared with Late PRBC:FFP treatment (TEG R and K times) in both the prehospital (P = 0.004 and P = 0.003 respectively, ANOVA) and early in-hospital (P = 0.002 and P = 0.005) phases, although clotting was normalised in the Late group within 60 minutes of initiating PRBC:FFP. Prehospital base defi cit (BD) was signifi cantly attenuated in ShBl Early versus Late (9.0 ± 2.1 vs. 14.4 ± 2.2 mM). BD improved in both Early and Late treatment groups during the in-hospital phase but remained greater in the Late group throughout (P <0.001). In the Bl injury strand the trend in coagulation was similar to that seen in the ShBl injury strand (but the diff erences between Early and Late did not attain statistical signifi cance). By contrast, Early versus Late PRBC:FFP treatment did not result in a diff erence in BD in the Bl strand. Finally, there was no diff erence in the total amount of PRBC:FFP used between the two treatments in either injury strand, but in both injury strands the Early treatment groups required signifi cantly less saline (P <0.001). Conclusion Prehospital use of PRBC:FFP may attenuate ATC and improve physiological status. Furthermore the amount of crystalloid may be reduced with potential benefi t of reducing the third-space eff ect and later tissue oedema. M Honickel1, T Braunschweig1, J Van Ryn2, R Rossaint1, O Grottke1 1RWTH Aachen University Hospital, Aachen, Germany; 2CardioMetabolic Diseases Research, Boehringer Ingelheim GmbH & Co KG, Biberach, Germany Critical Care 2015, 19(Suppl 1):P351 (doi: 10.1186/cc14431) Introduction The anticoagulant eff ect of dabigatran can be reversed with idarucizumab or PCCs in porcine blood in vitro [1]. However, the impact on clinical parameters such as blood loss is not known. Thus, this study assessed the effi cacy of idarucizumab in comparison with PCC and aPCC in dabigatran-anticoagulated swine following polytrauma on clinically relevant endpoints. Reference 1. Grottke O, et al. Crit Care. 2014;18:R27. p p Results According to LFTEG, polytrauma patients had statistically signifi cant abnormalities in platelet aggregation (intensity of contact coagulation (ICC)), in coagulation (intensity of coagulation drive (ICD), clot maximum density (MA)) and in fi brinolytic activity (index of retraction and clot lysis (IRCL)). ICC in patients with multiple injuries was decreased by 27.51%, ICD was decreased by 34.68%, MA was decreased by 75.16%, IRCL was 91.06% above the norm. Patients of group 1 according to LFTEG had signifi cant changes in all parts of coagulation 24 hours after intensive care. Indicators of platelet hemostasis characterized by persistence of hypoaggregation: ICC was decreased by 24.51%, compared with the norm; parameters of coagulation and fi brinolysis had a reliable trend toward normal and decreasing the activity, the fi brinolysis index reached normal reference values. P350 Results Dabigatran levels were comparable between groups (571 ± 174 ng/ml) and resulted in altered coagulation variables. Blood loss was comparable 12 minutes post trauma between groups (801 ± 49 ml) and increased to 3,816 ± 236 ml in anticoagulated control animals post injury. Idarucizumab treatment reduced total blood loss to 1,086 ± 55 ml (P <0.005 vs. all), aPCC to 1,639 ± 104 ml (P <0.05 vs. control) and PCC to 1,797 ± 80 ml (P <0.05 vs. control) after 5 hours. All animals in the intervention groups survived, whereas control animals died within the observation period (mean survival: 89 minutes, range: 62 to 145 minutes). In histopathology no signs of thromboembolic events were present. Altered coagulation variables returned to baseline levels after idarucizumab application and were also signifi cantly, although inconsistently and to a lesser extent, ameliorated following PCCs. Effi cacy of idarucizumab, prothrombin complex concentrate (PCC) and activated PCC to reverse the anticoagulatory potential of dabigatran in a porcine polytrauma model y p Methods After ethical approval, 28 male pigs were administered dabigatran etexilate (30 mg/kg twice daily p.o.) for 3 days. Dabigatran was administered intravenously in anaesthetised animals on day 4 to achieve consistent high concentrations. Animals were randomised to receive idarucizumab (60 mg/kg, n = 7), PCC (50 U/kg; n = 7), aPCC (50 U/kg; n = 7) or placebo (n = 7). Intervention started 12 minutes after bilateral femur fractures and a standardised blunt liver injury. The primary endpoint was blood loss (observation period 300 minutes). Further, histopathology, haemodynamics and several coagulation variables were also assessed. Data were analysed by repeated-measures ANOVA (mean ± SD). Acknowledgements © Crown copyright 2014. Published with the permission of the Dstl on behalf of the Controller of HMSO. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 of prehospital versus immediate in-hospital packed red blood cells and fresh frozen plasma (PRBC:FFP) in two models of severe battlefi eld injury. of prehospital versus immediate in-hospital packed red blood cells and fresh frozen plasma (PRBC:FFP) in two models of severe battlefi eld injury. Patients in group 2 had hypoaggregation and hypocoagulation state with increased activity of fi brinolysis: ICC was reduced by 25.62%, ICD decreased by 19.76%, MA was decreased by 22.34%, IRCL was increased by 24.52%. Clinically, patients of group 1 had reduced indicators for infectious complications, reducing the term of mechanical ventilation and reducing the volume of blood transfusions. j y Methods This is a prospective randomised controlled trial using in vivo models of injury conducted in accordance with the Animals (Scientifi c Procedures) Act, 1986. Two injury strands were investigated in 43 terminally anaesthetised Large White pigs: whole body blast exposure (Bl) or no blast (ShBl) plus soft tissue injury and haemorrhage. Thirty minutes later animals were randomly allocated to a 60-minute simulated prehospital hypotensive resuscitation with either PRBC:FFP (1:1 ratio) or 0.9% saline (Early and Late groups respectively). This was followed by 150 minutes of simulated in-hospital resuscitation with a revised normotensive target whereby PRBC:FFP was initiated in the Late group and continued in the Early group.i g Conclusion Patients with multiple injuries have violation in all parts of blood coagulation. The use of prothrombin complex concentrate can reduce the severity of pathological changes in the hemostatic system in patients with polytrauma. Comparing prothrombin complex concentrate and fresh frozen plasma with blood viscosity characteristics in patients with trauma-induced coagulopathy Comparing prothrombin complex concentrate and fresh frozen plasma with blood viscosity characteristics in patients with trauma-induced coagulopathy O Tarabrin, I Tyutrin, S Shcherbakov, D Gavrychenko, G Mazurenko, V Ivanova, P Tarabrin Odessa National Medical University, Odessa, Ukraine Critical Care 2015, 19(Suppl 1):P350 (doi: 10.1186/cc14430) Comparing prothrombin complex concentrate and fresh frozen plasma with blood viscosity characteristics in patients with trauma-induced coagulopathy O Tarabrin, I Tyutrin, S Shcherbakov, D Gavrychenko, G Mazurenko, V Ivanova, P Tarabrin Odessa National Medical University, Odessa, Ukraine Critical Care 2015, 19(Suppl 1):P350 (doi: 10.1186/cc14430) g p y O Tarabrin, I Tyutrin, S Shcherbakov, D Gavrychenko, G Mazurenko, V Ivanova, P Tarabrin Odessa National Medical University, Odessa, Ukraine Critical Care 2015, 19(Suppl 1):P350 (doi: 10.1186/cc14430) Introduction To compare the eff ectiveness of prothrombin complex concentrate and fresh frozen plasma (FFP) in patients with multiple injuries, complicated with coagulopathy bleeding. Introduction To compare the eff ectiveness of prothrombin complex concentrate and fresh frozen plasma (FFP) in patients with multiple injuries, complicated with coagulopathy bleeding. Methods The study involved 51 patients who entered Odessa Regional Hospital with traumatic injuries (concomitant skeletal trauma) complicated with hypocoagulation. Patients were divided into two groups: in the fi rst group (26 patients), as a treatment for coagulopathy, was administered PCC in a dose of 1 ml/kg (25 IU/kg); in the second group (25 patients) was administered FFP in a dose of 15 ml/kg. Evaluation of the functional state of the hemostasis system was carried out using low-frequency thromboelastography (LFTEG) on admission to hospital and 24 hours after the patient’s admission to the ICU. y g Conclusion All medical interventions were associated with reduced blood loss and increased survival. However, idarucizumab, a specifi c antidote to dabigatran, reduced total blood loss more prominently and normalised coagulation parameters to a greater degree as compared with either PCC or aPCC. Reference 1. Grottke O, et al. Crit Care. 2014;18:R27. Reference Benefi cial eff ects of prehospital versus immediate in-hospital blood products during resuscitation in two models of severe military injury S Watts, G Nordmann, C Wilson, A Carter, H Poon, E Kirkman Dstl, Salisbury, UK Critical Care 2015, 19(Suppl 1):P349 (doi: 10.1186/cc14429) Methods Rats received an oral dose of 2.5 mg/kg phenprocoumon. At 15.75 hours post dosing, animals were treated with a single intravenous dose of saline, 4F-PCC (Beriplex® P/N, Kcentra®; CSL Behring) or 3F-PCC (Bebulin® VH; Baxter and Profi lnine® SD; Grifols). Study endpoints included bleeding following tail clip, activated partial thromboplastin Introduction Acute trauma coagulopathy (ATC) is seen in 30 to 40% of severely injured trauma casualties. Early use of blood products is thought to attenuate ATC. This study determined the potential impact S123 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P352 Coagulation support algorithm with rapid TEG and functional fi brinogen TEG in critical bleeding: more results and less time E De Blasio, C Pellegrini, A Federico, V Rocco, M Fumi, Y Pancione, S Sale, D Liberti Hospital G. Rummo, Benevento, Italy Critical Care 2015, 19(Suppl 1):P352 (doi: 10.1186/cc14432) Hospital G. Rummo, Benevento, Italy Critical Care 2015, 19(Suppl 1):P352 (doi: 10.1186/cc14432) Introduction Early coagulation support is essential in massively bleeding patients. A Coagulation Support Algorithm (CSA), integrating rapid TEG (r-TEG) and functional fi brinogen TEG (ff -TEG) could shorten the time to a tailored treatment (Figure 1). Introduction Early coagulation support is essential in massively bleeding patients. A Coagulation Support Algorithm (CSA), integrating rapid TEG (r-TEG) and functional fi brinogen TEG (ff -TEG) could shorten the time to a tailored treatment (Figure 1). Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 S124 , pp http://ccforum.com/supplements/19/S1 T d s e s e A e e l , g Table 1 (abstract P353). Results of the cost-eff ectiveness model Total medical Total costs/ Treatment QALYs costs ($) QALY ($) Antibiotics + albumin 2.45 7,628 3,111 Antibiotics 1.48 7,682 5,182 Results Total costs were decreased when using albumin, and the improved survival resulted in an additional QALY for patients on albumin, decreasing the cost per QALY. See Table 1 and Figure 2. Conclusion The use of albumin in the treatment of SPB is cost-eff ective. References 1. Poca M, et al. Clin Gastroenterol Hepatol. 2012;10:309-15. 2. Wells CD, et al. Dig Dis Sci. 2004;49:453-8. P354 Estimation of the latent therapeutic demand for albumin in the USA: a focus on three indications 1 l2 Figure 1 (abstract P353). Structure of decision tree for patients with SBP. Figure 2 (abstract P353). Cost-eff ectiveness acceptability across range of WTP. Figure 1 (abstract P353). Structure of decision tree for patients with SBP. Figure 1 (abstract P352). Coagulation Support Algorithm. Figure 1 (abstract P352). Coagulation Support Algorithm. Table 1 (abstract P352). Comparison of time to results Test k-TEG r-TEG r-TEG + ff -TEF SCT r (minutes) 13.8 ± 7.1 2.6 ± 2 – ACT (seconds) 265.7 ± 171.9 – 105.2 ± 46.3 TMA (minutes) 42.6 ± 12.4 25.4 ± 14.1 – CSAT (minutes) 21 ± 7.4 Data presented as mean ± SD. ACT, activated clotting time; CSAT, Coagulation Support Algorithm total time; SCT, standard coagulation tests; TMA, time to maximum amplitude. P352 r: r-TEG versus k-TEG, P = 0.0000003; r-TEG versus SCT, P = 0.000000001; k-TEG versus SCT, P = 0.000000009; TMA: r-TEG versus k-TEG, P = 0.0001; r-TEG versus SCT, P = 0.00000004; k-TEG versus SCT, P = 0.000002; ACT versus r of k-TEG (seconds), P = 0.000004; CSAT versus k-TMA, P = 0.00000005. Table 1 (abstract P352). Comparison of time to results Figure 1 (abstract P353). Structure of decision tree for patients with SBP. Figure 2 (abstract P353). Cost-eff ectiveness acceptability across range of WTP. Figure 2 (abstract P353). Cost-eff ectiveness acceptability across range of WTP. Methods A retrospective comparison of the time to available TEG and Standard Coagulation Tests (SCT: INR, aPTTr, fi brinogen level) results in two groups of bleeding and coagulopathic patients using citrate kaolin-TEG (k-TEG) or the CSA protocol (r-TEG/ff -TEG). Statistical analysis was performed with Student’s t test for unpaired samples. Figure 2 (abstract P353). Cost-eff ectiveness acceptability across range of WTP. Results Twenty-three patients for each k-TEG and CSA group were compared. The time to available results was shorter using the CSA protocol in comparison with k-TEG (Table 1). The diff erences were both statistically (P <0.00001) and clinically (mean reduction time 21 minutes) signifi cant. SCT needed the longest time to obtain the fi nal results. Table 1 (abstract P353). Results of the cost-eff ectiveness model Total medical Total costs/ Treatment QALYs costs ($) QALY ($) Antibiotics + albumin 2.45 7,628 3,111 Antibiotics 1.48 7,682 5,182 Conclusion The implementation of a CSA, including r-TEG and ff -TEG, could shorten the time to a targeted treatment in critically bleeding patients. References Results Total costs were decreased when using albumin, and the improved survival resulted in an additional QALY for patients on albumin, decreasing the cost per QALY. See Table 1 and Figure 2. C l i Th f lb i i th t t t f SPB i t ff ti 1. Stensballe J, et al. Curr Opin Anesthesiol. 2014;27:212-18. 3. Kashuk JL, et al. Ann Surg. 2010;251:604-14. g g Conclusion The use of albumin in the treatment of SPB is cost-eff ective. f P353 Use of albumin in spontaneous bacterial peritonitis is cost-eff ective A Farrugia1, M Bansal2, P Caraceni3 P353 Use of albumin in spontaneous bacterial peritonitis is cost-eff ective A Farrugia1, M Bansal2, P Caraceni3 1University of Western Australia, Perth, Australia; 2Thought Semantics LLC, Sterling, VA, USA; 3University of Bologna, Italy Critical Care 2015, 19(Suppl 1):P353 (doi: 10.1186/cc14433) g 1University of Western Australia, Perth, Australia; 2Thought Semantics LLC, Sterling, VA, USA; 3University of Bologna, Italy Critical Care 2015, 19(Suppl 1):P353 (doi: 10.1186/cc14433) P353 1. Poca M, et al. Clin Gastroenterol Hepatol. 2012;10:309-15. 2. Wells CD, et al. Dig Dis Sci. 2004;49:453-8. Lactated Ringer Versus Albumin in Early Sepsis Therapy (RASP) study: preliminary data of a randomized controlled trial C Park, E Osawa, J Almeida, R Nakamura, I Duayer, J Fukushima, G Queiroz, F Galas, L Hajjar ICESP, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P355 (doi: 10.1186/cc14435) Introduction Adequate fl uid therapy is essential to the care of septic patients, aiming to optimize oxygen delivery without compromising microcirculation. In recent years, a few studies have suggested that albumin may be superior when compared with crystalloids in severe cases of septic shock. However, there are no data in the fi rst hours of resuscitation. The aim of this study is to evaluate whether albumin 4% solution compared with lactated Ringer decreases 30-day mortality in cancer patients with septic shock. p p Methods The Lactated Ringer Versus Albumin in Early Sepsis Therapy (RASP) study is a prospective, randomized, double-blind and controlled trial, with 360 patients. Until November 2014, at the Cancer Institute of University of São Paulo, we enrolled 110 patients with cancer and septic shock to receive as resuscitation fl uid in the fi rst 12 hours of ICU an admission bolus of albumin 4% solution or lactated Ringer. The primary outcome was 30-day mortality. Secondary outcomes include ICU mortality, ICU and hospital length of stay, 90-day mortality, daily SOFA score, rates and length of mechanical ventilation, renal replacement, needing of vasopressor drugs, status performance and fl uid balance. Results From 650 eligible patients, 110 patients were included in the study – 50 patients in the albumin group and 60 in the Ringer group. The mean age was 63 (57 to 70) years in the albumin group and 61 (51 to 71) in the Ringer group, P = 0.508. Most patients were male (58% in the albumin group vs. 56.1% in the Ringer group, P = 0.846). The ECOG was similar between the albumin and Ringer groups ((0) 26% vs. 8%, (1) 38% vs. 36.8%, (2) 20% vs. 38.6%, (3) 16% vs. 15.8%, P = 0.05). The SAPS 3 admission score was 51 ± 13 in the albumin group and 49 ± 10 in the Ringer group, P = 0.492. The total amount of administered fl uid in the fi rst 12 hours of resuscitation was 1,000 ml (1,000 to 1,500) in the albumin group and 1,000 ml (1,000 to 1,000) in the Ringer group, P = 0.59. The 12-hour fl uid balance was 1,053 ml (385 to 1,700) in the albumin group and 990 ml (200 to 1,525) in the Ringer group. The 30- day mortality was similar in both groups (60% in the albumin group and 50.9% in the Ringer group, P = 0.34). Reference Reference 1. Caironi P, et al. N Engl J Med. 2014;370:1412-21. Methods A decision analysis model was constructed using Excel. The model is based on the relationships of the epidemiological and clinical factors shown in the infl uence diagram (exemplifi ed in Figure 1 for sepsis). Data for the individual factors were obtained from the literature. One-way sensitivity analysis was used to generate Tornado diagrams (exemplifi ed in Figure 2 for albumin use in sepsis) to determine the relative contribution of diff erent factors to the LTD. Probabilistic sensitivity analysis was used to generate a probability distribution and calculate a mean level for the LTD of each indication. p g p y p E Scotti, M Ferrari, M Chiodi, F Zadek, I Belloni, L Zazzeron, T Langer, L Gattinoni, P Caironi Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy Critical Care 2015, 19(Suppl 1):P356 (doi: 10.1186/cc14436) E Scotti, M Ferrari, M Chiodi, F Zadek, I Belloni, L Zazzeron, T Langer, L Gattinoni, P Caironi One-way sensitivity analysis was used to generate Tornado diagrams (exemplifi ed in Figure 2 for albumin use in sepsis) to determine the relative contribution of diff erent factors to the LTD. Probabilistic sensitivity analysis was used to generate a probability distribution and calculate a mean level for the LTD of each indication. Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy Critical Care 2015, 19(Suppl 1):P356 (doi: 10.1186/cc14436) g , , y Critical Care 2015, 19(Suppl 1):P356 (doi: 10.1186/cc14436 Results On average, albumin use was calculated as 104 g per 1,000 inhabitants in severe sepsis, 157 g per 1,000 inhabitants in liver diseases and 61 g per 1,000 inhabitants in CABG. This shows a total LTD of 322 g per 1,000 use of albumin in the US annually. Introduction The induction of ECMO may result in metabolic acidosis [1] due to circuit priming with chloride-rich fl uids, and the sudden decrease in plasma strong ion diff erence (SID). This eff ect can be attenuated using balanced solutions with a SID equal to the patient’s plasma bicarbonate concentration (HCO3 –) [2]. We aimed to compare the eff ects of a novel balanced solution (SID equal to patients’ HCO3 –) with those of commonly employed crystalloids for circuit priming in patients undergoing venovenous ECMO. y Conclusion Albumin consumption in the USA currently averages 479 g per 1,000 population [3]. Hence, the LTD of these three evidence-based indications represents 67% of current usage. Further work is needed to assess the LTD for albumin in other, less well-defi ned areas. R f Lactated Ringer Versus Albumin in Early Sepsis Therapy (RASP) study: preliminary data of a randomized controlled trial C Park, E Osawa, J Almeida, R Nakamura, I Duayer, J Fukushima, G Queiroz, F Galas, L Hajjar ICESP, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P355 (doi: 10.1186/cc14435) No signifi cant diff erences in the other secondary outcomes were observed between the two groups. Methods The Lactated Ringer Versus Albumin in Early Sepsis Therapy (RASP) study is a prospective, randomized, double-blind and controlled trial, with 360 patients. Until November 2014, at the Cancer Institute of University of São Paulo, we enrolled 110 patients with cancer and septic shock to receive as resuscitation fl uid in the fi rst 12 hours of ICU an admission bolus of albumin 4% solution or lactated Ringer. The primary outcome was 30-day mortality. Secondary outcomes include ICU mortality, ICU and hospital length of stay, 90-day mortality, daily SOFA score, rates and length of mechanical ventilation, renal replacement, needing of vasopressor drugs, status performance and fl uid balance. Figure 1 (abstract P354). Variables used to construct the LTD model in sepsis. Figure 1 (abstract P354). Variables used to construct the LTD model in sepsis. Figure 2 (abstract P354). Relative importance of inputs into the LTD model for sepsis. g Conclusion In cancer patients with septic shock, resuscitation with albumin 4% as compared with lactated Ringer did not improve the rate of survival at 30 days. allocation, but many of the clinical and epidemiologic variables are subject to uncertainty. Decision analysis [2] may assist in generating an assessment of the demand for albumin. 2. Goel V. CMAJ. 1992;147:413-7. Estimation of the latent therapeutic demand for albumin in the USA: a focus on three indications g y g y Critical Care 2015, 19(Suppl 1):P353 (doi: 10.1186/cc14433) Introduction Assessing the cost-eff ectiveness of therapeutic interven- tions is increasingly crucial for health decision-making. Spontaneous bacterial peritonitis (SBP) is one of the major complications of liver cirrhosis. The use of albumin in conjunction with antibiotics has been shown to be eff ective through clinical trials [1]. Introduction The use of albumin in therapeutics is controversial in several areas and requires assessment based on evidence for eff ective resource allocation. Supported indications include sepsis, areas of hepatic diseases and coronary artery bypass grafts (CABG). Latent therapeutic demand (LTD) [1] is the underlying evidence-based demand ensuring ample supplies of drugs are available and aff ordable. Estimating the LTD would assist decision-making and resource Methods A decision tree (TreeAge®) (Figure 1) was populated from published sources for clinical, cost and epidemiologic variables. The perspective taken was that of the US payer. The robustness of the model was checked using one-way and probabilistic sensitivity analyses. The clinical course was followed for 3 months or until death. Total medical costs and quality-adjusted life years (QALYs) [2] were calculated. S125 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P354). Variables used to construct the LTD model in sepsis. Lactated Ringer Versus Albumin in Early Sepsis Therapy (RASP) study: preliminary data of a randomized controlled trial C Park, E Osawa, J Almeida, R Nakamura, I Duayer, J Fukushima, G Queiroz, F Galas, L Hajjar ICESP, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P355 (doi: 10.1186/cc14435) Intraoperative use of gelatin in living donor liver transplantation and postoperative acute kidney injury Conclusion During the resuscitation phase of the burn patients, the use of HES (130/0.4/6%) at low doses does not seem to cause more risk or injury according to RIFLE or AKIN criteria than those reported by studies in burn patients resuscitated without HES. However, the need for RRT is associated with a high mortality, although in many cases the display is terminal. Introduction The aim of our study is to investigate the eff ect of intraoperative use of gelatin in living donor liver transplantation on postoperative acute kidney injury (AKI). It has been demonstrated that ischemia and chloride-liberal fl uid management cause AKI in liver transplantation [1]. Gelatin has minimal side eff ects on renal functions [2]; however, it might be a reason for postoperative AKI. g Methods A total of 154 liver transplantation patients were retrospectively evaluated between September 2011 and September 2013, and among these, 128 patients were included in the study. The patients who were under 18 years old, transplanted from cadaveric donors and needed preoperative renal replacement therapy were excluded. The patients were divided into two groups as GI (without gelatin administration) and GII (with gelatin administration). The patient’s age, gender, actual body weight, diagnoses, MELD score, APACHE II score, duration of operation, total clamping time, noradrenalin infusion rate, amount of erythrocyte suspension, fresh frozen plasma (FFP) and thrombocyte suspension used, intraoperative fl uid balance, intraoperative and total clamping diuresis, serum creatinine levels on the postoperative 1st, 2nd, 4th and 7th days, duration of mechanical ventilation, length of ICU and hospital stay, hospital and 1-year mortality rate were recorded. The changes in creatinine levels on the 1st, 2nd, 4th and 7th days were evaluated according to the KDIGO guideline for AKI [3]. Infl uence of anaesthetic factors on skin graft viability in a burns ICU C Isitt, KA McCloskey, A Cabello, P Sharma, MP Vizcaychipi Chelsea and Westminster Hospital, London, UK Critical Care 2015, 19(Suppl 1):P359 (doi: 10.1186/cc14439) Introduction Graft failure is a major cause of morbidity in patients with burns, resulting in increased length of hospital stay and increased number of operations. At our regional burns unit we collated the data from anaesthetic charts of patients admitted to our burns ICU who required skin grafting. The aim was to analyse whether any anaesthetic variables contribute to graft failure. g Methods Thirty-fi ve patients were included in the analysis with a total of 191 operations. References Methods We randomly assigned patients with acute respiratory failure in need of ECMO to receive either NaCl 0.9% (NS, SID = 0), Ringer lactate (RL, SID = 28), or a novel balanced solution (Solution X, SID equal to the patient’s HCO3 –) for circuit priming solution. Arterial blood gases and laboratory parameters were collected at 0, 5, 30, 60, 90, and 1. Stonebraker J, et al. J Clin Immunol. 2014;34:233-44. 2. Goel V. CMAJ. 1992;147:413-7. 3. Market Research Bureau. The plasma proteins market in the USA (2013). http://marketingresearchbureau.com/list-of-reports/ the-plasma-proteins-market-in-the-united-states/. S126 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 120 minutes after pump start. SID, base excess (BE) and total weak acids (Atot) were calculated. total clamping time was longer and amount of blood products used during surgery was more than the other group. Which of these factors is associated with AKI has to be revealed with further studies. 120 minutes after pump start. SID, base excess (BE) and total weak acids (Atot) were calculated. total clamping time was longer and amount of blood products used during surgery was more than the other group. Which of these factors is associated with AKI has to be revealed with further studies. Results We enrolled 20 patients (23 priming procedures – RL, n = 8; NS, n = 8; Solution X, n = 7). ECMO was initiated for ARDS (45%), bridge to lung transplant (25%), acute graft failure after transplant (15%), and acute on chronic respiratory failure (15%). Average priming volume was 10 ± 5 ml/kg; patients’ baseline HCO3 – was 28 ± 6 mEq/l. During the fi rst 2 hours after ECMO initiation, arterial pH raised similarly in all groups (P = 0.39) due to CO2 removal. In contrast, BE decreased starting after 5 minutes in both the NS and RL groups (BE variation, –2.2 ± 1.7 and –1.9 ± 1.3 mEq/l, P <0.001 vs. baseline; P = 0.04 for interaction, two-way ANOVA, 2-hour period). No BE changes were observed in the Solution X group (0.3 ± 0.8 mEq/l). In the NS group, BE reduction was associated with a reduction in SID (from 39 ± 8 to 34 ± 6 mEq/l at 5 minutes, P = 0.008), entirely due to an increase in Cl (103 ± 7 vs. 108 ± 6 mEq/l, P = 0.001). References In the RL group, BE and SID reductions (40 ± 8 vs. 36 ± 8 mEq/l, P = 0.008) were associated with an increase in both Cl (105 ± 7 vs. 107 ± 7 mEq/l, P = 0.01) and lactate (1.4 ± 0.6 vs. 2.2 ± 1.0 mEq/l, P = 0.008). No changes were observed in other electrolyte concentrations. Dilution did not diff er between groups (P = 0.25 for Atot variation). The acidifying eff ect of NS and RL was amplifi ed in patients with higher baseline HCO3 –. References 1. Nadeem A, et al. Crit Care. 2014;18:625. 2. Eremenko AA, et al. Anesteziol Reanimatol. 2001;3:58-61. 3. KDIGO AKI Work Group. Kidney Int. 2012;2 Suppl:1–138. 1. Nadeem A, et al. Crit Care. 2014;18:625. 2. Eremenko AA, et al. Anesteziol Reanimatol. 2001;3:58-61. 3. KDIGO AKI Work Group. Kidney Int. 2012;2 Suppl:1–138. Incidence of acute kidney injury in critically burned patients resuscitated with crystalloid and colloid according to parameters of transpulmonary thermodilution, diuresis and lactic acid P Extremera Navas, M Sanchez Sanchez, I Pozuelo Echegaray, A Agrifoglio Rotaeche, A Robles Caballero, A García de Lorenzo Hospital Universitario la Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P358 (doi: 10.1186/cc14438) Introduction The purpose was to study the incidence of acute kidney injury (AKI) according to RIFLE and AKIN criteria in critically ill burn patients resuscitated with Ringer’s solution and supplements of lower molecular weight hydroxyethyl starch (HES)130/0.4/6%, and to determine the relationship between RRT indication and mortality. 3 Conclusion As compared with NS and RL, the use of a novel balanced solution with a SID equal to the patient HCO3 – level for ECMO priming uniquely avoids the addition of metabolic acidosis to patients with uncompensated hypercapnia. Methods We studied 165 consecutive patients admitted to the critical care burn unit. Resuscitation was performed using lactated Ringer’s solution and HES at a low dose to achieve urine output, lactate levels, and transpulmonary thermodilution parameters. The contributions of colloids and crystalloids were measured, and renal function was evaluated. Statistical analysis was performed using the Spearman test. Results The average total body surface area (TBSA) burned was 30 ± 15%, and the median of the total volume needed in the fi rst 24 hours was 4.01 ml/kg/% TBSA burned. According to the RIFLE criteria, 10 (6.1%) patients presented with risk, 11 (6.7%) presented with injury, and 11 (6.7%) presented with failure. References 1. Liskaser, et al. Anesthesiology. 2000;93:1170-3. 2. Langer, et al. Intensive Care Med. 2012;38:686-93. 1. Liskaser, et al. Anesthesiology. 2000;93:1170-3. 2. Langer, et al. Intensive Care Med. 2012;38:686-93. References According to the AKIN criteria: 9.7% presented stage I, 3% stage II and 10.3% stage III. Replacement therapy (RRT) was performed in 15 patients (9.1%). In six of these patients RRT was employed in the fi nal stages of multiorgan failure. In the remaining nine patients, for various reasons only one survived. P357 Intraoperative use of gelatin in living donor liver transplantation and postoperative acute kidney injury HK Atalan1, B Gucyetmez2, S Aslan1, M Berktas3, KY Polat1 1Atasehir Memorial Hospital, Istanbul, Turkey; 2International Hospital, Istanbul, Turkey; 3Kappa Consulting, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P357 (doi: 10.1186/cc14437) Association of elevated levels of plasma chloride, in severity and mortality, in adult patients in the ICU M Aguilar Arzapalo Hospital O’Horan, Mérida, Mexico Critical Care 2015, 19(Suppl 1):P360 (doi: 10.1186/cc14440) Introduction For a long time, many investigators have tried to demon- strate increased mortality associated with acid–base distur bances. In this study, we sought to determine the association of hyperchloremia measured at ICU admission and whether this electrolyte disturbance is associated with an increase in morbidity and mortality. Methods A retrospective study was conducted. Patients with a diagnosis of AKI according to KDIGO creatinine criteria and available urinary chemistry at one point during their ICU stay were evaluated. Day 0 was defi ned as the day when SIDu was calculated from urinary spot analysis (SIDu = Na+U + K+U – Cl–U). Patients were followed and staged for AKI in the next 3 days. AKI reversibility was defi ned according to the lack of criteria for AKI. y y Methods Data were retrospectively collected for consecutive adult patients admitted to Agustin O’Horan Hospital ICU, between January 2011 and July 2014, who underwent inpatient medical treatment using electronic fi les. Results In total, 143 critically ill patients with a diagnosis of AKI were included. SIDu at day 0 did not diff er between diff erent AKI stages at day 0. SIDu at day 0 was statistically diff erent between diff erent AKI stages at days 1, 2, 3 (Table 1). SIDu at day 0 was statistically diff erent between reversible and not reversible AKI at days 1, 2, 3 (Table 2). A conventional receiver-operating curve was generated to assess the accuracy of SIDu to predict AKI reversibility at day 1. AUC for SIDu was 0.82 (P <0.0001; 95% CI: 0.75 to 0.88). i Results The dataset consisted of 936 medical fi les and serum chloride concentration values on admission, 853 being eligible. Hyperchloremia (serum chloride >110 mmol/l) is quite common, with an incidence of 47.71%. Patients were propensity matched based on their association with death and hyperchloremia. Of the 853 patients collected, patients with hyperchloremia after admission (n = 446, 52.3%), patients were matched to patients who had normal serum chloride levels after admission. These two groups were well balanced with respect to all variables collected. The hyperchloremic group was at increased risk of mortality at ICU discharge, relative risk ratio = 1.81; 95% confi dence interval, 1.41 to 2.51 risk increase of 25.31%. Intraoperative use of gelatin in living donor liver transplantation and postoperative acute kidney injury These were a combination of debridement, split skin grafts (SSG) and change of dressings. All patients were admitted to our burns ICU between January 2009 and October 2013. Exclusion criteria were death prior to discharge and initial surgery at a diff erent hospital. Sixteen patients had good graft viability (Group A) and 19 patients had poor graft viability (Group B). Logistical regression was performed using SPSS (Version 22.0). Hosmer and Lemeshow testing was used to confi rm goodness of fi t. Independent variables were age, sex, preoperative haemoglobin, intraoperative fl uid resuscitation, blood products, inotropes, volatile agents and temperature. Poor graft viability was defi ned as requiring at least one additional skin graft. Analysis was performed on all operations and then by subtype of operation (that is, SSG and debridement, SSG only). Results In total, 128 patients were categorized as GI (58, 45%) or GII (70, 55%). Total clamping time, intraoperative diuresis, intraoperative crystalloid use, intraoperative fl uid balance, operation bleeding, erythrocyte suspension, FFP and thrombocyte suspension use and postoperative lactate levels of GII were statistically signifi cantly higher than GI (P <0.001 for each). According to the KDIGO guideline, AKI in GII on the 1st, 2nd, 4th and 7th days (11.4%; 20%; 24.3%; 17.1%) was statistically signifi cantly higher than GI (P <0.001 for each). Conclusion In patients who received gelatin, kidney dysfunction in the postoperative period was observed more frequently. Also in this group, S127 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results There was no signifi cant diff erence in age, %total burn surface area or Belgian Outcome Burns Injury score between the groups. For all operation data, use of colloids was found to signifi cantly contribute towards poor graft viability (P = 0.035, 95% CI). When analysis was performed on only SSG and debridement operations, colloids remained signifi cant (P = 0.034, 95% CI) and metarminol use was found to signifi cantly contribute (P = 0.028, 95% CI) to poor graft viability. Overall use of inotropes was not signifi cant between the two groups. Other variables including minimum and maximum temperature, preoperative haemoglobin and blood transfusion were not found to be signifi cant. References 1. Gauthier PM, Szerlip HM. Metabolic acidosis in the intensive care unit. Crit Care Clin. 2002;18:289-308. 1. Gauthier PM, Szerlip HM. Metabolic acidosis in the intensive care unit. Crit Care Clin. 2002;18:289-308. 2. Eisenhut M. Causes and eff ects of hyperchloremic acidosis. Crit Care. 2006;10:413. 2. Eisenhut M. Causes and eff ects of hyperchloremic acidosis. Crit Care. 2006;10:413. 3. Wooten EW. Science review: quantitative acid–base physiology using the Stewart model. Crit Care. 2004:8:448-52. 3. Wooten EW. Science review: quantitative acid–base physiology using the Stewart model. Crit Care. 2004:8:448-52. 36 Urinary strong ion diff erence and acute kidney injury: an early marker of renal dysfunction? i Conclusion Our results suggest that the use of colloids is a contributor to poor graft viability in burns. This was found to be independent of temperature and overall inotrope use; however, the use of metarminol may be a contributing factor. y P Balsorano1, A De Gaudio1, Stefano Romagnoli1, Ipsita Krishnan2 1AOUC Careggi, Florence, Italy; 2Rhode Island Hospital, Providence, RI, USA Critical Care 2015, 19(Suppl 1):P361 (doi: 10.1186/cc14441) Introduction Kidneys play a crucial role in the regulation of electrolytes and acid–base homeostasis. Impaired renal function is associated with greater urinary strong ion diff erence (SIDu) in patients with metabolic acidosis [1]. In critically ill patients, several factors, such as infused fl uids and acid endogenous production, would lead to changes in plasma SID and acid–base homeostasis without renal regulation of urinary electrolytes and SIDu [2]. Hence, AKI can be highlighted as an inability to address acid–base metabolic disturbances, which may be detected before major increases in creatinine or decreases in urine output. We evaluated the eff ects of renal function on urinary strong ion excretion using the Stewart approach to acid–base in critically ill patients with AKI. P360 Association of elevated levels of plasma chloride, in severity and mortality, in adult patients in the ICU Admission hyperchloremia was associated with increased morbidity, mortality and higher scores in severity scales; this association was statistically important. See Figure 1. Conclusion This retrospective cohort trial demonstrates an association between hyperchloremia and poor ICU admission outcome (death). Additional studies are required to demonstrate a causal relationship between these variables. Table 1 (abstract P361). SIDu (mEq/l) between diff erent AKI stages at days 1, 2, 3 post admission AKI stage 3 2 1 0 P value Day 1 48.1 (21) 46 (22) 37.9 (20) 17.3 (22) <0.001 Day 2 40.2 (23) 45.9 (20) 45 (23) 29 (22) 0.004 Day 3 40.3 (26) 47.2 (18) 53.2 (23) 31 (23) 0.006 Table 2 (abstract P361). SIDu (mEq/l) between reversible versus not reversible AKI at days 1, 2, 3 Reversible Not reversible P value Day1 16.8 (23) 43.9 (21) 0.0001 Day2 28.5 (24) 45.3 (22) 0.0001 Day3 30 (24) 47.3 (21) 0.0001 Conclusion SIDu identifi ed patients with reversible AKI with good accuracy. SIDu can be a promising, simple and cost-eff ective tool in AKI patient evaluation. Further research is needed to assess SIDu capability to early detect patients with renal dysfunction before increases in creatinine or decreases in urine output. References 1. Moviat M, et al. J Crit Care. 2012;27:255-60. 2. Masevicius FD, et al. Crit Care Resusc. 2010;12:248-54. Table 1 (abstract P361). SIDu (mEq/l) between diff erent AKI stages at days 1, 2, 3 post admission Table 1 (abstract P361). SIDu (mEq/l) between diff erent AKI stages at days 1, 2, 3 post admission AKI stage 3 2 1 0 P value Day 1 48.1 (21) 46 (22) 37.9 (20) 17.3 (22) <0.001 Day 2 40.2 (23) 45.9 (20) 45 (23) 29 (22) 0.004 Day 3 40.3 (26) 47.2 (18) 53.2 (23) 31 (23) 0.006 Table 2 (abstract P361). SIDu (mEq/l) between reversible versus not reversible AKI at days 1, 2, 3 Figure 1 (abstract P360). Group mortality, high and low chlorine. Reference Reference 1. Ridley SA, et al. Anaesthesia. 2004;59:1193-200. 1. Ridley SA, et al. Anaesthesia. 2004;59:1193-200. P366 Incidence and predisposing factors for the development of disturbed glucose metabolism and diabetes mellitus after intensive care admission: the DIAFIC study S Van Ackerbroeck, K Janssens, P Jorens, T Schepens, W Verbrugghe, V Van Hoof, L Van Gaal, C De Block University Hospital Antwerp, Edegem, Belgium Critical Care 2015, 19(Suppl 1):P366 (doi: 10.1186/cc14446) Low serum 25-hydroxyvitamin D at critical care initiation is associated with sepsis and morbidity in Dutch critically ill patients K De Haan Erasmus MC, Rotterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P365 (doi: 10.1186/cc14445) Low serum 25-hydroxyvitamin D at critical care initiation is associated with sepsis and morbidity in Dutch critically ill patients K De Haan Erasmus MC, Rotterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P365 (doi: 10.1186/cc14445) Introduction Vitamin D defi ciency may frequently occur in critically ill patients and may be associated with sepsis and increased mortality. We therefore evaluated the prevalence of 25-hydroxyvitamin D defi ciency in a Dutch ICU, and its relationship with sepsis, morbidity and mortality. Methods We conducted a prospective observational study in a 10-bed mixed ICU. A total of 1,372 patients were admitted between July 2011 and June 2013 including 198 readmissions, of which 940 patients were studied. 25-Hydroxyvitamin D levels were determined within 24 hours after admission. 25-Hydroxyvitamin D levels were judged as suffi ciency (>50 nmol/l), insuffi ciency (30 to 50 nmol/l) and defi ciency (<30 nmol/l). Results The prevalence of defi ciency and insuffi ciency was 36% and 38%, respectively. Only 26% of the patients had suffi cient vitamin D levels. Vitamin D defi ciency is associated with sepsis (P <0.001) at ICU admission. Patients with defi cient levels had higher mean APACHE IV scores, 64 versus 52 (P <0.001), and longer length of hospital stay, 12 versus 9 days (P <0.001), respectively, as compared with patients with suffi cient levels. Patients with defi cient vitamin D levels had an odds ratio for in-hospital mortality of 1.4 (95% confi dence interval of 0.84 to 2.29, P = 0.2) relative to patients with suffi cient vitamin D levels.i Conclusion Implementation of i.v. potassium replacement guidelines improved the use of i.v. potassium in the ICU by reducing the requirement for i.v. potassium supplementation and increasing the overall time patients spent without hypokalaemia. Whilst nursing staff found the guideline useful and felt it increased safe use of i.v. potassium, more work is needed to ensure nurse workload is not increased signifi cantly. fi Conclusion 25-Hydroxyvitamin D defi ciency frequently occurs in Dutch critically ill patients. Although relating to sepsis, disease severity and morbidity, vitamin D defi ciency is not an independent predictor of mortality in these patients, which was otherwise relatively low. References 1. Moviat M, et al. J Crit Care. 2012;27:255-60. Masevicius FD, et al. Crit Care Resusc. 2010;12:248-54. S128 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P362 Evaluation of the eff ect of guidelines to reduce intravenous potassium infusions in ICU patients MC Law Min1, RS Bourne1, S Burd2, M Stone2 1Sheffi eld Teaching Hospitals, Sheffi eld, UK; 2De Montfort University, Leicester, UK Critical Care 2015, 19(Suppl 1):P362 (doi: 10.1186/cc14442) P362 P362 Evaluation of the eff ect of guidelines to reduce intravenous potassium infusions in ICU patients MC Law Min1, RS Bourne1, S Burd2, M Stone2 1Sheffi eld Teaching Hospitals, Sheffi eld, UK; 2De Montfort University, Leicester, UK Critical Care 2015, 19(Suppl 1):P362 (doi: 10.1186/cc14442) almost every patient and at every studied time point. Moreover, these levels were signifi cantly higher than in controls or compared with referenced literature. The chronology of exposure was demonstrated: the preoperative urine and serum levels of the DEHP metabolites were often below the detection limit. Medical devices are the source of these chemicals: patients on hemofi ltration, extracorporeal membrane oxygenation or both showed serum levels 100-fold or 1,000-fold higher than the general population or workers in plastic industry. The serum and some of the urinary levels of the DEHP metabolites are the highest ever reported in humans; some at biologically highly relevant concentrations of even ≥10 to 50 μM. almost every patient and at every studied time point. Moreover, these levels were signifi cantly higher than in controls or compared with referenced literature. The chronology of exposure was demonstrated: the preoperative urine and serum levels of the DEHP metabolites were often below the detection limit. Medical devices are the source of these chemicals: patients on hemofi ltration, extracorporeal membrane oxygenation or both showed serum levels 100-fold or 1,000-fold higher than the general population or workers in plastic industry. The serum and some of the urinary levels of the DEHP metabolites are the highest ever reported in humans; some at biologically highly relevant concentrations of even ≥10 to 50 μM. Critical Care 2015, 19(Suppl 1):P362 (doi: 10.1186/cc14442) Introduction The aim was to evaluate whether guidelines for intra- venous (i.v.) potassium replacement improved plasma potassium homeostasis in ICU patients. Prompt and eff ective treatment of hypokalaemia is an important intervention in the ICU, but concentrated i.v. potassium solutions may cause serious harm if used inappropriately [1]. There were previously no formalised guidelines on i.v. potassium supplementation in the ICU at Sheffi eld Teaching Hospitals. Practice was reviewed and guidelines were introduced to improve patient safety, plasma potassium homeostasis and reduce i.v. potassium supplementation requirements. Conclusion Adult ICU patients are exposed to plastic softeners, in particular PMs. Despite the continuously tightening regulations, BPA and DEHP are still present in medical devices. Because patient safety is a concern in the ICU, further research into the (possibly toxic and clinical) eff ects of chemicals released from medical devices should be undertaken. pp q Methods A before and after evaluation of plasma potassium homeo- stasis in ICU patients requiring i.v. potassium supplementation was conducted over a period of 8 months (August 2013 to May 2014). Patient data on plasma potassium levels, i.v. and oral potassium supplements administered were obtained from the clinical information system. Clinical appropriateness of i.v. potassium acetate prescriptions, fl uid and chloride intake related to potassium infusions and cost linked to the guidelines were also compared pre/post implementation. Impact of the guidelines on nurses’ practice was assessed using questionnaires. Results Median i.v. potassium replacement dose per patient was signifi cantly reduced in the post-guidelines group from 215 (IQR: 94; 485) to 80 (IQR: 40; 160) mmol; P <0.001. Although the percentage time per group for patients who were hypokalaemic was less in the post group (18.2% vs. 14.8%), there was no diff erence in mean patient values (24.2 (20.3)% vs. 22.1 (17.5)%; P = 0.228). The duration of hyperkalaemia was increased. Prescribing of i.v. potassium acetate was not always appropriate. Median patient fl uid-related dose was increased (107.5 (IQR: 47.1; 242.4) vs. 250 (IQR: 100; 600) ml; P <0.001), whilst chloride doses were reduced (170.7 (IQR: 91.3; 438.3) vs. 110 (IQR: 55; 250) mmol; P <0.009). Nurses were satisfi ed with the new practice, reporting it was safe, eff ective and clinically useful. However, compared with baseline practice, they perceived the guidelines as less eff ective and felt the workload was higher. Associations between the degree of correction of hypoglycemia and ICU mortality g g Results The median glucose in the EndoTool group (141.5 mg/dl) was lower than in the Adult ICU group (159.9 mg/dl) (P <0.0001). The standard deviation of glucose in the EndoTool group (32.3 mg/ dl) was lower than the Adult ICU group (39.5 mg/dl) (P = 0.0001). The proportion of patients in each group with 10% or higher of measurements at a severe hyperglycemia level (≥200 mg/dl) in the EndoTool group (35.2%) was lower than the Adult ICU group (64.1%) (P <0.0001). The proportion of patients who had at least one moderate hypoglycemic measurement (<70 mg/dl) was not signifi cantly diff erent between the EndoTool group versus the Adult ICU group (11.73% vs. 9.3%, respectively; P = 0.34). However, there was a higher overall incidence of hypoglycemia in the EndoTool group (5.65 hypoglycemic measurements/100 person-protocol days) compared with the Adult ICU group (3.43/100 person-protocol days) (RR = 1.65, 95% CI = 1.09 to 2.45, P = 0.014). Severe hypoglycemia (<40 mg/dl) was rare, only occurring in 1/179 (0.56%) in the EndoTool group and 4/580 (0.69%) in the Adult ICU group. R Van Hooijdonk1, JM Binnekade1, A Abu-Hanna1, j , , , F Van Braam Houckgeest2, LS Hofstra3, J Horn1, MA Kuiper4, f F Van Braam Houckgeest2, LS Hofstra3, J Horn1, MA Kuiper4, f NP Juff ermans1, HL Van den Oever5, JP Van der Sluijs6, PE Spronk7, MJ Schultz1 1Academic Medical Center, Amsterdam, the Netherlands; 2Tergooi Hospitals, Hilversum, the Netherlands; 3Scheper Hospital, Emmen, the Netherlands; 4Medical Centre Leeuwarden, the Netherlands; 5Deventer Hospital, Deventer, the Netherlands; 6Medical Center Haaglanden, The Hague, the Netherlands; 7Gelre Hospitals, Apeldoorn, the Netherlands Critical Care 2015, 19(Suppl 1):P367 (doi: 10.1186/cc14447) Introduction It is conjectured that transition of hypoglycemia to hyperglycemia may be more harmful than hypoglycemia itself. We investigated the association between the degree of correction of hypoglycemia and ICU mortality in patients under moderately strict to strict glycemic control. Methods This is a retrospective analysis from a pooled cohort from seven ICUs in the Netherlands over 6 years. ICU patients who developed hypoglycemia (<70 mg/dl) were included. We excluded patients who were readmitted, and patients with hypoglycemia in whom no follow- up blood glucose measurement was performed within 8 hours. Marked exposure to the endocrine-disrupting chemicals phthalates and bisphenol A in the ICU J Huygh, P Jorens Antwerp University Hospital, Edegem, Belgium Critical Care 2015, 19(Suppl 1):P364 (doi: 10.1186/cc14444) J Huygh, P Jorens J Huygh, P Jorens Introduction Care for ICU patients has benefi ted from medical devices. Bisphenol A (BPA) and phthalates can leach from the plastic matrix. We hypothesized that ICU patients are exposed to BPA and phthalates through medical devices. Introduction Stress hyperglycaemia (SH) is commonly observed during hospitalisation in the ICU and adversely infl uences outcome [1]. When SH occurs in previously nondiabetic patients, this might refl ect a latent disturbance of glucose metabolism and predict future risk of diabetes. We wanted to assess the incidence of disturbed glucose metabolism (DGM) and identify predictors for future diabetes risk. This could support timely diagnosis, prevention, and early treatment of impending diabetes mellitus (DM). Methods Serum (n = 118) and urinary (n = 102) samples of adult (n = 35) ICU patients were analyzed for total BPA and di(2-ethylhexyl)phthalate (DEHP) and other phthalate metabolites (PMs). We also enrolled patients preoperatively before scheduled thoracic surgery and repeat samples were taken on days 1 to 4 during the ICU stay. Control data came from 44 healthy controls or from referenced literature. Methods In this prospective observational study, we enrolled 338 patients without known DM, who were admitted for at least 36 hours to the ICU of the Antwerp University Hospital between September 2011 and March 2013. A 75 g oral glucose tolerance test was performed Results Our results show that adult ICU patients are continuously exposed to phthalates (that is, DEHP) as well as to BPA, albeit to a lesser extent, resulting in detectable serum and urinary levels in S129 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion Not the transition to hyperglycemia, but insuffi cient recovery from hypoglycemia is associated with an increased ICU mortality in patients under moderately strict or strict glucose control with insulin. 6 to 9 months post ICU admission to screen for disturbed glucose metabolism. Furthermore, we examined whether post-discharge glucose disturbances could be predicted by the FINDRISC questionnaire [2], patient demographics, comorbidities, HbA1c at ICU admission, and by parameters related to ICU stay (glucose parameters, insulin need, caloric intake, disease severity). y Results In total, 246 patients (73%) experienced SH during their ICU stay. Eight months post ICU admission, glucose metabolism was disturbed in 119 (35%) subjects. Computer versus paper insulin protocol for managing hyperglycemia in three ICUs A Peckham Oregon Health & Science University, Portland, OR, USA Critical Care 2015, 19(Suppl 1):P368 (doi: 10.1186/cc14448) Computer versus paper insulin protocol for managing hyperglycemia in three ICUs A Peckham Oregon Health & Science University, Portland, OR, USA Critical Care 2015, 19(Suppl 1):P368 (doi: 10.1186/cc14448) Introduction The purpose of this study was to compare a computer protocol against a paper protocol in managing three domains of glucose control. Hyperglycemia is common in critically ill patients, and their risk of death is associated with hyperglycemia, hypoglycemia, and glucose variability. A safe and eff ective insulin protocol must minimize hyperglycemia and glucose variability while also avoiding hypoglycemia. Computer-based insulin protocols promise better performance by adjusting to each individual’s sensitivity to insulin. Conclusion Stress hyperglycaemia is frequent in nondiabetic patients and has a tendency towards future disturbances in glucose metabolism and DM. Glucose metabolism was disturbed in 35% of subjects 8 months post ICU admission, of whom 7% was diagnosed with diabetes mellitus. Predictors of elevated risk included a high FINDRISC score, high SAPS 3 score, and a lower daily caloric intake during ICU stay. R f Methods This is a historical cohort study with 759 patients admitted to three ICUs (medical/cardiac, trauma, and neuroscience) at an academic tertiary care hospital. All adult patients from January 2012 to October 2013 on one of two continuous insulin protocols for at least 8 hours were included. At the start of the study period the paper protocol in use (Adult ICU) had a target glucose of 140 to 180 mg/dl and was used for any patient with a glucose higher than 180 mg/dl. In June 2013 this was replaced by a computer-based insulin protocol (EndoTool) that had the same criteria for initiation and had a target glucose of 150 mg/dl. The primary exposure was the insulin protocol, and the primary outcome was performance in maintaining glucose control. 1. De Block C, et al. Curr Diabetes Rev. 2008;4:234-44. 2. Schwarz PE, et al. Horm Metab Res. 2009;41:86-97. 1. De Block C, et al. Curr Diabetes Rev. 2008;4:234-44. 2. Schwarz PE, et al. Horm Metab Res. 2009;41:86-97. Associations between the degree of correction of hypoglycemia and ICU mortality We determined the association between three measures of correction of hypoglycemia within 8 hours after hypoglycemia and ICU mortality: predefi ned ranges of the ‘highest blood glucose level’ (<80 mg/dl; 80 to 110 mg/dl; 110 to 150 mg/dl (reference category); 150 to 180 mg/ dl; and >180 mg/dl); quartiles of the ‘delta glucose’, defi ned as the diff erence between minimum and maximum blood glucose level with the third quartile as reference category; and quartiles of the ‘standard deviation’ of the blood glucose level with the third quartile as reference category. Conclusion Patients on the computer protocol had a lower median glucose, less variability, and less hyperglycemia than patients on the paper protocol. There was a higher risk of moderate but not severe hypoglycemia in the computer group. Marked exposure to the endocrine-disrupting chemicals phthalates and bisphenol A in the ICU J Huygh, P Jorens Antwerp University Hospital, Edegem, Belgium Critical Care 2015, 19(Suppl 1):P364 (doi: 10.1186/cc14444) Of these, 27 (8%) had impaired fasting glucose, 43 (13%) had impaired glucose tolerance, 25 (7%) had impaired fasting glucose and impaired glucose tolerance, and 24 (7%) were diagnosed with DM. A disturbed glucose metabolism tended to be more prevalent in subjects who experienced SH during ICU stay as compared with those without SH (38% vs. 28%, P = 0.065). HbA1c on admission correlated with the degree of SH (r = 0.308, P <0.001). The FINDRISC score (9.5 vs. 11, P = 0.001), SAPS 3 score (median of 42 in both groups, P = 0.003) and daily caloric intake during ICU stay (222 vs. 197, P = 0.011) were associated with a DGM. Point accuracy and reliability of an interstitial continuous glucose monitoring device in critically ill patientsf yp g y y Results Of the 1,059 patients admitted with sepsis, 526 (55.8%) had admission glucose levels within the normal range, 270 (25.5%) had mild hyperglycemia and 202 (19.1%) severe hyperglycemia. Patients with severe hyperglycemia were older, had higher APACHE IV scores and were more often diabetics compared with euglycemic patients. Shock on admission was more common in patients admitted with euglycemia. Crude mortality increased with increased admission glucose and a Cox regression analysis showed increased risk for 30- day (HR = 1.67, CI = 1.24 to 2.23), 60-day (HR = 1.42, CI = 1.08 to 1.87) and 90-day (1.31, CI = 1.02 to 1.70) mortality in patients admitted with severe hyperglycemia compared with euglycemia. The association between mortality and severe hyperglycemia on admission was only present in patients without known diabetes but not in patients with a history of diabetes (30-day mortality HR = 1.67, CI = 1.15 to 2.43 vs. 1.84, CI = 0.97 to 3.49). Severe hyperglycemia was associated with a blunted proinfl ammatory cytokine response (IL-6 and IL-8) on admission in patients without, but not in patients with diabetes. g y p R Van Hooijdonk, JH Leopold, T Winters, JM Binnekade, NP Juff ermans, J Horn, JC Fischer, EC Van Dongen-Lases, MJ Schultz Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P370 (doi: 10.1186/cc14450) Introduction There is a need for continuous glucose monitoring in critically ill patients. The objective of this trial was to determine the point accuracy and reliability of a device designed for continuous monitoring of interstitial glucose levels in ICU patients (Sentrino; Medtronic MiniMed, Northridge, CA, USA). Methods Critically ill patients with an anticipated life expectancy >96 hours were eligible for participation, if the platelet count was >30 × 1012 ml. Device readings were compared with glucose measurements in arterial blood using blood gas analyzers (RapidLab Siemens Healthcare Diagnostics, The Hague, the Netherlands). We used a linear mixed model to determine which factors aff ect point accuracy. In addition, we determined the reliability, including duration of device start-up and calibration, skips in data acquisition, and premature disconnections of sensors. Conclusion Severe hyperglycemia on admission is associated with increased 30-day, 60-day and 90-day mortality in sepsis patients without a history of diabetes mellitus. Results We included 50 patients, aged 65 (56 to 72) years with an APACHE II score of 23 (17 to 26). P370 Point accuracy and reliability of an interstitial continuous glucose monitoring device in critically ill patients R Van Hooijdonk, JH Leopold, T Winters, JM Binnekade, NP Juff ermans, J Horn, JC Fischer, EC Van Dongen-Lases, MJ Schultz Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P370 (doi: 10.1186/cc14450) Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 The number of skips in data acquisition was low, resulting in availability of real-time data during 95 (89 to 98)% of the connection time per sensor. glucose data prove in such routine use?’ Using actual case data, we have shown how comparing the mean absolute relative diff erence (MARD) and integration of the area under the curve (AUC) from the continuous glucose monitoring and intermittent measurement can be used to measure patient risk. Conclusion The point accuracy of the device was relatively low in critically ill patients. The device reliability was relatively good, although sensors were removed prematurely for a variety of reasons. p Methods The analysis used aggregated case data generated from our recent clinical trials, where a GlySure sterile, single-use sensor and dedicated monitoring system was used to measure the blood glucose concentration in patients continuously and in real time. The measurement of risk was compared using the MARD, an accepted error calculation tool, and the AUC was calculated using an AUC analysis software program. g References 1. Mulavisala KP, Gopal PB, Crane B. ISICEM 2014. p. 442. http://ccforum.com/ content/18/S1/P442. 1. Mulavisala KP, Gopal PB, Crane B. ISICEM 2014. p. 442. http://ccforum.com/ content/18/S1/P442. 1. Mulavisala KP, Gopal PB, Crane B. ISICEM 2014. p. 442. http://ccforum.com/ content/18/S1/P442.i 1. Mulavisala KP, Gopal PB, Crane B. ISICEM 2014. p. 442. http://ccforum.com/ content/18/S1/P442.i 2. Gopal PB, Mulavisala KP. ESICM 2014. Abstract 0264. http://react-profi le.org/ Download/ESICM2014_Abstract_Book_fi nal_version.pdf. P370 Eff ect of admission hyperglycemia in sepsis patients with or without a history of diabetes g Results When MARD from the GlySure sensor and intermittent measurement using the hospital’s existing protocol was compared, the measure of risk to the patient (that is, the uncertainty regarding the patient’s absolute blood glucose status) for the GlySure sensor was 50.5% lower than the intermittent measurement. The results also showed that as the variability of the BG data increases, the benefi t of continuous monitoring increases by signifi cantly reducing patient risk. The continuous monitoring reduces the patient’s risk by 88%, 73%, and 69% respectively in high, medium and low variability situations. Introduction Hyperglycemia is common and often multifactorial in critically ill patients. The association of hyperglycemia with adverse outcome has repeatedly been established in a variety of settings. The objective of this study was to investigate whether hyperglycemia on admission to the ICU impacts presentation and outcome of sepsis patients and whether this eff ect is diff erent for patients with a history of diabetes mellitus. p y g y Conclusion It is more and more evident that continuous glucose technology will be instrumental in driving safe and eff ective glucose management protocols that will support more consistent glycemic management standards within ICUs and across institutions. Methods A two-center, prospective observational cohort study was conducted including all consecutive critically ill patients admitted to the ICU between January 2011 and July 2013. Sepsis patients were identifi ed using strict clinical and diagnostic criteria. The fi rst glucose measurement within a time window of 4 hours before up to 4 hours after ICU admission was categorized into euglycemia (71 to 140 mg/dl), mild hyperglycemia (141 to 200 mg/dl) or severe hyperglycemia (>200 mg/ dl), patients with hypoglycemia were excluded. A multivariable Cox proportional hazard model was used to determine the eff ect of admission hyperglycemia on mortality corrected for covariates. Continuous blood glucose monitoring reduces the risk to ICU patients KP Mulavisala1, J Norrie2, B Crane3, N Barwell3 1CARE Hospitals, Hyderabad, India; 2SumStats Ltd, Edinburgh, UK; 3GlySure Ltd, Abingdon, UK g , Critical Care 2015, 19(Suppl 1):P369 (doi: 10.1186/cc14449) Results In total, 4,516 ICU patients developed at least one episode of hypoglycemia. In three separate multivariate analyses for each of the three measures we adjusted for the respective confounders. The category 80 to 110 mg/dl of the ‘highest blood glucose level’ was associated with increased mortality compared with the reference category (odds ratio (OR) = 1.31, 95% confi dence interval (CI) = 1.06 to 1.61). The lowest quartile of the ‘delta glucose’ (OR = 1.32, 95% CI = 1.03 to 1.69) and the lowest quartile of the ‘standard deviation’ (OR = 1.55, 95% CI = 1.23 to 1.96) were associated with higher ICU mortality than their reference categories. Introduction GlySure Limited (Abingdon, UK) has developed a continuous intravascular glucose monitoring system (CIGMS) to simplify the application of hospital protocols for optimal glucose control at the point of care. We have previously reported on the early results achieved in cardiac patients [1] and MICU patients [2]. This initial success has been sustained and demonstrated in further patient groups. We have now reached the point where we can conjecture upon the regular application of the GlySure CIGMS in day-to-day ICU practice. This in turn prompts the question, ‘How eff ective will continuous blood S130 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P371f Eff ect of admission hyperglycemia in sepsis patients with or without a history of diabetes LA Van Vught1, MA Wiewel1, PM Klein Klouwenberg2, AJ Hoogendijk1, DS Ong2, OL Cremer2, MJ Bonten2, MJ Schultz1, T Van der Poll1 1Academic Medical Center, Amsterdam, the Netherlands; 2University Medical Center Utrecht, the Netherlands Critical Care 2015, 19(Suppl 1):P371 (doi: 10.1186/cc14451) 1. Mulavisala KP, Gopal PB, Crane B. ISICEM 2014. p. 442. http://ccforum.com/ content/18/S1/P442. Point accuracy and reliability of an interstitial continuous glucose monitoring device in critically ill patientsf Admission types were medical (62%), elective surgery (22%) and emergency surgery (16%), and 22% had diabetes. For the accuracy analyses we had 929 comparative samples from 100 sensors in 45 patients (11 (7 to 28) samples per patient) during 4,639 hours (46 (27 to 134) hours per patient and 46 (21 to 69) hours per sensor). The Bland–Altman plot showed a bias of –0.6 mg/dl with limit of agreement between –57.2 and 56 mg/dl. Glucose prediction error analysis showed 60% of the glucose values <75 mg/dl within ±15 mg/dl and 75.8% of the glucose values ≥75 mg/dl within 20% of the comparative RapidLab results. Clarke error grid analysis showed 75.3% in zones A and 23.5% of the paired measurements in zones B, 0.3% of the paired measurements in zones C and 0.9% of the paired measurements in zones D. Point accuracy did not meet the ISO14971 standard for dosing accuracy, but improved with increasing numbers of calibrations, and was better in patients who did not have diabetes mellitus. Sixty out of 105 sensors were removed prematurely for a variety of reasons. The device start-up time was 49 (43 to 58) minutes. Acknowledgement This research was performed within the framework the Center for Translational Molecular Medicine (http://www.ctmm.nl), project MARS (grant 04I-201). Point and trend accuracy of continuous glucose monitoring using intravenous microdialysis in critically ill patients JH Leopold, RT Van Hooijdonk, M Boshuizen, T Winters, LD Bos, A Abu-Hanna, MJ Schultz Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P372 (doi: 10.1186/cc14452) Introduction Insulin infusion in critically ill patients mandates frequent measurements of the blood glucose level [1]. Microdialysis is a well- established technology that off ers the opportunity to sample blood analytes with high accuracy, without the need for drawing blood samples [2,3]. We aimed to determine point and trend accuracy of S131 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 values and arterial glycemia correlated well with 98.6% of data falling in regions A and B of error grid analysis. microdialysis-based continuous glucose monitoring (CGM) (EIRUS®; Maquet Critical Care AB, Solna, Sweden). g g y Conclusion In our study, the use of RT-CGM neither improved glucose control and variability, nor did it reduce hypoglycemic events. y g References 2. Schierenbeck F, et al. Diabetes Technol Ther. 2015;15:26-31. y y p y Results Ninety-nine FP patients were admitted between April 2008 and January 2014. Median age was 73 (IQR 61 to 79), with a female preponderance (53.5%). The median ICU length of stay (LOS) was 5 days (IQR 2 to 16). On admission to critical care, clinical data included (all medians): temperature 36.6°C (IQR 36 to 37.2), systolic blood pressure (BP) 113 mmHg (IQR 104 to 136), diastolic BP 56 mmHg (IQR 49 to 67), lactate 2.3 mmol/l (IQR 1.5 to 3.7), bilirubin 12 μmol/l (IQR 9 to 20), haemoglobin 104 g/l (IQR 93 to 116), haematocrit 31 (IQR 28 to 36), creatinine 88 μmol/l (IQR 66 to 152), prothrombin time 13.1 seconds (IQR 11.9 to 14.4). In 86 patients the initial operation was an emergency laparotomy, with primary perforation in 53 cases. Subsequent anastomotic dehiscence and need for relaparotomy happened in 24 and 33 cases respectively. Forty per cent of patients underwent more than one surgical abdominal intervention. The most common antibiotic used was tazobactam and fl uconazole was the commonest antifungal. The percentages of patients receiving mechanical ventilation, renal replacement therapy and inotropic/vasopressor support during ICU stay were 72.7%, 25.3% and 84.8% respectively. The ICU and hospital mortality rates were 23.5% and 26.1%, respectively, increasing to 26.7% at 28 days, 28.4% at 90 days and 32.2% at 1 year. None of the surgical factors or diabetes infl uenced survival. The strongest independent risk factors associated for ICU mortality were systolic BP on ICU admission (OR = 1.05, 95% CI = 1.01 to 1.09, P = 0.015), acute kidney injury (AKI) within the fi rst 24 hours of ICU admission (OR = 0.15, 95% CI = 0.03 to 0.9, P = 0.026) and lactate on ICU admission (OR = 0.62, 95% CI = 0.39 to 1, P = 0.05). , ; 4. Krouwer JS, et al. J Diabetes Sci Technol. 2010;4:75-83. 5. Clarke WL, et al. Diabetes Care. 1987;10:622-8. 6. Kovatchev, et al. Diabetes Care. 2004;27:1922-8. P373 P373 Real-time continuous glucose monitoring in the ICU J Gios1, B Manuel-y-Keenoy2, P Rogiers3 1University Hospital Antwerp, Edegem, Belgium; 2University of Antwerp, Wilrijk, Belgium; 3Ziekenhuisnetwerk Antwerpen Middelheim General Hospital, Antwerp, Belgium Critical Care 2015, 19(Suppl 1):P373 (doi: 10.1186/cc14453) P373 Real-time continuous glucose monitoring in the ICU J Gios1, B Manuel-y-Keenoy2, P Rogiers3 J Gios1, B Manuel-y-Keenoy2, P Rogiers3 1University Hospital Antwerp, Edegem, Belgium; 2University of Antwerp, Wilrijk, Belgium; 3Ziekenhuisnetwerk Antwerpen Middelheim General Hospital, Antwerp, Belgium Critical Care 2015, 19(Suppl 1):P373 (doi: 10.1186/cc14453) J Gios1, B Manuel-y-Keenoy2, P Rogiers3 1University Hospital Antwerp, Edegem, Belgium; 2University of Antwerp, Wilrijk, Belgium; 3Ziekenhuisnetwerk Antwerpen Middelheim General Hospital, Antwerp, Belgium Critical Care 2015, 19(Suppl 1):P373 (doi: 10.1186/cc14453) J Gios , B Manuel y Keenoy , P Rogiers 1University Hospital Antwerp, Edegem, Belgium; 2University of Antwerp, Wilrijk, Belgium; 3Ziekenhuisnetwerk Antwerpen Middelheim General Hospital, Antwerp, Belgium Critical Care 2015, 19(Suppl 1):P373 (doi: 10.1186/cc14453) Introduction Hyperglycemia occurs in 50 to 85% of patients admitted to a medical ICU (MICU) and has been associated with poor prognosis [1,2]. Whether applying intensive insulin therapy to achieve tight glycemic control in critically ill patients is benefi cial remains controversial [2]. Another important observation is a link between glycemic variability and mortality [3]. We performed a pilot study hypothesizing that when implementing intensive insulin therapy, real-time continuous glucose monitoring (RT-CGM) may help to safely achieve tight glucose control, while avoiding hypoglycemia and reducing glycemic variability in MICU patients. Methods This two-center randomized controlled pilot study was performed during a 3-year period. To be included, patients had to be severely ill (APACHE II score ≥20) and CGM monitoring had to be started within 48 hours after admission in the MICU. Thirty-fi ve patients (age 66 ± 10 years; nondiabetic/diabetic patients 27/8; APACHE II score 28 ± 6) were randomly assigned to RT-CGM (n = 16) or to blinded CGM. In both groups a microdialysis-based glucose sensor (GlucoDay®S) was used during a 96-hour period of glucose monitoring. Insulin infusion was performed using a modifi ed Yale protocol. Outcome measures were percentage of time in normoglycemia and in hypoglycemia, glycemic variability, and CGM accuracy. Conclusion In this cohort of critically ill FP patients the ICU and 12-month mortality rates were 23.5% and 32.2%, respectively. The most consistent predictors of mortality across all time points were AKI within 24 hours of ICU admission and admission lactate. fi 1. Tridente A, et al. Intensive Care Med. 2014;40:202-10. 1. Tridente A, et al. Intensive Care Med. 2014;40:202-10. References 1. De Block C, et al. Curr Diabetes Rev. 2008;4:234-44. 2. Kavanagh BP, et al. N Engl J Med. 2010;363:2540-6. 3. Hermanides J, et al. Crit Care Med. 2010;38:838-42. 1. De Block C, et al. Curr Diabetes Rev. 2008;4:234-44. 2. Kavanagh BP, et al. N Engl J Med. 2010;363:2540-6. 3. Hermanides J, et al. Crit Care Med. 2010;38:838-42. Results Three-hundred and fi fty-four paired samples were obtained from seven patients (66 (59 to 79) years old, APACHE II score 23 (20 to 28), 51 (19 to 77) samples per patient). Point accuracy: 91% of paired values were in zone A, with the remaining 9% of the values in zone B in the Clarke error grid. In the Bland–Altman, bias was 5.4 mg/dl with an upper limit of agreement of 32.5 mg/dl and a lower level of agreement of –21.8 mg/dl. Glucose prediction error analysis showed that 91% of the values ≥75 mg/dl within 20% of the values measured by the blood gas analyzer were within range. Trend accuracy: in the rate error grid of the continuous glucose error grid analysis, 96% of the paired values were in zone A, 3.7% were in zone B and 0.3% were in zone C. Point accuracy and reliability of an interstitial continuous glucose monitoring device in critically ill patientsf On the other hand we can state that our insulin infusion protocol already led to overall tight glucose control without a signifi cant hypoglycemia risk, leaving little space for improvement. R f Methods Patients with an expected stay in the ICU of >48 hours needing an arterial catheter and a central venous catheter (CVC) were eligible. For a maximum of 3 days, during 8 hours per day, 125 μl blood was drawn from the arterial line every 15 minutes. Point accuracy was expressed using Clarke error grids, Bland–Altman plots and glucose prediction error analysis [4,5]. Trend accuracy was expressed using continuous glucose error grid analysis [6].i Critically ill patients with faecal peritonitis: a 5-year review in a tertiary centre Critically ill patients with faecal peritonitis: a 5-year review in a tertiary centre V Paul1, A Tridente2, P Kaur1, M Mahmood1, R Mellors1, AH Raithatha1 1Sheffi eld Teaching Hospitals, Sheffi eld, UK; 2Whiston Hospital, St Helens & Knowsley, UK Critical Care 2015, 19(Suppl 1):P374 (doi: 10.1186/cc14454) V Paul1, A Tridente2, P Kaur1, M Mahmood1, R Mellors1, AH Raithatha1 1Sheffi eld Teaching Hospitals, Sheffi eld, UK; 2Whiston Hospital, St Helens & Knowsley, UK Critical Care 2015, 19(Suppl 1):P374 (doi: 10.1186/cc14454) y Critical Care 2015, 19(Suppl 1):P374 (doi: 10.1186/cc14454 Introduction Faecal peritonitis (FP) is a common cause of sepsis and admission to the ICU [1]. We report a review of all patients admitted to our ICU over 5 years with FP. The aim was to defi ne the clinical characteristics, outcomes and risk factors for mortality in ICU patients with FP. Introduction Faecal peritonitis (FP) is a common cause of sepsis and admission to the ICU [1]. We report a review of all patients admitted to our ICU over 5 years with FP. The aim was to defi ne the clinical characteristics, outcomes and risk factors for mortality in ICU patients with FP. Conclusion Point and trend accuracy of the tested microdialysis-based CGM are good in critically ill patients. Acknowledgement Maquet Critical Care AB provided two CGM systems and disposables for the duration of the study, but had no infl uence on study design or study reporting. y Methods Data were extracted retrospectively from electronic case fi les. The primary outcome was ICU mortality. Secondary outcomes were hospital, 28-day, 90-day and 1-year mortality. Logistic regression analysis was used to identify independent risk factors for mortality. P377 Results We included 349 patients: age 67.5 ± 10.8 years, M/F sex ratio 252/97, preoperative left ventricle ejection fraction 58.8 ± 10.6%, bypass/valve ratio 234/154, number of grafts 2.7 ± 0.9, mammal arteries 1.8 ± 0.5. In univariate analyses, bypasses received more anaesthetic drugs (P <0.01), had shorter extracorporeal circulation duration, 67 ± 27 versus 75 ± 24 minutes (P <0.01), and received less blood products (P <0.0001). Bypasses had lower postoperative levels of troponin (3.9 ± 7.6 vs. 8.1 ± 21 pg/ml, P <0.01) and LDH (330 ± 162 vs. 420 ± 175 pg/ ml). In contrast, the intra-abdominal pressure (IAP) was higher and related to the number of grafts at day 0 (Figure 1) and day 1 (P = 0.01 and 0.02 respectively), and to the number of mammal grafts at day 0 and day 1 (P = 0.01 and 0.04 respectively). The TTFE was longer but did not reach signifi cance (P = 0.13) as well as the occurrence of abdominal ischaemia (P = 0.22). The occurrence of pneumonia was higher (P = 0.01). In multivariate analysis, the IAP at day 0 and day 1 was related to propofol quantities only. The predictors of pneumonia were: duration of mechanical ventilation, peak lactate in the postoperative 24 hours, and coronary bypass: OR = 163, 2.6, and 4.2 respectively. P377 Disseminated intravascular coagulation score predicts mortality in critically ill patients with liver cirrhosis A Drolz, T Horvatits, K Rutter, K Roedl, S Kluge, V Fuhrmann University Medical Center Hamburg-Eppendorf, Hamburg, Germany Critical Care 2015, 19(Suppl 1):P377 (doi: 10.1186/cc14457) Introduction The disseminated intravascular coagulation (DIC) score is a predictor of outcome in critically ill patients [1,2]. Yet disturbances of coagulation and hemostasis, as refl ected by the DIC score, are a common fi nding in patients with liver cirrhosis. Thus, it is unclear whether the DIC score has prognostic value in critically ill patients with liver cirrhosis. The aim of this study was to assess the applicability and prognostic impact of the DIC score in critically ill patients with liver cirrhosis. Methods Patients with liver cirrhosis admitted to the medical ICU were analyzed for this study. Detailed laboratory analyses including platelet count, D-dimer, fi brinogen and prothrombin index were performed on admission and the DIC score was calculated. Survival was assessed on site or by contacting the patients or the attending physician. Bowel and related complications after cardiac surgery Results In the RT-CGM group the percentage of time at the target glycemia (80 to 110 mg/dl) was 37 ± 12% versus 34 ± 10% in the control group (NS) and glycemia averaged 119 ± 17 mg/dl versus 122 ± 11 mg/ dl respectively (NS). Time spent in hypoglycemia (<60 mg/dl) was not statistically diff erent between the group assigned to RT-CGM (0.6 ± 1.6% of the time) versus those with blinded CGM registration (2.4 ± 4.3% of the time). Parameters of glucose variability (standard deviation of mean glucose value, coeffi cient of variation, mean amplitude of glucose excursions) did not diff er between the groups. The GlucoDay®S Bowel and related complications after cardiac surgery CK Kerneis, AL Lafarge, LL Larnier, F Scalbert, AB Brusset, PE Estagnasie, PS Squara Clinique Ambroise Paré, Neuilly-sur-Seine, France Critical Care 2015, 19(Suppl 1):P375 (doi: 10.1186/cc14455) CK Kerneis, AL Lafarge, LL Larnier, F Scalbert, AB Brusset, PE Estagnasie, PS Squara q Clinique Ambroise Paré, Neuilly-sur-Seine, France q Clinique Ambroise Paré, Neuilly-sur-Seine, France Clinique Ambroise Paré, Neuilly-sur-Seine, France Critical Care 2015, 19(Suppl 1):P375 (doi: 10.1186/cc14455) Introduction Postoperative ileus appears to be underestimated after cardiac surgery. We conducted this study to analyse the incidence, risk factors and outcomes of postoperative ileus. Introduction Postoperative ileus appears to be underestimated after cardiac surgery. We conducted this study to analyse the incidence, risk factors and outcomes of postoperative ileus. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S132 Figure 1 (abstract P375). Figure 1 (abstract P375). Results Eighty-seven patients (69.9%) were females. Mean age was 48.9 years. Primary cancer was colorectal in 42 patients (32.5%), ovarian in 39 (30%), appendiceal in 29 (22%), others in 15.5%. Average operative time was 11 ± 2.1 hours. Average intraoperative crystalloids given were 12,217 ± 4,359 ml, packed RBCs were 2 ± 2.3 units, colloids 1,083 ± 898 ml, average blood loss was 1,108 ± 785 ml. All patients were admitted to the ICU post procedure. The average fl uid balance during the OR was 9,481 ± 4,694 ml. Patients stayed in the ICU for an average of 6 ± 5.3 days. All patients survived the ICU stay. The duration of mechanical ventilation was 57 ± 83 hours, total fl uid balance while in the ICU was 1,467 ± 3,399 ml. Hypomagnesemia was the most frequent electrolyte abnormalities in 79 (61%). 1. Taylor FB, Toh CH, Hoots WK, Wada H, Levi M, Scientifi c Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Towards defi nition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. 2001;86:1327-30. 2. Angstwurm MWA, Dempfl e C-E, Spannagl M. New disseminated intravascular coagulation score: a useful tool to predict mortality in comparison with Acute Physiology and Chronic Health Evaluation II and Logistic Organ Dysfunction scores. Crit Care Me. 2006;34:314-20; quiz 328. ICU outcome of patients undergoing cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy: a single-center study A Nadeem, A Al-Tarifi King Faisal Specialist Hospital, Riyadh, Saudi Arabia Critical Care 2015, 19(Suppl 1):P376 (doi: 10.1186/cc14456) g y A Nadeem, A Al-Tarifi King Faisal Specialist Hospital, Riyadh, Saudi Arabia Critical Care 2015, 19(Suppl 1):P376 (doi: 10.1186/cc14456) overt DIC was 70% compared with 40% in those with a DIC score <5. Conclusion Disturbances in coagulation and hemostasis are found in the majority of cirrhotic patients admitted to the ICU. The DIC score is a suitable predictor of 28-day mortality in critically ill patients with liver cirrhosis. Introduction Peritoneal carcinomatosis (PC) is associated with poor prognosis. The advent of complete cytoreductive surgery (CRRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) has shown promise in improved survival for locally advanced intra- abdominal carcinomatosis. Such patients are routinely admitted to the ICU postoperatively. Little is known about the natural course of such patients while in the ICU. P377 Conclusion The number of coronary grafts and of mammal artery used in cardiac surgery is associated with higher IAP and higher risk of pneumonia. However, whether this is due to direct bowel ischaemia or longer anaesthesia remains to be studied in larger trials. Results In total, 150 admissions to the ICU with liver cirrhosis were analyzed. Thirty-nine percent were female. Median age was 56 (IQR 49 to 63) years. The median SOFA score on admission was 9 (6 to 13), median MELD score 26 (IQR 18 to 36). Twenty-eight-day mortality was 59%. Median DIC score on admission was 5 (IQR 4 to 6). Overt DIC (DIC score ≥5) was found in 65%. DIC score was signifi cantly higher in nonsurvivors compared with survivors (5 (IQR 4 to 7) vs. 4 (IQR 3 to 6); P <0.01). AUROC for the DIC score in prediction of 28-day mortality was 0.68 (95% CI = 0.59 to 0.77). Overt DIC on admission was signifi cantly associated with 28-day mortality (OR = 3.4 (95% CI = 1.69 to 6.84), P <0.01). The 28-day mortality rate in admissions with cirrhosis and overt DIC was 70% compared with 40% in those with a DIC score <5. P376 Bowel and related complications after cardiac surgery Pleural eff usions in 48 (37%), of which three patients only required drainage, Seven patients (5.6%) developed pneumonia, no patient required renal replacement therapy. Average hospital LOS was 33.7 ± 29 days. Only two patients died in the hospital. When the fi rst 65 patients were compared with the last 64 patients, the duration of MV, ICU LOS and hospital LOS were all signifi cantly shorter in the latter group (72 vs. 43 hours, 6.8 vs. 5.0 and 40 vs. 27 days respectively; P <0.01 for all). Methods In this single-centre observational study we prospectively enrolled all patients undergoing elective cardiac surgery. The primary output was the time to faeces (TTFE) as representing the postoperative ileus. Secondary outputs were the occurrence of ischaemic colitis and pneumonia. Quantitative variables were compared by ANOVA or Wilcoxon tests, qualitative variables by chi-square tests. Multivariate analyses were performed by logistic regression, P <0.1 for inputs P <0.05 for outputs. Methods In this single-centre observational study we prospectively enrolled all patients undergoing elective cardiac surgery. The primary output was the time to faeces (TTFE) as representing the postoperative ileus. Secondary outputs were the occurrence of ischaemic colitis and pneumonia. Quantitative variables were compared by ANOVA or Wilcoxon tests, qualitative variables by chi-square tests. Multivariate analyses were performed by logistic regression, P <0.1 for inputs P <0.05 for outputs. Conclusion With proper selection of patients, CRS with HIPEC can be done safely with no major complications. There is a signifi cant reduction in ICU utilization and shorter hospital LOS with more experience in such procedure, suggesting a learning curve as well as better utilization of resources by referring such patients to a high-volume center. P377 References 1. Taylor FB, Toh CH, Hoots WK, Wada H, Levi M, Scientifi c Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Towards defi nition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. 2001;86:1327-30. Methods The procedure was introduced in our hospital in 2008 as the fi rst regional center performing such therapy. A retrospective chart review of 129 cases of CRS-HIPEC admitted to a 22-bed surgical ICU in a tertiary care academic center between November 2008 and March 2014. Primary outcomes were ICU length of stay (LOS) and duration of mechanical ventilation (MV). Secondary outcomes were hospital LOS and hospital mortality. 2. Angstwurm MWA, Dempfl e C-E, Spannagl M. New disseminated intravascular coagulation score: a useful tool to predict mortality in comparison with Acute Physiology and Chronic Health Evaluation II and Logistic Organ Dysfunction scores. Crit Care Me. 2006;34:314-20; quiz 328. S133 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P378 Conclusion In the present study, it was observed that the sero- prevalences of HBsAg, anti-HCV and anti-HIV were not higher than in our city population. However, taking the safety precautions of the healthcare workers during surgical or invasive procedures such as catheterization, intubation or tracheostomy without any information about the serological test results of the patients will reduce the contamination of these agents. P378 Warm ischemia time, postreperfusion syndrome and initial poor function after liver transplantation: are they connected? E Scarlatescu, G Manga, G Droc, D Tomescu Fundeni Clinical Institute, Bucharest, Romania Critical Care 2015, 19(Suppl 1):P378 (doi: 10.1186/cc14458) Introduction Factors associated with initial poor graft function (IPGF) after liver transplantation are still under debate. Although the initial insult to the graft begins during the cold ischemia time (CIT), recent studies showed that most injuries occur during rewarming. Ischemic– reperfusion (I/R) injuries are present in all grafts and may be responsible for postoperative graft dysfunction. Along with other factors, I/R injury may also play a role in the development of postreperfusion syndrome (PRS) after revascularization of the liver graft. The aim of this study was to assess whether longer warm ischemia time (WIT) is associated with PRS or with IPGF after liver transplant. Outcomes of decompensated chronic liver disease in a UK district general hospital critical care setting E Ahmadnia1, F Manneh2, K Raveendran2 1Homerton University Hospital, London, UK; 2Queen’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P380 (doi: 10.1186/cc14460) , , 1Homerton University Hospital, London, UK; 2Queen’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P380 (doi: 10.1186/cc14460) , , 1Homerton University Hospital, London, UK; 2Queen’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P380 (doi: 10.1186/cc14460) p p Methods This retrospective observational study included 60 liver transplant patients. We excluded from the study group patients with retransplant procedures, and the recipients of divided grafts and of grafts from extended criteria donors. We recorded: demographic data, intraoperative PRS, CIT, WIT, ALT, AST levels and standard coagulation tests on postoperative days (POD) 1 to 5. Statistical analysis was performed using SPSS Statistics v.19.1 with signifi cant P value under 0.05. Results We used the criteria of Nanashima and colleagues for the diagnosis of IPGF (ALT and/or AST level above 1,500 IU/l within 72 hours after OLT). The study group included 33 men (55%) and 27 women. Mean (±SD) age was 50.56 (±13.26) years. WIT longer than 60 minutes correlated signifi cantly with ALT and AST levels in POD 1 to 3 (P <0.0001 for ALT in POD 1 to 3, P = 0.001 for AST in POD 1, P = 0.007 and 0.013 for AST in POD 2 and 3) and with prothrombin time (P = 0.008 in POD 1, P = 0.03 in POD 2 and P = 0.015 in POD 3). We could not fi nd a correlation between PRS and WIT (P = 0.566), CIT (P = 0.439) or transaminase levels on POD 1 to 3. The correlation between WIT >60 minutes and IPGF was confi rmed using the Pearson chi-square test (P <0.0001). The same test was used to correlate IPGF with PRS with nonsignifi cant results (P = 0.876). Introduction Patients with decompensated cirrhosis admitted to the ICU have historically had a very high mortality rate [1]. It has been suggested that improving patient selection can improve ICU outcomes in patients with cirrhosis [2]. The aim of this study was to determine the mortality and evaluate the risk factors that may infl uence the outcome of this group of patients in a large UK district general hospital with a view to introducing selection criteria for future ICU admission of patients with decompensated liver disease. p p Methods A retrospective analysis was performed of all adult patients with decompensated chronic liver disease admitted to a general (nontransplant) critical care unit between January 2012 and December 2013. References The secondary aim was to investigate whether patients with intraoperative PRS have a higher risk for postoperative IPGF. P379 Seroprevalence of hepatitis B, hepatitis C and HIV in ICU patients H Bayir, I Yildiz, E Kocoglu, A Kurt, H Kocoglu Abant Izzet Baysal University, Medical School, Bolu, Turkey Critical Care 2015, 19(Suppl 1):P379 (doi: 10.1186/cc14459) Conclusion Those with decompensated chronic liver disease admitted to the ICU have a signifi cant ICU/hospital mortality, which is increased in alcoholic liver disease. Sepsis and AKI were the most common acute diagnoses in this cohort. Alcoholic liver disease patients requiring organ support have a very high mortality, and the outlook for multiorgan failure requiring RRT in this group is dismal. Introduction Healthcare workers are at risk for infections caused by hepatitis B (HBV), hepatitis C (HCV) and human immunodefi ciency (HIV) viruses that transmit via blood and body fl uids. In the present study, it was aimed to investigate the seroprevalences of HBsAg, anti- HCV and anti-HIV in patients admitted to the ICU. References References 1. Olson JC, et al. Hepatology. 2011;54:1864-72. 2. Sauneuf B, et al. Crit Care. 2013;17:R78. Methods HBsAg, anti-HCV and anti-HIV test results and demographical data of the patients admitted to the Reanimation ICU between January 2012 and December 2014 were evaluated retrospectively. HBsAg, anti-HCV and anti-HIV tests were assayed with a macro-ELISA method (Axsym-Abbott, Architect i2000; Abbott, USA). Statistical analysis was performed with the chi-square test. References 1. Erdem K, Tas T, Tekelioglu UY, Bugra O, Akkaya A, Demirhan A, et al. The hepatitis B, hepatitis C and human immunodefi ciency virus seroprevalence of cardiac surgery patients. SDÜ Tip Fak Derg. 2013;20:14-17 1. Erdem K, Tas T, Tekelioglu UY, Bugra O, Akkaya A, Demirhan A, et al. The hepatitis B, hepatitis C and human immunodefi ciency virus seroprevalence of cardiac surgery patients. SDÜ Tip Fak Derg. 2013;20:14-17 y 2. Tekin A, Deveci O. Seroprevalences of HBV, HCV and HIV among healthcare workers in a state hospital. J Clin Exp Invest. 2010;1:99-103. 2. Tekin A, Deveci O. Seroprevalences of HBV, HCV and HIV among healthcare workers in a state hospital. J Clin Exp Invest. 2010;1:99-103. Outcomes of decompensated chronic liver disease in a UK district general hospital critical care setting E Ahmadnia1, F Manneh2, K Raveendran2 1Homerton University Hospital, London, UK; 2Queen’s Hospital, London, UK Critical Care 2015, 19(Suppl 1):P380 (doi: 10.1186/cc14460) Data were collected regarding demographics, ICU mortality, hospital mortality, aetiology of chronic liver disease, severity scores, acute diagnoses, and organ support requirements.i Results Thirty-seven patients were identifi ed, with a median age of 57 years, predominantly male (62%). Seventy-six per cent had alcohol-related cirrhosis. Overall ICU mortality was 29.7% and hospital mortality was 48.6% – these values were higher in the alcoholic group (39.3% and 57.1% respectively). All ICU deaths were in those with alcoholic liver disease. Median scores were: APACHE III 93, SOFA (day 1) 9, Child–Pugh 11, MELD 21. Seventy per cent were treated for sepsis, 22% had a GI bleed, 57% had encephalopathy, 24% had suspected/ confi rmed spontaneous bacterial peritonitis, and 70% had an acute kidney injury. Organ support requirements were: 35% respiratory (non-invasive or invasive ventilation), 38% vasoactive agent support, 24% renal replacement therapy (RRT). Alcoholic liver disease patients requiring respiratory or cardiovascular support had an ICU mortality of 64%, and those requiring RRT had a mortality of 75%. Alcoholic liver disease patients requiring combined respiratory, cardiovascular, and RRT support had 100% mortality. Conclusion Our study showed that PRS is not a risk factor for IPGF after liver transplantation. WIT over 60 minutes does not infl uence the development of PRS, but is associated with IPGF after liver transplantation. Close monitoring of liver tests in the early postoperative period is very important especially in recipients of grafts with WIT over 60 minutes. Further eff orts to decrease WIT may prove useful for the reduction of IPGF in liver transplant patients. First clinical experience with a new type of albumin dialysis: the HepaWash® system First clinical experience with a new type of albumin dialysis: the HepaWash® system First clinical experience with a new type of albumin dialysis the HepaWash® system B Henschel, R Schmid, W Huber TU-München Klinikum rechts der Isar, Munich, Germany Critical Care 2015, 19(Suppl 1):P383 (doi: 10.1186/cc14463) B Henschel, R Schmid, W Huber TU-München Klinikum rechts der Isar, Munich, Germany Critical Care 2015, 19(Suppl 1):P383 (doi: 10.1186/cc14463) Introduction Liver failure (LF) is associated with prolonged hospital stay, increased cost and substantial mortality. With regard to a limited number of donor organs, extracorporeal liver support is an appealing concept to bridge to transplant or to avoid transplant in case of recovery. A new type of albumin dialysis, the HepaWash® system, was recently introduced. The HepaWash® system provides rapid re- generation of toxin-binding albumin by secondary circuits altering binding capacities of albumin by biochemical (changing pH) and physical (changing temperature) modulation of the dialysate.i Results Eight children (fi ve male/three female), 8.6 ± 5.9 years old (range 2 to 15.6 years), BW 32 ± 21 kg, GFR 71 ± 20 ml/minute/1.73 m2, with an uncuff ed double lumen dialysis catheter (8 to 14 Fr Femoralis (n = 6) and 9 Fr Jugularis (n = 2)) were treated according to this protocol. In total, 19 sessions were executed using FX40 (n = 13), FX50 (n = 3), and FX60 (n = 3) dialysers during 6.5 ± 0.9 hours. Blood fl ow was 149 ± 45 ml/minute, albumin fl ow 226 ± 49 ml/minute, and ultrafi ltration fl ow 432 ± 517 ml. RRs were 70 ± 15% (urea), 34 ± 14% (Crea), 44 ± 16% (bili), and 36 ± 10% (NH3). Primary survival rate was 100%. Four patients were transplanted (bridge to transplant) of which, however, one died within 30 days after discharge from the ICU. The fi fth patient died due to primary disease 9 months after treatment, and the remaining three patients fully recovered (bridge to recovery). y y Methods We evaluated the fi rst 14 patients treated with the HepaWash® system with regard to safety and effi cacy. Seven patients were treated in the context of the run-in phase of the studies (HEPATICUS 1 and HEPATICUS 2) and seven patients were treated since the HepaWash® system received the CE certifi cate in July 2013. P381 Prometheus® liver therapy in children with acute liver failure J Vande Walle, S Claus, E Snauwaert, J De Rudder, A Raes, M Dick, A Prytula, W Van Biesen, S Eloot Ghent University Hospital, Gent, Belgium Critical Care 2015, 19(Suppl 1):P381 (doi: 10.1186/cc14461) Results The records of 462 patients admitted to our ICU were reviewed. The results of 36 patients could not be reached, so 426 patients were evaluated in the study. Among 426 patients, 169 (39.7%) were female and 257 (60.3%) were male. The mean age was 63.7 ± 18.7. HBsAg was positive in nine (2.1%) patients; all of these nine were male. Anti-HCV was positive in four (0.9%) patients; among these, three were male and one was female. Only one patient was positive for anti-HIV. Introduction The Fractionated Plasma Separation and Adsorption System Prometheus® (Fresenius Medical Care, Germany) aims at being S134 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion Close observation and treatment of coagulopathy and electrolyte disturbances is essential when treating patients with MARS. MARS can reduce and stabilize ammonium and other biomedical markers in patients listed for urgent liver transplantation with high MELD score and liver encephalopathy. It seems that, in some cases and with our settings, the detoxifi cation properties of MARS may be insuffi cient. a supportive therapy as a bridge to transplantation or recovery in adults with liver failure. The system off ers specifi c challenges when applied in children due to the large extracorporeal volume (700 to 750 ml). We therefore developed an adapted protocol for the application in children. Methods Priming of the blood circuit is performed using 2 l isotonic saline, whereas the plasma circuit, containing both adsorption devices, is fi lled with 2 U fresh frozen plasma or 400 ml stabilized solution of human plasma proteins. Next, for children with body weight (BW) <25 kg, a solution of 60 to 65% packed cells (PC) is infused in the inlet blood line at 40 ml/minute. The volume of PC needed is calculated based on the circuit priming volume and the maximum allowed extracorporeal blood volume of the child (= 8 ml/kg × BW). After the priming phase, blood and plasma fl ow are increased to at least 100 ml/ minute and 200 ml/minute, respectively, and dialysate fl ow is set at 300 ml/minute. P381 Regional citrate anticoagulation is done with a calcium- free dialysate, while, eventually, heparin is added to the priming solution. Post treatment, the circuit volume is either not reinfused (BW <25 kg) or reinfused using isotonic saline (BW >25 kg), with a volume depending on the hydration status and the originally infused volume of PC. Reduction ratios (RRs, %) of urea, creatinine (Crea), bilirubin (bili), and ammonia (NH3) were calculated from pretreatment and posttreatment serum concentrations. Primary and secondary patient outcome was evaluated.i P383 Molecular adsorbent recirculating system treatment in 69 patients listed for liver transplantation P Oli H H Molecular adsorbent recirculating system treatment in 69 patients listed for liver transplantation P Olin, H Haugaa Oslo University Hospital, Oslo, Norway Critical Care 2015, 19(Suppl 1):P382 (doi: 10.1186/cc14462) Introduction The molecular adsorbent recirculating system (MARS) is used to remove circulating albumin-bound toxins in patients with liver failure. However, the application of MARS has not demonstrated improved survival in randomized clinical trials and the clinical utility has not been fi nally established. In our department, the use of MARS is now restricted to the most critically ill patients with acute or acute on chronic liver failure. We aimed to explore MARS effi cacy in removing toxicity parameters and the safety of the system. Conclusion So far the HepaWash® system has proven to be a safe and feasible procedure to eff ectively eliminate water and protein-bound toxins in humans with LF. First clinical experience with a new type of albumin dialysis: the HepaWash® system Patients treated suff ered under acute on chronic LF (n = 9) or secondary LF which resulted from nonhepatic diseases such as sepsis (n = 5). Primary endpoint: comparison of serum bilirubin, creatinine and serum BUN before and after the fi rst treatment with the HepaWash® system. Statistics: IBM SPSS Statistics version 22. The Wilcoxon test for paired samples was used to detect signifi cant treatment eff ects. gif Results A total of 254 treatments (1 to 101 per patient) were performed in 14 patients (six female, eight male). Mean age 54 ± 13. MELD score 33.7 ± 7.0, CLIF-SOFA 14.6 ± 2.7. Main underlying disease: nine acute- on-chronic LF; fi ve secondary LF. While bilirubin did not change signifi cantly on the day before HepaWash® treatment (26.2 ± 15.4 vs. 26.0 ± 15.4 mg/dl; P = 0.116), serum bilirubin levels were signifi cantly decreased by the HepaWash® procedure (26.0 ± 15.4 vs. 17.7 ± 10.5 mg/ dl; P = 0.001). Similarly, serum creatinine (2.2 ± 0.8 vs. 1.6 ± 0.7 mg/dl; P = 0.005) and serum BUN (49.4 ± 23.3 vs. 31.1 ± 19.7 mg/dl; P = 0.003) were signifi cantly lowered by the HepaWash® procedure. There were no serious adverse events observed in conjunction with the HepaWash® treatment. Conclusion This adapted Prometheus® protocol is promising for the treatment of children with liver failure. P382 Intensive care referral and admission: do the criteria for liver disease match? J McPeake, CR Soulsby, T Quasim, J Kinsella University of Glasgow, UK Critical Care 2015, 19(Suppl 1):P384 (doi: 10.1186/cc14464) to c ty pa a ete s a d t e sa ety o t e syste . Methods Since 2005, we have treated 69 patients (30 males/39 females with median age of 39 years ranging from 1 month to 70 years) listed for liver transplantation with MARS. The median Model of End Stage Liver Disease (MELD) score in patients older than 12 years of age (n = 56) was 33 (interquartile range 26 to 39). The fl ow rate was 35 to 40 ml/ kg/hour and treatment kits were changed every 8 to 12 hours. The patients were treated for a median of 31 hours (range 1 to 240 hours). Results Fifty-fi ve patients (79%) were successfully bridged to transplantation. Nine died before they could be transplanted, and fi ve patients recovered without liver transplantation. Forty-four (81%) of the transplanted patients were alive 30 days after transplantation. Ammonium decreased modestly from a median of 148 to 124 μM (P = 0.03) during MARS treatment. We detected worsening of coagulopathy with signifi cant decreases in platelet count and fi brinogen concentrations, and increase in International Normalized Ratio. Phosphate and magnesium decreased signifi cantly during MARS treatment. J McPeake, CR Soulsby, T Quasim, J Kinsella University of Glasgow UK J McPeake, CR Soulsby, T Quasim, J Kinsella University of Glasgow, UK Introduction Hospital admission and mortality rates for patients with cirrhosis in the UK are rising [1]. Cirrhotic patients are physiologically challenged and at increased risk of sepsis and death [2]. Mortality rates for cirrhosis in nontransplant ICUs are up to 37% [3]. Increased availability of medical therapies and public expectation places pressure on limited intensive care resources. There is a lack of research into factors used to decide which patients to admit or refer to the ICU Introduction Hospital admission and mortality rates for patients with cirrhosis in the UK are rising [1]. Cirrhotic patients are physiologically challenged and at increased risk of sepsis and death [2]. Mortality rates for cirrhosis in nontransplant ICUs are up to 37% [3]. Increased availability of medical therapies and public expectation places pressure on limited intensive care resources. There is a lack of research into factors used to decide which patients to admit or refer to the ICU. Methods A prospective survey was sent to all consultant gastroenterologists and consultant intensivists in Scotland. Mortality in patients with cirrhosis admitted to the ICU: time to rethink strategies? g A Vaz, M Eusebio, A Antunes, A Sousa, P Perez, R Ornelas, C Granja, H Guerreiro Centro Hospitalar do Algarve, Faro, Portugal Critical Care 2015, 19(Suppl 1):P385 (doi: 10.1186/cc14465) Methods A prospective study of 132 consecutive patients admitted to the Critical Burn Unit between October 2008 and October 2011. In all of them resuscitation was performed by objectives: blood pressure (>65 mmHg), hourly diuresis (0.5 to 1 cm3/kg), lactic acid clearance and thermodilution transpulmonary parameters (CI >2.5 l/minute/m2, ITBI: 600 ml/m2). We performed measurements of IAP with a bladder catheter every 8 hours in the fi rst 72 hours. Introduction Cirrhotic patients admitted to the ICU are usually regarded as having a particularly poor prognosis when compared with other groups of critically ill patients. The aim of our study was to evaluate the prevalence, case mix and outcomes of patients with cirrhosis admitted to the general ICU of a nontransplant center. yi Results Ninety-eight men and 34 women were studied. Mean age 48 ± 18 years and a TBSA of 35 ± 22%. The fl uid provided by %TBSA in the fi rst 8 hours was less than predicted by Parkland (4.05 ml/kg), although the total contribution in the fi rst 24 hours was similar. The evolution of the intra-abdominal pressure was: admission 9.7 mmHg, 8 hours 11, 16 hours 10.5, 24 hours 12.1, 32 hours 12.0, 40 hours 12.0, 48 hours 11.1, 56 hours 10.3, 64 hours 10.0 and 72 hours 10.0. A total of 44 patients (33.3%) had a determination higher than 12 mmHg, distributed: 15 patients between 12 and 15 mmHg (IAHT I grade), 14 between 16 and 20 mmHg (II), nine between 21 and 25 mmHg (III) and six >25 mmHg (IV). See Figures 1 and 2.l g p Methods Data were collected from a running ICU database. We studied cirrhotic patients admitted to the ICU between January 2013 and November 2014. Results A total of 30 patients with cirrhosis were admitted, accounting for 3% of total ICU admissions. Mean age was 54.5 years, with a male preponderance (76.7%). The main cause for cirrhosis was alcohol (53.3%), followed by alcohol plus chronic hepatitis C virus (HCV) infection (20%) and HCV virus infection alone (13.3%). The most common causes for admission were sepsis/septic shock (26.7%), surgical (23.4%), gastrointestinal bleeding and hepatic encephalopathy (16.7% each). Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 decision. Recipients listed additional criteria used in their own practice and asked whether they would admit or refer individual grades of Child–Pugh cirrhosis with either a gastrointestinal bleed or sepsis.i decision. Recipients listed additional criteria used in their own practice and asked whether they would admit or refer individual grades of Child–Pugh cirrhosis with either a gastrointestinal bleed or sepsis.i C in the Child–Pugh score; mean Acute Physiology and Chronic Health Evaluation (APACHE II) 29.2 ± 8.7 and new Simplifi ed Acute Physiology Score (SAPS II) 62.7 ± 29. Regarding organ failure at admission, the mean Sequential Organ Failure Assessment score was 12.8 ± 4.5. The ICU mortality of these patients was 43.3% and hospital mortality was 53.3%. The variables at admission that related signifi cantly with ICU mortality were: all scores described except for Child–Pugh score, bilirubin, the International Normalized Ratio, creatinine, bicarbonate, lactate, pH and the use of renal replacement therapy during the ICU stay (P <0.05). The mortality rate of cirrhotic patients was superior to the general ICU mortality (43% vs. 26%). However, patients with cirrhosis presented signifi cantly higher severity scoring systems (APACHE II; SAPS II) at admission compared with noncirrhotics, with high prevalence of organ dysfunction as assessed by SOFA score. Results Thirty-fi ve consultant gastroenterologists and 65 intensive care consultants responded, representing a response rate of 34% and 45% respectively. The only criterion given an average rating of 5 by both gastroenterologists and intensivists was Child–Pugh score when stable. Presence on the transplant list, referral secondary to bleeding varices, recent discharge from the ICU, abstinence from alcohol, nutritional status, age under 30 and more than one additional organ failure all scored 4 or 5 from both groups. Sex, employment, smoking or drug use, deprivation and positive virology status did not infl uence the decision to refer or admit patients. Clinicians reported compliance with medication and outpatient appointments plus an obvious precipitant factor as important features in their decision. The majority of respondents would refer or admit all grades of Child–Pugh cirrhosis with gastrointestinal bleeding. Most would refer or admit Child–Pugh A or B with sepsis. A total 76.5% of gastroenterologists would refer Child–Pugh C cirrhosis with sepsis but only 33.3% of intensivists would accept. P385 Mortality in patients with cirrhosis admitted to the ICU: time to rethink strategies? A Vaz, M Eusebio, A Antunes, A Sousa, P Perez, R Ornelas, C Granja, H Guerreiro Centro Hospitalar do Algarve, Faro, Portugal Critical Care 2015, 19(Suppl 1):P385 (doi: 10.1186/cc14465) Introduction The aim was to study the evolution and incidence of intraabdominal hypertension in critical burn patients using a slightly restrictive fl uid therapy protocol based on monitoring transpulmonary thermodilution and lactic acid. Intraabdominal pressure in critical burn patients PM Millan 2. Foreman MG, et al. Chest. 2003;124:1016-20. , ; 3. Filloux B, et al. Eur J Gastroenterol Hepatol. 2010;22:1474-80. 3. Filloux B, et al. Eur J Gastroenterol Hepatol. 2010;22:1474-80. Hospital Universitario La Paz, Madrid, Spain Hospital Universitario La Paz, Madrid, Spain Critical Care 2015, 19(Suppl 1):P386 (doi: 10.1186/cc14466) p , , p Critical Care 2015, 19(Suppl 1):P386 (doi: 10.1186/cc14466) Intensive care referral and admission: do the criteria for liver disease match? J McPeake, CR Soulsby, T Quasim, J Kinsella University of Glasgow, UK Critical Care 2015, 19(Suppl 1):P384 (doi: 10.1186/cc14464) Each recipient rated the signifi cance of 18 physiological and social criteria on their decision to refer or admit a patient to intensive care from 1 to 5, with 1 being no infl uence and 5 denoting signifi cant impact on the Results Fifty-fi ve patients (79%) were successfully bridged to transplantation. Nine died before they could be transplanted, and fi ve patients recovered without liver transplantation. Forty-four (81%) of the transplanted patients were alive 30 days after transplantation. Ammonium decreased modestly from a median of 148 to 124 μM (P = 0.03) during MARS treatment. We detected worsening of coagulopathy with signifi cant decreases in platelet count and fi brinogen concentrations, and increase in International Normalized Ratio. Phosphate and magnesium decreased signifi cantly during MARS treatment factors used to decide which patients to admit or refer to the ICU. Methods A prospective survey was sent to all consultant gastroenterologists and consultant intensivists in Scotland. Each recipient rated the signifi cance of 18 physiological and social criteria on their decision to refer or admit a patient to intensive care from 1 to 5, with 1 being no infl uence and 5 denoting signifi cant impact on the S135 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion The high severity of disease in conjunction with the high mortality rate observed in this group of patients should make us consider the possible benefi ts of earlier referring/admission to the ICU, ideally before multiorgan failure arises. On the other hand, in nontransplant centers where cirrhotic patients constitute a small percentage of total ICU admissions, the complexity and peculiarities of the management of these patients should prompt their early transfer to a specialized center. Conclusion Referral and admission decisions for patients with cirrhosis are multifactorial. Child–Pugh status when stable appears to be of greatest signifi cance. The diff erence in opinion of admission of patients with Child–Pugh C with sepsis requires further evaluation. References 1. Thomson SJ, et al. Alcohol Alcohol. 2008;43:416-22. 2. Foreman MG, et al. Chest. 2003;124:1016-20. 3. Filloux B, et al. Eur J Gastroenterol Hepatol. 2010;22:1474-80. 1. Thomson SJ, et al. Alcohol Alcohol. 2008;43:416-22. P387 Intraabdominal hypertension in burn patients Results are depicted as mean values ± SD in Tables 1 and 2. y y Results Twenty patients were enrolled in the study. The mean age was 36 ± 13 years. There were 14 males and six females. The average TBSA was 44 ± 17%. Screening and monitoring of IAP were applied by: oliguria (42%), abdominal distension (31.5%) and gastrointestinal trouble (21%). IAH occurred between day 2 and day 3 after early burn resuscitation, respectively in 52% and 63%. IAH was observed in 69% of cases in patients admitted to the ICU with a delay of 1.6 days post burn injury. IAH was noted in 13 patients; of these, fi ve patients developed an abdominal compartment syndrome. The mean IAP was 16 ± 7 mmHg. Patients were assigned into two groups: G1 (IAH+; n = Conclusion Both sepsis and IAH have negative eff ects on respiratory mechanics. However, their combination has even more detrimental eff ects, which do not ameliorate after deinsuffl ation. Table 1 (abstract P388). P387 Intraabdominal hypertension in burn patients Methods Sixteen pigs were divided into two groups of eight (G-A/ G-B). All animals received general anesthesia and were mechanically ventilated. Parameters recorded included respiratory system, chest wall and lung compliance (CRS, CCW, CL) and respiratory system and chest wall inspiratory and expiratory resistances (RRSisp, RRSexp, RCWisp, RCWexp). After baseline measurements (0 minutes), intra- abdominal pressure IAP was raised by helium insuffl ation to 25 mmHg in both groups and remained at that level for the whole study. In G-B, sepsis was induced 60 minutes after IAP increase, by i.v. administration of Escherichia coli endotoxin. Parameters were recorded every 20 minutes. The last measurement was made at 180 minutes, right after deinsuffl ation, and IAP return to baseline levels.i Intraabdominal hypertension in burn patients A Mokline, I Rahmani, L Gharsallah, A Hachani, S Tlaili, R Hammouda, B Gasri, A Ksontini, AA Mesadi Trauma and Burn Centre of Tunis, Tunisia Critical Care 2015, 19(Suppl 1):P387 (doi: 10.1186/cc14467) Introduction Intra-abdominal hypertension (IAH) is frequent in the ICU and has been associated with adverse outcomes and worse prognosis. The purpose of our study was to assess risk factors for IAH and prognosis of major injured patients during burn resuscitation. Introduction Intra-abdominal hypertension (IAH) is frequent in the ICU and has been associated with adverse outcomes and worse prognosis. The purpose of our study was to assess risk factors for IAH and prognosis of major injured patients during burn resuscitation. j j p g Methods Adult burned patients with a burn injury exceeding 20% of total body surface area, from 1 April to 30 November 2013, were included. IAP was measured when IAH was suspected, according to the Kron method via the Foley catheter. Monitoring of IAP was performed every 6 hours during 5 days until normalization. fl Results CRS decreased statistically signifi cantly in both groups after IAP increase and increased after deinsuffl ation only in G-A. Similarly, CCW decreased in both groups but returned to baseline values in both groups after deinsuffl ation. CL decreased more signifi cantly in G-B and returned to baseline values only in G-A. RRSisp increased only in G-B and did not decrease after deinsuffl ation, whereas RRSexp increased in both groups, in a more signifi cant manner in G-B, and decreased only in G-A after deinsuffl ation. RCWisp and RCSesp did not show any alterations during the study period. P388 Eff ects of sepsis on respiratory mechanics in a porcine model of intra-abdominal hypertension Figure 2 (abstract P386). IAH classifi cation. Introduction The aim of our study was to investigate the eff ects of sepsis on respiratory mechanics in a porcine model of intra-abdominal hypertension (IAH). aSepsis induction. Comparison with baseline: P <0.05, ** P<0.01. Mortality in patients with cirrhosis admitted to the ICU: time to rethink strategies? At admission, these patients presented an average Model for End- Stage Liver Disease score of 23.5 ± 10.4 with 70% classifi ed as grade Conclusion IAH incidence when a slightly restrictive fl uid protocol used is less than expected. Figure 1 (abstract P386). Intraabdominal pressure. S136 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 2 (abstract P386). IAH classifi cation. Figure 2 (abstract P386). IAH classifi cation. 13) and G2 (IAH–; n = 7). Comparative study of the two groups shows that HIA increases signifi cantly body weight gain within the fi rst 5 days after injury: 8 kg for G1 versus 2 kg for G2 (P = 0.04), occurrence of ARDS (70% for G1 vs. 16.7% for G2, P = 0.02), respiratory failure (77% for G1 vs. 28.5% for G2, P = 0.06), shock (70% for G1 vs. 16.7% for G2, P 0.02) and mortality (61.5% vs. 50%). 13) and G2 (IAH–; n = 7). Comparative study of the two groups shows that HIA increases signifi cantly body weight gain within the fi rst 5 days after injury: 8 kg for G1 versus 2 kg for G2 (P = 0.04), occurrence of ARDS (70% for G1 vs. 16.7% for G2, P = 0.02), respiratory failure (77% for G1 vs. 28.5% for G2, P = 0.06), shock (70% for G1 vs. 16.7% for G2, P 0.02) and mortality (61.5% vs. 50%). Conclusion IAH was frequent in early burn resuscitation of major injured patients. It seems to be associated with fl uid overload in burns and contributes to organ damage. P388 P388 Eff ects of sepsis on respiratory mechanics in a porcine model of intra-abdominal hypertension B Fyntanidou, K Kotzampasi, M Kyparissa, G Stavrou, E Oloktsidou, X Mpesi, K Papapostolou, V Grosomanidis Aristotle Medical School, Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P388 (doi: 10.1186/cc14468) aSepsis induction. Comparison with baseline: P <0.05, * P<0.01. P387 Intraabdominal hypertension in burn patients Compliance alterations during the study CRS (ml/cmH2O) CCW (ml/cmH2O) CL (ml/cmH2O) Minutes A B P value A B P value A B P value 0 35 ± 8 31 ± 4 NS 58 ± 20 46.1 ± 11 NS 99 ± 22 98 ± 14 NS 20 14 ± 4 12 ± 3 NS 20 ± 6 17.7 ± 3 NS 52 ± 21 35 ± 11 NS 40 13 ± 4 12 ± 1 NS 19 ± 6 16.8 ± 3 NS 47 ± 23 36 ± 13 NS 60a 12 ± 3 11 ± 2 NS 20 ± 5 18.4 ± 4 NS 41 ± 20 28 ± 7 NS 80 13 ± 3 10 ± 1 NS 20 ± 6 18.2 ± 44 NS 41 ± 21 24 ± 6 <0.05 100 12 ± 3 10 ± 2 NS 21 ± 8 19.9 ± 5 NS 37 ± 20 19 ± 4 <0.05 120 12 ± 3 10 ± 1 NS 20 ± 6 21.9 ± 7 NS 37 ± 20 17 ± 3 <0.05 140 12 ± 3 9 ± 1 NS 21 ± 7 21.8 ± 6 NS 37 ± 20 17 ± 5 <0.05 160 12 ± 3 9 ± 1 NS 21 ± 7 22.3 ± 7 NS 37 ± 19 16 ± 4 <0.05 180 33 ± 7 16 ± 5 <0.001 50 ± 18 77.0 ± 18 <0.05 81 ± 20* 21 ± 7** <0.001 aSepsis induction. Comparison with baseline: P <0.05, * P<0.01. Table 1 (abstract P388). Compliance alterations during the study S137 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Table 2 (abstract P388). P389 P390 Randomized, double-blind, placebo-controlled study of the effi cacy of four probiotics to modify the risk for postoperative complications in colorectal surgery K Kotzampassi1, G Stavrou1, G Damoraki2, M Georgitsi2, G Basdanis1, G Tsaousi1, EJ Giamarellos-Bourboulis2 1Aristotle University of Thessaloniki, Greece; 2 University of Athens Medical School, Athens, Greece Critical Care 2015, 19(Suppl 1):P390 (doi: 10.1186/cc14470) P390 Randomized, double-blind, placebo-controlled study of the effi cacy of four probiotics to modify the risk for postoperative complications in colorectal surgery K Kotzampassi1, G Stavrou1, G Damoraki2, M Georgitsi2, G Basdanis1, G Tsaousi1, EJ Giamarellos-Bourboulis2 1Aristotle University of Thessaloniki, Greece; 2 University of Athens Medical School, Athens, Greece Critical Care 2015, 19(Suppl 1):P390 (doi: 10.1186/cc14470) P390 Randomized, double-blind, placebo-controlled study of the effi cacy of four probiotics to modify the risk for postoperative complications in colorectal surgery Introduction CD73/ecto-5’-nucleotidase is an enzyme that generates adenosine, which dampens infl ammation and improves vascular barrier function in several disease models. CD73 also circulates in a soluble form in the blood [1]. We studied whether levels of soluble form of CD73 and cytokines/chemokines predict the development of organ failure in acute pancreatitis [2,3]. Introduction Heterogeneous published results led us to conduct a clinical trial to assess the effi cacy of a new formulation of four probiotics (P) as prophylaxis for complications after colorectal surgery. p Methods Altogether, 161 patients with acute pancreatitis (107 were subclassifi ed according to the revised Atlanta criteria into mild, 29 into moderately severe and 25 into severe forms) were studied. Serum and blood cell samples were collected at admission. Protein levels of soluble form of CD73 in serum were determined using a novel enzyme- linked immunosorbent assay, activity of soluble form of CD73 using radioactive enzyme assays, and CD73 messenger RNA levels from leukocytes using quantitative PCR. Serum levels of 48 cytokines and growth factors were determined using Bio-Plex Pro Human Cytokine Assay 21-plex and 27-plex magnetic bead suspension panels. y g y Methods A double-blind, placebo-controlled randomized study was conducted enrolling patients undergoing colorectal cancer surgery. Placebo or a formulation of L. acidophilus, L. plantarum, B. lactis and S. boulardii was administered starting 1 day before operation and continuing for 15 days post operation. Patients were followed-up for 30 days with the development of postoperative complications as the primary outcome. PAXGene tubes and serum were collected on postoperative day 4 for measurement of gene expression and serum cytokines (ClinicalTrials.gov NCT02313519). 1. Salmi M, Jalkanen S. Semin Immunopathol. 2014;36:163-76. 2. Maksimow M, et al. Crit Care Med. 2014; 42:2556 3. Nieminen A, et al. Crit Care. 2014 [Epub ahead of print]. P387 Intraabdominal hypertension in burn patients Respiratory system resistance alterations during the study RRSisp (cmH2O/l/minute) RRSexp (cmH2O/l/minute) Minutes A B P value A B P value 0 8.1 ± 0.8 8.3 ± 0.7 NS 13.6 ± 4.1 15.5 ± 3.7 NS 20 7.8 ± 0.6 8.1 ± 0.7 NS 17.1 ± 5.2 19.3 ± 2.2 NS 40 7.8 ± 0.8 7.6 ± 0.9 NS 18.1 ± 5.4 20.6 ± 3.1 NS 60a 7.6 ± 0.9 7.5 ± 1.1 NS 18.9 ± 4.4 19.9 ± 4.7 NS 80 7.8 ± 1.2 8.2 ± 1.2 NS 18.6 ± 4.2 21.1 ± 4.12 NS 100 7.8 ± 0.9 7.9 ± 0.9 NS 18.2 ± 4.5 22.7 ± 4.5 NS 120 8 ± 0.6 9.1 ± 1.1 <0.05 18.6 ± 4.3 20.9 ± 2.2 NS 140 7.7 ± 0.6 9.5 ± 1.2 <0.01 18.8 ± 3.5 22.9 ± 3.2 <0.05 160 7.3 ± 0.7 9.6 ± 1.5* <0.01 17.7 ± 3.5 22.2 ± 2.3 <0.01 180 8.1 ± 0.8 9.7 ± 1.2* <0.01 14.9 ± 3.3 18.9 ± 2.3* <0.05 aSepsis induction. Comparison with baseline: P <0.05, P <0.01. Table 2 (abstract P388). Respiratory system resistance alterations during the study P389 Severity markers in acute pancreatitis S Jalkanen University of Turku, Finland Critical Care 2015, 19(Suppl 1):P389 (doi: 10.1186/cc14469) P390 Randomized, double-blind, placebo-controlled study of the effi cacy of four probiotics to modify the risk for postoperative complications in colorectal surgery K Kotzampassi1, G Stavrou1, G Damoraki2, M Georgitsi2, G Basdanis1, G T i1 EJ Gi ll B b li 2 P389 y g Results Administration of P signifi cantly decreased the rate of all postoperative major complications (28.6% vs. 48.8% of placebo, P = 0.010, odds ratio: 0.42). Major benefi t was found in the reduction of the postoperative pneumonia rate (2.4% vs. 11.3%, P = 0.029), of wound infections (7.1% vs. 20.0%, P = 0.020), of anastomotic leakage (1.2% vs. 8.8%, P = 0.031) and of the need for mechanical ventilation (20.2% vs. 35.0%, P = 0.037). The time until hospital discharge was shortened as Results Activity and protein concentration of soluble form of CD73 and messenger RNA level of CD73 all decreased along with the disease severity (P ≤0.01 for all). The activity of soluble form of CD73 at admission predicted the development of severe pancreatitis in diff erent groups of the patients. Especially, activity of soluble form of CD73 was better than C-reactive protein or creatinine in predicting the severity of pancreatitis in the group of patients without any signs of organ failure at admission. In subgroup analyses of patients with severe pancreatitis and without organ dysfunction upon admission, IL- 8, hepatocyte growth factor and granulocyte colony-stimulating factor (G-CSF) levels predicted the development of severe pancreatitis, with G-CSF being the most accurate cytokine. Figure 1 (abstract P390). Figure 1 (abstract P390). y Conclusion Activity of soluble form of CD73 and levels of certain cytokines at admission to the hospital have prognostic value in predicting the development of the severe form of acute pancreatitis. The possibility that combining them with other prognostic markers might improve prognostic accuracy requires further studies. References 3. Nieminen A, et al. Crit Care. 2014 [Epub ahead of print]. Figure 1 (abstract P390). S138 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 well. Gene expression of SOCS3 was positively related with circulating IL-6 in the P group but not in the placebo group (Figure 1). Conclusion The studied P formulation signifi cantly decreased the risk of postoperative complications, namely mechanical ventilation, infections and anastomotic leakage. Modulation of the gene expression of SOCS3 is one suggested mechanism. thiamine 200 mg or placebo i.v. twice/day for 7 days. The primary outcome was lactate levels at 24 hours. Secondary outcomes included the SOFA score at 24 hours and mortality. Role of ultrasonography in detection of the localization of the nasoenteric tube R Dagli1, H Bayir2, Y Dadali1, T Tokmak1, Z Erbesler1 1Ahi Evran University Education and Research Hospital, Kirsehir, Turkey; 2Abant Izzet Baysal University, Medical School, Bolu, Turkey Critical Care 2015, 19(Suppl 1):P391 (doi: 10.1186/cc14471) Introduction In this study, we aimed to determine the success rate of nasoenteric tube (NET) insertion into the postpyloric area by ultrasonography (USG) and compare it with the commonly used method, direct abdominal radiography. g p y Methods Patients admitted to an adult ICU between April and July 2014 with an indication for NET insertion for enteral feeding were included in the study after informed consent was given from patients’ relatives. Nasoenteric feeding tubes were placed using the blind bedside method by a single anesthesiologist. Any motility stimulant agent was not used. The outside of the polyurethrane 8 F with unweighted NET (Bexen, Spain) and its guiding wire were lubricated with gel. The NET was inserted into the nostril after determination of the mouth– posterior ear–xiphoid distance and pushed on at least such a distance. Followed by auscultation of the gastric area and air infusion of 30 to 50 ml into the tube, the patient was positioned on their right side and the tube was advanced 20 to 30 cm more. Then the guiding wire inside the NET was removed. The patient was then brought to the supine position and NET was visualized by two radiologists simultaneously by M5 portable USG (Mindray, PRC), with a 3.5 MHz convex probe whether it passes through the postpyloric area or not. Localization of the tube was confi rmed with abdominal radiography in all patients. During the fi rst insertion of the NET, the ratios for inaccurate localization and correct placements through the postpyloric area were recorded and results were compared with abdominal radiography. Conclusion Thiamine defi ciency is prevalent in septic shock. Thiamine did not decrease overall median lactate levels at 24 hours. In the patients with thiamine defi ciency, there were statistically signifi cant lower lactate levels at 24 hours in the thiamine group and a large, although nonsignifi cant, diff erence in mortality. P392 Thiamine as a metabolic resuscitator in septic shock: a randomized, double-blind, placebo-controlled, pilot trial M Donnino1, LW Andersen1, M Chase1, KM Berg1, TA Giberson1, H Smithline2, M Tidswell2, R Wolfe1, M Cocchi1 1Beth Israel Deaconess Medical Center, Boston, MA, USA; 2Baystate Medical Center, Springfi eld, MA, USA Critical Care 2015, 19(Suppl 1):P392 (doi: 10.1186/cc14472) Unraveling the link between malnutrition and adverse clinical outcomes: association of acute and chronic malnutrition measures with blood biomarkers from diff erent pathophysiological systems S Felder, N Braun, A Kutz, M Batschwaroff , P Schuetz Kantonsspital Aarau, Switzerland Critical Care 2015, 19(Suppl 1):P393 (doi: 10.1186/cc14473) Introduction Malnutrition is common in hospitalized medical patients and is associated with poor clinical outcomes. Whether malnutrition has a direct link to adverse outcomes or is rather a mirror of the severe patient condition remains debated. Our aim was to study the association of acute and chronic malnutrition status with blood biomarkers from diff erent pathophysiological concepts to better understand the underlying mechanisms of malnutrition. Results In this study, the bedside blind method was used for NET insertion into 34 patients. Eleven of the tubes were detected passing through the postpyloric area by USG. In one case the NET could not be seen in the postpyloric area by USG, but it was detected in the postpyloric area by control abdominal radiography. In 22 patients, NETs were detected in the stomach with control abdominal radiography. Success for NET placement with the bedside blind method and USG imaging was 35% versus 91.6%, respectively. Methods We prospectively followed consecutive adult medical inpatients hospitalized between February 2013 and October 2013 in a tertiary care Swiss hospital. Nutritional risk was assessed using the Nutritional Risk Screening (NRS 2002) score, which incorporates acute and chronic measures of malnutrition. Multiadjusted regression models were used to investigate the associations between acute and chronic nutritional risk and biomarkers mirroring infl ammation (CRP, PCT, proADM, leucocytes), stress (copeptin), renal dysfunction (creatinine, urea), nutritional status (vitamin D25, albumin, calcium, glucose), and hematological function (platelets, INR, Hb, RDW). Biomarker levels were transformed into deciles due to skewed distributions. Conclusion The success rate of the bedside blind method in the NET placement was low. It is clear that if any other placement techniques with high success rate will be applied, USG will be useful in a higher number of patients reducing the need for abdominal radiography. P389 Lactate levels at 24 hours were compared between groups using the Wilcoxon rank-sum test and categorical variables were compared using the Fisher’s exact test. Lactate values at 24 hours, for those who died before 24 hours, were imputed according to a predefi ned plan. We performed a preplanned analysis in those with baseline thiamine defi ciency (≤7 nmol/l). well. Gene expression of SOCS3 was positively related with circulating IL-6 in the P group but not in the placebo group (Figure 1).i thiamine 200 mg or placebo i.v. twice/day for 7 days. The primary outcome was lactate levels at 24 hours. Secondary outcomes included the SOFA score at 24 hours and mortality. Lactate levels at 24 hours were compared between groups using the Wilcoxon rank-sum test and categorical variables were compared using the Fisher’s exact test. Lactate values at 24 hours, for those who died before 24 hours, were imputed according to a predefi ned plan. We performed a preplanned analysis in those with baseline thiamine defi ciency (≤7 nmol/l). Conclusion The studied P formulation signifi cantly decreased the risk of postoperative complications, namely mechanical ventilation, infections and anastomotic leakage. Modulation of the gene expression of SOCS3 is one suggested mechanism. yi y ( ) Results We enrolled 88 patients; 43 received thiamine and 45 placebo. Baseline characteristics were similar between groups. We found no overall statistical signifi cant diff erence in 24-hour lactate levels between thiamine and placebo groups (2.5 (IQR: 1.5 to 3.4) vs. 2.6 (IQR: 1.6 to 5.1), P = 0.40). Fewer patients in the thiamine group had lactate levels >4 mmol/l at 24 hours (21% vs. 38%, P = 0.10) and this was statistically signifi cant if only evaluating survivors at 24 hours (7% vs. 33%, P = 0.03), although our preplanned analysis was to impute data. We found no diff erence in 24-hour SOFA score or mortality. A total of 28 (35%) patients were thiamine defi cient. Of the defi cient patients, those receiving thiamine had statistically signifi cant lower lactate levels at 24 hours (2.1 (IQR: 1.4 to 2.5) vs. 3.1 (IQR: 1.9 to 8.3), P = 0.03) and more patients in the placebo group had a lactate >4 mmol/l (38% vs. 7%, P = 0.07). Mortality in the thiamine and placebo groups was 13% and 46%, respectively (P = 0.10).i Thiamine as a metabolic resuscitator in septic shock: a randomized, double-blind, placebo-controlled, pilot trial We considered target calories to be 25 kcal/kg/day and target proteins to be 1.5 g/kg/day. Introduction The provision of nutrition in the critical care unit (CCU) has shifted from nutrition support to nutrition therapy, and the potential benefi ts derived from this in the recovery of the critically ill is being explored [1]. We audited the management of nutrition in the CCU in a South African Hospital against the American Society of Parenteral and Enteral Nutrition Guidelines. Furthermore, we reviewed the knowledge and confi dence of healthcare providers in the management of nutrition in the CCU. g y g p g g y Results Patients received more calories (78.3% vs. 59.1%) and more proteins (70.2% vs. 54.6%) post implementation. The mean percentage of patients in the post group who achieved >70% of required calories was 80.1% versus 30.9% in the pre group. The mean percentage of patients who achieved >70% of required proteins was 58.3% versus 32.1% in the pre group. p g p Conclusion The multipronged approach of the quality improvement methodology helped to increase the provision of calories and proteins in our population of critically ill surgical patients. However, there is still room for improvement in terms of achieving optimal enteral nutrition targets early in our population. There is also a need to look into sustaining such results. Methods Retrospective data collection of patients admitted to a four- bed CCU over a 4-month period in 2013. A survey was distributed to diff erent disciplines involved in patient nutrition in the CCU. Results Seventy-two patients were admitted to the CCU during this time period, and notes were able for 44. Three paediatric patients were excluded. Twenty-nine patients stayed for 2 or more days (the audit population). The median age of the audit population was 38, 19 were female. Sixteen were postoperative admissions. The median APACHE II score of the patients with suffi cient available data (n = 16) was 14 (range 6 to 34). The audit found that 21 of the patients had nutrition started in the CCU, with 15 having nutrition started within 48 hours. Only eight patients had a nutritional assessment done. A total of 45 responded to the survey: eight anaesthetists, 25 from surgical disciplines, seven CCU nurses, and fi ve dieticians. All agreed that nutrition should be started in the fi rst 48 hours, except from the surgeons only 14 (56%) agreed. Thiamine as a metabolic resuscitator in septic shock: a randomized, double-blind, placebo-controlled, pilot trial The average self-rating of knowledge of nutrition management in the CCU (1 = lowest, 5 = highest) was 2.1 with the dieticians and CCU nurses showing the highest confi dence with 3.4 and 2.6, respectively. The anaesthetists rated their knowledge at 1.9 and the surgeons rated themselves at 1.8. P397 Introduction Optimizing enteral nutrition early has been shown to be benefi cial in critically ill patients. However, underfeeding is still a common problem. The critically ill surgical patient often presents with additional challenges to optimal enteral feeding. The objective of this study was to improve enteral feeding practices in a surgical ICU. P395 P395 Quality improvement project to optimize enteral nutrition in a tertiary hospital’s surgical ICU J Li, LY Koh, JH Yang, C Khoo, T Ter, BH Tan National University Health System, Singapore Critical Care 2015, 19(Suppl 1):P395 (doi: 10.1186/cc14475) g p g Conclusion Perioperative optimal nutrition support for at least 7 days could modulate the infl ammatory status and clinical outcome of severe malnourished surgical neoplasic patients. Thiamine as a metabolic resuscitator in septic shock: a randomized, double-blind, placebo-controlled, pilot trial Results A total of 529 patients (mean age 72 years, 57.1% male) were included. Overall, there was a signifi cant association of NRS and most biomarkers of infl ammation, stress, renal function, nutrition and the hematological system (coeffi cient and 95% CI): CRP 0.021, P = 0.0021, PCT 0.28, P = 0.003, proADM 0.4, P <0.001, copeptin 0.44, P <0.001, urea 0.28, P = 0.002, vitamin D25 –0.23, P = 0.012, albumin –0.6, P <0.001, hemoglobin –0.5, P <0.001, RDW 0.46, P <0.001. These associations remained robust after adjustment for sociodemographics (model 1), comorbidities (model 2) and main medical diagnosis (model 3). Subgroup analysis suggested that mainly the acute part of malnutrition and not chronic malnutrition was associated with an increase in biomarker levels. H Smithline2, M Tidswell2, R Wolfe1, M Cocchi1 1Beth Israel Deaconess Medical Center, Boston, MA, USA; 2Baystate Medical Center, Springfi eld, MA, USA Introduction The objective was to determine whether the administration of thiamine mitigates elevated lactate levels in patients with septic shock. Thiamine is essential for aerobic metabolism and we have found that thiamine levels are low and inversely correlated with lactate levels in patients with sepsis. Conclusion Acute malnutrition was associated with a pronounced infl ammatory response and an increase in biomarkers from diff erent pathophysiological systems which may partly explain the link between malnutrition and adverse medical outcomes. However, interventional trials are needed to prove causal relationships. Methods We performed a randomized, double-blind, placebo- controlled, two-center trial from January 2010 to October 2014. We enrolled patients with septic shock, elevated lactate (≥3 mmol/l) and no obvious competing cause of lactate elevation. Patients received S139 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P394 Evaluation of the provision of nutrition in a South African provincial hospital S Kudsk-Iversen, R Matos-Puig, R Naidoo, S Moorad Stanger Provincial Hospital, Stanger, South Africa Critical Care 2015, 19(Suppl 1):P394 (doi: 10.1186/cc14474) interventions were conducted with lectures to physicians and nurses. Visual aids in the form of screensavers at each bedside computer served as reminders to the team to optimize feeding. A subsequent audit was then conducted to determine the improvement in achieving the desired outcomes, namely the amount of calories and proteins received as well as the proportion of patients who achieved >70% of their target calories and proteins. Could preoperative and postoperative optimal nutrition support modulate the infl ammatory response and clinical outcome of severe malnourished surgical patients with gastrointestinal neoplasia? p L Mirea, D Pavelescu, I Grintescu Emergency Hospital Floreasca, Bucharest, Romania Critical Care 2015, 19(Suppl 1):P396 (doi: 10.1186/cc14476) p L Mirea, D Pavelescu, I Grintescu Emergency Hospital Floreasca, Bucharest, Romania Critical Care 2015, 19(Suppl 1):P396 (doi: 10.1186/cc14476) p L Mirea, D Pavelescu, I Grintescu Introduction Our aim was to assess whether perioperative and postoperative optimal 7-day nutrition support could modulate the infl ammatory status and clinical outcome of severe malnourished patients with surgery for gastrointestinal neoplasia. Methods A prospective randomized study of 64 patients with gastrointestinal neoplasia, severe malnourished BMI <18.5, albumin level <3 g/dl, BW loss >10%, NRS >3, scheduled for surgery, allocated into two groups. Group A: 32 patients, minimal enteral nutrition in the postoperative period according to tolerance, medium 500 kcal/day. Group B: 32 patients received optimal parenteral nutrition support (25 kcal/kg/day) 3 days before surgery and continued for at least 4 days postoperatively. We measured CRP, fi brinogen, IL-6, TNF, albumin level preoperative and at 96 hours, the incidence of complications, and the length of ICU stay.i Conclusion We found that there is poor management of nutrition in the CCU. This is paired with limited knowledge and low confi dence in management amongst the attending staff . Evidence would suggest that the development and dissemination of clear hospital guidelines could improve rates of correct management [2]. However, the lack of uniform guidance based on strong evidence from the leading global authorities on nutrition suggests that, in order to improve implementation of adequate nutrition, more research is urgently required. References 1. McClave S, et al. JPEN J Parenter Enteral Nutr. 2009;33:277-316. 2. Martin CM, et al. CMAJ. 2004;170:197-204. Results There was a signifi cant decrease in the values of CRP, IL-6, TNF, albumin at 96 hours in group B. No diff erence in fi brinogen. A signifi cantly lower rate of complications and a shorter time of ICU stay were observed in group B. See Figures 1 and 2 (overleaf). 1. McClave S, et al. JPEN J Parenter Enteral Nutr. 2009;33:277-316. 2. Martin CM, et al. CMAJ. 2004;170:197-204. Does discontinuation of the use of hydroxyethyl starches in the critically ill cardiac surgery patient have an impact on caloric intake? E De Waele, K De Bondt, S Mattens, J Czapla, J Nijs, M La Meir, D Nguyen, PM Honoré, H Spapen Universitair Ziekenhuis Brussel, Brussels, Belgium Critical Care 2015, 19(Suppl 1):P397 (doi: 10.1186/cc14477) Methods The Clinical Practice Improvement Programme is a local quality improvement initiative involving a multidisciplinary team aimed at identifying and improving defi ciencies in the process of delivery of care. A team led by an intensivist, consisting of doctors, surgeons, nurses and a pharmacist, was formed to improve enteral feeding practices in a surgical ICU. The quality improvement methodology was employed. An audit was carried out to determine the problem of underfeeding in the unit. Root cause analyses were conducted and team members identifi ed key barriers to optimal feeding and areas for improvement. Protocols were developed to standardize and encourage early enteral feeding as well as to reduce the time feeds are interrupted for patients who were going for surgeries or for various other reasons. Educational Introduction After research revealed unwanted eff ects of the use of starches in critically ill patients, its use in the immediate postoperative period of cardiac surgery patients came to an abrupt ending. However, they constitute an important source of non-intended calories, providing 4 calories per gram. We investigated whether this phenomenon (involuntary) attributed to an increase in caloric debt for this critically ill patient population. Methods We retrospectively searched a database of 417 elective cardiac surgery patients, representing 5,004 observation-days. Caloric S140 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 Figure 1 (abstract P396). Results 1. Figure 2 (abstract P396). Results 2. Figure 1 (abstract P396). Results 1. Figure 1 (abstract P396) Results 1 Figure 1 (abstract P396). Results 1. Figure 2 (abstract P396). Results 2. Figure 2 (abstract P396). Results 2. by aggressive nutrition therapy, in the general population of an ICU. Cancer patients are more prone to be at nutritional risk due to the disease and treatment complications. Our aim was to characterize NUTRIC score behavior in the population of patients admitted to an oncologic ICU. intake was evaluated in the group of patients before and after the cessation of starch use. Results Patient characteristics and caloric needs were comparable: 2,054 ± 395 kcal/day and 2,056 ± 347 kcal/day. Does discontinuation of the use of hydroxyethyl starches in the critically ill cardiac surgery patient have an impact on caloric intake? The 140 patients who in the immediate postoperative period had volume resuscitation without the use of starches had a mean non-intended fl uid caloric intake of 69 (± 36.3) kcal/day. The group of 277 patients who received starches in the postoperative period had a mean non-intended fl uid caloric intake of 105 (± 100.2) kcal/day. g Methods Between January and June 2014 we applied the NUTRIC score to all patients, age >18 years, without cerebral death criteria and with a length of stay (LOS) >72 hours. Data were collected and analyzed using SPSS v20.0. To evaluate the impact on mortality we used logistic regression. y Conclusion Withdrawal of the use of starches resulted in a 34% decrease of non-intended caloric intake by fl uids, contributing to caloric debt. Whether outcome is infl uenced and/or whether these fi ndings are clinically relevant needs further research. g Results Sixty-nine patients were included, 23 women (33.3%) and 46 men (66.7%). Most patients were aged between 50 and 75 years (72.5%) and had normal range weight 58% (n = 40). The mean LOS was 11.56 (minimum: 3 to maximum: 69). The most common motive for admission was sepsis (7.7%, n = 26). APACHE II score was above 15 in 77% of the patients (n = 53) and SOFA score was superior to 6 in 56.5% (n = 30). The NUTRIC score was low risk in 42% (n = 29) of the patients and high in 58% (n = 40). Twenty-eight-day mortality was 26.1% (n = 18). A high NUTRIC score corresponded to a 22-fold increased odds of dying in the fi rst 28 days (P <0.001). Both APACHE II and SOFA were mortality predictors alone, with an increase of 1 point in APACHE score corresponding to an increase of 14% (P = 0.002) and an increase of Measurement of skeletal muscle glycogen status in critically ill patients: a new approach in critical care monitoring I San Millan, J Hill, P Wischmeyer University of Colorado, Aurora, CO, USA Critical Care 2015, 19(Suppl 1):P400 (doi: 10.1186/cc14480) Measurement of skeletal muscle glycogen status in critically ill patients: a new approach in critical care monitoring I San Millan, J Hill, P Wischmeyer University of Colorado, Aurora, CO, USA Critical Care 2015, 19(Suppl 1):P400 (doi: 10.1186/cc14480) Conclusion The NUTRIC score is a good tool in cancer patients to predict 28-day mortality. Nevertheless, the only compounds of the NUTRIC score that correlated independently with mortality were APACHE II and SOFA scores. Further investigation towards the inclusion of other categories such as tumor staging and the type of tumor could be useful to develop a specifi c prognostic tool for this population. Introduction Critically ill patients experience hypermetabolism in- creas ing substrate utilization, especially glucose oxidation. Glycogen is the main source of glucose in the body, being 85% and 15% stored in skeletal muscle and liver respectively. Since glycogen stores are limited we evaluated the hypothesis that critical illness could be associated with glycogen depletion leading to skeletal muscle catabolism for gluconeogenesis and eventually resulting in cachexia, an important determinant of future ICU survival and ICU-acquired weakness. Methods Nine critically ill patients (58.75 ± 25 to 75 years old) with an ICU stay from 1 day to 5 weeks were evaluated for skeletal muscle glycogen content using a rapid, non-invasive high-frequency ultrasound methodology (MuscleSound®, Denver, CO, USA). Scans were obtained from the rectus femoris and vastus lateralis muscles. Glycogen content was measured with a score from 0 to 100 according to the MuscleSound® scale. Patients had a variety of primary diagnoses including septic shock (n = 3), hemorrhagic shock/abdominal hypertension (n = 1), hypovolemic shock/post major oncologic surgery (n = 1), trauma (n = 3), and burn injury (n = 1). Early calorie-dense immune nutrition in haemodynamically compromised cardiac patients S Efremov, V Lomivorotov Research Institute of Circulation Pathology, Novosibirsk, Russia Critical Care 2015, 19(Suppl 1):P399 (doi: 10.1186/cc14479) Introduction The aims of present study were to test the hypothesis that early enteral nutrition (EN) with calorie-dense food supplemented with glutamine improves recovery of nutritional status in critically ill cardiac patients and to evaluate their resting energy expenditure (REE). Results Six out of nine patients had no glycogen present in the muscle (score = 0). The other three patients had glycogen scores between 5 and 15 which are well below scores of healthy individuals (reference 50 to 70). Measurement of skeletal muscle glycogen status in critically ill patients: a new approach in critical care monitoring I San Millan, J Hill, P Wischmeyer University of Colorado, Aurora, CO, USA Critical Care 2015, 19(Suppl 1):P400 (doi: 10.1186/cc14480) As a comparison we collected post-competition levels in competitive athletes, which decrease their glycogen stores (score 15 to 25) but are well above those of most critically ill patients we have studied. p g gy p Methods A prospective randomised study of 40 adult cardiac patients undergoing elective cardiopulmonary bypass surgery no more than 24 hours before eligibility assessment, complicated with acute heart failure syndrome. Patients were randomised to receive either standard isocaloric isonitrogenic early EN (standard group, n = 20) or immunomodulating early EN (immune group, n = 20). The daily energy target was set using REE measured by indirect calorimetry (CCM Express; Medgraphics, St. Paul, MN, USA). Serum prealbumin, transferrin, C-reactive protein, blood lactate and clinical characteristics were analysed. Conclusion This is the fi rst time that muscle glycogen stores have been evaluated in critical illness. Our data show severe glycogen depletion in ICU patients which probably leads to muscle catabolism necessary for gluconeogenesis, eventually resulting in cachexia. This fi nding poses severe metabolic challenges for ICU patients in which interfering with recovery can contribute to poor survival. In light of our fi ndings, re-evaluation of nutritional protocols and potential anabolic/anti- catabolic therapy to decrease muscle catabolism may improve survival. Diff erent therapeutics that may prevent hypermetabolism (such as beta-blockers) should be re-evaluated along with anabolic agents (that is, oxandrolone) which could counteract the severe catabolic response in critical illness. Monitoring of muscle glycogen repletion could signal the transition from the catabolic to anabolic phase. y Results The actual REE was an average of 6.8 and 7.5 kcal/kg/day higher than the REE calculated using the Harris–Benedict equation and empiric approach (25 kcal/kg/day), respectively (Figure 1). Early EN with immune formula was associated with higher levels of prealbumin concentration on the 14th day (0.13 ± 0.01 g/l and 0.21 ± 0.1 g/l; P = 0.04) and transferrin on the 3rd, 5th, 7th, and 14th day (P <0.05) after surgery. Conclusion Haemodynamically compromised cardiac patients have increased REE, which in the absence of indirect calorimetry should be set at 30 kcal/kg/day. Early EN using a calorie-dense immune formula leads to better recovery of nutritional status as assessed by serum protein levels. Plasma glutamine after acute or elective admission on the ICU H Buter, M Koopmans MCL, Leeuwarden, the Netherlands Critical Care 2015, 19(Suppl 1):P402 (doi: 10.1186/cc14482) NUTRIC score in oncologic patients A Patrão, L Bei, F Coelho A Patrão, L Bei, F Coelho Instituto Português de Oncologia – Porto, Portugal g g , g Critical Care 2015, 19(Suppl 1):P398 (doi: 10.1186/cc14478) Introduction The NUTRIC score is a tool designed to quantify the risk of critically ill patients developing adverse events that may be modifi ed S141 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 1 point in SOFA corresponding to an increase in the odds of being dead at 28 days (P = 0.002). Body mass index, age, number of comorbidities, and days in the ICU did not correlate with mortality. Conclusion The NUTRIC score is a good tool in cancer patients to predict 28-day mortality. Nevertheless, the only compounds of the NUTRIC score that correlated independently with mortality were APACHE II and SOFA scores. Further investigation towards the inclusion of other categories such as tumor staging and the type of tumor could be useful to develop a specifi c prognostic tool for this population. 1 point in SOFA corresponding to an increase in the odds of being dead at 28 days (P = 0.002). Body mass index, age, number of comorbidities, and days in the ICU did not correlate with mortality. Intravenous fi sh oil lipid emulsions in ICU patients: an updated systematic review and meta-analysis y p Methods Sepsis was induced by E. coli LPS. GLN was infused: i.v. through the femoral vein (0.5 g/kg); enterally (E) through jejunostomy (0.5 g/kg); and i.v. + E. Blood was drawn continuously from the femoral artery and the portal vein for GLN plasma levels in systemic-S and portal-P circulation. P Langlois1, R Dhaliwal2, M Lemieux2, D Heyland3, W Manzanares4 1Hospital Fleurimont, Sherbrooke, QC, Canada; 2Kingston General Hospital, Kingston, ON, Canada; 3Queen´s University, Kingston, ON, Canada; 4University Hospital, Montevideo, Uruguay Critical Care 2015, 19(Suppl 1):P403 (doi: 10.1186/cc14483) P Langlois1, R Dhaliwal2, M Lemieux2, D Heyland3, W Manzanares4 1Hospital Fleurimont, Sherbrooke, QC, Canada; 2Kingston General Hospital, Kingston, ON, Canada; 3Queen´s University, Kingston, ON, Canada; 4University Hospital, Montevideo, Uruguay Critical Care 2015, 19(Suppl 1):P403 (doi: 10.1186/cc14483) p Results In healthy swine, GLN levels remained stable, both in S and P; i.v. infusion, and even more i.v. + E signifi cantly increased GLN in the S circulation (P <0.001), whereas E infusion failed to do so (P = 0.4). On the contrary, GLN P levels were signifi cantly increased after i.v. + E infusion, as well as after E infusion (P <0.001) and to a lesser extent, after i.v. (P <0.001). In sepsis, both S and P GLN levels decreased signifi cantly. Introduction Intravenous fi sh oil (FO) lipid emulsions (LEs) are rich in ω-3 polyunsaturated fatty acids, which exhibit anti-infl ammatory and immunomodulatory eff ects. We previously demonstrated that FO- containing emulsions may be able to decrease mortality and ventilation days in the critically ill. Over the last year, several additional randomized controlled trials (RCTs) of FO-based LEs have been published. Therefore, the purpose of this meta-analysis was to update our systematic review aimed to elucidate the effi cacy of FO-based LEs on clinical outcomes in the critically ill. Figure 1 (abstract P404). Figure 1 (abstract P404). y Methods We searched computerized databases from 1980 to 2014. Overall mortality was the primary outcome and secondary outcomes were infections, ICU and hospital length of stay (LOS), and mechanical ventilation (MV) days. We included RCTs conducted in critically ill adult patients that evaluated FO-based LEs in parenteral nutrition (PN) or enterally fed patients. We analyzed data using RevMan 5.1 (Cochrane IMS, Oxford, UK) with a random eff ects model. f Results A total of 10 RCTs (n = 733), including four trials published over the last year, met inclusion criteria. Plasma glutamine after acute or elective admission on the IC H Buter, M Koopmans MCL, Leeuwarden, the Netherlands Critical Care 2015, 19(Suppl 1):P402 (doi: 10.1186/cc14482) Figure 1 (abstract P399). Indirect calorimetry measured signifi cantly higher resting energy expenditures. Introduction Low plasma glutamine concentrations are associated with unfavourable outcome at acute ICU admission. We questioned whether there is a diff erence in plasma glutamine level after acute or elective ICU admission. Methods We performed a single-centre prospective observational study in a 22-bed mixed ICU. Exclusion criteria were age <18 years and total parental nutrition at admission. Patients were divided into two groups: elective surgery and acute admissions. Blood samples were taken at ICU admission and daily at 6.00 a.m. Glutamine levels were measured using the Bioprofi le 100 plus analyser (Nova Biomedical UK, Cheshire, UK). A Mann–Whitney U test was used to detect diff erences between groups and a Bonferroni method to correct for multiple comparisons. Results We included 88 patients after elective surgery (76 cardiac and 12 general surgery) and 90 patients after acute admission (27 sepsis, 17 acute surgery, two trauma and 44 medical). Baseline characteristics are presented in Table 1. Plasma glutamine levels at admission were signifi cantly lower in acute patients compared with elective surgery, 0.25 mmol/l (IQR 0.09 to 0.37) versus 0.43 mol/l (IQR 0.33 to 0.55) Figure 1 (abstract P399). Indirect calorimetry measured signifi cantly higher resting energy expenditures. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S142 Table 1 (abstract P402) Elective Acute Age (years) 68 ± 10 59 ± 17 APACHE IV 46 ± 14 67 ± 29* LOS ICU 2 (2 to 2) 4 (2 to 7)* Survival (n) 88 85* Mean ± SD or median (IQR). P <0.01. 0.17, heterogeneity I2 = 0%), and hospital LOS (WMD –4.06; 95% CI, –10.14 to 2.03; P = 0.19, I2 = 89%, P <0.00001), without eff ect on ICU LOS. See Figure 1. Conclusion FO-based LEs may be associated with a reduction in infections, as well as clinically important reductions in duration of ventilation, and hospital LOS. Nevertheless, according to current literature there is inadequate evidence to give a fi nal recommendation on the routine use of FO-containing emulsions in PN and/or as a pharmaconutrient strategy in enterally fed critically ill patients. Further large-scale RCTs which should aim to consolidate potential positive treatment eff ects are warranted. (P <0.001). There appeared to be a signifi cant correlation between the APACHE IV score and glutamine levels (R = 0.52, P <0.001). P403 P403 Intravenous fi sh oil lipid emulsions in ICU patients: an updated systematic review and meta-analysis P Langlois1, R Dhaliwal2, M Lemieux2, D Heyland3, W Manzanares4 1Hospital Fleurimont, Sherbrooke, QC, Canada; 2Kingston General Hospital, Kingston, ON, Canada; 3Queen´s University, Kingston, ON, Canada; 4University Hospital, Montevideo, Uruguay Critical Care 2015, 19(Suppl 1):P403 (doi: 10.1186/cc14483) P404 Glutamine administration in sepsis: enteral, parenteral or both? Experimental study in swine G Stavrou1, E Filidou2, K Arvanitidis2, K Fotiadis1, V Grosomanidis1, A Ioannidis1, G Tsaousi1, A Michalopoulos1, G Kolios2, K Kotzampassi1 1Aristotle University of Thessaloniki, Greece; 2Democritus University of Thrace, Alexandroupolis, Greece Critical Care 2015, 19(Suppl 1):P404 (doi: 10.1186/cc14484) Plasma glutamine after acute or elective admission on the IC H Buter, M Koopmans MCL, Leeuwarden, the Netherlands Critical Care 2015, 19(Suppl 1):P402 (doi: 10.1186/cc14482) Moreover, in a backward linear regression analysis this correlation was independently associated with APACHE IV scores and the presence of infection, but not with the type of admission.i Glutamine administration in sepsis: enteral, parenteral or both? Experimental study in swine G Stavrou1, E Filidou2, K Arvanitidis2, K Fotiadis1, V Grosomanidis1, A Ioannidis1, G Tsaousi1, A Michalopoulos1, G Kolios2, K Kotzampassi1 1Aristotle University of Thessaloniki, Greece; 2Democritus University of Thrace, Alexandroupolis, Greece Critical Care 2015, 19(Suppl 1):P404 (doi: 10.1186/cc14484) G Stavrou1, E Filidou2, K Arvanitidis2, K Fotiadis1, V Grosomanidis1, A Ioannidis1, G Tsaousi1, A Michalopoulos1, G Kolios2, K Kotzampassi1 1Aristotle University of Thessaloniki, Greece; 2Democritus University of Thrace, Alexandroupolis, Greece Critical Care 2015, 19(Suppl 1):P404 (doi: 10.1186/cc14484) yp Conclusion Plasma glutamine levels were signifi cantly lower after acute admission compared with elective surgery. In both groups a considerable amount of patients had decreased glutamine levels, but this was not independently associated with the type of admission. In contrast to previous studies we found that glutamine levels were determined by severity of illness and the presence of an infection. p Critical Care 2015, 19(Suppl 1):P404 (doi: 10.1186/cc14484) Introduction Glutamine (GLN) is recommended in the critically ill for i.v. administration but enteral use is not quite clarifi ed. We decided to measure GLN plasma levels in healthy and septic swine after GLN given by i.v., enteral or both routes, over a 3-hour period. P405 Methods The SALOMON algorithm is based on 53 common presentation fl owcharts using specifi c discriminators to triage calls into four categories according to the level of care required: emergency medical services, nonemergent visit to local emergency department, PCP home visit or PCP delayed consultation. Using an appropriate statistical test, we assessed the accuracy of presentation fl owchart and triage category selections attributed to 130 clinical scenarios, by 10 diff erent nurses, in comparison with references established by a local team of experts, at two diff erent time periods: immediately after training (T0) and 3 to 6 months after algorithm practice (T1).l Prehospital factors associated with an ICU admission from the emergency department P406 P406 Reliability of a new French-language triage algorithm for out-of- hours primary care calls: the SALOMON rule E Brasseur1, A Ghuysen1, AF Donneau2, V D’Orio1 1C.H.U. of Liège, Belgium; 2University of Liège, Belgium Critical Care 2015, 19(Suppl 1):P406 (doi: 10.1186/cc14486) Figure 2 (abstract P404). Introduction Because of increased workloads associated with primary care physician (PCP) shortage, many western countries have been facing the diffi cult challenge of optimizing their out-of-hours primary care services. PCPs initially gathered in small rotation groups, and then further collaborations led to larger-scale cooperatives. In such models, implementation of patient call triage is mandatory to increase the effi ciency, quality and safety of care [1]. Organization models diff er, from the PCP performing all patient calls to nurses and nurse assistants answering calls and performing triage, but no validated triage algorithm has been reported to date. We developed a specifi c French- language triage algorithm called SALOMON (Système Algorithmique Liégeois d’Orientation pour la Médecine Omnipraticienne Nocturne) in order to guide nurse triage PCP out-of-hours calls. The present study tested this algorithm reliability. As previously, i.v. (P = 0.001) and even more i.v. + E (P <0.001) infusion signifi cantly increased S GLN levels, while E infusion failed to have any eff ect. In the P vein, both i.v. (P = 0.02) and i.v. + E (P <0.001) GLN increased signifi cantly, whereas the E had no eff ect (P = 0.08). See Figures 1 and 2. As previously, i.v. (P = 0.001) and even more i.v. + E (P <0.001) infusion signifi cantly increased S GLN levels, while E infusion failed to have any eff ect. In the P vein, both i.v. (P = 0.02) and i.v. + E (P <0.001) GLN increased signifi cantly, whereas the E had no eff ect (P = 0.08). See Figures 1 and 2. Conclusion In our experimental early sepsis model, a combination of E and i.v. GLN seems to be the most appropriate; this results in high GLN levels for the functional needs, including those of the gut mucosa. Reference 1. Crit Care. 2014;18:R76. Reference Reference 1. Huibers L, et al. Scand J Prim Health Care. 2011;29:198-209. 1. Huibers L, et al. Scand J Prim Health Care. 2011;29:198-209. Prehospital factors associated with an ICU admission from the emergency department TA Williams1, J Finn1, D Fatovich2, D Brink3, KM Ho2, H Tohira4 1Curtin University, Bentley, Australia; 2Royal Perth Hospital, Perth, Australia; 3St John Ambulance – WA, Belmont, Australia; 4 Curtin University Health Sciences, Bentley, Australia Critical Care 2015, 19(Suppl 1):P405 (doi: 10.1186/cc14485) Introduction This study aimed to describe the patient characteristics and prehospital factors associated with an ICU admission from the ED. There is a paucity of information about the early recognition of critical illness by paramedics; especially in the Australian prehospital setting. Methods A retrospective cohort study, July 2012 to June 2014, conducted in the Perth metropolitan area, which is served by a single ambulance service. Adult patients were included if transported to a public hospital ED that used the ED information system (EDIS) (seven of eight EDs) and were admitted to the ICU from the ED (ED-ICU group). Patients aged <16 years, those from rural areas or transfers were excluded. We used existing ambulance clinical data linked to EDIS data. Prehospital cohort characteristics are described using univariate statistical techniques. Logistic regression was conducted with admission to the ICU from the ED (critical illness surrogate) as the outcome variable. Variables included in regression models were age, sex, paramedic-identifi ed urgency, that is the time patients should be seen by a doctor based on the Australasian Triage Scale, paramedic- identifi ed patient problem and the time taken from the ambulance service receiving the call to hospital arrival. Physiological variables: systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR), temperature, oxygen saturation, and GCS were included in the logistic models. Results Overall selection of fl owcharts was accurate for 94.1% of scenarios at T0 and 98.7% at T1. Triage category selection was correct for 93.3% of scenarios at T0 and 98.4% at T1. Both fl owchart selection and triage category were correct in of 89.5% case in T0 and at 97.5% T1. When an incorrect fl owchart was used, triage category remained accurate in 64.9% and 70.5% respectively. Both fl owchart and triage selection accuracy improved signifi cantly from T0 to T1 (P <0.0001). y gi y Conclusion The results of the present study revealed that using the SALOMON algorithm is reliable for out-of-hours PCP call triage by nurses. Validity of this rule may be further evaluated through its actual implementation in real-life conditions. Reference Intravenous fi sh oil lipid emulsions in ICU patients: an updated systematic review and meta-analysis There was considerable heterogeneity in interventions tested in these trials. No eff ect on overall mortality was found. When the results of fi ve RCTs that reported infections were aggregated, FO-containing emulsions signifi cantly reduced infections (RR 0.64; 95% CI, 0.44 to 0.92; P = 0.02, heterogeneity I2 = 0%). Furthermore, FO-based LEs were associated with a trend toward a reduction in MV days (WMD, –1.41; 95% CI, –3.43 to 0.61; P = Figure 1 (abstract P404). Figure 1 (abstract P403). Eff ects of parenteral fi sh oil lipid emulsions on infections. S143 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 As previously, i.v. (P = 0.001) and even more i.v. + E (P <0.001) infusion signifi cantly increased S GLN levels, while E infusion failed to have any eff ect. In the P vein, both i.v. (P = 0.02) and i.v. + E (P <0.001) GLN increased signifi cantly, whereas the E had no eff ect (P = 0.08). See Figures 1 and 2. Conclusion In our experimental early sepsis model a combination of Figure 2 (abstract P404). (all P <0.001) except the time taken from receiving the call to hospital arrival (P = 0.48). Figure 2 (abstract P404). Conclusion Three-quarters of the ED-ICU patients were transported to the ED with high urgency. Currently no prehospital severity of illness or early warning system (EWS) is used in our ambulance service. Given the small proportion of ED-ICU patients who presented with abnormal observations, it is unlikely that introducing an EWS would alter practice or patient outcome. P407 Adequacy of trained assistance, emergency equipment and drugs at emergency calls in the ICU and in remote areas of the hospital I Kolic1, S Unell2, A Watts2, A Barry2, J Short2 1South London Healthcare NHS Trust, London, UK; 2Lewisham and Greenwich NHS Trust, London, UK Critical Care 2015, 19(Suppl 1):P407 (doi: 10.1186/cc14487) Results Of the 142,448 eligible patients transported by ambulance, 1,076 (0.75%) were admitted to the ICU from the ED: the ED-ICU group was younger (mean 53 vs. 61 years, P <0.001). Seventeen percent of ICU patients were transported as Urgency 1 (resuscitation/immediate) and 58% as Urgency 2 (within 10 minutes) while 70% of non-ICU patients were transported as Urgency 3 to 5 (P <0.001). Thirteen percent of ICU patients had a SBP <90 mmHg, 15% had a HR ≥130 and 19% had a RR >30. Drug overdose (21%) and respiratory conditions (18%) were the most common ICU conditions identifi ed by paramedics for the ED-ICU group. All variables entered into the logistic models were signifi cant Introduction We aimed to identify the adequacy of assistance provided and to assess correct anaesthetic equipment and drug availability at emergency calls made in the ICU and in remote areas of the hospital. Emergency calls often involve managing critically ill patients with the highest mortality results. The importance of a clinical team with the necessary competencies and the right level of resources are paramount. Methods We undertook a prospective survey of all adult patients with emergency calls put out to the anaesthetic team in a London district S144 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 general hospital over a 6-week period. We performed a snapshot audit of equipment in resuscitation trolleys across each ward and in the radiology department. We compared the data collected on available equipment with the standard set by the Resuscitation Council (UK) Recommended Minimum Equipment Checklist [1]. The survey addressed the availability, clinical competency and appropriate duration of stay of the anaesthetic assistant at the emergency calls. Further qualitative data were collected on the availability of required emergency drugs. general hospital over a 6-week period. We performed a snapshot audit of equipment in resuscitation trolleys across each ward and in the radiology department. Use of an electronic early warning score and mortality for patients admitted out of hours to a large teaching hospital Use of an electronic early warning score and mortality for patients admitted out of hours to a large teaching hospital Use of an electronic early warning score and mortality for patients admitted out of hours to a large teaching hospital J Bannard-Smith, S Abbas, S Ingleby, C Fullwood, S Jones, J Eddleston Manchester Royal Infi rmary, Manchester, UK Critical Care 2015, 19(Suppl 1):P408 (doi: 10.1186/cc14488) g g p J Bannard-Smith, S Abbas, S Ingleby, C Fullwood, S Jones, J Eddleston Manchester Royal Infi rmary, Manchester, UK Critical Care 2015, 19(Suppl 1):P408 (doi: 10.1186/cc14488) J Bannard-Smith, S Abbas, S Ingleby, C Fullwood, S Jones, J Eddleston Manchester Royal Infi rmary, Manchester, UK f Results The intervention signifi cantly increased satisfaction amongst staff regarding: identifi cation of the team leader and other key staff members at the response; and time out eff ectiveness in reducing repetition and improving staff understanding of the patient’s status and medical issues. We found no signifi cant change in staff perceptions regarding the clarity of the ongoing treatment plan at the end of the MET call response. Introduction There is widespread concern regarding excess mortality for patients admitted to hospital out of hours. We introduced an electronic track and trigger system (Patientrack) with automated alerts in a large university teaching hospital between 2010 and 2012. The system computes the patient’s early warning score and alerts medical staff via a pager. It is operational 24 hours a day, 7 days a week and could be an eff ective tool to reduce variations in mortality throughout the working week. Conclusion Utilising a low-cost intervention in a regional setting, we were successful in improving staff perceptions of role allocation and communication within our MET call responses. The intervention also led to signifi cantly increased overall satisfaction with the MET call system. Through our surveys we have identifi ed other facets of the MET call response that also require attention. Given our encouraging results we are designing a follow-up intervention incorporating structured multidisciplinary training in MET call scenarios. g Methods We extracted hospital outcome data for all admissions during the fi nancial years between 2007 and 2014. We identifi ed variables that predicted mortality and incorporated them into a multivariate logistic regression model to assess risk of death for admissions in hours (9:00 am to 5:00 pm, Monday to Friday) versus out of hours (all other times). P409 Revitalising the medical emergency team call KP Verma1, S Jasiowski2, K Jones2 1Melbourne Health, Melbourne, Australia; 2Ballarat Health Services, Ballarat, Australia Critical Care 2015, 19(Suppl 1):P409 (doi: 10.1186/cc14489) P409 Revitalising the medical emergency team call KP Verma1, S Jasiowski2, K Jones2 1Melbourne Health, Melbourne, Australia; 2Ballarat Health Services, Ballarat, Australia Critical Care 2015, 19(Suppl 1):P409 (doi: 10.1186/cc14489) 1Melbourne Health, Melbourne, Australia; 2Ballarat Health Services, Ballarat, Australia Critical Care 2015, 19(Suppl 1):P409 (doi: 10.1186/cc14489) Introduction Medical emergency team (MET) calls are quickly becoming an integral part of the response to a deteriorating patient in Australia. Conceptually the MET call response incorporates a structured approach, but in practice this can quickly disintegrate. This collapse of method can leave patients without clear treatment plans and staff disenfranchised. We sought to improve the process of the MET call response at our regional hospital by introducing targeted interventions focused on teamwork, communication, leadership and role allocation. Introduction Medical emergency team (MET) calls are quickly becoming an integral part of the response to a deteriorating patient in Australia. Conceptually the MET call response incorporates a structured approach, but in practice this can quickly disintegrate. This collapse of method can leave patients without clear treatment plans and staff disenfranchised. We sought to improve the process of the MET call response at our regional hospital by introducing targeted interventions focused on teamwork, communication, leadership and role allocation. Methods We invited junior doctors and nurses to complete a survey designed by a multidisciplinary MET Call Working Group; 138 staff (40% of population) completed the survey. Based on analysis of responses, a focused three-pronged intervention was formulated and implemented hospital wide. The arms of the intervention were: identifi cation of the name and role of each staff member using highly visible labels; role allocation according to policy written through a multidisciplinary working group; and a time out during the response allowing a structured synopsis of the patient’s current status to be communicated to the team. The intervention was preceded by extensive staff education, and 175 staff (50%) completed the survey 6 months later to assess its success. Results The intervention signifi cantly increased satisfaction amongst staff regarding: identifi cation of the team leader and other key staff members at the response; and time out eff ectiveness in reducing repetition and improving staff understanding of the patient’s status and medical issues. We found no signifi cant change in staff perceptions regarding the clarity of the ongoing treatment plan at the end of the MET call response. Conclusion Emergency calls require standards to be met involving the competency of responding team members and adequate resources. This leads us to question whether guidelines should exist regarding the clinical competency and timeliness of the assistant available to the physician at emergency calls. Revitalising the medical emergency team call KP Verma1, S Jasiowski2, K Jones2 1Melbourne Health, Melbourne, Australia; 2Ballarat Health Services, Ballarat, Australia C l C (S l ) P (d / ) 1Melbourne Health, Melbourne, Australia; 2Ballarat Health Services, Ballarat, Australia Methods We invited junior doctors and nurses to complete a survey designed by a multidisciplinary MET Call Working Group; 138 staff (40% of population) completed the survey. Based on analysis of responses, a focused three-pronged intervention was formulated and implemented hospital wide. The arms of the intervention were: identifi cation of the name and role of each staff member using highly visible labels; role allocation according to policy written through a multidisciplinary working group; and a time out during the response allowing a structured synopsis of the patient’s current status to be communicated to the team. The intervention was preceded by extensive staff education, and 175 staff (50%) completed the survey 6 months later to assess its success.i Reference 1. Resuscitation Council (UK). Recommended minimum equipment for in hospital adult resuscitation (October 2004). https://www.resus.org.uk/pages/ eqipIHAR.html. P407 We compared the data collected on available equipment with the standard set by the Resuscitation Council (UK) Recommended Minimum Equipment Checklist [1]. The survey addressed the availability, clinical competency and appropriate duration of stay of the anaesthetic assistant at the emergency calls. Further qualitative data were collected on the availability of required emergency drugs. sex, unplanned admission and admission from supportive care. Risk of death for out-of-hours admissions was not signifi cantly diff erent to in- hours for any year (1.01 (0.92 to 1.11), P = 0.784). There was a signifi cant fall in risk of death over the 7-year period compared with baseline values in 2007/08 (Table 1). Conclusion In our cohort there was no evidence of increased mortality for patients admitted out of hours compared with in hours. This remained true after adjustment for age, sex, emergency admissions and admission source. Our data demonstrated an overall fall in risk of death over the study period. The introduction of Patientrack could have contributed to this reduction in mortality. Results During the study period 44 emergency calls were attended. Twenty-three (52%) of these calls were in the accident and emergency department, and four (9%) in the ICU. Survey results demonstrated two cases where no anaesthetic assistant arrived at the emergency call put out to them. In cases where timely assistance was available, the assistant did not have the adequate clinical and anaesthetic skills required by the attending physician. In 6% of cases where skilled assistance was required (n = 2), it was felt that the assistant did not stay for the clinically required length of time. Emergency drugs required were found to not be available in 11% of cases (n = 5) and in 17% of cases (n = 6) the necessary emergency equipment was not available. Data were collected on equipment from 17 resuscitation trolleys. The inadequacies identifi ed were the oxygen cylinders were fi lled less than 75% full in 41% cases (n = 7) and end-tidal capnography was identifi ed to be absent. P409 Use of an electronic early warning score and mortality for patients admitted out of hours to a large teaching hospital P410 S Results Data were available for 1,180,268 hospital admissions, of which 7,264 (0.6%) died. Predictors for hospital mortality included: age, male P412 Attention Code Blue: a comprehension of in-hospital cardiac arrest from a multispeciality hospital in South India M Hisham, MN Sivakumar, T Sureshkumar, R Senthil Kumar, A Satheesh Kovai Medical Center and Hospital, Coimbatore, India Critical Care 2015, 19(Suppl 1):P412 (doi: 10.1186/cc14492) Among true cardiac arrest events, 92.6% was due to pulseless electrical activity/asystole and 7.7% was due to ventricular fi brillation (VF)/pulseless ventricular tachycardia (VT); both of these did not have any diff erence on the initial outcome. But having an initial rhythm of VF/pulseless VT had 90% more chance for discharge from the hospital, with P = 0.04. Although arrival time of the CBT did not have any infl uence on the fi nal outcome, duration of resuscitation ≤20 minutes had an odds ratio of 10.6 with P <0.001 favoring return of spontaneous circulation over death after controlling for age. Of the 203 patients who had true cardiac arrest events, 43 (21.2%) were discharged from the hospital. Good neurological outcome at discharge was seen among 22 (10.8%) of the patients based on Cerebral Performance Category Score. Conclusion Our experience shows that out of every 1,000 patients admitted to our hospital, about fi ve sustained cardiac arrest, of whom only 11.3% survived to hospital discharge with good neurological recovery. Variation in the eff ectiveness of the cardiopulmonary resuscitation quality in comparison with world data could be due to the inherent diff erence in the severity of the primary illness in the patients and diversity in the reported data. P411 Evaluation of emergency call Code Blue over a 5-year period N Bakan, G Karaoren, S Tomrk, S Keskin Istanbul Umraniye Training and Research Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P411 (doi: 10.1186/cc14491) Introduction Code systems are the emergency call and management systems for rapid response in healthcare institutions. The main aim of these systems is to provide common institutional understanding of what is necessary to be done immediately at the time of an event. Code Blue (CB), which is used throughout the world and was described in the 2008 service quality standards of Turkey, defi nes the necessary emergency intervention in cases of respiratory or cardiac arrest. This study aimed to evaluate the clinical and application data of patients for whom a CB call was made between 2009 and 2013. Methods After approval of local ethics committee, retrospective examination was made of CB forms. P412 Attention Code Blue: a comprehension of in-hospital cardiac arrest from a multispeciality hospital in South India M Hisham, MN Sivakumar, T Sureshkumar, R Senthil Kumar, A Satheesh Kovai Medical Center and Hospital, Coimbatore, India Critical Care 2015, 19(Suppl 1):P412 (doi: 10.1186/cc14492) Introduction Numerous American and European studies have associated survival rates of in-hospital cardiac arrest (IHCA) with diff erent quality markers. There has been a paucity of studies that explain IHCA in Asian populations. This study was conducted to assess the characteristics and survival among patients suff ering from IHCA. Methods All Code Blue activations from 1 January 2012 to 31 December 2012 were analyzed retrospectively. Data were gathered from the Code Blue form and fi ner details of individual patients were linked through their medical records. Code Blue was activated only for events that happened outside the medical and surgical ICUs. Introduction Numerous American and European studies have associated survival rates of in-hospital cardiac arrest (IHCA) with diff erent quality markers. There has been a paucity of studies that explain IHCA in Asian populations. This study was conducted to assess the characteristics and survival among patients suff ering from IHCA. Introduction Numerous American and European studies have associated survival rates of in-hospital cardiac arrest (IHCA) with diff erent quality markers. There has been a paucity of studies that explain IHCA in Asian populations. This study was conducted to assess the characteristics and survival among patients suff ering from IHCA. f Methods All Code Blue activations from 1 January 2012 to 31 December 2012 were analyzed retrospectively. Data were gathered from the Code Blue form and fi ner details of individual patients were linked through their medical records. Code Blue was activated only for events that happened outside the medical and surgical ICUs. Conclusion The MET has been successfully implemented, with demand for its services having increased by 32.7% in 1 year. The unadjusted immediate mortality rate of patients for whom a MET/cardiac arrest call is activated is 3.64%. Response time had no infl uence on mortality, most probably due to the rapid response time. Immediate mortality was low, probably as a result of early adequate intervention. Further evaluation of overall hospital mortality is warranted for future studies. pp g Results A total of 260 Code Blue activations were made, out of which there were 203 true cardiac arrest events among 40,168 in-patients; the cumulative incidence of the same was 0.51%. Mean (SD) duration of arrival of the Code Blue Team (CBT) to the scene was 64.5 (27.7) seconds. Cardiovascular illness was the predominant baseline morbidity but none of the baseline illness showed increased risk of mortality in this group. P410 Successful implementation of a medical emergency team: 2-year experience in a teaching hospital A Tridente, J Elmore, R Varia, T Mahambrey St Helens and Knowsley, Liverpool, UK Critical Care 2015, 19(Suppl 1):P410 (doi: 10.1186/cc14490) Table 1 (abstract P408). Overall risk of death ratios compared to 2007/08 Year ROD 95% CI 2008/09 1.01 0.73 to 1.5 2009/10 1.03 0.74 to 1.5 2010/11 0.46 0.33 to 0.7 2011/12 0.31* 0.22 to 0.4 2012/13 0.27* 0.2 to 0.39 2013/14 0.26* 0.2 to 0.37 P <0.001. Table 1 (abstract P408). Overall risk of death ratios compared to 2007/08 Introduction A medical emergency team (MET) was introduced in our institution in January 2012 to provide timely response to the needs of acutely ill inpatients and cardiac arrest calls. The MET assesses the patient and prescribes a management plan for the responsible team to follow; promptly stabilising and transferring patients to a place of safety where required. We aimed at evaluating the eff ects of introducing the MET on clinically relevant processes and outcomes. Methods Prospective data were analysed using STATA 10.1. The primary outcome measure was immediate mortality (defi ned as mortality at S145 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion The time taken to reach patients conformed with the global standard mean 2 to 3 minutes [1]. The rates of erroneous CB and time to reach patients reduced each year due to more staff experienced and knowledgeable in CB and the structuring of the emergency clinic. Conclusion The time taken to reach patients conformed with the global standard mean 2 to 3 minutes [1]. The rates of erroneous CB and time to reach patients reduced each year due to more staff experienced and knowledgeable in CB and the structuring of the emergency clinic. conclusion of the MET intervention); the secondary outcome measures were admission to critical care after a MET call and cardiac arrest. conclusion of the MET intervention); the secondary outcome measures were admission to critical care after a MET call and cardiac arrest. Results A total of 5,763 MET calls were made between 9 January 2012 and 4 March 2014, of which 5,310 (92.1%) were MET calls, 349 (6.1%) cardiac arrest calls, 36 (0.6%) false alarms and 68 (1.2%) unclassifi ed. The number of calls increased by 32.7% from 2,255 in 2012 to 2,993 in 2013, with all month-specifi c comparisons showing signifi cant increases in MET activity (ranging from 0.5% to 103.6% increases). P410 Successful implementation of a medical emergency team: 2-year experience in a teaching hospital A Tridente, J Elmore, R Varia, T Mahambrey St Helens and Knowsley, Liverpool, UK Critical Care 2015, 19(Suppl 1):P410 (doi: 10.1186/cc14490) MET activity displayed cyclical yearly changes, with the winter months and the month of August (junior doctors’ changeover period) being particularly busy. Median response time (interquartile range) was 1 (1 to 2) minutes, with 99.1% calls attended to within 3 minutes. There were 210 (3.64%) immediate deaths (with no signifi cant diff erences between years), 112 (1.9%) patient transfers to critical care, 233 (4%) patients were transferred to other locations (other than critical care) while 4,697 (81.5%) patients remained on the ward of origin. In 408 cases (7.1%) a do-not-resuscitate order was instituted. On multiple logistic regression analyses, when the type of call was taken into consideration, the response time had no infl uence on primary (mortality OR = 0.83, 95% CI = 0.63 to 1.09, P = 0.18) and secondary outcomes (admission to critical care OR = 0.85, 95% CI = 0.62 to 1.17, P = 0.33; subsequent cardiac arrest OR = 0.57, 95% CI = 0.27 to 1.2, P = 0.14). References 1. Abella BS, et al. JAMA. 2005;293:305-10. 2. Merchant RM, et al. Crit Care Med. 2011;39:2401-6. 1. Abella BS, et al. JAMA. 2005;293:305-10. 1. Abella BS, et al. JAMA. 2005;293:305 10. 2. Merchant RM, et al. Crit Care Med. 2011;39:2401-6. 2. Merchant RM, et al. Crit Care Med. 2011;39:2401-6. Results From CB calls for a total of 1,195 patients over the 5-year period, 1,035 (86.6%) were evaluated. The rate of erroneous CB was 36.9%. Patients comprised 413 (39.9%) females and 622 (60.1%) males with a mean age of 59.73 ± 23.13 years (range, 0.1 to 102 years). The distribution of total cases over the 5 years (2009 to 2013) was 15.5%, 25.2%, 26.5%, 19% and 13.8% respectively. Distribution according to clinic was emergency internal (37.5%), internal (16.5%) and emergency surgical (9.5%). Clinical diagnosis was cardiac 28.8%, neurological 15.6% and end-stage cancer 13.5%. A total 19.9% of the patients were those discharged from intensive care. The total survival rate was 59.6%. The duration of CPR in survivors was statistically longer than in nonsurvivors (P <0.01). There was no statistically signifi cant relationship between the duration of CPR and age (P >0.05). The overall mean time taken to reach the patient was 102.71 ± 22.47 seconds, which reduced to 93.64 ± 19.91 seconds in 2013. The APACHE II–PRISM scores and mortality rates were low in the cases of erroneous CB (P <0.05). P412 Attention Code Blue: a comprehension of in-hospital cardiac arrest from a multispeciality hospital in South India M Hisham, MN Sivakumar, T Sureshkumar, R Senthil Kumar, A Satheesh Kovai Medical Center and Hospital, Coimbatore, India Critical Care 2015, 19(Suppl 1):P412 (doi: 10.1186/cc14492) The age and gender of the patient, diagnosis, department to which admitted, time of CB call, reason for CB, whether or not CB was appropriate, whether or not CPR was applied, duration of CPR if applied, APACHE II and PRISM scores and predicted mortality were recorded from the hospital automated record system and the CB form. Patients who refused treatment or who could not reach the necessary parameters for the calculation of APACHE II and PRISM scores were excluded. References Reference 1. Nolan JP, et al. European Resuscitation Council guidelines for resuscitation 2010 section 1. Executive summary. Resuscitation. 2010;81:1219-76. P412 P413 Are we failing to teach cardiopulmonary resuscitation (CPR) in schools? A pilot study to assess CPR and automated external defi brillator training in London schools J Salciccioli, D Marshall, M Sykes, A Wood, S Joppa, M Sinha, PB Lim Imperial College London, UK Critical Care 2015, 19(Suppl 1):P413 (doi: 10.1186/cc14493) TRACE: a new protocol for ultrasound examination during out-of- hospital cardiac arrest TRACE: a new protocol for ultrasound examination during out-of- hospital cardiac arrest Methods We conducted a registered audit of CPR and AED training in London schools. Secondary schools were identifi ed via web links for each of the London Borough Councils. Telephone interviews with school staff familiar with CPR and AED training practices were conducted prospectively using a standardized web-based survey. All survey response data were captured electronically. We defi ned universal training as any programme which delivers CPR and AED training to all students in the school. We used simple descriptive statistics to summarise the results. J Callerova1, R Skulec2, J Knor3, V Cerny3 1Emergency Medical Service of Central Bohemian Region, Beroun, Czech Republic; 2Charles University in Prague, University Hospital Hradec Kralove, Czech Republic; 3J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic Critical Care 2015, 19(Suppl 1):P416 (doi: 10.1186/cc14496) J Callerova1, R Skulec2, J Knor3, V Cerny3 1Emergency Medical Service of Central Bohemian Region, Beroun, Czech Republic; 2Charles University in Prague, University Hospital Hradec Kralove, Czech Republic; 3J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic Critical Care 2015 19(Suppl 1):P416 (doi: 10 1186/cc14496) Introduction Implementation of point-of-care ultrasound examination into cardiopulmonary resuscitation (CPR) may increase diagnostic accuracy for determining the cause of cardiac arrest. However, current protocols either do not refl ect all causes detectable by ultrasound or are too complicated for prehospital use. Thus, we decided to construct and validate a new protocol TRACE (ThoRacic and Abdominal sonography in Cardiac arrEst) for ultrasound examination during out-of-hospital cardiac arrest (OHCA). Results A total of 51 schools completed the survey covering an estimated student population of 54,037. There were four (8%) schools that provide universal training programmes and an additional 23 (45%) off er optional training programmes for students. There were 16 (31%) schools which have an AED available on the school premises. The most common reasons for not having a universal CPR training programme is the requirement for additional class time (15/51; 29%) and that funding is unavailable for such a programme (12/51; 24%). There were three students who died from sudden cardiac arrest over the period of the past 10 years. Methods We designed a new protocol for ultrasound examination during OHCA to increase the success rate for the establishment of OHCA cause. Body position during transport in a refractory cardiac arrest porcine model p Methods Data were prospectively collected from January 2011 to January 2012 from 336 female medical and pharmacy students undergoing CPR training at the Lithuanian University of Health Sciences. During the training process, the instructors performed a simple 5-second intervention (Andrew’s manoeuvre) with all of the rescuers in the study group. The instructor pushed 10 times on the shoulders of each trainee while she performed CCs to achieve the maximal required compression depth. Immediately after training, the participants were asked to perform a 6-minute BLS test on a manikin that was connected to a PC with SkillReporter™ System software (Laerdal, Norway); the quality of the participants’ CPR skills was then evaluated. Body position during transport in a refractory cardiac arrest porcine model J Belohlavek1, M Mlcek2, M Huptych3, T Boucek1, T Belza2, P Krupickova2, O Kittnar2 1General University Hospital, Prague, Czech Republic; 2Charles University in Prague, Czech Republic; 3Czech Technical University in Prague, Czech Republic Critical Care 2015, 19(Suppl 1):P417 (doi: 10.1186/cc14497) 1General University Hospital, Prague, Czech Republic; 2Charles University in Prague, Czech Republic; 3Czech Technical University in Prague, Czech Republic Critical Care 2015, 19(Suppl 1):P417 (doi: 10.1186/cc14497) Introduction Cardiac arrest patients are not transported only supine. The eff ect of body position on resuscitability and cerebral perfusion in a 30° and 60° incline is not known.i Results The CC depth in the study group increased by 6.4 mm (P <0.001) compared with the control group (52.9 vs. 46.6 mm). A regression analysis showed that Andrew’s manoeuvre increased the depth of the CCs among women by 14.87 × (1 – 0.01 × weight) mm.i Methods Twenty-fi ve female pigs were subjected to a simulated cardiac arrest (3 minutes no fl ow, 5 minutes mechanical CPR). Next, animals were randomly assigned to one of the three groups: GROUP 60 (n = 8), 60° incline for 3 minutes to simulate transport in space restricted elevator; GROUP 30 (n = 8), 30° incline for 8 minutes to simulate staircase transport; and GROUP 0, with no incline. During subsequent standard CPR including rescue ECMO, resuscitability and cerebral perfusion were assessed. Conclusion Andrew’s manoeuvre during CPR training signifi cantly improved the performance of the female rescuers and helped them achieve the CC depth required by 2010 resuscitation guidelines. It is most eff ective among the women with the lowest body weight. Are we failing to teach cardiopulmonary resuscitation (CPR) in schools? A pilot study to assess CPR and automated external defi brillator training in London schools Introduction Mortality from cardiac arrest remains high [1]. Bystander cardiopulmonary resuscitation (CPR) and the use of automated external defi brillators (AED) are two of the most important factors favouring survival [2]. CPR/AED training in schools is a recommended intervention for signifi cantly improving training rates across a large population [3]. The current practice for CPR/AED training in London schools is unknown. The primary aim of this study was to assess current Introduction Mortality from cardiac arrest remains high [1]. Bystander cardiopulmonary resuscitation (CPR) and the use of automated external defi brillators (AED) are two of the most important factors favouring survival [2]. CPR/AED training in schools is a recommended intervention for signifi cantly improving training rates across a large population [3]. The current practice for CPR/AED training in London schools is unknown. The primary aim of this study was to assess current S146 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 practices relating to CPR and AED training in London secondary schools. 1. Krikscionaitiene A, et al. Magical manoeuvre: a 5-s instructor’s intervention helps lightweight female rescuers achieve the required chest compression depth. Eur J Emerg Med. 2014;21:424-8. Magical manoeuvre: a 5-second instructor’s intervention helps lightweight female rescuers achieve the required chest compression depth Magical manoeuvre: a 5-second instructor’s intervention helps lightweight female rescuers achieve the required chest compression depth A Krikscionaitiene, A Pranskunas, M Dambrauskiene, N Jasinskas, Z Dambrauskas, E Vaitkaitiene, J Vencloviene, D Vaitkaitis Lithuanian University of Health Sciences, Kaunas, Lithuania Critical Care 2015, 19(Suppl 1):P415 (doi: 10.1186/cc14495) A Krikscionaitiene, A Pranskunas, M Dambrauskiene, N Jasinskas, Z Dambrauskas, E Vaitkaitiene, J Vencloviene, D Vaitkaitis Lithuanian University of Health Sciences, Kaunas, Lithuania Critical Care 2015, 19(Suppl 1):P415 (doi: 10.1186/cc14495) Conclusion Implementation of the TRACE protocol to the CPR process was feasible, required minimal interruption of cardiac compressions and resulted in a high recognition rate for the cause of OHCA. Introduction Adequate chest compression (CC) depth is crucial for resuscitation outcomes. Lightweight rescuers, particularly women, are often unable to achieve the required 5 to 6 cm CC depth. This nonrandomised cohort study investigated new strategies to improve CC performance. TRACE: a new protocol for ultrasound examination during out-of- hospital cardiac arrest The subcostal view was performed during planned rhythm check to assess the presence of cardiac tamponade and size of the right and left ventricle and inferior caval vein. Thereafter, during ongoing cardiac compressions, Morrison’s pouch and right pleural space were investigated to exclude intraperitoneal and inrapleural free fl uid. The same procedure was applied on the left side of the body. Finally, the anterior thoracic view was done to exclude pneumothorax. Working diagnosis was compared with the fi nal in-hospital diagnosis or autopsy. Conclusion CPR and AED training rates in London secondary schools are low. The majority of schools do not have an AED available on premises. The most common reason for not providing CPR training is the requirement for additional class time. These data highlight an opportunity to vastly improve CPR training rates in a large population. Future studies should assess programmes which are cost-eff ective and which do not require signifi cant amounts of additional class time. References 1. Berdowski J, et al. Resuscitation. 2010;81:1479-87 2. Go AS, et al. Circulation. 2014;129:e28. 3. Cave DM, et al. Circulation. 2011;123:691-706. 1. Berdowski J, et al. Resuscitation. 2010;81:1479-87. 2. Go AS, et al. Circulation. 2014;129:e28. 3. Cave DM, et al. Circulation. 2011;123:691-706. 1. Berdowski J, et al. Resuscitation. 2010;81:1479-87. Results We examined 40 consecutive OHCA patients. Correct cause of OHCA during CPR was recognised in 38 patients (95%). Leading causes were acute coronary syndrome (55.0%), pulmonary embolism (15.0%) and complication of chronic heart failure (10.0%). Incorrect recognition was performed in one patient with respiratory cause, originally considered as pulmonary embolism, and in another with pulmonary embolism, considered as respiratory cause. One rhythm check was suffi cient to perform TRACE in 31 patients, in the other two interruptions of cardiac compressions were required. Return of spontaneous circulation was achieved in 15 (37.5%) patients, favourable neurological outcome at hospital discharge in eight (20%) patients. Specifi c therapy to aff ect the cause of OHCA was applied during OHCA in 12 (30%) patients. 2. Go AS, et al. Circulation. 2014;129:e28. 3. Cave DM, et al. Circulation. 2011;123:691-706. P417 Body position during transport in a refractory cardiac arrest porcine model J Belohlavek1, M Mlcek2, M Huptych3, T Boucek1, T Belza2, P Krupickova2, O Kittnar2 1General University Hospital, Prague, Czech Republic; 2Charles University in Prague, Czech Republic; 3Czech Technical University in Prague, Czech Republic Critical Care 2015, 19(Suppl 1):P417 (doi: 10.1186/cc14497) Predictors of return of spontaneous circulation and survival in in- hospital cardiac arrest: a retrospective study in a single institution JL Ch 1 ZM Li 1 JH T 1 S S h 1 M H i Bi I k d 1 B L 2 Predictors of return of spontaneous circulation and survival in in- hospital cardiac arrest: a retrospective study in a single institution JL Chua1, ZM Lin1, JH Tan1, S Surentheran1, M Haris Bin Iskander1, B Leong2 1National University of Singapore, Singapore; 2National University Hospital, Singapore Critical Care 2015 19(Suppl 1):P418 (doi: 10 1186/cc14498) Introduction Despite several large studies concerning out-of-hospital cardiac arrests in recent years, it is not clear whether their in-hospital counterparts have benefi ted from advances in resuscitation as well as post-resuscitation care. Introduction Despite several large studies concerning out-of-hospital cardiac arrests in recent years, it is not clear whether their in-hospital counterparts have benefi ted from advances in resuscitation as well as post-resuscitation care. p Methods We identifi ed all cases of in-hospital cardiac arrest (IHCA) occurring in the National University Hospital in Singapore from 1 June 2008 to 31 May 2009. Patients for which IHCA occurred but where no resuscitation was attempted were excluded. Key outcomes were classifi ed as primary (survival to discharge) and secondary (return of spontaneous circulation). Additionally, various arrest characteristics were analysed to identify predictive factors for survival to discharge with level of signifi cant set at P <0.05. Figure 1 (abstract P419). Patient demographics and clinical fi ndings. Figure 2 (abstract P419). Comparison complications of CPR between the OHCA group and the IHCA group. gi Results Among 353 unique cases of IHCA analysed, 63 patients (17.8%) had a shockable rhythm (ventricular fi brillation and pulseless ventricular tachycardia) of which 17 (27.0%) survived to discharge. While 290 (82.2%) patients presented with nonshockable rhythm (asystole or pulseless electrical activity), only 32 patients (11%) survived to discharge. For patients who survived to discharge, univariate analysis showed that event location (P = 0.016), nationality (P = 0.035), paying class (P = 0.038), use of ECG monitoring (P = 0.048), initial cardiac rhythm (P = 0.000) and presence of a house offi cer (P = 0.005) were statistically signifi cant. Multivariate analysis showed that patients with shockable rhythms were 2.52 times more likely to survive but other factors were not signifi cant. For patients who attained ROSC, univariate analysis showed that time of day (P = 0.006), event location (P = 0.000), and number of adrenaline doses administered (P = 0.000) were statistically signifi cant. 9 Comparison of complications secondary to cardiopulmonary resuscitation between out-of-hospital cardiac arrest and in-hospital cardiac arrest M Seung Y Park M Seung, Y Park Yonsei University Severance Hospital/Yonsei University College of Medicine, Seoul, South Korea Critical Care 2015, 19(Suppl 1):P419 (doi: 10.1186/cc14499) M Seung, Y Park Yonsei University Severance Hospital/Yonsei University College of Medicine, Seoul, South Korea Critical Care 2015, 19(Suppl 1):P419 (doi: 10.1186/cc14499) Introduction Chest compression during cardiopulmonary resuscitation (CPR) could bring out unintended complications which are mainly composed of chest injuries. The aim of this study was to assess whether there was a signifi cant diff erence in the complications of CPR between out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) survivors using multidetector computed tomography (MDCT). g p g p y Methods We performed a retrospective cohort study in the emergency departments of two academic tertiary care centres from January 2009 to May 2014. We enrolled both OHCA and IHCA patients who underwent successful CPR. The enrolled patients had undergone a chest CT within 48 hours after ROSC. We evaluated the MDCT fi ndings of the CPR-related chest injuries and compared complications between OHCA and IHCA patients. Figure 1 (abstract P417). Figure 1 (abstract P417). (baseline, cardiac arrest, initial supine CPR and 30° vs. 60° CPR) are depicted in Figure 1. (baseline, cardiac arrest, initial supine CPR and 30° vs. 60° CPR) are depicted in Figure 1. p Results A total of 148 patients were fi nally enrolled in this study, OHCA were 89 (60.1%) and IHCA were 59 (39.8%). The mean CPR time, both in-hospital and total, was longer in OHCA survivors. Rib fractures were Conclusion Positional changes during simulated refractory cardiac arrest in this experimental model signifi cantly aff ect resuscitability and brain perfusion. Animals subjected to shorter time in a more inclined (GROUP 60) position were more easily resuscitated; however, cerebral blood fl ow was better preserved in GROUP 30. Figure 1 (abstract P419). Patient demographics and clinical fi ndings. Figure 1 (abstract P419). Patient demographics and clinical fi ndings. P418 Predictors of return of spontaneous circulation and survival in in- hospital cardiac arrest: a retrospective study in a single institution JL Chua1, ZM Lin1, JH Tan1, S Surentheran1, M Haris Bin Iskander1, B Leong2 1National University of Singapore, Singapore; 2National University Hospital, Singapore Critical Care 2015, 19(Suppl 1):P418 (doi: 10.1186/cc14498) Body position during transport in a refractory cardiac arrest porcine model Reference Results Attainment of ROSC (3, 5, 5 in respective groups, P = 0.021), time to ROSC (15:24 (13:26; 16:02) vs. 19:19 (18:28; 19:37) vs. 9:10 minutes (8:28; 9:41), respectively, P = 0.005) signifi cantly diff ered. Changes in carotid blood fl ow according to the respective periods of the protocol 1. Krikscionaitiene A, et al. Magical manoeuvre: a 5-s instructor’s intervention helps lightweight female rescuers achieve the required chest compression depth. Eur J Emerg Med. 2014;21:424-8. S147 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 (baseline, cardiac arrest, initial supine CPR and 30° vs. 60° CPR) are depicted in Figure 1 Figure 1 (abstract P417). Figure 1 (abstract P417). Impact of intra-arrest fl uid loading with diff erent doses of crystalloid infusion on hemodynamics in experimental cardiac arrest R Skulec1, A Truhlar1, R Parizkova1, Z Turek1, D Astapenko1, J Dudakova2, V Cerny3 R Skulec1, A Truhlar1, R Parizkova1, Z Turek1, D Astapenko1, J Dudakova2, V Cerny3 y 1Charles University in Prague, University Hospital Hradec Kralove, Czech Republic; 2Emergency Medical Service of Central Bohemian Region, Kladno, Czech Republic; 3J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic l ( l ) (d ) 1Charles University in Prague, University Hospital Hradec Kralove, Czech Republic; 2Emergency Medical Service of Central Bohemian Region, Kladno, Czech Republic; 3J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic Critical Care 2015, 19(Suppl 1):P420 (doi: 10.1186/cc14500) Introduction Fluid loading during cardiopulmonary resuscitation for nonhypovolemic cardiac arrest remains controversial. Thus, we conducted an experimental study comparing the impact of two diff erent doses of balanced crystalloid infusion on hemodynamics in a porcine model of ventricular fi brillation.i Conclusion Although our study has a number of methodological limitations, these results about incidence in cardiac arrest survivors corroborate previous retrospective reports. It is possible that every cardiac arrest survivor has had to live a NDE, regardless of brain mechanisms associated with experience, but only some patients remember it. If some chronic medications, such as benzodiazepine, may decrease memorization, the role of the elements of the clinical context about NDE during resuscitation is speculative References i Methods Ventricular fi brillation was induced for 15 minutes in 19 anesthetized domestic pigs. Before induction, the animals were randomized to receive either 1,000 ml (34 ± 3 ml/kg, group A, n = 7) or 500 ml (16 ± 2 ml/kg, group B, n = 7) of balanced crystalloid solution or to undergo no fl uid loading during CPR (group C, n = 5). After spontaneous circulation (ROSC) was restored, the animals were observed for 90 minutes. 1. Van Lommel P, van Wees R, Meyers V, Elff erich I. Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands. Lancet. 2001;358:2039-45. Results In all groups, signifi cant increase of intracranial pressure followed by its decrease after ROSC was observed. While in groups B (from 12 ± 2 to 18 ± 2 mmHg, P <0.05) and C (from 13 ± 1 to 18 ± 3 mmHg, P <0.05) it was comparable (P >0.05), the rise of intracranial pressure in group A was signifi cantly higher (from 12 ± 3 to 23 ± 3 mmHg, P <0.05). Impact of intra-arrest fl uid loading with diff erent doses of crystalloid infusion on hemodynamics in experimental cardiac arrest Whereas coronary perfusion pressure was lower in group A than in control group C during volume loading, fl uid infusion induced its mild increase in group B (group A: 12.1 ± 2.4, group B: 16.0 ± 2.6, group C: 13.6 ± 2.8 mmHg, P = 0.043). Decrease of cerebral perfusion pressure was equal in all groups. Cardiac index 10 minutes after ROSC signifi cantly diff ered among all groups (group A: 8.9 ± 2.2, group B: 7.1 ± 1.3, group C: 4.9 ± 1.9 l/minute/m2, P = 0.007) and the dose of crystalloid infusion during cardiac arrest positively correlated with cardiac index increase (r = 0.815, P <0.001).i 2. Parnia S, Spearpoint K, de Vos G, Fenwick P, Goldberg D, Yang J, et al. AWARE – AWAreness during REsuscitation – a prospective study. Resuscitation. 2014;85:1799-805. 3. Greyson B. The near-death experience scale. Construction, reliability, and validity. J Nerv Ment Dis. 1983;171:369-75. 3. Greyson B. The near-death experience scale. Construction, reliability, and validity. J Nerv Ment Dis. 1983;171:369-75. f References 1. Kim EY, Yang HJ, Sung YM, et al. Multidetector CT fi ndings of skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation. 2011;82:1285-8. Kim EY, Yang HJ, Sung YM, et al. Multidetector CT fi ndings of skeleta Methods In a retrospective study from 2005 to 2012, 295 consecutive cardiac patients who were successfully resuscitated after cardiac arrest were enrolled. In total, 204 (69%) were alive during the research period (mean delay: 55 months). A total of 118 (40%), over 18 years, able to answer a short standardized interview were included in the study when they accepted to participate. Demographic, medical, pharmacological and psychological data were recorded and we used the Greyson NDEs scale to identify and characterize NDEs. Descriptive and unifactorial analysis was performed using the Jacknife method and Wald test according to low event frequency. 2. Kim MJ, Park YS, Kim SW, et al. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation. Resuscitation. 2013;84:361-4. g y Results From our 118 reports, 20 described a core experience and 18 (15.3%) met the criteria for NDEs (Greyson NDEs total score >6/32 (7 to 19)). Only one patient recounted a negative experience. Regarding the risk factors for NDEs, using univariate analysis, we found for demographic data: woman (CI: 1.11 (1.10 to 1.12), P <0.0001), age under 60 (CI: 1.23 (1.21 to 1.24), P <0.0001), prior knowledge of NDEs (CI: 1.97 (1.95 to 1.99)) and previous NDE (CI: 5.82 (4.19 to 8.08)). According to the history of previous disease, we found an increased risk for pulmonary disease (CI: 1.75 (1.73 to 1.77)), rheumatic disease (CI: 3.79 (3.75 to 3.84)), endocrine disease (CI: 1.45 (1.43 to 1.46)), and a decrease for cardiac disease (CI: 0.65 (0.64 to 0.66)), psychiatric disease (CI: 0.71 (0.69 to 0.72)) and digestive tract disease (CI: 0.71 (0.69 to 0.72)). For previous pharmacological treatment we found a decrease of risk for all classes and particularly when two drugs were simultaneously given (CI: 0.37 (0.36 to 0.38)). Near-death experiences in survivors of cardiac arrest: a study about demographic, medical, pharmacological and psychological context F Lallier, G Velly, A Leon Centre Hospitalier Universitaire, Reims Cedex, France Critical Care 2015, 19(Suppl 1):P421 (doi: 10.1186/cc14501) Near-death experiences in survivors of cardiac arrest: a study about demographic, medical, pharmacological and psychological context F Lallier, G Velly, A Leon Near-death experiences in survivors of cardiac arrest: a study about demographic, medical, pharmacological and psychological context F Lallier, G Velly, A Leon Centre Hospitalier Universitaire, Reims Cedex, France Critical Care 2015, 19(Suppl 1):P421 (doi: 10.1186/cc14501) p Critical Care 2015, 19(Suppl 1):P421 (doi: 10.1186/cc14501) Introduction Near-death experiences (NDEs) are increasingly being reported as a clear reality of clinical signifi cance. Previous studies, essentially, have been trying to estimate their incidence in various populations, notably after cardiac arrest resuscitation, and to understand the implication of resuscitation characteristics [1,2]. Using the Greyson NDE scale [3], the present retrospective study aimed at exploring cardiac arrest survivors and the correlations between NDE and physiological, medical, psychological and pharmacological context. i Conclusion Frequency of rib fractures and multiple rib fractures were higher in OHCA survivors. Further investigation is needed into the relation between the location of CPR and the CPR-related injuries, eff orts to reduce the complications after CPR. Predictors of return of spontaneous circulation and survival in in- hospital cardiac arrest: a retrospective study in a single institution JL Ch 1 ZM Li 1 JH T 1 S S h 1 M H i Bi I k d 1 B L 2 Multivariate analysis showed that an arrest occurring in the ICU setting was 2.9 times more likely to attain ROSC (95% CI: 1.02 to 5.59, P = 0.044). Conclusion The results of this study have described some key predictive factors regarding positive outcomes in IHCA in Singapore. These are vital in understanding important features regarding IHCAs and will aid in developing policies to help improve care and survival in this group of patients. S148 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P421 detected more in OHCA survivors. Frequency of multiple rib fractures was higher in OHCA survivors. Frequency of sternum fractures was higher in OHCA survivors, showing no signifi cant diff erence. In lung injuries, lung contusion and pneumothorax account for the large part, and OHCA survivors had higher incidence in both complications but statistically insignifi cant. Major complications occurred in eight cases in OHCA survivors and three cases in IHCA survivors during the study period. After adjusting for the time factor in multiple logistic regression analysis, rib fractures and multiple rib fractures became statistically signifi cant in OHCA survivors. See Figures 1 and 2. Utilisation and prognostic impact of cathlab investigation prior to intensive care admission for patients following out-of-hospital cardiac arrest Eighty-three percent (n = 45) of survivors admitted to the ICU went to the cardiac cathlab before ICU admission compared with 53% (n = 39) of nonsurvivors. Forty-three percent of survivors had PPCI compared with 26% of nonsurvivors. Eighty- one percent (n = 44) of survivors received therapeutic hypothermia compared with 62% (n = 48) of nonsurvivors. Introduction Mild hypothermia and fever control have been shown to improve neurological outcomes post cardiac arrest. Common methods to induce hypothermia include body surface cooling and intravascular cooling; however, a new approach using a catheter placed into the esophagus has recently become available. p g y Methods We report the fi rst three cases of temperature control using an esophageal cooling device (ECD). The ECD was placed orally in a similar fashion to orogastric tubes. Temperature reduction was achieved by connecting the ECD to a commercially available heat exchange unit (Blanketrol II or III). Conclusion Over 3 consecutive years our annual case mix, ICU and hospital mortalities for OOHCA patients admitted to the ICU have remained stable, while our annual pre-ICU cathlab and PPCI utilisation have risen consistently in both survivors and nonsurvivors. ICU survivors were more likely to have had a shockable rhythm, been to the cathlab, and received PPCI and TH, but all may simply refl ect selection bias. Any benefi t these conferred to cardiac patients may have been off set by our liberal ICU admission policy to OOHCAs with nonshockable rhythms. Access to 24–7 PPCI in this group may determine survival and we suggest that OOHCA patients should be taken directly to regional heart attack centres. Results The fi rst patient, a 59-year-old male (73 kg), was admitted after successful resuscitation from a protracted out-of hospital cardiac arrest. His initial temperature was 35°C, which is within our current institutional protocol of 34 to 36°C. Several hours after arrival, his temperature slowly increased to 35.8°C despite application of a cooling blanket and ice packs to the groin and axilla. The ECD was inserted and a reduction of temperature to 34.8°C was achieved within 3 hours. The patient expired on day 3. The second patient, a 54-year-old female (95 kg), was admitted after resuscitation from an out-of-hospital PEA arrest. Despite initiating our cooling protocol with surface-cooling blankets and cold intravenous saline, she mounted a fever peaking at 38.3°C shortly after admission. Utilisation and prognostic impact of cathlab investigation prior to intensive care admission for patients following out-of-hospital cardiac arrest L Eveson, S Shrestha, V Achan, M Davies, M Peck Frimley Park Hospital, Frimley, UK y p y Critical Care 2015, 19(Suppl 1):P422 (doi: 10.1186/cc14502) y p y Critical Care 2015, 19(Suppl 1):P422 (doi: 10.1186/cc14502) Conclusion Fluid loading during CPR had signifi cant impact on hemodynamics in our experimental model. While a high dose led to unintentional increase of intracranial pressure and decrease of coronary perfusion pressure, a low dose did not aff ect intracranial pressure and was associated with mild increase of coronary perfusion pressure during cardiac arrest. Introduction Our 700-bed hospital has a 24–7 cathlab service that routinely investigates patients with indications prior to ICU admission following out-of-hospital cardiac arrest (OOHCA). Our aim was to compare survivors and nonsurvivors and evaluate utilisation and S149 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 nonshockable rhythms. However, access to 24–7 PPCI may determine survival and we suggest that all OHCA patients should be taken directly to regional heart attack centres. nonshockable rhythms. However, access to 24–7 PPCI may determine survival and we suggest that all OHCA patients should be taken directly to regional heart attack centres. prognostic impact of angiography and primary percutaneous coronary intervention (PPCI) in this patient group. Methods A retrospective analysis using Trust electronic databases (Symphony, WardWatcher, PICIS, PRISM) of all OOHCA patients admitted to our ICU over 3 consecutive years between 1 November 2011 and 31 October 2014. P424 Targeted temperature management after cardiac arrest and fever control with an esophageal cooling device A Hegazy, D Lapierre, E Althenayan University of Western Ontario, London, ON, Canada Critical Care 2015, 19(Suppl 1):P424 (doi: 10.1186/cc14504) Results A total of 351 patients presented to our emergency department (ED) following OOHCA in this period, and of these 50% died in the ED, 37% were admitted to the ICU and 13% were admitted elsewhere. Of the 129 patients admitted to the ICU, median age was 66 (range 18 to 93), 71% were male, 68% had a shockable presenting rhythm, median ICU LOS was 3.75 (range 1 to 34 days) and ICU and hospital mortalities were 50% and 60% respectively. Eighty-nine percent (n = 48) of OOHCA survivors admitted to the ICU had a shockable rhythm compared with 55% (n = 41) of nonsurvivors. P425 P425 Is selective nasopharyngeal brain cooling detrimental to neuroprotection? M Kumar, L Johnson, A Goldberg, M Kashiouris, L Keenan, A Rabinstein Mayo Clinic, Rochester, MN, USA Critical Care 2015, 19(Suppl 1):P425 (doi: 10.1186/cc14505) P423 Utilisation and prognostic impact of angiography and primary percutaneous coronary intervention prior to intensive care admission for patients following out-of-hospital cardiac arrest L Eveson, S Shrestha, M Davies, V Achan, M Peck Frimley Park Hospital, Frimley, UK Critical Care 2015, 19(Suppl 1):P423 (doi: 10.1186/cc14503) P423 Utilisation and prognostic impact of angiography and primary percutaneous coronary intervention prior to intensive care admission for patients following out-of-hospital cardiac arrest L Eveson, S Shrestha, M Davies, V Achan, M Peck Frimley Park Hospital, Frimley, UK Critical Care 2015, 19(Suppl 1):P423 (doi: 10.1186/cc14503) Introduction Our 700-bed hospital has a 24–7 cathlab service that routinely investigates patients with indications prior to ICU admission following out-of-hospital cardiac arrest (OHCA). Our aim was to compare ICU survivors and nonsurvivors and evaluate the utilisation and prognostic impact of angiography and primary percutaneous coronary intervention (PPCI) in this patient group. f Conclusion The ECD is a novel technology that can be used for temperature management post cardiac arrest and for fever control in critically ill patients. Despite patients mounting a febrile response, temperature control was achieved and maintained successfully. The device was reported as being easy to use, by both physicians and nurses. y p g p Methods A retrospective analysis using Trust electronic databases (Symphony, WardWatcher, PICIS, PRISM) of all OHCA patients admitted to our ICU over 3 consecutive years between 1 November 2011 and 31 October 2014. Results A total of 351 patients presented to our hospital following OHCA in this period, and of these 50% died in the ED, 37% were admitted to the ICU and 13% elsewhere. Of the 129 patients admitted to the ICU, median age was 66 (range 18 to 93), 71% were male, 68% had a shockable presenting rhythm, median ICNARC score was 31 (range 10 to 66), median ICU LOS was 3.75 (range 1 to 34 days) and ICU and hospital mortality were 50% and 60% respectively. ICU survivors were more likely to have had a shockable rhythm (89 vs. 55%), been to the cathlab (83 vs. 53%), received PPCI (43 vs. 26%) and TH (82 vs. 62%) and had lower median ICNARC scores (26 vs. 35) than nonsurvivors. Over the 3 consecutive years, pre-ICU cathlab and PPCI utilisation increased annually in ICU survivors (73 vs. 86 vs. 89% and 45 vs. 54 vs. 59% respectively) and nonsurvivors (40 vs. 38 vs. 50% and 20 vs. 27 vs. 31% respectively). However, our annual ICU and hospital mortality remained unchanged (46 vs. 51 vs. 51% and 60 vs. 57 vs. 62% respectively). Utilisation and prognostic impact of cathlab investigation prior to intensive care admission for patients following out-of-hospital cardiac arrest After ECD insertion and confi rming the external heat exchanger connection, her temperature gradually dropped to 35.7°C over a period of 4 hours. She subsequently made a favorable neurological recovery and was discharged home at day 23. The third patient, a 47-year-old male patient (86 kg) presented with an ongoing fever secondary to necrotizing pneumonia in the postoperative period after coronary artery bypass grafting. His fever was unresponsive to empiric antibiotic therapy, antipyretics, cooling blankets, and ice packs. ECD insertion resulted in a decrease in temperature from 39.5°C to 36.5°C in less than 5 hours. The patient eventually made a full recovery and was discharged home after 59 days. In all three patients, placement of the device occurred in less than 3 minutes and ease of use was reported as excellent by nursing staff and physicians. P427 Pharmacologic evaluation of shivering management in neurologically injured patients utilizing therapeutic normothermia T Lam, B Heather, J Jancik Hennepin County Medical Center, Minneapolis, MN, USA Critical Care 2015, 19(Suppl 1):P427 (doi: 10.1186/cc14507) P427 Pharmacologic evaluation of shivering management in neurologically injured patients utilizing therapeutic normothermia T Lam, B Heather, J Jancik Hennepin County Medical Center, Minneapolis, MN, USA Critical Care 2015, 19(Suppl 1):P427 (doi: 10.1186/cc14507) Introduction Uncontrolled shivering may have negative consequences by increasing metabolic demand and subsequently neutralize the benefi ts of therapeutic normothermia [1]. Previous anti-shivering protocols that utilize the least sedation have been described in therapeutic temperature modulation (TTM) [2]. Our aim is to describe and evaluate an anti-shivering protocol that emphasizes the least sedating regimen with the least number of pharmacologic agents for patients undergoing therapeutic normothermia. brain temperature, intracranial pressure (ICP), core temperatures and vital signs were continuously recorded. Cooling was terminated once the brain reached 32°C and the animals were allowed to passively rewarm. Results In the SNBC group, the brain target temperature was reached in 54 ± 11 minutes. The mean ICP dropped precipitously to a nadir of –15 mmHg. TCD showed signifi cant vasospasm in the MCA, compared with the internal carotid artery (ICA), during the entire cooling phase (Table 1). Upon termination of cooling, the brain temperature spontaneously rewarmed to core temperature in 13 ± 4 minutes. Rewarming was associated with hyperemia and elevation of ICP. In group 2, there was no cerebral vasospasm or hyperemia during cooling and rewarming respectively.i Methods This retrospective chart review includes patients with neurologic injury who underwent TTM from March 2013 to November 2014 and were evaluated for the following outcomes: percentage of total patient hours in each score of the Bedside Shivering Assessment Scale (BSAS) at 72 hours, 168 hours, and total duration of TTM; percentage of total patient days in each tier of the anti-shivering protocol at 72 hours, 168 hours, and total duration of TTM; de- escalation of anti-shivering agents with or without the necessary need for re-escalation; ICU and hospital length of stay (LOS); rescue agents utilized; and hospital mortality. Conclusion SNBC is associated with signifi cant vasospasm of the MCA. In addition, spontaneous and rapid rewarming of the brain, vasodilation, rapid reperfusion, and rebound elevation of ICP, all occurring minutes after termination of SNBC, are likely to be detrimental to an already ischemic brain. y Results Evaluation of 47 patients who underwent TTM resulted in a total of 505 patient-days of TTM with 6,967 BSAS hours. Predictors of survival of therapeutic hypothermia based on analysis of a consecutive American inner-city population over 4 years BR Roberts, HT Toca, JM Martinez Louisiana State University Health Sciences Center – New Orleans, LA, USA Critical Care 2015, 19(Suppl 1):P428 (doi: 10.1186/cc14508) 2 yg Methods A prospective, observational study during therapeutic hypothermia (24 hours –33°C) in 82 post-CA patients monitored with near-infrared spectroscopy. Louisiana State University Health Sciences Center – New Orleans, LA, USA Critical Care 2015, 19(Suppl 1):P428 (doi: 10.1186/cc14508) y Results Forty-three patients (52%) survived in CPC 1 to 2 until 180 days post CA. The mean MAP range associated with maximal survival was 76 to 86 mmHg (OR = 2.63, 95% CI (1.01; 6.88), P = 0.04). The mean SVO2 range associated with maximal survival was 67 to 72% (OR = 8.23, 95% CI (2.07; 32.68), P = 0.001). In two separate multivariate models, a mean MAP (OR = 3.88, 95% CI (1.22; 12.33), P = 0.02) and a mean SVO2 (OR = 8.79, 95% CI (1.69; 18.36), P = 0.01) in the optimal range persisted as independently associated with increased survival after correction for presence of early bystander CPR and presenting shockable rhythm. Based on more than 1,625,000 data points, we found a strong linear relation between SVO2 (range 40 to 90%) and average cerebral saturation (R2 = 0.86) and between MAP and average cerebral saturation for MAPs between 40 and 87 mmHg (R2 = 0.70). Based on our hemodynamic model, the optimal MAP and SVO2 were determined to be 87 mmHg and 72%. Introduction Therapeutic hypothermia (TH) is the international standard of care for all comatose patients after cardiac arrest, but criticism focuses on poor outcomes. We sought to develop criteria to identify American urban patients more likely to benefi t from TH. Introduction Therapeutic hypothermia (TH) is the international standard of care for all comatose patients after cardiac arrest, but criticism focuses on poor outcomes. We sought to develop criteria to identify American urban patients more likely to benefi t from TH. Methods A retrospective chart review of 107 consecutive adults under- going TH in downtown New Orleans from 2010 to 2014 yielded records for 99 patients with all 44 survivors or families contacted up to 4 years. Results Sixty-nine males and 38 females with a mean age of 60.2 years showed 63 dead (58%) and 44 survivors (42%). Presenting cardiac rhythm was divided into shockable (pulseless ventricular tachycardia, ventricular fi brillation) and nonshockable (pulseless electrical activity, asystole). Presenting in shockable rhythms with ROSC <20 minutes were 21 patients with 15 (71%) survivors (P = 0.001). P427 Pharmacologic evaluation of shivering management in neurologically injured patients utilizing therapeutic normothermia T Lam, B Heather, J Jancik Hennepin County Medical Center, Minneapolis, MN, USA Critical Care 2015, 19(Suppl 1):P427 (doi: 10.1186/cc14507) Overall, patients spent 85.5% of total hours at BSAS 0, 11.4% of total hours at BSAS 1, 2.5% of total hours at BSAS 2, and 0.6% of total hours at BSAS 3. Patients were in tier 0 of the anti-shivering protocol 33.1% of the time, in tier 1 of the anti-shivering protocol 20.6% of the time, in tier 2 of the anti-shivering protocol 43.6% of the time, and in tier 3 of the anti- shivering protocol 2.8% of the total duration of TTM. There were 487 rescue doses of fentanyl and 243 rescue doses of meperidine that were required for shivering. Patients had a mean ICU LOS of 19 days, mean hospital LOS of 21 days, and a mortality rate of 23.4%.fi P426 Conclusion This study demonstrates a high level of effi cacy of our protocol and the feasibility of de-escalation to limit the number of pharmacologic interventions. With our patient population spending a large percentage of time without shivering, it would suggest that this protocol could be revised further by utilizing rescue agents more frequently in order to prevent escalation of therapy to the next tier. References Hemodynamic targets during therapeutic hypothermia after cardiac arrest: a prospective observational study K Ameloot, I Meex, C Genbrugge, W Boer, F Jans, B Ferdinande, W Mullens, M Dupont, C Dedeyne, J Dens ZOL Genk, Belgium Critical Care 2015, 19(Suppl 1):P426 (doi: 10.1186/cc14506) 1. Badjiatia N, et al. Crit Care Med. 2009;37:S250-7. 2. Choi HA, et al. Neurocrit Care. 2011;14:389-94. 1. Badjiatia N, et al. Crit Care Med. 2009;37:S250-7. 2. Choi HA, et al. Neurocrit Care. 2011;14:389-94. Introduction In analogy with sepsis, current postcardiac arrest (post- CA) guidelines recommend to target mean arterial pressure (MAP) above 65 mmHg and SVO2 above 70%. This is unsupported by mortality or cerebral perfusion data. The aim of this study was to explore the associations between MAP, SVO2, cerebral oxygenation and survival. Introduction In analogy with sepsis, current postcardiac arrest (post- CA) guidelines recommend to target mean arterial pressure (MAP) above 65 mmHg and SVO2 above 70%. This is unsupported by mortality or cerebral perfusion data. The aim of this study was to explore the associations between MAP, SVO2, cerebral oxygenation and survival. Methods A prospective, observational study during therapeutic hypothermia (24 hours –33°C) in 82 post-CA patients monitored with near-infrared spectroscopy. P428 Predictors of survival of therapeutic hypothermia based on analysis of a consecutive American inner-city population over 4 years BR Roberts, HT Toca, JM Martinez Louisiana State University Health Sciences Center – New Orleans, LA, USA Critical Care 2015, 19(Suppl 1):P428 (doi: 10.1186/cc14508) Is selective nasopharyngeal brain cooling detrimental to neuroprotection? M Kumar, L Johnson, A Goldberg, M Kashiouris, L Keenan, A Rabinstein Mayo Clinic, Rochester, MN, USA Critical Care 2015, 19(Suppl 1):P425 (doi: 10.1186/cc14505) M Kumar, L Johnson, A Goldberg, M Kashiouris, L Keenan, A Rabinstein Mayo Clinic, Rochester, MN, USA Introduction Clinical outcomes vary depending on the method used to induce therapeutic hypothermia following stroke or cardiac arrest. In swine, we tested the hypothesis that selective nasopharyngeal brain cooling (SNBC), in contrast to systemic hypothermia, adversely impacts cerebral perfusion. Methods In two groups of animals (34 to 35 kg), blood fl ow in the right middle cerebral artery (MCA) was measured using transcranial Doppler (TCD). In group 1, SNBC was initiated using perfl uorohexane aerosol (1 ml/kg/minute) and oxygen (1 l/kg/minute) through a nasopharyngeal catheter atomizer. In group 2, the animals were body surface cooled using water-circulating blankets (4°C). In both groups, Conclusion ICU survivors were more likely to have had a shockable rhythm, been to the cathlab, received PPCI and TH and been less sick than nonsurvivors, but these may simply refl ect selection and other biases. Any benefi t these factors did confer to cardiac patients may have been off set by our liberal ICU admission policy to OHCAs with S150 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 brain temperature, intracranial pressure (ICP), core temperatures and vital signs were continuously recorded. Cooling was terminated once the brain reached 32°C and the animals were allowed to passively rewarm. Results In the SNBC group, the brain target temperature was reached in 54 ± 11 minutes. The mean ICP dropped precipitously to a nadir of –15 mmHg. TCD showed signifi cant vasospasm in the MCA, compared with the internal carotid artery (ICA), during the entire cooling phase (Table 1). Upon termination of cooling, the brain temperature spontaneously rewarmed to core temperature in 13 ± 4 minutes. Rewarming was associated with hyperemia and elevation of ICP. In group 2, there was no cerebral vasospasm or hyperemia during cooling and rewarming respectively. Conclusion SNBC is associated with signifi cant vasospasm of the MCA. In addition, spontaneous and rapid rewarming of the brain, vasodilation, rapid reperfusion, and rebound elevation of ICP, all occurring minutes after termination of SNBC, are likely to be detrimental to an already ischemic brain. Is selective nasopharyngeal brain cooling detrimental to neuroprotection? P426 Hemodynamic targets during therapeutic hypothermia after cardiac arrest: a prospective observational study K Ameloot, I Meex, C Genbrugge, W Boer, F Jans, B Ferdinande, W Mullens, M Dupont, C Dedeyne, J Dens ZOL Genk, Belgium Critical Care 2015, 19(Suppl 1):P426 (doi: 10.1186/cc14506) Introduction In analogy with sepsis, current postcardiac arrest (post- Table 1 (abstract P425). Cerebral vasospasm during SNBC MCA fl ow ICA fl ow velocity velocity Lindegaard Pulsatility ICP Intervention (cm/second) (cm/second) ratio ratio (mmHg) Baseline 62 41 1.51 0.77 13 SNBC cooling 128 52 2.46 0.48 –15 SNBC rewarming 96 44 1.74 1.12 21 Table 1 (abstract P425). Cerebral vasospasm during SNBC Somatosensory evoked high-frequency oscillations and prognostication after cardiac arrest Somatosensory evoked high-frequency oscillations and prognostication after cardiac arrest p g C Endisch, C Storm, CJ Ploner, C Leithner C Endisch, C Storm, CJ Ploner, C Leithner Methods With IRB approval, we prospectively measured rSO2 during ALS in consecutive OHCA patients. One sensor of the Equanox™ 7600 (NONIN) was applied on the patient’s forehead’s right side when the medical emergency team arrived in an OHCA. ROSC was defi ned as ROSC >20 minutes. Charité Universitätsmedizin Berlin, Germany Charité Universitätsmedizin Berlin, Germany Critical Care 2015, 19(Suppl 1):P431 (doi: 10.1186/cc14511) y Critical Care 2015, 19(Suppl 1):P431 (doi: 10.1186/cc14511) Introduction Electrical median nerve stimulation elicits a burst of high-frequency oscillations (HFOs) superimposing onto the cortical short-latency potential. Digital fi ltering of somatosensory evoked potentials (SSEPs) enables non-invasive analysis of these HFOs. The late HFO component following the cortical N2O peak is ascribed to spiking activity of cortical neurons. Results We included 88 prehospital cardiac arrest patients between December 2011 and October 2014 with eight (9%) patients with CPC 1 or 2. Twenty-seven patients of the nonsurvivors had ROSC >20 minutes and one patient had CPC 3 at hospital discharge. We observed no signifi cant diff erence between both groups in age (P = 0.161), time between emergency call and start of ALS (P = 0.788) and duration of basic life support performed by bystanders, general practitioners or paramedics (P = 0.649). The initial rhythm was asystole in one (12.5%) survivor and in 50 (62.5%) nonsurvivors (P = 0.009), ventricular fi brillation in six (75%) survivors and 13 (16%) nonsurvivors (P = 0.001), and pulseless electrical activity in one (12.5%) survivor and 17 (21%) nonsurvivors (P = 1.00). The cardiac arrest was witnessed in all survivors (100%) and in 49 (61%) nonsurvivors (P = 0.046). First measured rSO2 was 38% (27 to 67) in the survivor group compared with 22% (8 to 32) in the nonsurvivor group (P = 0.004). Also a signifi cant diff erence was found in mean rSO2 until 1 minute before ROSC between survivors and nonsurvivors, respectively 46% (40 to 74) and 34% (22 to 42). We observed no signifi cant diff erence in increase of rSO2 until 1 minute before ROSC between survivors 12.5% (5 to 21) and nonsurvivors 11% (5 to 18) (P = 0.719). Predictors of survival of therapeutic hypothermia based on analysis of a consecutive American inner-city population over 4 years BR Roberts, HT Toca, JM Martinez Louisiana State University Health Sciences Center – New Orleans, LA, USA Critical Care 2015, 19(Suppl 1):P428 (doi: 10.1186/cc14508) Time >20 minutes until ROSC in shockable rhythms had fi ve patients with three survivors (78%, P = 0.001). Presenting in nonshockable rhythms with ROSC <20 minutes were 54 patients with 18 survivors (33%, P = 0.001). ROSC >20 minutes in nonshockable rhythms had 19 patients with two survivors (8%, P = 0.001). Survivors of shockable rhythms showed 19 (100%) living post TH. Fifteen survivors (79%, n = 19, P = 0.001) had CPC g Conclusion The optimal SVO2 (72%) and MAP (87 mmHg) derived from our hemodynamic model matched with the observed SVO2 (67 to 72%) and MAP (76 to 86 mmHg) associated with maximal survival. Prospective interventional studies to reach or maintain these targets are needed to confi rm these fi ndings. S151 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 of this study were to investigate the association between hemoglobin, cerebral oxygenation (SctO2) and outcome in post-CA patients. score 1 or 2 with four survivors (21%, n = 19) having a CPC score of 3. A total of 25 survived nonshockable rhythm. Acute survival of patients with nonshockable rhythm showed 18 expired <72 hours (72%, n = 25) with long-term survival of four patients (5%, n = 74) and CPC scores of 1 or 2 (P = 0.001). Interestingly, patients with time to ROSC <20 minutes exhibiting more than one loss of sustained ROSC showed 100% mortality (P = 0.001). Patients presenting with shockable >20 minutes ROSC had overall survival of 70% (P = 0.001), but those undergoing >3 cardiac rhythm changes had 100% mortality (P = 0.001). yg 2 Methods A prospective observational study in 82 post-CA patients during hypothermia in the fi rst 24 hours of ICU stay. Hemoglobin was determined hourly together with a corresponding SctO2 by NIRS and SVO2 in patients with a pulmonary artery catheter (n = 62). 2 Results Based on 2,099 paired data, we found a strong linear relationship between hemoglobin and average SctO2 (SctO2 = 0.70 × hemoglobin + 56 (R2 = 20.84, P = 10–6)). Given the previously suggested SctO2 target between 66 and 68%, hemoglobin levels below 10 g/dl generally resulted in suboptimal brain oxygenation. Forty-three patients (52%) had a good neurological outcome (CPC 1 to 3) at 180 days post CA. P432 P432 One-size-fi ts-all or patient-tailored hemodynamic targets in post-cardiac arrest patients: an observational near-infrared spectroscopy study on cerebral autoregulation C Genbrugge, K Ameloot, I Meex, W Boer, F Jans, W Mullens, M Dupont, B Ferdinande, J Dens, C Dedeyne ZOL Genk, Belgium Critical Care 2015, 19(Suppl 1):P432 (doi: 10.1186/cc14512) P432 One-size-fi ts-all or patient-tailored hemodynamic targets in post-cardiac arrest patients: an observational near-infrared spectroscopy study on cerebral autoregulation C Genbrugge, K Ameloot, I Meex, W Boer, F Jans, W Mullens, M Dupont, B Ferdinande, J Dens, C Dedeyne ZOL Genk, Belgium Critical Care 2015, 19(Suppl 1):P432 (doi: 10.1186/cc14512) Somatosensory evoked high-frequency oscillations and prognostication after cardiac arrest y Methods We retrospectively studied late HFO components of median nerve SSEPs obtained 24 hours to 4 days after cardiac arrest in patients treated with mild hypothermia (33°C for 24 hours). Cortical average recordings were digitally fi ltered at 450 to 750 Hz and noise- corrected maximum peak-to-peak amplitudes of the cortical late HFO bursts determined. Outcome upon ICU discharge was dichotomized according to the Cerebral Performance Category (CPC) scale. CPC 1 to 3 was classifi ed as good outcome, CPC 4 to 5 (unresponsive wakefulness syndrome and death) as poor outcome. Results Of 307 consecutive patients, 153 (50%) achieved good outcome (CPC 1 to 3) and 154 (50%) had poor outcome. Late HFO bursts were present in 102 (33%) recordings. Among patients with late HFO amplitudes above 0.1 μV, 26 had CPC 1 to 3, none had CPC 4 and eight died. Case review indicated causes of death other than hypoxic encephalopathy in all patients who died despite HFO amplitudes above 0.1 μV. Conclusion We found cortical late HFO bursts, obtained by digital fi ltering of standard SSEP recordings, in a signifi cant proportion of patients after cardiac arrest treated with mild hypothermia. Our data indicate that the presence of late HFO bursts with amplitudes above 0.1 μV may confi rm absence of severe hypoxic encephalopathy early after cardiac arrest with high specifi city. Conclusion We observed a signifi cant diff erence in fi rst measured rSO2 and mean rSO2 until 1 minute before ROSC between patients with good neurological outcome (CPC 1 or 2) at hospital discharge and patients with worse neurological outcome or nonsurvivors (CPC 3 or 4 or 5). However, no signifi cant diff erence was observed in the increase between both groups. Larger studies are necessary to confi rm these results. Predictors of survival of therapeutic hypothermia based on analysis of a consecutive American inner-city population over 4 years BR Roberts, HT Toca, JM Martinez Louisiana State University Health Sciences Center – New Orleans, LA, USA Critical Care 2015, 19(Suppl 1):P428 (doi: 10.1186/cc14508) There was a signifi cant association between average hemoglobin above 12.3 g/dl and good neurological outcome (OR = 2.88, 95% CI = 1.02; 8.16, P = 0.04). In a multivariate model, this association persisted after correction for comorbidities and age by the modifi ed Charlson score (OR = 2.99, 95% CI = 1.05; 8.53, P = 0.03). This association was entirely driven by results obtained in patients with an average SVO2 below 70% (OR = 17.55, 95% CI = 1.67; 184.41, P = 0.01). Conclusion Patients presenting with shockable rhythms undergoing TH had overall acute survival of 70% followed by long-term survival of 100% after 4 years. In contrast, patients presenting with nonshockable rhythm had long-term survival of 5%. TH is not recommended. Diff erence in cerebral saturation during cardiopulmonary resuscitation between survivors with favorable neurological outcome and compromised neurological outcome at hospital discharge C Genbrugge1, W Boer1, I Meex2, F Jans1, C Deyne1, J Dens1 1ZOL, Genk, Belgium; 2Hasselt University, Hasselt, Belgium Critical Care 2015, 19(Suppl 1):P429 (doi: 10.1186/cc14509) C Genbrugge , W Boer , I Meex , F Jans , C Deyne , J Dens 1ZOL, Genk, Belgium; 2Hasselt University, Hasselt, Belgium Critical Care 2015, 19(Suppl 1):P429 (doi: 10.1186/cc14509) Conclusion There is a steep linear relationship between hemoglobin and SctO2 in post-CA patients with hemoglobin levels below 10 g/dl generally resulting in cerebral desaturation. Average hemoglobin below 12.3 g/ dl was independently associated with worse neurological outcome 180 days post CA. An interventional trial is necessary to investigate whether maintaining higher hemoglobin would improve outcome. Introduction During out-of-hospital cardiac arrest (OHCA) monitoring possibilities are limited. Recently, the role of cerebral oximetry, using near-infrared spectroscopy, during ALS was investigated. In this study we determined whether the magnitude of increase in cerebral saturation (rSO2) or mean rSO2 during prehospital ALS was associated with good neurological outcome at hospital discharge (Cerebral Performance Category (CPC) 1 or 2). P431 Response of regional oxygen saturation technologies during hypoxia UB Borg, AM Neitembach Covidien, Boulder, CO, USA Critical Care 2015, 19(Suppl 1):P433 (doi: 10.1186/cc14513) Results Thirty-four simplifi ed EEG samples were analysed. According to standard EEG, 11 patients showed a DS pattern, three had CI, six showed BS, four showed PEDs and 10 had an SE. Neurophysiologists interpreted all samples with a high accuracy. Mean sensitivity was 82.12% and mean specifi city was 91.88%. Only one SE was missed by one neurophysiologist. Unfortunately, only one PED was confi rmed by both neurophysiologists. Interobserver reliability was high (κ = 0.843). High correlations were found for the comparison of full and simplifi ed EEG for both neurophysiologists (r = 0.809). Further, the two inexperienced physicians identifi ed SE with a sensitivity of 85% and specifi city of 98%. Introduction The purpose of this study was to determine the rate and magnitude of response to hypoxia for three diff erent regional oxygen saturation (rSO2) devices. rSO2 technologies are focused on absolute accuracy without consideration of response characteristics. Current rSO2 technologies assume that the oxygen saturation is a fi xed ratio of arterial and venous blood. Cerebral arteries have an oxygenation- related vasoactivity that may change the arterial/venous ratio during hypoxia. Thus, absolute rSO2 accuracy may be less important compared with sensitivity to changes in cerebral rSO2. pi y Conclusion Simplifi ed EEG monitoring, using BIS, resulted in high accuracy of a simple classifi cation system in post-CA patients. Not only neurophysiologists, but also treating physicians were capable to identify SE, which may play an important role in the early detection of SE. We suggest using BIS as a screening tool in post-CA patients to save valuable time in the detection of SE, without replacing the need for full EEG monitoring for confi rmation. 2 Methods Ten subjects completed the study and are included in the analysis. One INVOS sensor (SAFB-SM) was placed on the left side and one Equanox (8000CA) or Foresight (1 July 2007 or 1 July 2005) sensor (alternated between subjects) was placed on the right side of the forehead for bilateral monitoring. Desaturation was induced by adjusting the inspiratory gas mixture of O2/N2. Desaturation was titrated from room air to achieve a plateau of 70% arterial oxygen saturation (SpO2). Resaturation was induced by rapid change in FiO2 to 1.0. Diff erences in cerebral saturation measured during prehospital advanced life support, between patients with presumed cardiac origin and noncardiac origin of cardiac arrest C Genbrugge1, W Boer1, K Anseeuw2, I Meex3, F Jans1, J Dens1, C De Deyne1 2 g p Results The rate of rSO2 change during desaturation was similar for all devices with an average slope factor of 0.17 for Foresight, 0.16 for Equanox and 0.21 for INVOS. The rate of rSO2 change in seconds during resaturation from SaO2 70% to SaO2 100% was signifi cantly faster for INVOS (42 ± 16) compared with Foresight (57 ± 20) (P <0.05). There was signifi cant diff erence in total rSO2 change between INVOS (23 ± 4%) and Equanox (15 ± 4%) during desaturation and resaturation (P <0.005) and between INVOS compared with Foresight (20 ± 5%) (P <0.05). Conclusion All rSO2 devices followed the SpO2 slope during desaturation as expected. The diff erences between the devices in terms of total rSO2 change reached statistical signifi cance. There were also signifi cant diff erences in the rate of rSO2 change in seconds between INVOS and Foresight during resaturation. The rate of absolute change 2 Results The rate of rSO2 change during desaturation was similar for all devices with an average slope factor of 0.17 for Foresight, 0.16 for Equanox and 0.21 for INVOS. The rate of rSO2 change in seconds during resaturation from SaO2 70% to SaO2 100% was signifi cantly faster for INVOS (42 ± 16) compared with Foresight (57 ± 20) (P <0.05). There was signifi cant diff erence in total rSO2 change between INVOS (23 ± 4%) and Equanox (15 ± 4%) during desaturation and resaturation (P <0.005) and between INVOS compared with Foresight (20 ± 5%) (P <0.05). Introduction During out-of hospital cardiac arrest (OHCA) cerebral saturation may provide relevant information on cerebral oxygenation. In this study we examined the time course in cerebral saturation (rSO2) during prehospital ALS comparing patients with a presumed cardiac origin (survivor = Sc, nonsurvivor = NSc) of arrest and noncardiac origin (survivor = Snc, nonsurvivor = NSnc) of arrest. Conclusion All rSO2 devices followed the SpO2 slope during desaturation as expected. The diff erences between the devices in terms of total rSO2 change reached statistical signifi cance. There were also signifi cant diff erences in the rate of rSO2 change in seconds between INVOS and Foresight during resaturation. The rate of absolute change Methods With IRB approval, we prospectively measured rSO2 from the start of ALS in consecutive OHCA patients. Association between hemoglobin, cerebral oxygenation and neurologic outcome in postcardiac arrest patients (4) The time under the individual optimal MAP was negatively associated with survival (OR = 0.97, 95% CI (0.96; 0.99), P = 0.02). The time under previously proposed fi xed targets (65, 70, 75, 80 mmHg) was not associated with a diff erential survival rate. Introduction Assessment of prognosis in postcardiac arrest (post- CA) patients became very challenging since the introduction of therapeutic hypothermia (TH). Continuous EEG monitoring has been proposed to improve prognostication; however, its use is limited due to diffi culties in ready interpretation. Thus emerges the need for a simple EEG montage. The bispectral index (BIS) monitor is a simplifi ed EEG system, mainly calculating an index ranging from 0 (isoelectric EEG) to 100 (full consciousness) to provide information on hypnotic depth of anaesthesia. The aim of the study was to validate the accuracy of simplifi ed EEG monitoring in a CA setting. pi g g Methods BIS monitoring (BIS VISTATM) was applied to collect frontotemporal data in TH-treated CA patients. A standard 19-channel EEG was performed after return to normothermia. Afterwards, small EEG frames coincident with the time of full EEG registration were extracted from the BIS monitor. We asked two neurophysiologists to indicate the presence of status epilepticus (SE), cerebral inactivity (CI), burst suppression (BS), periodic epileptiformic discharges (PEDs) or a diff use slowing pattern (DS). In addition, these samples were analysed by two inexperienced physicians, who were asked to indicate the presence of SE. Association between hemoglobin, cerebral oxygenation and neurologic outcome in postcardiac arrest patients g , yg neurologic outcome in postcardiac arrest patients I Meex, K Ameloot, C Genbrugge, M Dupont, B Ferdinande, J Dens, C Dedeyne ZOL Genk, Belgium Critical Care 2015, 19(Suppl 1):P430 (doi: 10.1186/cc14510) I Meex, K Ameloot, C Genbrugge, M Dupont, B Ferdinande, J Dens C Dedeyne ZOL Genk, Belgium Critical Care 2015, 19(Suppl 1):P430 (doi: 10.1186/cc14510) p py y g C Genbrugge, K Ameloot, I Meex, W Boer, F Jans, W Mullens, M Dupont, B Ferdinande, J Dens, C Dedeyne ZOL Genk, Belgium Critical Care 2015, 19(Suppl 1):P432 (doi: 10.1186/cc14512) Introduction The safety of a restrictive transfusion threshold of 7 g/dl applied in all critically ill patients can be questioned in postcardiac arrest (post-CA) patients since these are phenotypically clearly distinct. The aims Introduction A subgroup of post-CA patients with disturbed cerebral autoregulation might benefi t from higher mean arterial pressures S152 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 in seconds and the magnitude of absolute change may result in better resolution to detect physiological changes. Clinical studies are required to elucidate the clinical relevance of the diff erences. (MAPs). We aimed to (1) investigate whether patients with disturbed autoregulation have a worse prognosis, (2) phenotype these patients, (3) defi ne an individual optimal MAP and (4) investigate whether time under this individual optimal MAP is associated with outcome. Methods A prospective observational study in 51 post-CA patients monitored with near-infrared spectroscopy. (MAPs). We aimed to (1) investigate whether patients with disturbed autoregulation have a worse prognosis, (2) phenotype these patients, (3) defi ne an individual optimal MAP and (4) investigate whether time under this individual optimal MAP is associated with outcome. (MAPs). We aimed to (1) investigate whether patients with disturbed autoregulation have a worse prognosis, (2) phenotype these patients, (3) defi ne an individual optimal MAP and (4) investigate whether time under this individual optimal MAP is associated with outcome. p Methods A prospective observational study in 51 post-CA patients monitored with near-infrared spectroscopy. Association between hemoglobin, cerebral oxygenation and neurologic outcome in postcardiac arrest patients P434 P434 Use of bispectral index EEG monitoring for a fast and reliable detection of epileptic activity in postcardiac arrest patients J Haesen1, L Desteghe1, I Meex2, C Genbrugge2, J Demeestere2, J Dens2, L Ernon2, C De Deyne2 1Universiteit Hasselt, Belgium; 2Ziekenhuis Oost-Limburg, Genk, Belgium Critical Care 2015, 19(Suppl 1):P434 (doi: 10.1186/cc14514) p py Results (1) In multivariate analysis, patients with preserved auto- regulation (33.65%) had a signifi cant higher 180-day survival rate (OR = 4.62, 95% CI (1.06; 20.06), P = 0.04). (2) Phenotypically, a higher proportion of patients with disturbed autoregulation had pre- CA hypertension (31 ± 47 vs. 65 ± 49%, P = 0.02) suggesting that right shifting of autoregulation is caused by chronic adaptation of cerebral blood fl ow to higher blood pressures. Based on an index of autoregulation (COX), the average COX-predicted optimal MAP was 85 mmHg in patients with preserved and 100 mmHg in patients with disturbed autoregulation. (3) An individual optimal MAP could be determined in 33/51 patients. (4) The time under the individual optimal MAP was negatively associated with survival (OR = 0.97, 95% CI (0.96; 0.99), P = 0.02). The time under previously proposed fi xed targets (65, 70, 75, 80 mmHg) was not associated with a diff erential survival rate. Conclusion Cerebral autoregulation was shown to be disturbed in 35% of post-CA patients of which a majority had pre-CA hypertension. Disturbed cerebral autoregulation within the fi rst 24 hours after CA is associated with a worse outcome. In contrast to uniform MAP goals, the time spent under a patient-tailored optimal MAP, based on an index of autoregulation, was negatively associated with survival. Results (1) In multivariate analysis, patients with preserved auto- regulation (33.65%) had a signifi cant higher 180-day survival rate (OR = 4.62, 95% CI (1.06; 20.06), P = 0.04). (2) Phenotypically, a higher proportion of patients with disturbed autoregulation had pre- CA hypertension (31 ± 47 vs. 65 ± 49%, P = 0.02) suggesting that right shifting of autoregulation is caused by chronic adaptation of cerebral blood fl ow to higher blood pressures. Based on an index of autoregulation (COX), the average COX-predicted optimal MAP was 85 mmHg in patients with preserved and 100 mmHg in patients with disturbed autoregulation. (3) An individual optimal MAP could be determined in 33/51 patients. Response of regional oxygen saturation technologies during hypoxia After 5 minutes of SpO2 100%, the process was repeated by desaturation to SpO2 70% and rapid return to SpO2 100%. Cerebral and pulse oximetry data were recorded during the study and the time of each FiO2 change and plateau was recorded. rSO2 levels at 10, 20, 40, 60 and 80% of the total SpO2 response were calculated for each device to assess the rate of rSO2 change. The rate of rSO2 change in seconds and total rSO2 change were compared. P436 Amplitudes of cortical somatosensory evoked potentials and outcome prediction after cardiac arrest C Storm, CJ Ploner, C Leithner Charite Universitaetsmedizin, Berlin, Germany Critical Care 2015, 19(Suppl 1):P436 (doi: 10.1186/cc14516) Amplitudes of cortical somatosensory evoked potentials and outcome prediction after cardiac arrest C Storm, CJ Ploner, C Leithner Charite Universitaetsmedizin, Berlin, Germany Critical Care 2015, 19(Suppl 1):P436 (doi: 10.1186/cc14516) C Storm, CJ Ploner, C Leithner Introduction Bilaterally absent cortical somatosensory evoked potentials (SSEPs) predict poor outcome after cardiac arrest. A threshold for the amplitude of early cortical SSEPs above which patients may survive with good outcome has not been determined. Thus, tolerable noise levels for the interpretation of cortical SSEPs are poorly defi ned. Furthermore, it has not been systematically investigated whether high amplitudes of cortical SSEPs may exclude severe hypoxic encephalopathy incompatible with re-awakening. Conclusion In patients with cardiac arrest and targeted temperature management at 33°C, an NSE serum concentration of >90 μg/l strongly indicates poor outcome. NSE producing tumors, acute brain diseases, severe hematologic diseases, use of an intra-aortic balloon pump and blood transfusions need to be considered as potential confounders. An NSE serum concentration of <17 μg/l largely excludes hypoxic encephalopathy incompatible with re-awakening. p p y p g Methods We prospectively studied SSEPs after median nerve stimulation obtained 24 hours to 4 days after cardiac arrest in patients treated with targeted temperature management at 33°C for 24 hours. Amplitudes of cortical SSEPs were determined, if at least two peripheral, spinal and cortical recordings per side were available, spinal potentials were bilaterally reproducible and cortical noise level was below 0.25 μV. Cortical SSEP amplitude was defi ned as largest amplitude of a reproducible cortical SSEP of four cortical recordings (two per side) within 50 milliseconds after stimulation. Outcome was assessed upon ICU discharge using the Cerebral Performance Category (CPC) scale. CPC 1 to 3 was defi ned as good outcome, CPC 4 to 5 as poor outcome. Results Of 318 consecutive patients examined, 293 had complete SSEP recordings with reproducible spinal potentials and cortical noise levels below 0.25 μV. Of those, 137 (47%) had good outcome and 156 (53%) had poor outcome. The lowest amplitude of the early cortical SSEPs in a survivor with good outcome was 0.62 μV. All 79 patients with amplitudes below this threshold had poor outcome. None of 27 patients who survived with CPC 4 (unresponsive wakefulness syndrome) had cortical SSEP amplitudes above 2.5 μV. Twenty-four patients with amplitudes above this limit died. Detailed case review indicated a cause of death other than hypoxic encephalopathy in these patients. P436 Results Of 601 included patients, 309 (51%) had good outcome. An NSE serum concentration threshold of 90 μg/l predicted poor outcome with a positive predictive value of 0.98 and a sensitivity of 0.51. Three patients survived with good outcome despite an NSE serum concentration >90 μg/l. In two of these patients NSE elevations had been documented prior to cardiac arrest. One patient had a neuroendocrine tumor of the pancreas, the other patient suff ered from encephalitis of unknown etiology and an osteomyelofi brosis. Potential confounders in the third patient were an ovarian carcinoma, the use of an intra-aortic balloon pump and blood transfusions shortly after cardiac arrest. Only 16 of 205 patients with NSE <17 μg/l had poor outcome, the majority of these patients died from causes other than hypoxic encephalopathy. Diff erences in cerebral saturation measured during prehospital advanced life support, between patients with presumed cardiac origin and noncardiac origin of cardiac arrest One sensor (Equanox™ 7600; Nonin) was applied on the patient’s forehead’s right side when S153 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 the medical emergency team arrived at the OHCA setting. ROSC was defi ned as ROSC >20 minutes. Retrospectively, included patients were divided into two groups with respect to their presumed origin of arrest. Results Between December 2011 and October 2014, 113 OHCA patients were included. We observed a signifi cant diff erence in asystole and VF as initial rhythm between NSc and NSnc, respectively (P = 0.035 and P = 0.001). In both groups of NS, duration of ALS was signifi cant longer compared with the two S groups (P = 0.001 in both comparisons). We observed no signifi cant diff erence in fi rst measured rSO2, mean rSO2 until 1 minute before ROSC and increase in rSO2 until 1 minute before ROSC (respectively P = 0.123, P = 0.501, P = 0.265) between Sc and Snc. However, when we compare the nonsurvivors of cardiac with noncardiac origin, we observed a signifi cant diff erence in mean rSO2 until 1 minute before ROSC, 35% (27 to 44) in the NSc group and 27 (21 to 34) in the NSnc group (P = 0.026). First measured rSO2 was 24.5% (13 to 34) in the NSc group and 14 (4 to 28) in the NSnc group (P = 0.069) trending to be signifi cantly diff erent. No signifi cant diff erence was observed in increase until 1 minute before ROSC between both groups of NS (P = 0.920). Signifi cant diff erences was observed in mean rSO2 until 1 minute before ROSC and increase in rSO2 between Snc and NSnc (P = 0.033; P <0.001) and between Sc and NSc (P = 0.001; P <0.001).i Prognostic value of neuron-specifi c enolase after cardiac arrest and targeted temperature management Prognostic value of neuron-specifi c enolase after cardiac arrest and targeted temperature management g p g K Streitberger, C Leithner, CJ Ploner, C Storm Charité Universitätsmedizin, Berlin, Germany Critical Care 2015, 19(Suppl 1):P437 (doi: 10.1186/cc14517) K Streitberger, C Leithner, CJ Ploner, C Storm Charité Universitätsmedizin, Berlin, Germany Critical Care 2015, 19(Suppl 1):P437 (doi: 10.1186/cc14517) Introduction The serum concentration of neuron-specifi c enolase (NSE) has been established as a highly specifi c predictor of poor outcome after cardiac arrest. Recent studies have indicated that patients treated with targeted temperature management at 33°C for 24 hours may have good outcome despite NSE serum concentrations considerably higher than the cutoff established for normothermic patients. The threshold above which survival with good outcome becomes very unlikely, its positive predictive value and sensitivity for prediction of poor outcome have not been established in this patient group. Furthermore, a threshold below which hypoxic encephalopathy may be largely excluded has not been determined. Methods From 2006 through 2014 we prospectively included in- hospital and out-of-hospital cardiac arrest patients treated with targeted temperature management at 33°C for 24 hours. The NSE serum concentration was determined 3 days after cardiac arrest and the outcome was assessed according to the Cerebral Performance Category (CPC) upon ICU discharge. CPC 1 to 3 was defi ned as good outcome and CPC 4 to 5 as poor outcome. Individual case review was performed in patients with good outcome despite very high NSE serum concentration and in patients with poor outcome despite very low NSE serum concentration. Conclusion We can conclude that NSc have a signifi cant higher mean rSO2 and trend to have a signifi cant diff erence in fi rst measured rSO2 compared with NSnc. However, no signifi cant diff erence was observed between Sc and Snc. P442 Eff ect of alcohol in blood on neurological outcome and survival of patients with combination of polytrauma and head injury S Pristovnik1, M Strnad2, V Vujanoviæ1, T Pelcl1, V Borovnik-Lesjak1 1Health Center Dr. Adolf Drolc, Maribor, Slovenia; 2Medical Faculty Maribor, Slovenia Critical Care 2015, 19(Suppl 1):P442 (doi: 10.1186/cc14522) P442 Eff ect of alcohol in blood on neurological outcome and survival of patients with combination of polytrauma and head injury S Pristovnik1, M Strnad2, V Vujanoviæ1, T Pelcl1, V Borovnik-Lesjak1 1Health Center Dr. Adolf Drolc, Maribor, Slovenia; 2Medical Faculty Maribor, Slovenia Critical Care 2015, 19(Suppl 1):P442 (doi: 10.1186/cc14522) Critical Care 2015, 19(Suppl 1):P442 (doi: 10.1186/cc14522 Results One hundred and ninety-three patients (110 males, 83 females, mean age 48.2 ± 18.3 years) were studied. The mean time interval between collapse and onset of resuscitation was 2.3 ± 2.1 minutes. A total of 65.3% arrests were witnessed. Sustained ROSC occurred in 36.8% patients and the SOHD was 24.9%. The initial rhythm recorded during CPR was asystole in 133 patients, pulseless electrical activity in 21 patients and ventricular fi brillation/tachycardia (VF/VT) in 39 patients. SOHD for these rhythms was 8.3%, 33.3% and 76.9%, respectively. On univariate analysis, type of rhythm, witnessed arrests and time to resuscitation were associated with sustained ROSC and SOHD. On multivariate analysis, only type of rhythm, VF/VT (P = 0.000) and PEA (P = 0.017), were signifi cantly associated with SOHD, while witnessed arrest and time to resuscitation were not. Introduction The association between blood alcohol level (BAL) on mortality and neurologic outcome in patients with polytrauma and head injury is not clear and the data in the literature are sometimes confl icting. Some studies suggest a possible neuroprotective eff ect of alcohol and increased survival while others show the opposite. The rationale for this study was to investigate whether BAL has any impact on presentation, neurologic outcome and survival in patients with combination of polytrauma and head injury. y j y Methods This is a retrospective study of 43 polytraumatized patients with head injury who were intubated and treated by the prehospital unit and transported to the trauma center. Patients were grouped according to their BAL into BAL+ (>0.5 mg/l) and BAL– (≤0.5 mg/l). Inclusion criteria were age ≥18, Injury Severity Score ≥16 and head Abbreviated Injury Scale (AIS) ≥3. Physiological parameters and outcome with respect to survival to hospital discharge (STHD) and functional outcomes were analyzed. Severity of injuries was measured using the Trauma–Injury Severity Score (TRISS) and head injury using AIS. Functional outcome was measured using the Glasgow Outcome Scale (GOS), Cerebral Performance Category (CPC) and Glasgow Coma Conclusion Sustained ROSC occurred in 36.8% patients and the SOHD was 24.9%. P440 Outcome after CPR: when we cannot save lives, we can save organs C Caestecker, J Froyman, P Lormans, W Stockman AZ Delta, Roeselare, Belgium Critical Care 2015, 19(Suppl 1):P440 (doi: 10.1186/cc14520) Introduction Patients resuscitated after cardiac arrest (CA) who suff er bad neurologic outcome or become brain dead might become organ donors (OD) when well managed and identifi ed. We report on the cohort of patients resuscitated after in-hospital or out-of-hospital CA becoming OD in a tertiary community hospital with an intensive donor identifi cation program. i g Methods Data from our 28-bed mixed medical/surgical adult ICU in a 900-bed tertiary hospital were analyzed from 2010 to 2014. y y Results Our ICU admitted 2,320 patients/year. Overall ICU mortality in this period was 7.4%. A summary of the results is presented in Table 1. Of the 219 patients admitted after CA, 21 (10%) became OD. This resulted in 55 successfully transplanted organs (28 kidneys, 17 livers, seven lung pairs, three hearts). Of note, good outcome (CPC 1 and 2) was achieved in 55 patients (25%). frequently suff ered cardiogenic shock, had more organ dysfunctions and died more frequently, respectively, with hospital mortality of 79.5% versus 29.1%, P <0.001; see also Figure 1. Table 1 (abstract P440) Organ Donors ICU admission Year donors after CA DCD/DBD after CA 2010 11 3 0/3 40 2011 9 5 3/2 41 2012 18 4 3/1 47 2013 17 5 4/1 53 2014 13 4 1/3 38 Total 68 21 (31%) 11/10 219 Conclusion Ten percent of patients resuscitated after CA and admitted to the ICU become OD, consisting of up to 31% of the total number of OD in our center. Patients resuscitated after CA who suff er severe irreversible brain damage or are brain dead can thus substantially expand the donor pool. This justifi es extensive resuscitation eff orts, if not to save lives, then to save organs. This might be reassuring for families, staff and the community. Table 1 (abstract P440) Organ Donors ICU admission Year donors after CA DCD/DBD after CA 2010 11 3 0/3 40 2011 9 5 3/2 41 2012 18 4 3/1 47 2013 17 5 4/1 53 2014 13 4 1/3 38 Total 68 21 (31%) 11/10 219 Conclusion In patients hospitalized for acute heart failure, both prehospital and postadmission resuscitated cardiac arrest is a severe complication associated with signifi cantly morbidity and mortality. Outcome of cardiopulmonary resuscitation in cancer patients in an Indian tertiary cancer center Conclusion Ten percent of patients resuscitated after CA and admitted to the ICU become OD, consisting of up to 31% of the total number of OD in our center. Patients resuscitated after CA who suff er severe irreversible brain damage or are brain dead can thus substantially expand the donor pool. This justifi es extensive resuscitation eff orts, if not to save lives, then to save organs. This might be reassuring for families, staff and the community. Introduction Cardiopulmonary resuscitation (CPR) after cardiac arrest in cancer patients is often discouraged as it is associated with poor outcome. In our 700-bed tertiary cancer hospital in Mumbai, India, the ICU runs an in-hospital cardiac arrest team (CAT). We reviewed our data to determine outcome from CPR, identify factors associated with improved outcomes and justify the presence of a CAT in our cancer hospital. p Methods All in-hospital patients from November 2012 to November 2014 (2-year period) with unanticipated cardiorespiratory arrests were included. Data were recorded prospectively using the Utstein template. Only patients with cardiac arrest rhythms were included. Patients with anticipated progression towards arrest, those with seizures, hypotension without dysarrythmias or other medical emergencies were excluded. The outcomes studied were return of spontaneous circulation (ROSC) and survival on hospital discharge (SOHD). Binary logistic regression analysis was performed to determine factors associated with ROSC and SOHD. P436 Amplitudes of cortical somatosensory evoked potentials and outcome prediction after cardiac arrest C Storm, CJ Ploner, C Leithner Charite Universitaetsmedizin, Berlin, Germany Critical Care 2015, 19(Suppl 1):P436 (doi: 10.1186/cc14516) P438 38 Resuscitated cardiac arrest in patients admitted with acute heart failure: analysis of a large prospective AHEAD network registry J Parenica1, J Belohlavek2, J Spinar1, G Dostalova2, S Havranek2, A Linhart2 R Miklik1, L Dusek3, J Jarkovsky3 1University Hospital Brno, Czech Republic; 2General University Hospital, Prague, Czech Republic; 3Masaryk University, Brno, Czech Republic Critical Care 2015, 19(Suppl 1):P438 (doi: 10.1186/cc14518) Introduction Heart failure is a frequent cause of cardiac arrest and vice versa, cardiac arrest frequently complicates acute heart failure episodes. We aimed to characterize the infl uence of cardiac arrest on outcome of acute heart failure patients admitted to hospital. Methods The AHEAD registry includes patients hospitalized for acute heart failure from 10 PCI and fi ve non-PCI centers in the Czech Republic. The data were collected from September 2006 to October 2012. Conclusion Our data indicate that the prognostic value of SSEP after cardiac arrest extends beyond a mere absent–present dichotomy. Bilaterally absent as well as very low amplitude SSEPs predict poor outcome with high positive predictive value. SSEPs should not be used for prognostication, if noise in cortical recordings could mask critically low amplitudes. High amplitudes of early cortical SSEPs strongly argue against severe hypoxic encephalopathy incompatible with re-awakening. Results In the respective period, a total of 6,242 patients were enrolled into the registry. Resuscitated cardiac arrest occurred in 313 patients prehospitally and in 484 after admission; the remaining 5,445 patients were not resuscitated during their index hospitalization. Patients resuscitated after admission in comparison with prehospitally resuscitated were older, had lower left ventricle ejection fraction, more S154 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P438). Overall mortality (including hospitalization). Total n = 6,242. Endothelial dysfunction in acute brain injury and the development of cerebral ischemia Endothelial dysfunction in acute brain injury and the development of cerebral ischemia S Van Ierssel1, VM Conraads1, EM Van Craenenbroeck1, Y Liu2, AI Maas1, PM Parizel1, VY Hoymans1, CJ Vrints1, PG Jorens1 1University Hospital Antwerp, Edegem, Belgium; 2The Third Xiangya Hospital, Changsha, China Critical Care 2015, 19(Suppl 1):P443 (doi: 10.1186/cc14523) Introduction Since most patients with acute brain injury are treated head-up at 30 to 45°, there can be a height diff erence of up to 15 cm between the heart and the ear canal. This causes a diff erence between mathematical CPP and true CPP of up to 11 mmHg depending on the zero reference level used and the body length of the patient (Figure 1). We conducted a survey to analyze the current practice on CPP targets and zero reference levels in diff erent ICUs. Introduction Cerebral ischemia (CeI) is a major complicating event after acute brain injury (ABI) in which endothelial dysfunction is a key player. p y Methods We studied cellular markers of endothelial dysfunction and peripheral reactive hyperemia index (RHI) in 26 patients with ABI at admission and after 6 and 12 days, and compared these with healthy volunteers (n = 15). CeI was determined clinically or using computer tomography.i f Methods Neuro-ICU physicians were invited to participate in a survey on ICP and CPP targets and the level of measurement. Results The results of 30 centers are summarized in Table 1. Most centers (83.3%) use head-up elevation of 30 to 45° and consider an ICP of 20 mmHg as the threshold to start treating ICP (80%). More variation is noted in minimal and maximal CPP threshold. All centers measure ICP at the ear canal. Twenty-seven centers (90%) measure MAP at the heart, three centers measure MAP at the ear canal. These three centers use >50, 60 and 65 mmHg as minimal CPP and raise the bed to 30 to 45°. The two centers using minimal CPP >60 mmHg do not apply an upper limit. g p y Results In patients with ABI, RHI at admission was signifi cantly reduced compared with healthy subjects (P = 0.003), coinciding with a decrease in circulating endothelial progenitor cells (EPC) (P = 0.002) (Table 1). The RHI recovered in eight patients without development of CeI (Figure 1, black), but failed to fully recover by day 12 in three out of four patients that developed CeI (Figure 1, red). P442 Eff ect of alcohol in blood on neurological outcome and survival of patients with combination of polytrauma and head injury S Pristovnik1, M Strnad2, V Vujanoviæ1, T Pelcl1, V Borovnik-Lesjak1 1Health Center Dr. Adolf Drolc, Maribor, Slovenia; 2Medical Faculty Maribor, Slovenia Critical Care 2015, 19(Suppl 1):P442 (doi: 10.1186/cc14522) A reduced response time, witnessed arrest and type of rhythm are associated with ROSC and improved SOHD. The type of rhythm was independently associated with SOHD, with VF/VT and PEA having improved survival while asystolic patients had a poor outcome. These considerations justify the presence of a CAT in our cancer hospital. S155 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Table 1 (abstract P443). Evolution in time of markers of endothelial dysfunction after acute brain injury Scale (GCS) at discharge. Diff erences among groups were analyzed using Student’s t test, the Mann–Whitney U test and the chi-square test. Results BAL did not have a signifi cant eff ect on presenting physiological parameters. There was a signifi cant diff erence in the age of the groups, showing that patients in the BAL+ group were younger (32.6 vs. 56.8 years; 95% confi dence level; P = 0.000). BAL had a lasting eff ect on functional measures of neurological outcome which showed better results in the BAL+ group; it had signifi cantly better GOS (4.7 vs. 3.9; 95% confi dence level; P = 0.027), and GCS at discharge was on the border of statistical signifi cance (15 vs. 14; 95% confi dence level; P = 0.05). Other variables (TRISS, AIS, STHD, CPC) did not show statistically signifi cant diff erences among groups. gif g g p Conclusion Presence of alcohol in the blood had a positive eff ect on neurological outcome but there was no signifi cant diff erence in survival. However, the positive results in neurologic outcome in the BAL+ group may also be due to the fact that this group was younger. The small number of patients in the study is another limiting factor of the interpretation. Therefore, the neuroprotective role of alcohol needs further clarifi cation. Conclusion Patients with ABI exhibit impaired microvascular endo thelial function measured as RHI and a decreased circulating level of EPC. P444 P444 P444 Survey on ICP, target CPP and MAP measurement level in patients with severe acute brain injury in diff erent ICUs M Van Laer1, K Deschilder2, W Stockman2 1UZ Brussel, Brussels, Belgium; 2AZ Delta, Roeselare, Belgium Critical Care 2015, 19(Suppl 1):P444 (doi: 10.1186/cc14524) Endothelial dysfunction in acute brain injury and the development of cerebral ischemia Despite recovery Figure 1 (abstract P443). y Conclusion Considering the infl uence of position on CPP, the variations among centers and the narrow range of CPP thresholds, future studies and guidelines should describe where MAP is measured. Alternatively, we propose a new formula for CPP: true CPP = MAP(heart) – ICP(ear) – height diff erence (heart to ear canal (cm)) × 0.73. Conclusion Considering the infl uence of position on CPP, the variations among centers and the narrow range of CPP thresholds, future studies and guidelines should describe where MAP is measured. Alternatively, we propose a new formula for CPP: true CPP = MAP(heart) – ICP(ear) – height diff erence (heart to ear canal (cm)) × 0.73. Figure 1 (abstract P443). Figure 1 (abstract P444). Table 1 (abstract P444) ICP threshold (mmHg); n (%) >15; 2 (6.7%) >18; 1 (3.3%) >20; 24 (80%) >25; 3 (10%) Minimal CPP (mmHg); n (%) >50; 6 (20%) >55; 4 (13.3%) >60; 16 (53.3%) >65 to 70; 4 (13.3%) Maximal CPP (mmHg); n (%) <70 to 75; 8 (26.7%) <80; 8 (26.7%) <85; 2 (6.7%) No limit; 12 (40%) Figure 1 (abstract P444). Figure 1 (abstract P444). Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S156 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P445 with traumatic brain injuries defi ned as a Glasgow Coma Score <8 upon admission. Patients included were 18 to 59 years of age and were mechanically ventilated with intracranial pressure monitoring for greater than 72 hours. The primary outcome evaluated was the number of patients treated for confi rmed infections. Secondary outcomes included the antibiotic length of therapy (LOT), antibiotic days of therapy (DOT), number of cultures, and ICU and hospital length of stay (LOS). DOT was defi ned as the sum of days on which each antibacterial drug was administered. P445 Comparison of 15oxygen positron emission tomography and near-infrared spectroscopy for measurement of cerebral physiology J Simpson1, N Sudhan1, H Hare2, J Donnelly1, X Liu1, F Aigbirhio1, T Fryer1, G Stocks-Gee1, P Smielewski1, D Bulte2, J Coles1 1University of Cambridge, UK; 2University of Oxford, UK Critical Care 2015, 19(Suppl 1):P445 (doi: 10.1186/cc14525) Introduction The gold standard technique for imaging cerebral blood fl ow (CBF) and metabolism is 15oxygen positron emission tomography (15O PET). g References 1. Zweifel C, et al. Stroke. 2010;41:1963-8. 1. Zweifel C, et al. Stroke. 2010;41:1963-8. 2. Coles JP, et al. JCBFM. 2004;24:202-11. 3. Culver JP, et al. JCBFM. 2003;23:911-24. f Results Sixty-four treatments (32 HTS, 32 Man) were studied among 26 patients (19 TBI, seven SAH; age 42 ± 17 years, time from injury to treatment 2.6 ± 1.9 days). Man and HTS eff ectively decreased ICP (coeffi cient = –2.5 mmHg, 95% CI = –3.2 to –1.8 mmHg and –2.9 (–3.8 to –2.0) respectively; both P < 0.0001). No signifi cant diff erence was found in CMD lactate, pyruvate, glucose and PbtO2 after HTS or Man treatment. CMD glutamate decreased signifi cantly after Man (–0.73 ( –1.41 to –0.052); P <0.05), but not after HTS. Eff ect of osmotherapy with mannitol or hypertonic saline on cerebral oxygenation and metabolism in patients with intracranial hypertension after severe brain injury y j T Suys, H Quintard, C Patet, M Oddo Introduction Osmotherapy with mannitol (Man) or hypertonic saline (HTS) is currently used to treat elevated intracranial pressure after severe acute brain injury (sABI); however, their eff ect on cerebral oxygenation and metabolism has not been extensively evaluated. Methods A retrospective analysis of a cohort of patients with sABI after traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) monitored with cerebral microdialysis (CMD), brain oxygen (PbtO2) and ICP, who were treated with Man (20%, 0.5 g/kg) or HTS (7.5%, 100 ml) for ICP >25 mmHg. Osmotherapy was administered over 20 minutes and each patient’s individual response to intervention was analyzed up to 120 minutes following infusion. Only episodes where no other hypertonic solute was administered within 2 hours before or after treatment were selected. Variables analyzed included CMD lactate, pyruvate, glucose, glutamate, lactate/pyruvate ratio, and main brain physiologic variables ICP, PbtO2, CPP. Analysis was conducted using mixed-eff ects multilevel regression. Introduction Osmotherapy with mannitol (Man) or hypertonic saline (HTS) is currently used to treat elevated intracranial pressure after severe acute brain injury (sABI); however, their eff ect on cerebral oxygenation and metabolism has not been extensively evaluated. Conclusion We found no relationship between NIRS and baseline physiology as determined by 15O PET. Further studies should assess the dynamic response of NIRS to a measured change in physiology in patients. Further confi nes of NIRS include its limited and focal brain coverage. Conclusion We found no relationship between NIRS and baseline physiology as determined by 15O PET. Further studies should assess the dynamic response of NIRS to a measured change in physiology in patients. Further confi nes of NIRS include its limited and focal brain coverage. Endothelial dysfunction in acute brain injury and the development of cerebral ischemia Continuous near-infrared spectroscopy (NIRS) has been used to assess adequacy of cerebral oxygenation following stroke, traumatic brain injury and subarachnoid haemorrhage [1], and measurements have been compared with jugular oxygen saturation. In this study we compared NIRS with 15O PET within healthy volunteers. g Results A total of 23 patients treated with normothermia and 119 patients in the control group were evaluated between January 2009 and September 2014. The number of patients treated for confi rmed infections was similar between groups (normothermia: 73.9%, control: 80%, P = 0.803). Empiric antibiotic therapy was more commonly utilized in the normothermia group at 34% versus 20.5% (P = 0.173). Antibiotic LOT and DOT were 13.8 versus 10.8 days (P = 0.157) and 18.3 versus 16.2 days (P = 0.575) in the normothermia versus control groups, respectively. Total culture rate was lower in the normothermia group with 13.2 versus 8.78 (P = 0.0002) cultures per patient. No signifi cant diff erence in hospital LOS (normothermia: 23 days, control: 18 days, P = 0.158) or ICU LOS (normothermia: 17 days, control: 15 days, P = 0.185) was demonstrated.i y Methods Fifteen healthy subjects were recruited (12 male, average age 38 years); PET precluded females of reproductive age. Steady-state 15O PET with arterial sampling was performed to measure CBF, cerebral metabolic rate of oxygen (CMRO2), oxygen extraction ratio (OEF) and cerebral blood volume (CBV) [2]. Simultaneously, NIRS data were collected using a Hamamatsu NIRO 200 with sensors on either side of the forehead. NIRS OEF was calculated from tissue oxygen saturation, SaO2 and an assumed arterial/venous blood volume ratio of 30/70 [3]. Results The frontal region 15O PET CBF, CMRO2, OEF and CBV were mean (SD) 44.9 (10) ml/100 ml/minute, 158.7 (24.7) μmol/100 ml/minute, 45.8 (7.3)%, and 2.8 (0.8) ml respectively, and there was no relationship between NIRS and 15O PET (Figure 1). Conclusion Rates of confi rmed infections and number of antibiotic days were similar between the normothermia and control groups, suggesting that normothermia does not increase infection risk. However, the number of cultures obtained in the control group was signifi cantly greater than the normothermia group with a trend toward increased empiric antibiotic use. Figure 1 (abstract P445). Linear correlation between NIRS and PET OEF. Reference Figure 1 (abstract P445). Linear correlation between NIRS and PET OEF. Reference 1. Greer DM, et al. Stroke. 2008;39:3029-35. 1. Greer DM, et al. Stroke. 2008;39:3029-35. Neuroenergetic response to prolonged cerebral glucose depletion after severe brain injury and the role of lactate C Patet1, H Quintard1, T Suys1, L Pellerin2, P Magistretti3, M Oddo1 1CHUV – Lausanne University Hospital, Lausanne, Switzerland; 2University of Lausanne, Switzerland; 3Brain Mind Institute, Lausanne, Switzerland Critical Care 2015, 19(Suppl 1):P448 (doi: 10.1186/cc14528) Introduction In patients with acute brain injury (ABI), increased cerebral energy demand is frequent, potentially leading to cerebral glucose depletion (GD) and poor outcome. In this setting, lactate may act as supplemental fuel. We examined dynamics of cerebral lactate supply during prolonged GD in ABI. Results ICP registrations were made parallel with all TCD measurements in 51 patients. Intraparenchymal ICP monitoring was inserted within the fi rst 3 hours after trauma and there was no complication (infections, intracranial hemorrhage, or technical failure) related to invasive ICP monitoring. Increased ICP was noted upon transducer insertion in 38 children with male prevalence (10 girls, 28 boys). Median GCS was 6, indicating the magnitude of injury in this group of patients. The overall results of the 38 patients showed a strong correlation between the ICP and PI and during outbursts of ICP with a correlation coeffi cient of r = 0.89 (ICP >20 mmHg) and r = 0.90 (ICP <20 mmHg). The relation between ICP and PI was estimated by the linear regression equation: ICP = 22,299 × PI – 10,705 (ICP >20 mmHg) and ICP = 38,592 × PI – 16,972 (ICP <20 mmHg). The CPP and PI were correlated signifi cantly during the changes in intracranial pressure. However, a better correlation was found when ICP >20 mmHg and PPC <50 mmHg (PI was 2.4 ± 0.89 when CPP was 35.96 ± 4.48 with a correlation coeffi cient of Pearson r = 0.80) than when ICP <20 mmHg and CPP >50 mmHg (PI was 0.78 ± 0.14 when CPP was 57.11 ± 9.62 with a correlation coeffi cient of Pearson r =0.76). y Methods We retrospectively analyzed severe ABI (18 TBI, eight SAH) monitored with brain oxygen and cerebral microdialysis (CMD) to measure hourly levels of cerebral extracellular glucose, lactate, pyruvate and lactate/pyruvate ratio (LPR). Variations of CMD variables were analyzed as a function of GD (defi ned as spontaneous decreases of CMD glucose from normal to low (<1.0 mM), at least 2 hours) and increased cerebral energy demand (LPR >25). Results During GD (60 episodes; 26 patients), we found an increase of CMD lactate (4 ± 2.3 vs. 1. Paolin A, Manuali A, Di Paola F, Boccaletto F, Caputo P, Zanata R, et al. Reliability in diagnosis of brain death. Intensive Care Med. 1995;21:657-62. 2. Gan TJ, Glass PS, Windsor A, Payne F, Rosow C, Sebel P, et al. Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. Anesthesiology. 1997;87:808-15. Correlation between intracranial pressure and pulsatility index measured by transcranial Doppler in children with severe trauma brain injury Correlation between intracranial pressure and pulsatility index measured by transcranial Doppler in children with severe trauma brain injury g Conclusion The BIS is a noninvasive, simple, and easy to interpret method, showing a perfect correlation with the other diagnostic methods. BIS can be used in severely comatose patients as an assessment of brain death. j y H Bouguetof, M Negadi, K El Halimi, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P449 (doi: 10.1186/cc14529) H Bouguetof, M Negadi, K El Halimi, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P449 (doi: 10.1186/cc14529) Neuroenergetic response to prolonged cerebral glucose depletion after severe brain injury and the role of lactate 5.4 ± 2.9 mM) and LPR (27 ± 6 vs. 35 ± 9; all P <0.005) while brain oxygen and blood lactate remained normal. Dynamics of lactate and glucose supply were studied by analyzing the relationship between blood and CMD samples. No correlation between blood and brain lactate was found when brain glucose and LPR were normal (r = –0.12, P = 0.48; Figure 1), while this correlation became linear during GD, progressively rising to r = 0.53 (P <0.0001) when energy demand increased, suggesting increased cerebral lactate availability. The correlation between blood and brain glucose changed in the opposite direction, decreasing from r = 0.78 to 0.37 (P <0.0001) during GD and at LPR >25. Conclusion The absolute value of the PI is a reliable noninvasive indicator of ICP in pediatric severe TBI. A strong correlation between PI and ICP was demonstrated. Therefore, PI may be of guiding value in the invasive ICP placement decision in the neurointensive care patient when ICP monitoring is not systematically performed. In particular, ICP monitoring remains as grade C in the latest guidelines of management of STBI in children published in 2012. Conclusion Energy dysfunction is associated with increased supply of nonhypoxic cerebral lactate. Our data suggest lactate may act as alternative substrate after ABI when availability of cerebral glucose is reduced. P449 Correlation between intracranial pressure and pulsatility index measured by transcranial Doppler in children with severe trauma brain injury H Bouguetof, M Negadi, K El Halimi, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P449 (doi: 10.1186/cc14529) Figure 1 (abstract P448). Correlations between blood and brain lactate. Figure 1 (abstract P448). Correlations between blood and brain lactate. P450 P449 P449 Correlation between intracranial pressure and pulsatility index measured by transcranial Doppler in children with severe trauma brain injury H Bouguetof, M Negadi, K El Halimi, D Boumendil, Z Chentouf Mentouri University Ahmed Benbella Oran 1, Oran, Algeria Critical Care 2015, 19(Suppl 1):P449 (doi: 10.1186/cc14529) Evaluation of infection risk and antibiotic exposure in traumatic brain injury patients treated with therapeutic normothermia h k , , Hennepin County Medical Center, Minneapolis, MN, USA Hennepin County Medical Center, Minneapolis, MN, USA p y p Critical Care 2015, 19(Suppl 1):P446 (doi: 10.1186/cc14526) Introduction The purpose of this study is to assess the rate of confi rmed infections, antibiotic exposure, and monitoring practices with normothermia protocol utilization for traumatic brain injury patients. Treatment and prevention of fever is a focus of therapy for patients with severe neurological injury as fever has been identifi ed as an independent risk factor for morbidity and mortality [1]. Conclusion Osmotherapy with Man and HTS treatment had no eff ect on cerebral oxygenation and metabolism. Man, but not HTS, favorably reduced brain glutamate. These fi ndings support further investigation to test the value of alternative osmotic agents (such as hypertonic lactate) that may reduce ICP and at the same time improve cerebral metabolism after sABI. Methods The retrospective chart review analyzed outcomes of maintaining normothermia at 36.5°C versus a similar population without temperature control as a standard of care in patients admitted Acknowledgements Supported by grants from the Swiss National Science Foundation and the Novartis Foundation for Biomedical Research. S157 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P448 Methods A prospective and descriptive study conducted in our PICU from June 2011 to December 2013. We investigated 51 children with severe trauma brain injury (TBI). The TCD measurements were routinely performed bilaterally on the middle cerebral artery parallel to the ICP registration. The ICP and CPP data were correlated to PI and the correlation coeffi cient calculated. To control the linear correlation, the residuals were tested for normal distribution around the regression line. P448 Neuroenergetic response to prolonged cerebral glucose depletion after severe brain injury and the role of lactate C Patet1, H Quintard1, T Suys1, L Pellerin2, P Magistretti3, M Oddo1 1CHUV – Lausanne University Hospital, Lausanne, Switzerland; 2University of Lausanne, Switzerland; 3Brain Mind Institute, Lausanne, Switzerland Critical Care 2015, 19(Suppl 1):P448 (doi: 10.1186/cc14528) Bispectral index as a predictor of unsalvageable traumatic brain injury Introduction The aim was to evaluate the accuracy of bispectral index (BIS) monitoring for the diagnosis of brain death in severely comatose patients. We aimed to determine the utility of the BIS as a tool for clinical evaluation of the moment of brain death. Methods A prospective observational study with waiver of consent was conducted in the trauma ICU for 2 years from October 2012 to September 2014. Monitoring of BIS occurred during patient stay in the ICU. Population: 62 severely comatose patients (Glasgow Coma Score less than 6) admitted to the ICU mainly because of intracerebral hemorrhage, head injury, or postanoxic coma. BIS was recorded continuously during the hospitalization in the ICU. Where necessary, clinical brain death was confi rmed by EEG or brain stem test. Conclusion Energy dysfunction is associated with increased supply of nonhypoxic cerebral lactate. Our data suggest lactate may act as alternative substrate after ABI when availability of cerebral glucose is reduced. Conclusion Energy dysfunction is associated with increased supply of nonhypoxic cerebral lactate. Our data suggest lactate may act as alternative substrate after ABI when availability of cerebral glucose is reduced. Conclusion Energy dysfunction is associated with increased supply of nonhypoxic cerebral lactate. Our data suggest lactate may act as alternative substrate after ABI when availability of cerebral glucose is reduced. Results Twenty-nine patients were already clinically brain dead at the time of admission, and their individual BIS values were 0. Twenty-four patients were not clinically brain dead at the time of admission, and their individual BIS values were between 20 and 30. These patients became brain dead, and their individual BIS values dropped to 0 in a few hours to a few days. Seventeen patients who did not become brain dead during their hospitalization in the ICU had persistent electrocerebral activity on EEG, and their average BIS values remained above 31. References Introduction This study was designed to see whether there is a correlation between the transcranial Doppler (TCD) parameters and the CCP and intracranial pressure (ICP) monitoring during the cerebral hemodynamic changes and to evaluate ICP indirectly by TCD. S158 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P451 P451 Neuromonitoring of patients with severe traumatic brain injury at the bedside M Aries1, JG Regtien1, M Czosnyka2, J Donnelly2, P Smielewski2 1UMCG, Groningen, the Netherlands; 2Addenbrookes Hospital, University of Cambridge, UK Critical Care 2015, 19(Suppl 1):P451 (doi: 10.1186/cc14531) PbtO2 decreased and the microdialysis showed continuous signs of ischemia and cellular degradation. Conclusion This experimental study documents that during protracted pronounced hemorrhagic shock, cerebral energy metabolism was severely compromised and exhibited a biochemical pattern typical of ischemia and cellular degradation. After retransfusion this pattern continued. From intravenous microdialysis in the sagittal sinus, it is possible to achieve semiquantitative information of the intracerebral redox state. Accordingly, it might be possible to monitor the global cerebral energy state continuously with a strictly extracerebral technique. This technique might be valuable in various severe conditions during critical care when cerebral energy metabolism may be compromised; for example, resuscitation after cardiac standstill, open heart surgery, multitrauma and so forth. Interestingly the study also showed that after reinfusion of blood other parts of the body recovered, evaluated by microdialysis, but the brain showed signs of damage, making the brain the limiting organ in hemorrhagic shock. Introduction Measurement of intracranial pressure (ICP) and arterial blood pressure is used to derive cerebral perfusion pressure (CPP) and to guide targeted therapy of severe traumatic brain injury (TBI) necessitating ICU admission. In this review we discuss the evidence for ICP monitoring, CPP calculation, and ICP/CPP-guided therapy after severe TBI. Despite its widespread use, there is currently no class I evidence that ICP/CPP-guided therapy improves outcomes. Similarly, no class I evidence can currently advise the ideal CPP. y Methods A review of current literature with special focus on autoregulation (PRx)-guided CPP treatment in TBI patients.i Results Optimal CPP is probably patient, time, and pathology specifi c and related to cerebral autoregulation status. P453 P453 Amantadine sulfate treatment in cases with brain injury in the ICU: a retrospective clinical trial S Goksu Tomruk, N Bakan, G Karaören, A Salvarcý Umraniye Research and Training Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P453 (doi: 10.1186/cc14533) P452 y Results The patients’ diagnoses included two post-CPR, fi ve intracranial and one subdural hematoma, one CVA, one postoperative aneurysm, one subarachnoid hemorrhage and one brain contusion. Table 1 (overleaf) presents the fi ndings. The AS therapy was initiated between days 3 and 33 of admission in all patients other than Patients 2 and 8. A dramatic improvement was observed in a patient with both GCS and JFK- CRS score of 5 when AS therapy was initiated in month 5 and the patient was discharged for home care. In Patient 9, AS therapy was withdrawn on day 5 due to persistent thrombocytopenia (TP) despite exclusion of other reasons; subsequently, improvement was observed in TP. The complications were relatively less severe with average acceptability. Amantadine sulfate treatment in cases with brain injury in the ICU: a retrospective clinical trial S Goksu Tomruk, N Bakan, G Karaören, A Salvarcý Umraniye Research and Training Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P453 (doi: 10.1186/cc14533) Introduction Improvement of recovery is a challenging process in cases with varying degrees of severe brain injury (BI) requiring intensive care. Amantadine sulfate (AS) is recommended for use in cases with brain injury. The Coma Remission Scale (JFK-CRS) consists of auditory–visual– motor–mouth–tongue functions, communication and awareness scales; provides a score between 0 and 23; and shows numeric recovery from coma. The aim of this study was to evaluate outcomes and eff ects of AS used for neurorecovery on the Glasgow Coma Scale (GCS) and JFK-CRS in our ICUs during the last 5 months. Conclusion The management of TBI is likely to become increasingly based on a more comprehensive monitoring and management approach rather than relying on absolute numbers of ICP and CPP in isolation. This will allow individual optimization of perfusion and therefore of oxygen and energy substrate delivery. We await further robust, high-quality evidence to support the benefi ts of using more sophisticated monitoring tools like the autoregulation- guided CPP concept during the ICU management of TBI. For the near future, more important is a greater understanding of the underlying pathophysiology. Methods After approval of the Ethics Committee, we recruited 12 patients with brain injury resulted from trauma or hemorrhage who had initial GCS of ≤9 and received AS (500 mg, twice daily over 10 days) during the recovery period. In all subjects, age, gender, diagnosis, initial APACHE II score, time of initiation of AS therapy, JFK-CRS and GCS scores, aspartate aminotransferase, alanine aminotransferase, BUN, creatinine, platelet count, electrocardiography fi ndings, electrolyte values and arterial blood gas values on days 1, 6, 10 and 14 were recorded.i p p y References References 1. Aries MJ, et al. Crit Care Med. 2012;40:2456-63. 2. Jaeger M, et al. Crit Care Med. 2010;38:1343-7. 1. Aries MJ, et al. Crit Care Med. 2012;40:2456-63. 2. Jaeger M, et al. Crit Care Med. 2010;38:1343-7. 1. Aries MJ, et al. Crit Care Med. 2012;40:2456-63. 2 Jaeger M et al Crit Care Med 2010;38:1343-7 Technique for continuous bedside monitoring of the global cerebral energy state gy R Jakobsen1, A Granfeldt2, TH Nielsen1, P Toft1, CH Nordström1 1Odense University Hospital, Odense, Denmark; 2Regional Hospital of Randers, Denmark Critical Care 2015, 19(Suppl 1):P452 (doi: 10.1186/cc14532) Introduction In the present experimental study we explore whether cerebral venous lactate/pyruvate ratio (LP ratio) measured by intra- vascular microdialysis during induced hemorrhagic shock may be used as a surrogate marker for compromised cerebral oxidative metabolism. Methods Six female pigs were anesthetized and vital parameters was recorded. Microdialysis catheters were placed in cerebral hemisphere parenchyma, the superior sagittal sinus and femoral artery. Brain tissue oxygenation (PbtO2) and intracranial pressure (ICP) was recorded. Hemorrhagic shock was achieved by bleeding the animals to a mean arterial pressure (MAP) of approximately 35 mmHg. Animals were kept at a MAP of about 30 to 40 mmHg for 90 minutes. The animals were resuscitated with reinfusion of shed blood followed by 3 hours of observation. Conclusion We suggest that an AS dose of 1,000 mg/day (over 10 days) seems to improve neurorecovery in BI patients with good tolerability. Prospective controlled studies with large, homogeneous BI populations will better defi ne the role of AS for recovery and complications. P454 References The fact that optimal CPP and autoregulation status varies between individual patients and over time makes it an attractive bedside tool to serve as a (simplifi ed) model to investigate the use of autoregulation (PRx) status to fi ne tune or feedback clinical treatments in individual sedated TBI patients (optimal CPP concept) [1]. Evidence is emerging for the role of other monitors (representing (local) metabolism, oxygen supply/use, perfusion, neuronal functioning) that enable the intensivist to employ an individualized multimodality monitoring approach in TBI [2]. P453 Prognostic value of ubiquitin carboxy-terminal hydrolase L1 in patients with moderate or severe traumatic brain injury: a systematic review M Shemilt1, JF Laforest1, F Lauzier1, A Boutin1, D Fergusson2, R Zarychanski3, L Moore1, L McIntyre2, L Nadeau1 1CHU de Québec, QC, Canada; 2Ottawa Health Research Institute, Ottawa, ON, Canada; 3University of Manitoba, Winnipeg, MB, Canada Critical Care 2015, 19(Suppl 1):P454 (doi: 10.1186/cc14534) P454 Prognostic value of ubiquitin carboxy-terminal hydrolase L1 in patients with moderate or severe traumatic brain injury: a systematic review M Shemilt1, JF Laforest1, F Lauzier1, A Boutin1, D Fergusson2, R Zarychanski3, L Moore1, L McIntyre2, L Nadeau1 1CHU de Québec, QC, Canada; 2Ottawa Health Research Institute, Ottawa, ON, Canada; 3University of Manitoba, Winnipeg, MB, Canada Critical Care 2015, 19(Suppl 1):P454 (doi: 10.1186/cc14534) Prognostic value of ubiquitin carboxy-terminal hydrolase L1 in patients with moderate or severe traumatic brain injury: a systematic review M Shemilt1, JF Laforest1, F Lauzier1, A Boutin1, D Fergusson2, R Zarychanski3, L Moore1, L McIntyre2, L Nadeau1 1CHU de Québec, QC, Canada; 2Ottawa Health Research Institute, Ottawa, ON, Canada; 3University of Manitoba, Winnipeg, MB, Canada Critical Care 2015, 19(Suppl 1):P454 (doi: 10.1186/cc14534) Results In the cerebral hemisphere, hemorrhagic shock caused a marked increase in the LP ratio, while a signifi cant but minor increase was observed in the sagittal sinus. The LP ratio increased and continued doing so to a very high level. In the femoral artery, the shock period was associated with a slight increase of the LP ratio. The increase in the LP ratio in the sagittal sinus was markedly and signifi cantly higher than in the arterial blood. Further, the dynamic changes in the LP ratio in the sagittal sinus followed that of the parenchyma, not the arterial blood. After infusion of blood ICP increased, cerebral perfusion pressure and M Shemilt1, JF Laforest1, F Lauzier1, A Boutin1, D Fergusson2, R Zarychanski3, L Moore1, L McIntyre2, L Nadeau1 1CHU de Québec, QC, Canada; 2Ottawa Health Research Institute, Ottawa, ON, Canada; 3University of Manitoba, Winnipeg, MB, Canada Critical Care 2015, 19(Suppl 1):P454 (doi: 10.1186/cc14534) Introduction Traumatic brain injury (TBI) prognostication is a developing fi eld striving to identify indicators, notably neurochemical S159 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Table 1 (abstract P453). Findings of 12 patients receiving amantadine sulfate Table 1 (abstract P453). P454 The main purpose of this study was to determine the impact of CB2R inhibition on leukocyte activation within the microcirculation following endotoxin challenge in an experimental stroke model. Methods This was a prospective, randomized animal study. Five experimental groups (male C57BL/6 mice, age: 6 to 8 weeks) were subjected to the following treatments: control; endotoxemia (LPS 5 mg/kg, i.v.); transient cerebral hypoxia–ischemia (HI) + endotoxemia; HI + endotoxemia + CB2R antagonist (AM630 2.5 mg/kg, i.v.). HI was induced by unilateral carotid artery occlusion, followed by 50-minute exposure to a low oxygen atmosphere (8% O2). The CB2R antagonist was given 15 minutes prior to LPS administration. Intravital microscopy was carried out 2 hours after LPS administration. Brains were then extracted and stained with tetrazolium chloride to calculate the infarct volume. The primary outcome measurement in this study regarding the immune response after stroke was the quantifi cation of leukocyte adhesion following endotoxin challenge in submucosal venules of the gut – an important organ in the development of multiorgan failure in endotoxemia and sepsis. Methods The MEDLINE, Embase, The Cochrane Library and BIOSIS electronic databases, conference abstracts and existing narrative reviews were searched from their inception to July 2013. Cohort studies including patients with moderate or severe TBI having evaluated the prognostic value of UCHL-1 according to mortality or the Glasgow Outcome Scale (GOS) were considered. Data concerning patients, outcomes, study methods, and laboratory methods were abstracted. Pooled results were planned to be presented using mean diff erences and analyzed using random eff ect models, as well as sensitivity analyses to explain potential heterogeneity.i Results Our search strategy yielded 2,257 articles, of which fi ve studies corresponded to our inclusion criteria (n = 730). All studies were performed by the same group of researchers. Five studies reported mortality (n = 515), two studies reported GOS (n = 58). Results from all included studies observed that UCHL-1 was a signifi cant predictor of mortality. However, only two studies represented a unique study population, thus precluding a meta-analysis. Results Compared with endotoxemic animals without CNS injury, mice subjected to HI displayed reduced leukocyte activation in intestinal submucosal venules indicative of CIDS. Administration of the CB2R antagonist in animals with CIDS challenged with endotoxin restored peripheral leukocyte recruitment without a detrimental impact on infarct size. P455 Cannabinoid 2 receptor antagonism reverses central nervous system injury-induced immune defi ciency syndrome IB Burkovskiy, J Zhou, G Robertson, C Lehmann Dalhousie University, Halifax, NS, Canada Critical Care 2015, 19(Suppl 1):P455 (doi: 10.1186/cc14535) P454 Findings of 12 patients receiving amantadine sulfate Initiation of Patient number Sex/age (years) APACHE II GCS A/B/C AS therapy (day) CRS score D/E/F/G Complications Outcome 1 M/14 24 3/5/7 6 0/4/5/6 H, J Still in ICU 2 F/78 33 8/8/10 84 0/0/0/0 K Ex 3 F/75 35 5/6/4 4 1/1/0/Ex K, L Ex 4 M/24 29 3/3/3 6 0/0/Ex K, L Ex 5 M/27 27 4/4/15 6 1/13/18/22 L, M, J Discharged 6 F/70 45 3/3/3 20 0/0/0/0 – Ex 7 F/72 22 5/5/12 3 4/7/11/17 K, L, I Discharged 8 F/53 27 3/5/10 150 5/7/10/14 K Discharged 9 F/38 34 4/4/4 33 0/0/1/1 H, J Still in ICU 10 M/50 26 4/6/13 8 0/7/18/19 L, J Discharged 11 M/63 24 8/10/12 14 6/8/8/12 – Discharged 12 M/50 31 4/6/11 6 2/5/7/9 L, J Still in ICU F, female; M, male. GCS, Glasgow Coma Scale: A, at admission to ICU; B, at initiation of AS therapy; C, outcome value. CRS: D, value on day 1; E, value on day 6; F, value on day 10; G, value on day 14. Complications observed: H, low platelet; J, ALT increase by twofold; K, BUN increase by twofold; L, AST increase by twofold; M, convulsion. F, female; M, male. GCS, Glasgow Coma Scale: A, at admission to ICU; B, at initiation of AS therapy; C, outcome value. CRS: D, value on day 1; E, value on day 6; F, value on day 10; G, value on day 14. Complications observed: H, low platelet; J, ALT increase by twofold; K, BUN increase by twofold; L, AST increase by twofold; M, l i F, female; M, male. GCS, Glasgow Coma Scale: A, at admission to ICU; B, at initiation of AS therapy; C, outcome value. CRS: D, value on day 1; E, value on day 6; F, value on day 10; G, value on day 14. Complications observed: H, low platelet; J, ALT increase by twofold; K, BUN increase by twofold; L, AST increase by twofold; M, convulsion. biomarkers, of long-term outcomes. Among these, ubiquitin carboxy- terminal hydrolase L1 (UCH-L1) is currently being investigated to defi ne its potential prognostic value. The objective of this systematic review is to determine the ability of UCH-L1 to predict prognosis following a moderate or severe TBI. CIDS. P454 Conclusion In this systematic review, we observed that all published studies on UCHL-1 were conducted by the same group of investigators and presented results from an intersecting cohort of patients. Due to the paucity of data, we could not perform a pooled analysis and conclude on the association of this biomarker with long-term prognosis. Assays using UCHL-1 were only recently developed and further studies done by diff erent research teams will be needed to determine the reproducibility and validity of UCH-L1 as a potential prognostic tool. Conclusion CB2R-related modulation of leukocyte activation is involved in the impaired immune response following CNS injury. Future studies will explore the CB2R pathway in order to develop novel therapies to improve the immune response in CIDS. P456 Implementation process of a large multicenter study in trauma AF Turgeon, TBI-Prognosis Team in collaboration with the CCCTG CHU de Québec, QC, Canada Critical Care 2015, 19(Suppl 1):P456 (doi: 10.1186/cc14536) Levels of N-terminal pro-brain natriuretic peptide in brain injury patients Levels of N-terminal pro-brain natriuretic peptide in brain injury patients Results Overall, 33.4 weeks (95% CI = 24.8 to 42.1) were required on average from the start-up package mailing to centers and the start of the screening process. Data sharing and fi nancial agreement were mainly responsible for this delay with an average of 28.6 weeks (95% CI = 20.4 to 36.7) needed to complete the agreement with the coordinating center. REB approval was obtained on average 17.5 weeks (95% CI = 13.8 to 21.2) from the shipping of the study package to the participating centers. Eighty percent of the REBs had members with prior experience in multicenter clinical research, and more than half with specifi c clinical expertise in critical care medicine or neurology/ neurosurgery. A standardized electronic REB submission process was used in most REBs (60%). All centers had experience in implementing multicenter clinical studies. PIs had experience conducting from zero to 40 prior clinical studies and from 3 to 24 years of research experience with protected research time ranging from 5 to 75%. RCs had managed from zero to more than 50 clinical studies. Most centers (87%) organized specifi c presentation of the study to the critical care medical staff (93%), while some (60%) presented the study to other medical teams. Agreements from other departments such as radiology (87% of centers), electrophysiology (80%) and clinical imaging (73%) were requested in most centers. p L Tsentsiper, E Kondratyeva, S Kondratyev, N Dryagina Russian Polenov’s Neurosurgical Institute, Saint-Petersburg, Russia Critical Care 2015, 19(Suppl 1):P458 (doi: 10.1186/cc14538) p L Tsentsiper, E Kondratyeva, S Kondratyev, N Dryagina Russian Polenov’s Neurosurgical Institute, Saint-Petersburg, Russia Critical Care 2015, 19(Suppl 1):P458 (doi: 10.1186/cc14538) Introduction Currently, the most common way to predict the outcome of acute brain damage is to study the level of protein S-100 in the serum. This method lacks specifi city as the concentration of protein S-100 signifi cantly increases with age, more for men than women, and there are no data on prognostically signifi cant changes in the level of S-100 after removal of the tumor and cerebral hemorrhages. Endothelins, vasopressin, some cytokines, excess sodium or calcium in serum, activation of the sympathoadrenal system, and tachycardia are the stimulants of brain natriuretic peptide production. Levels of N-terminal pro-brain natriuretic peptide in brain injury patients The rise of the natriuretic peptide level in cases of acute brain damage has a functionally adaptive nature, based on vasodilation, diuretic action peptide and ability to reduce sympathoadrenal system activity. Thus, we can suppose that the more severe the damage, the higher the stimulation of natriuretic peptide. In this study we investigate the level of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with severe brain damage and fi nd correlation between the level of peptide and outcome. Endothelins, vasopressin, some cytokines, excess sodium or calcium in serum, activation of the sympathoadrenal system, and tachycardia are the stimulants of brain natriuretic peptide production. The rise of the natriuretic peptide level in cases of acute brain damage has a functionally adaptive nature, based on vasodilation, diuretic action peptide and ability to reduce sympathoadrenal system activity. Thus, we can suppose that the more severe the damage, the higher the stimulation of natriuretic peptide. In this study we investigate the level of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with severe brain damage and fi nd correlation between the level of peptide and outcome. Conclusion The implementation of a large Canadian multicenter and multifaceted clinical study in the trauma population involved a signifi cant amount of time and energy from both the coordinating and the participating sites. The variable experience of participating sites and teams, as well as the involvement of diff erent medical disciplines, may have had an impact on study implementation time. Delays for REB approval but also for data sharing and fi nancial agreement must be taken into consideration in the timeline for implementing large multicenter clinical studies in trauma. Methods We studied 110 patients having brain injuries of various origins. All patients were divided into four groups. All patients were 20 to 72 years old, 58 men and 52 women. Group 1 (n = 17) – acute TBI, group 2 (n = 29) – patients operated on for the brain tumor, group 3 (n = 36) – hemorrhagic stroke, group 4 (n = 28) – vegetative state. We measured the level of brain natriuretic peptide on days 1 to 3, and then every 7 days for 21 days. Results All patients with severe acute brain damage (groups 1, 2, 3) had a level of NT-proBNP higher than normal (normal 0 to 125 pg/ml). Signifi cant diff erence in values between the groups was not observed. P458 the ongoing Pan-Canadian TBI-Prognosis Study. Descriptive statistics were used. the ongoing Pan-Canadian TBI-Prognosis Study. Descriptive statistics were used. P457 Optic nerve sheath diameter by bedside ultrasound is a reliable screening test for cerebral edema in the comatose ICU patient A Mohamed, N Alharbi, N Salahuddin, I Hussain, O Solaiman King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Critical Care 2015, 19(Suppl 1):P457 (doi: 10.1186/cc14537) Conclusion In cases of acute severe brain damage the level of NT- proBNP signifi cantly increased. Correlation between the level of NT-proBNP and etiology of acute brain damage was not observed. If the level of NT-proBNP is above 700 pg/ml and/or in the absence of its reduction to normal, then poor outcome of the disease – severe disability or death – can be predicted. Level of NT-proBNP cannot be used as an indicator for the severity of the status for patients in a vegetative state in contrast to patients with acute brain damage. Introduction ICU patients may remain comatose after resolution of critical illness. Frequently this is due to delayed sedative clearance but may also result from increases in intracranial pressure (ICP) and cerebral edema. We proposed that measurement of the optic nerve sheath diameter (ONSD) is a rapid, bedside screening test that can be used to quickly identify patients with cerebral edema and increased ICP. y y Methods This was a prospective, observational study carried on consecutive patients admitted to a multidisciplinary medical and surgical ICU. Stable patients with unexplained coma and scheduled for brain imaging were included. Patients with obvious ocular trauma or on sedative, narcotic infusions were excluded. ONSD was measured using a 7.5 to 10 MHz linear array ultrasound transducer probe placed on the closed eye in the transverse axis. The ONSD was measured at a predefi ned point 3 mm posterior to the globe. Both eyes were measured and the mean value used. The study protocol was approved by the Hospital Research Ethics Committee (RAC Prop No. 2141 103). Statistical analysis was carried out using SPSS version 20.0. Cannabinoid 2 receptor antagonism reverses central nervous system injury-induced immune defi ciency syndrome IB Burkovskiy, J Zhou, G Robertson, C Lehmann Dalhousie University, Halifax, NS, Canada Critical Care 2015, 19(Suppl 1):P455 (doi: 10.1186/cc14535) Introduction Our purpose was to evaluate the time from shipping of the study start-up package to study screening, as well as conditions that may impact this process, in the context of a large-scale multifaceted and multicenter clinical study in trauma. Introduction Our purpose was to evaluate the time from shipping of the study start-up package to study screening, as well as conditions that may impact this process, in the context of a large-scale multifaceted and multicenter clinical study in trauma. Introduction Central nervous system (CNS) injury, such as stroke, is known to increase susceptibility to infections that adversely aff ect clinical outcome. This impaired immune response to infection is termed CNS injury-induced immune defi ciency syndrome (CIDS). Activation of the cannabinoid 2 receptor (CB2R) suppresses immune function suggesting that antagonism of this receptor may overcome Methods We designed a survey questionnaire based on four domains: REB characteristics and process, centers’ characteristics, experience of the study and clinical teams, and center-specifi c implementation approaches. The questionnaire was self-administered to all lead research coordinators of the 17 level 1 participating trauma centers in S160 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Levels of N-terminal pro-brain natriuretic peptide in brain injury patients Level of NT-proBNP above 700 pg/ml and/or the absence of its reduction to normal dynamic indicators was marked by an unfavorable outcome of the disease – severe disability (n = 25) or death (n = 18). For patients from group 4 regardless of their age, sex, severity of condition and treatment results in a level of NT-proBNP below 250 pg/ml. P459 C b Cerebral oximetry monitoring in pediatric seizure patients in the emergency department T Abramo1, B Schnieder1, E Storm1, N Hobart-Porter1, Z Hu1, N Todd1, L Crawley1, M Meredith2, S Godbold1 1University of Arkansas School of Medicine, Little Rock, AR, USA; 2University of Tennessee School of Medicine, Memphis, TN, USA Critical Care 2015, 19(Suppl 1):P459 (doi: 10.1186/cc14539) Introduction During ictal/post-ictal events, altered cerebral physiology occurs: increased neuronal activity causes signifi cant increase in cerebral metabolism with changes in ipsilateral cerebral blood fl ow. Standard PED seizure monitoring is by O2SAT and ETCO2 which yield no direct data about regional cerebral oxygenation/physiology (rSO2). Signifi cant abnormal hemispheric cerebral physiology resulting in neurological injury can occur without knowing because the current monitoring system could not detect the abnormal hemispheric abnormality. Cerebral oximetry can provide a rapid, non-invasive detection of each hemisphere’s cerebral physiologic changes during ictal/post-ictal phases. The aim was to study left and right rSO2 values in patients in the pre and post seizure periods and in nonseizing controls. Methods An observational study of seizing and nonseizing patient’s left and right rSO2 readings compared with nonseizure patients. Results ONSD was measured in 43 patients; mean age was 62 ± 19.2 years, 48% (n = 20) were female. Admitting diagnosis was sepsis in 24% (n = 10), intracranial vascular event in 21% (n = 9), cardiac arrest in 12% (n = 5), hepatic encephalopathy in 7% (n = 3), malignancy with metastases in 7% (n = 3) and other causes in 28% (n = 12). The ONSD measured correlated highly between eyes, Spearman’s ρ = 0.799, P ≤0.001. The area under the ROC curve for detecting cerebral edema was 0.812 (95% CI = 0.667 to 0.957). Using a 0.58 cm cutoff ONSD diameter, the sensitivity was 86%, specifi city 74%, negative predictive value 96% and the positive likelihood ratio = 3.3. Conclusion This study suggests that bedside measurement of ONSD by ultrasound performs well as an initial screening test for cerebral edema. The identifi ed cutoff value of 0.58 cm can be used to detect cerebral edema with reasonable accuracy. S161 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P459). Results No diff erence for ictal left and right rSO2 readings across ages. See Figure 1. of our institute. In post-anoxic comatose patients we recorded EEG during hypothermia to assure burst suppression. P460 Neurophysiological tests in the neuro ICU Neurophysiological tests in the neuro ICU A Marudi1, Y Valzani2, F Valzania1, M Carpentiero1, C Parenti1, S Scacchetti1, S Baroni1, E Bertellini1 1Nuovo Ospedale Civile Sant’Agostino Estense, Modena, Italy; 2University of Modena and Reggio Emilia, Modena, Italy Critical Care 2015, 19(Suppl 1):P460 (doi: 10.1186/cc14540) P459 C b In post-traumatic brain-injured patients with a persistent comatose state we use EEG to detect nonconvulsive states which potentially can increase secondary brain injury if untreated. In malignant epilepticus status we use EEG to monitor the eff ect of therapy and to modify it. In patients who present profound weakness of legs and hands we performed EMG to distinguish primary peripheral myopolyneuropathy (Guillian Barrè, miastenia gravis) from secondary illness acquired in the ICU (critical polyneuropathy, critical myopathy) [3]. Conclusion We have demonstrated abnormal hemispheric cerebral physiology during focal or generalized ictal activity. In patients with generalized seizures, the left and right rSO2 values were signifi cantly decreased. In patients with focal seizures, the ipsilateral rSO2 values were signifi cantly diff erent from the contralateral rSO2 readings and correlated to the hemisphere experiencing the focal seizure. In certain patients, during the ictal phase their rSO2 readings rose and stayed or rose then dropped. Overall, cerebral oximetry has shown great monitoring potential for actively seizing patients in the emergency department. Conclusion NPT can improve management of patients admitted to the neuro ICU. The data provided can modify therapeutic strategies and improve outcome in these settings of patients. R f References 1. Guerit JM. Curr Opin Crit Care. 2010;16:98-104. 2. Bednarik J, et al. Intensive Care Med. 2003;29:1505-14. 3. Pohhmann-Eden B, et al. Intensive Care Med. 1997;23:301-8. References 1. Guerit JM. Curr Opin Crit Care. 2010;16:98-104. 2. Bednarik J, et al. Intensive Care Med. 2003;29:1505-14. 3. Pohhmann-Eden B, et al. Intensive Care Med. 1997;23:301-8. Goal-directed cerebral hemodynamic strategy decreases the incidence of postoperative delirium in patients with intracranial hypertension in major abdominal surgery Patients were randomized into two groups: MAP group, in which MAP S162 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 was maintained above 70 mmHg or within 20% from baseline (n = 78); or CPP group, in which CPP was maintained above 60 mmHg or within 20% from baseline (n = 54). ICP, MAP and CPP were assessed every hour of anesthesia. Time of recovery of consciousness, incidence of POD and length of stay in the ICU and in the hospital were also evaluated. ischemia-operated animals with normothermia (normothermia + ischemia group); sham-operated animals with hyperthermia (hyperthermia + sham group); and ischemia-operated animals with hyperthermia (hyperthermia + ischemia group). Hyperthermia (39.5 ± 0.2°C) was induced by exposing the gerbils to a heating pad connected to a rectal thermistor for 30 minutes before and during ischemia–reperfusion.i y Results Initial ICP was 14 ± 3 mmHg in the MAP group and 15 ± 2 mmHg in the CPP group. During the anesthesia it was stable without any signifi cant change. Decreasing of MAP after induction of anesthesia was similar in two groups and it was stable during the anesthesia. The frequency of use of vasopressors and infusion rate was higher in the CPP group. Time of recovery of consciousness in the MAP group was higher (28 ± 7 minutes vs. 18 ± 5 minutes (P <0.05)). The incidence of postoperative delirium was higher in the MAP group (18% vs. 11% in the CPP group (P <0.05)). There were no signifi cant diff erences between two groups in other complications. Total length of stay in the ICU and in the hospital was higher in the MAP group (6 ± 2 days vs. 4 ± 2 (P <0.05) and 15 ± 3 days vs. 12 ± 2 in the N group (P <0.05)). Results In the normothermia + ischemia group, a signifi cant delayed neuronal death was observed in the stratum pyramidale (SP) of the hippocampal CA1 region (CA1) 5 days after ischemia–reperfusion. In the hyperthermia + ischemia group, neuronal death in the SP of the CA1 occurred at 1 day post ischemia, and neuronal death was observed in the SP of the CA2/3 region at 2 days post ischemia. In addition, we examined activation of astrocytes and microglia using immunohistochemistry for anti-glial fi brillary acidic protein (GFAP) and anti-ionized calcium-binding adapter molecule 1 (Iba-1). Hydroquinone shows neuroprotective potential in an experimental ischemic stroke model via attenuation of blood–brain barrier disruption CW Park, JH Cho, TG Ohk, MC Shin, MH Won Kangwon National Univeristy, Chuncheon-si, Gangwondo, South Korea Critical Care 2015, 19(Suppl 1):P464 (doi: 10.1186/cc14544) JH Cho, CW Park, TG Ohk, MC Shin, MH Won Kangwon National Univeristy, Chuncheon-si, Gangwondo, South Korea Critical Care 2015, 19(Suppl 1):P462 (doi: 10.1186/cc14542) Introduction Therapeutic exercise is an integral component of rehabilitation for patients with stroke. Despite the high prevalence of cerebral ischemia in the older population, the mechanisms linking restorative exercise to memory recovery from ischemic stroke have not been completely understood in aged animals. In this study, we investigated eff ects of long-term exercise on neuronal death and memory recovery in the aged gerbil hippocampus after transient cerebral ischemia. We also investigated changes in gliosis, ischemia- induced myelin repair, microvessels, neurogenesis, and growth factor immunoreactivity in the hippocampus to study possible mechanisms of restorative exercise in memory recovery. Introduction Hydroquinone (HQ), a major benzene metabolite, occurs naturally in various plants and food, and is also manufactured for commercial use. Although many studies have demonstrated the various biological eff ects of HQ, the neuroprotective eff ects of HQ following ischemic stroke have not been investigated. Therefore, in this study, we fi rst examined the neuroprotective eff ects of HQ against ischemic damage in a focal cerebral ischemia rat model. Methods It was proven that pre and post treatment with 100 mg/ kg HQ protects from ischemia-induced cerebral damage, which was confi rmed by evaluation of neurological defi cit, positron-emission tomography and 2,3,5-triphenyltetrazoliumchloride staining. Methods The gerbils were divided into four groups (n = 12 in each group): the sham-operated group (Sham), 4-week sedentary group following ischemia (SD4), 1-week treadmill group following ischemia (TR1) and 4-week treadmill group following ischemia (TR4). Treadmill exercise was stared at 5 days after ischemia/reperfusion (I/R) and lasted for 1 or 4 weeks, and the animals were sacrifi ced 31 days after ischemia. Results In this study, 4 weeks of treadmill exercise facilitated memory recovery despite neuronal damage in the CA1 region after I/R. On the other hand, the long-term treadmill exercise alleviated the increased gliosis in the CA1 region, and increased the myelin repairing and microvessels in the CA1 region and DG, and enhanced the ischemia- induced cell proliferation, neuroblast diff erentiation, neuronal maturation of the newly generated cells, and BDNF expression in the ischemic DG of the aged gerbil. Eff ects of long-term exercise on memory recovery in the aged gerbil hippocampus after transient cerebral ischemia Eff ects of long-term exercise on memory recovery in the aged gerbil hippocampus after transient cerebral ischemia Goal-directed cerebral hemodynamic strategy decreases the incidence of postoperative delirium in patients with intracranial hypertension in major abdominal surgery Introduction Neurophysiological tests (NPTs) are important prog- nostic and diagnostic tools for patients admitted to the modern neuro ICU (NICU) [1]. Electroencephalography (EEG), somasensorial evoked potentials (SSEP), auditory brainstem response (ABR) and electromyography (EMG) complete clinical examination and radio- logical fi ndings in patients suff ering from post-traumatic brain injury, post-anoxic brain injury, refractory male epiletticus status, and neuromuscular illness. We evaluate the spread of NPTs in our NICU. Methods We collected data from patients admitted to our NICU from January 2014 to November 2014. We recorded the admission diagnosis and the NPT applied. y j I Zabolotskikh, N Trembach I Zabolotskikh, N Trembach Kuban State Medical University, Krasnodar, Russia Kuban State Medical University, Krasnodar, Russia Critical Care 2015, 19(Suppl 1):P461 (doi: 10.1186/cc14541) y Critical Care 2015, 19(Suppl 1):P461 (doi: 10.1186/cc14541) Introduction Increased intracranial pressure (ICP) adversely aff ects anesthesia due to a disturbed cerebral blood fl ow. In older patients this disturbance may increase the incidence of postoperative delirium (POD) and may lead to a poor outcome [1]. The standard hemodynamic protocol involves maintaining the mean arterial blood pressure (MAP), but in patients with intracranial hypertension it may not be enough to maintain adequate cerebral perfusion. The purpose of this study was to evaluate the protocol of maintaining cerebral perfusion pressure (CPP) in the prevention of postoperative delirium in older patients in abdominal surgery. Methods We collected data from patients admitted to our NICU from January 2014 to November 2014. We recorded the admission diagnosis and the NPT applied. Results From January 2014 to November 2014 we performed 521 EEG, 45 SSEP/ABR and 10 EMG. In post-anoxic and post-traumatic brain- injured comatose patients we performed EEG, SSEP and ABR 24 to 48 hours after the admission to predict later prognosis and expected neurological defi cit [2]. In the presence of a benign pattern no further evaluation was performed; in the presence of a malignant pattern the NPTs were repeated every 48 to 72 hours according to the protocol Methods A total of 132 ASA 3 patients, undergoing major abdominal surgery (duration 5.2 (4.3 to 6.5) hours) with ICP >12 mmHg evaluated by a venous ophthalmodynamometry [2], were included in our research. Goal-directed cerebral hemodynamic strategy decreases the incidence of postoperative delirium in patients with intracranial hypertension in major abdominal surgery GFAP-positive astrocytes and Iba-1-positive microglia in the ischemic hippocampus were activated much earlier and much more accelerated in the hyperthermia + ischemia group than those in the normothermia + ischemia group.i y g p Conclusion A goal-directed hemodynamic protocol of maintaining CPP can decrease the incidence of POD in older patients with intracranial hypertension after major abdominal surgery compared with a protocol of maintaining MAP. Conclusion Based on our fi ndings, we suggest that experimentally hyperthermic precondition before cerebral ischemic insult produces more extensive neuronal damage and glial activation in the ischemic hippocampus. Hydroquinone shows neuroprotective potential in an experimental ischemic stroke model via attenuation of blood–brain barrier disruption y y Results In addition, pre and post treatment with 100 mg/kg HQ signifi cantly attenuated ischemia-induced Evans blue dye extra- vasation, and signifi cantly increased the immunoreactivities and protein levels of SMI-71 and glucose transporter-1 (GLUT-1), which were well known as useful makers of endothelial cells, in ischemic cortex compared with a vehicle-treated group.l Conclusion Briefl y, these results indicate that pre and post treatment with HQ can protect from ischemic damage induced by transient focal cerebral ischemia, and the neuroprotective eff ects of HQ may be closely associated with the prevention of BBB disruption via increase of SMI-71 and GLUT-1 expressions. P462 P464 Eff ects of long-term exercise on memory recovery in the aged gerbil hippocampus after transient cerebral ischemia CW Park, JH Cho, TG Ohk, MC Shin, MH Won Kangwon National Univeristy, Chuncheon-si, Gangwondo, South Korea Critical Care 2015, 19(Suppl 1):P464 (doi: 10.1186/cc14544) References 1. Zabolotskikh I, et al. Eur J Anesth. 2013;30:114-5. 1. Zabolotskikh I, et al. Eur J Anesth. 2013;30:114-5. 2. Firsching R, et al. J Neurosurg. 2011;115:371-4. 2. Firsching R, et al. J Neurosurg. 2011;115:371-4. P463 Impact of hyperthermia before and during ischemia reperfusion on neuronal damage and gliosis in the gerbil hippocampus induced by transient cerebral ischemia CW Park, JH Cho, TG Ohk, MC Shin, MH Won Kangwon National Univeristy, Chuncheon-si, Gangwondo, South Korea Critical Care 2015, 19(Suppl 1):P463 (doi: 10.1186/cc14543) Conclusion These results suggest that, in the aged gerbil, long-term treadmill exercise after ischemic stroke could restore the impaired short-term memory function through the cumulative eff ects of multiple neurorestorative processes. Prognostic value of blood lactate and glucose levels after aneurysmal subarachnoid hemorrhage y g S Dijkland1, K Van Donkelaar2, W Van den Bergh2, J Bakker1, D Dippel1, M Nijsten2, M Van der Jagt1 1Erasmus MC – University Medical Center, Rotterdam, the Netherlands; 2University Medical Center Groningen, the Netherlands Critical Care 2015, 19(Suppl 1):P466 (doi: 10.1186/cc14546) j g 1Erasmus MC – University Medical Center, Rotterdam, the Netherlands; 2University Medical Center Groningen, the Netherlands Critical Care 2015, 19(Suppl 1):P466 (doi: 10.1186/cc14546) 1Erasmus MC – University Medical Center, Rotterdam, the Netherlands; 2University Medical Center Groningen, the Netherlands Critical Care 2015, 19(Suppl 1):P466 (doi: 10.1186/cc14546) Results A total of 307 patients were included in the validation cohort. The observed 60-day case fatality rate was 30.6%. Discrimination was good, and was considerably better for the model with WFNS grade at treatment decision (AUC = 0.89) compared with the model with WFNS grade on admission (AUC = 0.82). Calibration was poor, with mean predicted probabilities of 17.0% for the model with WFNS grade on admission and 17.7% for the model with WFNS grade at the time of treatment decision. Introduction In critically ill patients, blood lactate on admission is associated with outcome, but in patients with aneurysmal sub- arachnoid hemorrhage (SAH) this has not been investigated. We studied the association of early circulating lactate and glucose with unfavorable disease course. The prognostic role of both lactate and glucose was studied, hypothesizing that both may be increased due to sympathetic activation after SAH [1]. y p Methods In this retrospective cohort study we included consecutive patients with aneurysmal SAH admitted to the ICUs of two university hospitals in the Netherlands between November 2006 and December 2011. Exclusion criteria were: nonaneurysmal SAH, ICU admission >24 hours after ictus, death ≤48 hours after admission and no lactate measurement <24 hours after admission. Maximum blood lactate and glucose levels within the fi rst 24 hours after SAH were used for analyses. The outcomes were DCI, defi ned as a new hypodensity on brain CT due to DCI, and poor outcome, defi ned as a modifi ed Rankin Scale of 4, 5 or death 3 to 6 months after the ictus. We performed proportional hazard analyses to assess the associations of lactate and glucose with DCI, and logistic regression was used to assess the associations with poor outcome. Association between high arterial oxygen survival after intracerebral hemorrhage Introduction Hyperthermia can exacerbate the brain damage pro- duced by ischemia. In the present study, we investigated eff ects of hyperthermia before and during ischemia–reperfusion on neuronal damage and glial changes in the gerbil hippocampus following transient cerebral ischemia using cresyl violet staining, NeuN immunohistochemistry and Fluoro-Jade B histofl uorescence staining. Methods The animals were randomly assigned to four groups: sham- operated animals with normothermia (normothermia + sham group); M Fallenius1, R Raj1, M Reinikainen2, S Bendel3, MB Skrifvars1 1Helsinki University Hospital, Helsinki, Finland; 2North Karelia Central Hospital, Joensuu, Finland; 3Kuopio University Hospital, Kuopio, Finland Critical Care 2015, 19(Suppl 1):P465 (doi: 10.1186/cc14545) M Fallenius1, R Raj1, M Reinikainen2, S Bendel3, MB Skrifvars1 1Helsinki University Hospital, Helsinki, Finland; 2North Karelia Central Hospital, Joensuu, Finland; 3Kuopio University Hospital, Kuopio, Finland Critical Care 2015, 19(Suppl 1):P465 (doi: 10.1186/cc14545) Introduction Liberal use of oxygen after brain insults remains controversial [1,2]. We studied whether high arterial oxygen tension S163 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion Maximum lactate in the acute phase after aneurysmal SAH is associated with both DCI-related infarction and poor outcome. Once glucose was considered, early lactate remained independently associated with poor outcome, while glucose, instead of lactate, was associated with DCI. These routinely available laboratory measurements may improve identifi cation of patients at risk for complications or poor outcome after SAH. Confi rmation of the pathophysiological signifi cance of lactate and glucose in prospective research is warranted. Reference (PaO2) is associated with decreased long-term survival in patients with spontaneous intracerebral hemorrhage (ICH) treated in the ICU. (PaO2) is associated with decreased long-term survival in patients with spontaneous intracerebral hemorrhage (ICH) treated in the ICU. Methods Data on primary admissions for adult patients (>18 years) treated for ICH in Finnish ICUs between 2003 and 2012 were collected from a nationwide ICU database. Patients were divided into three groups according to the PaO2 value associated with the lowest measured PaO2/ FIO2 ratio during the fi rst 24 hours after ICU admission. High arterial oxygen tension was defi ned as PaO2 >19.9 kPa; intermediate as PaO2 13 to 19.9 kPa; and low as PaO2 <13 kPa. The primary outcome was 6-month mortality. 1. Kaukonen K, et al. Crit Care Med. 2014;42:1379-85. Association between high arterial oxygen survival after intracerebral hemorrhage Results Of the 3,033 patients, 63% (n = 1,923) had low PaO2, 29% (n = 892) intermediate PaO2, and 7% (n = 218) high PaO2. Forty-nine percent of the patients died during the 6-month follow-up. Of these, 75% died before discharge from hospital. Univariate analysis showed that 6-month mortality was higher in the high PaO2 group (61%) compared with the intermediate and low PaO2 groups (52% and 46% respectively, P <0.001). Multivariate analysis, however, showed no statistically signifi cant correlation between high PaO2 and mortality (with the low PaO2 group as the reference category, odds ratio for death (OR) for high PaO2 = 1.10, 95% confi dence interval (CI) = 0.76 to 1.58 and for intermediate PaO2 = 0.96, 95% CI = 0.78 to 1.17). P467 Prediction of 60-day case fatality after aneurysmal subarachnoid hemorrhage: external validation of a prediction model S Dijkland, B Roozenbeek, P Brouwer, H Lingsma, D Dippel, L Vergouw, M Vergouwen, M Van der Jagt Erasmus MC – University Medical Center, Rotterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P467 (doi: 10.1186/cc14547) Introduction Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease with substantial morbidity and mortality. Prognostic modeling is an important instrument to identify high- risk patients in both clinical practice and research settings. Recently, a prognostic model to predict 60-day case fatality after aneurysmal SAH was developed with data from the International Subarachnoid Aneurysm Trial (ISAT) [1]. Our aim was to externally validate this model in a retrospective cohort of consecutive SAH patients. 2 Conclusion High PaO2 is not predictive of 6-month mortality in patients treated for spontaneous ICH in the ICU. Therefore, targeting higher PaO2 values appears to be a safe approach in order to avoid hypoxemia. References 1. Rincon F, Kang J, Maltenfort M, et al. Association between hyperoxia and mortality after stroke. Crit Care Med. 2014;42:387-96. 1. Rincon F, Kang J, Maltenfort M, et al. Association between hyperoxia and mortality after stroke. Crit Care Med. 2014;42:387-96. p p Methods We included consecutive aneurysmal SAH patients admitted to one university hospital between October 2007 and October 2011. Exclusion criteria were: age <18 years, hospital admission >28 days after SAH, nonaneurysmal SAH, explicit objection by the patient to view the medical data and missing data on 60-day case fatality. The model’s predictors were age, maximum lumen size of the aneurysm, Fisher grade and World Federation of Neurological Surgeons (WFNS) grade. Two versions of the model were validated: one with WFNS grade scored on admission and the other with WFNS grade assessed at the time of treatment decision, as a proxy to WFNS grade at randomization used in the ISAT. The outcome was 60-day case fatality. Model performance was assessed by studying discrimination, expressed by the area under the receiver operating characteristic curve (AUC), and calibration. 2. de Jonge E, Peelen L, Keijzers PJ, et al. Association between administered oxygen, arterial partial oxygen pressure and mortality in mechanically ventilated intensive care unit patients. Crit Care. 2008;12:R156. P467 P467 Prediction of 60-day case fatality after aneurysmal subarachnoid hemorrhage: external validation of a prediction model S Dijkland, B Roozenbeek, P Brouwer, H Lingsma, D Dippel, L Vergouw, M Vergouwen, M Van der Jagt Erasmus MC – University Medical Center, Rotterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P467 (doi: 10.1186/cc14547) Reference 1. Risselada R, et al. Eur J Epidemiol. 2010;25:261-6. P468 Prognostic value of blood lactate and glucose levels after aneurysmal subarachnoid hemorrhage Multivariable analyses were adjusted for established predictors for DCI and poor outcome.i Conclusion Our results indicate that the ISAT prediction model is generalizable, since the model showed adequate performance in an independent, unselected cohort of aneurysmal SAH patients. The model discriminated well between patients who died and those who survived the fi rst 60 days after SAH. Additionally, use of WFNS grade at the time of treatment decision of the ruptured aneurysm improved model performance. However, since predicted probabilities were lower than observed probabilities, the ISAT prediction model needs to be adapted before use in clinical practice. Cortical spreading depolarizations in patients with intracerebral hemorrhage: preliminary datal Results Two hundred and eighty-fi ve patients were included in the analyses. DCI occurred in 84 patients (29%) and 106 patients (39%) had poor outcome. Lactate was independently associated with DCI (adjusted HR = 1.16, 95% CI = 1.04 to 1.30) and poor outcome (adjusted OR = 1.53, 95% CI = 1.25 to 1.94). Maximum lactate and glucose were strongly related (Spearman’s ρ = 0.55, P <0.001). In multivariable analyses including both lactate and glucose as independent variables, only lactate was independently related to poor outcome (OR = 1.42, 95% CI = 1.11 to 1.81), and only glucose was independently associated with DCI (HR = 1.10, 95% CI = 1.02 to 1.19). AJ Schiefecker1, R Beer1, M Kofl er1, B Pfausler1, I Unterberger1, P Lackner1, G Broessner1, P Rhomberg1, F Sohm1, M Mulino1, C Thome1, M Fabricius2, E Schmutzhard1, R Helbok1 1Medical University of Innsbruck, Austria; 2Rigshospitalet, Copenhagen, Denmark Critical Care 2015, 19(Suppl 1):P468 (doi: 10.1186/cc14548) Introduction Perihematomal edema (PHE) expansion contributes to increased morbidity and mortality after spontaneous intracerebral S164 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 positivity on admission is an independent prognostic predictor in acute ischemic stroke. Reference Figure 1 (abstract P469). hemorrhage (ICH). Pathophysiology of PHE is incompletely understood. Recently, the role of cortical spreading depolarizations (CSDs) in secondary brain injury was established in subarachnoid and traumatic brain injury patients. However, the value of CSDs after ICH is not known. Methods Patients with ICH fulfi lling the inclusion criteria were prospectively enrolled in the observational COSBID study (Co-operative Study on Brain Injury Depolarisations). g.BSamp (g.tec, Austria) connected to PowerLab and LabChart software (Adinstruments) was used for electrocorticography (EcoG). Electrocardiogram patches at the patient’s shoulder and bed served as groundings, and a surface reference electrode was glued on the mastoid. The duration of EcoG depressions was defi ned as the time between depression onset and start of EcoG recovery in the integral of power calculations (0.5 to 45 Hz; 60 seconds time constant decay). Brain tissue oxygen tension (PbtO2), cerebral blood fl ow (CBF), cerebral metabolism and intracranial pressure were monitored in the PHE region. Data are presented as median and interquartile range. q g Results Eighteen patients with ICH (ICH volume: 54 (33 to 69) ml) were analyzed. Hematoma evacuation was performed in 17 patients, one subject underwent craniectomy only. Troponin level as a predictor of prognosis in patients with acute ischemic stroke H Bayir1, R Dagli2, H Kaymaz2, I Yildiz1, H Kocoglu1 1Abant Izzet Baysal University, Medical School, Bolu, Turkey; 2Ahi Evran University Education and Research Hospital, Kirsehir, Turkey Critical Care 2015, 19(Suppl 1):P469 (doi: 10.1186/cc14549) H Bayir1, R Dagli2, H Kaymaz2, I Yildiz1, H Kocoglu1 1Abant Izzet Baysal University, Medical School, Bolu, Turkey; 2Ahi Evran University Education and Research Hospital, Kirsehir, Turkey Critical Care 2015, 19(Suppl 1):P469 (doi: 10.1186/cc14549) Methods The data from 1 million National Health Insurance bene fi ciaries were utilized. All adult benefi ciaries were followed from 1 January 2005 until 31 December 2012 to identify those who developed ischemic stroke. Meanwhile, each identifi ed patient with burn injury was matched with 100 unexposed patients based on the high-dimensional propensity score. Cox regression models were applied to compare the hazards of ischemic stroke in the matched cohorts. Introduction The aim of this study was to identify the association between troponin level and the outcome in patients with acute ischemic stroke. Introduction The aim of this study was to identify the association between troponin level and the outcome in patients with acute ischemic stroke. Methods We retrospectively investigated 152 patients admitted to our reanimation ICU for cerebrovascular accident between 1 January 2013 and 31 December 2013. Inclusion criteria were as follows: patients with acute ischemic stroke, measurement of serum troponin level and electrocardiography performed within 24 hours of admission. Not included were patients with intracerebral hemorrhage, no brain imaging or electrocardiography, previous myocardial infarction, stable or unstable angina pectoris before admission, previous coronary angioplasty or coronary bypass surgery. Figure 1 (abstract P470). Patient fl owchart of enrollment. g p y y yp g y Results Of 152 patients, 51 patients were excluded from the study because of the exclusion criteria. The serum troponin level was elevated in 81 patients. The patients were divided into two groups; patients in group 1 (n = 81) with serum troponin level >0.01, and those in group 2 (n = 20) with serum troponin level ≤0.01. For 1-month follow-up results of patients, death had occurred in 50.6% (n = 41) of patients in group 1 and in 25% (n = 5) of patients in group 2. There was a signifi cant positive correlation between the increase in troponin level and death within 1 month (r = 0.205; P = 0.040). P469 Introduction The results of studies attempting to assess the risks of ischemic stroke in patients with burn injury have been confl icting. We investigated the risks of ischemic stroke in hospitalized burn injury patients in Taiwan to evaluate whether the risk is higher compared with the general population.i Cortical spreading depolarizations in patients with intracerebral hemorrhage: preliminary datal Patients were 60 (55 to 67) years old and 38% female. Monitoring time per patient was 10 (6 to 14) days. A total of 129 CSDs with 16 (10 to 29) minutes of EcoG depression were observed. Eighty-four percent (n = 15) of patients showed expansion of PHE by 25 (10 to 50) ml within 3 to 6 days after bleeding. Neuromonitoring probes were 35 (23 to 58) mm distant from the EcoG strip. CSDs occurred in 73% (n = 11) of patients with PHE expansion. The interval between CSDs was 98 minutes (25 to 308). CSDs were associated with a signifi cant decrease of PbtO2 (–4 mmHg (–3; –7); duration 10 (5 to 23) minutes) in 68% (52/77), CBF changes in 95% (19/20) and metabolic derangement in 80% (80/100) of CSDs. PHE expansion was observed in all patients with spreading convulsions (n = 2) and patients with repetitive CSDs occurring as clusters (n = 3). positivity on admission is an independent prognostic predictor in acute ischemic stroke. positivity on admission is an independent prognostic predictor in acute ischemic stroke. Reference 1. Whiteley W, Chong WL, Sengupta A, Sandercock P. Blood markers for the prognosis of ischemic stroke: a systematic review. Stroke. 2009;40:e380-9. P470 Increased risk of ischemic stroke in patients with burn injury: a nationwide cohort study in Taiwan TY Hung1 YC Su2 Conclusion CSDs are common in ICH patients and associated with perihematomal PbtO2 decreases and metabolic derangement. Especially, clusters of CSDs might be associated with detrimental metabolic changes of the perihematomal brain tissue. TY Hung , YC Su 1Zhongxing Branch of Taipei City Hospital, Taipei, Taiwan; 2Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan Critical Care 2015, 19(Suppl 1):P470 (doi: 10.1186/cc14550) TY Hung , YC Su 1Zhongxing Branch of Taipei City Hospital, Taipei, Taiwan; 2Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan Critical Care 2015, 19(Suppl 1):P470 (doi: 10.1186/cc14550) Eff ect of coronary artery bypass grafting surgery with a pump on cerebral blood fl ow in high-risk patientsf R Juliana, G Ferreira, L Camara, S Zeff erino, D Azevedo, R Groehs, M Lima, R Nogueira, E Bor-Seng-Shu, E Osawa, J Jardim, J Almeida, F Galas, L Hajjar Heart Institute, São Paulo, Brazil R Juliana, G Ferreira, L Camara, S Zeff erino, D Azevedo, R Groehs, M Lima, R Nogueira, E Bor-Seng-Shu, E Osawa, J Jardim, J Almeida, F Galas, L Hajjar Heart Institute, São Paulo, Brazil fi y Results Ninety-nine of 204 included patients developed ICU-AW. Patients with ICU-AW had higher APACHE IV and SOFA scores, a longer duration of mechanical ventilation, longer ICU stay, and died more often on the ICU compared with ICU patients without ICU-AW. Maximal levels of IL-1β, IL-6, IL-8, IL-10, TNFα, IFNγ, fractalkine and sICAM-1 were higher in patients who developed ICU-AW compared with patients who did not develop ICU-AW (univariable analysis). PC 1 to 4 derived from maximal levels explained >69% of the total variance in the data. Multivariable logistic regression models showed that PC 1 (mainly loaded by IL-6, IL-8 and IL-10) and PC 4 (mainly loaded by sP-selectin) were signifi cantly higher in patients with ICU-AW compared with patients without ICU-AW (OR of 1.27 (95% CI = 1.02 to 1.60) and 1.55 (1.06 to 2.27) respectively). Introduction Coronary artery bypass grafting (CABG) surgery usually improves myocardial contractility, reducing cardiovascular events. However, it is a high-risk procedure associated with signifi cant neurological complications, including stroke, delirium and cognitive impairment. The pathophysiology of these complications is not very well known, and may include low fl ow state after surgery, low cardiac output, embolism and reperfusion lesion. The aim of this study is to prospectively evaluate the cerebral hemodynamics through transcranial color and spectral Doppler sonography in high-risk patients undergoing cardiac surgery with a pump. y Methods This was a prospective, single-center study, performed at the Heart Institute from University of São Paulo. From May to November 2014 we included 35 patients in the study, aged older than 18 years old, submitted to CABG with a pump, with EuroSCORE higher than 6 or left ventricular ejection fraction lower than 40%. Transcranial color and spectral Doppler sonography was performed 48 hours before surgery (T0), 7 days (T1) and 6 months after surgery (T2). We used a probe of 2.5 to 2 MHz (Doppler Box DWL/Compumedics, Singen, Germany). All recordings were taken with the patient in a supine position. P471f Eff ect of coronary artery bypass grafting surgery with a pump on cerebral blood fl ow in high-risk patients R Juliana, G Ferreira, L Camara, S Zeff erino, D Azevedo, R Groehs, M Lima, R Nogueira, E Bor-Seng-Shu, E Osawa, J Jardim, J Almeida, F Galas, L Hajjar Heart Institute, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P471 (doi: 10.1186/cc14551) P472 ncreased early systemic infl ammation in patients with ICU-acquired weakness k h d ll h k E Witteveen, L Wieske, C Verhamme, T Van der Poll, IN Van Schaik, MJ Schultz, J Horn Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P472 (doi: 10.1186/cc14552) Introduction Infl ammation may be important in the pathogenesis of ICU-acquired weakness (ICU-AW) since SIRS, sepsis and multiple organ failure are the main risk factors. Local infl ammation has been found in muscle and nerve tissue of patients with ICU-AW, but little is known about the association with systemic infl ammation. We hypothesized that systemic infl ammation is increased in patients who develop ICU- AW compared with patients who do not develop ICU-AW. Figure 2 (abstract P470). Burn injury patients have higher adjusted hazard ratio of ischemic stroke. Results A total of 743,237 patients were enrolled. After matching, 1,763 burn injury patients and 176,300 unexposed patients were selected. The adjusted hazard ratio of ischemic stroke was signifi cantly increased in burn injury patients (1.84; 95% CI, 1.43 to 2.36). Such phenomenon remained signifi cantly after 12 months (1.54; 95% CI, 1.11 to 2.13). See Figures 1 and 2. p p p Methods Newly admitted ICU patients ≥48 hours on mechanical ventilation were included. Daily plasma samples were collected from leftover plasma. Muscle strength was evaluated as soon as patients were awake and attentive. ICU-AW was defi ned by a mean Medical Research Council score <4. IL-1β, IL-6, IL-8, IL-10, IL-13, TNFα, IFNγ, fractalkine, GM-CSF, sICAM-1, sE-selectin and sP-selectin were measured in plasma samples of days 0, 2 and 4 using cytometric bead arrays and FACS. Diff erences of maximum levels between patients with and without ICU- AW were calculated using Mann–Whitney U tests. Principal component (PC) analysis was used to avoid multicollinearity and to reduce the set of mediators into a smaller set of PCs. To investigate whether diff erent infl ammatory profi les are associated with development of ICU-AW, we used multivariable logistic regression models of selected PCs, corrected for a priori selected variables, being age, gender, BMI, sepsis, SOFA score, APACHE IV score, immune insuffi ciency and corticosteroids. Conclusion The risk of ischemic stroke is higher in patients hospitalized with burn injury than in the general population, and the eff ects may be extended longer than expected previously. f 1. Cho SJ, Minn YK, Kwon KH. Stroke after burn. Cerebrovasc Dis. 2007;24:261-3. Troponin level as a predictor of prognosis in patients with acute ischemic stroke The best cutoff point revealed by the ROC curve of troponin was 0.291 mg/l; at which the sensitivity was 73% and the specifi city was 79% when used for prediction of death within 1 month (area = 0.319, CI = 0.214 to 0.423, P = 0.021; Figure 1). Conclusion These results suggest that increased serum troponin g Conclusion These results suggest that increased serum troponin level at admission is associated with higher mortality rate. Troponin Figure 1 (abstract P470). Patient fl owchart of enrollment. S165 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 2 (abstract P470). Burn injury patients have higher adjusted hazard ratio of ischemic stroke. at T0, 0.85 ± 0.24 at T1 and 0.91 ± 0.25 at T2, P = 0.146). There was a signifi cant diff erence in the levels of hemoglobin (13.19 ± g/dl 1.97 at T0 and 9.64 ± 1.48 g/dl at T1, P = 0.002). However, this diff erence was not maintained at T2 (12.7 ± 2.02 g/dl at T2, P = 0.252). There were no diff erences regarding PETCO2 at the time points. f g g 2 p Conclusion After cardiac surgery with a pump in high-risk patients, improvement of cerebral hemodynamic occurs, perhaps due to the optimization of cardiovascular function. These fi ndings must be better investigated. Eff ect of coronary artery bypass grafting surgery with a pump on cerebral blood fl ow in high-risk patientsf We measured the middle cerebral artery mean fl ow velocity and pulsatility index. The end-expiratory pressure of CO2 (PETCO2) was measured with infrared capnography attached to a face mask. Blood pressure, hematocrit and axillary temperature was also recorded. Conclusion Development of ICU-AW is associated with increased systemic infl ammation in the fi rst days after ICU admission. li Acknowledgement This research was supported by the Center for Translational Molecular Medicine (MARS). P473f P472 P472 Increased early systemic infl ammation in patients with ICU-acquired weakness E Witteveen, L Wieske, C Verhamme, T Van der Poll, IN Van Schaik, MJ Schultz, J Horn Academic Medical Center, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P472 (doi: 10.1186/cc14552) Eff ect of prolonged critical care admissions on upper and lower limb muscle architecture P Turton1, R Hay1, JK Taylor2, J Little2, J McPhee3, I Welters4 1Royal Liverpool and Broadgreen University Hospitals, Liverpool, UK; 2Warrington and Halton Hospitals NHS Trust, Warrington, UK 3Manchester Metropolitan University, Manchester, UK; 4University of Liverpool, UK Critical Care 2015, 19(Suppl 1):P473 (doi: 10.1186/cc14553) P Turton1, R Hay1, JK Taylor2, J Little2, J McPhee3, I Welters4 1Royal Liverpool and Broadgreen University Hospitals, Liverpool, UK; 2Warrington and Halton Hospitals NHS Trust, Warrington, UK 3Manchester Metropolitan University, Manchester, UK; 4University of Liverpool, UK Critical Care 2015, 19(Suppl 1):P473 (doi: 10.1186/cc14553) Results The mean age of patients was 64 years; most patients were male (74%). Middle cerebral artery mean fl ow velocity increased signifi cantly after cardiac surgery. It was 53.89 ± 17.23 m/second at T0, 61.48 ± 15.18 m/second at T1 and 59.27 ± 16.12 m/second at T2 (P = 0.029). The pulsatility index was similar at all time points (0.88 ± 0.25 Introduction Muscle wasting is a common consequence of long- term stay in the critical care environment, which may slow down the rehabilitation of survivors. Previous ultrasound studies have S166 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 (35.6% vs. 15.2%, P <0.001). This association remained signifi cant after correction for weakness and other risk factors (OR: 2.463 (95% CI: 1.113 to 5.452), P = 0.026). Also among conscious/cooperative patients without weakness, reduced CMAP was independently associated with a higher likelihood of death within 1 year (HR: 2.818 (95% CI: 1.074 to 7.391), P = 0.035). (35.6% vs. 15.2%, P <0.001). This association remained signifi cant after correction for weakness and other risk factors (OR: 2.463 (95% CI: 1.113 to 5.452), P = 0.026). Also among conscious/cooperative patients without weakness, reduced CMAP was independently associated with a higher likelihood of death within 1 year (HR: 2.818 (95% CI: 1.074 to 7.391), P = 0.035). demonstrated a loss of cross-sectional area of lower limb muscles during a 10-day intensive care stay. In this study, we have looked at how markers of muscle architecture (muscle thickness, pennation angle and fascicle length) change in the lower limb, as well as looking at changes in muscle thickness in the upper limb. demonstrated a loss of cross-sectional area of lower limb muscles during a 10-day intensive care stay. Predictive value for weakness and 1-year mortality of screening electrophysiology tests in the ICU g Results A total of 115 ICU patients were included. The average age was 61 years and 67% of the patients were male. ICU admission diagnoses were 53% acute surgery, 14% elective surgery and 33% were admitted for medical nonsurgical reasons. Inter-rater reliability of the DEMMI was high: intraclass correlation coeffi cient (ICC) ranging from >0.91 (range 0.85 to 0.94) at ICU admission, >0.98 (range 0.96 to 0.99) at the MICU and >0.97 (range 0.96 to 0.98) at the general ward. Internal consistency reliabilities (Cronbach α) of the DEMMI were 0.84, 0.87 and 0.98 at the ICU, MICU and hospital ward respectively. Validity coeffi cients (Spearman’s rank correlations) with BI, Katz-ADL and MMT were 0.63, –0.45 and 0.62. Introduction Muscle weakness in long-stay ICU patients contributes to 1-year mortality [1]. Whether electrophysiological screening is an alternative diagnostic tool also in unconscious/uncooperative patients remains unknown. The aims of this study were to determine the diagnostic properties of abnormal compound muscle action potential (CMAP), sensory nerve action potential (SNAP) and spontaneous electrical activity (SEA) for Medical Research Council (MRC)-sum score defi ned weakness and their predictive value for 1-year mortality. i p y y Methods Data were prospectively collected during the EPaNIC trial (ClinicalTrials.gov NCT00512122) [2] from October 2008 to November 2010. From day 8 onwards, nerve conduction studies and electromyography were performed weekly in 642 long-stay and 88 randomly selected short-stay patients and muscle strength was assessed in cooperative patients using the MRC-sum score. The electrophysiologist was blinded for the clinical assessments of the physiotherapists and vice versa. The two primary outcomes were: sensitivity, specifi city, positive and negative predictive values of abnormal CMAP, SNAP and SEA for weakness (MRC-sum score <48); and the predictive value for 1-year mortality of abnormal fi ndings on fi rst electrophysiological screening. This association was assessed by univariate and multivariate analyses correcting for weakness and other risk factors, including baseline risk factors, comorbidities, illness severity and ICU exposures. Conclusion The DEMMI is a reliable, responsive and feasible measure ment instrument for the assessment of mobility in critically ill ICU patients. R f 1. Stevens RD. Intensive Care Med. 2007;33:1876-91. 2. de Morton NA, et al. Health Qual Life Outcomes. 2008;6:63. 2. de Morton NA, et al. Health Qual Life Outcomes. 2008;6:63. Eff ect of prolonged critical care admissions on upper and lower limb muscle architecture In this study, we have looked at how markers of muscle architecture (muscle thickness, pennation angle and fascicle length) change in the lower limb, as well as looking at changes in muscle thickness in the upper limb. Methods Following ethical approval, patients who were intubated and ventilated in one of two critical care departments were assented to take part in the study by their next of kin. B-mode ultrasound scans of the right biceps, vastus lateralis and the medial head of gastrocnemius were performed on days 1, 5 and 10. Scans were not performed in patients once they were free of sedation. Muscle thickness (MT) was measured in all three muscles, with pennation angle (PA) being measured in the lower limb muscles. Fascicle length (FL) was derived from PA and MT. Conclusion The diagnostic properties of electrophysiological screening vary over time. Abnormal CMAP documented early during critical illness carries information about longer-term outcome, which should be further investigated mechanistically. Acknowledgement HVM and GH contributed equally. Acknowledgement HVM and GH contributed equally. References 1. Hermans G, et al. Am J Respir Crit Care Med. 2014;190:410-20. 2. Casaer M, et al. N Eng J Med. 2011;365:506-17. 1. Hermans G, et al. Am J Respir Crit Care Med. 2014;190:410-20. 2. Casaer M, et al. N Eng J Med. 2011;365:506-17. g Results Twenty patients were recruited, of which 15 were scanned on day 5, and eight were scanned on day 10. In the biceps, there were no alterations in MT over 5 or 10 days. MT of the vastus lateralis signifi cantly decreased on day 5 (1.77 ± 0.06 mm muscle loss, P = 0.03) and day 10 (5.58 ± 0.09 mm muscle loss, P = 0.01). There was also a signifi cant loss in PA over 5 days (1.48 ± 0.63°, P = 0.01) and 10 days (2.96 ± 0.72°, P = 0.01). However, FL was unchanged over time. There was a signifi cant relationship between size of PA and percentage loss of PA and FL in over 5 days. Loss of MT and PA (MT: 3.21 ± 2.08 mm lost, PA: 2.19 ± 1.64°) was observed in the medial gastrocnemius over 10 days, but did not approach signifi cance. Large fascicles on day 1 were associated with greater percentage loss of FL on day 5 (P = 0.012). P475 P474 y Methods The inter-rater reliability and validity were determined in a prospective observational study. Patients were included and assessed by two independent raters until hospital discharge. Reliability was expressed using the intraclass correlations (ICC). To evaluate the validity, the DEMMI scores were compared with the Barthel Index (BI), Katz-ADL and manual muscle testing (MMT). Predictive value for weakness and 1-year mortality of screening electrophysiology tests in the ICU H Van Mechelen1, G Hermans1, F Bruyninckx2, T Vanhullebusch1, B Clerckx1, P Meersseman2, Y Debaveye1, MP Casaer1, A Wilmer2, PJ Wouters1, I Vanhorebeek1, R Gosselink1, G Van den Berghe1 1KU Leuven, Belgium; 2UZ Leuven, Belgium Critical Care 2015, 19(Suppl 1):P474 (doi: 10.1186/cc14554) Psychometric properties of the de Morton Mobility Index in ICU patients J Sommers1, T Vredeveld2, J Horn1, RH Engelbert2, R Lindeboom1, M Vd Schaaf1 1Academical Medical Center, Amsterdam, the Netherlands; 2Amsterdam School of Health Professions (ASHP), University of Applied Sciences, Amsterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P475 (doi: 10.1186/cc14555) Conclusion In the lower limb, we have shown that MT and PA alterations occur in the fi rst 10 days. Patients with larger PA and FL appear to lose a greater percentage of angle and fascicle length in the fi rst 5 days. In contrast, we have demonstrated a sparing eff ect on the muscles of the upper limb compared with the lower limb. These fi ndings may have implications for rehabilitation and interventions to preserve muscle mass. Introduction Many ICU patients develop ICU-acquired muscle weak- ness (ICU-AW) due to inactivity and critical illness. ICU-AW is associated with short-term and long-term physical impairments and impaired functional status [1]. The de Morton Mobility Index (DEMMI) was developed to measure changes in mobility across clinical settings and proved to be reliable, feasible and sensitive to small but clinically relevant changes in functioning [2]. Our aim was to evaluate the psychometric properties of the DEMMI in ICU patients. Prevalence of psychiatric disorders in trauma patients: results from a major trauma unit M Adlam, A Feehan, V Metaxa Methods This was a prospective observational study of trauma patients from two critical care trauma centers. We excluded patients who had ICU stay <48 hours and those with severe traumatic brain injury (TBI) (GCS ≤8). Patients were followed until ICU discharge, resolution of delirium, death or ICU length of stay >28 days. Delirium was assessed daily using the Confusion Assessment Method for the ICU until the end of the follow-up period. Demographic and admission data, daily consumption of medications, and environmental factors (that is, presence of clock, TV/radio, and so forth) were collected daily. Univariate analysis was performed using Cox regression analysis to identify risk factors for delirium. The independent eff ect of modifi able risk factors was assessed using multivariate Cox regression analysis adjusting for severity of illness and nonmodifi able risk factors. King’s College Hospital, London, UK g g p Critical Care 2015, 19(Suppl 1):P477 (doi: 10.1186/cc14557) Introduction Mental illness has been recognised as a potential risk factor both for intentional and unintentional injury. About 50% of patients presenting with self-infl icting injuries in emergency departments had previous known psychiatric disorder (PD) [1,2], whereas individuals with mental illness were admitted for unintentional injury twice as often as those without [3]. We aimed to assess the prevalence of PD in trauma patients being admitted to a major trauma ICU and compare it with the nontrauma population. Methods We retrospectively reviewed all admissions from January 2010 to December 2013 in a tertiary, mixed ICU that serves a London major trauma centre (MTC) hospital. Data obtained were age, APACHE II score, reason for admission, length of stay (LOS), mortality and a diagnosis of depression, bipolar, self-harm, psychosis, schizophrenia and suicide attempt. j g yi Results We enrolled 150 trauma patients resulting mostly from falls (40%) and motor vehicle accidents (28.7%) over 14 months. Patients with TBI accounted for 56.7% while polytrauma patients without TBI accounted for 43.3%. Mean ICU length of stay was 8.1 ± 7.1 days, 69.3% required mechanical ventilation, 14.7% required a tracheostomy. Delirium developed in 58 patients (38.7%) (mean age 62.9 ± 15.7, mean APACHE score 15.4 ± 6.1, mean ISS score 23.4 ± 9.1). Univariate analysis revealed that delirium was signifi cantly associated with the following nonmodifi able risk factors: age (per 10-year range), APACHE II score (per 10-point increase), need of mechanical ventilation, presence of TBI and pre-existing diabetes. j References 1. Schecter WP, et al. Arch Surg. 2005;140:90. 1. Schecter WP, et al. Arch Surg. 2005;140:90. 2. Colman I, et al. Acad Emerg Med. 2004;11:136. 3 Wan JJ et al J Tra ma 2011 61 1299 2. Colman I, et al. Acad Emerg Med. 2004;11:136. 3. Wan JJ, et al. J Trauma. 2011;61:1299. B-type natriuretic peptide and estimated glomerular fi ltration rate at ICU admission as a predictor of delirium Introduction Delirium in the ICU is a predictor of mortality and cognitive impairment at hospital discharge. Although several pathways for delirium have been described, it is very diffi cult to predict the occurrence of delirium. In this study, we examined plasma biomarkers in delirious and nondelirious patients at admission and whether the biomarkers can predict onset of delirium. y Results A total of 730 patients were electrophysiologically screened, of which 432 were tested for weakness. On day 8, only normal CMAP excluded weakness with a high negative predictive value (80.5%). By day 15, abnormal SNAP and the presence of SEA revealed a high positive predictive value (91.7% and 80.0%, respectively). On day 8, only a reduced CMAP was associated with higher 1-year mortality S167 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods We targeted 103 ICU patients in Okayama University Hospital between April 2013 and February 2014. Delirium was diagnosed using the Confusion Assessment Method – ICU. On admission, blood was obtained for biomarker analysis. Patients with severe head injury and under 16 years old were excluded. P <0.05 was considered statistically signifi cant. Conclusion Trauma patients with PD have increased mortality and LOS. MTCs provide a unique opportunity to identify mental illness during hospitalisation through screening and intervention programmes. Integration of mental health services into ICU care should be examined, as it might provide an effi cient and cost-eff ective way of decreasing the risk of reinjury. gi Results Thirty-seven delirious and 66 nondelirious patients were included. We found that delirious patients tented to have higher B-type natriuretic peptide (BNP) levels and to have lower estimated glomerular fi ltration rate (eGFR) (BNP: delirious patients 188.6 pg/ml, nondelirious patients 78.2 pg/ml (P = 0.001); eGFR: delirious patients 58.6 ml/ minute/1.73 m2, nondelirious patients 81.3 ml/minute/1.73 m2 (P = 0.020)). Procalcitonin (PCT) and D-dimer were almost the same between delirious and nondelirious patients (PCT: delirious patients 0.202 ng/ml, nondelirious patients 0.150 ng/ml (P = 0.613); D-dimer: delirious patients 5.25 ng/ml, nondelirious patients 5.35 ng/ml (P = 0.714)). Modifi able risk factors for delirium in critically ill trauma patients: a multicenter prospective study Conclusion BNP and eGFR in ICU admission was associated with delirium. PCT and D-dimer in ICU admission was not associated with delirium. BNP and eGFR might evaluate a predictor of delirium in ICU. References 1. Ely EW, et al. JAMA. 2004;291:1753-62. 1. Ely EW, et al. JAMA. 2004;291:1753-62. Introduction Delirium is associated with signifi cant morbidity and mortality in critically ill medical and surgical patients. However, patients suff ering from trauma are generally excluded from these studies. Our objectives were to assess the incidence of delirium and identify modifi able risk factors associated with delirium among critically ill trauma patients. y 2. van den Boogaard M, et al. Crit Care. 2011;15:R297. P478i Modifi able risk factors for delirium in critically ill trauma patients: a multicenter prospective study MA Duceppe1, A Elliott1, M Para1, MC Poirier1, M Delisle1, AJ Frenette2, D Deckelbaum1, T Razek1, M Desjardins2, JC Bertrand2, F Bernard2, P Rico2, L Burry3, D Williamson2, MM Perreault1 1The Montreal General Hospital, Montreal, QC, Canada; 2Hôpital du Sacré- Coeur de Montreal, QC, Canada; 3Mount Sinai Hospital, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P478 (doi: 10.1186/cc14558) Modifi able risk factors for delirium in critically ill trauma patients: a multicenter prospective study MA Duceppe1, A Elliott1, M Para1, MC Poirier1, M Delisle1, AJ Frenette2, D Deckelbaum1, T Razek1, M Desjardins2, JC Bertrand2, F Bernard2, P Rico2, L Burry3, D Williamson2, MM Perreault1 1The Montreal General Hospital, Montreal, QC, Canada; 2Hôpital du Sacré- Coeur de Montreal, QC, Canada; 3Mount Sinai Hospital, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P478 (doi: 10.1186/cc14558) Prevalence of psychiatric disorders in trauma patients: results from a major trauma unit In a multivariate analysis when adjusting for the nonmodifi able risk factors, opioids (adjusted HR = 0.37, 95% CI (0.14 to 1.0)), presence of a TV/radio in the room (adjusted HR = 0.28, 95% CI (0.12 to 0.67)), and number of hours mobilized (adjusted HR = 0.77, 95% CI (0.68 to 0.88)) had a protective eff ect on delirium; whereas use of physical restraints (adjusted HR = 2.20, 95% CI (1.11 to 4.35)) and active infection (adjusted HR = 2.08, 95% CI (1.16 to 3.71)) remained strongly associated with delirium. Results Of 978 trauma patients admitted to the ICU, 68 (7%) had a known PD. Their diagnoses are shown in Figure 1. Median APACHE II score and unadjusted mortality were 13 and 18% respectively in the PD group (15 and 12% in the entire cohort, P >0.05). Patients suff ering from more than one diagnosis or self-harm alone had increased median LOS (6 vs. 4 days in the entire cohort, P >0.05). Figure 1 (abstract P477). Conclusion Considering the long-term consequences of delirium, steps should be implemented to prevent its development in trauma and include optimizing opioids and mobilizing patients while limiting use of physical restraints. References References 1. Page VJ, et al. Routine Crit Care. 2009;13:R16. 2. Pisani MA, et al. Am J Respir Crit Care Med. 2009;180:1092-7. 3. van den Boogaard M, et al. Intensive Care Med. 2014;40:361-9. 4. Ely EW, et al. JAMA. 2001;286:2703-10. References 1. Page VJ, et al. Routine Crit Care. 2009;13:R16. 2. Pisani MA, et al. Am J Respir Crit Care Med. 2009;180:1092-7. 3. van den Boogaard M, et al. Intensive Care Med. 2014;40:361-9. 4. Ely EW, et al. JAMA. 2001;286:2703-10. 1. Page VJ, et al. Routine Crit Care. 2009;13:R16. 2. Pisani MA, et al. Am J Respir Crit Care Med. 2009;180:1092-7. 3. van den Boogaard M, et al. Intensive Care Med. 2014;40:361-9. 4. Ely EW, et al. JAMA. 2001;286:2703-10. P479 Evaluation of the PRE-DELIRIC delirium prediction tool on a general ICU J Hanison, S Umar, K Acharya, D Conway Manchester Royal Infi rmary, Manchester, UK Critical Care 2015, 19(Suppl 1):P479 (doi: 10.1186/cc14559) Introduction Delirium is a frequently occurring complication of critical care, occurring in approximately 45% of unplanned UK ICU admissions Introduction Delirium is a frequently occurring complication of critical care, occurring in approximately 45% of unplanned UK ICU admissions Figure 1 (abstract P477). Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S168 Figure 1 (abstract P479). Range of PRE-DELIRIC scores. Methods A literature study via MEDLINE and Embase search with keywords ‘PRIS’, ‘lactic acid’, ‘propofol’ and ‘sedation’. All cases in English, French and Spanish were indentifi ed. Exclusion criteria were onset >48 hours, unclear description of time pattern and dose. p p Results Twenty-two cases of early PRIS were found. These concerned 10 pediatric versus 12 adult patients. Eleven were identifi ed in the ICU versus 11 in the operating room. The survival rate of early PRIS was 95.5%, and morbidity was restricted to four patients. In the adult subgroup, the mean propofol dose was 4.9 mg/kg/hour. Triggering factors such as use of catecholamines and corticosteroids were found in 36.4% and 45% of patients. In total, 3/22 cases matched Bray’s defi nition of PRIS. In 14/22 cases, lactic acidosis was interpreted as onset of PRIS. Conclusion Compared with a review by Fudickar [1], we found signifi cant diff erences in critical dose, risk factors, symptomatology and morbidity/mortality between PRIS and early PRIS cases. As criticisms are off ered, a question is whether these cases really are the onset of the fatal syndrome PRIS. Therefore, we completed diff erential diagnosis of lactic acidosis and found that not all possible causes (for example, hyperglycemia, ketonemia, pharmacologic confounders as biguanides, epinephrine) were ruled out in most cases. This is important since PRIS is an exclusion diagnosis. The existence of early PRIS should indeed be questioned and investigated by large, multicenter observational trials. Reference [1]. The presence of delirium in critical care is an independent risk factor for mortality; for every day of delirium, there is an additional 10% relative risk of death at 1 year [2]. A delirium prediction tool PRE- DELIRIC has been recently developed and calibrated in a multinational project [3]. This study aimed to determine the utility of PRE-DELIRIC on our ICU. Propofol sedation reduces contraction and motion of diaphragm in humans: preliminary results p y G Ranieri, M Luigi, F Belsito, M Rocco, RA De Blasi Sant’Andrea, Rome, Italy Results The PRE-DELIRIC scores predicted a mean rate of delirium of 39%. PRE-DELIRIC risk scores ranged from 4 to 93% (Figure 1). Six (15%) patients developed delirium in the fi rst 24 hours following extubation. Fifteen (37%) of patients were predicted 20% or less probability of delirium. Twelve (29%) patients developed delirium at any point during their ICU stay. This resulted in 36 total delirium bed-days. Introduction Among drugs used for sedation, propofol has a primary role [1]. Despite propofol being described to exert a relaxant eff ect on skeletal muscle, no data showing its action on diaphragm are reported. The aim of this observational study on humans is to apply ultrasound to assess propofol’s eff ect on diaphragmatic contraction and motion during endoscopic procedures. y y Conclusion Our observation that <30% of patients experienced delirium is less than the reported prevalence in similar settings and our own audits. This study demonstrates that there is some agreement between recorded rates of delirium and predicted rates using PRE- DELIRIC. We suggest that PRE-DELIRIC can be used in quality/audit work on UK ICUs in order to assess attempts to improve the management of delirium. Further work is required to assess the utility of PRE-DELIRIC as a risk assessment tool in individual patients. Methods We investigated seven consecutive patients undergoing gastroscopy or colonoscopy in the endoscopy unit of our hospital. Patients received propofol at a dose able to induce and maintain sedation to level 6 of the Ramsay Sedation Scale during the procedure. Measurements were obtained on right side of the thorax in millimeters; diaphragmatic motion (DM) and diaphragmatic motion at maximal inspiration (DM forced) were measured in M-Mode with a 3.5 MHz array convex probe placed on the midclavicular line using the liver acoustic window. Thickness at end inspiration (TEI) and thickness at end expiration (TEE) were measured in M-Mode with a 10 MHz vascular probe. The thickening fraction (TF) was calculated: (TEI – TEE) / TEE [2]. Time points of measurements were taken when the patient arrived in the surgery room (Baseline), 1 minute after level 6 of the Ramsey Sedation Scale was obtained (Sedation) and 5 minutes after the patient had a recovery to level 1 on the Ramsey Sedation Scale (Awakening). q Reference 1. Fudickar A. Propofol infusion syndrome in anaesthesia and intensive care medicine. Curr Opin Anaesthesiol. 2006;19:404-10. Methods This study prospectively investigated 41 patients. Medical and surgical general ICU patients were included after 24 hours of sedation and mechanical ventilation. The researchers calculated PRE-DELIRIC scores for each patient. PRE-DELIRIC involves recording 10 variables, submitted into an online algorithm that estimates the percentage risk of delirium. We diagnosed delirium with the CAM-ICU which was performed 12 hourly [4]. P484 Prolonged dexmedetomidine infusion and drug withdrawal in critically ill children A Haenecour, A Goodwin, W Seto, C Urbain, P Laussen, C Balit The Hospital for Sick Children, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P484 (doi: 10.1186/cc14564) Prolonged dexmedetomidine infusion and drug withdrawal in critically ill children A Haenecour, A Goodwin, W Seto, C Urbain, P Laussen, C Balit The Hospital for Sick Children, Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P484 (doi: 10.1186/cc14564) Results One hundred and twenty-six of 174 respondents indicated that they practice in the ICU setting. Sixty-six per cent were specialists and mainly anaesthesiologists (42%), whilst 32% were critical care subspecialists. The respondents indicated that on average 30 ± 20% of their patients experience delirium. Eighty per cent of the respondents indicated that delirium impacts signifi cantly negatively on patient outcomes whilst 1% indicated that there was no such association. Delirium screening is achieved mainly by clinical assessment (77%). Twenty-four per cent utilise an objective tool to screen for delirium and amongst them the CAM-ICU is utilised by 80%. Amongst delirious patients the sedative of choice is dexmedetomidine in the majority. However, 20% prescribe midazolam as a fi rst choice in this setting. Conclusion The fi ndings are comparable with reports of similar surveys conducted in other regions. The delirium screening method is inadequate as the vast majority do not utilise an objective method. Introduction We investigated the incidence, symptoms and risk factors for withdrawal associated with prolonged dexmedetomidine use. Dexmedetomidine is an α2-adrenergic receptor agonist, with anxiolytic, analgesic and sedative properties. Intended for short-term use, there is increasing literature describing prolonged use for sedation. However, this raises the potential of withdrawal syndrome and there is no recommendation for the discontinuation of dexmedetomidine. Other goals included determining the hemodynamic eff ects of discontinuation of dexmedetomidine and role of clonidine in patients with prolonged dexmedetomidine use. g Methods A retrospective review of patients admitted to the critical care unit who had exposure to dexmedetomidine for longer than 48 hours, between 1 January 2014 and 15 July 2014. Data included patient demographics, dexmedetomidine exposure (bolus dose, total cumulative dose, duration), other sedative exposure, withdrawal symptoms measured by WAT-1 score, nursing subjective assessment and treatment given for withdrawal. Each potential withdrawal episode was reviewed by two reviewers. Hemodynamic parameters were analyzed to assess hemodynamic changes associated with discontinuation of dexmedetomidine. Short-term propofol infusion syndrome (PRIS): fact or fi ction? A systematic review on early PRIS in intensive care and anesthesia J Vandenbrande than 48 hours who were potential candidates for weaning from the ventilator and who exhibited agitation defi ned by a Richmond Agitation Sedation Scale (RASS) >2 after sedation withdrawal were randomly assigned to receive either loxapine or placebo. All participants were masked to group of allocation. After randomization, patients received 150 mg loxapine or placebo by nasogastric tube. RASS was monitored every 4 hours. A second dose of loxapine or placebo was administered if agitation persisted or worsened. In case of severe agitation, usual sedation (benzodiazepines and morphinic agents) was immediately resumed. Extubation was contemplated when patients were conscious and calm. The primary endpoint was the time between the fi rst administration of loxapine or placebo and successful extubation (no reintubation in the following 48 hours). Three hundred patients were necessary to have 90% power to detect a 2-day reduction of weaning time in the loxapine group with a one-sided type I error rate of 5%. i Results During propofol administration TEI reduced 19% whereas after awakening it increased 14.5% but did not reach baseline. Conversely TEE did not change during the study. During propofol sedation, TF decreased 34% and returned to baseline after recovery. DM showed 29% reduction during propofol administration whereas the forced diaphragmatic motion tested when patients were conscious (forced DM) did not evidence any change. y g Conclusion In this observational study, ultrasound assessed that propofol causes a reduction of diaphragmatic contraction and motion during endoscopic procedures. P482 Delirium knowledge and assessment by ICU practitioners in South Africa: results of a national survey S Chetty, F Paruk University of the Witwatersrand, Johannesburg, South Africa Critical Care 2015, 19(Suppl 1):P482 (doi: 10.1186/cc14562) Delirium knowledge and assessment by ICU practitioners in South Africa: results of a national survey S Chetty, F Paruk University of the Witwatersrand, Johannesburg, South Africa Critical Care 2015, 19(Suppl 1):P482 (doi: 10.1186/cc14562) p g p Conclusion These results are consistent with the hypothesis of 2 days reduction of the median weaning time in the loxapine group, but the diff erence was not statistically signifi cant. Loxapine reduces the need for resuming sedation during weaning from MV. Given the quality of the data and methodology, these results may be useful in future meta-analyses. Introduction Delirium recognition in critically ill patients is considered to be important taking into account the poor outcomes associated with its occurrence. The purpose of this study was to evaluate knowledge pertaining to delirium as well as the implementation of screening practices. This study constituted a component of a survey that explored current sedation-related practices in South African ICUs. Methods Following approval from the University Human Research ethics committee, a validated questionnaire was distributed electronically to physician members of various medical databases in South Africa as South Africa does not have a formal registry of critical care practitioners. P484 Descriptive statistics were used with t test and chi-square test. Median and interquartile range (IQR) are reported. Short-term propofol infusion syndrome (PRIS): fact or fi ction? A systematic review on early PRIS in intensive care and anesthesia J Vandenbrande In case of severe agitation, usual sedation (benzodiazepines and morphinic agents) was immediately resumed. Extubation was contemplated when patients were conscious and calm. The primary endpoint was the time between the fi rst administration of loxapine or placebo and successful extubation (no reintubation in the following 48 hours). Three hundred patients were necessary to have 90% power to detect a 2-day reduction of weaning time in the loxapine group with a one-sided type I error rate of 5%. Results The trial was discontinued after 101 patients had been randomized because of insuffi cient enrollment. Fifteen patients withdrew consent, leaving 86 patients for analysis. Forty-seven patients were assigned to the loxapine group and 39 to the placebo group. Median time to successful extubation was 3.2 days in the loxapine group and 5 days in the placebo group (RR = 1.2, 95% CI = 0.75 to 1.88; P = 0.45). During the fi rst 24 hours, sedation was more frequently resumed in the placebo group (44% vs. 17%, P = 0.01). One patient had a transient seizure in the loxapine group. Data analyzed are reported in Table 1 and expressed as mean (SD). ANOVA was used to compare data for repeated measurements. Post hoc statistical comparison with Bonferroni’s test was used to identify signifi cant variations. than 48 hours who were potential candidates for weaning from the ventilator and who exhibited agitation defi ned by a Richmond Agitation Sedation Scale (RASS) >2 after sedation withdrawal were randomly assigned to receive either loxapine or placebo. All participants were masked to group of allocation. After randomization, patients received 150 mg loxapine or placebo by nasogastric tube. RASS was monitored every 4 hours. A second dose of loxapine or placebo was administered if agitation persisted or worsened. In case of severe agitation, usual sedation (benzodiazepines and morphinic agents) was immediately resumed. Extubation was contemplated when patients were conscious and calm. The primary endpoint was the time between the fi rst administration of loxapine or placebo and successful extubation (no reintubation in the following 48 hours). Three hundred patients were necessary to have 90% power to detect a 2-day reduction of weaning time in the loxapine group with a one-sided type I error rate of 5%. g References p g p yp Results The trial was discontinued after 101 patients had been randomized because of insuffi cient enrollment. Fifteen patients withdrew consent, leaving 86 patients for analysis. Forty-seven patients were assigned to the loxapine group and 39 to the placebo group. Median time to successful extubation was 3.2 days in the loxapine group and 5 days in the placebo group (RR = 1.2, 95% CI = 0.75 to 1.88; P = 0.45). During the fi rst 24 hours, sedation was more frequently resumed in the placebo group (44% vs. 17%, P = 0.01). One patient had a transient seizure in the loxapine group. 1. Singh H, et al. Cochrane Database Syst Rev. 2008;4:CD006268. 2. Matamis D, et al. Intensive Care Med. 2013;39:801-10. 1. Singh H, et al. Cochrane Database Syst Rev. 2008;4:CD006268. 2. Matamis D, et al. Intensive Care Med. 2013;39:801-10. 1. Singh H, et al. Cochrane Database Syst Rev. 2008;4:CD006268. 2. Matamis D, et al. Intensive Care Med. 2013;39:801-10. Short-term propofol infusion syndrome (PRIS): fact or fi ction? A systematic review on early PRIS in intensive care and anesthesia J Vandenbrande Short-term propofol infusion syndrome (PRIS): fact or fi ction? A systematic review on early PRIS in intensive care and anesthesia J Vandenbrande University Hospitals Leuven, Belgium Critical Care 2015, 19(Suppl 1):P480 (doi: 10.1186/cc14560) University Hospitals Leuven, Belgium University Hospitals Leuven, Belgium y g Critical Care 2015, 19(Suppl 1):P480 (doi: 10.1186/cc14560) Table 1 (abstract P481) Variable Baseline Sedation Awakening P value Thickness end inspiration (mm) 3.25 (0.21) a2.66 (0.20) b,c3.22 (0.30) <0.001* Thickness end expiration (mm) 2.11 (0.20) d2.00 (0.15) 2.07 (0.15) 0.112* Thickening fraction 0.54 (0.07) e0.36 (0.10) f,g0.49 (0.11) <0.001* Diaphragmatic motion (mm) 18.66 (2.23) h13.27 (4.93) 15.31 (0.40) 0.055 Diaphragmatic motion forced 54.61 (19.34) – 56.34 (13.75) 0.298 (mm) aP <0.001 versus baseline. bP = 0.043 versus baseline. cP <0.001 versus sedation. dP = 0.030 versus baseline. eP =0.012 versus baseline. fP =0.353 versus baseline. gP = 0.041 versus sedation. hP = 0.022 versus baseline. Introduction Propofol infusion syndrome (PRIS) is a rare propofol complication, leading to cardiac failure. It was fi rst described in critically ill children and in adults with traumatic brain injury. Pathophysiology is unknown although common factors are the prolonged (>48 hours) use of high-dose (>5 mg/kg/hour) propofol combined with elevated levels of catecholamines and corticosteroids. Recently, case reports of early- onset PRIS during anesthesia and in the early postoperative setting were published. In many of these, lactic acidosis is interpreted as onset of PRIS. Criticism off ers that it might concern a poor diff erential diagnostic approach or an observational bias. Also, lactic acidosis is not an obligate PRIS symptom and incidence of lactic acidosis during propofol sedation is unknown. To gain insight into the incidence and characteristics of early PRIS, we performed a systematic review on early PRIS cases. S169 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 than 48 hours who were potential candidates for weaning from the ventilator and who exhibited agitation defi ned by a Richmond Agitation Sedation Scale (RASS) >2 after sedation withdrawal were randomly assigned to receive either loxapine or placebo. All participants were masked to group of allocation. After randomization, patients received 150 mg loxapine or placebo by nasogastric tube. RASS was monitored every 4 hours. A second dose of loxapine or placebo was administered if agitation persisted or worsened. P487 Eff ects of administration of dexmedetomidine on infl ammatory responses and severity in severe septic patients T Taniguchi, M Okajima, K Sato, T Noda Kanazawa University, Kanazawa, Japan Critical Care 2015, 19(Suppl 1):P487 (doi: 10.1186/cc14567) Eff ects of administration of dexmedetomidine on infl ammatory responses and severity in severe septic patients T Taniguchi, M Okajima, K Sato, T Noda Kanazawa University, Kanazawa, Japan Critical Care 2015, 19(Suppl 1):P487 (doi: 10.1186/cc14567) Eff ects of administration of dexmedetomidine on infl ammatory responses and severity in severe septic patients Introduction Recently, several animal studies observed that dexmedetomidine (DEX), a new sedative and α2-adrenoceptor agonist, inhibited the infl ammatory responses [1-3]. Moreover, DEX was reported to have anti-infl ammatory eff ects in patients [4,5]. However, these studies were the small-sized studies and there are few studies about the eff ects of long-term administration of DEX in severe septic patients. The present study evaluated the eff ects of long-term administration of DEX on infl ammatory responses and severity in severe septic patients. We hypothesize that the administration of DEX has benefi cial eff ects for severe septic patients. y y g y Methods We investigate the role of DEX as a sedative agent used during recovery from deep sedation and weaning from extracorporeal support in patients on vv-ECMO. From May 2014 to October 2014 we prospectively enrolled seven patients aff ected by ARDS of diff erent etiologies treated with vv-ECMO. The mean age was 53.7 ± 7.9 years and the mean ICU stay was 21.4 ± 11.5 days. Initially, all patients were sedated with association of opioids and GABA receptor agonists, following the internal protocol. At the time of weaning from ECMO, ruled out cardiovascular instability, we started the administration of DEX (0.7 μg/kg/hour, without initial bolus) with progressive decrease of the dose of other sedative drugs. if Methods In 66 patients (M/F 44/22, mean age 66 years) with severe sepsis, who were administered propofol (0.5 to 4.0 mg/kg/hour) only for sedation, 42 patients (M/F 28/14, mean age 67 years) were administered DEX (0.2 to 0.7 μg/kg/hour) for more than 24 hours in addition to propofol (DEX group). Twenty-four patients were not administered DEX (Control group). Primary outcome were changes in infl ammatory responses at 48 hours after the administration of DEX or none, and secondary outcomes were changes in APACHE II and SOFA scores at 48 hours after the administration of DEX or none. Results The mean duration of DEX infusion was 6.1 ± 4.8 days. Loxapine to control agitation during weaning from mechanical ventilation: a randomized controlled trial S Gaudry1, B Sztrymf2, R Sonneville3, B Megarbanne4, C Clec’h5, J Ricard1, D Hajage3, D Dreyfuss1 1Hôpital Louis Mourier, Colombes, France; 2Hôpital Béclère, Clamart, France; 3Hôpital Bichat, Paris, France; 4Hôpital Lariboisière, Paris, France; 5Hôpital Avicennes, Bobigny, France Critical Care 2015, 19(Suppl 1):P483 (doi: 10.1186/cc14563) Results A total of 53 patients accounted for 69 unique dexmedetomidine treatment courses. Median age at the time of dexmedetomidine infusion was 5 months (range 1 day to 3 years). Dexmedetomidine dose ranged from 0.1 to 2 μg/kg/hour with a median cumulative dose of 87 μg/kg (IQR 53, 156). Median duration of exposure to dexmedetomidine was 124 hours (IQR 76, 178) with a maximum duration of 466 hours. We identifi ed 24 separate episodes of withdrawal (incidence 35%). Most common symptoms were agitation (100%), fever (67%), vomiting/retching (46%), loose stools (29%) and decreased sleep (20%). Statistical analysis showed that factors signifi cantly associated Introduction Weaning from prolonged mechanical ventilation (MV) in the ICU may be impeded by the occurrence of agitation. Loxapine had the ability to control agitation without aff ecting the effi cacy of spontaneous ventilation in an observational study, justifying the implementation of a randomized controlled trial. Methods We conducted a multicenter, placebo-controlled, parallel group, randomized trial at fi ve French ICUs between November 2011 and November 2013. Patients (aged >18 years) under MV for more S170 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 to help tolerate intubation and reduce pain and anxiety. Propofol (Pr) is a widely used option, but other viable alternatives for short-term sedation (STS; that is, <24 hours) include benzodiazepines (BDZ) and dexmedetomidine (Dx). We aimed at pooling all available evidence on the comparative eff ects of Pr in terms of awakening and recovery times after STS in mechanically ventilated ICU patients. with withdrawal were cumulative dose (P = 0.01) and duration of use of dexmedetomidine (P = 0.02). Duration of opioids exposure prior to dexmedetomidine wean was also a risk factor for withdrawal (P = 0.01). Use of clonidine as a transition from dexmedetomidine did not protect against withdrawal (P = 0.59). g Conclusion This study showed that withdrawal syndrome is associated with prolonged infusion of dexmedetomidine. Patients with higher cumulative doses and longer duration of exposure were more at risk. P486 P486 Short-term sedation of mechanically ventilated ICU patients with propofol, benzodiazepines, or dexmedetomidine: systematic review and meta-analysis on awakening and recovery times A Feuersenger1, L Pradelli2, A Aliano2, JF Baron3, M Westphal1 1Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany; 2AdRes, Torino, Italy; 3Fresenius Kabi ELAMA, Paris, France Critical Care 2015, 19(Suppl 1):P486 (doi: 10.1186/cc14566) Conclusion In the present study, the long-term administration of DEX has benefi cial eff ects of infl ammatory responses and severity for severe septic patients. P485 Weaning from extracorporeal membrane oxygenation: experience with dexmedetomidine in seven adult ARDS patients M Cozzolino, A Franci, A Peris, L Tadini Buoninsegni, B Loriga A.O.U. Careggi, Firenze, Italy Critical Care 2015, 19(Suppl 1):P485 (doi: 10.1186/cc14565) Introduction Sedation in the ICU is a basic therapeutic procedure to increase tolerance of invasive treatments and reduce discomfort. Extracorporeal membrane oxygenation (ECMO) is a highly invasive treatment and prolonged sedation may be required. Patients undergoing ECMO represent a challenge with respect to sedation. Initially, deep sedation may be required to optimize ventilation and circuit–patient fl ows and to minimize oxygen consumption. The other critical phase is represented by weaning from ECMO support. Optimal sedation is not clearly defi ned, moreover there are no data on sedation practices with dexmedetomidine (DEX) in adult patients undergoing ECMO. In contrast to other sedatives, DEX has analgosedative eff ects without respiratory depression, and could be useful to facilitate spontaneous respiratory activity during recovery from sedation. i Conclusion In conclusion, Pr is associated with shorter awakening and recovery times after STS than BDZ, while no diff erence could be shown when Pr was compared with Dx. P487f P487 Eff ects of administration of dexmedetomidine on infl ammatory responses and severity in severe septic patients T Taniguchi, M Okajima, K Sato, T Noda Kanazawa University, Kanazawa, Japan Critical Care 2015, 19(Suppl 1):P487 (doi: 10.1186/cc14567) Except for one patient, who received DEX as a single drug after suspension of other sedatives, a low-dose infusion of another sedative (<50% compared with initial dose) was maintained. Three patients presented adverse events: two bradycardia and one hypotension. In four patients DEX was discontinued after recovery of respiratory function; in two patients deeper sedation for ventilatory dyssynchrony was needed so other sedative drugs were started. Only in one patient was the drug suspended for extreme bradycardia, resolved after suspension. Results The administration of DEX occurred for a mean 130 hours (24 to 433 hours) in the DEX group. White blood cell counts, C-reactive protein (CRP) and procalcitonin (PCT) in both groups signifi cantly decreased after the administration of DEX or none. However, CRP and PCT in the DEX group were signifi cantly lower than those in the control group: CRP 7.7 (5.0) versus 13.6 (7.9) mg/dl; P <0.05, PCT 7.6 (11.7) versus 18.6 (11.6) ng/ml; P <0.05, mean (SD). APACHE II and SOFA scores in both groups decreased after the administration of DEX or none, but APACHE II and SOFA scores in the DEX group were lower than those in the control group: APACHE II 10.8 (4.8) versus 15.2 (5.1); P <0.05, SOFA 3.6 (2.0) versus 5.8 (2.9); P <0.05, mean (SD). p y p Conclusion In our study, DEX allowed the reduction of doses of other sedative drugs during weaning from vv-ECMO; this may lead to a cooperative sedation, promoting spontaneous breathing. Side eff ects described and the cost–benefi t ratio must still be verifi ed extensively in patients during weaning from ECMO. Loxapine to control agitation during weaning from mechanical ventilation: a randomized controlled trial Our results suggested that clonidine use is not protective for withdrawal from dexmedetomidine. y Methods We planned a systematic literature review searching Medline and Scopus and performed a meta-analysis on direct comparisons reporting on weaning time (Tw), duration of mechanical ventilation (Tmv), time to extubation (Tex) and length of stay in the ICU (Ticu). The primary analysis considered only data from RCTs, while in a secondary analysis observational studies were also included.i y Results The literature search identifi ed 15 relevant RCTs, of which 11 versus BDZ, and a further fi ve observational studies, of which one versus BDZ. When compared with BDZ, Pr associated with signifi cantly reduced Tw (–1.6 hours, 95% CI: –2.5 to –0.8), Tmv (–2.0 hours, 95% CI: –3.7 to –0.2), and Ticu (–5.0 hours, 95% CI: –8.5 to –1.4); no statistically signifi cant diff erence resulted when comparing Pr and Dx. When nonrandomized evidence was included, results did not change signifi cantly. P490 Best pain management for critical older patients in the surgical ICU W Huang Mackay Memorial Hospital, Taipei, Taiwan Critical Care 2015, 19(Suppl 1):P490 (doi: 10.1186/cc14570) Best pain management for critical older patients in the surgical ICU W Huang Mackay Memorial Hospital, Taipei, Taiwan Critical Care 2015, 19(Suppl 1):P490 (doi: 10.1186/cc14570) Results A total of 77 children with a median age of 15 (4 to 84) months, weight of 10 (5.7 to 20) kg and length of ICU stay of 8 (5 to 14) days received DEX, with a mortality rate of 9%. Indications were: weaning from mechanical ventilation (32.5%), neurosurgical postoperative (NCI) and upper airway surgery (VAS) (24.7%), non-invasive ventilation (13%), refractory tachycardia (6.5%) and other indications (23.3%). There was no diff erence between the initial and maximum doses and infusion length. There was a signifi cant decrease in MAP and HR after 6 hours infusion of DEX in the total group; however, no signifi cant diff erence occurred between groups when analyzing MAP and HR 24 hours after the start of infusion (P = 0.798 and 0.379, one-way ANOVA, respectively). In six patients (8%) DEX was suspended for possible side eff ects. Introduction To determine which of three methods of pain manage- ment provided the best pain control in severe ASA III older patients in the surgical ICU (SICU). As technology improves, more older patients benefi t from surgery and need SICU care. Older surgery patients frequently present two medical problems. First is unspecifi c symptoms and decreased pain sensation resulting in delayed diagnosis. Second, they usually are not given enough perioperative pain relief. Optimal pain management results in perioperative stable hemodynamic status and decreased morbidity, mortality, length of stay and medical costs. Methods A retrospective cohort study chart review of 1,872 all-cause patients in a 16-bed SICU during April 2011 to September 2012. Un- consciousness, uncooperative, ASA <III and <65-year-old patients were excluded. The primary point was to compare eff ectiveness of three diff erent methods of pain management: P.R.N. i.v. Demerol/NSAID (D/N), i.v. patient-controlled analgesia (PCA) and patient-controlled epidural analgesia (PCEA), in three diff erent conditions: rest, movement and coughing, with visual analogue scales (VAS 0 to 100). Secondary point was patient satisfaction. Introduction To determine which of three methods of pain manage- ment provided the best pain control in severe ASA III older patients in the surgical ICU (SICU). As technology improves, more older patients benefi t from surgery and need SICU care. Older surgery patients frequently present two medical problems. P490 Best pain management for critical older patients in the surgical ICU W Huang Mackay Memorial Hospital, Taipei, Taiwan Critical Care 2015, 19(Suppl 1):P490 (doi: 10.1186/cc14570) First is unspecifi c symptoms and decreased pain sensation resulting in delayed diagnosis. Second, they usually are not given enough perioperative pain relief. Optimal pain management results in perioperative stable hemodynamic status and decreased morbidity, mortality, length of stay and medical costs. Methods A retrospective cohort study chart review of 1,872 all-cause patients in a 16-bed SICU during April 2011 to September 2012. Un- consciousness, uncooperative, ASA <III and <65-year-old patients were excluded. The primary point was to compare eff ectiveness of three diff erent methods of pain management: P.R.N. i.v. Demerol/NSAID (D/N), i.v. patient-controlled analgesia (PCA) and patient-controlled epidural analgesia (PCEA), in three diff erent conditions: rest, movement and coughing, with visual analogue scales (VAS 0 to 100). Secondary point was patient satisfaction. f Conclusion Increased DEX indications have been observed in the pediatric population. In this study DEX was demonstrated to be a safe and tolerable drug with few side eff ects, especially related to the cardiovascular system. References 1. Pichot C, Ghignone M, Quintin L. Dexmedetomidine and clonidine: from second- to fi rst-line sedative agents in the critical care setting? J Intensive Care Med. 2012;27:219-37. 1. Pichot C, Ghignone M, Quintin L. Dexmedetomidine and clonidine: from second- to fi rst-line sedative agents in the critical care setting? J Intensive Care Med. 2012;27:219-37. 1. Pichot C, Ghignone M, Quintin L. Dexmedetomidine and clonidine: from second- to fi rst-line sedative agents in the critical care setting? J Intensive Care Med. 2012;27:219-37. 2. Afonso J RF. Dexmedetomidina: Papel Atual em Anestesia e Cuidados Intensivos. Rev Bras Anestesiol. 2012;62:118-33. 3. Panzer O, Moitra V, et al. Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists. Crit Care Clin. 2009;25:451-69. 4. Hsu CD CJ. Pharmacologic agents for pediatric procedural sedation outside of the operating room. UpToDate2014. http://www.uptodate.com/contents/ pharmacologic-agents-for-pediatric-procedural-sedation. 5. Tobias JD. Dexmedetomidine: applications in pediatric critical care and pediatric anesthesiology. Pediatr Crit Care Med. 2007;8:115-31. p p Results A total of 1,292 patients were excluded. VAS results are presented in Table 1 as mean ± SD. At rest, the PCEA group is signifi cantly better than the other two groups. When at movement, there is no diff erence between the PCEA group and the D/N group but both are better than the PCA group. While coughing, the PCEA group is worse than the D/N group, although there is no diff erence between the PCEA group and the PCA group. The PCEA group gets the best grades in patient satisfaction. 2. Afonso J RF. Dexmedetomidina: Papel Atual em Anestesia e Cuidados Intensivos. Rev Bras Anestesiol. 2012;62:118-33. 3. Panzer O, Moitra V, et al. Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists. Crit Care Clin. 2009;25:451-69. 4. Hsu CD CJ. Pharmacologic agents for pediatric procedural sedation outside of the operating room. UpToDate2014. http://www.uptodate.com/contents/ pharmacologic-agents-for-pediatric-procedural-sedation. 5. Tobias JD. Dexmedetomidine: applications in pediatric critical care and pediatric anesthesiology. Pediatr Crit Care Med. 2007;8:115-31. Psychometric comparison of three behavioral scales for the assessment of pain in critically ill patients unable to self-report p y p G Papakitsos1, A Kapsali1, T Papakitsou2 p , p , p 1GHA, Arta, Greece; 2General Hospital Messologi, Greece p g Critical Care 2015, 19(Suppl 1):P489 (doi: 10.1186/cc14569) Introduction Pain assessment is associated with important out omes in ICU patients but remains challenging, particularly in non communicative patients. Use of a reliable tool is paramount to allow any implementation of sedation/analgesia protocols in a multidisciplinary team. This study compared psychometric properties (inter-rater agreement primarily; validity, responsiveness and feasibility secondarily) of three pain scales: Behavioural Pain Scale (BPS/BPS-NI, that is BPS for non-intubated patients), Critical Care Pain Observation Tool (CPOT) and Non-Verbal Pain Scale (NVPS), the pain tool routinely used in this 16-bed medical ICU. Conclusion PCEA provided better pain control at rest than the other two methods, whereas P.R.N. Demerol/NSAID and PCEA were somewhat better than PCA when patients were moving. While coughing, P.R.N. Demerol/NSAID provided the best pain control. However, patient satisfaction was signifi cantly better with PCEA. p p References References 1. Taniguchi T, et al. Crit Care Med. 2004;32:1322-6. 2. Qiano H, et al. Crit Care. 2009;13:R136. 3. Wu Y, et al. Mediators Infl amm. 2013;2013:562154. 4. Pandharipande PP, et al. Crit Care. 2010;14:R38. 5. Ji F, et al. Circulation. 2013;127:1576-84. 1. Taniguchi T, et al. Crit Care Med. 2004;32:1322-6. 2. Qiano H, et al. Crit Care. 2009;13:R136.l Introduction Sedation in the ICU is crucial in reduction of patients’ discomfort, in particular in patients undergoing mechanical ventilation Introduction Sedation in the ICU is crucial in reduction of patients’ discomfort, in particular in patients undergoing mechanical ventilation S171 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P488 P488 Characteristics of the use of dexmedetomidine in critically ill children: a Brazilian study PL Lago, C Andreolio, J Piva, E Baldasso Hospital de Clinicas de Porto Alegre, Brazil Critical Care 2015, 19(Suppl 1):P488 (doi: 10.1186/cc14568 FRAP values. We found that FRAP values were inversely correlated with APACHE II score (r = –0.266, P <0.01) suggesting that, in trauma patients, increased antioxidant response, as measured by the FRAP assay, could be a pathophysiological response to stress. Albumin and uric acid concentrations reproduced the FRAP trend with severity. Conclusion FRAP values in trauma ED patients are independently infl uenced by age (β = 0.271, P <0.021), APACHE II score (β = –0.356, P <0.002) and head trauma (β = –0.219, P <0.045). These results accen- tuate the infl uence of trauma location and severity in TAC changes. The TAC response in ED patients reinforces the need for adequate tailoring of treatments aimed at their recovery, such as antioxidant therapies. Table 1 (abstract P490) Demerol/NSAID PCA PCEA (n = 449) (n = 62) (n = 69) P value VAS (rest) 21 ± 14 * 19 ± 9* 12 ± 10 <0.001 VAS (movement) 35 ± 20 41 ± 12* 33 ± 11 0.02 VAS (coughing) 40 ± 24* 58 ± 14 51 ± 14 <0.001 *Signifi cant diff erence. P488 Characteristics of the use of dexmedetomidine in critically ill children: a Brazilian study Conclusion FRAP values in trauma ED patients are independently infl uenced by age (β = 0.271, P <0.021), APACHE II score (β = –0.356, P <0.002) and head trauma (β = –0.219, P <0.045). These results accen- tuate the infl uence of trauma location and severity in TAC changes. The TAC response in ED patients reinforces the need for adequate tailoring of treatments aimed at their recovery, such as antioxidant therapies. Introduction To describe the main indications, doses, infusion length and side eff ects of dexmedetomidine (DEX) administered to children and adolescents admitted to the pediatric ICU (PICU). p Methods A retrospective observational study including children (<18 years) admitted to a Brazilian PICU who received DEX between November 2011 and June 2014. Demographic data, indications, initial dose, maximum dose and time of infusion of DEX, side eff ects and impact on heart rate (HR) and mean arterial pressure (MAP) 6 and 24 hours after the start of infusion. P491 P491 Subanesthetic xenon increases erythropoietin levels in humans and remains traceable in the fi rst 24 hours after exposure: a randomized controlled trial J Ney, C Stoppe, M Brenke, A Goetzenich, S Kraemer, G Schaelte, A Fahlenkamp, R Rossaint, M Coburn RWTH Aachen University, Aachen, Germany Critical Care 2015, 19(Suppl 1):P491 (doi: 10.1186/cc14571) Methods In a prospective observational study of ED polytraumatized patients (n = 23, mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 11 ± 6) we measured (in the fi rst 24 hours) plasma TAC by the ferric reducing activity/antioxidant power (FRAP). For control subjects, we used age-matched and gender-matched volunteers (n = 32). We also evaluated the contribution of antioxidant molecules (uric acid, bilirubin, and albumin) to these values.f J Ney, C Stoppe, M Brenke, A Goetzenich, S Kraemer, G Schaelte, A Fahlenkamp, R Rossaint, M Coburn RWTH Aachen University, Aachen, Germany Critical Care 2015, 19(Suppl 1):P491 (doi: 10.1186/cc14571) Introduction The noble gas xenon was recently amended to the list of prohibited substances by the World Anti-Doping Agency as Introduction The noble gas xenon was recently amended to the list of prohibited substances by the World Anti-Doping Agency as Results Polytraumatized patients show diff erences in TAC with reference to control subjects. ED polytraumatized patients show high S172 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P491). Erythropoietin levels after 30% xenon exposure. system (Pall Medical), a new device for sedation in ICU patients [2]. The system delivers volatile anesthetics in mechanically ventilated patients. An open reservoir scavenger and a dedicated gas fi lter avoid residual volatile anesthetic halogenate escaping into the room air. g p g Methods Ten mechanically ventilated patients electively admitted for ICU postoperative monitoring were sedated with sevofl urane delivered with the MIRUS™ system. Two patients were excluded from the analysis because inclusion criteria had been lost during the study period. Analgesia was obtained with morphine sulfate: bolus 0.1 mg/ kg i.v. at the end of surgery and 0.2 to 0.4 mg/kg/24 hours. The primary endpoint was to achieve predefi nite levels of sedation (Riker scale 4). Secondary endpoints were the assessment of hemodynamic stability (MAP and HR), blood lactates, any type of side eff ects, and sevofl urane consumption. Data were collected at the following times: admission to the ICU (T1), 1 hour after initiation of sedation (T2), and 1 hour after sedation withdrawal (T3). i References Figure 1 (abstract P491). Erythropoietin levels after 30% xenon exposure. 1. Reade MC, et al. N Engl J Med. 2014;370:444. 1. Reade MC, et al. N Engl J Med. 2014;370:444. 2. Bomberg H, et al. Anaesthesia. 2014;69:1241. 1. Reade MC, et al. N Engl J Med. 2014;370:444. 2. Bomberg H, et al. Anaesthesia. 2014;69:1241. 2. Bomberg H, et al. Anaesthesia. 2014;69:1241. it is supposed to trigger the production of HIF-1α and subsequently erythropoietin. Subsequently, researchers and clinicians started a scientifi c discussion about the potential clinical benefi t in support of humans exposed to high demand, such as critically ill patients. The objective of this study was therefore to evaluate the eff ect of xenon on serum levels of erythropoietin in healthy volunteers. P491 Results were expressed as median (IQR) or mean (SD), where appropriate. Figure 1 (abstract P491). Erythropoietin levels after 30% xenon exposure. pp p Results The local ethical board approved the protocol. Median duration of sedation was 4 (5.5 to 2) hours. Predefi nite levels of sedation were achieved in all patients with a median MAC of sevofl urane of 0.5 (0.5 to 0.3)% and with a median gas consumption of 9.9 (14.3 to 5.3) ml/hour. MAP and HR values at T1 were 86.5 (97 to 80.8) mmHg and 81.5 (103.8 to 65) bpm, respectively; at T2, 74.5 (89 to 69.5) mmHg and 74 (82 to 58.3) bpm, respectively; and at T3 92.5 (101 to 76.8) mmHg and 74 (88.5 to 66.3) bpm, respectively. Lactates were always normal. Mechanical ventilation was interrupted 5.4 (3.1) minutes after withdrawal of sevofl urane and respiratory parameters always were within normal values. Finally, no side eff ects were registered at any phase of the study. Conclusion This pilot study shows that MIRUS™ is eff ective and safe in delivering sevofl urane for sedation at a predefi nite target level in postsurgical patients, without side eff ects. Further data with a larger number of patients and for a longer duration of sedation are required to confi rm these positive, preliminary observations. References Bispectral index-guided anesthesia on time to tracheal extubation after onpump cardiac surgery Bispectral index-guided anesthesia on time to tracheal extubation after onpump cardiac surgery E Kaval, P Zeyneloglu, A Camkiran, A Sezgin, A Pirat, G Arslan Baskent University Faculty of Medicine, Ankara, Turkey Critical Care 2015, 19(Suppl 1):P493 (doi: 10.1186/cc14573) y y Methods This is a monocenter, randomized, blinded, crossover trial, which was registered at ClinicalTrials.gov (NCT01285271). Healthy study test persons were spontaneously breathing randomly 1 hour of xenon 30% (Xe/O2 30%/65%) or control gas (N2/O2 30%/65%). The primary outcome parameter was the erythropoietin level 24 hours after exposure. Secondary outcome parameters are xenon’s elimination kinetics measured in blood and exhalation samples. Introduction Electroencephalographic-based cerebral monitors such as the bispectral index (BIS) have been used for titration of both inhalational and intravenous anesthetics during general anesthesia. Titration of anesthetics using these monitors may facilitate an earlier recovery from general anesthesia and less consumption of anesthetics. The primary aim of this study was to investigate whether BIS-guided anesthesia would reduce time to tracheal extubation when compared with minimum alveolar concentration (MAC)-guided anesthesia in patients undergoing onpump cardiac surgery. Results The application of xenon increases erythropoietin levels with a maximum 24 hours after exposure (1.32 (0.99 to 1.66) P = 0.033) compared with the baseline values and compared with control values (0.87 (0.68 to 1.05) P = 0.012, Figure 1). Xenon was gas chromatographically traceable in blood and exhalation probes up to 24 hours after exposure. Methods Fifty patients undergoing elective coronary artery bypass grafting surgery from a single tertiary referral university hospital were randomized to BIS-guided anesthesia (Group BIS, n = 25) and MAC-guided anesthesia (Group MAC, n = 25). The inspired desfl urane concentration was titrated to maintain a BIS value of 40 to 60 in Group BIS and an age adjusted minimum alveolar concentration of 0.7 to 1 was used in Group MAC. Time to tracheal extubation across the two groups was the primary outcome measure. Secondary outcomes included intraoperative desfl urane consumption, postoperative complications, and lengths of stay in the ICU and hospital. p Conclusion One hour of a subanesthetic level of xenon increases erythropoietin levels in healthy study test persons and remains gas chromatographically traceable in blood and exhalation probes 24 hours after exposure. These fi ndings may stimulate larger studies to confi rm these results and to open new avenues for the therapeutic use of xenon in critically ill patients. P492 MIRUS™, a new system for sedation with halogenates in the ICU: a preliminary study of feasibility in postsurgical patients P Mancinelli, S Romagnoli, C Chelazzi, G Zagli, E Bonicolini, A Belardinelli, AR De Gaudio Azienda Ospedaliero-Universitaria Careggi, Florence, Italy Critical Care 2015, 19(Suppl 1):P492 (doi: 10.1186/cc14572) Results Demographic features, logistic EuroSCOREs, duration of cardiopulmonary bypass and surgery were similar in both groups. Mean desfl urane consumption was signifi cantly lower in Group BIS (11.9 ± 1.7 ml/hour) compared with Group MAC (13.4 ± 3.0 ml/hour) (P = 0.031). Time to tracheal extubation was not signifi cantly diff erent between the groups (13.3 ± 9.6 hours vs. 17.0 ± 22.4 hours) (P = 0.68). Incidences of postoperative complications were similar and lengths of stay in the ICU and hospital were 2.4 ± 0.7 days versus 3.2 ± 2.7 days Introduction Sedation is standard practice in the ICU [1]. The aim of this study was to investigate the effi ciency and safety of the MIRUS™ Introduction Sedation is standard practice in the ICU [1]. The aim of this study was to investigate the effi ciency and safety of the MIRUS™ S173 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods The study was approved by the appropriate institutional review board. After written informed consent, 63 ASA I to III patients undergoing elective hip or knee replacement surgery under general anaesthesia were included. Patients were randomly organised into three groups (20 to 22 each). Anaesthesia was induced with intravenous anaesthetics. After tracheal intubation MIRUS™ automatically adjusted the end-tidal VA concentration to 1.0 MAC. Patients were ventilated with the Puritan Bennett 840 ICU ventilator. After 1 hour of anaesthesia with 1.0 MAC the ventilator mode was switched from SIMV VC+ (totally controlled ventilation, passive patient, with a tidal volume of 8 ml/IBW) to proportional assist ventilation with 50% support (active patient). At the end of surgery the MIRUS™ system was stopped (MAC set to 0.0) and recovery times were measured. and 5.3 ± 1.2 days versus 6.5 ± 3.1 days in Group BIS and Group MAC respectively (P >0.05 for all). and 5.3 ± 1.2 days versus 6.5 ± 3.1 days in Group BIS and Group MAC respectively (P >0.05 for all). Use of sevofl urane in the medical ICU: 2-year experience, patient and safety profi le Use of sevofl urane in the medical ICU: 2-year experience, patient and safety profi le Use of sevofl urane in the medical ICU: 2-year experience, patient and safety profi le A Koroša1, A Markota2, F Svenšek2, A Sinkovič2 1University of Maribor, Slovenia; 2University Medical Centre Maribor, Slovenia Critical Care 2015, 19(Suppl 1):P494 (doi: 10.1186/cc14574) A Koroša1, A Markota2, F Svenšek2, A Sinkovič2 1University of Maribor, Slovenia; 2University Medical Centre Maribor, Slovenia Critical Care 2015, 19(Suppl 1):P494 (doi: 10.1186/cc14574) A Koroša1, A Markota2, F Svenšek2, A Sinkovič2 1University of Maribor, Slovenia; 2University Medical Centre Maribor, Slovenia Critical Care 2015, 19(Suppl 1):P494 (doi: 10.1186/cc14574) y Results Patients were comparable in age, height, weight and operation time. In 60/63 patients a MAC of 1.0 was reached by MIRUS™. Therefore, ISO 11.2 ± 3.3 ml/hour, SEVO 24.3 ± 4.8 ml/hour or DES 41.7 ± 7.9 ml/ hour (mean ± SD; t test: P <0.001) were used during passive ventilation. During patients’ active ventilation, mean VA consumptions of ISO 9.6 ± 5.1 ml/hour, SEVO 19.4 ± 9.6 ml/hour or DES 35.5 ± 23.0 ml/hour were detected (NS between passive and active patients). ISO was the cheapest VA (€2.70 ± 3.10/hour passive patient, €1.90 ± 2.30 active patient), followed by SEVO (€8.40 ± 3.70 passive patient and €6.8 ± 3.8 active patient) and DES (€9.6 ± 4.1 passive patient and €8.6 ± 6.5 active patient). Recovery times were signifi cantly shorter after SEVO and DES compared with ISO (minutes:seconds; ISO 9:31 ± 6:04, SEVO 6:19 ± 2:56, DES 5:27 ± 1:59). Introduction The aim of this study is to present our experience with sevofl urane in the ICU, outline which patients were sedated with sevofl urane and present the safety profi le. Sevofl urane has some potential advantages over intravenous sedation: rapid elimination and few interactions. The optimal role of sevofl urane in ICU is not known. Methods We performed a retrospective study on adult patients who were sedated with sevofl urane in the medical ICU. The decision to use sevofl urane was left to the attending physician. Institutional ethics committee approval was obtained. The target mean alveolar concentration in all patients was 0.5 to 1%. The AnaConDa® device (Sedana Medical, Uppsala, Sweden) was used along with the Anastasia® (Sedana Medical) gas monitor. Data were obtained from patients’ medical records. P495 Automated control of end-tidal volatile anaesthetic concentration using the MIRUS™ system: a comparison of isofl urane, sevofl urane and desfl urane in anaesthesia V Vinnikov, D Drees, J Herzog-Niescery, P Gude, H Vogelsang, B Cevik, T Weber, M Bellgardt St. Josef-Hospital, Ruhr-Universität, Bochum, Germany Critical Care 2015, 19(Suppl 1):P495 (doi: 10.1186/cc14575) P492 Conclusion Intraoperative use of BIS monitoring in patients undergoing onpump cardiac surgery reduced desfl urane requirement but BIS- guided anesthesia did not facilitate time to extubation and lengths of stay in the ICU and hospital. P494 Interaction between etomidate and beta tumoral necrosis factor on hemodynamic response after cardiac surgery Interaction between etomidate and beta tumoral necrosis factor on hemodynamic response after cardiac surgery JL Iribarren, JJ Jimenez, N Perez, M Brouard, R Perez, O Gonzalez, A Arbesu, R Martinez, ML Mora Hospital Universitario de Canarias, La Laguna, Spain Critical Care 2015, 19(Suppl 1):P496 (doi: 10.1186/cc14576) Interaction between etomidate and beta tumoral necrosis factor on hemodynamic response after cardiac surgery JL Iribarren, JJ Jimenez, N Perez, M Brouard, R Perez, O Gonzalez, A Arbesu, R Martinez, ML Mora Hospital Universitario de Canarias, La Laguna, Spain Critical Care 2015, 19(Suppl 1):P496 (doi: 10.1186/cc14576) Introduction The use of etomidate is a risk factor for relative adrenal insuffi ciency in patients undergoing cardiopulmonary bypass (CPB) [1]. The objective was to determine the possible interaction between Conclusion We identifi ed sevofl urane as an appropriate sedation agent in a diverse group of patients. Sevofl urane advantages over intravenous sedation could be more pronounced in some patient groups (for example, successful resuscitation after cardiac arrest). The safety profi le of sevofl urane sedation was comparable with intravenous sedation [1]. Reference Figure 1 (abstract P496). 1. Mesnil et al. Intensive Care Med. 2011;37:933-41. 1. Mesnil et al. Intensive Care Med. 2011;37:933-41. Reference 1. Bomberg H, et al. Anaesthesia. 2014;69:1241-50. 1. Bomberg H, et al. Anaesthesia. 2014;69:1241-50. P496 Use of sevofl urane in the medical ICU: 2-year experience, patient and safety profi le Introduction The aim of this study is to present our experience with sevofl urane in the ICU, outline which patients were sedated with sevofl urane and present the safety profi le. Sevofl urane has some potential advantages over intravenous sedation: rapid elimination and few interactions. The optimal role of sevofl urane in ICU is not known. l Methods We performed a retrospective study on adult patients who were sedated with sevofl urane in the medical ICU. The decision to use sevofl urane was left to the attending physician. Institutional ethics committee approval was obtained. The target mean alveolar concentration in all patients was 0.5 to 1%. The AnaConDa® device (Sedana Medical, Uppsala, Sweden) was used along with the Anastasia® (Sedana Medical) gas monitor. Data were obtained from patients’ medical records. Conclusion This study showed that MIRUS™ could automatically control end-tidal VA concentrations in ventilated and spontaneously breathing patients. Using ISO reduces costs. Further studies must be taken to analyse feasibility, costs and recovery times of ISO, SEVO and DES used for sedation in an ICU setting. f Results We included 61 adult patients who were admitted from April 2012 to November 2014. Mean age was 62.6 ± 14.9 years, 39 (63.9%) were male. ICU mortality was 41%, hospital mortality was 43%. Mean duration of sevofl urane use was 3.56 ± 2.31 days. Admission diagnoses were: successful resuscitation after cardiac arrest (44.2%), sepsis (37.7%), cardiogenic shock (4.9%), pancreatitis (3.3%) and liver failure, acute exacerbation of COPD, asthma, tetanus and intracerebral hemorrhage (1.6% each). During treatment with sevofl urane, no patients developed malignant hyperthermia, new hyperkalemia or QT prolongation. In three (4.9%) patients, worsening liver function tests prompted sevofl urane discontinuation. Ischemic hepatitis was considered an alternative in all three patients. Seven (11.4%) patients developed renal failure while receiving sevofl urane. Sevofl urane was continued in all patients and renal failure was attributed to alternative diagnoses. No self-extubations were recorded. In seven (11.4%) patients, sevofl urane was discontinued because of worsening ventilation. In six (9.8%) patients, unexpected awakening occurred. Eight patients (13.1%) had symptoms of delirium after sevofl urane inhalations were concluded.il Reference Automated control of end-tidal volatile anaesthetic concentration using the MIRUS™ system: a comparison of isofl urane, sevofl urane and desfl urane in anaesthesia l V Vinnikov, D Drees, J Herzog-Niescery, P Gude, H Vogelsang, B Cevik, T Weber, M Bellgardt St. Josef-Hospital, Ruhr-Universität, Bochum, Germany Critical Care 2015, 19(Suppl 1):P495 (doi: 10.1186/cc14575) Introduction The new MIRUS™ system as well as the established AnaConDa® system uses a refl ector to conserve volatile anaesthetics (VA) [1]. Both systems act with commercially available ICU ventilators. In contrast to AnaConDa®, MIRUS™ includes an automated control of end-tidal VA concentrations. In this study we compared feasibility, costs and recovery times after anaesthesia with isofl urane (ISO), sevofl urane (SEVO) or desfl urane (DES) in ventilated and spontaneously breathing patients. S174 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 of more signifi cant impact than medication errors. We assessed the incidence and characteristics of operation-related MEs to improve patient safety in such patients. etomidate and beta tumoral necrosis factor (TNFβ) polymorphism on hemodynamics after CPB. Methods A prospective cohort study on CPB patients who received etomidate or not during anesthetic induction during 2008 to 2011. Demographic and postoperative variables were collected. We tested the Hardy–Weinberg equilibrium in order to avoid selection bias. V18 SPSS was used. Methods The Japan Adverse Event (JET) study was a prospective cohort study which had evaluated AEs and MEs at two tertiary care hospitals. We included all adult patients aged ≥15 years old who had operations over a 2-month period. The primary outcome of this study was the operation-related MEs, defi ned as any deviation from appropriate process of an operation or perioperative care. Trained nurses placed at each participating hospital reviewed all charts daily on weekdays, along with laboratories, incident reports, and prescription queries to collect any potential event. They also collected the characteristics of the patients in the cohort. Some operation-related MEs are associated with operation-related AEs, which are operation-related preventable AEs. After those suspected events were collected, physician reviewers independently evaluated them and classifi ed them as operation- related MEs, AEs, or rule violations. Physician reviewers assessed and rated operation-related AEs according to the symptom and the severity of injury. Results We studied 433 patients undergoing CPB, 285 (65.8%) men and 148 (34.2%) women, 66 ± 6 years, EuroSCORE I 5.3 ± 4%. TNFβ was in Hardy–Weinberg equilibrium (χ2: 0.6; P = 0.42). Visualising patients’ dynamics in the ICU and predicting mortality in real-time using big data MK Komorowski, AF Faisal MK Komorowski, AF Faisal Imperial College London, UK Critical Care 2015, 19(Suppl 1):P499 (doi: 10.1186/cc14579) , Imperial College London, UK Critical Care 2015, 19(Suppl 1):P499 (doi: 10.1186/cc14579) Introduction As informatisation of hospitals continues to spread, increasing amounts of healthcare related data are being collected, and the ICU is no exception. Large datasets are being made available to the scientifi c community, and off er the potential to answer clinical questions and to develop the next generation of clinical tools. A demonstration of such a tool is presented here, built using data from the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) open database. Methods All of the adult patients who died during their stay in the ICU were included, as well as a matched cohort of patients who survived for more than 28 days after discharge. Data regarding their vital signs, laboratory tests and demographics were collected. Using Matlab, a graphical method involving principal component analysis was developed. The expected mortality was computed using the k-nearest neighbours’ method and compared with several classifi cation algorithms (logistic regression, random forest, support vector machine, Gaussian mixture models). g Conclusion The fi ndings are comparable with reports of sedation surveys conducted in other countries. There is an evidence–practice gap that needs to be addressed. Sedation practices in South African ICUs: results of a national survey F Paruk, S Chetty University of Witwatersrand, Johannesburg, South Africa Critical Care 2015, 19(Suppl 1):P497 (doi: 10.1186/cc14577) Introduction There has been a paradigm shift in the approach to sedation of critically ill patients. The purpose of this study was to evaluate current sedation-related practices in South African ICUs. Conclusion Ninety-three percent of operation-related MEs resulted in operation-related AEs and 21% of them resulted in life-threatening events. Prevention of operation-related MEs should improve the mortality of surgical patients. p Methods A validated questionnaire was distributed electronically to physician members of various medical databases in South Africa as South Africa does not have a formal registry of critical care practitioners. Results One hundred and twenty-six of 174 respondents indicated that they practice in the ICU setting. Sixty-six per cent were specialists and mainly anaesthesiologists (42%), whilst 32% were critical care subspecialists. The public and private-sector representation was 64% and 46% respectively. A written sedation guideline is implemented by 42%. Forty-three per cent utilise a sedation scale, with the Ramsey Sedation Scale being the commonest in use. However, 38% of sedation scale users do so infrequently. Daily interruption of sedation is practiced by 75%. Light sedation is targeted by 42% and 14% do not follow any sedation targets. Upon admission and on subsequent days, sedation targets are achieved most of the time by 48% and 69% of the respondents respectively. Whilst a wide variety of sedatives are prescribed, midazolam constitutes the most commonly prescribed agent. Dexmedetomidine is the agent of choice for postcardiac surgery patients with cardiovascular comorbidities, delirious patients, during weaning and for non-invasive ventilation. Propofol is the agent of choice amongst neurological patients. The respondents indicated that there is a need for local sedation guidelines.i Automated control of end-tidal volatile anaesthetic concentration using the MIRUS™ system: a comparison of isofl urane, sevofl urane and desfl urane in anaesthesia A total of 254 (58.7%) patients received etomidate, 152 out of them required vasoactive drugs. Homozygous G was defi ned as unfavorable TNFβ versus the A allele [2]. Using the general linear model after adjusting for sex and amines dose at 4 hours, an independent association was observed between the systemic vascular resistance index (SVRI) at 4 hours and the use of etomidate (F: 18; P <0.001): 1,849 (95% CI: 1,673 to 2,024) versus 2,493 (95% CI: 2,258 to 2,729) dinas.seg/cm5.m2, the presence of homozygous G (F: 6.5; P = 0.01), and also showed a signifi cant etomidate–homozygous G interaction (F: 22.8: P <0.001): 1,687 (95% CI: 1,350 to 2,023) versus 3,041 (95% CI: 2,589 to 3,492) dinas seg/cm5. m2 (Figure 1). y Results This study included 389 patients with 6,624 patient-days. The median age of patients was 69 years and 224 (58%) were male. Among these 389 patients, 31 patients had 46 operation-related MEs during their hospital stay and the incidence of operation-related MEs was 12 per 100 patients. Operation-related AEs occurred in 29 patients with 43 events. The most frequent symptoms for operation-related MEs were skin (26%), bleeding (21%), and central nervous system (14%). Among 46 operation-related MEs, 43 (93%) were not intercepted, and they resulted in operation-related AEs that were considered as preventable operation-related AEs. Nine of preventable operation-related AEs (21%) were fatal or life-threatening: fi ve were nerve injury during operation and stroke after neurosurgical operation, and one biliary peritonitis after gastrectomy and cholecystectomy, and tension pneumothorax after lung lobectomy, and two unexpected massive bleeding due to vessels injury. Conclusion Etomidate use is associated with lower postoperative SVRI which is increased in the presence of G homozygosity for TNFβ polymorphism. P498 Epidemiology of operation-related medical errors in inpatients in Japan: the JET study y References 1. Iribarren JL, et al. J Cardiothorac Surg. 2010;5:26. 1. Iribarren JL, et al. J Cardiothorac Surg. 2010;5:26. 2. Iribarren et al. Interact Cardiovasc Thorac Surg. 2008;7:1071-4. 2. Iribarren et al. Interact Cardiovasc Thorac Surg. 2008;7:1071-4. Organizational factors and patient outcomes in Brazilian ICUs: the ORCHESTRA study y M Soares1, JM Kahn2, FA Bozza1, T Lisboa3, LP Azevedo4, W Viana5, L Brauer6, PE Brasil1, DC Angus2, JI Salluh1 1DOr Institute for Research and Education – IDOR, Rio De Janeiro, Brazil; 2University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 3Sta. Casa de Porto Alegre, Brazil; 4Hospital Sírio Libanês, São Paulo, Brazil; 5Hospital Copa DOr, Rio de Janeiro, Brazil; 6Hospital Sao Luiz Itaim, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P500 (doi: 10.1186/cc14580) Figure 1 (abstract P501). HEWS prior to critical event. Methods We conducted a prospectively identifi ed, retrospectively gathered cohort study at two hospitals of consecutively admitted medical and surgical patients over a 6-month period. One hospital had a rapid response team (RRT) and used HEWS with a trigger of 5 while the other was undergoing implementation of the HEWS without a RRT. HEWS was calculated for each patient on the fi rst day of admission and for the 3 days prior to inpatient arrest or death. A study investigator reviewed all events for accuracy. Our outcome of interest was a composite of inpatient cardiac arrest and hospital mortality. Introduction The aim was to investigate the impact of organizational factors on patient outcomes in a large sample of Brazilian ICUs. Introduction The aim was to investigate the impact of organizational factors on patient outcomes in a large sample of Brazilian ICUs. Methods A retrospective cohort study of 59,483 patients admitted to 78 ICUs in 51 hospitals during 2013. We retrieved demographic, clinical and outcome data from an electronic ICU quality registry (Epimed Monitor System). We surveyed ICUs using a standardized questionnaire regarding hospital and ICU structure, organization, staffi ng patterns, process of care, and family care policies. We used multilevel logistic regression analysis to identify characteristics associated with hospital mortality. y Results There were 7,138 patients admitted over 6 months. We found 0.5% of patients suff ered an inpatient arrest and 3.6% of patients died. Moreover, 66% of patients who died or arrested were admitted to the hospital without a RRT. Patients who arrested or died had more comorbidities defi ned by the Charlson Comorbidity Index (CCI) of 6.0 and 8.2 respectively compared with the general population, which had a CCI of 5.2. Epidemiology of operation-related medical errors in inpatients in Japan: the JET study Results A total of 6,084 patients were included in the analyses, adding up to more than 12 million data points. Using this multidimensional dataset, a 3D representation of the clusters of survivors and nonsurvivors was built, showing how their trajectories diverge through time. Patterns in the evolution of individuals or subgroups of patients can be identifi ed using this approach. For example, the evolution of a new patient can be visualised, progressing through the clusters as his severity changes. His expected mortality can be predicted at any point in time, with an AUC ROC constantly above 0.85. Epidemiology of operation-related medical errors in inpatients in Japan: the JET study Y Ohta1, M Sakuma1, D Bates2, T Morimoto1 1Hyogo College of Medicine, Hyogo, Japan; 2Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P498 (doi: 10.1186/cc14578) Epidemiology of operation-related medical errors in inpatients in Japan: the JET study Y Ohta1, M Sakuma1, D Bates2, T Morimoto1 1Hyogo College of Medicine, Hyogo, Japan; 2Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P498 (doi: 10.1186/cc14578) p y Y Ohta1, M Sakuma1, D Bates2, T Morimoto1 1Hyogo College of Medicine, Hyogo, Japan; 2Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P498 (doi: 10.1186/cc14578) y Y Ohta1, M Sakuma1, D Bates2, T Morimoto1 1Hyogo College of Medicine, Hyogo, Japan; 2Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA Critical Care 2015, 19(Suppl 1):P498 (doi: 10.1186/cc14578) Introduction Operation therapy is more invasive than medication therapy and then operation-related medical errors (MEs) might be Introduction Operation therapy is more invasive than medication therapy and then operation-related medical errors (MEs) might be S175 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P501). HEWS prior to critical event. Conclusion Machine learning tools off er an appealing mathematical framework for modelling complex medical situations. This proof of concept demonstrates that the application of computational sciences to high-quality data such as the MIMIC-II database has the potential to lead to the development of meaningful tools which will ultimately be capable of assisting physicians in making the right decision at the right time for an individual patient. P500 P500 Organizational factors and patient outcomes in Brazilian ICUs: the ORCHESTRA study M Soares1, JM Kahn2, FA Bozza1, T Lisboa3, LP Azevedo4, W Viana5, L Brauer6, PE Brasil1, DC Angus2, JI Salluh1 1DOr Institute for Research and Education – IDOR, Rio De Janeiro, Brazil; 2University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 3Sta. Casa de Porto Alegre, Brazil; 4Hospital Sírio Libanês, São Paulo, Brazil; 5Hospital Copa DOr, Rio de Janeiro, Brazil; 6Hospital Sao Luiz Itaim, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P500 (doi: 10.1186/cc14580) Epidemiology of operation-related medical errors in inpatients in Japan: the JET study Only tight cooperation between clinicians and data scientists can help close the gap that currently separates these two worlds, for the ultimate benefi t of patients. Organizational factors and patient outcomes in Brazilian ICUs: the ORCHESTRA study The median and mean HEWS at time of admission was 1 and 1.7 for the general population, 2 and 2.4 for patients who suff ered an inpatient arrest and fi nally 3 and 3.8 for those who died. There was a rise in median HEWS from 2 to 5 in the 24 hours prior to in patient arrest or death. See Figure 1. y Results ICUs were mostly medical or medical–surgical (62.79%) and located in private hospitals (67.86%). Approximately half (40.51%) had critical care training programs. Median physician and nurse staff – bed ratios were 0.15 (IQR, 0.12 to 0.19) and 0.71 (0.61 to 0.84); board- certifi ed intensivists were present 24/7 in 16 (21%) of ICUs. Routine clinical rounds occurred in 67 (86%) and daily clinical checklists were used in 36 (46%) ICUs. Most frequently implemented protocols focused on sepsis management and VAP and CLABSI prevention. Median number of patients per center was 898 (IQR 585 to 1,715) and there were 67% medical admissions; 18% patients received mechanical ventilation (MV). Median SAPS 3 score was 41 (33 to 52) points. ICU and hospital mortality rates were 9.6% and 14.3%, respectively. Adjusting for relevant patients’ characteristics (SAPS 3 score, diagnostic admission category, chronic health status, comorbidities, MV use), case-volume and type of ICU, the ICU size (OR = 1.50 (95% CI, 1.45 to 1.95), for 11 to 20 beds; OR = 2.02 (1.40 to 2.92), for >20 beds) and ≥2 clinical protocols (OR = 0.65 (0.42 to 0.99)) were the organizational characteristics associated with mortality. g Conclusion We found that a 2.5-fold increase in HEWS occurred 24 hours prior to critical events. Similar to previous studies, a RRT in conjunction with HEWS is the best system to reduce unanticipated adverse events. An absolute HEWS of 5 and/or a rapidly increasing HEWS should trigger rapid assessment and treatment to reduce preventable inpatient deaths and arrests. Reference 1. McNeill, Bryden. Resuscitation. 2013;84:1652-67. 1. McNeill, Bryden. Resuscitation. 2013;84:1652-67. Conclusion In a large sample of Brazilian ICUs, the implementation of clinical protocols was associated with better outcomes. Conversely, mortality was higher in larger ICUs. Ethnicity and trial recruitment h y g g Acknowledgements Funded by IDOR, CNPq and FAPERJ. Endorsed by BRICNet. HL Cronshaw, SW Scott, S Bowrey, JP Thompsoni HL Cronshaw, SW Scott, S Bowrey, JP Thompson Leicester Royal Infi rmary, Leicester, UK , , y, Leicester Royal Infi rmary, Leicester, UK yi y Critical Care 2015, 19(Suppl 1):P502 (doi: 10.1186/cc14582 Introduction Surrogate consent and time-sensitive recruitment in critical care research is challenging, yet low enrolment numbers or omitting ethnic groups skew results and conclusions. Patients from diff erent ethnic groups may respond diff erently to therapeutics [1]. There are few data about the eff ect of ethnicity on recruitment into ICU trials. Our ICU recruits to national trials and serves an increasingly non- White British population (24% of population). We undertook this study to determine whether ethnicity aff ects ICU consent rates. Validation of an electronic early warning score using decision tree analysis: proposal M Xu, B Tam, L Thabane, AE Fox-Robichaud McMaster University, Hamilton, ON, Canada Critical Care 2015, 19(Suppl 1):P503 (doi: 10.1186/cc14583) M Xu, B Tam, L Thabane, AE Fox-Robichaud McMaster University, Hamilton, ON, Canada Critical Care 2015, 19(Suppl 1):P503 (doi: 10.1186/cc14583) Introduction Decision tree analysis uses an algorithm to classify data items by recursively posing a series of questions about items within a dataset. Each question leads to another node and potentially more questions until a predefi ned end condition is reached or no more questions can be asked (Figure 1). We hypothesize that scores generated using the decision tree method will improve upon our existing Hamilton Early Warning Score (HEWS) for a composite endpoint of cardiac arrest, unplanned ICU admission or death. Introduction Timely availability of a kidney specialist poses a formidable challenge in ICUs located in tier II and tier III cities of the developing world. Renal replacement therapy (RRT) is often required in the ICU for acute renal failure patients but availability of a nephrologist/ specialist is scarce, leading to unnecessary and risky transfer to higher centers in metropolitans or even worse to death. We explored whether a remotely monitored ICU – an electronic ICU (eICU) – would help mitigate this demand–supply gap. Methods A database of 156,642 electronically captured vital signs from 6,757 consecutively admitted patients to eight medical and surgical wards will be used to train and test the decision tree early warning score. One-third of the data will be withheld from the algorithm for use as a testing set. The algorithm will look for signifi cant changes in vitals 72 hours prior to an outcome and develop the score based upon the resulting relative risk of the composite endpoint happening given a certain vital sign. The scores and predictions generated by the decision tree analysis will then be compared with that of the inception HEWS cohort. y Methods This retrospective study was conducted at four Critinext affi liates where the eICU was being used to provide 24 × 7 support on 89 ICU beds from a remote command center with intensivist and other requisite staff . The eICU had complete access to the patient’s real-time vitals, hemodynamic parameters, imaging, laboratory values, audiovisuals and appropriately engineered smart alerts. The eICU model was further extended in initiating and getting RRT done in patients whenever deemed necessary in times of unavailability of a specialist at the same site. P501 Hamilton Early Warning Score: predict, prevent and protect B Tam, M Xu, AE Fox-Robichaud McMaster University, Hamilton, ON, Canada Critical Care 2015, 19(Suppl 1):P501 (doi: 10.1186/cc14581) Introduction This study determined the pattern of decline prior to an inpatient arrest. We implemented the Hamilton Early Warning Score (HEWS) within our electronic vital signs documentation to track and trigger care for deteriorating patients. Other EWS have been described in the literature with varying success [1]. In contrast to previous observational studies, we chose to implement a score modifi ed from published EWS using the consensus opinion of a steering committee and evaluate the score in real time. f Methods We performed a retrospective review of screening logs from three national UK trials (PROMISE, BALTI-P, GAiNS) and one local trial (Nociceptin in Sepsis). We analysed consent rates of eligible patients by ethnicity, age, sex, interventional or observational trial, and ethnicity of the researcher seeking consent. We performed chi-squared analysis, and entered signifi cant values into a logistic regression model using SPSS v22. S176 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results The planned analysis for determining the discriminatory and predictive ability of the decision tree HEWS will be conducted with area under the receiver operating characteristic curves. We will test whether the current HEWS has the appropriate sensitivity and specifi city when compared with that of the decision tree score. The AUROC will be calculated for both the training set of data as well as the separate population of additional medical and surgical patients. The two scores will also be plotted along an effi ciency curve, comparing the percentage of vitals that precede a critical event with the percentage of vitals that produce a EWS value greater than or equal to a given EWS value. Results We identifi ed 332 eligible patients across all trials, of whom 37 (11%) were not White British (nWB). Analysis demonstrated consent/assent refusal being signifi cantly associated with: nWB (14, 38%, P <0.001), interventional trial (21, 25%, P = 0.003) and diff erent researcher–patient ethnicities (P <0.001). P504 P503 Validation of an electronic early warning score using decision tree analysis: proposal M Xu, B Tam, L Thabane, AE Fox-Robichaud McMaster University, Hamilton, ON, Canada Critical Care 2015, 19(Suppl 1):P503 (doi: 10.1186/cc14583) P504 Can an electronic ICU support timely renal replacement therapy in resource-limited areas of the developing world S Gupta1, A Kaushal1, S Dewan2, A Varma1 1Fortis Escorts Heart Institute, New Delhi, India; 2Fortis Memorial Research Institute, Gurgaon, India Critical Care 2015, 19(Suppl 1):P504 (doi: 10.1186/cc14584) . Lilly CM, et al. Chest. 2014;145:500-7. 1. Bjornsson TD, et al. J Clin Pharmacol. 2003;43:943-67. P501 Logistic regression analysis confi rmed these as independent factors (nWB OR = 4.5, 95% CI = 2.1 to 9.8, P <0.001; interventional trial OR = 2.7, 95% CI = 1.4 to 5.2, P = 0.003; data points missing for researcher–patient ethnicity so variable excluded).f Conclusion This initial study suggests that ethnicity may aff ect assent/ consent to ICU research, with patients from diff erent ethnicities being four times less likely to be recruited. Whilst data are incomplete for researcher–patient ethnicity, our data suggest that this may be an important factor and may infl uence future consent processes. We believe that the role of ethnicity warrants further investigation, not only in clinical trials but also in areas such as organ donation. Reference Conclusion Decision tree analysis methodology with real-life vital signs can produce an EWS superior to previous observational studies. Using a decision tree, especially one that composites all vitals, may show that certain vitals are more predictive of critical events than others. Data will be used to further improve our current HEWS score. 1. Bjornsson TD, et al. J Clin Pharmacol. 2003;43:943-67. Validation of an electronic early warning score using decision tree analysis: proposal Patient baseline demographics, including risk factors, severity score, all-cause mortality at 30 days, transfers to higher center for RRT and its prevention were recorded. Descriptive analysis was performed. Between-group comparison was performed by applying the chi-squared statistic, signifi cance was assumed at a value of P <0.05. Out of a total of 5,146 admissions, 752 inpatient fi les with acute kidney injury/acute renal failure were reviewed, January to July 2013 (n = 373) and July 2013 to January 2014 (n = 379) pre and post eICU implementation respectively.i Figure 1 (abstract P503). Sample heart rate decision tree. p p y Results While baseline demographics and the patient profi le in the two groups did not show statistically signifi cant diff erence, mean APACHE II score was 14.25 ± 1.94 and 14.65 ± 1.76 pre and post eICU respectively; there was a statistically signifi cant diff erence in all-cause mortality at 30 days which decreased from 31 (8.3%) to 16 (4.2%) pre and post eICU respectively, a reduction of >49% (P = 0.030) and transfer out for RRT came down by >77%, from 15 (4%) to two (0.5%) post eICU implementation (P <0.002). Conclusion Over the years there is now broad consensus over the benefi ts of eICU intervention in deprived areas [1]. There is now a need for a paradigm shift to elevate specialized care to improve outcomes. Our small study has clearly indicated the benefi ts in outcome and economics even while providing intervention in such remote areas. An eICU as a bridge to the demand–supply gap needs to be explored and utilized further to its full potential in the emerging world. Reference Reference Figure 1 (abstract P503). Sample heart rate decision tree. Figure 1 (abstract P503). Sample heart rate decision tree. 1. Lilly CM, et al. Chest. 2014;145:500-7. S177 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Table 1 (abstract P506). Mean change in systolic and diastolic BP and HR in relation to ICU work experience Table 1 (abstract P506). Mean change in systolic and diastolic BP and HR in relation to ICU work experience P505 Outcomes and resource use in Brazilian ICUs: results from the ORCHESTRA study M Soares1, DC Angus2, JI Salluh1, AB Cavalcanti3, F Colombari4, R Costa5, E Silva6, A Japiassu7, JM Kahn2, FA Bozza1 1DOr Institute for Research and Education – IDOR, Rio De Janeiro, Brazil; 2University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 3Hospital do Coracao, São Paulo, Brazil; 4Hospital Alemao Oswaldo Cruz, São Paulo, Brazil; 5Hospital Quinta DOr, Rio de Janeiro, Brazil; 6Hospital Israelita Albert Einstein, São Paulo, Brazil; 7Rede Amil de Hospitais, Rio de Janeiro, Brazil Critical Care 2015, 19(Suppl 1):P505 (doi: 10.1186/cc14585) Outcomes and resource use in Brazilian ICUs: results from the ORCHESTRA study Group 1 Group 2 P value SBP (mmHg) 3.22 –0.40 0.053 DBP (mmHg) 2.08 –0.27 0.061 HR (bpm) 4.46 1.16 0.048 M Soares1, DC Angus2, JI Salluh1, AB Cavalcanti3, F Colombari4, R Costa5, E Silva6, A Japiassu7, JM Kahn2, FA Bozza1 1DOr Institute for Research and Education – IDOR, Rio De Janeiro, Brazil; 2University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 3Hospital do Coracao, São Paulo, Brazil; 4Hospital Alemao Oswaldo Cruz, São Paulo, Brazil; 5Hospital Quinta DOr, Rio de Janeiro, Brazil; 6Hospital Israelita Albert Einstein, São Paulo, Brazil; 7Rede Amil de Hospitais, Rio de Janeiro, Brazil Critical Care 2015, 19(Suppl 1):P505 (doi: 10.1186/cc14585) Results The mean duration of working in an ICU was 7.3 ± 5.32 years (from 2 to 18 years). The nurses were grouped according to experience – Group A: 17 nurses with <10 years of experience (mean: 4.4 years), Group B: six nurses with >10 years (mean: 15.6 years). There were 640 BP–HR measurements. The mean systolic BP, diastolic BP and HR did not diff er between the two groups (systolic BP: 111.2 ± 10.9 vs. 113.7 ± 14.1 mmHg, P = 0.654; diastolic BP: 72.8 ± 8.2 vs. 71.9 ± 8.1 mmHg, P = 0.835; HR: 81.4 ± 7.2 vs. 78.1 ± 8.4 bpm, P = 0.365). Nevertheless, the mean change in BP and HR during the shift did diff er between the two groups, with the more experienced nurses showing a trivial reduction in systolic and diastolic BP and minor increase in HR whereas the less experienced ones showed slight increase in both BP and HR measurements (Table 1), reaching almost statistical signifi cance. For the less experienced nurses in Group 1, it was noted that the mean changes were bigger in night shifts although the limited number of measurements did not allow robust statistical analysis. Introduction The aim was to evaluate outcomes and resource use and to investigate the association between organizational factors and effi cient resource use in a large sample of Brazilian ICUs. Methods A retrospective cohort study in 59,483 patients (medical admissions: 39,734 (67%)) admitted to 78 ICUs (private hospitals, n = 67 (86%); medical or medical–surgical, n = 62 (79%)) during 2013. We retrieved demographic, clinical and outcome data from an electronic ICU quality registry (Epimed Monitor System). P506 Blood pressure and heart rate changes during shifts in ICU nurses in relation to their work experience A Ioannidis, E Terzenidou, D Gklava, I Politi, E Georgiadou, A Georgousi, V Aidonoudis, A Kalea, P Melitzana, N Gritsi-Gerogianni Thessaloniki General Hospital ‘Ippokratio’, Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P506 (doi: 10.1186/cc14586) y y Methods We included all adult patients (≥18 years) with a fi rst-time ambulance transport to the ED at Odense University Hospital in the period 1 April 2012 to 30 September 2013. Ambulance personnel recorded vital signs and other clinical fi ndings on a structured form on paper during the ambulance transport. Each contact was linked to information from population-based healthcare registers in order to identify comorbid conditions and information on mortality. Demographic factors and fi rst registered vital sign were analysed by univariate logistic regression analysis, with 7-day mortality as outcome. Results In total, 18,572 fi rst-time ambulance contacts were identifi ed in the period of inclusion. Overall 7-day mortality was 4.3% (95% CI = 4.0 to 4.6). Univariate analysis showed increasing age, Charlson Comorbidity Index ≥2, vital parameters outside the normal reference range and summoned physician-assisted mobile emergency care units to be associated with 7-day mortality. Further analyses are currently being carried out. Prehospital transported patients: a resource for accessing prognostic risk factors p g C Bech1, M Brabrand2, A Lassen1 1Od U i it H it l Od C Bech1, M Brabrand2, A Lassen1 1Odense University Hospital, Odense, Denmark; 2Sydvestjysk Sygehus Esbjerg, Denmark Critical Care 2015, 19(Suppl 1):P507 (doi: 10.1186/cc14587) Conclusion We observed a great variability in outcome and resources in a large sample of Brazilian ICUs. Implementation of clinical protocols and nursing staffi ng patterns can be targets to improve the effi ciency in resource use in emerging countries such as Brazil. Critical Care 2015, 19(Suppl 1):P507 (doi: 10.1186/cc14587) Introduction The survival of patients transported by ambulance to the emergency department (ED) depends on clinical conditions, patient-related factors and organisational prehospital set up. Data and information concerning patients in the prehospital system could form a valuable resource for assessing potential risk factors associated with adverse outcomes and mortality. Our aim was to describe ambulance transports to the ED and identify prognostic factors accessible in the prehospital phase and associated with 7-day mortality.i Acknowledgements Funded by IDOR, CNPq and FAPERJ. Endorsed by BRICNet. Reference 1. Rothen et al. Intensive Care Med. 2007;33:1329-36. 1. Rothen et al. Intensive Care Med. 2007;33:1329-36. Outcomes and resource use in Brazilian ICUs: results from the ORCHESTRA study We surveyed ICUs using a standardized questionnaire regarding hospital and ICU structure, organization, staffi ng patterns, process of care and family care policies. Effi cient resource use was assessed by estimating standardized mortality rates (SMR) and standardized resource use (SRU) adjusted for the severity of illness according to the SAPS 3 score, as proposed by Rothen and colleagues [1]. y Conclusion The less experienced ICU nurses, with <10 years of ICU work experience, tended to increase their BP and HR levels during the shift, a fi nding probably heightened during night shifts. Further research, including not only cardiovascular parameters, is warranted to uncover the eff ects of shift-work pattern in ICU nurses, taking into account this specifi cally stressful work environment. Results The median admissions per center was 898 (IQR 585 to 1,715) and SAPS 3 score was 41 (33 to 52) points. Median ICU length of stay was 2 (1 to 5) days, and ICU and hospital mortality rates were 9.6% and 14.3%, respectively. Estimated SMR and SRU were 0.97 (0.72 to 1.15) and 1.06 (0.89 to 1.37), respectively. There were 28 (36%) most effi cient (ICUs with both SMR and SRU <median), 28 (36%) least effi cient (ICUs with both SMR and SRU >median), 11 (14%) overachieving (ICUs with low SMR and high SRU) and 11 (14%) underachieving (ICUs with high SMR and low SRU) ICUs. Most effi cient ICUs were usually located in private and accredited hospitals, with step-down units and training programs in critical care. In univariate analyses comparing most and least effi cient ICUs, ≥2 clinical protocols (OR = 7.22 (95% CI, 1.41 to 36.97)) and graduated nurse/bed ratio >0.25 (OR = 4.40 (1.04 to 18.60)) were associated with effi cient resource use. Daily checklists also tended to be associated with effi cient resource use (OR = 2.89 (0.95 to 8.72), P = 0.057). P508 Contribution of medical senior house offi cers to a medical referral in the emergency department i g Conclusion In 2011 the Royal College of Physicians emphasized the impact that the quality of the care provided within the fi rst 48 to 72 hours had on clinical outcomes. An evaluation of consultant input into acute admissions management revealed that hospitals in which two or more ward rounds of all acute medical unit patients were performed daily had a lower adjusted case fatality rate for patients with hospital stays over 7 days. Despite twice-daily consultant ward rounds of all new acute admissions and the addition of a third 4:00 pm round from Monday to Friday, only 62% of patients were seen by a consultant within 12 hours. With 67% of patients being admitted between the hours of 12:00 am and 12:00 pm, it is possible that the substitution of an evening round for one of the afternoon rounds would help increase the number of patients seen within the target time frame. This would require a change in the working pattern of the acute medicine consultants. f Introduction In Irish hospitals, the medical senior house offi cer (SHO) is the most junior fully qualifi ed doctor on the medical on-call team. After a patient has been seen by an emergency department doctor of any level, they are almost always referred directly to the medical SHO. This process has been shown to delay a patient’s ward admission by 3 hours 30 minutes [1]. We attempted to quantify the additional benefi t for the patient of being seen by the on-call medical SHO, in terms of patients discharged, new diagnoses reached, and new treatments initiated. g g Methods The emergency department notes and clinical charts of 182 patients were assessed. This constituted a random sample of patients referred by emergency department doctors to the medical team on call over a 2-month period (November to December 2011). Results Discharged: 3/182 (1.6%) of patients referred to the medical team were discharged directly by the medical SHO. Diagnosed: medical SHOs suggested a diagnosis which was diff erent from, or additional to, the ED doctor, in 52/182 cases (28.6%). However, the medical consultant only agreed with this diagnosis in 25 cases (13.7%). This means an incorrect new diagnosis was reached more often than not (14.9%). Treatment: the majority of cases (116/182 (63.7%)) saw no new treatment initiated by the medical SHO. P508 Contribution of medical senior house offi cers to a medical referral in the emergency department Of the rest, only 31 (17%) had a new treatment initiated by the medical SHO which was continued on by the medical consultant through the admission. P510 Interhospital critical care transfer delays result from organisational not geographical factors: secondary analysis of deteriorating ward patients in 49 UK hospitals DJ Wong1, SK Harris2 1King’s College Hospital, London, UK; 2University College London, UK Critical Care 2015, 19(Suppl 1):P510 (doi: 10.1186/cc14590) Conclusion Few direct discharges, new diagnoses, or key new treatments were initiated by the medical SHO in the emergency department. A paper from our hospital shows that more patients referred in by GPs to ED are admitted compared with those referred in to the acute medical assessment unit, with comparable disease severity (43% vs. 12.5) [2]. That paper highlighted the fact that the junior level of the medical NCHDs who see patients in the ED may contribute to their lack of discharging/decision-making zeal. Our survey further illustrated this feature. Our study provided no evidence that a formal medical assessment should delay a patient progressing to the medical ward. Additional genuine urgent OPD appointment slots could be another benefi cial measure. Introduction Critically ill patients may require interhospital transfer for specialist care or because of a lack of local ICU capacity. Harm is assumed from delays that result, but it is not clear whether these delays are due to transfer distances or defi ciencies in the organisation of care. Methods In total, 151 of 15,602 deteriorating ward patients in the (SPOT)light study [1] were transferred rather than admitted locally. We defi ned delay as the time from critical care assessment in the fi rst hospital to arrival in critical care in the second hospital. We used hospital postcodes to derive latitude and longitude, and calculated both geodesic (straight-line) distances (Figure 1) and road distances between the sites using R version 3.1.1 [2]. We compared daytime versus overnight (7:00 pm to 7:00 am) transfer durations assuming traffi c would contribute less to delay overnight. Mapping and visualisation was performed on Quantum GIS version 2.4 [3]. i References 1. Gilligan P, et al. The referral and complete evaluation time study. Eur J Emerg Med. 2010;17:349-53. 1. Gilligan P, et al. The referral and complete evaluation time study. Eur J Emerg Med. 2010;17:349-53. 2. Watts M, et al. Acute medical assessment units: an effi cient alternative to in-hospital acute medical care. Ir Med J. 2011;104:47-9. 2. Watts M, et al. Acute medical assessment units: an effi cient alternative to in-hospital acute medical care. Ir Med J. 2011;104:47-9. Results The median delay to admission was 22 hours (range 41 to 167 hours). The median geodesic distance was 18 km (range 1 to 141 km), and road distance was 24 km (range 2 to 180 km). Correlations between time delay and geodesic/road distances were weak (Figure 2, Blood pressure and heart rate changes during shifts in ICU nurses in relation to their work experience A Ioannidis, E Terzenidou, D Gklava, I Politi, E Georgiadou, A Georgousi, V Aidonoudis, A Kalea, P Melitzana, N Gritsi-Gerogianni Thessaloniki General Hospital ‘Ippokratio’, Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P506 (doi: 10.1186/cc14586) A Ioannidis, E Terzenidou, D Gklava, I Politi, E Georgiadou, A Georgousi, V Aidonoudis, A Kalea, P Melitzana, N Gritsi-Gerogianni Thessaloniki General Hospital ‘Ippokratio’, Thessaloniki, Greece Critical Care 2015, 19(Suppl 1):P506 (doi: 10.1186/cc14586) Introduction The aim of the study was to assess the blood pressure (BP) and heart rate (HR) changes during shifts in ICU nurses in relation to their work experience. Our hypothesis was that less experienced nurses, in comparison with more experienced ones, would be subjected to more work stress and this could be demonstrated by higher changes in BP and HR during shifts. Methods We enrolled 23 nurses working in an 8-hour shift schedule at a general adult ICU. Demographic and clinical data were obtained by completing a short questionnaire. The nurses were invited to measure their BP and HR at the beginning, in the middle and at the end of their shift. An ESH/BSH-certifi ed automatic device was used for the BP and HR measurements. Conclusion We found that several prehospital-registered vital signs recorded by ambulance personnel at fi rst contact with the patient were prognostic factors of 7-day mortality. S178 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P508 P508 Contribution of medical senior house offi cers to a medical referral in the emergency department GF Fitzpatrick University Hospital, Limerick, Ireland Critical Care 2015, 19(Suppl 1):P508 (doi: 10.1186/cc14588) of patients were fi rst seen by a consultant within 12 hours of admission, with a range from 23 minutes to 26 hours. When looking at patients admitted during the weekdays, 63% of them were seen within 12 hours; for those admitted at the weekend the fi gure was 57%. Reference 1. Royal College of Physicians. Acute medical care: the right person in the right setting-fi rst time. Report of the Acute Medicine Task Force. London: RCP; 2007. References 1. Gantner D, et al, Intensive Care Med. 2014;40:1528-35. 2. Flower M, et al, Crit Care. 2011;15:P464. R2 = 0.015 and 0.011, respectively). Transfer delays in the daytime and overnight were similar (Wilcoxon rank sum, P = 0.6).i P512 g Conclusion Interhospital transfers are subject to clinically signifi cant delays, and substantial travel distances. Delays are only weakly correlated to distances travelled and may refl ect delays resulting from organisational ineffi ciencies. We infer that eff orts to improve the effi ciency of transfer should focus on local organisational issues. There was no diff erence in the duration taken for overnight versus daytime transfers. R f Achieving a time to fi rst consultant review of under 12 hours for acutely ill medical patients y B Greatorex, EC Colley B Greatorex, EC Colley Figure 1 (abstract P510). Map of transfers. y Great Western Hospital, Swindon, UK p , , Critical Care 2015, 19(Suppl 1):P509 (doi: 10.1186/cc14589) Critical Care 2015, 19(Suppl 1):P509 (doi: 10.1186/cc14589) Introduction In 2007, the Acute Medicine Task Force made recommendations about the operation and staffi ng of acute medical units (AMU). Consultant-led care was seen as critical to ensuring high standards of care for patients and maintaining effi cient patient fl ow [1]. It also recommended that during the hours when the AMU is staff ed by a consultant, all new patients should be seen within 6 to 8 hours. Patients admitted overnight should have a consultant review within 12 to 14 hours. Following the introduction of a 4:00 pm consultant ward round of newly admitted acute medical patients to the existing 8:00 am and 2:00 pm rounds, it was our intention to establish whether our trust was meeting those recommendations. Methods We conducted a prospective survey of all new acute medical admissions over a 2-week period. Data collected included date and time of admission to the hospital, location on arrival, time of fi rst medical clerking, and time of fi rst consultant review. i Results Data were collected for 420 admissions. Sixty-seven percent of patients were admitted to the hospital between 12:00 am and 12:00 pm with a peak occurring between 4:00 pm and 6:00 pm. Sixty-two percent Figure 1 (abstract P510). Map of transfers. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S179 R2 = 0.015 and 0.011, respectively). Transfer delays in the daytime and overnight were similar (Wilcoxon rank sum, P = 0.6). Conclusion Interhospital transfers are subject to clinically signifi cant delays, and substantial travel distances. Delays are only weakly correlated to distances travelled and may refl ect delays resulting from organisational ineffi ciencies. We infer that eff orts to improve the effi ciency of transfer should focus on local organisational issues. There was no diff erence in the duration taken for overnight versus daytime transfers. References 1. Harris SK, et al. Intensive Care Med. 2014;40 Suppl 1:127. 2. www.r-project.org. 3 i Figure 2 (abstract P510). (a) Time duration versus geodesic distance (R2 = 0.015). (b) Time duration versus road distance (R2 = 0.011). in those patients who are discharged out of hours is nearly twice that of those discharged during the day [1]. Evaluation of patients with wild mushroom poisoning in the emergency department Introduction Wild mushroom poisoning (MP) is an important medical emergency that may have bad clinical outcome. We aimed to evaluate the clinical and laboratory features of patients with wild MP admitted to our emergency department in the Central Black Sea Region and to inform the emergency department physicians about early diagnosis and management of wild MP in the light of obtained data.i Achieving a time to fi rst consultant review of under 12 hours for acutely ill medical patients These results have been replicated in our institution with a mortality of 8.7% (discharged 22:00 to 06:59) versus 4.8% (discharged 07:00 to 21:59). In the UK, NICE CG50 advised that transfer from critical care to the ward out of hours should be avoided and documented as an adverse event. We postulated that one important factor in our hospital is the decreased medical and nursing cover overnight and so looked at the delay from discharge to fi rst medical review and to outreach review. in those patients who are discharged out of hours is nearly twice that of those discharged during the day [1]. These results have been replicated in our institution with a mortality of 8.7% (discharged 22:00 to 06:59) versus 4.8% (discharged 07:00 to 21:59). In the UK, NICE CG50 advised that transfer from critical care to the ward out of hours should be avoided and documented as an adverse event. We postulated that one important factor in our hospital is the decreased medical and nursing cover overnight and so looked at the delay from discharge to fi rst medical review and to outreach review. Methods The case notes of 100 consecutive patients discharged to the ward between September 2013 and October 2013 were examined to identify the time of discharge from the ICU and the subsequent fi rst review by the receiving medical team and the Critical Care Outreach team. The grade of the doctor reviewing the patient was recorded. Results Of these 100 patients, 22 were discharged between 22:00 and 07:59. From the 100 case notes requested, only 50 were available for examination. Forty patients were discharged to the wards, with only 37 having further documented medical reviews in the notes. Only 62% of patients were reviewed by a consultant following intensive care, with over 20% of patients waiting more than 24 hours for any medical review. During this time 18% of patients received a review by the nurse- led outreach team. See Figure 1. Conclusion It is clear that a highly vulnerable group of patients who are recovering from critical illness [2] receive inadequate early follow-up within the hospital. We postulate that the delay in medical review and the lack of senior review may be caused by over 40% being discharged overnight and contribute to the increased mortality seen in our institution and the ANZICS study [1] with nighttime discharges. References Delayed ICU discharges and medical follow-up: a cause of increased mortality? The BASIC Patient Safety course was only administered to staff from ICU1, and safety culture was assessed in both units before and after, using a survey based on the Hospital Survey on Patient Safety Culture [2]. Relative risk (95% CI) of improvement: baseline to follow-up in hospitals in patient safety domains, adjusted for duration of work in the unit (≤10 years vs. >10 years), was calculated. Responses were coded according to the Survey User’s Guide, and positive response percentages for each patient safety domain were compared with the 2012 Agency for Healthcare Research and Quality (AHRQ) ICU sample of 36,120 respondents. organizational culture to improve patient safety culture is considered important. We conducted a prospective, controlled study to assess the impact of a standardized patient safety course on an ICU’s patient safety culture, using a validated patient safety culture assessment tool. Methods Staff from two ICUs – ICU1 (tertiary referral hospital) and ICU2 (district hospital) – in Hong Kong were recruited to compare changes in the measured safety culture before and after a patient safety course. The BASIC Patient Safety course was only administered to staff from ICU1, and safety culture was assessed in both units before and after, using a survey based on the Hospital Survey on Patient Safety Culture [2]. Relative risk (95% CI) of improvement: baseline to follow-up in hospitals in patient safety domains, adjusted for duration of work in the unit (≤10 years vs. >10 years), was calculated. Responses were coded according to the Survey User’s Guide, and positive response percentages for each patient safety domain were compared with the 2012 Agency for Healthcare Research and Quality (AHRQ) ICU sample of 36,120 respondents. Conclusion Wild MP can cause bad clinical outcome. The public should be informed about the probable hazards of wild mushroom ingestion because collection and consumption of wild mushrooms from nature is common. Public health units should take protective precautions against wild MP. Education of health personals regarding MP will lead to successful results in patient management. Results Preintervention and postintervention period response rates for ICU1 were 88.1% (37/42) and 79.3% (23/29); and for ICU2 63% (20/32) and 63% (15/24). Delayed ICU discharges and medical follow-up: a cause of increased mortality? Methods This study was designed retrospectively by examining fi les of the patients with wild MP who were admitted to Ondokuz Mayis University Emergency Department, between January 2008 and December 2012. Patients older than 18 years were included in the study. Patients were evaluated according to gender, age, location, duration between mushroom intake and the start of clinical symptoms, time of application to hospital, clinical features and fi ndings and treatment method. The number of patients has been compared with the regional distribution of population, monthly temperature and average annual rainfall. y p , , Critical Care 2015, 19(Suppl 1):P511 (doi: 10.1186/cc14591) Introduction Discharge from intensive care is a potentially vulnerable time for patients who are recovering from critical illness. Recent data from the ANZICS group have highlighted that the mortality diff erence Figure 1 (abstract P511). S180 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results A total of 420 patients poisoned by wild mushrooms were studied. The male/female ratio was 1/1.5. The age of patients changed from 18 to 92 and mean age was 46 years. MP constituted 13.3% of all intoxication cases. The time when the fi rst symptom occurred after mushroom intake was a mean 2 (0.17 to 2.15) hours. Of the patients, 47.6% lived in villages, 38.6% in towns and 13.8% in city centers. Admissions were mostly made in autumn, with 57.6%. Eighty-six percent of intoxications happened because of wild mushrooms collected in nature. The most frequent symptoms were nausea (93.8%), and vomiting (87.1%). Increase in liver function tests in 47 patients was observed. Two of these patients died while 10 patients were transferred to further centers for liver transplantation. The remaining patients were discharged from the hospital. organizational culture to improve patient safety culture is considered important. We conducted a prospective, controlled study to assess the impact of a standardized patient safety course on an ICU’s patient safety culture, using a validated patient safety culture assessment tool. Methods Staff from two ICUs – ICU1 (tertiary referral hospital) and ICU2 (district hospital) – in Hong Kong were recruited to compare changes in the measured safety culture before and after a patient safety course. P513 Triage after drug overdose: eff ect of the introduction of a medical psychiatry unit on the allocation of ICU beds D Kleinloog, F Braam Houckgeest, D Sierink Tergooiziekenhuizen, Hilversum, the Netherlands Critical Care 2015, 19(Suppl 1):P513 (doi: 10.1186/cc14593) y y D Kleinloog, F Braam Houckgeest, D Sierink y y D Kleinloog, F Braam Houckgeest, D Sierink Tergooiziekenhuizen, Hilversum, the Netherlands g Critical Care 2015, 19(Suppl 1):P513 (doi: 10.1186/cc14593) Introduction Many patients with drug overdose are sedated, but do not have medical reasons to warrant ICU admission. Historically, monitoring behavior and suicide risk was done in the ICU, until the patient was awake enough for psychiatric consultation. Conclusion The study provides supportive evidence that a structured, reproducible short course on patient safety is associated with a general improvement in the ICU’s patient safety culture, measured with a validated safety culture assessment tool. Methods A medical psychiatry unit (MPU) was instituted as part of the Department of Clinical Psychiatry. For all patients with drug overdose in the emergency department, a risk assessment was made by the intensivist. Those without ICU indication (such as cardiac or respiratory monitoring) were admitted to the MPU. Alternatively, when awake enough, they were seen by the psychiatrist immediately. We performed an analysis of all patients with drug overdose, admitted to our ICU (before MPU n = 88, after MPU n = 191). We used the Welch t test for comparisons. Delayed ICU discharges and medical follow-up: a cause of increased mortality? Post intervention, compared with ICU2, ICU1 showed signifi cantly improved perceptions of teamwork within the hospital unit, RR (95% CI for diff erence between ICUs) 1.55 (1.10 to 2.19, P = 0.01); and overall perception of safety, 1.94 (1.11 to 3.37, P = 0.02); but not increased frequency of reporting mistakes, 0.90 (0.33 to 2.49, P = 0.84). Overall, ICU1 demonstrated a greater improvement in positive responses in fi ve safety culture domains than staff from ICU2. Patient safety culture indices were generally poorer in the two ICUs than the average ICU in the AHRQ database. Table 1 (abstract P513). Patient numbers and disease severity before and after introduction of MPU Table 1 (abstract P513). Patient numbers and disease severity before and after introduction of MPU Table 1 (abstract P513). Patient numbers and disease severity before and after introduction of MPU Before MPU Since MPU (18 months) (51 months) Diff erence 95% CI P value Admissions per month 4.9 3.5 –1.4 –2.7 to –0.1 0.04 APACHE II score 8.4 12.5 +4.0 +1.8 to +6.2 0.0004 APACHE III score 30.9 40.3 + 9.4 +2.6 to +16.2 0.0069 Length of stay 0.8 1.3 + 0.5 –0.0 to +1.0 0.05 Conclusion Introduction of an MPU was associated with reduced numbers of patients with drug overdose admitted to the ICU. Those admitted to the ICU after the institution of the MPU were sicker, probably indicating more appropriate use of ICU beds. P514 Prospective controlled study to compare the eff ects of a basic patient safety course on healthcare worker patient safety culture L Ling, G Joynt, A Lee, W Samy, H Fung, CD Gomersall The Chinese University of Hong Kong, Shatin, Hong Kong Critical Care 2015, 19(Suppl 1):P514 (doi: 10.1186/cc14594) Introduction It is estimated that about one in 10 patients may be harmed by adverse events during their hospital stay [1]. Transforming Before MPU Since MPU (18 months) (51 months) Diff erence 95% CI P value Admissions per month 4.9 3.5 –1.4 –2.7 to –0.1 0.04 APACHE II score 8.4 12.5 +4.0 +1.8 to +6.2 0.0004 APACHE III score 30.9 40.3 + 9.4 +2.6 to +16.2 0.0069 Length of stay 0.8 1.3 + 0.5 –0.0 to +1.0 0.05 Methods Patients admitted to the ICU between 21 September 2014 and 2 October 2014 were included. If an investigation did not involve ionising radiation or was not requested by intensive care clinicians it was excluded. The indication for imaging was noted, and patient notes were analysed no less than 48 hours after the imaging was reported. Figure 1 (abstract P515). Conclusion Introduction of an MPU was associated with reduced numbers of patients with drug overdose admitted to the ICU. Those admitted to the ICU after the institution of the MPU were sicker, probably indicating more appropriate use of ICU beds. References 1. de Vries EN, et al. Qual Saf Health Care. 2008;17;216-23. 2. Nieva VF, et al. Qual Saf Health Care. 2003;12 Suppl 2:ii17-23. Audit of imaging documentation on an ICU l N Arora, SJ Glover p Results After institution of the MPU, there was a 28% reduction in the number of patients with drug overdose per month, admitted to the ICU. Also, patients admitted to the ICU were sicker and stayed longer (see Table 1). There were no patients admitted to the ICU after initial MPU admission. p pi Critical Care 2015, 19(Suppl 1):P515 (doi: 10.1186/cc14595) Introduction The Ionising Radiation (Medical Exposure) Regulations 2001 recommend to ‘ensure that a clinical evaluation of the outcome of each medical exposure is recorded’ [1]. This audit looked at whether ICU documentation of investigations involving ionising radiation could be improved. Anticipated benefi ts would be improved communication between the multidisciplinary team and better- informed decision-making. Table 1 (abstract P513). Patient numbers and disease severity before and after introduction of MPU P514 P514 Prospective controlled study to compare the eff ects of a basic patient safety course on healthcare worker patient safety culture L Ling, G Joynt, A Lee, W Samy, H Fung, CD Gomersall The Chinese University of Hong Kong, Shatin, Hong Kong Critical Care 2015, 19(Suppl 1):P514 (doi: 10.1186/cc14594) P516 Barriers to the implementation of checklists in the ICU: a survey on the perceptions of 314 Brazilian critical care nurses and physicians J Salluh1, W Viana2, F Machado3, A Cavalvanti4, F Bozza1, M Soares1 1IDOR, Rio de Janeiro, Brazil; 2Hospital Copa D’OR, Rio de Janeiro, Brazil; 3UNIFESP, São Paulo, Brazil; 4Hcor, São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P516 (doi: 10.1186/cc14596) Introduction Checklists have been used increasingly in the ICU aiming at mitigating avoidable adverse events, but their content is variable and little is known about barriers to their full implementation. This survey reported practices on the use of checklists and perceptions regarding barriers on its implementation. Methods A web-based survey was conducted among a convenience sample of Brazilian ICU nurses and physicians between August and October 2014. Standard descriptive statistics were used. Results A total of 314 professionals, 104 nurses (33.1%) and 210 physicians (66.9%), responded. The majority (82.4%) had more than 5 years of experience in intensive care. Checklists were applied every day, including weekends, in only 49.8% (n = 227). When we compared the barriers perceived by those working in smaller versus larger ICUs (<10 beds vs. >20 beds), the absence of a more comprehensive checklist content (93.6% vs. 81.9%, P = 0.026), the absence of specialized software or app (80.8% vs. 63.8%, P = 0.014), low availability of mobile devices (87.2% vs. 72.4%, P = 0.019), Internet unavailability (83.3% vs. 67.6%, P = 0.017), and the limited number of computers (88.5% vs. 76.2%, P = 0.0366) were the most often barriers to implementation. Checklists were applied with similar frequencies (<3 times a week, three to fi ve times a week, and every day, including on weekends, P >0.05) regardless of the ICU size. When the type of tool used (paper vs. electronic) was considered, the main barrier highlighted was the lack of 100% Internet availability in the ICU (64.8% vs. 100%, P = 0.009). Users of paper form had higher demands for more comprehensive checklist content (84.3% vs. 63.6%, respectively, P = 0.037) and experienced more barriers to team adherence (98.1% vs. 86.4%, respectively, P = 0.034) as compared with those using specialized software. Conclusion Although checklists are recognized as valuable tools for the adherence to best practice in the ICU, it is diffi cult to ensure the uniformity of their daily use. Prospective controlled study to compare the eff ects of a basic patient safety course on healthcare worker patient safety culture L Li G J A L W S H F CD G ll g y y g The Chinese University of Hong Kong, Shatin, Hong Kong y g g g g Critical Care 2015, 19(Suppl 1):P514 (doi: 10.1186/cc14594) Introduction It is estimated that about one in 10 patients may be harmed by adverse events during their hospital stay [1]. Transforming Figure 1 (abstract P515). S181 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 to concentrate, multitasking and the need to frequently change priorities in patient care-related procedures. It is therefore a continuous challenge to communicate and implement plans in an early, effi cient and reliable way within the team and to constantly keep track about tasks that are completed, postponed or that are about to be forgotten. To facilitate every caregiver’s workfl ow and to early and effi ciently communicate, we implemented the After Round Comprehensive Plan Summary (ARCoPS) tool. to concentrate, multitasking and the need to frequently change priorities in patient care-related procedures. It is therefore a continuous challenge to communicate and implement plans in an early, effi cient and reliable way within the team and to constantly keep track about tasks that are completed, postponed or that are about to be forgotten. To facilitate every caregiver’s workfl ow and to early and effi ciently communicate, we implemented the After Round Comprehensive Plan Summary (ARCoPS) tool. Results As shown in Figure 1, imaging requests were generally poorly documented (61%). In total, 17/26 (65%) chest X-rays (CXRs) were documented. A total of 0/2 CT scans were documented, despite one showing acute changes. In total, 17/20 (85%) CXRs requested following procedures carried out on ITU (such as insertion of central venous catheters) were documented, and the three not documented had no signifi cant fi ndings. The six other CXRs were requested to investigate worsening respiratory function. None were documented. Five had signifi cant fi ndings. y Methods Most of our patient care-related therapeutic and diagnostic decisions are made during the morning round consisting of intensivists, nursing team, surgeons, respiratory therapists, dieticians, clinical pharmacists and physiotherapists. P516 Resource limitations in smaller ICUs and the absence of comprehensive digital tools, mobile devices and Internet availability preclude full compliance at the bedside. P518 P518 Multicenter Thai university-based surgical ICU study (Thai-SICU study): adverse events and outcome in the SICU S Kongsayreepong, K Chittawatanarat Siriraj Hospital, Mahidol University, Bangkok, Thailand Critical Care 2015, 19(Suppl 1):P518 (doi: 10.1186/cc14598) Introduction The aim of this Thai-SICU was to study the incidence and outcome of adverse events in nine SICU university-based hospitals in Thailand. Introduction The aim of this Thai-SICU was to study the incidence and outcome of adverse events in nine SICU university-based hospitals in Thailand. Methods This multicenter prospective observational study was done in >18 years old, admission >6 hours surgical patients admitted to the large, postgraduate medical training university-based SICU during April 2011 to January 2012. Patient data were divided into three main phases as admission, discharge data and daily CRFs during the ICU stay. The patients were followed until they were discharged from the ICU or up to 28 days of their ICU admission and up to 28 days following discharge from the ICU if they survived. Results Following a 19.7-month recruitment period, a total of 4,654 patients (17,579 ICU-days) were included in the analysis process. Admitted patients had the median age of 64 years. Most of the patients were admitted directly from the OR for postoperative monitoring with median APACHE II score 10, 23% were admitted with priority I who needed aggressive hemodynamic resuscitation and respiratory support. ICU mortality and 28-day mortality were 9.61% and 13.80%. Each day of ICU increment was associated with a 1.38-day increase of hospital stay (95% CI, 1.24 to 1.53; P <0.01). On the surveillance periods, the six most common adverse events were sepsis (19.5%), AKI (16.9%), new cardiac arrhythmias (6.17%), respiratory failure (5.83%), cardiac arrest (4.86%) and delirium (3.5%) respectively. The other events including reintubation within 72 hours, intraabdominal hypertension, acute MI, unplanned extubation, upper GI hemorrhage, pneumohemothorax, seizure, drug error and pulmonary aspiration were <3% each. The risk Prospective controlled study to compare the eff ects of a basic patient safety course on healthcare worker patient safety culture L Li G J A L W S H F CD G ll Immediately thereafter, all plans for the next 24-hour period are again discussed, summarized, confi rmed, prioritized and organized by the multidisciplinary team under aspects of optimal patient care and workfl ow effi ciency by entering the plan data into a fl at screen visualized template connected to our intranet immediately accessible at every physician and nursing caregiver workstation. ii Conclusion Investigations following procedures were generally well documented, but investigations seeking pathology were not documented at all, regardless of the fi ndings. This may have infl uenced the management of the patient and compromised patient safety. As such, the audit was presented at a departmental meeting to emphasise the importance of imaging documentation. A place for investigations was added to the ICU patient list to improve communication between the team, and a second audit is planned to assess the impact of this. Reference Results Twelve months after implementation of the ARCoPS tool we conducted caregiver interviews and identifi ed the following eff ects: increase in treatment confi dence through standardized multidisciplinary decision-making; reduced loss of information through immediate plan summarization by the whole team; reduction of ambiguity and misunderstanding about care plans through early written documentation; higher level of security not to forget procedures or tasks; positive acceptance of the tool to fl exibly change priorities of care procedures; positive acceptance of the tool to mark accomplished tasks providing visual feedback about the care plan status; individual caregiver workfl ow economization through permanent treatment plan availability; and higher job satisfaction throughout the caregiver team. Conclusion ARCoPS tool utilization has become a daily routine in our ICU. It functions as an eff ective communication and workfl ow tool and has helped us to reduce patient care-related misunderstandings and delays. It also enhanced the economics of our work sequence, which also highly contributes to a better level of patient safety. Furthermore, it has markedly contributed to an improved level of quality of work for caregivers. 1. The ionising radiation (medical exposure) regulations 2000. London: Stationery Offi ce; 2000. 1. The ionising radiation (medical exposure) regulations 2000. London: Stationery Offi ce; 2000. P517 After Round Comprehensive Plan Summary tool: an effi ciency approach for the ICU R Marktanner, M Mostafa, A Shafei, H Hon, R Ashraf, P Sreedhara, N Syed, D Gharaibeh, A Taha Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Critical Care 2015, 19(Suppl 1):P517 (doi: 10.1186/cc14597) Introduction ICU workfl ow for physicians, nurses and other healthcare providers is often complicated by distractions, interruptions, diffi culties Introduction ICU workfl ow for physicians, nurses and other healthcare providers is often complicated by distractions, interruptions, diffi culties S182 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods We performed an observational study in a 17-bed, mixed clinical and surgical emergency department observation. Before the year 2012, the staff were composed of fi rst-year internal medicine and surgical residents. There were no senior physicians specifi cally assigned to this unit, and residents were supervised by the members of the emergency department team, who changed shifts on a daily basis. In February 2012, two senior physicians (one cardiologist and one intensive care doctor) were specifi cally assigned to supervise the internal medicine residents and provide horizontal care for medical patients during the day, from Monday to Friday. There was no change in assistance for surgical patients. The schedule for nights and weekends remained unchanged. Mortality and length of stay for medical and surgical patients were measured in 2011, 2012 and 2013.i of adverse events on 28-day mortality were signifi cant on cardiac arrest (RR = 9.45; P <0.01), ARDS (RR = 4.58; P <0.01), AKI (RR = 4.18; P <0.01), sepsis (RR = 3.62; P <0.01), iatrogenic pneumohemothorax (RR = 3.23; P <0.01), seizure (RR = 3.12; P <0.01), upper GI hemorrhage (RR = 2.97; P <0.01), cardiac arrhythmia (RR = 2.91; P <0.01), ALI (RR = 2.71; P <0.01), delirium (RR = 2.13; P <0.01), MI (RR = 2.12; P <0.01), unplanned extubation (RR = 2.06; P <0.01), abdominal hypertension (RR = 1.75; P <0.01) and reintubation within 72 hours (RR = 1.51; P = 0.02). Conclusion This is the largest systemic surveillance observation in the SICU. The study results are the reference for future research and also provide information for patient and relative advice when confronted with adverse events during SICU admission. P521 Results There were 6,203 surgical admissions during the 8-year study period. For both ICU and in-hospital mortality; the median LOS in days for survivors was 2.2 (IQR: 1.2 to 4.9) and that of nonsurvivors was 3.2 (IQR: 1.5 to 7.9). At 28 days, 1 year, and 2 years, the respective values were 2.2 (1.2 to 4.9) and 3.3 (1.5 to 6.7); 2.1 (1.2 to 4.7) and 3.1 (1.5 to 7.3); and 2.1 (1.2 to 4.6) and 3.0 (1.5 to 7.0), all P <0.0001. The greatest median LOS was found in neurosurgery and cardiothoracic surgery; 3.3 days (IQR: 1.7 to 9.5) and 3.1 days (IQR: 1.5 to 8.0) respectively. They corresponded to the specialities with the greatest percentage ICU (9.7% and 10.2%) and 2-year mortality (27.9%, and 35%). The greatest mortality and median LOS was found in ventriculostomy cases; 40.8% at 2 years and 10.6 days (IQR: 4.8 to 18.2). Retrospective observational cohort study of mortality and length of stay for surgical ICU admissions Introduction A signifi cant number require a postoperative ICU stay which may be prolonged [1]. Very limited data exist to characterise mortality and ICU length of stay (LOS) in diff erent surgical specialties [2,3]. We aim to describe this relationship in a large cohort of surgical patients. Conclusion Emergency department observation units are an alternative to alleviate emergency room overcrowding when there are no intensive care beds available. However, patients end up staying in those units for days and horizontal care by senior doctors may improve outcomes. p Methods We performed a retrospective observational cohort study of adult surgical admissions to the ICU of a large academic tertiary medical centre. The primary endpoint was 28-day mortality. We used simple descriptive statistics to characterise the population. The Wilcoxon rank- sum test or Kruskall–Wallis test was used, as appropriate, for tests of continuous data. Rejection for ICU admission: analysis and results of this modality of limitation of therapeutic eff ort Williams TA, et al. Br J Anaesth. 2010:104:459-64. P517 Results In the fi rst year after the implementation of the clinic intensive care team, mortality in internal medicine patients decreased from 47% to 34% in 2012 and 33% in 2013. Although other changes happened in this period (the number of beds decreased from 24 to 17, nurses and physical therapists were hired and trained specifi cally for this unit), we believe the horizontal staff was critical, because mortality between surgical patients remained almost unchanged in the same period of time (23% in 2011, 22% in 2012 and 23% in 2013), in spite of the structural improvements that equally aff ected those patients. Length of stay decreased from 6.35 days in 2011 to 3.43 in 2012 and 3.15 in 2013 in medical patients and from 3.9 days on average in 2011 to 3.2 in 2012 and 2.8 in 2013 in surgical patients. Rejection for ICU admission: analysis and results of this modality of limitation of therapeutic eff ort pf F Acosta, O Moreno, M Muñoz, R Fernandez, M Colmenero Hospital Universitario San Cecilio, Granada, Spain Critical Care 2015, 19(Suppl 1):P521 (doi: 10.1186/cc14601) Critical Care 2015, 19(Suppl 1):P521 (doi: 10.1186/cc14601) Introduction The aim was to know the frequency, criteria and implications of rejection for ICU admission to our ICU unit, a second- level hospital (18 beds). Introduction The aim was to know the frequency, criteria and implications of rejection for ICU admission to our ICU unit, a second- level hospital (18 beds). Methods An observational retrospective study in a time interval of 6 months (January to June 2013). We retrospectively registered all patients rejected for admission to our unit, analyzing the clinical rejection report used in our hospital. From this report we extracted diff erent variables: demographical (age, sex), provenance (emergency room, hospital), clinical (comorbidity, functional situation, diagnosis, reason of requesting admission), rejection motive (‘too good’, ‘too bad’, futility, lack of beds, patient rejection), whether it was defi nitive or conditional, whether the patient was admitted afterwards, and the state at hospital discharge. We realized a descriptive analysis (frequencies) and multivariant analysis of the factors related to futility rejection. Conclusion There is an association between postoperative ICU LOS and mortality that persists for at least 2 years after admission. Neurosurgery and cardiothoracic surgery patients appear to have a worse prognosis and also a more prolonged LOS. Our results may provide a more objective basis for clinical decisions, the use of limited resources, and inform on appropriate expectations of treatment. 1. Pearse RM, et al. Lancet. 2012:380:1059-65. y y j Results There were 165 rejections, which represents 25% of total ICU patients evaluated for admission. A total of 59.4% were male. Mean age was 69 ± 7 years (19 to 98). In total, 53.9% had more than two comorbidities (pluripathological) and 31.5% moderate to severe functional disability. The cause of rejection was in 55.2% of situations that the patient was ‘too good’, 37.6% related to qualitative futility, 4.8% was ‘too bad’ and in 1.2% a mix of lack of space (beds) and patient rejection. In the multivariant analysis the signifi cant variables related to futility rejection were age (by years) with an OR of 1.05 (1.02 to 1.08), severe functional disability, OR of 4.35 (2.09 to 9.06), and the hospital provenance with an OR of 2.82 (1.1 to 7.2). 2. Timmers TK, et al. Ann Surg. 2011:253:151-7. 3. References 1. Komindr A, et al. Int J Emerg Med. 2014;5:1-6. 1. Komindr A, et al. Int J Emerg Med. 2014;5:1-6. 2. Baugh C, et al. Health Care Manag Rev. 2011;36:28-37. 2. Baugh C, et al. Health Care Manag Rev. 2011;36:28-37. P519 Retrospective observational cohort study of mortality and length of stay for surgical ICU admissions M Hameed1, M Maruthappu2, D Marshall3, M Pimentel1, L Celi4, J Salciccioli3, J Shalhoub3 1University of Oxford, UK; 2National Institute for Health and Care Excellence, London, UK; 3Imperial College London, UK; 4Massachusetts Institute of Technology, Cambridge, MA, USA Critical Care 2015, 19(Suppl 1):P519 (doi: 10.1186/cc14599) P522 Impact of age, physiological status and APACHE score on acceptance of patients to the ICU Introduction Evidence suggests that age, chronic health status and acute illness severity aff ect the decision-making of clinicians regarding admission to the ICU (ITU) [1-3]. This prospective service review assesses the impact of age, APACHE II score and WHO functional score towards admission acceptance or refusal to ITU in a tertiary-level facility. p Results Following implementation of the new transfer process, the average wait time decreased by 58 minutes, process time decreased by 9 minutes, and lead time decreased by 66.5 minutes. The handoff error rate decreased by 1.3 errors/patient and fi rst-time quality rate increased by 67%. Staff satisfaction improved from 48% to 73%. By elimination of the PACU stay, the costs involved in admission to the PACU were deferred. admission acceptance or refusal to ITU in a tertiary-level facility. Methods Design: a planned prospective review of all referrals over a 14- day period. Data collection: review (LT, DP, SP) of case notes of patients referred to ITU with the following variables collected: age, sex, APACHE II scores, WHO functional status score, grade of referrer and source of referral. Data were collected on 37 patients: 22 accepted to ITU and 15 refused admission. Statistics: data were analyzed using GraphPad 6.05. Categorical variables were expressed as mean and standard error of mean. For unpaired variables, statistical signifi cance is determined using unpaired t test. P <0.05 is considered statistically signifi cant. Results The WHO functional status was the most signifi cant variable aff ecting admission (P <0.001). The APACHE score of patients admitted to ITU was signifi cantly lower than refused patients (P = 0.039). Patient age did not aff ect admission status (P = 0.15). See Table 1. Methods Design: a planned prospective review of all referrals over a 14- day period. Data collection: review (LT, DP, SP) of case notes of patients referred to ITU with the following variables collected: age, sex, APACHE II scores, WHO functional status score, grade of referrer and source of referral. Data were collected on 37 patients: 22 accepted to ITU and 15 refused admission. Statistics: data were analyzed using GraphPad 6.05. Categorical variables were expressed as mean and standard error of mean. For unpaired variables, statistical signifi cance is determined using unpaired t test. P <0.05 is considered statistically signifi cant.i Conclusion A single, multidisciplinary bedside handoff process between the OR and ICU leads to cost and time savings. Improved interprofessional communication, handover and ward rounds in critical care (ICARUS) Introduction There is growing evidence that optimising communication and patient assessment practices including ward rounds and handoff s can improve clinical, safety and operational outcomes, particularly in the critical care setting [1,2]. Here we describe the design and baseline phases of a 5-year project utilising improvement sciences to optimise the quality of interprofessional communication, handoff s and rounding in one of the largest critical care units in the UK. Conclusion This study was performed to assess decision-making for admission to the ITU in times of increased demand and limited availability. We want to validate our fi ndings from this short pilot study in a larger prospective study. Multivariate regression analysis will be used to identify signifi cant features that aff ect clinician decision- making in critical care admission. Methods We obtained institutional ethical and research approvals. We used mixed methods including interviews of opinion leaders and a representative cross-section of staff , roundtables, a survey targeting the whole critical care team (n = 546) and a Delphi exercise to generate a baseline consensus for the need to improve and a set of novel quality improvement interventions and tools. We tested two of these in a pilot plan–do–study–act (PDSA) cycle. g References References 1. Reignier J, et al. Crit Care Med. 2008;36:2076-83. 2. Garrouste-Orgeas M, et al. Crit Care Med. 2005;33:750-5. 3. Azoulay E, et al. Crit Care Med. 2001;29:2132-6. References 1. Reignier J, et al. Crit Care Med. 2008;36:2076-83. 2. Garrouste-Orgeas M, et al. Crit Care Med. 2005;33:750-5. 3. Azoulay E, et al. Crit Care Med. 2001;29:2132-6. Results Baseline consensus for the need and potential to improve was obtained (97.4% and 94.5%). Despite a large degree of heterogeneity of perceptions around current communication and rounding practices, it was possible to develop a set of interventions based on consensus that could be applied in this complex setting. These included a handoff bundle, an operational touch-base, a unit-level safety briefi ng, a unit- level safety check, a lean rounding bundle and board rounds. These core interventions were supported by several more detailed resources describing the evidence base around best handoff and rounding practices; and a feedback document that described all outputs and recommendations from the ICARUS project. A pilot PDSA cycle demonstrated a 55.3% and 76.3% improvement in key information transfer using a safety briefi ng and board round summary. P522 Impact of age, physiological status and APACHE score on acceptance of patients to the ICU By elimination of redundant, nonvalue-added processes, less opportunity for medical errors occurred, with substantial improvements in fi rst-time quality. Such a process can be successfully attained while aff ecting staff satisfaction positively. g p y gi Results The WHO functional status was the most signifi cant variable aff ecting admission (P <0.001). The APACHE score of patients admitted to ITU was signifi cantly lower than refused patients (P = 0.039). Patient age did not aff ect admission status (P = 0.15). See Table 1. Table 1 (abstract P522) Accepted Refused P value Mean age 56.5 ± 4.4 65.3 ± 3.6 0.15 Sex 73% male 56% male N/A WHO 0.45 ± 0.2 2.21 ± 0.3 <0.001 APACHE 13.5 ± 1.6 18.8 ± 2.0 0.039 5 Improved interprofessional communication, handover and ward rounds in critical care (ICARUS) P Hopkins, A Chan, S Rasoli, C Bell, K Peters, A Feehan, J Dawson King’s Health Partners AHSC, London, UK Critical Care 2015, 19(Suppl 1):P524 (doi: 10.1186/cc14604) Lean Six Sigma handoff process between operating room and pediatric ICU: improvement in patient safety, effi ciency and eff ectiveness f SJ Gleich, ME Nemergut, AA Stans, DT Haile, SA Feigal, AL Heinrich, CL Bosley, JW Ward, S Tripathi Mayo Clinic, Rochester, MN, USA Critical Care 2015, 19(Suppl 1):P523 (doi: 10.1186/cc14603) Introduction This Six Sigma project was initiated to evaluate and improve the transfer of care of patients from the OR to the ICU. Medical errors are responsible for billions of dollars in increased healthcare spending. Miscommunication among healthcare providers is a major contributor to these errors, with handoff s a particularly vulnerable period in the care process. At our institution, surgical patients with scheduled admissions to the ICU are fi rst recovered in the postanesthesia care unit (PACU). With this process, multiple, unstructured, and individual handoff s occur in parallel between providers, which may lead to communication errors, diff erential information sharing, content variability, care delays, and ineffi ciency. Conclusion Despite wide heterogeneity in baseline beliefs, opinions and perceptions around inter-professional communication, rounding and handoff s, we were able to develop a novel set of feasible quality improvement interventions, targeting these areas, that can be applied in a large complex critical care setting. Furthermore, they can be driven by improvement science methodology and tested for eff ectiveness using qualitative and quantitative measures. We now plan to use these interventions to deliver quality improvements in communication practices in parallel with the planning and implementation phases of a new critical care facility and electronic clinical information system. R f Implementation of a horizontal intensive care team can impact effi ciency in an emergency observation unit in Brazil S Ribeiro, C Petrini, L Marino, R Brandao-Neto Hospital das Clinicas School of Medicine, University of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P520 (doi: 10.1186/cc14600) fi y g y S Ribeiro, C Petrini, L Marino, R Brandao-Neto Hospital das Clinicas School of Medicine, University of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P520 (doi: 10.1186/cc14600) Introduction Emergency department observation units are often used to monitor critical patients in a situation of constant emergency department overcrowding and lack of intensive care beds. However, those units are often understaff ed and might not have enough personnel and equipment to provide the same quality of care as a conventional ICU. Conclusion Rejection for admission to ICU units is a frequent medical activity in our day-to-day job. The type of patient most rejected is cardiologic, mostly evaluated for thoracic pain probably ischemic but with low risk. In second place we found patients for which we decide rejection based on subjective qualitative futility, related mostly to age, prior functional disability and provenance. S183 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P522 were conducted, which began by defi ning the current process via direct observation and value stream mapping of orthopedic and neurosurgical patients. A new process was then introduced, including direct transfer of the patient to the ICU and a single, structured, bedside report between all care providers. A standardized handoff tool was implemented. We used process times, wait times and information content as process measures and handoff errors as outcome measures. A 10-point satisfaction score was also measured. were conducted, which began by defi ning the current process via direct observation and value stream mapping of orthopedic and neurosurgical patients. A new process was then introduced, including direct transfer of the patient to the ICU and a single, structured, bedside report between all care providers. A standardized handoff tool was implemented. We used process times, wait times and information content as process measures and handoff errors as outcome measures. A 10-point satisfaction score was also measured. P522 Impact of age, physiological status and APACHE score on acceptance of patients to the ICU L Terry, S Passey, D Porter, F Clark, R Matsa Royal Stoke University Hospital, Stoke on Trent, UK Critical Care 2015, 19(Suppl 1):P522 (doi: 10.1186/cc14602) P523 P523 Lean Six Sigma handoff process between operating room and pediatric ICU: improvement in patient safety, effi ciency and eff ectiveness SJ Gleich, ME Nemergut, AA Stans, DT Haile, SA Feigal, AL Heinrich, CL Bosley, JW Ward, S Tripathi Mayo Clinic, Rochester, MN, USA Critical Care 2015, 19(Suppl 1):P523 (doi: 10.1186/cc14603) P523 Lean Six Sigma handoff process between operating room and pediatric ICU: improvement in patient safety, effi ciency and eff ectiveness SJ Gleich, ME Nemergut, AA Stans, DT Haile, SA Feigal, AL Heinrich, CL Bosley, JW Ward, S Tripathi Mayo Clinic, Rochester, MN, USA Critical Care 2015, 19(Suppl 1):P523 (doi: 10.1186/cc14603) P526 Out-of-hours discharge from critical care: does it matter? M Ahmed, G Lumley, S Nourse, A Hurding, A Thomas, M Healy The Royal London Hospital, London, UK Critical Care 2015, 19(Suppl 1):P526 (doi: 10.1186/cc14606) Introduction The aim of this audit was to assess the clinical impact of out-of-hours (OOH) discharge from the adult critical care unit (ACCU) in a tertiary care hospital. Discharging patients from critical care OOH has been associated with both higher mortality and increased rate of readmissions [1,2]. As a result, national guidance stipulates that OOH discharges from critical care should be avoided [3]. Results A total of 2,248 emergency admissions were analysed. The majority of patients were admitted within 1 week of hospital admission (n = 1,897). They were younger and had lower APACHE II scores (15 vs. 19; P <0.001). APACHE II scores were the same in all other groups (groups 2 to 5). Patients admitted to the ICU 3 weeks following hospital admission had signifi cantly higher hospital mortality (up to 50%; P <0.001) and ICU length of stay (12 ± 15 vs. 8 ± 10 days; P <0.001). ICU mortality remained the same in all groups (20 to 28%). ICNARC and SOFA scores were equal between the groups. The post-ICU lengths of stay were signifi cantly longer in groups 3 to 5. In-hospital CPR prior to admission to ICU was lower in patients from groups 4 and 5, probably signifying appropriate DNAR decisions made on the ward. Methods A retrospective snapshot analysis of patients was conducted at least 48 hours after discharge from the ACCU in October 2014. Patients discharged OOH (20:00 to 07:59) were compared with those discharged in hours (IH; 08:00 to 19:59). Analysis included: patient demographics, APACHE II score, handover procedure prior to discharge, follow-up by the receiving team, appropriate and timely drug prescribing, recognising and acting upon clinical deterioration and readmission rates. Conclusion Prolonged pre-ICU hospital admission is associated with higher hospital but not ICU mortality. Commonly measured scores do not refl ect this higher mortality in patients admitted after prolonged stay in hospital. Further research into parameters that may refl ect changes in physiological reserves may strengthen these scores for such patients. Results A total of 161 patients were discharged from the ACCU in October 2014. Of these, 46% of the patients were discharged OOH. P526 Forty-one (of 74) OOH and 19 (of 87) IH discharges were sampled for further analysis. The baseline demographics and APACHE II score were similar between both groups. The majority of discharges were delayed (>4 hours, 90% IH vs. 93% OOH). More patients had nursing handover completed if discharged IH (88% IH vs. 61% OOH) and doctors’ summaries were less frequently completed OOH (83% OOH vs. 94.4% IH). A management plan for the ward was outlined in 94% Pre-ICU length of hospital stay is a predictor of hospital but not ICU mortality y K Flavin, D Hall, G Marshall, P Zolfaghari g Royal London Hospital, London, UK Royal London Hospital, London, UK Critical Care 2015, 19(Suppl 1):P527 (doi: 10.1186/cc14607) Introduction Prolonged hospital stay prior to admission to the ICU was previously shown to be independently associated with poorer outcome [1,2]. This is probably due to slow deterioration of physiological function in hospital and infl uenced by processes leading to critical care admission [2]. We investigated whether commonly measured severity scoring systems (Acute Physiology and Chronic Health Evaluation (APACHE) II, Intensive Care National Audit and Research Centre (ICNARC) and Sequential Organ Failure Assessment (SOFA) scores) are signifi cantly diff erent in patients admitted with prolonged pre-ICU hospital length of stay, and describe mortality and hospital length of stay. Conclusion There is a higher prevalence of adverse events in readmitted patients with similarity in the type of adverse eff ects despite readmission. g References 1. Priestap F, et al. Crit Care Med. 2006;34:2946-51. p 2. Hanane T, et al. Crit Care Med. 2008;36:2232-7. 2. Hanane T, et al. Crit Care Med. 2008;36:2232-7. 3. Acutely ill patients in hospital. NICE; 2007 2. Hanane T, et al. Crit Care Med. 2008;36:2232-7. 3 Acutely ill patients in hospital NICE; 2007 gii Results The readmission rate was 15% (n = 392), particularly among males (55% (n = 214)). A 14.3% adverse event rate was observed among the readmitted patients (9.5% among those who were not readmitted). The readmitted patients were older (median (md): 68.0 (95% CI: 65.7 to 67.3) vs. md: 71.0 (95% CI: 67.1 to 71.3); P <0.05) and remained hospitalized for a longer period of time (md: 5.0 (95% CI: 13.2 to 20.7) vs. md: 11.0 (95% CI: 17.0 to 33.2); P <0.05), but not necessarily in the CICU (P = 106).The most prevalent adverse events in readmitted patients were pressure ulcers (n = 16 (4.1%)), drug administration error (n = 13 (3.3%)) and enteral feeding tube (n = 10 (2.6%)). Meanwhile, among the nonreadmitted, phlebitis due to peripheral vein access and pressure ulcers (n = 42 (1.9%)), drug administration error (n = 41 (1.9%)) and enteral feeding tube (n = 31 (1.4%)). There was a tendency (P = 0.71) that readmitted patients were presented with higher prevalence of pressure ulcers (n = 16 (4.1%) vs. n = 42 (1.9%)). 3. Acutely ill patients in hospital. NICE; 2007 Critical Care 2015, 19(Suppl 1):P525 (doi: 10.1186/cc14605) Introduction Security policies for the patient are of interest to any health professional. The rates of adverse events in hospitals reach values ranging between 3.7 and 16.6%, being the highest range (40 to 70%) considered preventable or avoidable [1]. The objective of this study is to assess the prevalence and types of adverse eff ects in intensive care patients according to readmission. g p Conclusion This audit compares with current evidence suggesting harm from OOH discharge despite most discharges being delayed. Discharging patients is a complex hospital process, but focus needs to be on discharging patients IH. Therefore, areas for improvement include targeting forward fl ow of patients throughout the hospital, completion of handover documents IH and publication of guidance for receiving teams. Methods During 4 years the data from 2,582 patients admitted to the coronary ICU (CICU) were analyzed in the coronary care unit of the city of Presidente Prudente, Brazil. We analyzed the rate of readmissions, length of stay and the mainly detected adverse events. We considered signifi cant P <0.05 two-tailed and confi dence intervals at 95% (CI). p Reference 1. Forster AJ, et al. CMAJ. 2004;170:345-9. 1. Forster AJ, et al. CMAJ. 2004;170:345-9. y Methods A retrospective analysis of prospectively collected data of all emergency admissions in the ICNARC database of a 44-bed adult critical care unit within a major trauma centre over a 2-year period. Demographic data, APACHE II score, SOFA score, ICNARC model score, mortality, and length of hospital stay prior to and after ICU admission were collected. Five groups of patients were defi ned as follows: those admitted to ICU within 1 week of hospitalization (group 1), within 8 to 14 days (group 2), within 15 to 21 days (group 3), within 22 to 28 days (group 4), and more than 28 days (group 5). Chi-squared and ANOVA tests were performed using the SOFA statistics package. References Methods A multidisciplinary QI project was initiated with input from the ICU, anesthesia and surgical services. A series of PDSA cycles Lane D. Crit Care Med. 2013;41:2015. Starmer AJ. N Engl J Med. 2014;371:1803. S184 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 of IH versus 65.% of OOH discharges. Seventy-eight per cent OOH versus 95% IH patients discharged were reviewed by a doctor within 24 hours. Twenty-nine per cent OOH versus 67% IH patients discharged were reviewed by a consultant within 24 hours. Following discharge a management plan was followed in 94% of IH patients versus 44% OOH, patients had drug charts correctly charted in 100% of IH cases versus 66% OOH and missed/delayed doses were documented in 11.1% of IH cases versus 61% OOH. There was no diff erence between the groups in incidence of clinical deterioration and recognition and follow-up of clinical deterioration. Two patients were readmitted within 48 hours from the OOH group. of IH versus 65.% of OOH discharges. Seventy-eight per cent OOH versus 95% IH patients discharged were reviewed by a doctor within 24 hours. Twenty-nine per cent OOH versus 67% IH patients discharged were reviewed by a consultant within 24 hours. Following discharge a management plan was followed in 94% of IH patients versus 44% OOH, patients had drug charts correctly charted in 100% of IH cases versus 66% OOH and missed/delayed doses were documented in 11.1% of IH cases versus 61% OOH. There was no diff erence between the groups in incidence of clinical deterioration and recognition and follow-up of clinical deterioration. Two patients were readmitted within 48 hours from the OOH group. P525 Adverse events in patients in a Brazilian intensive care unit according to readmission GM Plantier1, CE Bosso1, AC Correa2, BN Azevedo3, JS Alves2, CD Monteiro2, SV Ferreira3, GE Valerio3, JV Moraes3, V Raso3 1Instituto do Coração de Presidente Prudente, Brazil; 2Santa Casa de Presidente Prudente, Brazil; 3Faculdade de Medicina – UNOESTE, Presidente Prudente, Brazil Critical Care 2015, 19(Suppl 1):P525 (doi: 10.1186/cc14605) Higgins TL, et al. Crit Care Med. 2003;31:45-51. Goldhill DR, et al. Intensive Care Med. 2004;30:1908-13. P525 Adverse events in patients in a Brazilian intensive care unit according to readmission Critical Care 2015, 19(Suppl 1):P525 (doi: 10.1186/cc14605) P528 Study of the costs of an ICU according to age groups relating to SAPS 3 gravity, stay and outcomes MB Velasco, MA Leitão, DM Dalcomune, MB Leitão Hospital Meridional S.A., Cariacica, Brazil Critical Care 2015, 19(Suppl 1):P528 (doi: 10.1186/cc14608) F Kavanagh, I Browne g National Maternity Hospital, Dublin, Ireland g National Maternity Hospital, Dublin, Ireland y p Critical Care 2015, 19(Suppl 1):P530 (doi: 10.1186/cc14610) y p Critical Care 2015, 19(Suppl 1):P530 (doi: 10.1186/cc14610) Introduction Pregnancy and labour usually progress uneventfully; however, serious complications can occur and develop rapidly, necessitating critical care admission and support. Successive confi dential enquires have highlighted defi ciencies in this area and suboptimal care leading to increased morbidity and mortality [1]. The National Maternity Hospital is the largest maternity hospital in the Republic of Ireland where a total of 8,954 babies were delivered in 2013. It is a stand-alone institution and onsite facilities include a two- bed dedicated anaesthesia lead high-dependency unit. Introduction Hospital costs are a constant concern within health, especially in the ICU. Hospital admissions and average life expectancy have been growing gradually mainly in older and critical patients. This study is aimed to observe the direct costs of patients admitted to an ICU and their relation to the SAPS 3, length of stay in the ICU and fi nal outcome. Methods A retrospective observational study in which the direct costs were studied (materials, medicines, oxygen therapy and hospital fees) for 1,790 ICU patients from November 2013 to November 2014. The readmissions within 48 hours were excluded and also 10% of patients who had the highest and lowest costs. The remaining 1,401 patients were divided by age groups. Methods A retrospective observational study was carried out from January 2011 to January 2014 especially looking at the following parameters: admitting diagnosis, demographics, length of stay and the number of admissions requiring transfer for tertiary-level care. y g g Results Of the patients studied, 54.6% were male. Average age was 57.8 years (18 to 105 years). The biggest ICU average cost was in the group of patients 81 to 90 years old (US$793.00), as well as longest ICU stay (9.25 days), highest SAPS 3 (53.96) and higher ICU and in-hospital mortality (14.29% and 19.25% respectively). This study shows that the direct cost of the ICU stay for older patients was higher than for younger patients. The diff erence was explained by the higher severity measured by SAPS 3 in the older age groups (Figure 1), and the required greater length of stay in the ICU (Figure 2). As might be expected, the mortality in the group of older patients was also signifi cantly higher. References Higgins TL, et al. Crit Care Med. 2003;31:45-51. Goldhill DR, et al. Intensive Care Med. 2004;30:1908-13. S185 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P528 Reference 1. Special issue: Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confi dential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118 Suppl S1:1-203. 1. Special issue: Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confi dential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118 Suppl S1:1-203. P528 Study of the costs of an ICU according to age groups relating to SAPS 3 gravity, stay and outcomes MB Velasco, MA Leitão, DM Dalcomune, MB Leitão Hospital Meridional S.A., Cariacica, Brazil Critical Care 2015, 19(Suppl 1):P528 (doi: 10.1186/cc14608) q g y Results In total, 29,344 deliveries occurred. A total of 376 HDU admissions were recorded in this period, representing 1.28% of all admissions. The average age of patients admitted to the HDU was 34 years. The predominant reasons for admission were hypertensive disease of pregnancy (49.7%), haemorrhage (antepartum/postpartum) (36.4%), sepsis (4.2%) and other reasons (11.1%) including cardiac rhythm disturbances, neurological complications and pre-existing medical disease. In 2013 the average length of stay was 2 days. A total 6.1% of those admitted to HDU required transfer for tertiary-level ICU care in other centres during the study period, this represented 0.07% of all deliveries.i Conclusion This study showed that greater age is associated with higher severity measured by SAPS 3, higher direct costs, and higher mortality both in the ICU and in-hospital environment. Conclusion There is signifi cant demand within our institution for HDU care for our patients, with the number of admissions increasing in 2013. The main admitting diagnoses are hypertensive disease of pregnancy and haemorrhage with an increase in the number of patients being admitted for management of sepsis in 2013. This highlights the increasing awareness, recognition and management of this condition in pregnancy. The increased number of HDU admissions in 2013 could also be explained by the recent introduction of an early warning score for the deteriorating patient in our hospital but this would require further evaluation. The low number of transfers of patients to other tertiary centres underpins the importance of an anaesthesia lead service. Figure 1 (abstract P528). Figure 2 (abstract P528). Figure 1 (abstract P528). Figure 1 (abstract P528). Reference P530 Critical care in a maternity hospital: a retrospective observational study P530 Critical care in a maternity hospital: a retrospective observational study P528 Study of the costs of an ICU according to age groups relating to SAPS 3 gravity, stay and outcomes MB Velasco, MA Leitão, DM Dalcomune, MB Leitão Hospital Meridional S.A., Cariacica, Brazil Critical Care 2015, 19(Suppl 1):P528 (doi: 10.1186/cc14608) P531 Post-traumatic stress symptoms in intensive care staff working in adult and paediatric settings G Colville1, J Hammond1, L Perkins-Porras2 1St George’s Hospital, London, UK; 2St George’s University of London, UK Critical Care 2015, 19(Suppl 1):P531 (doi: 10.1186/cc14611) P534 P534 Mortality in a French military burn centre: a 12-year retrospective study analysing seasonal variations M Boutonnet1, C Dussault2, N Donat1, P Laitselart1, A Cirodde1, J Schaal1, C Hoff mann1, P Jault1, T Leclerc1 1HIA Percy, Clamart, France; 2IRBA, Brétigny sur Orge, France Critical Care 2015, 19(Suppl 1):P534 (doi: 10.1186/cc14614) f Methods After local ethics committee approval, a total of 1,004 patients (2012, n = 492; 2013, n = 454; 2014, n = 58) treated in the ICU in a 2-year period were reviewed. This study included for evaluation 135 patients determined with traumatic or nontraumatic brain damage, with a more than 24-hour stay in the ICU. Reasons for brain damage were determined as brain damage associated with head trauma (Group HT), head trauma accompanying general body trauma (Group HT + GBT) and spontaneous haemorrhage (Group SH). The type of brain damage was defi ned from the radiological diagnosis (CT and/or MRI) as subarachnoid haemorrhage, intracranial haemorrhage (ICH), subdural haematoma (SDH), epidural haematoma (EDH), skull fracture, brain contusion or a combination of these (COM). Operations were evaluated as performed by the brain surgery department. Introduction Factors associated with mortality in severely burned patients are well known. We aimed to assess the seasonal variations of the mortality of patients admitted to the main French military intensive care burn unit (ICBU) and to determine their relations to seasonal variations of severity or other factors (for example, staffi ng). Methods We performed a retrospective study analysing the medical records of all patients admitted to the ICBU of Percy Military Hospital (France) between January 2000 and December 2011. Statistical analysis was performed with R version 3.1.2. We fi rst conducted univariate analyses with simple logistic regression, then a simple periodic regression for seasonal variations (with and without harmonics for robustness), and fi nally a multivariate logistic regression with periodic terms in order to adjust seasonal variations for known severity factors. Results A total of 1,913 patients were admitted for acute burn injury during the study period, with a male to female ratio of 2.34. Mean total body surface area burned (TBSA) was 23.2% (IQR: 10 to 30) and mean full thickness total body surface area burned (FTBSA) was 13.4% (IQR: 0 to 15). Association with amount of registration and outcome in pediatric severe trauma patients S Ohnishi, N Saito, T Yagi, Y Konda, Y Hara, H Matsumoto Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan Critical Care 2015, 19(Suppl 1):P533 (doi: 10.1186/cc14613) Figure 1 (abstract P531). Main themes of staff descriptions of traumatic events on ICU. Introduction Unexpected trauma is a one of the most major causes of death for children in the world. However, pediatric severe trauma patients are rare and scattered. Although there is a strong association between patient’s volume of trauma center volume and outcomes in adults, such a report is less in children. In this study, we aimed to clarify the relationship of the amount of registration and outcome in pediatric trauma patients. most commonly endorsed: patient death (and particularly untimely deaths on adult units); handling distressed families; and concerns about the quality of care and dealing with staff confl ict (see Figure 1). Conclusion A signifi cant minority of staff reported clinically signifi cant levels of post-traumatic stress related to their work. The facts that post- traumatic stress levels were higher on paediatric units despite their lower rates of mortality and that untimely deaths were frequently mentioned by adult unit staff suggest it may be that untimely deaths are particularly hard to deal with. More research is needed on the prevalence of distress in staff working in these settings. Methods This retrospective study analyzed data of the Japan Trauma Data Bank from 2004 to 2012. We registered pediatric patients aged younger than 12 years with severe multiple or torso trauma (maximum Abbreviated Injury Scale score ≥3 or Injury Severity Score ≥9, and excluded patients with cardiopulmonary arrest on arrival, burn, isolated head or limb injury, lack of data). We divided the facilities into six groups according to every 10 patients registered and compared mortality between each group. Results A total of 1,015 patients from 105 facilities were included in the study. Number of registrations: 0 to 10 patients: 673 patients/68 facilities, 11 to 20: 381/28, 21 to 30: 141/6, 31 to 40: 101/3, 41 to 50: 45/1, 51 to 60: 58/1. Victims of blunt trauma accounted for 98.1%. Median age was 7 (interquartile range: 5 to 10) years, median injury severity score (ISS) was 17 (10 to 26). P533 P533 Association with amount of registration and outcome in pediatric severe trauma patients S Ohnishi, N Saito, T Yagi, Y Konda, Y Hara, H Matsumoto Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan Critical Care 2015, 19(Suppl 1):P533 (doi: 10.1186/cc14613) Distribution and mortality factors of cases with traumatic and nontraumatic brain damage treated in ICU S G k T k N B k G K ö E Ak S K ki Distribution and mortality factors of cases with traumatic and nontraumatic brain damage treated in ICU S Goksu Tomruk, N Bakan, G Karaören, E Akcay, S Keskin Umraniye Research and Training Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P532 (doi: 10.1186/cc14612) S Goksu Tomruk, N Bakan, G Karaören, E Akcay, S Keskin Umraniye Research and Training Hospital, Istanbul, Turkey Critical Care 2015, 19(Suppl 1):P532 (doi: 10.1186/cc14612) Introduction Cases of traumatic and nontraumatic brain damage have high rates of morbidity and mortality. In this study of cases being treated in the ICU for a diagnosis of brain damage, it was aimed to evaluate the relationship between mortality and the distribution of reason for and resulting type of brain damage and to determine other factors aff ecting mortality. i Conclusion There was a strong association between amount of registration and outcome. Post-traumatic stress symptoms in intensive care staff working in adult and paediatric settings Figure 2 (abstract P528). Figure 2 (abstract P528). Introduction The objectives of this survey were to establish the prevalence of symptoms of post-traumatic stress in mixed staff groups working in adult and paediatric intensive care settings and to examine the main themes in staff descriptions of the most traumatic event they had experienced at work. p Methods A total of 355 health professionals working on three adult and four paediatric units at two centres were asked to rate their current level of post-traumatic stress symptoms on the Trauma Screening Questionnaire (TSQ).f Results Paediatric/neonatal intensive care staff were more likely to score above the clinical cutoff point for post-traumatic stress symptoms on the TSQ in relation to an incident at work than adult intensive care staff in this sample (PICU n = 33/193 (17%) vs. AICU n = 13/162 (8%), P <0.001). For the 172 staff who provided a description of the most traumatic event they had experienced, the following themes were S186 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P531). Main themes of staff descriptions of traumatic events on ICU. (P <0.01). No statistical diff erence was determined in mortality in terms of age, gender, duration in ICU, surgical treatment or not, or reasons for brain damage (P >0.05). Conclusion There is considerable variation in causes of head injury. From this retrospective study it can be suggested that mortality of neurological/neurosurgical patients, regardless of management method, depends on APACHE II, arrival GCS, number of ventilator-days and type of brain damage. Association with amount of registration and outcome in pediatric severe trauma patients Multivariate analysis adjusted for age, revised trauma score and ISS revealed that the amount of registration (every 10 patients) was independently associated with survival (odds ratio: 1.55, 95% confi dence interval: 1.06 to 2.26, P = 0.023). P534 Simple periodic regression showed a biannual seasonal eff ect on mortality, documented with a 1-year periodic (P <0.01) and a 6-month periodic (P = 0.01) dependency. Multivariate analysis with or without periodic terms identifi ed age, past medical history, TBSA, FTBSA, inhalation, intoxication and admission date as the only factors independently associated with mortality. Conclusion Predictive factors for mortality in our ICBU are in line with the literature. The documented seasonal variations in mortality are fully explained by variations in these severity factors. Complementary analyses are under way to further study a nonlinear age eff ect. Results Baseline liver function was assessed in 1,565 patients. Of those, 522 (33%) exhibited liver dysfunction at baseline. No relationship was found with mortality according to baseline liver dysfunction status at day 28 (HR, 0.847 (95% CI, 0.647 to 1.109); P = 0.2267), day 90 (HR, 0.883 (95% CI, 0.701 to 1.112); P = 0.2892) and day 180 (HR, 0.885 (95% CI, 0.710 to 1.103); P = 0.2761). A total of 403 (26%) patients developed a new liver dysfunction (257/1,043, 25%) or worsened liver dysfunction (146/522, 28%) in the 28-day post-baseline period. The overall median time to develop or to worsen liver dysfunction was 2 (1 to 4) days. Signifi cant relationships between the new onset or the worsening of liver dysfunction post baseline and mortality at day 28 (HR, 1.67 (95% CI, 1.26 to 2.21); P = 0.0004), day 90 (HR, 1.65 (95% CI, 1.30 to 2.09); P <0.0001) and day 180 (HR, 1.57 (95% CI, 1.26 to 1.97); P <0.0001) were found. P534 Inhalation injury was present in 441 (23.1%) cases, intoxication (CO, CN) was present in 88 (4.6%) cases, and associated traumatisms also y g y Results The patients comprised 73.3% males and 26.7% females with a mean age of 40.58 ± 24.14 years (range, 1 to 87 years), mean APACHE II score of 19.07 ± 10.19 (range, 2 to 41), mean GCS of 9.17 ± 4.42 (range, 3 to 15) and 68.1% of whom were discharged and 31.9% were exitus. When the causes of brain damage were evaluated according to the type, the most frequently seen in the HT and HT + GBT groups were COM (37.3%, 42.9%), followed by EDH (13.6%, 28.6%). In the SH group, the most common reason was ICH (43.9%) followed by SDH (24.4%). Directly proportionally, only an increase in APACHE II score increased the mortality risk 1.3-fold (logistic regression analyses, coeffi cient 0.658) but the duration of intubation and ICH ratio was statistically signifi cantly high and GCS was low in the exitus cases, and rates of EDH were determined as high in discharged cases compared with exitus S187 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods All of the patients enrolled in the PROWESS-SHOCK were included. Liver dysfunction at baseline was defi ned by a liver Sequential Organ Function Assessment (SOFA) score >0. The onset of a liver dysfunction post baseline was defi ned as any post-baseline increase of the hepatic SOFA score from 0. The worsening of liver dysfunction post baseline was defi ned as any increase of the hepatic SOFA score from the baseline assessment. The post-baseline period studied extended from study drug infusion to day 28. The main outcome was the mortality at day 180, and the secondary outcomes were the mortality at day 28 and at day 90. Cox proportional hazard models were used to estimate the hazard ratio of death. in 88 (4.6%) cases. The mortality rate was 10.9%. The following factors were associated with mortality in univariate logistic regression: age, body mass index, past medical history, TBSA, FTBSA, intoxication (CO, CN), inhalation injury, fl ame burns, self-infl icted burns (all P <0.0001), sex (P <0.001), and admission date (P <0.01). Predictors of 30-day mortality in cancer patients with septic shock E Osawa, C Park, F Bergamin, B Pileggi, J Almeida, R Nakamura, I Duayer, G Queiroz, F Galas, J Ribeiro, I Bispo, J Fukushima, L Hajjar Institute of Cancer of University of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P537 (doi: 10.1186/cc14617) Predictors of 30-day mortality in cancer patients with septic shock E Osawa, C Park, F Bergamin, B Pileggi, J Almeida, R Nakamura, I Duayer, G Queiroz, F Galas, J Ribeiro, I Bispo, J Fukushima, L Hajjar Institute of Cancer of University of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P537 (doi: 10.1186/cc14617) Results One patient was admitted twice during this period. The sample comprised 11 males and 11 females (50%, respectively). Featuring an average age of 52 years, 78% of them were admitted to the ICU because of respiratory failure, 50% were due to diff use alveoli hemorrhage, 36% due to sepsis, 4% hypovolemic shock and fi nally 4% because of tuberculosis. According to the BVAS/WG, 20 patients corresponded to severe disease, one to limited diseases and one to persistent disease. The average ICU length of stay was 20.6 days and as inpatients 43 days. While comparing the SOFA score between alive and deceased patients there was a 0.5-point diff erence (P = 0.077), 63% of the alive patients were diagnosed while they were in the ICU. Plasmapheresis was found to be a protector factor (P <0.05).if Introduction In cancer patients, sepsis is the main cause of admission to the ICU and is associated with elevated mortality rates and healthcare costs. In this population, specifi c factors such as poor functional status and immunosuppression secondary to malignancy and/or antineoplastic treatment contribute to decreased survival. The aim of this study is to identify predictors of mortality in cancer patients admitted to the ICU with septic shock. Methods This is a retrospective study that analyzed predictors of 30- day mortality in 269 patients admitted to the ICU of the Institute of Cancer of State of São Paulo, Brazil, from February 2012 to November 2014. Conclusion The BVAS/WG score was signifi cantly diff erent between alive and deceased patients. Plasmapheresis was found to be a survival predictor. This study has shown that both SOFA and APACHE II scores have no prognostic value in these patients. Results From 1,250 patients admitted to the ICU, 269 patients had the admission diagnosis of septic shock and were analyzed. The mean age was 62 ± 14 years and 152 patients (56.5%) were male. Most patients had solid cancer (93.6%), and 87 patients (34.5%) had gastrointestinal neoplasm. Predictors of 30-day mortality in cancer patients with septic shock E Osawa, C Park, F Bergamin, B Pileggi, J Almeida, R Nakamura, I Duayer, G Queiroz, F Galas, J Ribeiro, I Bispo, J Fukushima, L Hajjar Institute of Cancer of University of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P537 (doi: 10.1186/cc14617) Upon admission, the median SOFA score was 4 (IQR: 2 to 7), median SAPS 3 score was 55 (IQR: 48 to 68) and median lactate level was 1.88 mmol/l (IQR: 1.22 to 3.21). After 48 hours of ICU admission, acute kidney injury (AKI) was diagnosed according to AKIN classifi cation as follows: 202 patients (75.1%) had grade 0, 49 (18.2%) grade 1, seven (2.6%) grade 2 and 11 (4.1%) had grade 3. The 30-day mortality rate was 24.9%. In the univariate analysis, associated variables with 30-day mortality were age, urea and creatinine levels at admission, SOFA score at admission, SAPS 3 score and 48-hour AKI. In multivariate analysis, the predictive factors for 30-day mortality were SOFA score at admission (OR = 1.12; 95% CI: 1.04 to 1.21, P = 0.002) and 48-hour AKI defi ned as AKIN grades 1, 2 and 3 (OR = 2.69; 95% CI: 1.45 to 4.97, P = 0.002). P534 P535 ICU outcomes in patients suff ering granulomatosis with polyangitis C Hernandez-Cardenas1, GL Lugo-Goytia1, MS Sierra Beltran2, G Dominguez Cherit3 1Instituo Nacional de Enfermedades Respiratorias, Mexico DF, Mexico; 2Medica Sur, Mexico DF, Mexico; 3Instituo Nacional de Ciencias Medicas y Nutrición Salvador Zubirán, Mexico DF, Mexico Critical Care 2015, 19(Suppl 1):P535 (doi: 10.1186/cc14615) Introduction This study aims to describe both the clinical course and prognostic factors of patients suff ering granulomatosis with polyangitis (Wegener granulomatosis) (GP) who were admitted to the Salvador Zubirán National Medical Sciences and Nutrition ICU.f Introduction This study aims to describe both the clinical course and prognostic factors of patients suff ering granulomatosis with polyangitis (Wegener granulomatosis) (GP) who were admitted to the Salvador Zubirán National Medical Sciences and Nutrition ICU.f Conclusion The new onset or the worsening of liver dysfunction during the course of septic shock impacts strongly on long-term mortality. Septic patients with liver dysfunction need long-term follow-up. Future research should focus on developing specifi c septic liver therapeutics and new tools for earlier detection of septic liver dysfunction. Reference Methods Twenty-two patients suff ering GP admitted to the ICU, between January 2002 and December 2012, were included. The Acute Physiology and Chronic Health Evaluation (APACHE) II prognostic score scale was used in order to assess the severity of illness on the fi rst ICU day. The Sequential Organ Failure Assessment (SOFA) score was used to measure organ dysfunction, and the Birmingham vasculitis activity score for Wegener granulomatosis (BVAS/WG) was used to assess vasculitis activity. The outcome measurements taken into account were ICU mortality and ICU length of stay. 1. Ranieri et al. N Engl J Med. 2012;366;2055-64. Liver dysfunction is associated with long-term mortality in septic shock N Nesseler1, Y Launey1, C Aninat1, J White2, P Seguin1, Y Mallédant1 Liver dysfunction is associated with long-term mortality in septic shock N Nesseler1, Y Launey1, C Aninat1, J White2, P Seguin1, Y Mallédant1 1CHU Pontchaillou, Rennes, France; 2Duke University Medical Centre, Durham, NC, USA Critical Care 2015, 19(Suppl 1):P536 (doi: 10.1186/cc14616) Liver dysfunction is associated with long-term mortality in septic shock N Nesseler1, Y Launey1, C Aninat1, J White2, P Seguin1, Y Mallédant1 1CHU Pontchaillou, Rennes, France; 2Duke University Medical Centre, Durham, NC, USA Critical Care 2015, 19(Suppl 1):P536 (doi: 10.1186/cc14616) 1CHU Pontchaillou, Rennes, France; 2Duke University Medical Centre, Durham, NC, USA Critical Care 2015, 19(Suppl 1):P536 (doi: 10.1186/cc14616) Critical Care 2015, 19(Suppl 1):P536 (doi: 10.1186/cc14616) Critical Care 2015, 19(Suppl 1):P536 (doi: 10.1186/cc14616) Introduction Knowledge of the impact of liver dysfunction on mortality during septic shock is limited. However, the liver appears to play a key role during septic illness. To better explore this issue, we investigated the data collected during the Prospective Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis and Septic Shock (PROWESS-SHOCK) trial in which a cohort of 1,697 septic shock patients were constituted [1]. The study aimed to assess the relationship of liver dysfunction at the onset and during the course of septic shock on short-term and long-term mortality. Conclusion In cancer patients with septic shock, SOFA score at admission and acute kidney injury at 48 hours of admission were predictors of 30-day mortality. These fi ndings reinforce the needing of early strategies of diagnosis and therapy in this subset of patients. S188 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 disease remission and 31 (11.2%) had newly diagnosed disease. The ICU mortality rate was 26%, hospital mortality was 35.7% and 6-month mortality was 55.2%. The median number of organ dysfunction was 3 (IQR 2 to 4) and respiratory failure was the leading dysfunction, being present in 209 patients (75.5%). During the ICU stay, 21 patients needed hemodialysis (8%), 69 (25%) needed mechanical ventilation, 162 (58%) used vasoactive agents and 22 (8%) had a decision for limitation of medical treatment. On univariate analysis, risk factors for hospital mortality were acute myeloid leukemia, hospital stay prior to ICU admission >4 days, number of organ dysfunction ≥2, colonization and infection by a multidrug-resistant (MDR) agent, use of mechanical ventilation, use of vasoactive agents and renal replacement therapy. I Duayer, E Osawa, C Park, J Fukushima, J Almeida, R Nakamura, F Galas, L Hajjar I Duayer, E Osawa, C Park, J Fukushima, J Almeida, R Nakamura, F Galas, L Hajjar Institute of Cancer of State of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P539 (doi: 10.1186/cc14619) Introduction In recent decades, therapeutic advances resulted in increased survival of patients with hematologic malignancies. These patients are increasingly admitted to the ICU due to infections, treatment toxicity and decompensation of chronic diseases. The aim of this study is to evaluate ICU, hospital and 6-month mortality in patients with hematological malignancies admitted to the ICU and to identify predictors of ICU mortality. y g Conclusion In our study, ICU and hospital mortality were lower than the pooled mortalities seen in a recent large systematic review [3] – despite our study excluding planned postoperative admissions (who are known to have better outcomes). The 180-day mortality was signifi cantly lower than in a previous study at our own institution [4]. Our study looked at a number of factors that might reasonably be expected to be associated with short-term and long-term outcomes and identifi ed several that were independent predictors of death by 180 days. Methods We performed a retrospective study of 277 consecutive patients with hematological malignancies admitted to the ICU of the Institute of Cancer of State of São Paulo, Brazil, from January 2010 to December 2013. Patient clinical and laboratory characteristics, evaluation of organ dysfunctions and need for hemodialysis, mechanical ventilation and vasoactive agents in the ICU were collected. The primary outcome was ICU mortality. Data were analyzed with univariate and multivariate logistic regression. Liver dysfunction is associated with long-term mortality in septic shock N Nesseler1, Y Launey1, C Aninat1, J White2, P Seguin1, Y Mallédant1 Multivariate analysis revealed that renal replacement therapy (OR = 6.35 (95% CI: 1.5 to 25.92), P = 0.010), SOFA score (OR = 1.69 (95% CI: 1.38 to 2.06), P <0.001), RDW (OR = 1.27 (95% CI: 1.11 to 1.46), P = 0.001), lactate (OR = 1.04 (95% CI: 1.02 to 1.06), P <0.001), colonization of MDR agent (OR = 10.73 (95% CI: 2.13 to 53.96), P = 0.004) and hospital stay prior to ICU admission >4 days (OR = 4.72 (95% CI: 1.8 to 12.3), P = 0.002) were predictive factors of ICU mortality. Factors associated with short-term and long-term mortality in solid cancer patients admitted to the ICU R Fi h 1 C D i 1 S C i h 2 S Sl 1 L S 1 Factors associated with short-term and long-term mortality in solid cancer patients admitted to the ICU R Fisher1, C Dangoisse1, S Crichton2, S Slanova1, L Starsmore1, T Manickavasagar1, C Whiteley1, M Ostermann1 1Guy’s and St Thomas’ NHS Trust, London, UK; 2King’s College London, UK Critical Care 2015, 19(Suppl 1):P540 (doi: 10.1186/cc14620) Introduction Despite multiple reports demonstrating an improvement in outcomes of critically ill cancer patients admitted to ICUs over the last two decades [1], there is concern that admission policies for patients with cancer are overly restrictive [2]. The purpose of this study was to identify factors associated with mortality in the 180 days following unplanned ICU admission in patients with nonhaematological malignancy. Introduction Despite multiple reports demonstrating an improvement in outcomes of critically ill cancer patients admitted to ICUs over the last two decades [1], there is concern that admission policies for patients with cancer are overly restrictive [2]. The purpose of this study was to identify factors associated with mortality in the 180 days following unplanned ICU admission in patients with nonhaematological malignancy. Conclusion The ICU mortality of critically ill patients with HM is high, particularly in the group on MV. Diff erent factors were independent predictors of mortality, but 46.4% of admitted patients survived because of adequate support possibilities and were transferred back to hematology ward. The ICU admission with organ support is according results important for life saving in this extremely high-risk patient group. g p References Methods We carried out a retrospective analysis of all patients with solid tumours admitted to the Guy’s Critical Care Unit (13-bed level 3 ICU) as an emergency between August 2008 and July 2012. Data were collected regarding patient demographics, type of cancer, reason for referral and organ support required during the ICU stay. References 1. Azoulay E, et al. The intensive care support of patients with malignancy: do everything that can be done. Intensive Care Med. 2006;32:3-5. 1. Azoulay E, et al. The intensive care support of patients with malignancy: do everything that can be done. Intensive Care Med. 2006;32:3-5. 1. Azoulay E, et al. The intensive care support of patients with malignancy: do everything that can be done. Intensive Care Med. 2006;32:3-5. 2. Grgic Medic M, et al. Hematologic malignancies in the medical intensive care unit – outcomes and prognostic factors. Hematology. 2014 [Epub ahead of print]. y Results During the 4-year study period there were 356 unplanned admissions of patients with solid cancer (8.3% of all admissions). Three hundred individual patients were admitted and 180-day survival data were available for 293 of these. Mean age at fi rst admission was 65.2 years, 115 (38.3%) were female. The most frequently present malignancies were lung (42.7%), head and neck (17.3%) and renal (6.7%). ICU, hospital and 180-day mortality were 19.1%, 31.0% and 52.2% respectively. Those factors found to be independently associated (in multivariate analysis) with increased risk of 180-day mortality include: metastases (OR = 4.0, 95% CI = 2.1 to 7.6); sepsis on admission (OR = 2.2, 95% CI = 1.2 to 4.1); APACHE II score on admission (OR = 1.06, 95% CI = 1.004 to 1.12); need for inotropes/vasopressors during admission (OR = 2.3, 95% CI = 1.05 to 4.8); and need for renal replacement therapy during admission (OR = 4.65, 1.7 to 12.8). References 1. Mokart D, et al. Intensive Care Med. 2014;40:1570-2. 2. Azoulay E, et al. Ann Intensive Care. 2011;1:5. 3. Puxty K, et al. Intensive Care Med. 2014;40:1409-28. 4. McGrath S, et al. QJM. 2010;103:397-403. P538 Is admission of hematologic malignancies in the ICU justifi ed? VG Gasparovic, MM Grgic Medic, IG Gornik KBC Zagreb, Croatia Critical Care 2015, 19(Suppl 1):P538 (doi: 10.1186/cc14618) P538 Is admission of hematologic malignancies in the ICU justifi ed? VG Gasparovic, MM Grgic Medic, IG Gornik KBC Zagreb, Croatia Critical Care 2015, 19(Suppl 1):P538 (doi: 10.1186/cc14618) Introduction The admission of malignant hematology patients to the ICU is combined with poor prognosis [1]. A young population on one side and serious prognosis on the other are the main characteristics. Do we help? We are analyzing continuously clinical characteristics, treatment, and outcomes of critically ill patients with hematologic malignancies admitted to the medical ICU to identify predictors of adverse outcome [2]. Methods Demographic characteristics, hematologic diagnosis, reasons for ICU admission, transplant status, the presence of neutropenia, and APACHE II and SOFA scores were analyzed. Predictors of ICU mortality were evaluated using univariate analysis. g y Results There was a total of 194 patients (103 male), APACHE II score by admission was 27 ± 8, SOFA 9 ± 3. Acute leukemia (L) in 81 patients (41.8%), chronic L in 19 patients (9.8%), lymphoma in 58 patients (29.9%), and multiple myeloma in 28 patients (14.4%) were the etiology. Respiratory insuffi ciency, hemodynamic instability, AKI and CNS disturbances were responsible for the admission of 169 patients (87.1%) from the hematology ward to the ICU. In total, 127 patients (59.7%) were mechanically ventilated; 93 required invasive mechanical ventilation (MV). Non-invasive ventilation started in 34 patients and was successful in 14 (6.5%). The ICU mortality rate was 104 patients (53.6%), and the mortality of MV patients was 98 (77.2%). Need for vasopressors at admission, MV, neutropenia, and APACHE II and SOFA scores were identifi ed as independent predictors of fatal outcome. Overall mortality of admitted patients was 53.6% (104 patients), and in ventilated patients was 77.2% (98 patients). Conclusion Patients from our institution have survival rates comparable with data from the literature. Our study suggests that mortality is associated with late ICU admission and colonization of MDR bacteria. P540 P540 Outcomes of patients with hematologic malignancies admitted to the ICU I Duayer, E Osawa, C Park, J Fukushima, J Almeida, R Nakamura, F Galas, L Hajjar Institute of Cancer of State of São Paulo, Brazil Critical Care 2015, 19(Suppl 1):P539 (doi: 10.1186/cc14619) y References References 1. Mokart D, et al. Intensive Care Med. 2014;40:1570-2. 2. Azoulay E, et al. Ann Intensive Care. 2011;1:5. 3. Puxty K, et al. Intensive Care Med. 2014;40:1409-28. 4. McGrath S, et al. QJM. 2010;103:397-403. Results The median age of the population was 57 years and 144 patients (52%) were male. Upon admission, 15 patients (5.4%) had S189 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 P541 Characteristics and outcomes of lung cancer patients requiring ventilatory support: results from a multinational study AC Toff art1, JF Timsit1, J Salluh2, G Burghi3, C Irrazabal4, N Pattison5, E Tobar6, B Almeida7, E Azoulay8, M Soares9 1Hopital A. Michalon CHU Grenoble, France; 2Post-graduation Program – Inst. Nacional de Cancer, Rio de Janeiro, Brazil; 3Hospital Maciel, Montevideo, Uruguay; 4Instituto Alexander Fleming, Buenos Aires, Argentina; 5Royal Brompton Hospital, London, UK; 6Hospital Clinico Universidad de Chile, Santiago, Chile; 7Hospital A.C. Camargo, São Paulo, Brazil; 8Hopital Saint Louis, Paris, France; 9DOr Institute for Research and Education – IDOR, Rio de Janeiro, Brazil Critical Care 2015, 19(Suppl 1):P541 (doi: 10.1186/cc14621) P541 using Hosmer–Lemeshow goodness of fi t test. Data will be reported as median (range) or proportions (95% confi dence interval). P541 Characteristics and outcomes of lung cancer patients requiring ventilatory support: results from a multinational study AC Toff art1, JF Timsit1, J Salluh2, G Burghi3, C Irrazabal4, N Pattison5, E Tobar6, B Almeida7, E Azoulay8, M Soares9 1Hopital A. Michalon CHU Grenoble, France; 2Post-graduation Program – Inst. Nacional de Cancer, Rio de Janeiro, Brazil; 3Hospital Maciel, Montevideo, Uruguay; 4Instituto Alexander Fleming, Buenos Aires, Argentina; 5Royal Brompton Hospital, London, UK; 6Hospital Clinico Universidad de Chile, Santiago, Chile; 7Hospital A.C. Camargo, São Paulo, Brazil; 8Hopital Saint Louis, Paris, France; 9DOr Institute for Research and Education – IDOR, Rio de Janeiro, Brazil Critical Care 2015 19(S ppl 1) P541 (doi 10 1186/cc14621) Results A total of 2,769 patients were included, median age 65 (18 to 100) years and 52% female. Thirty-day mortality was 4.5% and 2.2% were admitted to ICU. Median time to ICU admission was 1 (0 to 70) day. Nursing staff assessed 65% and physicians 26% of admissions. NEWS could be calculated for 85%. Nursing staff had a discriminatory power of 0.865 (0.786 to 0.944) with little variation with experience. Calibration was acceptable, except for the least experienced nurses (<5 years). References 1. Fuchs L, et al. Intensive Care Med. 2012;38:1654-61. 2. Nielsson MS, et al. Acta Anaesthesiol Scand. 2014;58:19-26. Hospital of South West Jutland, Esbjerg, Denmark Critical Care 2015, 19(Suppl 1):P542 (doi: 10.1186/cc14622) Introduction Not all patients in need of critical care arrive in clinical distress and some deteriorate after arrival. Identifying these patients early in their clinical course could potentially improve outcome. The present study was performed with the aim of assessing whether nursing and physician staff were able to identify patients in need of critical care using only clinical judgment and to compare this with the National Early Warning Score (NEWS). y References Physicians had a discriminatory power of 0.789 (0.641 to 0.937), with little variation with experience. Calibration was very good, regardless of experience. NEWS had a discriminatory power of 0.809 (0.727 to 0.891) and poor calibration. There was no signifi cant diff erence in discriminatory power between the three assessments.f Critical Care 2015, 19(Suppl 1):P541 (doi: 10.1186/cc14621) Introduction The aim was to evaluate clinical characteristics and outcomes of patients with lung cancer requiring ventilatory support. Methods Secondary analysis of a prospective multicenter study including patients requiring either invasive (IMV) or non-invasive (NIV) mechanical ventilation for >24 hours admitted to 22 ICUs in six countries from Europe and South America during 2011. We used shared frailty models to identify factors associated with 6-month survival. f y p Conclusion Both nursing staff and physicians were as good as NEWS at identifying patients at increased risk of ICU admission after admission to a medical admission unit. However, both nursing staff and physicians had better calibration (accuracy) than NEWS. P543 5 3 Clinical characteristics in surviving and nonsurviving older patients admitted to the ICU Results Out of 449 patients admitted to the ICUs, 239 (small-cell (SCLC) = 34; non-SCLC = 205) required ventilatory support (NIV = 104; IMV = 135). Out of NIV patients, 31 (30%) were subsequently intubated for IMV. Main reasons for ventilatory support were sepsis (n = 119; among them, 102 patients had pneumonia), airway involvement by tumor (n = 79), ARDS (n = 47) and coma (n = 18). Mean SAPS II score was 54 ± 20 and median SOFA score was 7 (4 to 12) points. Hospital and 6-month mortality rates were 55% and 67%; 94 (39%) patients received treatment limitations in the ICU. Mortality according to ventilatory strategy was 56% for NIV only, 77% for NIV followed by IMV, and 70% for IMV only. In the multilevel model, adjusting for the hospital size, presence of step-down units, type of admission and treatment limitation, performance status (PS) 3 to 4 (HR = 2.25 (95% CI, 1.52 to 3.34)), metastasis (HR = 1.66 (1.18 to 2.33)) and the ventilatory strategy compared with NIV only (HR = 1.73 (1.02 to 2.92), for NIV followed by IMV; HR = 2.25 (1.51 to 3.35), for IMV only) were associated with increased mortality. Conversely, patients with sepsis had higher survival (HR = 0.67 (0.46 to 0.96)). Introduction In recent years the proportion of older people admitted to the ICU has increased. A variety of clinical and physiological factors are associated with outcome in these patients. The aim of this study is to determine the clinical characteristics associated with survival of ICU mechanically ventilated older patients. Introduction In recent years the proportion of older people admitted to the ICU has increased. A variety of clinical and physiological factors are associated with outcome in these patients. The aim of this study is to determine the clinical characteristics associated with survival of ICU mechanically ventilated older patients. Methods We retrospectively studied 74 patients, aged >65 years, admitted to the ICU who underwent mechanical ventilation. Standard demographic, clinical, and physiologic data were recorded. We examined the signifi cant diff erences in clinical characteristics between survivors and nonsurvivors using the Student t and chi-square tests. Methods We retrospectively studied 74 patients, aged >65 years, admitted to the ICU who underwent mechanical ventilation. Standard demographic, clinical, and physiologic data were recorded. Admission to intensive care can be reliably predicted using only clinical judgment Admission to intensive care can be reliably predicted using only clinical judgment M Brabrand Hospital of South West Jutland, Esbjerg, Denmark Critical Care 2015, 19(Suppl 1):P542 (doi: 10.1186/cc14622) M Brabrand 5 3 Clinical characteristics in surviving and nonsurviving older patients admitted to the ICU We examined the signifi cant diff erences in clinical characteristics between survivors and nonsurvivors using the Student t and chi-square tests. Results The mean age of patients studied (43 men and 31 women) was 79 ± 6.4 years. The type of admission was surgical 18%, trauma 26% and medical 57%. The ICU mortality of these patients was 57% and it was not associated with gender and cause of admission to ICU. Patients who survived had lower Charlson Comorbidity Index (P <0.05) and shorter duration of mechanical ventilation (P <0.01). The episodes of ventilation-associated pneumonia, sepsis and renal failure were less frequently in survivors (P <0.05). Also, in addition serum iron and cholesterol levels were signifi cantly lower in nonsurvivors (P <0.01). Conclusion The mortality of ICU older patients is high. VAP, sepsis and renal failure are frequent complications in nonsurvivors. Pre-existing comorbidities considerably aff ect mortality. R f su o s a d o su o s us g t e Stude t t a d c squa e tests. Results The mean age of patients studied (43 men and 31 women) was 79 ± 6.4 years. The type of admission was surgical 18%, trauma 26% and medical 57%. The ICU mortality of these patients was 57% and it was not associated with gender and cause of admission to ICU. Patients who survived had lower Charlson Comorbidity Index (P <0.05) and shorter duration of mechanical ventilation (P <0.01). The episodes of ventilation-associated pneumonia, sepsis and renal failure were less frequently in survivors (P <0.05). Also, in addition serum iron and cholesterol levels were significantly lower in nonsurvivors (P <0 01) Conclusion In a multinational study, 6-month survival in lung cancer patients requiring ventilatory support is better than perceived a priori. Palliative care should be preferred in patients with poor PS. p p p Acknowledgements Funded by INCA, CNPq and FAPERJ. cholesterol levels were signifi cantly lower in nonsurvivors (P <0.01). Conclusion The mortality of ICU older patients is high. VAP, sepsis and renal failure are frequent complications in nonsurvivors. Pre-existing comorbidities considerably aff ect mortality. References Frailty predicts increased resource use and postoperative care requirements after revision hip surgery P546 Emergency laparotomy clinical outcome according to patient characteristics, level of postoperative care and time of surgery T Banerjee1, M Templeton2, C Gore2 1St Mary´s Hospital, London, UK; 2Imperial College Healthcare NHS Trust, London, UK Critical Care 2015, 19(Suppl 1):P546 (doi: 10.1186/cc14626) Critical Care 2015, 19(Suppl 1):P546 (doi: 10.1186/cc14626) Introduction Emergency laparotomies have poor outcomes with variable postoperative critical care provision [1-3]. All patients requiring an emergency laparotomy with an estimated risk of death of >10% should go to critical care. Time of surgery should not aff ect standard of care [3,4]. In advance of the National Emergency Laparotomy Audit (NELA) results [2], our objective was to see whether the level of postoperative care and time of surgery aff ect outcome. Results A total of 389 patients with a mean age of 68.7 years were identifi ed. Frail patients were signifi cantly more likely to need vasopressors postoperatively (P = 0.012). Each increase in frailty score was associated with 0.16 increase in length of stay on the HDU (P = 0.025). Analysis of patient location at 30 days shows that frail patients stay in hospital longer (P = 0.00). Frail patients also bleed more intraoperatively (P = 0.00 with a coeffi cient value of 239; that is, for every point increase in frailty, average blood loss increases by 239 ml). For each increase by unit of blood transfused, the length of stay increased by 5.3 days (P = 0.000). The use of epidural is not associated with increased need for postoperative vasopressors (P = 0.598). See Figure 1. g yf Methods Retrospective data were collected across the Imperial NHS trust for all emergency laparotomies over 3 months in 2014: length of stay in days (LOS); mortality; age; ASA; surgery time and postoperative care level, that is ward (L1), high dependency (L2), or ICU (L3). Statistical tests: Mann–Whitney, Pearson correlation (PCC) and multilinear regression analysis. g y Results Seventy-one patients underwent surgery. Overall mortality was 13% and 70% of patients went to a L2/3 bed. More ASA 1/2 patients went to L1 and all ASA 4/5 went to L2/3. Median (IQR) for age was 61 (44 to 67) for L1, 65 (48 to 73) for L2/3 (P = 0.11), LOS was 10 (7 to 16) for L1, 19 (12 to 57) for L2/3 (P = 0.002), and mortality (%) was 0 for L1 and 18 for L2/3. g p References 1. Saunders D, et al. Br J Anaesth. 2012;109:368-75. 1. Saunders D, et al. Br J Anaesth. 2012;109:368-75. 1. Saunders D, et al. Br J Anaesth. 2012;109:368 75. 2. NELA project team. Executive summary, fi rst organisational report of the National Emergency Laparotomy Audit. London: RCoA; 2014. 3. www.ncepod.org.uk/2011poc.htm. 4. www.rcseng.ac.uk/publications/docs/ emergency-surgery-standards-for-unscheduled-care. , ; 2. NELA project team. Executive summary, fi rst organisational report of the National Emergency Laparotomy Audit. London: RCoA; 2014. 3. www.ncepod.org.uk/2011poc.htm. 4. www.rcseng.ac.uk/publications/docs/ emergency-surgery-standards-for-unscheduled-care. 2. NELA project team. Executive summary, fi rst organisational report of the N ti l E L t A dit L d RC A 2014 2. NELA project team. Executive summary, fi rst organisational report of the National Emergency Laparotomy Audit. London: RCoA; 2014. National Emergency Laparotomy Audit. London: RCoA; 2014. 3. www.ncepod.org.uk/2011poc.htm. 4. www.rcseng.ac.uk/publications/docs/ emergency-surgery-standards-for-unscheduled-care. Methods We prospectively collected data on 339 adult patients admitted to two ICUs in Rwanda between August 2013 and July 2014. We described demographic and presenting characteristics and outcomes. We assessed the discrimination and calibration of the MPMo-III model. Using stepwise selection, we then developed a new logistic model for mortality prediction, the R-MPM. Frailty predicts increased resource use and postoperative care requirements after revision hip surgery A Panickar1, N Singatullina1, J Stubbs1, C Johnson1, R Porter2, D Bryden1 1Sheffi eld Teaching Hospitals, Sheffi eld, UK; 2Leicester Hospitals, Leicester, UK Critical Care 2015, 19(Suppl 1):P544 (doi: 10.1186/cc14624) A Panickar1, N Singatullina1, J Stubbs1, C Johnson1, R Porter2, D Bryden1 1Sheffi eld Teaching Hospitals, Sheffi eld, UK; 2Leicester Hospitals, Leicester, UK Critical Care 2015, 19(Suppl 1):P544 (doi: 10.1186/cc14624) y Methods This was a prospective cohort study of all adult patients with a fi rst-time admission to a medical admission unit at a 450-bed regional teaching hospital over a 3-month period in 2010. All subspecialties of internal medicine are present as well as a level 2 ICU. Upon fi rst contact with the patient after arrival, nursing staff and physicians were asked to report their estimation of the probability of ICU admission (0 to 100%). Survival status was extracted from the Danish Civil Registry. All administrative details (including transfers to other hospitals, wards and ICUs) were extracted from the National Patient Registry, both ensuring complete follow-up. The discriminatory power (ability to identify patients at increased risk) was estimated using area under the receiver- operating characteristics curve. Calibration (accuracy) was assessed Introduction There is increasing demand for revision hip surgery in older patients with poor frailty. Our previously submitted work demonstrated that frailty predicts the need for medical review [1]. We reviewed patients for a further 16 months to see whether frailty impacts on care [2]. This is the largest reported study reviewing frailty and the need for organ supports and outcomes in complex orthopaedic surgery. Methods A retrospective note review of all patients from January 2012 to April 2014 undergoing revision hip surgery. Data collected included frailty, comorbidities, operative blood loss, anaesthetic technique and level of organ supports and patient location at 30 days. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 S190 Figure 1 (abstract P544). Frailty versus length of stay. of 8.881. The MPMo-III predicted mortality with area under the curve of 0.720 and Hosmer–Lemeshow chi-square statistic of 16.391, indicating that the predictive risk scores of the MPMo-III were not well calibrated to the Rwandan data. Figure 1 (abstract P544). Frailty versus length of stay. Conclusion The MPMo-III had modest risk prediction capacity in a population of Rwandan ICU patients. The R-MPM is an alternative severity score with fewer and more accessible variables that provides better predictive power. This model needs to be validated in other ICUs. References References 1. Singatullina et al. Abstract. Crit Care. 2014;18 Suppl 1:P49N. 2. Rockwood K, et al. Can Med J. 2005;173:489-95. 1. Singatullina et al. Abstract. Crit Care. 2014;18 Suppl 1:P49N. 2. Rockwood K, et al. Can Med J. 2005;173:489-95. Frailty predicts increased resource use and postoperative care requirements after revision hip surgery For surgery between 08:00 and 17:59, 14 went to L1, 28 to L2/3. Mortality was 5% and LOS 15 (9 to 24). Between 18:00 and 21:59, two went to L1, 10 to L2/3. Mortality was 17% and LOS 22 (8 to 34). Between 22:00 and 07:59, fi ve went to L1, 12 to L2/3. Mortality was 29% and LOS 15 (9 to 36). ASA strongly predicted mortality (P = 0.006, PCC 0.32). There was a negative correlation between postoperative destination and mortality with all deaths happening in those who went to L2/3 (P = 0.038 and PCC –0.25); however, sicker patients may have gone here. There was a strong correlation between mortality and time of surgery, night surgery being a strong predictor of mortality (PCC 0.31, P = 0.008). LOS can be predicted by a combination of ASA, age and care level (P = 0.027); the postoperative care regression coeffi cient was negative (–18.04, SE 10.41) with prolonged LOS in patients admitted to L2/3, which could also be explained by illness severity. g Conclusion Frailty is associated with increased intraoperative resource use and postoperative care requirements independent of choice of anaesthetic technique. This type of surgery should be subject to health economic analysis as demand amongst the frailer surgical population increases. P545 P545 Predicting outcomes in critically ill patients in a resource-poor setting: the Rwanda Mortality Probability Model T Twagirumugabe1, E Riviello2, R Fowler3, V Novack4, A Mueller2, W Kiviri1, V Banner-Goodspeed2, D Talmor2 1University of Rwanda, Kigali, Rwanda; 2Beth Israel Deaconess Medical Center, Boston, MA, USA; 3University of Toronto, ON, Canada; 4Ben-Gurion University of the Negev, Beer Sheva, Israel Critical Care 2015, 19(Suppl 1):P545 (doi: 10.1186/cc14625) Predicting outcomes in critically ill patients in a resource-poor setting: the Rwanda Mortality Probability Model g y y T Twagirumugabe1, E Riviello2, R Fowler3, V Novack4, A Mueller2, W Kiviri1, V Banner-Goodspeed2, D Talmor2 p y y Conclusion Trust mortality is similar to that in the Emergency Laparotomy Network audit [1]. Higher ASA patients are appropriately going to L2/3 care. Baseline health status and time of surgery are the strongest predictors of mortality in emergency laparotomy patients. References Introduction ICU mortality prediction models provide robust tools for research and benchmarking in the developed world, but an ICU mortality prediction model has not been validated in a resource-poor setting. We sought to validate the Mortality Probability Admission Model, version III (MPMo-III) in two public ICUs in Rwanda and to develop a simplifi ed Rwanda Mortality Probability Model (R-MPM) for use in developing countries. P549 P549 Disturbed circadian rhythm in ICU patients as indicated by melatonin levels: a prospective pilot study K Kiss1, I Földesi1, L Kemény1, V Csernus2, Z Molnár1, J Singer3 1University of Szeged, Hungary; 2University of Pécs, Hungary; 3Hungarian Society for Clinical Biostatistics, Hungary Critical Care 2015, 19(Suppl 1):P549 (doi: 10.1186/cc14629) pi y Results Age, platelets, ALT and APACHE II were selected to be included in the new laboratory-based score. The AUC for the score was 0.714, which was higher than each of the individual laboratory parameters. The AUC was increased further to 0.781 by including all 14 variables (age, lactate, FiO2, urea, creatinine, ALT, APACHE II, platelet, bicarbonate, haemoglobin, pH, ionised Ca, carboxyhaemoglobin and albumin), although this improvement was not considered signifi cant as the confi dence intervals of the two scores (4 and 14 variables) overlapped. Conclusion A laboratory-based score was successfully established in ICU patients, revealing an AUC of 0.714 which is comparable with established scores in a similar population. The compilation of the variables to produce a laboratory-based score showed greater prognostic power than individual variables. Model developers require an AUC of >0.7 to be termed useful; however, in order to be used in a clinical setting the AUC must be at least 0.75. Further research including internal and external validation studies must be performed to optimise the model before clinical implementation. Introduction The aim of this prospective pilot study was to test how melatonin levels follow the circadian cycle in ICU patients. There is strong evidence that changes of circadian rhythm are refl ected in melatonin levels with peak levels at dawn and low levels during daytime [1]. The ICU stay is accompanied by disturbed circadian rhythm [2], which could potentially be the result of artifi cial lighting conditions. Methods Melatonin levels were determined in eight medical ICU patients on mechanical ventilation, without brain injury or infection. Arterial blood samples were taken on the day of admission at 18:00 (TE0) and 03:00 in the morning (TM0), then at the same time points 48 hours later (TE1, TM1). Blood samples were centrifuged at 3,000 rpm for 8 minutes, and then serum samples were stored at –80°C. Measurements were performed using a US-CEA908Ge melatonin ELISA kit. For statistical analysis, a binary (yes/no) variable was created from the pairs for each day, assigning ‘Yes’ if the TE values were greater than TM (melatonin peak reversion). Developing a laboratory-based score to predict mortality in patients admitted to the ICU A Iqbal1, I Welters2, R Kolamunnage-Dona3, C Toh3, C Downey2 1Institute of Ageing and Chronic Disease, Liverpool, UK; 2Royal Liverpool University Hospital, Liverpool, UK; 3University of Liverpool, UK Critical Care 2015, 19(Suppl 1):P547 (doi: 10.1186/cc14627) A Iqbal1, I Welters2, R Kolamunnage-Dona3, C Toh3, C Downey2 1Institute of Ageing and Chronic Disease, Liverpool, UK; 2Royal Liverpool University Hospital, Liverpool, UK; 3University of Liverpool, UK Critical Care 2015, 19(Suppl 1):P547 (doi: 10.1186/cc14627) g y p Results Patient median age was 34 (IQR 26 to 49) years; 48.7% were male. Mortality was 50.3%. The variables most predictive of mortality in univariate analyses were: age, sepsis within 24 hours of ICU admission, hypotension or shock at ICU admission, Glasgow Coma Scale score at ICU admission, and heart rate (beats per minute) at ICU admission. Using these fi ve variables, the R-MPM predicted mortality with area under the curve of 0.829 and Hosmer–Lemeshow chi-square statistic Introduction Scoring systems can be used to predict mortality in patients admitted to the ICU. They are produced using variables that are associated with an increased risk of mortality such as patient Introduction Scoring systems can be used to predict mortality in patients admitted to the ICU. They are produced using variables that are associated with an increased risk of mortality such as patient S191 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion The citizens surveyed valued outcomes associated with quality of life and intact neurological function. Mortality and other indices of duration of critical illness were valued less. These preferences need to be confi rmed in larger groups with greater diversity. Future research also needs to further understand these outcome preferences in survivors of critical illness, clinicians, decision-makers, and researchers. Understanding the outcome preferences of pertinent stakeholders and whether these preferences are congruent is imperative to inform the design of future critical care trials. Conclusion The citizens surveyed valued outcomes associated with quality of life and intact neurological function. Mortality and other indices of duration of critical illness were valued less. These preferences need to be confi rmed in larger groups with greater diversity. Future research also needs to further understand these outcome preferences in survivors of critical illness, clinicians, decision-makers, and researchers. Understanding the outcome preferences of pertinent stakeholders and whether these preferences are congruent is imperative to inform the design of future critical care trials. Patient preferences for outcomes in critical care trials (OPTICS): preliminary resultsf p y J Muscedere1, F Lamontagne2, G Boyd1, M Herridge3, S Fleury1, T Sinuff 3 1Queen’s University, Kingston, ON, Canada; 2University of Sherbrooke, QC, Canada; 3University of Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P548 (doi: 10.1186/cc14628) Results Melatonin levels were not normally distributed and were ranging between 9.2 and 23.7 pg/ml at T0 and 11.3 and 17.9 pg/ ml at T1. The median diff erences of the morning and evening serum melatonin levels were: TM0 – TE0 = –2.8 (–3.8 – (–0.2)); TM1 – TE1 = –1.2 (–2.5 – (–0.4)) presented as median (IQR). The proportion of subjects with peak reversals was 92.9% (80.8 to 100.0%). Introduction Although patient-centered outcomes are important to inform therapeutic choices for critically ill patients, patient preferences for outcomes in critical care studies are unknown. It is also unknown whether outcome preferences diff er between researchers, decision- makers and those who have never been critically ill (citizens). The aim of the OPTICS Program is to investigate these preferences. Herein we report the preliminary results for outcomes preferences in citizens. Conclusion Our preliminary data suggest that circadian rhythm disturbances may occur in critically ill patients within 48 hours after admission, and can be detected by inversion of melatonin peaks. Despite the limitations of this study, it may justify the need for larger observational and randomized trials on the eff ect of light on melatonin levels and on outcomes in ICU patients. Methods We recruited and surveyed lay public members without a history of critical illness as to their preferences for outcomes in critical care trials. After an in-person educational session, citizens were asked to rank 11 potential critical care trial outcomes in order of personal preference. Each outcome was also rated for importance on a 7-point Likert scale. Participants were then asked to indicate their agreement with potential tradeoff s between potential outcomes. References 1. Pevet P, et al. J Physiol. 2011;105:170-82. 1. Pevet P, et al. J Physiol. 2011;105:170-82. 2. Castro R, et al. Annual update in Intensive Care and Emergency Medicine. J.-L. Vincent, editor. Berlin: Springer-Verlag; 2011. p. 766-80. 2. Castro R, et al. Annual update in Intensive Care and Emergency Medicine. J.-L. Vincent, editor. Berlin: Springer-Verlag; 2011. p. 766-80. pf p Results The in-person session was attended by 31 citizens whose had a mean age (SD) of 71.6 (5.9) years and 1.5 (1.4) chronic health conditions; 25 (81%) had partially or fully completed post-secondary school education. Of the 11 potential outcomes, the three outcomes ranked of highest importance were: permanent brain dysfunction, quality of life, and requirement for long-term institutional care. The three outcomes ranked of least importance were: duration of hospitalization, death after a prolonged illness, and occurrence of delirium. When rated on a 7-point Likert scale the results were similar. Of the participants, 24/27 (89%) indicated that they would be willing to receive a therapy which was associated with a higher mortality rate but resulted in an improved quality of life in survivors. Conversely, 16/27 (59%) indicated that they would not be willing to receive a therapy which increased the chances of survival but was associated with a reduced quality of life in the survivors. Developing a laboratory-based score to predict mortality in patients admitted to the ICU demographics, physiological measurements and coexisting conditions and can be used to evaluate ICU performance, to stratify patients in clinical trials and to assist in-hospital and healthcare decisions such as resource allocation. The aim of the project was to determine whether a general score derived from routine laboratory parameters could be used to predict mortality rates in patients admitted to the ICU in the UK. Methods P values were calculated using the t test, Mann–Whitney U test and chi-squared test, depending on distribution of data, in order to determine which variables were signifi cantly diff erent in the survivors and nonsurvivors of critical illness. Signifi cant variables were categorised into subgroups according to medically relevant landmarks and univariately analysed by assessing the correlation with mortality. Forward logistic regression models were used to choose the parameters to include in our score. ROC curves illustrated the sensitivity and specifi city of selected variables via their AUC. P549 The proportion of reversals and their 95% confi dence intervals were estimated using a GEE model for repeated binary data, assuming a binomial distribution and log link, and accounting for subject as a repetition factor. All calculations were done in SAS 9.4. P548 Patient preferences for outcomes in critical care trials (OPTICS): preliminary results J Muscedere1, F Lamontagne2, G Boyd1, M Herridge3, S Fleury1, T Sinuff 3 1Queen’s University, Kingston, ON, Canada; 2University of Sherbrooke, QC, Canada; 3University of Toronto, ON, Canada Critical Care 2015, 19(Suppl 1):P548 (doi: 10.1186/cc14628) Trait anxiety mediates stress-related psychopathology after cardiac surgery and ICU stay Both devices can be used to eff ectively monitor and characterize sleep in the ICU environment. g y Methods In this multicenter follow-up study of the Dexamethasone for Cardiac Surgery (DECS) trial, validated self-report questionnaires were sent 1.5 to 4 years after cardiac surgery and ICU treatment to assess symptoms of PTSD and depression, in relation to cumulative life stress (that is, childhood trauma, major stressful life events) and trait anxiety as determinants of psychopathology. Data were available for 1,125 out of 1,244 (90.4%) eligible participants. Mediating and moderating analyses were performed with multivariable linear regression to assess the eff ect of trait anxiety. Subgroup analyses were performed for both sexes. P552 P552 Hospital anxiety and depression after ICU survival: results of a post-ICU aftercare program D Ramnarain, C Slobbe, W Schapendonk, J Van Gorp, I Gnirrip, S Voermans, A Rutten, G Van der Nat, N Van der Lely St.Elisabeth Hospital Tilburg, the Netherlands Critical Care 2015, 19(Suppl 1):P552 (doi: 10.1186/cc14632) Hospital anxiety and depression after ICU survival: results of a post-ICU aftercare program Introduction Although the ICU survival rate has increased in the last decade, the negative eff ects on mental health and related quality of life become more clear. In the literature the prevalence of anxiety and depressive symptoms post ICU ranges from 10 to 43% [1]. Early recognition and treatment of anxiety and depressive symptoms is important because depression caries a risk for suicide, limited quality of life, and delayed return to work. We studied hospital anxiety and depression (HAD) symptoms after ICU discharge. Results Trait anxiety partially mediates the relationship between cumulative life stress and PTSD (β-value reduction from 0.325 to 0.068; P = 0.000 to P = 0.003) and fully mediates the association between cumulative life stress and depression (β-value reduction from 0.282 to 0.015; P = 0.000 to P = 0.507). Trait anxiety was not a moderating factor between cumulative life stress and psychopathology. Full mediation of trait anxiety was found in female patients (n = 247), whereas only partial mediation was seen in male patients (n = 878) with regard to PTSD symptoms. As for depression, full mediation was present in both female and male patients. p y p g Methods Patients who were treated in our ICU from 1 January 2013 until 31 December 2013 for more than 5 days were invited to visit our post-ICU aftercare clinic. Trait anxiety mediates stress-related psychopathology after cardiac surgery and ICU stay L Kok1, M Sep1, D Veldhuijzen2, S Cornelisse1, A Nierich3, J Van der Maaten4, P Rosseel5, J Hofl and6, J Dieleman1, C Vinkers1, L Peelen1, M Joëls1, D Van Dijk1, M Hillegers1 L Kok1, M Sep1, D Veldhuijzen2, S Cornelisse1, A Nierich3, J Van der Maaten4, P Rosseel5, J Hofl and6, J Dieleman1, C Vinkers1, L Peelen1, M Joëls1, D Van Dijk1, M Hillegers1 1University Medical Center Utrecht, the Netherlands; 2Leiden University, the Netherlands; 3Isala Clinics, Zwolle, the Netherlands; 4University Medical Center Groningen, the Netherlands; 5Amphia Hospital, Breda, the Netherlands; 6Erasmus Medical Center, Rotterdam, the Netherlands Critical Care 2015, 19(Suppl 1):P550 (doi: 10.1186/cc14630) Introduction ICU survivors are at risk for post-traumatic stress disorder (PTSD) and depression. The development of psychopathology depends partially on stable personality factors such as trait anxiety. Introduction ICU survivors are at risk for post-traumatic stress disorder (PTSD) and depression. The development of psychopathology depends partially on stable personality factors such as trait anxiety. S192 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 distribution was light sleep 62.2% (PAT) and 74.1% (PSG); REM 13.0% (PAT) and 10.7% (PSG); deep sleep 14.5% (PAT) and 7.9% (PSG). Conclusion Both wristwatch-style PAT and miniature PSG devices successfully recorded sleep in ICU patients. Although the simple PAT device overestimated TST, sleep stage times were generally in agreement, especially REM time which correlated strongly. Both devices can be used to eff ectively monitor and characterize sleep in the ICU environment. distribution was light sleep 62.2% (PAT) and 74.1% (PSG); REM 13.0% (PAT) and 10.7% (PSG); deep sleep 14.5% (PAT) and 7.9% (PSG). Among ICU patients a high level of trait anxiety is relatively common and associated with intrusions, a symptom of PTSD. Independently, childhood trauma and stress exposure throughout life have been associated with depression. In cardiac surgery patients admitted to the ICU postoperatively, the eff ect of trait anxiety on the relationship between cumulative life stress and stress-related psychopathology remains unknown. Therefore we aimed to assess the mediating or moderating role of trait anxiety in this at-risk patient population. Conclusion Both wristwatch-style PAT and miniature PSG devices successfully recorded sleep in ICU patients. Although the simple PAT device overestimated TST, sleep stage times were generally in agreement, especially REM time which correlated strongly. Sleep monitoring in ICU patients Sleep monitoring in ICU patients S Namba1, K Hayashi1, T Hirayama1, T Hirayama1, Y Namba1, M Terado1, P Easton2, Y Ujike1 1Okayama University Hospital, Okayama, Japan; 2University of Calgary, AB, Canada Critical Care 2015, 19(Suppl 1):P551 (doi: 10.1186/cc14631) Sleep monitoring in ICU patients S Namba1, K Hayashi1, T Hirayama1, T Hirayama1, Y Namba1, M Terado1, P Easton2, Y Ujike1 1Okayama University Hospital, Okayama, Japan; 2University of Calgary, AB, Canada Critical Care 2015, 19(Suppl 1):P551 (doi: 10.1186/cc14631) Introduction Sleep disruption and deprivation is a continuing problem in the ICU. Strategies to improve sleep are confounded by diffi culties in monitoring and measuring sleep in the ICU; traditional polysomnography cannot be utilized. Practical, non-intrusive diagnostic monitoring of sleep is required. The aims were to test two new ambulatory sleep diagnostic devices to monitor sleep in the ICU, compare sleep data generated by the diff erent devices, and characterize sleep in the ICU. p Methods The devices were: Watch PAT 200 (Itamar), simple wristwatch style, employing peripheral arterial tone and actigraphy to evaluate sleep time and sleep stage by an automatic algorithm (PAT device); and ALICE PDx (Respironics Philips), miniature polysomnographic device utilizing EEG and EMG recordings, requiring post-study sleep technician scoring (PSG device). Nineteen ICU patients provided informed consent (mean age 37 years, two female). Diagnosis of most patients was trauma. Device technical problems terminated one ALICE PDx study and three Watch PAT study; one patient revoked consent. Therefore, 14 patients were recorded successfully in a private room in the ICU, while simultaneously wearing both devices, from 20:00 to 06:00. No patient received sedation. Subjective sleep quality was estimated by the visual analog scale. i References 1. Myhren H, et al. Crit Care. 2010;14:R14. 1. Myhren H, et al. Crit Care. 2010;14:R14. 2. Zimond M, et al. Behav Res Ther. 2003;41:1489-96. 2. Zimond M, et al. Behav Res Ther. 2003;41:1489-96. Trait anxiety mediates stress-related psychopathology after cardiac surgery and ICU stay Six weeks after discharge they received a letter of invitation together with a health-related questionnaire, the Hospital Anxiety and Depression Scale (HADS) questionnaire [2]. Patients were asked to return the questionnaire prior to their visit. All data were analyzed and if the HADS score indicated a clinically signifi cant anxiety or depression, patients were referred to a psychologist for further analyses and treatment. All patient data were analyzed retrospectively. Results Seventy-nine patients, 54 men and 43 women, mean age 57 years. Median APACHE II and IV was 18 and 60 respectively. Median ICU and hospitals days were 9 and 20 respectively. Seventy-six percent were mechanically ventilated with a median of 5 days. Median time after ICU discharge to aftercare visit was 165 days. Patients were divided into three categories: 1, no HAD (45.4%); 2, possible HAD (9.3%); and 3, clinically signifi cant HAD (45.4%). Women compared with men showed signifi cantly more HAD symptoms (26.8% vs. 18.6%, P <0.05). Patients with subarachnoid hemorrhage, neurotrauma and multitrauma patients showed more HAD symptoms. Pain, fatigue, muscle weakness, impairment of daily activity dyspnea, and hoarseness were signifi cantly associated with clinically signifi cant HAD. No association between age and HAD was found. Diagnosis at ICU admission, length of stay, severity of illness, delirium and use of sedatives were not associated with HAD. Conclusion Prevalence of clinically signifi cant post-ICU HAD was 45.4%. Female sex and post-ICU physical complaints – pain, fatigue, muscle weakness, impairment in daily activities, hoarseness and dyspnea – were signifi cantly associated with HAD. Conclusion In cardiac ICU patients, trait anxiety mediates the infl uence of cumulative life stress on the occurrence of PTSD and depression symptoms. Further prospective research is necessary to establish these factors as reliable measures for the early identifi cation of ICU patients at risk for stress-related psychopathology. Somatic complaints after ICU survival: results of a post-ICU aftercare program p g D Ramnarain, W Schapendonk, I Gnirrip, G Van der Nat, A Rutten, N Van der Lely St Elisabeth Hospital Tilburg, the Netherlands Critical Care 2015, 19(Suppl 1):P554 (doi: 10.1186/cc14634) p g D Ramnarain, W Schapendonk, I Gnirrip, G Van der Nat, A Rutten, N Van der Lely St Elisabeth Hospital Tilburg, the Netherlands Critical Care 2015, 19(Suppl 1):P554 (doi: 10.1186/cc14634) Introduction Critical illness today is well recognized as being associated with new or worsening physical impairment, diminished mental health and cognitive dysfunction. We studied the scope of somatic complaints in ICU survivors 4 to 6 months after ICU treatment. Introduction Critical illness today is well recognized as being associated with new or worsening physical impairment, diminished mental health and cognitive dysfunction. We studied the scope of somatic complaints in ICU survivors 4 to 6 months after ICU treatment. yp yp p Conclusion Irrespective of defi nition using PCL-S or DSM-IV mapping, PTSD was identifi ed in no more than one in 10 survivors of critical illness at either 3 or 12 months post ICU, which is still nearly double the US population past-year PTSD prevalence. In ICU survivors with moderate probability PTSD by PCL-S, the CAPS gold-standard interview is challenging to complete and adds only a small number of diagnoses. However, two in fi ve ICU survivors will develop PTSD subtypes of avoidance or hyperarousal, which both occur twice as frequently as the intrusion subtype. Targeting predominant PTSD subtypes may help optimize treatment strategies for the ICU survivor, such as prolonged exposure and eye movement desensitization and reprocessing for those with the avoidance subtype, and pharmacologic antidepressants targeting the sympathetic nervous system to produce anxiolysis for those with the hyperarousal subtype. Methods Patients who were treated in our ICU from 1 January 2013 until 31 December 2013, for 5 or more days, were invited to visit our ICU aftercare clinic. Six weeks after ICU discharge a letter of invitation together with a health-related questionnaire, the Hospital Anxiety and Depression Scale questionnaire [1] and Impact of Event Scale Revised questionnaire [2], was sent. Patients were asked to return the questionnaires before visiting our clinic. The main purpose of the post- ICU aftercare was to screen for somatic complaints, mental health and cognitive dysfunction. If necessary, further examination or treatment was advised. All data were retrospectively analyzed. y y Results Ninety-seven patients visited our aftercare program in 2013. P553 Post-traumatic stress disorder after ICU discharge: results of a post-ICU aftercare program D Ramnarain, I Gnirrip, W Schapendonk, A Rutten, G Van der Nat, N Van der Lely St Elisabeth Hospital Tilburg, the Netherlands Critical Care 2015, 19(Suppl 1):P553 (doi: 10.1186/cc14633) Results Both devices calculated total sleep time (TST), but the results were signifi cantly diff erent (P <0.05), with mean TST reported as 443.07 and 270.8 minutes for PAT and PSG devices. VAS correlated tightly with TST calculated by the PSG device (r = 0.559, P <0.05). Both devices were able to successfully discern diff erent sleep stages, summarized as light sleep, deep sleep, and REM. Measurements of sleep stage were generally in agreement between the two devices; REM sleep time correlated strongly between PAT and PSG devices (P <0.05). Sleep stage Introduction Patients who survive ICU treatment may experience psychological distress for some time after discharge from the ICU. In the literature the reported prevalence of post-traumatic stress disorder (PTSD) ranges from 5 to 64% [1]. We studied PTSD symptoms in relation to ICU factors, demographic data and physical complaints reported by patients 4 to 6 months after ICU discharge. Introduction Patients who survive ICU treatment may experience psychological distress for some time after discharge from the ICU. In the literature the reported prevalence of post-traumatic stress disorder (PTSD) ranges from 5 to 64% [1]. We studied PTSD symptoms in relation to ICU factors, demographic data and physical complaints reported by patients 4 to 6 months after ICU discharge. S193 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Methods Patients who were treated in our ICU from 1 January 2013 until 31 December 2013 for more than 5 days were invited to visit our ICU aftercare clinic. Six weeks after discharge a letter of invitation together with a health-related questionnaire, the Hospital Anxiety and Depression Scale questionnaire and Impact of Event Scale (IES-R) questionnaire, was sent to the patient. Patients were asked to return the questionnaires prior to visiting the aftercare clinic. All data were analyzed and if the IES-R score indicated a possible PTSD, patients were referred to a psychologist for further analyses and treatment. All patient data were analyzed retrospectively. y Referencefi Referencefi 1. Griffi ths J, et al. Intensive Care Med. 2007;33:1506-18. , yp g Results Of the 180 eligible participants at 3 months, PTSD was identifi ed in 10 (6%) using PCL-S scores and 15 (8%) using DSM-IV mapping of the PCL-S. Of the 160 eligible participants at 12 months, PTSD was identifi ed in two (1%) using PCL-S scores and 10 (6%) using DSM-IV mapping of the PCL-S. Of those eligible for CAPS assessments, at 3 months only 13 of 24 (54%) interviews were completed resulting in three extra PTSD diagnoses, and at 12 months only six of 22 (27%) interviews were completed resulting in two extra PTSD diagnoses. At 3 and 12 months, the intrusion subtype was present in 25 (14%) and in 25 (16%), the avoidance subtype was present in 78 (43%) and 60 (38%), and the hyperarousal subtype was present in 82 (46%) and 71 (44%). Conclusion Irrespective of defi nition using PCL-S or DSM-IV mapping, PTSD was identifi ed in no more than one in 10 survivors of critical illness at either 3 or 12 months post ICU, which is still nearly double the US population past-year PTSD prevalence. In ICU survivors with moderate probability PTSD by PCL-S, the CAPS gold-standard interview is challenging to complete and adds only a small number of diagnoses. However, two in fi ve ICU survivors will develop PTSD subtypes of avoidance or hyperarousal, which both occur twice as frequently as the intrusion subtype. Targeting predominant PTSD subtypes may help optimize treatment strategies for the ICU survivor, such as prolonged exposure and eye movement desensitization and reprocessing for those with the avoidance subtype, and pharmacologic antidepressants targeting the sympathetic nervous system to produce anxiolysis for those with the hyperarousal subtype. Results Of the 180 eligible participants at 3 months, PTSD was identifi ed in 10 (6%) using PCL-S scores and 15 (8%) using DSM-IV mapping of the PCL-S. Of the 160 eligible participants at 12 months, PTSD was identifi ed in two (1%) using PCL-S scores and 10 (6%) using DSM-IV mapping of the PCL-S. Of those eligible for CAPS assessments, at 3 months only 13 of 24 (54%) interviews were completed resulting in three extra PTSD diagnoses, and at 12 months only six of 22 (27%) interviews were completed resulting in two extra PTSD diagnoses. y Referencefi At 3 and 12 months, the intrusion subtype was present in 25 (14%) and in 25 (16%), the avoidance subtype was present in 78 (43%) and 60 (38%), and the hyperarousal subtype was present in 82 (46%) and 71 (44%).i P553 The Pearson chi-squared test was used to compare groups and Cramer’s V analyses was used to examine strength of the association between groups. activity, pain and hoarseness were associated signifi cantly with PTSD and HAD. There was no signifi cant diff erence in somatic complaints between men and women. Conclusion Somatic complaints after ICU discharge are frequently reported in our post-ICU aftercare patients, infl uencing daily performance and quality of life. Patient-centered research and treatment focusing on somatic complaints is of great importance. References 1. Zimond AS, et al. Acta Psychatr Scand. 1983;67:361-70. 2. Creamer M, et al. Behav Res Ther. 2003;41;1489-96. 1. Zimond AS, et al. Acta Psychatr Scand. 1983;67:361-70. 2. Creamer M, et al. Behav Res Ther. 2003;41;1489-96. 1. Zimond AS, et al. Acta Psychatr Scand. 1983;67:361-70. 2. Creamer M, et al. Behav Res Ther. 2003;41;1489-96. Results Seventy-nine patients, 54 male and 43 women, with mean age 57 years. Median APACHE II and APACHE IV were 18 and 60 respectively. Median ICU days and hospital days were 9 and 20 respectively. Seventy- six percent of patients were mechanically ventilated with a median of 5 days. Median time of ICU discharge to aftercare visit was 165 days. Delirium occurred in 22 (22.7%) patients during ICU treatment. The prevalence of PTSD was 43.3% and was most seen in patients after subarachnoid hemorrhage (SAH) (28.6%). Pain, muscle weakness, fatigue, impairment in daily activity, dyspnea, and hoarseness reported during the ICU aftercare clinic visit were signifi cantly associated with PTSD. There was no signifi cant diff erence in men and women. Sedation, opiates, benzodiazepine, inotropic medication and delirium during ICU treatment were not associated with higher prevalence of PTSD. None of the other demographic data analyzed were signifi cantly associated with PTSD. Post-traumatic stress disorder prevalence and subtypes among survivors of critical illness Post-traumatic stress disorder prevalence and subtypes among survivors of critical illness M Patel1, J Jackson1, A Morandi2, T Girard1, C Hughes1, A Kiehl1, J Thompson1, R Chandrasekhar1, E Ely1, P Pandharipande1 1Vanderbilt University, Nashville, TN, USA; 2Ancelle Hospital, Cremona, Italy Critical Care 2015, 19(Suppl 1):P555 (doi: 10.1186/cc14635) M Patel1, J Jackson1, A Morandi2, T Girard1, C Hughes1, A Kiehl1, J Thompson1, R Chandrasekhar1, E Ely1, P Pandharipande1 1Vanderbilt University, Nashville, TN, USA; 2Ancelle Hospital, Cremona, Italy Critical Care 2015, 19(Suppl 1):P555 (doi: 10.1186/cc14635) Introduction Among North American survivors of critical illness, we aim to describe the prevalence of post-traumatic stress disorder (PTSD), and its subtypes of intrusion, avoidance, and hyperarousal. Methods In this prospective, observational, multicenter cohort study from 2009 to 2010, we screened adults (age ≥18 years) with new- onset respiratory failure, cardiogenic shock, or septic shock, who were admitted to medical and surgical ICUs in four facilities. At 3-month and 12-month follow-ups, high probability of PTSD was defi ned by 17-symptom PTSD Checklist – Event Specifi c Version (PCL-S) score ≥50. Also, PCL-S responses were mapped onto DSM-IV criteria for PTSD. To augment PTSD identifi cation, those with a moderate probability of post-ICU PTSD (PCL-S score ≥35) were further confi rmed with the Clinician Administered PTSD Scale (CAPS) structured interview. Moderate or greater symptoms for each PTSD subtype of intrusion, avoidance, and hyperarousal were categorized. Conclusion Prevalence of PTSD was 43.3% and most seen in patients after SAH, refl ecting the majority of patients treated in our ICU. PTSD was associated signifi cantly with pain, muscle weakness, fatigue, dyspnea, hoarseness and impairment of daily activity after a median 165 days post ICU treatment. Somatic complaints after ICU survival: results of a post-ICU aftercare program Median time after ICU discharge and visit to our after care clinic was 165 days. Twenty-fi ve patients died after ICU discharge. Fifty-four patients were excluded because of various reasons; that is, language barrier, psychiatric illness, mental handicap, hospital admittance elsewhere, great distance. Seventy patients (81.4%) had somatic complaints infl uencing daily performance and quality of life. Fatigue (74.4%), muscle weakness (48.8%), dyspnea (34.9%), impairment of daily activity (81.4%), pain (38.4%) and weight loss (33.3%) were the most frequently reported complaints. Pain was most reported in patients with subarachnoid hemorrhage (27.3%), multitrauma (15.2%) and pneumonia (12.1%). Pain was most localized in the head (15.6%), one or both legs (15.6%), back (10.9%), shoulder (9.3%), hip (9.3%) and thorax (6.3%). Muscle weakness, fatigue, dyspnea, impairment of daily Physiotherapy in the ICU: an evidence-based, expert-driven, practical statement J Sommers1, R Engelbert2, D Dettling1, R Gosselink3, P Spronk4, J Horn 1, F Nollet1, M Van der Schaaf1 1Academical Medical Center, Amsterdam, the Netherlands; 2School of Health, Amsterdam, the Netherlands; 3KU Leuven, Belgium; 4Gelre Hospital, Apeldoorn, the Netherlands Critical Care 2015, 19(Suppl 1):P558 (doi: 10.1186/cc14638) J Sommers1, R Engelbert2, D Dettling1, R Gosselink3, P Spronk4, J Horn 1, F Nollet1, M Van der Schaaf1 1Academical Medical Center, Amsterdam, the Netherlands; 2School of Health, Amsterdam, the Netherlands; 3KU Leuven, Belgium; 4Gelre Hospital, Apeldoorn, the Netherlands Critical Care 2015, 19(Suppl 1):P558 (doi: 10.1186/cc14638) g q y Results A total of 1,743 papers were retrieved, of which 18 studies were eligible for inclusion in the review. Studies had a combined population of 1,970 patients admitted to 38 ICUs from Europe, Asia and North America. Eleven studies were randomized controlled trials (RCTs). Interventions were classifi ed as four groups – music; therapeutic touch; diary and psychotherapeutic interventions. Ten studies found that music interventions were eff ective in the short term; however, follow- up results were limited and some studies were low quality. There was moderate quality evidence from three studies for the eff ectiveness of diary interventions, with medium-term follow-up results. There was mixed-quality evidence for therapeutic touch interventions in the short term from three studies. The two psychotherapeutic interventions studied were of moderate quality, and one showed promising results at 12-month follow-up.fi Introduction Evidence-based, expert-driven, practical statements improve quality and eff ectiveness of the diagnostic and therapeutic process of patient care. Although the eff ectiveness of physiotherapy treatment strategies in ICU patients has been described, statements or guidelines of physiotherapy for ICU patients are not available [1]. Guidelines on safety management and on the diagnostic and therapeutic process may support and guide clinical decision-making leading towards evidence-based tailored care. The aim of this study was to develop an evidence-based statement for the physiotherapy treatment of ICU patients with recommendations for eff ective and safe diagnostic assessment and intervention strategies. Conclusion The evidence for the effi cacy of nonpharmacological interventions to reduce short-term or long-term stress in intensive care patients was of low to moderate quality. Studies included mainly short- term and medium-term follow-up. This highlights the need for larger- scale, better-quality RCTs with longer-term outcome measurement. However, the results indicate that nonpharmacological, including psychological, approaches are likely to be benefi cial for reducing short- term or long-term stress in intensive care patients. Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 particularly those of working age. More work is required to understand optimal rehabilitation pathways in this patient group. References particularly those of working age. More work is required to understand optimal rehabilitation pathways in this patient group. References effi cacy of such interventions. Previous work has shown that intensive care patients undergo many stressful experiences, which can aff ect their long-term psychological well-being. Studies have demonstrated a high prevalence of depression, anxiety or post-traumatic stress disorder after intensive care admissions. Methods A systematic review was carried out according to the Prisma statement. A search was conducted of Medline, Embase and Psychinfo databases. Inclusion criteria included studies of populations of adult patients in mixed or general ICUs. No study designs were excluded, but studies that focused on specifi c disease states were excluded. Included studies were assessed for risk of bias, using a quality checklist. P557 P557 Utilisation of existing community rehabilitation services by critical care survivors CR Soulsby, J McPeake, C Ashcroft, J Kinsella, M Shaw, T Quasim University of Glasgow, UK Critical Care 2015, 19(Suppl 1):P557 (doi: 10.1186/cc14637) Utilisation of existing community rehabilitation services by critical care survivors CR Soulsby, J McPeake, C Ashcroft, J Kinsella, M Shaw, T Quasim University of Glasgow, UK Critical Care 2015, 19(Suppl 1):P557 (doi: 10.1186/cc14637) l Results Three expert-based relevant clinical questions were formulated within the physiotherapy clinical reasoning process and were classifi ed according to the International Classifi cation of Functioning, Disability and Health. In a systematic literature search, 129 studies were identifi ed and assessed for methodological quality and classifi ed according to the level of evidence. The fi nal Evidence Statement consisted of recommendations for physiotherapy in ICU patients including safety criteria, a core set of instruments to assess impairments and activity restrictions and eff ective interventions. CR Soulsby, J McPeake, C Ashcroft, J Kinsella, M Shaw, T Quasim University of Glasgow, UK Critical Care 2015, 19(Suppl 1):P557 (doi: 10.1186/cc14637) Introduction Patients recovering from critical illness suff er many physical and psychological problems during their recovery, including muscle weakness, fatigue, signs and symptoms of PTSD, anxiety and depression [1]. At present, specialist intensive care follow-up and rehabilitation is inconsistent and in many geographical areas is nonexistent. As a result, many survivors of critical illness will require using existing community rehabilitation services [2]. The aim of this present service evaluation was to understand the utilisation of community rehabilitation services by critical care survivors. f Conclusion The Evidence Statement for physiotherapeutic diagnostics and intervention in ICU patients will contribute to the quality of clinical practice by supporting the clinical decision-making process. References 1. Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013;41:1543-54. 2. Burgers JS, van Everdingen JJE. Evidence-based richtlijnontwikkeling in Nederland: the EBRO-platform. Ned Tijdschr Geneeskd. 2004;148:2057-9. Methods A database of acute referrals to community rehabilitation services was retrospectively analysed from 1 May 2014 to 31 October 2014. Age, referring specialty and reason for referral for rehabilitation were documented. This database was cross-checked with the critical care database in Glasgow Royal Infi rmary to identify which individuals had been admitted to critical care during their admission. Physiotherapy in the ICU: an evidence-based, expert-driven, practical statement Methods For the development of this evidence statement, we used the EBRO method, as recommended by the Dutch Evidence Based Guideline Development Platform [2]. This method consists of the identifi cation of clinically relevant research questions, followed by a systematic literature search, quality assessment, and summary of the evidence eventually leading to establishing of concept and fi nal recommendations based on feedback from experts. The fi nal recommendations were prepared according to this methodical approach and summarized in fi gures, fl owcharts and appendices. Nonpharmacological interventions to reduce short-term or long-term psychological stress in ICU patients: a systematic review D Wade1, Z Moon2, S Windgassen2, J Weinman2 1University College Hospital, London, UK; 2Kings College London, UK Critical Care 2015, 19(Suppl 1):P556 (doi: 10.1186/cc14636) Introduction A systematic review was performed of studies of nonpharmacological interventions aiming to reduce short-term or long-term stress in intensive care patients, as little is known about the S194 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Payment options: do they aff ect outcome in the critically ill A Kar, A Datta Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P561 (doi: 10.1186/cc14641) i Results A total of 697 hospitals records were analyzed. Patients had on average (SD) 67.8 (13.1) years and the majority of them were males (57%). Our results revealed that 65% of patients in the CICU received phase 4 and 43% of patients in the CICU received phase 5 of the early mobilization protocol. No diff erences in the proportion of patients receiving phase 4 or 5 were found among arrhythmia, coronariopathies and congestive heart failure groups. The only diff erence found was between congestive heart failure group and other cardiovascular pathologies (P <0.001). The congestive heart failure group was mobilized 5.6 times (95% CI: 2.7 to 11.5) and 3.2 times (95% CI: 1.7 to 5.7) more than the other cardiovascular pathologies group in phase 4 and 5, respectively. Introduction Increasing cost is an important issue in critical care medicine. We tried to analyze in a level 3 care ICU in Kolkata of a tertiary care hospital whether the diff erent payment options (self-paying vs. insurance/corporate paying) do affect the outcome in the critically ill insurance/corporate paying) do aff ect the outcome in the critically ill. Methods Our prospective study included 1,520 patients admitted consecutively to a level 3 care ICU for a period of 20 months. Readmitted patients during the same period were excluded. Payment method was documented for all and divided into two groups as self-paying and insurance/corporate paying. Outcome assessment was done using the APACHE IV model for all cases. Demographic data, number of observed deaths, predicted mortality rate (PMR), standardized mortality ratio (SMR), average length of stay (ALOS), predicted length of stay, and number of discharge against medical advice (DAMA) were documented for each group. Statistical analysis was carried out using unpaired Student t test and P <0.05 was considered signifi cant. Conclusion A considerable proportion of patients was mobilized without any serious complications in the CICU. Our fi ndings suggest that patients diagnosed with arrhythmia, coronariopathies and congestive heart failure can be equally mobilized in an ICU. p gi Results Of 1,520 patients, 995 (65.46%) cases were self-paying while 525 (34.54%) cases were insurance/corporate paying. P559 E l Early mobilization according to diagnosis in a Brazilian coronary ICU GS Zavanelli1, SA Padulla1, MR Franco1, RZ Pinto1, LL Faccioli1, DN Barbosa1, DT Neves2, CE Bosso2 1Universidade Estadual Paulista – UNESP, Presidente Prudente, Brazil; 2Instituto do Coração de Presidente Prudente, Brazil Critical Care 2015, 19(Suppl 1):P559 (doi: 10.1186/cc14639) g Results Over this 6-month period 769 patients were referred from their parent specialty for community rehabilitation in North East Glasgow. Thirty-three of the 769 patients (4.3%) referred had a critical care stay during their admission. Of these, eight patients were referred for rehabilitation by orthopaedics, eight by medicine for the older patients, 11 from acute medicine and the remaining six from other specialties. Six of the 769 patients who had a critical care admission were of working age (<1%). Two individuals were admitted to critical care following trauma whilst four had complex social needs prior to their critical care admission. This included an individual with a high body mass index. None of the individuals of working age were referred as a consequence of their critical care stay. Introduction Early mobilization has been advocated to improve muscle function and, consequently, the patient quality of life after discharge. Nevertheless, few studies have explored it in a coronary ICU (CICU). The aims of the present study were to describe the use of an early mobilization protocol in a CICU and to investigate whether diff erent groups of diagnoses respond similarly to this protocol. Introduction Early mobilization has been advocated to improve muscle function and, consequently, the patient quality of life after discharge. Nevertheless, few studies have explored it in a coronary ICU (CICU). The aims of the present study were to describe the use of an early mobilization protocol in a CICU and to investigate whether diff erent groups of diagnoses respond similarly to this protocol. Conclusion This service evaluation demonstrates that very few critical care survivors are referred to community rehabilitation services, Methods This is a retrospective observational study conducted in a medium-sized hospital located in the city of Presidente Prudente, S195 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Brazil. P559 E l The early mobilization protocol consists of fi ve phases: 1 – passive exercises for the unconscious patient; 2 – active exercises associated with respiratory exercises (patient lying on the bed); 3 – phase 2 exercises with the patient sitting on the bed; 4 – phase 2 exercises with the patient sitting on a chair or in a standing position; 5 – phase 4 exercises plus walking. All hospital records from patients, between September 2013 and August 2014, were included in this study. Data extracted from hospital records were: age, gender, diagnosis (arrhythmia, coronariopathies, congestive heart failure and other pathologies), length of stay, number of discharge and number in each phase of the early mobilization protocol. Pearson chi-square test was used to compare the number of mobilizations (phase 4 and 5) per group of diagnoses. Odds ratios were calculated for those comparisons found to be statistically signifi cant (P <0.05). with mortality for pulmonary artery catheter, platelet transfusion and vasoactive drug infusion (one drug) (P >0.05). Conclusion In this large retrospective multicenter study, the TISS item associated with the highest risk of death was cardiac arrest and/or countershock. Unexpectedly, the independent eff ect of emergency admission was of comparable magnitude in terms of impact on hospital mortality. Of these, in-ICU cardiac arrest might be amenable to preventive measures and should be studied further. P561 P560 Need for therapeutic interventions as a predictor of mortality in intensive care Need for therapeutic interventions as a predictor of mortality in intensive care I Ef dij 1 R R j1 S H 2 MB Sk if 1 M R i ik i 3 Need for therapeutic interventions as a predictor of mortality in intensive care I Efendijev1, R Raj1, S Hoppu2, MB Skrifvars1, M Reinikainen3 1HUS, Helsinki, Finland; 2TAYS, Tampere, Finland; 3PKKS, Joensuu, Finland Critical Care 2015, 19(Suppl 1):P560 (doi: 10.1186/cc14640) I Efendijev1, R Raj1, S Hoppu2, MB Skrifvars1, M Reinikainen3 1HUS, Helsinki, Finland; 2TAYS, Tampere, Finland; 3PKKS, Joensuu, Finland Critical Care 2015, 19(Suppl 1):P560 (doi: 10.1186/cc14640) Introduction Various therapeutic interventions needed in critical care may refl ect a high risk of death. We evaluated associations between commonly used interventions and hospital mortality in Finnish ICU patients. Methods We retrieved data on adult patients treated in Finnish ICUs between 2003 and 2013 from the Finnish Intensive Care Consortium database. We used the Therapeutic Intervention Scoring System (TISS-76) for categorizing ICU interventions and the Simplifi ed Acute Physiology Score (SAPS II) for quantifying severity of illness. We excluded readmissions, patients with missing outcome, SAPS II and TISS data. We also excluded very common interventions (arterial line, bolus intravenous medication), very rare ones (prevalence <1%), and interventions only applicable in specifi c populations (intracranial pressure monitoring, intra-aortic balloon assist). We grouped several TISS categories when applicable. We performed a backward stepwise binary logistic regression analysis with TISS items to assess the impact of each intervention on hospital mortality (expressed as odds ratio (OR) with 95% confi dence intervals (CIs)). Age, admission type, and SAPS score (minus age and admission type scores) were adjusted for in the multivariate analysis. P562 P561 Payment options: do they aff ect outcome in the critically ill A Kar, A Datta Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P561 (doi: 10.1186/cc14641) Payment options: do they aff ect outcome in the critically ill A Kar, A Datta Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P561 (doi: 10.1186/cc14641) Payment options: do they aff ect outcome in the critically ill A Kar, A Datta In the self-paying group, mean age was 59.65 years ± 17.26 SD (median 62), APACHE IV score mean was 62.50 ± 33.61 SD (median 57), average LOS 4.67 days ± 4.29 SD (median 3), PMR was 22.71, 226 observed deaths, 85 cases of DAMA, and SMR was 1.00 (CI = 0.87 to 1.14). In the insurance/ corporate-paying group, mean age was 61.75 years ± 17.19 SD (median 65), APACHE IV score mean was 58.53 ± 32.94 SD (median 54), average LOS was 5.64 days ± 5.61 SD (median 4), PMR was 21.26, 113 observed deaths, six cases of DAMA, and SMR was 1.01 (CI = 0.83 to 1.21). In the two compared groups, predicted mortality and SMR were not statistically signifi cant (P = 0.2808); however, ALOS in the insurance/ corporate paying group was signifi cantly higher than the self-paying group (P = 0.0002), mean age of the insurance/corporate paying group was signifi cantly higher than the self-paying group (P = 0.02), and incidence of DAMA is signifi cantly higher in the self-paying group (8.54%) as compared with insurance/corporate paying group (1.14%). Root-cause analysis showed DAMA cases are mostly fi nancial (>95%). Conclusion Statistically signifi cant diff erences in ALOS and DAMA in the two groups are probably due to cost of healthcare not aff ordable to all. Source of ICU admission: does it really matter? A Datta, A Kar, A Ahmed Source of ICU admission: does it really matter? A Datta, A Kar, A Ahmed Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P562 (doi: 10.1186/cc14642) Introduction Source of admission to the ICU is of importance. We tried to identify the diff erent sources of ICU admission to a level 3 ICU of a tertiary care hospital in Kolkata and analyze whether the overall patient outcome is aff ected by the diff erent sources of admission. Results We identifi ed 161,134 patients eligible for analysis. The multivariate analysis showed that the highest risk for hospital mortality in all patients was associated with cardiac arrest and/or countershock, OR 2.58 (95% CI = 2.43 to 2.73), SAPS II emergency admission, OR 2.52 (95% CI = 2.32 to 2.74), vasoactive drug infusion (>1 drug), OR 1.66 (95% CI = 1.59 to 1.73) and blood transfusion (a combined TISS item), OR 1.53 (95% CI = 1.44 to 1.63). TISS items associated with the lowest risk of mortality in general population were: active anticoagulation, OR 0.51 (95% CI = 0.49 to 0.53), induced hypothermia, OR 0.68 (95% CI = 0.62 to 0.74) and measurement of cardiac output by any method, OR 0.87 (95% CI = 0.83 to 0.91). All aforementioned associations were statistically signifi cant (P <0.001). There was no notable association ff Methods Our prospective study included 2,056 patients admitted to a level 3 care ICU over a period of 2 years. Numbers of readmissions were not considered. ICU outcome was analyzed using the APACHE IV model and source of admission to the ICU was documented as either from emergency (ER), from the fl oor or from other hospital. Analysis was carried out between diff erent groups based on admission using unpaired Student t test and P <0.05 was considered signifi cant. Number of ventilations and the mortality rate in each group were also documented. S196 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Results Of 2,056 admissions, 1,223 cases (59.48%) were from ER, 809 cases (39.35%) were from fl oor and 24 cases (1.16%) were from other hospitals. Association between out-of-hours discharge and mortality in adult patients leaving critical care Association between out-of-hours discharge and mortality in adult patients leaving critical care S Edie, K Burt, J Paddle Royal Cornwall Hospital, Truro, UK Critical Care 2015, 19(Suppl 1):P564 (doi: 10.1186/cc14644) Introduction Out-of-hours (OOH) discharge from critical care is associated with a signifi cantly increased mortality rate in Australasia [1]. In the UK, daytime discharges from critical care are considered a core standard [2]. We sought to assess the impact of OOH discharge from critical care on mortality in a large general ICU, where operational pressures appear to have led to a high rate of OOH discharges. Methods Retrospective data for all patients admitted to our ICU from April 2007 to September 2014 were recorded, using routinely collected data from our databases. Adult patients (>15 years) discharged from their fi rst ICU admission during each hospital stay (episode) were included. Patients that died on the unit and those discharged for palliative care were excluded. Patients transferred to other centres were no longer subject to discharge within our control and were therefore also excluded. Patients discharged directly home from ICU were excluded. We defi ned OOH discharges as those occurring between 22:00 and 06:59, a standard defi nition in UK practice. Mortality status at the time of hospital discharge for each episode was used. We also recorded the readmission rate to ICU. The relative risk (RR) for OOH mortality and readmission was calculated. Statistical signifi cance was accepted at P <0.05. Conclusion The severity of illness index in patients admitted to the ICU from fl oors is signifi cantly higher than emergency admissions. Overall outcome for patients transferred to the ICU from the fl oor is worse based on mortality rate, SMR, and ALOS when compared with the emergency group. Readmission to the ICU: is it a big concern? An analysis A Ahmed, A Datta, A Kar Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P563 (doi: 10.1186/cc14643) Readmission to the ICU: is it a big concern? An analysis A Ahmed, A Datta, A Kar Medica Superspecialty Hospital, Kolkata, India Critical Care 2015, 19(Suppl 1):P563 (doi: 10.1186/cc14643) Results Of 4,476 index cases, 714 died on the unit and 80 were discharged for palliative care. A total of 490 patients were excluded for transfer to other centres and discharge directly home. Data were missing for three patients, which left 3,189 records for analysis. In total, 2,711 patients were discharged during daytime hours, of which 145 (5.35%) died. A total of 478 patients were discharged at night, 40 died (8.37%). The RR for OOH mortality was 1.56 (95% CI = 1.12 to 2.19, P = 0.0091). Readmission rate was 5.2% by day, 6.1% at night. The RR for readmission was 1.17 (95% CI = 0.79 to 1.72, P = 0.436). Introduction Readmission to the ICU is an important quality indicator of ICU care. We conducted a prospective study in a level 3 care ICU in Kolkata of a tertiary care hospital to analyze whether there are overall outcome diff erences when comparing the readmission group with the entire group. Conclusion Our data demonstrate an association between critical care discharge time and mortality, to a statistically signifi cant level. Due to the retrospective observational nature of the study, causation cannot be assumed; however, a number of factors may contribute to the increased risk of harm to patients discharged from the ICU at night. Further work will focus on annual OOH mortality trends, thereby gaining an insight into whether bed occupancy demands impact on the necessity for nighttime discharges. Methods Our prospective study included 2,140 patients admitted to a level 3 care ICU over a period of 1 year. The number of readmissions (n = 85) during the same period was also documented. Readmission was defi ned as all patients who were transferred back to the ICU prior to hospital death/discharge during the above period. ICU outcome was calculated using the predictive APACHE IV model. Payment methods were documented as either self-paying or corporate/insurance paying. A comparison analysis between the entire group with the readmission group was done using unpaired Student t test and P <0.05 was considered statistically signifi cant. Source of ICU admission: does it really matter? A Datta, A Kar, A Ahmed In the ER group, mean APACHE IV was 55.03 ± 31.49 SD (median 50), PMR 16.26, observed deaths 198, ALOS 4.78 days ± 4.83 SD (median 3), SMR 0.995 (CI = 0.86 to 1.14), mean age 60.52 years ± 17.63 SD (median 63), 323 ventilations. In the fl oor group, mean APACHE IV was 65.17 ± 34.40 SD (median 60), PMR 27.03, observed deaths 234, ALOS 5.23 days ± 5.22 SD (median 3), SMR 1.07 (CI = 0.94 to 1.21), mean age 61.38 years ± 15.72 SD (median 64), 302 ventilations. In the other hospital group, mean APACHE IV was 55.29 ± 29.82 SD (median 50), PMR 18.0, observed deaths 2, ALOS 6 days ± 5.85 SD (median 3), SMR 0.46 (CI: 0.23 to 0.88), mean age 56.08 years ± 17.79 SD (median 56.5), six ventilations. During analysis, the other hospital group was omitted because of inadequate sample size. There was statistically signifi cant diff erences in APACHE IV (fl oor >ER, P <0.0001), PMR (fl oor >ER, P <0.0001), ALOS (fl oor >ER, P = 0.04) noted between the fl oor and ER groups. Number of ventilations (37.33% vs. 26.4%), SMR (1.07 vs. 0.995), and mortality rate (28.92% vs. 16.19%) were also signifi cantly higher for patients admitted from the fl oor. No signifi cant statistical diff erence was observed in age between two groups (P = 0.26). y References 1. Gantner D, et al. Int Care Med. 2014;40:1528-35. 1. Gantner D, et al. Int Care Med. 2014;40:1528-35. 2. Faculty of Intensive Care Medicine and Intensive Care Society. Core standards for intensive care units (2013). http://www.fi cm.ac.uk/standards. 2. Faculty of Intensive Care Medicine and Intensive Care Society. Core standards for intensive care units (2013). http://www.fi cm.ac.uk/standards. y gi Results In the entire group (n = 2,140), mean APACHE IV was 50.34 ± 31.54 SD (median 42), PMR 15.49, observed deaths 327, ALOS 4.05 days ± 4.55 SD (median 3), SMR 0.99 (CI = 0.88 to 1.1), mean age 60.55 years ± 15.68 SD (median 63), 490 ventilations, 72.71% of patients were self-paying while 27.29% of patients were corporate/insurance paying. In the readmission group (n = 85), mean APACHE IV was 77.16 ± 33.72 SD (median 73), PMR 38.89, observed deaths 42, ALOS 5.23 days ± 4.18 SD (median 4), SMR 1.27 (CI = 0.95 to 1.67), mean age 64.79 years ± 14.40 SD (median 67), 43 ventilations, 75.3% of patients were self- paying while 24.7% of patients were corporate/insurance paying. During comparison between the two groups there were statistically signifi cant diff erences, with the readmission group having signifi cantly higher APACHE IV (P <0.0001), PMR (P <0.0001), ALOS (P = 0.002), age (P = 0.005), and SMR (1.27 vs. 0.99) compared with the entire group. Percentage of patients requiring ventilation (50.59% vs. 22.90%) and mortality rate (49.11% vs. 15.28%) were also signifi cantly higher in the readmission group. Readmission was signifi cantly higher in the self- paying group. Root-cause analysis showed most readmissions were due to deteriorating conditions (desaturation, hypotension, sepsis, arrhythmias); however, it was also associated with cases where transfer policy from the ICU was not followed by stakeholders and fi nancial issues were a cause of early transfer. P566 Determination of brain death for adult patients with ECMO I Ceylan, R Iscimen, E Cizmeci, N Kelebek Girgin, F Kahveci Uludag University Faculty of Medicine, Bursa, Turkey Critical Care 2015, 19(Suppl 1):P566 (doi: 10.1186/cc14646) f Results The CFA showed a good fi t indicating factorial validity (CFI: 0.97), reliabilities were from α 0.79 to 0.93 and ICCs were signifi cant (~0.20, P <0.001). HLM revealed that unit-level IL of nurses and residents was positively related to PS (b = 0.34, P <0.001). Being a resident and working in a smaller unit also predicted PS. As expected, unit-level PS was negatively related to individual PFC (b = –0.38, P = 0.025). Further predictors of higher PFC were: being a nurse, having more than 5 years of job experience and higher workload. PS mediated the relationship between unit-level IL and individual PFC (indirect eff ect: –0.13, P <0.001). Additional analyses revealed that attendings’ PFC was negatively related to their perception of residents PS (b = –0.44, P = 0.019). Introduction ECMO support in ARDS is an emerging strategy when conventional treatment modalities fail. ECMO has advantages on oxygenation and circulation but also it has some unfavorable eff ects. The most serious complication is brain death due to cerebrovascular hemorrhage. An apnea test is the most important component in confi rming brain death. For patients supported by ECMO, apnea testing remains challenging. Brain-death diagnosis is often made without an apnea test. p Methods We present two cases who receive V-V ECMO support after progression to ARDS. After initiation of ECMO we used sedation to prevent movement and improve adaptation to mechanical ventilation. Also we used anticoagulation with heparin to prevent thromboembolic events and ECMO circuit occlusion. On daily follow-up we noticed that patients had lost their pupil reactions to light. Their sedation was ceased and a computed brain tomography was performed. Both patients had intracerebral hemorrhage. We decided to determine brain death with apnea tests. We increased ECMO blood fl ow and fi O2 and then decreased sweep gas fl ow and disconnected the patient from mechanical ventilation respectively. In one patient we did not see any spontaneous breathing eff orts after carbon dioxide retention. We concluded that the apnea test was successful and confi rmed brain death. P566 On the other hand, we confi rmed the brain death of the other patient with cerebral angiography due to the occurrence of hypoxia and hypotension during apnea testing. p p Conclusion A sense of PS in an ICU team might reduce futile care by increasing the safety of speaking-up behavior of nurses and residents. PS can be enhanced by attending physicians who practice inclusive leadership behavior to foster autonomy and participation of residents and nurses. References 1. Manthous CA, et al. Am J Respir Crit Care Med. 2011;184:17-25. 2. Nembhard IM, et al. J Organ Behav. 2006;27:941-66. End-of-life decisions: how do patients die in the ICU? Introduction One of the main goals of intensive care medicine is to reduce the mortality of critically ill patients. However, it is essential to recognize end-of-life care as an integral component of critical care. Besides survival, the success of intensive care should also include the quality of lives preserved and the quality of dying. The objective of this study was to evaluate the incidence and type of end-of-life decisions (ELD) in critical patients that died in an ICU. y Results We experienced some challenges while determining brain death in patients under ECMO support for ARDS. It is challenging to conduct the apnea testing during ECMO support. Auxiliary tests are required for patients who cannot tolerate the changes needed to conduct the apnea test. With increasing use of ECMO therapies, clinicians may come face to face with more complicated life-ending decisions. p Methods Analysis of all patients included in an ICU running database and who died from 1 November 2013 to 31 October 2014. The following variables were evaluated: age, gender, reason for admission, SAPS II, length of ICU stay and type of ELD. To classify ELD, four concepts were defi ned: ‘Comfort care’, a change from curative therapy to comfort care therapy; ‘Limited therapy’, maintenance of curative therapy but without escalating it (for example, no renal substitution); ‘Decision not to resuscitate’, not to perform advanced life support if cardiac arrest occurs; and ‘Without previous end-of-life decisions’, when there was no prior decision regarding the ELD. Conclusion Current guidelines do not include brain death criteria using supportive therapies such as ECMO and therefore should be updated. References 1. Goswami S, et al. J Cardiothor Vasc Anesth 2013;27:312-4. 2. Jarrah RJ, et al. Pediatr Crit Care Med. 2014;15:38-43. 3. Marasco SF, et al. Heart Lung Circ 2008;17 Suppl:S41–7. 4. Farrah JM, et al. Arch Neurol. 2011;68:1543-9. P567 Results A total of 507 patients were admitted to the ICU and 132 died (26%). Reasons for admission in those who died were septic shock (47%), post cardiac arrest (13%), cardiogenic shock (8%), and nontraumatic brain bleeding (8%). Fifty-three patients (40%) died after a ‘Comfort care’ decision, 28 patients (21%) after ‘Decision not to resuscitate’ and 14 (11%) after a ‘Limited therapy’ decision. Thirty-seven patients died ‘Without previous end-of-life decisions’. However, specifi cally in this group, when looking for individual records, 32 patients died (86%) in the fi rst 48 hours after the admission and four (11%) had evidence of brain death and were organ donors, which leaves one patient (3%) in whom there was no ELD. Making it safe to speak up about futile care: a multiperspective survey on leadership, psychological safety and perceived futile care in the ICU D Schwarzkopf1, J Felfe2, CS Hartog1, F Bloos1 1Jena University Hospital, Jena, Germany; 2Helmut Schmidt University, Hamburg, Germany Critical Care 2015, 19(Suppl 1):P567 (doi: 10.1186/cc14647) Recovery of health-related quality of life in ICU patients: a 5-year prospective cohort study Recovery of health-related quality of life in ICU patients: a 5-year prospective cohort study J Hofhuis1, HF Van Stel2, AJ Schrijvers2, JH Rommes1, PE Spronk1 1Gelre Hospitals, Apeldoorn, the Netherlands; 2University Medical Center, Utrecht, the Netherlands Critical Care 2015, 19(Suppl 1):P565 (doi: 10.1186/cc14645) J Hofhuis1, HF Van Stel2, AJ Schrijvers2, JH Rommes1, PE Spronk1 1Gelre Hospitals, Apeldoorn, the Netherlands; 2University Medical Center, Utrecht, the Netherlands Critical Care 2015, 19(Suppl 1):P565 (doi: 10.1186/cc14645) J Hofhuis1, HF Van Stel2, AJ Schrijvers2, JH Rommes1, PE Spronk1 1Gelre Hospitals, Apeldoorn, the Netherlands; 2University Medical Center, Utrecht, the Netherlands Critical Care 2015, 19(Suppl 1):P565 (doi: 10.1186/cc14645) , Critical Care 2015, 19(Suppl 1):P565 (doi: 10.1186/cc14645) Introduction Severe critical illness requiring treatment in the ICU may have a serious impact on patients and their families. However, optimal follow-up periods are not defi ned and data on health-related quality of life (HRQOL) before ICU admission as well as those beyond 2-year follow-up are limited. The aim of our study was to assess the impact of ICU stay up to 5 years after ICU discharge. Methods We performed a long-term prospective cohort study in patients admitted >48 hours to a medical–surgical ICU. The Short-Form 36 was used to evaluate HRQOL before admission (by proxy within 48 hours after admission of the patient), at ICU discharge and at 1, 2 and 5 years following ICU discharge (all by patients). Changes in HRQOL were assessed using linear mixed modeling. Conclusion Readmission to the ICU was associated with worse outcome in our study group. Lack of adherence to transfer policy by concerned stakeholders was a concern as well as increasing cost of healthcare. Results We included a total of 749 patients (from 2000 to 2007). At 5 years after ICU discharge, 234 patients could be evaluated. After S197 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 correction for natural decline in HRQOL, the mean scores of four dimensions – physical functioning (P <0.001), physical role (P <0.001), general health (P <0.001) and social functioning (P = 0.003) – were still signifi cantly lower 5 years after ICU discharge compared with their preadmission levels, although eff ect sizes were small (<0.5). Recovery of health-related quality of life in ICU patients: a 5-year prospective cohort study Conclusion Five years after ICU discharge, survivors still perceived a signifi cantly lower HRQOL than their preadmission HRQOL (by proxies), and that of an age-matched general population. Importantly however, after correction for natural decline, the eff ect sizes were small suggesting that patients regain their age-specifi c HRQOL 5 years after their ICU stay. correction for natural decline in HRQOL, the mean scores of four dimensions – physical functioning (P <0.001), physical role (P <0.001), general health (P <0.001) and social functioning (P = 0.003) – were still signifi cantly lower 5 years after ICU discharge compared with their preadmission levels, although eff ect sizes were small (<0.5). report less perceived futile care (PFC). We also expected that attending physicians’ inclusive leadership (IL), which invites nurses’ and residents’ participation [2], would decrease PFC and that PS mediates this relationship. Methods The hypotheses were tested in a cross-sectional, multicenter paper-and-pencil survey addressing medical staff on participating ICUs. A total of 22 ICUs and four intermediate care units were included in the sample and 73 attendings, 147 residents and 659 nurses participated in the study (52% participation). Psychometric properties were tested by confi rmatory factor analysis (CFA), Cronbach’s α and intraclass correlations (ICC). A series of hierarchical linear models (HLM) were conducted to test the study hypotheses separately among nurses/residents and attendings. IL and PS were entered as unit-level predictors (mean values per unit). Covariates were demographics, working hours per week, workload and unit size (number of staff ). Mediation eff ects were tested.i gf Conclusion Five years after ICU discharge, survivors still perceived a signifi cantly lower HRQOL than their preadmission HRQOL (by proxies), and that of an age-matched general population. Importantly however, after correction for natural decline, the eff ect sizes were small suggesting that patients regain their age-specifi c HRQOL 5 years after their ICU stay. Making it safe to speak up about futile care: a multiperspective survey on leadership, psychological safety and perceived futile care in the ICU D Schwarzkopf1, J Felfe2, CS Hartog1, F Bloos1 1Jena University Hospital, Jena, Germany; 2Helmut Schmidt University, Hamburg, Germany Critical Care 2015, 19(Suppl 1):P567 (doi: 10.1186/cc14647) Introduction Psychological safety (PS), for example safety of speaking up, fosters team learning and prevents treatment errors on the ICU [1]. Since speaking up might also prevent excessive and inappropriate (futile) care for patients, we hypothesized that teams with higher PS Conclusion In this study, ‘Comfort care’ was the main ELD, which is in line with the concept that ELD are essential to ensure that care provided is S198 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 examine the association of palliative care screening criteria with adverse patient outcomes. consistent with quality of life and death. The apparent large proportion of patients ‘Without previous end-of-life decisions’ was due to patients who died in the fi rst 48 hours after ICU admission corresponding to conditions refractory to treatment. Additionally, this study also draws our attention to better plan ICU admissions and hospital outreach in order to reduce early ICU mortality. consistent with quality of life and death. The apparent large proportion of patients ‘Without previous end-of-life decisions’ was due to patients who died in the fi rst 48 hours after ICU admission corresponding to conditions refractory to treatment. Additionally, this study also draws our attention to better plan ICU admissions and hospital outreach in order to reduce early ICU mortality. Methods We performed an observational unicentric study on a 12-bed, medical emergency department intensive care unit (EDICU). A three- item palliative care screen was developed from consensus reports. A senior critical care physician screened patients upon admission using these questions during a 10-week period. The questions were: does this patient suff er from a life-limiting disease (end-stage lung, liver, heart or kidney disease, severe neurological disability, extreme frailty, locally advanced or metastatic cancer, advanced-stage AIDS). If the answer to the fi rst question is yes, we proceed to the next one: do you believe this patient will survive to hospital discharge? Answers to those questions were recorded, SAPS III was calculated and all patients were followed until death, discharge or transfer to another center. Diff erences in mortality and SAPS III score between groups were examined using a Student’s t test. Proportions were compared using chi-square test. References Table 1 (abstract P569). Respondents advocating withdrawal for the patient Withdrawal self (%) Withdrawal family (%) Day 3 71 67 Day 7 83 76 Day 28 96 88 Day 42 98 97 Table 1 (abstract P569). Respondents advocating withdrawal for the patient 1. Nelson JE, et al. Crit Care Med. 2013;41:2318-27. 2. Weissman DE, et al. J Palliat Med. 2011;14:17-23. 1. Nelson JE, et al. Crit Care Med. 2013;41:2318-27. 2. Weissman DE, et al. J Palliat Med. 2011;14:17-23. 1. Nelson JE, et al. Crit Care Med. 2013;41:2318-27. 2. Weissman DE, et al. J Palliat Med. 2011;14:17-23. Parents’ return to the hospital after the death of their children: importance of palliative care after death p p G Halal, PL Lago, J Piva, M Halal p g Critical Care 2015, 19(Suppl 1):P572 (doi: 10.1186/cc14652 Introduction To analyze the perception of parents regarding their return to the hospital where their children died to participate in a conversation with doctors and to analyze the feelings of parents about their participation in a study evaluating the care provided in the moments leading up to the death of children. p Withdrawal self (%) Withdrawal family (%) Day 3 16 10 Day 7 23 15 Day 14 25 19 Day 42 42 29 Methods A descriptive exploratory qualitative study. The study sites were the pediatric ICUs of the Hospital São Lucas and Hospital de Clinicas de Porto Alegre. Fifteen parents of children who died in the PICUs studied participated in the study. Data collection occurred in 2010 and was conducted through semistructured interviews. Data were analyzed using thematic content analysis. The research was approved by the research ethics committees of both hospitals. Conclusion Of the ICU physicians who would withdraw care for their patient, the majority would also want the same for themselves. The disparity between decision to continue to treat the patients versus treating self or family increased with increasing length of stay. Reference Results The ability to return to the hospital and talk to medical assistants was considered by parents as a positive and enlightening opportunity. Parents who participated in the study understood this moment as an opportunity to be heard and demonstrated the intention to contribute with their experiences in order to improve care in the hospitals studied. Conclusion We conclude that there is a need to implement measures to provide palliative care to parents after the death of their children. It is necessary to consider the possibility of providing families with follow-up meetings with the multidisciplinary team after the death of children. 1. Korones DN. What would you do if it were your kid? N Engl J Med. 2013;369:1291-3. 1. Piva J, Lago P, Othero J, Garcia PC, Fiori R, Fiori H, et al. Evaluating end of life practices in ten Brazilian paediatric and adult intensive care units. J Med Ethics. 2010;36:344-8. Making it safe to speak up about futile care: a multiperspective survey on leadership, psychological safety and perceived futile care in the ICU P <0.05 was considered statistically signifi cant. P569 Do intensivists prognosticate patients diff erently from themselves or their loved ones? Do intensivists prognosticate patients diff erently from themselves or their loved ones? S Gupta, C Green, R Tiruvoipati, J Botha S Gupta, C Green, R Tiruvoipati, J Botha Peninsula Health, Frankston, Australia Critical Care 2015, 19(Suppl 1):P569 (doi: 10.1186/cc14649) Introduction There is a paucity of data about whether our treatment philosophy is diff erent for our patients as compared with what we would have wanted for ourselves, or while acting as surrogate decision- makers for our loved ones. y gi Results During the period, 191 patients were admitted to the EDICU, from which 151 had complete data and follow-up. A total of 63 patients (41.7%) suff ered from a life-limiting disease and were evaluated as having a high probability of death in 1 year. This group was further divided between 35 patients who in the moment of initial screening were expected to die in this hospital admission and 28 patients who were believed to survive to discharge. Comparison between these two groups showed patients believed to die at this hospital admission had higher SAPS III scores (66.9 vs. 59, P = 0.010) and hospital mortality (48.6% vs. 10.7%, P = 0.001). Methods An anonymous survey was sent to all the members of Australia and New Zealand Intensive Care Society and the College of Intensive Care Medicine (CICM). The fi rst section comprised a hypothetical case scenario spanning over 6 weeks of ICU stay for a patient. At four diff erent stages of the ICU stay, responders were requested to answer multiple- choice questions regarding the philosophy of treatment, based on their perceived prognosis of the patient at that particular time. The following two sections contained the same set of questions with the hypothetical scenario of responders acting as surrogate decision-makers for the patient and that of responders being patients themselves, in the same situation. The responses were compared amongst three sections at each stage using the chi-square test. Conclusion A high percentage of patients admitted to our EDICU have life-limiting disease and might benefi t from palliative care. These patients can be identifi ed using simple screening questions at admission and positive answers to those questions can be associated with worse outcomes. Results A total of 115 responses were received from the fellows of CICM. The results are presented in Tables 1 and 2. P573 How readable are our Patient Information Sheets? L Strachan, M Booth Glasgow Royal Infi rmary, Glasgow, UK Critical Care 2015, 19(Suppl 1):P573 (doi: 10.1186/cc14653) Results Sixty-eight knowledge to care gaps were proposed, rated and revised by the committee over three rounds of review, resulting in 13 priorities for improvement. Then, 1,103 providers (62% response rate) representing nurses, respiratory therapists, allied health professionals and physicians evaluated the priorities and rated nine as necessary. In multivariable logistic regression analyses, provider (profession, experience and teaching status of ICU) and knowledge to care gap characteristics (strength of supporting evidence, potential to benefi t the patient, potential to improve patient/family experience, and potential to decrease costs) were associated with priorities rated as necessary. After disseminating the results to all network members, 627 responded (35% response rate) and indicated that the priorities were reasonable choices for quality improvement initiatives (87%), that they were highly supportive of working on initiatives targeting the priorities (61%) and would be willing to act as local champions for the initiatives (n = 92 individuals). Introduction We often need to obtain consent for clinical studies in the ICU. Participant Information Sheets (PIS) can be diffi cult to understand. A recent French publication [1] supports our hypothesis that PIS have poor readability scores. Methods Protocols submitted for ethics approval between 2008 and 2009 were obtained with permission from the Scotland A Ethics Research Committee. Ethical approval was not required for this observational study. All header, footers, diagrams and tables were removed. Readability scoring was performed using the Flesch Reading Ease and Flesch–Kincaid (FK) grades. Statistical analysis using Excel and MiniTab was then performed. The readability of these documents was compared with everyday documents – newspaper articles, politicians’ speeches [2] and standard contract agreements. p g Results A total of 104 protocols containing 209 PIS were reviewed. Of these, 99 (47%) were written for patients, 56 (27%) for GPs, 26 (12%) for relatives, 17 (8%) for carers, fi ve (2%) for legal representatives and six (3%) were summary sheets only. Sixty-seven (64%) of these protocols were submitted by academic institutions (for example, university or health boards) and 37 (36%) by pharmaceutical companies. Results are expressed as the median and 25th and 75th percentiles. P573 The word count and number of pages were higher for those PIS submitted by pharmaceutical companies compared with academic institutions: 1,561 (471; 5,167) versus 1,177 (626.5; 1,559.8) with P <0.05 and 4 (2; 10) versus 3 (2; 4) with P <0.05 respectively. The Flesch Reading Ease (63 (56; 69) vs. 60 (52.6; 65.4)) and FK grades (3 (5.4; 7.2) vs. 6.8 (6; 7.6)) were similar for both groups. Further subanalysis demonstrated that PIS designed for GPs had a lower word count, lower Flesch and higher FK grade compared with those for patients – the diff erence in Flesch and FK grade were compared using a Mann–Whitney test and were statistically signifi cant. Conclusion Our research approach engaged a diverse group of stakeholders to identify nine priorities for improving the quality and value of care provided to critically ill patients. This methodology can be used to engage stakeholders and identify priorities for quality improvement in other healthcare systems and domains. Additional work is required to reconcile provider/decision-maker and patient/ family priorities. p H Stelfox1, E McKenzie1, S Bagshaw2, M Gill1, P Oxland1, D Boulton1, D Oswell1, M Potestio1, D Niven1 1University of Calgary, AB, Canada; 2University of Alberta, Edmonton, AB, Canada Critical Care 2015, 19(Suppl 1):P575 (doi: 10.1186/cc14655) y gi Conclusion The FK grade is equivalent to US school grade level. The US government advises all policies produced should have a FK grade of <9. Our study suggests that protocols submitted to the ethics committee are easy to read, comparing favourably with broadsheet journalism and standard contract, for example loan contract. However, the average reading age in the UK is 9 years [3], suggesting participants may struggle with the information provided. References Introduction With increasing emphasis on patient and family-centred care, it follows that patients and their family members should be included when priorities for improving care are established. We therefore used a novel methodology that employs former patients and family members as researchers to describe the experiences of critically ill patients and their families with ICUs and to identify opportunities for improvement. journalism and standard contract, for example loan contract. However, the average reading age in the UK is 9 years [3], suggesting participants may struggle with the information provided. References p Methods Using the patient engagement framework developed by Marlett and Emes, we engaged four former patients and family members trained in qualitative research methods to conduct and analyse semistructured focus groups and interviews with adult patients who had recovered from critical illness and family members of both surviving and deceased patients. Participants were recruited from 13 ICUs in Alberta, Canada. Focus groups and interviews were recorded, transcribed and analysed using phenomenological reduction. Data collection continued until thematic saturation was reached. 1. Menoni V. The readability of information and consent forms in cl research in France. PLos One. 2010;5:e10576. Menoni V. The readability of information and consent forms in clinic research in France. PLos One. 2010;5:e10576. 2. http://www.britishpoliticalspeech.org/speech-archive.l 3. Gillies K. Patient information leafl ets for UK randomised controls. Trial. 2014;15:62. References 1. Piva J, Lago P, Othero J, Garcia PC, Fiori R, Fiori H, et al. Evaluating end of life practices in ten Brazilian paediatric and adult intensive care units. J Med Ethics. 2010;36:344-8. Introduction A high percentage of patients admitted to ICUs fulfi ll one or more criteria for palliative care. There are currently few comprehensive studies in critical care settings that have set out to 2. Lago PM, Nilson C, Pedro Piva J, Vieira AC, Halal MG, de Carvalho Abib GM, et al. Nurses’ participation in the end-of-life process in two paediatric intensive 2. Lago PM, Nilson C, Pedro Piva J, Vieira AC, Halal MG, de Carvalho Abib GM, et al. Nurses’ participation in the end-of-life process in two paediatric intensive S199 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 care units in Brazil. Int J Palliat Nurs. 2011;17:264, 267-70. 3. Abib El Halal GM, Piva JP, Lago PM, El Halal MG, Cabral FC, Nilson C, et al. Parents’ perspectives on the deaths of their children in two Brazilian paediatric intensive care units. Int J Palliat Nurs. 2013;19:495-502. Methods Using a modifi ed RAND/UCLA Appropriateness Methodology, a committee of 38 providers and decision-makers representing a population-based clinical network of adult (n = 14) and pediatric (n = 2) medical–surgical ICUs in Alberta, Canada (population 4 million) serially proposed, rated and revised potential knowledge to care gaps as priorities for improvement. The priorities developed by the committee were sent to the network’s 1,790 frontline providers to rate their importance. The fi nal list of priorities that were rated as important was disseminated to all network members for feedback. Using patient researchers to understand patient and family experiences in ICUs p H Stelfox1, E McKenzie1, S Bagshaw2, M Gill1, P Oxland1, D Boulton1, D Oswell1, M Potestio1, D Niven1 1University of Calgary, AB, Canada; 2University of Alberta, Edmonton, AB, Canada Critical Care 2015, 19(Suppl 1):P575 (doi: 10.1186/cc14655) Survey of visiting hours in critical care units in English trauma centres One hundred per cent were able have questions answered satisfactorily. Linked to the FS-ICU, we have seen marked improvements in decision-making and satisfaction. Methods A telephone survey on visiting times was conducted in 53 adult critical care units in trauma centres in England. A list of trauma centres was obtained from the NHS England website. All critical care units (other than obstetric high dependency units and coronary care units, unless part of a cardiothoracic critical care unit) within each hospital were surveyed. Each respondent was asked about the visiting hours, whether children were allowed to visit and how many visitors to a bed space. Conclusion We have shown progressive improvement over 3 years across all domains. Marked improvement in information provision and decision-making support from 53% to 96% over 3 years since introducing the FWR correlates with the improved overall satisfaction (Figure 1). Interestingly FWR is more helpful than relatives anticipated. The FWR was very well received and our results suggest an unrecognised need is being met. Because this was a pragmatic study, we feel this is a true representation of family satisfaction. It is encouraging that communication, information and decision-making support continue to improve. They have become embedded in the fabric of our critical care practice and lead to marked improvement in satisfaction for families. Reference Results Fifty-three units with between four and 75 beds and covering the whole of England were surveyed: there was a 100% response rate. Visiting hours varied between hospitals and between units within the same hospital. Nine units (17%) had open visiting hours, although most gave advice on times to avoid such as nursing handover. The majority of units (44.83%) operated restricted visiting with a median (range) of 6 (2 to 9) hours. All units allowed a maximum of two visitors to the bedspace. Children were allowed in nine units without restriction, the remaining units advised that it may not be appropriate for children to visit and it was at the discretion of the parents and medical staff . 1. Wall et al. Refi nement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med. 2007;35:271-9. f Conclusion The majority of adult critical care units in England, including our own, have restricted visiting policies. Survey of visiting hours in critical care units in English trauma centres Figure 1 (abstract P577). Trends in family satisfaction. E Taylor, N Bunker E Taylor, N Bunker The Royal London Hospital, London, UK round (FWR), to enhance and standardise communication and improve satisfaction. Following introduction of the FWR we have audited family satisfaction using the validated FS-ICU questionnaire [1]. round (FWR), to enhance and standardise communication and improve satisfaction. Following introduction of the FWR we have audited family satisfaction using the validated FS-ICU questionnaire [1]. Methods This was a prospective study of relatives’ satisfaction for patients completing their critical care episode. The questionnaire was completed anonymously and data collected. This was a pragmatic study, no changes were made to communication strategies. Results There is a high degree of satisfaction across all domains of the FS-ICU including treatment of family and provision of information (Figure 1). One hundred per cent found FWR to be helpful, only 55% had anticipated this. Fifteen per cent changed their perception of critical care. It enabled 15% to raise new concerns. One hundred per cent were able have questions answered satisfactorily. Linked to the FS-ICU, we have seen marked improvements in decision-making and satisfaction. Introduction The purpose of this study was to assess the visiting restrictions placed on families visiting adult patients on critical care units within trauma hospitals in England. Whilst it is well recognised that high-quality care for patients is of paramount importance, we should also be aware that supporting patients’ families off ers long- term benefi ts for patient, family and hospital. In our own unit we are reviewing whether we could adopt a more fl exible attitude to visiting times and assessing how to provide a more welcoming environment to relatives. To inform our own review and in order to develop a best practise approach, we surveyed all of the major trauma centres in England. Methods This was a prospective study of relatives’ satisfaction for patients completing their critical care episode. The questionnaire was completed anonymously and data collected. This was a pragmatic study, no changes were made to communication strategies. Results There is a high degree of satisfaction across all domains of the FS-ICU including treatment of family and provision of information (Figure 1). One hundred per cent found FWR to be helpful, only 55% had anticipated this. Fifteen per cent changed their perception of critical care. It enabled 15% to raise new concerns. Survey of visiting hours in critical care units in English trauma centres Visiting policies are a source of debate amongst staff in intensive care with concerns about open visiting including increased workload and interruptions to normal routine [1]. This is consistent with the views of staff at our own unit who, in appreciative enquiry, have expressed mixed opinions about extending visiting times. Extending visiting times is only part of a wider project to improve the way relatives experience intensive care whilst ensuring both medical and nursing staff feel supported, creating an environment for optimal communication. P578 Bereavement care in UK ICUs: a national survey M Berry1, E Brink2, V Metaxa2 1Imperial Healthcare Trust, London, UK; 2King’s College Hospital, London, UK Critical Care 2015, 19(Suppl 1):P578 (doi: 10.1186/cc14658) Introduction For the families of critically ill patients, the death of a loved one in the ICU is often an unexpected and traumatic event, characterised by diffi cult decisions regarding withholding or withdrawing life-sustaining therapy. Increasingly the importance of bereavement care (BC) in the ICU is being acknowledged, although reports continue to highlight the inadequacies around end-of life care in the critical care environment. In 1998, the Intensive Care Society (ICS) published guidelines mapping out BC in the ICU [1]. We aimed to compare BC in ICUs across England against the recommendations set out by the ICS. 1. Berti D, et al. Intensive Care Med. 2007;33:1060-5. 1. Berti D, et al. Intensive Care Med. 2007;33:1060-5. P574 Stakeholder engagement to identify priorities for improving the quality and value of care provided to critically ill patients H Stelfox1, D Niven1, S Bagshaw2, E McKenzie1, M Potestio1, F Clement1, D Zygun2 1University of Calgary, AB, Canada; 2University of Alberta, Edmonton, AB, Canada Critical Care 2015, 19(Suppl 1):P574 (doi: 10.1186/cc14654) Results Thirty-two participants including patients (n = 11) and family members (n = 21) participated in fi ve focus groups (n = 23 participants) and eight interviews (n = 9 participants). Participants articulated themes refl ecting important components of care organised across three phases of the ICU experience; admission to ICU, daily care in ICU and after ICU discharge. Admission to ICU comprised three themes: patient and family transition into ICU, patient and family disorientation upon admission to ICU and preferred staff actions to help patients/ family adapt to the ICU. The daily care phase of ICU consisted of fi ve themes: honouring patient’s voices, needing to know, making decisions, culture in ICU and medical care. The experience after ICU discharge comprised two themes: transition from ICU to a hospital ward and long-term eff ects of critical illness. Participants identifi ed fi ve Critical Care 2015, 19(Suppl 1):P574 (doi: 10.1186/cc14654) Introduction Healthcare systems do not make optimal use of evidence, which results in suboptimal patient care. Large amounts of scientifi c evidence are generated but not implemented into patient care (knowledge to care gap). We sought to identify and prioritize knowledge to care gaps in critical care medicine as opportunities to improve quality and value in care. S200 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Figure 1 (abstract P577). Trends in family satisfaction. priorities for improvement: provide families with a guide/navigator; educate providers about the fragility of family trust; improve provider communication skills; inform patients about the long-term eff ects of critical illness; and develop strategies to facilitate continuity of care between providers. p Conclusion Patients and family members are an untapped resource and engaging them as researchers is a viable strategy to identify opportunities for quality improvement that are patient and family centred. P577 y Methods All adult ICUs in England were contacted over a 2-week period, using a standardised questionnaire based on the nine domains identifi ed by the ICS. All answers were collected anonymously using SurveyMonkey®. An 80% compliance rate was deemed acceptable.i y Methods All adult ICUs in England were contacted over a 2-week period, using a standardised questionnaire based on the nine domains identifi ed by the ICS. All answers were collected anonymously using SurveyMonkey®. An 80% compliance rate was deemed acceptable. Results From the 148 ICUs identifi ed, 113 answered the questionnaire (76%). Forty-three per cent of the responders had access to training in BC and in communication skills, and 54% had a named member of staff responsible for training, writing, auditing and developing the R Handslip, A Molokhia Introduction Patient satisfaction is a crucial part of clinical care and there is now increasing recognition of the importance of family involvement and satisfaction in the provision of care for the critically ill. Since 2012 our unit has introduced a consultant-led family ward Results From the 148 ICUs identifi ed, 113 answered the questionnaire (76%). Forty-three per cent of the responders had access to training in BC and in communication skills, and 54% had a named member of staff responsible for training, writing, auditing and developing the S201 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Critical Care 2015, Volume 19 Suppl 1 http://ccforum.com/supplements/19/S1 Conclusion This is the fi rst national audit of BC in the ICU since the initial ICS guideline publication. Even though most ICUs provided relatives with information around the time of death, training, auditing and adequate facilities do not meet the recommended standards. The lack of adherence is defi nitely multifactorial and requires further research. In the meantime, vigorous implementation of these guidelines is warranted in order to ensure optimal care for the bereaved families. Reference BC policy. When asked about the presence of a written BC policy only 45% responded positively, and even less (19%) had provisions for audit and development of the service. Information to staff about cultural and religious rites around the time of death, and to relatives on what to do after a death was available in 81% and 96% respectively. The general practitioner was informed of the deaths taking place in the ICU in 77% of the cases. . Intensive Care Society (1998). http://www.ics.ac.uk/ics-homepage/ guidelines-and-standards/. P577 In more than 70% of the participating ICUs, eff orts were made to ensure privacy of the grieving relatives and to have dedicated follow-up facilities for the bereaved. Even though staff support programmes were recognised as paramount, only 54% of the ICUs had formal ones set up.
https://openalex.org/W1991681753	https://europepmc.org/articles/pmc6084510?pdf=render	English	null	Alternate Nitrogen Amendments for Organic Fertilizers	The scientific world journal/TheScientificWorldjournal	2,001	cc-by	3,585	INTRODUCTION The use of compost or manure in agriculture as an organic source of nutrients is common in many tropical, developing countries like Nigeria. One of the drawbacks of such materials is their low ni- trogen (N) content (=1% N). Farmers commonly use chemical N fertilizers such as urea, calcium ammonium nitrate (CAN), and NPK formulations to obtain better crop growth and yield. These chemical supplements may have a negative im- pact on the environment through nitrate leaching into water, leading to eutrophication of surface waters that can affect public health. Before the advent of mineral fertilizers about 150 years ago, manure and composts were practically the only sources of nutri- ents for crops[1]. However, after independence and the discov- ery of crude oil in the 1960s, the use of mineral fertilizers displaced organic sources as people found them easy to handle and to apply on their farms. In 4 decades, it was recognized that several problems occurred with intensive use of inorganic fertil- izers. Some of these problems were reliability of fertilizer sup- ply, high cost, N volatilization losses, soil degradation through erosion, and frequent overapplication with consequent pollution of surface and groundwater resources. These problems have been encountered in many countries. Gliricidia sepium, a fast-growing, tropical, pe- rennial hedge plant was tested as a source of N in organo-mineral fertilizer formulations. Average nutrient content of Gliricidia is 3.8% N, 0.32% P, 1.8% K, 0.8% Ca, and 0.2% Mg. Using a sand cul- ture and Amaranthus caudatus as a test crop, it was shown that amending commercial composts with 30% Gliricidia prunings would benefit many small-scale farmers and control environmental pollution. As a result, most countries began to put emphasis on the advantages of applying organic manure or organic fertilizers to replenish dwindling soil nutrients. Among the various organic materials in use are composted city refuse, green manure, de- composed animal wastes, and farmyard manure, which are usu- ally found in abundant quantities in most communities. In Nigeria, millions of tons of city refuse are produced annually, which has the potential to be composted and used to improve soil fertility. Gliricidia sepium[2,3], a common hedge plant in the humid trop- ics, was found to be useful as a source of green manure. Com- pared to other shrubs, Gliricidia has a high decomposition rate and N release[4]. Gliricidia is also productive, yielding from 2 to 15 t/ha/year of dry matter[2]. Research Article Optimizing Nitrogen Management in Food and Energy Production and Environmental Protection: Proceedings of the 2nd International Nitrogen Conference on Science and Policy TheScientificWorld (2001) 1(S2), 142–147 ISSN 1532-2246; DOI 10.1100/tsw.2001.454 Research Article Optimizing Nitrogen Management in Food and Energy Production and Environmental Protection: Proceedings of the 2nd International Nitrogen Conference on Science and Policy TheScientificWorld (2001) 1(S2), 142–147 ISSN 1532-2246; DOI 10.1100/tsw.2001.454 Research Article Optimizing Nitrogen Management in Food and Energy Production and Environmental Protection: Proceedings of the 2nd International Nitrogen Conference on Science and Policy TheScientificWorld (2001) 1(S2), 142–147 ISSN 1532-2246; DOI 10.1100/tsw.2001.454 * Corresponding Author. E-mails: 1mkcsridhar@skannet.com; 2spalna@cgiar.org © 2001 with author. Alternate Nitrogen Amendments for Organic Fertilizers M.K.C. Sridhar1,, G.O. Adeoye2, and O.O. AdeOluwa2 Organo-Mineral Fertilizer Research and Development Group, 1Division of Environmental Health, College of Medicine, University of Ibadan, Ibadan, Nigeria; 2Department of Agronomy, University of Ibadan, Ibadan, Nigeria INTRODUCTION In a study carried out by Handayanto et al.[5], it was observed that the N mineralization rate of low-grade prunings from Peltophorum dasyrrachis was significantly improved by mixing with G. sepium. Corresponding Author. Fertilizer Treatments indeed perform better for some crops. The use of organic matter as fertilizer in developing countries has received much less at- tention from economists because the beneficial effects are not visible immediately[10]. Araji and Stodick[11] found that the cost associated with the handling and spreading of manure ranges between 20 to 30% of the cost of commercial fertilizer. This cost differential indicates that the use of green manure can be less costly than using urea or any chemical amendment in compost. Even though the use of organo-mineral fertilizers is widely ac- cepted globally, the inorganic constituents may still pose envi- ronmental problems to some extent. Grade A OMF, Grade B OMF, and Gliricidia were used in the greenhouse experiments. With these materials, seven treatments were prepared (letter-coded as shown below) and applied as fol- lows: • Soil alone with no treatments (control) P • 20% dried Gliricidia prunings + 80% Grade B OMF A • 30% dried Gliricidia prunings + 70% Grade B OMF B • 40% dried Gliricidia prunings + 60% Grade B OMF C • 50% dried Gliricidia prunings + 50% Grade B OMF D • 100% dried Gliricidia prunings alone M • Grade B (unamended) OMF alone N • Grade A OMF alone O In order to minimize environmental impact, there is a need for local materials that can supplement the N and other minerals. One such alternative identified is G. sepium, which grows exten- sively as a wild hedge plant. This paper reports the assessment of G. sepium for its suitability as an amendment for organo-mineral fertilizers being prepared from market and slaughterhouse wastes. The soil used in the experiments was obtained from the Uni- versity of Ibadan campus, which from the composition may be considered as the worst of tropical eroded soil. The soil was sandy (with about 90% sand) and slightly acidic (with pH 6.6). It had very low levels of mineral nutrients and exchangeable cations. This soil was deliberately chosen for the experiment with a view of establishing the efficacy of the available nutrients from the treatments under study (Table 1). The soil was sieved to pass 2 mm to remove stones and other unwanted constituents. In each pot, 2 kg soil was mixed with various amendments. Amaranthus caudatus was used as the test crop. Fertilizer Sources • Grade B organo-mineral fertilizer (OMF): Compost was obtained from Pace Setter Organic Fertilizer Plant, developed by the authors for the Oyo state government. The compost was made from market and slaughterhouse wastes from Ibadan, in southwestern Nigeria. The unamended compost was prepared using an aerobic windrow system and was devoid of toxic and heavy metals. This is referred to as Grade B OMF. KEY WORDS: nitrogen, compost, organic fertilizer, Nigeria, environment, Gliricidia KEY WORDS: nitrogen, compost, organic fertilizer, Nigeria, environment, Gliricidia DOMAINS: plant sciences, agronomy, soil systems, eco- systems and communities, environmental chemistry, bioremediation and bioavailability, environmental technol- ogy, environmental management and policy, ecosystems management, biotechnology, agricultural biotechnology Many researchers have reported the superiority of combined inorganic and organic fertilizers (organo-mineral fertilizers) over their performance separately[6,7]. However, Cooke[8] and Peverly and Gates[9] showed that organic fertilizers could 142 Sridhar et al.: Nitrogen Amendment of Compost TheScientificWorld (2001) 1(S2), 142–147 RESULTS AND DISCUSSION The Grade B OMF, which is the normal compost made from urban wastes, as expected was low in N and P (Table 2). The Grade A OMF was amended with urea and bone meal to increase N and P levels, respectively. Most farmers in Nigeria prefer a formula that can supply adequate N to meet requirements of cer- tain high-N-demanding crops like maize and vegetables. P amend- ment is only needed for certain crops. In other African and Asian countries, the agricultural practice involves supplementing or- ganic manure separately with inorganic fertilizers sometime dur- ing the growing period, usually after several weeks of growth. This practice is not common in Nigeria, where traditional fal- lowing methods or green manure are used when inorganic fertil- izers are not available or cost effective. Soil pH was determined by suspending the soil samples in distilled water (1:1) using glass electrode (EIL pH meter)[13]. Organic carbon was analyzed by the dichromate wet-oxidation TABLE 1 Physico-Chemical Properties of the Experimental Soil TABLE 1 Physico-Chemical Properties of the Experimental Soil Parameter Value pH value (in water) 6.60 Organic carbon, % 1.50 Total Kjeldahl N, g/kg 1.3 Available P, mg/kg 7.50 Exchangeable bases, cmol/kg K 0.13 Na 7.50 Mg 0.18 Ca 0.14 Exchangeable acidity, cmol/kg 0.20 CEC, cmol/kg 4.28 Base saturation, % 95.50 Extractable micronutrients, mg/kg Mn 47.98 Fe 66.90 Cu 0.85 Zn 3.55 Mechanical composition, g/kg Sand 910.0 Silt 74.0 Clay 20.0 Gliricidia has three to four times higher N content compared to normal compost (i.e., Grade B OMF). Therefore, the Grade B OMF was amended with ground dry leaves at various percent- ages from 0 to 100 along with appropriate controls (soil alone) to compare the efficacy in providing N to the test crop. Green amaranth is a widely used vegetable among the low- and middle- income traditional families. This test crop was monitored for the growth and dry-matter yield. The highest Amaranthus yield at 5 WAP was 16.78 t/ha with the 30% Gliricidia-amended compost. Norman[20] reported a similar yield of 20 t/ha for amaranths grown on a sandy, infertile soil. If the soil is reasonably fertile, unlike the one used in this study, the yield can be substantial. Incorporation of Gliricidia improved the N levels of unamended compost (Table 2). Methods of Analyses Six soil core samples (passed through a 2-mm sieve) were taken randomly for physical and chemical analysis. They were air-dried and used. Particle size distribution was determined by hydrom- eter method[12] using sodium hexametaphosphate as the dispers- ing agent. The coarse-sand fraction was separated from the fine sand using a 1-mm sieve. Greenhouse Experiment If any weeds were seen, they were removed, ground, and put back into the same pots to account for nutrient loss. The fol- lowing parameters were observed at 5 weeks after planting (WAP) and 6 WAP for residual effect: plant height, leaf number, stem girth, and whole-plant fresh and dry weight. Plant height was taken from the ground level to the dewlap of the last fully opened leaf. Stem girth was determined by passing a thread around a predetermined mark of 10 cm on the stem above the soil level. The harvested samples were oven dried to constant weight at 80°C and expressed as tons per hectare. Exchangeable cations were determined by leaching with 1N neutral NH4OAc according to the method of Tisdale[16]. K was determined by flame photometer as described by Sillanpaa[17]. Micronutrients (Mn, Fe, Cu, Zn) were extracted with 0.1 N EDTA and determined using atomic absorption spec- trophotometer[18]. The results of the experiment were subjected to analysis of variance and the means compared using the Duncan Multiple Range test[19]. Greenhouse Experiment • Grade A OMF: The Grade B OMF was amended with urea and bone meal to enrich with extra N and P and is referred to as Grade A OMF. The greenhouse experiment was designed for evaluating the effi- cacy of the various treatments. Each treatment was applied at 5, 10, and 15 t/ha in 2-kg plastic pots in a randomized complete block design. Soil weight was 1.8 kg per pot. A. caudatus was planted twice successively, for main and residual effects. The ambient air temperature was about 28 to 30°C. A. caudatus was planted 1 week after the incorporation of the various treatments. • Gliricidia prunings were obtained from agricultural land by harvesting fresh leaves, drying to constant weight at a temperature of 80°C, and milling to pass through a 0.2-mm sieve. FIGURE 1. G. sepium in its natural habitat from a farm. FIGURE 1. G. sepium in its natural habitat from a farm. 143 TheScientificWorld (2001) 1(S2), 142–147 Sridhar et al.: Nitrogen Amendment of Compost method of Walkey-Black as described by Black[14], and the value of organic matter was obtained by multiplying the carbon level by 1.729. Total Kjeldahl N was determined by macro Kjeldahl method. Available P was determined by the Bray P (0.03 N NH4F + 0.025 N HCl) solution as described by Bray and Kurtz[15] and determined colorimetrically by the molybdate blue method. For finding the residual effect, fresh seeds were planted immedi- ately after the first harvest, with no additional treatments. Water was applied daily to field capacity to maintain soil moisture con- tent. If any weeds were seen, they were removed, ground, and put back into the same pots to account for nutrient loss. The fol- lowing parameters were observed at 5 weeks after planting (WAP) and 6 WAP for residual effect: plant height, leaf number, stem girth, and whole-plant fresh and dry weight. Plant height was taken from the ground level to the dewlap of the last fully opened leaf. Stem girth was determined by passing a thread around a predetermined mark of 10 cm on the stem above the soil level. The harvested samples were oven dried to constant weight at 80°C and expressed as tons per hectare. For finding the residual effect, fresh seeds were planted immedi- ately after the first harvest, with no additional treatments. Water was applied daily to field capacity to maintain soil moisture con- tent. RESULTS AND DISCUSSION While the 100% Gliricidia-prunings treatment proved to be most prof- itable, the 30% Gliricidia amendment seems to be ideal from the practical point of view. All the Gliricidia-amended composts in- deed performed better than the urea-amended composts. The optimum application rate of amended composts was 15 t/ha both in the first and second crops (Table 3). The yields observed in the second crop may be due to residual nutrient availability. Gliricidia prunings gradually released nutrients over a period of 120 days[4]. Even the 40 and 30% Gliricidia-amended compost had significant residual effects compared to the urea-amended compost. 144 TheScientificWorld (2001) 1(S2), 142–147 Sridhar et al.: Nitrogen Amendment of Compost Nitrogen Amendment of Compost TheScientificWorld (2001) 1(S2) FIGURE 3. Residual effect of various fertilizers on fresh weight of Amaranthus at the end of 6 weeks after planting. FIGURE 2. Effect of various fertilizers on fresh weight of Amaranthus at the end of 5 weeks after planting. TABLE 2 Nutrient Composition of Organo-Mineral Fertilizers and G. sepium Prunings Material Used Composition Grade A OMF Grade B OMF G. sepium Total Kjeldahl N, % 2.58 1.46 3.78 Total phosphorus (P), % 1.10 1.03 0.32 FIGURE 2. Effect of various fertilizers on fresh weight of Amaranthus at the end of 5 weeks after planting. FIGURE 2. Effect of various fertilizers on fresh weight of Amaranthus at the end of 5 weeks after planting. FIGURE 2. Effect of various fertilizers on fresh weight of Amaranthus at the end of 5 weeks after planting. TABLE 2 Nutrient Composition of Organo-Mineral Fertilizers and G. sepium Prunings Material Used Composition Grade A OMF Grade B OMF G. REFERENCES From an economic point of view (Table 3), the 100% Gliricidia-amended compost gave the best yield, and, in terms of currency, it amounted to about seven times higher than the control and almost double that of the urea-amended compost. However, it is not practicable to use the plant entirely, and the next best is 30%, which is very feasible when mixed with the composts prepared from wastes. When amended and applied at a rate of 10 t/ha, the economic returns are six times higher than the control. These results concur with Cooke[8] and Perverly and Gates[9], who reported that sole organic fertilizers performed better with some crops. Mafongoya et al.[21] studied the N-re- lease patterns from seven leguminous trees and found that the lignin + polyphenol to N ratio could be used to screen legumi- nous tree leaves for their potential to release N. In another study by Lionel et al.[22] in Haiti, G. sepium was found to decompose faster as compared to seven other Hedgerow species. Leaves decomposed faster than stems. These studies further confirm the value of Gliricidia in compost amendments. 1. Singh, A. (1974) Use of organic material and green manures as fertilizers in developing countries. Soil Bulletin 27. 1. Singh, A. (1974) Use of organic material and green manures as fertilizers in developing countries. Soil Bulletin 27. 2. Wilson, G.F., Kang, B.T., and Mulongoy, K. (1986) Alley crop- ping trees as source of green manure and mulch in the tropics. Biol. Agric. Hortic. 3, 251–267. 3. Agboola, A.A., Wilson, G.F., Getahum, A., and Yamoah, C.F. (1981) Gliricidia sepium: a shrub legume with a future for con- tinuous arable cropping in the humid tropics. Paper presented at the Workshop on Agroforestry in the African Humid Tropics, University of Ibadan, Ibadan, Nigeria, April 27–May 1. 4. Yamoah, C.F., Agboola, A.A., and Mulongoy, K. (1986) Decom- position and weed control by pruning of selected alley cropping shrubs. Agrofor. Syst. 4(3), 239–246. 5. Handayanto, E., Giller, K.E., and Cadish, G. (1997) Regulating N release from legume tree prunings by mixing residues of dif- ferent quality. Soil Biol. Biochem. 29(9–10), 1417–1426. 6. Agboola, A.A. and Obigbesan, C.O. (1974) Response of maize, rice and cassava to fertilizers in western Nigeria. First National Seminar on Planning and Fertilizer Use Development in Nigeria (Mines). RESULTS AND DISCUSSION sepium Total Kjeldahl N, % 2.58 1.46 3.78 Total phosphorus (P), % 1.10 1.03 0.32 Potassium (K), % 0.68 0.60 1.83 Calcium (Ca), % 3.62 1.19 0.80 Magnesium (Mg), % 0.18 0.11 0.20 Zinc (Zn), mg/kg 276.0 290.0 31.00 Copper (Cu), mg/kg 25.0 22.00 — Manganese (Mn), mg/kg 32.0 19.00 — Chromium (Cr), mg/kg NDa ND — Lead (Pb), mg/kg ND ND — 145 TheScientificWorld (2001) 1(S2), 142–147 Sridhar et al.: Nitrogen Amendment of Compost TABLE 3 Estimated Income from Amaranthus Production Based on Best Level of Performance for Each Treatment Yield (t/ha) Income/ha Treatments Main Yield Residual Effect Total (NGN)a Control P 2.5 0.25 2.75 27,500 20% Gliricidia-amended OMF A 12.19 1.24 13.43 134,300 30% Gliricidia-amended OMF B 16.78 1.46 18.34 183,400 40% Gliricidia-amended OMF C 15.16 1.09 16.25 162,500 50% Gliricidia-amended OMF D 15.03 0.56 15.59 155,900 100% Gliricidia-pruning M 15.88 2.85 18.73 187,300 Unamended Grade B OMF N 6.04 1.07 7.11 71,100 Urea-amended Grade A OMF O 9.58 0.48 10.06 100,600 a Currency equivalent: 1 USD = 114 NGN (Nigerian Nairas). TABLE 3 Estimated Income from Amaranthus Production Based on Best Level of Performance for Each Treatment TABLE 3 a Currency equivalent: 1 USD = 114 NGN (Nigerian Nairas). CONCLUSIONS The results of this study showed that Gliricidia prunings as an organic amendment for compost significantly improved growth and yield of A. caudatus compared to urea-amended compost. Cost and environmental advantages suggested that 100% Gliricidia prunings and their 30, 40, and 50% composition in compost could do better than urea-amended compost. Thus, the Gliricidia performed better in sandy soil than conventional urea used as a compost amendment. Based on results from the green- house study, the following conclusions may be drawn: 7. Egawa, T. (1975) Utilization of organic materials as fertilizers in Japan. In Organic Materials as Fertilizers. FAO Soils Bulletin 27. Food and Agriculture Organization, Rome. pp. 253–270. 8. Cooke, C.W. (1982) Fertilizing for Maximum Yield. Granada, London. 9. Peverly, J.H. and Gates. P.B. (1994) Utilization of municipal solid waste and sludge composts in crop production systems in sew- age sludge: land utilization and the environment. Proceedings of the Conference of the American Society of Agronomy, Madison, WI. August 11–12, 1993. 10. Duncan, A. (1975) Organic materials as fertilizers. In Economic aspects of the use of organic materials as fertilizers. FAO/SIDA Expert Consultation, Rome, December 2–6, 1974. In Organic Materials as Fertilizers. FAO Soils Bulletin 27. Food and Agri- culture Organization, Rome. • Dry Gliricidia prunings are shown to be a good substitute for mineral fertilizers in enriching N levels of normal composts such as Grade B. • 30% Gliricidia amendment of normal compost at an application rate of 15 t/ha optimized vegetable production, particularly when used in nutrient-depleted sandy soils. 11. Araji, A.A. and Stodick, L.D. (1990) Economic potential of feed- lot waste utilization in agricultural production. Biol. Waste. 32(2), 111–124. 146 TheScientificWorld (2001) 1(S2), 142–147 Sridhar et al.: Nitrogen Amendment of Compost 12. Bouyoucus, C.H. (1951) A recalibration of the hydrometer method for making mechanical analysis of soils. Agron. J. 43, 434–438. 21. Mafongoya, P.L., Nair, P.K.R., and Dzowela, B.H. (1998) Min- eralization of nitrogen from decomposing leaves of multipurpose trees as affected by their chemical composition. Biol. Fert. Soils 27(2), 143–148. 13. Peech, M. (1965) Hydrogen-ion activity. In Methods of Soil Analy- sis. Part 2. Chemical and Microbiological Properties. Black, C.A, Ed. Agronomy Monograph No. 9. American Society of Agronomy, Madison, WI. pp. 914–926. 22. Lionel, I., Wood, C.W., and Shannon, D.A. (2000) Decomposi- tion and Nitrogen release of prunings from hedgerow species assessed for alley cropping in Haiti. Agron. J. 92, 501–511. 14. CONCLUSIONS Black, C.A., Ed. (1965) Methods of Soil Analysis. Part 2. Chemi- cal and Microbiological Properties. Agronomy Monograph No. 9. American Society of Agronomy, Madison, WI. pp. 123–133. This article should be referenced as follows: 9. American Society of Agronomy, Madison, WI. pp. 123–1 15. Bray, R.H. and Kurtz, O. (1945) Determination of total organic and available forms of phosphorus. Soil Sci. 59, 45–49. Sridhar, M.K.C., Adeoye, G.O., and AdeOluwa, O.O. (2001) Alternate nitrogen amendments for organic fertilizers. In Optimizing Nitrogen Management in Food and Energy Production and Environmental Pro- tection: Proceedings of the 2nd International Nitrogen Conference on Science and Policy. TheScientificWorld 1(S2), 142–147. 16. Tisdale, S. L., Nelson, W.L., and Beaton, J.D. (1985) Soil Fertil- ity and Fertilizers. 4th ed. Macmillan, New York. 17. Sillanpaa, M. (1982) Micronutrients and the Nutrient Status of Soils: A Global Study. FAO Soils Bulletin 48. Food and Agricul- ture Organization, Rome. 18. Aubert, H. and Pinta, M. (1977) Trace Elements in Soils. Elsevier, Amsterdam. Received: July 27, 2001 Revised: November 12, 2001 Accepted: November 15, 2001 Published: December 19, 2001 19. Wagner, S.F. (1992) Introduction to Statistics. HarperPerennial, New York, 369 p. 20. Norman, J.C. (1992) Tropical Vegetable Crops. Arthur H. Stockwell, Ilfracombe, U.K. 147
https://openalex.org/W3119942078	https://www.researchsquare.com/article/rs-93362/v1.pdf?c=1603157968000	English	null	The Effects of Lithium on Inflammation Profiles and Nf-κB Nuclear Translocation in Raw 264.7 Macrophages Exposed to Rift Valley Fever Virus	Research Square (Research Square)	2,020	cc-by	10,731	The Effects of Lithium on Inflammation Profiles and Nf-κB Nuclear Translocation in Raw 264.7 Macrophages Exposed to Rift Valley Fever Virus The Effects of Lithium on Inflammation Profiles and Nf-κB Nuclear Translocation in Raw 264.7 Macrophages Exposed to Rift Valley Fever Virus Raymond Tshepiso Makola University of Limpopo - Turfloop Campus: University of Limpopo https://orcid.org/0000-0001-8394- 7096 Joe Kgaladi Rand Water South Africa Garland Kgosi More UNISA Petrus Jansen van Vuren H and B, Geelong AAHL Janusz Tadeusz Paweska NICD: National Centre for Disease Control Thabe Moses Matsebatlela (  thabe.matsebatlela@ul.ac.za ) University of Limpopo (Turfloop Campus) Sovenga https://orcid.org/0000-0001-6506-4070 Research Keywords: Macrophages, Inflammation, RVFV and NF-kB Posted Date: October 19th, 2020 DOI: https://doi.org/10.21203/rs.3.rs-93362/v1 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Introduction Rift Valley fever virus is a mosquito-transmitted zoonotic viral infection that results in Rift Valley fever disease. RVFV and other viruses have developed mechanism to circumvent the immune recognition in an attempt to advance their viral progeny. The RVFV S segment encodes a non-structural protein (NSs) known to be the main virulence factor that aid in immune suppression and viral replication. Thus, this study is aimed at investigating the inflammatory effects of lithium using macrophages as innate immune model. Results Lithium have shown to stimulate production of IFN-γ 3 hrs pi and reached its peak 12 hrs later. Moreover, the secondary pro-inflammatory cytokine and chemokine, IL-6, and RANTES were elevated at 12 hrs pi. Lithium was shown to stimulate expression of the primary pro-inflammatory molecule, TNF-α as early as 3 hrs pi. In addition to TNF-α expression, the regulatory cytokine, IL-10, was stimulated by lithium and reached its peak 12 hrs pi. The RVFV-infected cells treated with lithium have shown lowered ROS and RNS production as opposed to lithium-free RVFV-infected control cells. The regulatory properties of lithium were further supported by the protein expression assay that showed low expression of the iNOS while stimulating heme oxygenase (HO) and IκB. Lithium was shown to reverse NF-κB nuclear translocation in RVFV-infected Raw 264.7 cells as shown by the Immunocytochemistry assay. Moreover, lithium lowered the presence of nuclear NF-κB in RVFV-infected cells as opposed to untreated RVFV- infected cells and 5 mg/ml LPS controls as shown by the protein expression assay. Research Page 1/26 Page 1/26 Page 1/26 Conclusion This study demonstrates that lithium inhibits NF-kB nuclear translocation and modulate inflammation profiles in RVFV-infected Raw 264.7 cells. Methods The supernatant from RVFV-infected Raw 264.7 cells and treated with lithium, was examined with Elisa assay kit to measure production levels of the cytokines and chemokines. The H2DCF-DA and DAF-2 DA oxidant florigenic assays were used to determine the levels of ROS and RNS by measuring the fluorescence intensity shown by the cells post RVFV-infection and lithium treatment. While on the other hand Western blotting assay was used to measure expression levels of the inflammatory proteins and immunocytochemistry measured the cellular location of the NF-κB. Introduction Page 2/26 Page 2/26 Immune response is the vertebrate-dependent phylogenetic defence mechanism against infectious agents such as toxins and microbes. It is classified into innate immune response and humoral immune response (Akira et al., 2006; Xiao, 2017). Macrophages play a central role in the innate immune system and inflammation. These cells are antigen presenter cells (APC) located in various locations as tissue residential cells and as well as circulating cells in plasma (Plowden et al., 2004). The innate immune response is not entirely non-specific since myeloid lineage cells such as dendritic and macrophages express the pathogen recognition receptors (PRR) that recognise the conserved microbial components termed pathogen associated molecular patterns (PAMP) (Wang et al., 2004). The toll like receptors (TLRs), NOD-1 & 2 and retinoic acid–inducible gene I (RIG-I)–like helicase receptors (RLRs) are PRR known to recognise conserved microbial components and activate onset of various signalling pathways (Akira et al., 2006; Wang et al., 2013). Viral components are recognised by a number of receptors that include TLR-7 & 8 recognising viral ssRNA while RIG-I and TLR-3 detect viral dsRNA. These molecules are expressed intracellularly on the endosome membrane. Viral glycol proteins are shown to be recognised by TLR 2 & 4, thereby stimulating other inflammatory mediators and not the anti- viral specific molecules such as type I IFN. Binding of viral ligands to the receptors recruit adaptor molecules such as MyD88, TIRAP and TRIF to the cytoplasmic domain of the receptors (Akira et al., 2006). Toll like receptor-3 (TLR3) induce production of the IFN via a MyD88-independent signalling pathway. TRIF is then recruited and dimerise with TLR-3 on the cytoplasmic domain. The pathway culminates with activation of IRF-3 and IRF-7 which translocate into the nucleus and bind to the IFN-stimulated response elements (ISREs), resulting in the expression of IFN-inducible genes. Conversely, TLR 7 & 9 induce production of IFN via the MyD88 signalling pathway (Akira et al., 2006). RIG-I is a cytoplasmic dsRNA detecting receptor which is not accessible to TLR-3. This molecule interacts with IPS-1 to RIG-I using the CARD domain as its adaptor molecule. The resulting signalling cascade activates IRF-3 and IRF-7 in a similar manner used by TLR-3. The RIG-I was shown to detect cytoplasmic replicating dsRNA while TLR-3 detect dsRNA in the apoptotic bodies of virally infected cells undergoing apoptosis (Akira et al., 2006). Introduction RVFV is a mosquito-born zoonotic viral infection that result in various symptoms from flue like symptoms to a sever encephalitis and haemorrhagic fever. It contains a negative sense single-stranded RNA genome made up of 3 segments namely the L segments that encode viral RNA dependent RNA polymerase, the M segments that encode envelop glycoproteins (Gn and Gc) a 78 kDa protein and a 14 kDa non-structural protein (NSm). (Nfon et al., 2012). Moreover, The S segments encode the nucleoprotein (N) in the negative-sense and a non-structural protein (NSs) in the genomic direction (Nfon et al., 2012). The non- structural protein NSs was shown to be the main virulence molecule, this protein has innate immune suppressive properties that aid in the viral replication and viremia (Nfon et al., 2012). RVFV NSs protein circumvent the innate immune response system through inhibition of type I IFN (α & β) (Nfon et al., 2012), other studies (Le May et al., 2004; Wood et al., 2004) have shown RVFV NSs protein to induce suppression of mRNA synthesis machinery. This virulent molecules have shown to interact with p44 and XPD subunit of the TFIIH basal transcription factor. Page 3/26 Page 3/26 The NSs disturb the assembly of this basal transcription factor suggesting the suppression of several mechanism of gene expression (Le May et al., 2004; Wood et al., 2004). NSs aggregate with p44 and XPD and form nuclear filament-like structures that are thought to impair the transcription machinery (Le May et al., 2004; Wood et al., 2004). NSs is involved in the RVFV pathogenesis through transcriptional shut down that lead to a weakened anti-viral response and IFNs production system. IFNs are important antiviral factors that stimulate antiviral molecules and recruit other immune cells to the inflamed site in order to limit viral spread. The type I IFNs have been shown to enhance the constitutively expressed protein kinase RNA-activation (PKR). In addition to the IFNs system the PKR expression is enhanced by dsRNA and ssRNA. The role of this serine threonine kinase is to phosphorylate eukaryotic translational inhibition factor 2 (eIF2), leading to translational arrest of both cellular and viral mRNAs (Habjan et al., 2009). The PKR has shown some activity in the absence of NSs protein since NSs was shown to directly degrade PKR (Habjan et al., 2009). Monkeys that have shown high expression of IFNs cytokines have not developed RVF disease after exposure to RVFV. Introduction As a result these cytokines where suggest to possess protective properties against RVFV. Animal model studies show selective inhibition of the IFN-α since production of IFN-γ, TNF-α, IL-6, IL-12, and IL-1 β was observed without detectable levels of IFN-α. Interestingly, IFN-γ and IL-12 have been suggested to lower viremia by stimulating NK cells and cytotoxic role (Nfon et al., 2012). The evidence that NSs antagonise the IFNs cytokines makes RVFV infection difficult to clear. An in vitro vivo study conducted by Jansen van Vuren and colleagues showed contradictory findings with those that postulate that NSs result in transcriptional shut down and weakened inflammatory response (van Vuren et al., 2015, Le May et al., 2004). The work by Jansen van Vuren et al showed that immune response was mounted to a similar extend in both the fatal cases and none fatal cases. This study shows that early infection samples have high levels of IL-8 and CCL-2/MCP-1 in serum as compared to sera from uninfected controls. Interestingly, fatal case serum has shown 10-fold increased levels of IL-6 (pro-inflammatory cytokine) than non-fatal cases. The serum level of IL-10 in both early and late samples of the fatal and non-fatal cases were statistically not different. This study demonstrated that the fatality and survival of patients might not rely on inflammatory response but rather the extent of the regulation of inflammatory response (Jansen van Vuren et al., 2015). This immune regulatory evidence reported is in agreement with other similar publications that have shown deleterious outcomes of under-regulated or persistent inflammation (Reuter et al., 2010). It was shown that during inflammation the innate immune cell produces an excess of toxic reactive oxygen/ nitrogen species primarily used in digesting invading pathogens. Thus, persistent inflammation exposes cellular biomolecules such as proteins nucleic acids and lipids to these toxic free radical molecules. Damage to these biomolecules molecules attenuate cellular function, triggering cell death (Reuter et al., 2010). The uncontrolled production of these inflammatory molecules has been linked to pathogenesis of most of the chronic ailments such as neurodegeneration and cancer (Jope et al., 2007). Wang and colleagues have linked West Nile virus (WNV) infection outcomes to elevated inflammation Page 4/26 Page 4/26 and damage to the endothelial integrity. This lead to leukocyte extravasation, encephalitis and death (Wang et al., 2004). Cell Culture and Viral Propagation The RVFV AR 20368 strain was isolated during the 1974 RVF outbreak in South Africa. The virus was propagated on Vero C1008 cells at an MOI of 0.2, followed by harvesting the monolayer after extensive cytopathic effect (cpe). The supernatant fluid was store at -70°C after centrifugation at 3,000 xg for 30 minutes (Martín-Folgar et al ., 2010). The RVFV Raw 264.7 macrophage cells were obtained from Prof Lyndy McGraw (University of Pretoria, photochemistry division, Onderstepoort campus), MNA cells from Dr Kgaladi (NICD, Arbo). The cells were maintained in cell culture flasks at 37oC, in a humidified 95% air and 5% CO2 atmosphere. Raw 264.7 and MNA cells were propagated in Dulbecco Modified Eagle Medium‎ (DMEM) supplemented with 10% Fetal Bovine Serum (FBS), 2 mM L-glutamine and 1x penicillin- streptomycin. Vero C1008 cells where purchased from ATCC and propagated in Minimum Essential Medium (MEM), supplemented with 10 % FBS, 2 mM L-glutamine and 1x penicillin-streptomycin (Lonza). Trypan blue dye and haemocytometer where used to determine cell density (Matsebatlela et al., 2012). Introduction Induced autoimmune encephalomyelitis studies has further shown that under controlled inflammation weakens endothelial barrier and uncontrolled leukocyte extravasation (De Sarno et al., 2008). It is therefore the aim of the study to determine the effects of lithium on inflammation profiles and NF-κB nuclear translocation in Raw 264.7 macrophages exposed to Rift valley fever virus. Cell treatment Lithium Chloride was purchased from Fluka (Chemika, Switzerland) and the stock was prepared at 500 mM LiCl stored at 4 °C. Sodium Chloride was purchased from Sigma-aldrich (USA) and the stock was prepared at 500 mM NaCl stored at 4 °C. The experiments were executed by seeding the Raw 264.7 at various cell densities depending on the experimental setting and then treated with LiCl (2.5, 1.25 and 0.625 mM) as well as NaCl (2.5 mM). Materials And Methods Cell Culture and Viral Propagation Determination of the cytokines expression pattern using ELISA In an attempt to measure the production of the cytokines and chemokines Raw 264.7 cell as a model of macrophages where seeded at 2.4 X106 Cells for 3 hrs in T25 flasks and inoculation with 104.8 TCID50/mL for an hour and then the supernatant was removed. Thereafter the cells were treated with lithium (as outlined in Cell treatment) and 5 mg/ml LPS for 24 hrs while the supernatant was collected in 3, 6, 12 24 hrs time intervals. The collected supernatant was frozen at -20 °C for later use. Enzyme linked immunosorbent assay (ELISA) was executed according to manufacturer’s protocol (Preprotech, USA). The capture antibody (for IL-10, IL-6, TNF-α, IFN-γ and RANTES) was diluted with PBS to 0.5 µg/ml and l00 µL was added to each well in a 96 well plate and incubated at RT overnight. Liquid was aspirated followed by 4 times washing with 300µL wash buffer (0.05 % tween-20 in 1x PBS) per well using ELx 405 auto plate washer (Bio-TEK instruments-Inc). Page 5/26 The standard was serially diluted 2 fold and 100µL was added in triplicates, the samples were added in triplicates as well for 2 hrs. The added samples were aspirated and washed 4 times with wash buffer. The detection antibody was diluted in diluent to 0.5µg/mL and 100 µL was added in each well for 2 hrs at RT. This was then followed aspiration of the excess detection antibody and plates were washed 4 times with wash buffer. The 5.5µL avian peroxidase was then diluted 1: 2000 in 11 ml diluent, thereafter 100 µL of this diluted avian peroxidase was added to each well and incubated for 30 min at RT. This solution was aspirated followed by 4 times wash with wash buffer, and then 100 µL of ABTS substrates solution was added to each well and the plates were incubated for colour development. Thereafter the colour was measured by reading the OD at 405 nm with ELx 802 universal microplate reader (Bio-TEK instruments- Inc) Determination of the production of the reactive oxygen species (ROS) 2′,7′-Dichlorofluorescin diacetate (H2DCF-DA) is a cell-permeable reactive oxygen species (ROS) non- fluorescent probe. This molecule is deacetylate by cellular esterase and then react with ROS turning in to a highly fluorescent 2′,7′-dichlorofluorescein. The Raw 264.7 cells were seeded at 4x105 cells/well in a 6 well plate for 3 hrs and treated with lithium (as outlined in Cell treatment) and 5 mg/ml LPS, this was then followed by inoculation with RVFV at 1x104.8 TCID50/ 100µL for 24 hrs. After 24 hrs of inoculation, cells were staining with permeant H2DCF-DA at RT for 30 min in the dark then cell were fixed with 3.7% paraformaldehyde for an hour. The pictures where captured at 480 and 535 nm (Ex/Em) with EVOS FL Colour imaging system (Life technologies, USA). On the other hand the Raw 264.7 cells where seeded in at 5x105 cells/well in a 96 well plate for 3 hrs and treatment as well as inoculation was done as above for 12 and 24 hrs. After the incubation time H2DCF-DA was added for 30 min and then fluorescence intensity was measured at ex/em 480/535 nm using a Fluoroskan Ascent FL (Thermo Fisher Scientific, USA). Determination of the production of the reactive nitrogen species (RNS) 5,6-Diaminofluorescein diacetate (DAF-2 Da) is a cell permeant NO indicator that is deacetylated by intracellular esterases to DAF-2 that react with NO to yield a highly fluorescent triazolofluorescein (DAF- 2T). The Raw 264.7 cells were seeded at 4x105 cells/well in a 6 well plate for 3 hrs and treated with lithium (as outlined in Cell treatment) and 5 mg/ml LPS, this was then followed by inoculation with RVFV at 1x104.8 TCID50 /100 µL for 24 hrs. After 24 hrs of inoculation, cells were staining with permeant DAF-2 DA at RT for 30 min in the dark then cell were fixed with 3.7% paraformaldehyde for an hour. The pictures where captured at 480 and 535 nm (Ex/Em) with EVOS FL Colour imaging system (Life technologies, USA). For Fluorescence intensity, Raw 264.7 cells where seeded in at 5x105 cells/well in a 96 well plate for 3 hrs and treatment as well as inoculation was done as above for 12 and 24 hrs. After the incubation time DAF-2 Da was added for 30 min and then fluorescence intensity was measured at ex/em 480/535 nm using a Fluoroskan Ascent FL (Thermo Fisher Scientific, USA). NF-κB translocation immunofluorescence assay Page 6/26 Raw 264.7 macrophage cells were cultured in 6 well plates on the slides at 4 x105 cells/well for 3hrs before treatment with lithium (as outlined in Cell treatment) and 5 mg/ml LPS, this was then followed by inoculation with RVFV at 1x104.8 TCID50 /100 µL for 24 hrs. After fixation with 4% paraformaldehyde cells were permeablised with 0.1% Triton X-100, 1%BSA for 60 min. The nonspecific binding sites were blocked by adding 1% BSA for 1 hr, followed by 2 x wash with wash buffer. Cells were incubated for 60 min with rabbit anti-p65 antibody (1:500) (Santa Cruiz) followed by 3x wash with wash buffer, and then FITC- labelled goat anti-rabbit secondary Ab incubation for 60 min. After 5 min nuclear staining with DAPI cells were mounted on slides using 50% glycerol and analysed using the fluorescent inverted Nikon Ti-E microscope at 20x magnification. Examination of inflammatory protein expression using Western blotting assay In order to examine apoptosis/NF-κB related protein expression on Raw 264.7 cells seeded in T25 flasks for 3 hrs at a density of 1x106 cell/ml. The cells where treated with lithium (as outlined in Cell treatment) and infected for 3 days with RVFV 104.8 TCID50 /ml. Cells were washed once with 1x PBS, thereafter cells lysis was accomplished with 500µL lysis buffer [10 mM Tris-HCl, pH 6.8, 1 % SDS, 100 mM sodium chloride, 1 mM EDTA, 1% NP 40, protease inhibitor], the cells where vortexed for 10 sec and incubated on ice for 30 minutes. The supernatant was collected by centrifugation at 15 000 хg for 20 minutes at 4°C and then protein concentration was determined using BCA protein assay at 562 nm. For SDS PAGE 50µg proteins was mixed with the sample buffer [1 mM Tris buffer pH 6.8, 20 % SDS, 20 % glycerol, 0.05 % β- mercaptoethanol, 0.002 % bromophenol blue] and then separated by 12 % SDS-PAGE then transferred to a polyvinyilidene fluoride (PVDF) membrane using a semi-dry blotting system (Bio-Rad). The membranes was blocked with Tris buffered saline (TBS) [150 mM NaCl, 50 mM Tris, 0.1 % Tween, pH 7.5] containing 3 % fat free dried milk. The membranes was washed with wash buffer [0.05 % TBS- Tween] and then incubated each time with one of the 1:500 dilutions of anti- NF-κB-p65, IκB, HO-1, iNOS and β-actin primary antibodies for 1 hr at RT. After incubation, the membranes was washed 3 X with wash buffer and the primary will be bound by corresponding peroxidase-conjugated secondary antibodies at 1:10 000 dilutions for 1hr at RT. The membranes was washed with wash buffer and the immune-reactive proteins was detected using the supersignal west pico chemiluminescent substrate (Thermo Scientific, Rockford, USA) thereafter visualised and photographed using the ChemiDoc XRS+ (Bio-RAD, USA). Extraction of the cytoplasmic and nuclear proteins In order to extract bot the cytosolic and nuclear NF-kB protein the on Raw 264.7 cells where seeded in T25 flasks for 3 hrs at a density of 1x106 cell/ml. The cells where treated with lithium (as outlined in Cell treatment) and infected for 3 days with RVFV 104.8 viral titer/ml, cells where then washed once with 1x PBS and then harvested. For cytoplasmic proteins buffer A composed of (10 mM HEPES, 10 mM KCl, 1 mM MgCl2, 5% glycerol, 0.5 mM EDTA, 0.1 mM EGTA, 1X protease inhibitor solution, 2 mM PMSF and 0.5 mM DTT) was added and the cell pallet where incubated on ice for 15 min with an addition of 0.5 % NP- 40. This was flowered by vortexing for 10 sec then centrifugation at 12,000 x g for 1 min. For nuclear NF- Page 7/26 Page 7/26 Page 7/26 kB protein extraction the centrifugation pellet was exposed to 500ml high salt buffer B (20 mM HEPES, 1% NP-40, 400 mM NaCl, 10 mM KCl, 1 mM MgCl2, 20% glycerol, 0.5 mM EDTA, 0.1 mM EGTA, 1X protease inhibitor solution, 2 mM PMSF and 0.5 mM DTT) for 1 hr on ice. The mixture was followed by vortexed for 15 sec and then 12,000 x g for 1 min. kB protein extraction the centrifugation pellet was exposed to 500ml high salt buffer B (20 mM HEPES, 1% NP-40, 400 mM NaCl, 10 mM KCl, 1 mM MgCl2, 20% glycerol, 0.5 mM EDTA, 0.1 mM EGTA, 1X protease inhibitor solution, 2 mM PMSF and 0.5 mM DTT) for 1 hr on ice. The mixture was followed by vortexed for 15 sec and then 12,000 x g for 1 min. Statistical analyses All assays were performed 3 times in duplicates and the error bars represent the degree of variance. Graph-Pad prism 6 software was used to plot the graphs and statistical analysis was executed with Instat 3 software. Duncan's multiple comparison t-test was used to determine significant differences between the means of treated and untreated groups. Differences were considered significant at * p ≤ 0.05; p ≤ 0.01, * p ≤ 0.001. Influence of lithium on production of the inflammatory pro and anti-inflammatory Cytokines Most viruses have developed mechanisms to invade the immune surveillance system which favours viral replication and increased viral progeny. RVFV is not an exception to this type of virus-induced immune invasion mechanism. RVFV is known to inhibit the innate immune system, particularly the type I IFN cytokine production as its mechanism of host invasion (Nfon et al., 2012); while other studies (Caroline et al., 2016; van Vuren et al., 2015) outlined prolonged immune response as the primary detrimental factor in patients who are suffering from this type of viral infection. This study examined the impact of lithium on cytokine and chemokines production after RVFV inoculation. This study has demonstrated that lithium stimulates production of INF-γ in the Raw 264.7 macrophage model system. Increase in lithium concentrations in RVFV-infected Raw 264.7 cells resulted in elevated INF-γ production in comparison to the RVFV-infected control cells not exposed to lithium (Fig 1A). The increase in INF-γ production also increased proportionally with increase in incubation time. INF-γ production in RVFV- infected Raw 264.7 cells treated with lithium was even higher than treatments with LPS albeit reaching comparable levels at 24 hrs post inoculation (pi). Lithium at 1.25 mM seemed to induce the highest amount of INF-γ production compared to other concentrations in all the time points. Another prominent inflammatory cytokine, IL-6, was shown to be produced after 12 hrs pi (Fig 1B). As depicted in figure 1B, lithium 1.25 mM stimulate elevated levels of IL-6 as from 6 hrs (pi) compared to untreated control RVFV- infected cells. After 12 hrs (pi), 0.625mM lithium dramatically increased IL-6 production in RVFV-infected cells compared to untreated RVFV-infected cells and those treated with LPS. The chemokine (RANTES/CCL-5) showed similar increment profiles to those observed in IL-6. Lithium induced CCL-5 production after 12 hrs pi the three concentrations of lithium induced production levels CCL-5 (Fig 1D). Although lithium generally increased CCL-5 production compared to control cells, CCL-5 production seems to be inversely proportional to LiCl concentrations in RVFV-infected cells at 12 and 24 hrs pi. Page 8/26 Furthermore, increases in lithium concentrations was shown to increase production of the TNF-α compared to that of RVFV-infected control cells as from 6 hrs pi (Fig 1E). The increase in TNF-α production was also shown to be time-dependent. The level of TNF-α after treatment with lithium was shown tobe above that of positive control 5 mg/ml LPS at all three concentrations. Influence of lithium on production of the inflammatory pro and anti-inflammatory Cytokines The effect of lithium on production of pro-inflammatory cytokines such as IL-10 was also studied. Lithium was shown to stimulate IL-10 production in RVFV-infected cells (Fig 1C). Lithium was shown to stimulate IL-10 production as from 3 hrs pi, increasing with increase in incubation time. IL-10 production was maximal at 1.25 mM LiCl compared to other concentrations. IL-10 production in control RVFV showed improvement as from 6 hrs pi and reached the same levels in all lithium concentrations after 24 hrs pi (Fig 1C). Effects of lithium on production of reactive oxygen and nitrogen species after RVFV inoculation. Reactive oxygen species are generated as metabolic by-products during mitochondrial respiratory chain and excessively produced during inflammation as a result of encounter with inflammatory stimulus (Reuter et al., 2010). In this study fluorescent probes such as 2’,7’–dichlorofluorescein diacetate (H2DCF- DA) and 4,5-diamino-fluorescein diacetate (DAF-2 DA) are used to determine the level of ROS and NOS after a viral infection. Figure 2 A and 3 A represent qualitative levels of ROS and RNS production in Raw 264.7 cells after treatment with lithium and infection with RVFV. Lithium concentrations are shown to downregulate production of this reactive molecules as the green fluorescence intensity is reduced with lithium treatment. Quantitative measurement of fluorescence intensity (Fig 2 B and 3 B) show that lithium lowered production of ROS in a concentration dependent manner. Maximum inhibition of RNS production was observed in cells treated with lithium at 2.5 mM. These findings also show that production of this ROS/RNS molecules only reach their peak levels at 24 hpi. Moreover, lithium concentrations are shown to upregulate antioxidant enzyme Heme oxygenase-1 (HO-1) (fig 2 C). Lithium is shown to induce HO-1 expression in a concentration dependent manner. Determination of RNS production using DAF-2 show that lithium inhibited RNS production in RVFV- infected Raw 264.7 cells. Treatment of cells with lithium notably reduced DAF-2 fluorescence intensity. These observations were accompanied by elevated NOS-2 expression as represented in figure 3 C. Higher expression levels of the inducible nitric oxide synthase were elevated in control RVFV and LPS. Expression of NOS-2 was shown to be lowered by lithium in a concentration-dependent manner. Inducible nitric oxide synthase is an enzyme that stimulate production of the nitric oxide. These findings are consistent with the findings in figure 3 A and B. Determination of RNS production using DAF-2 show that lithium inhibited RNS production in RVFV- infected Raw 264.7 cells. Treatment of cells with lithium notably reduced DAF-2 fluorescence intensity. These observations were accompanied by elevated NOS-2 expression as represented in figure 3 C. Higher expression levels of the inducible nitric oxide synthase were elevated in control RVFV and LPS. Expression of NOS-2 was shown to be lowered by lithium in a concentration-dependent manner. Inducible nitric oxide synthase is an enzyme that stimulate production of the nitric oxide. These findings are consistent with the findings in figure 3 A and B. Effects of lithium on nuclear translocation and expression of the NF-κB sig The molecular location of a transcription factor NF-κB is used as a measure of inflammatory responsive. NF-κB binds to the kappa responsive element and induce inflammatory mediators. Thus, cellular location parameters of the NF-κB molecule is an essential phenomenon studying inflammatory patterns. The molecular location of the NF-κB was examined using immunocytochemistry depicted in figure 4 A. Figure 4 A shows that NF-κB is located in both the nucleus and cytoplasm in lithium-treated cells, since green Page 9/26 fluorescence is on either side of the nucleus. However, control untreated cells show less of the green fluorescence in the nucleus and the image overlays showed an intense blue nuclear fluorescence, displaying that the two stains are not in the same location. fluorescence is on either side of the nucleus. However, control untreated cells show less of the green fluorescence in the nucleus and the image overlays showed an intense blue nuclear fluorescence, displaying that the two stains are not in the same location. The positive control 5 mg/ml LPS shows light blue nuclear fluorescence since all the green (NF-kB staining) and the blue (nucleus staining) are all in the same location (nucleus). The control RVFV show similar patterns as control LPS, with more NF-κB nuclear staining observed, indicative of nuclear translocation. On the other hand, figure 4 B and C shows that lithium inhibit translocation of NF-κB with LiCl 2.5 mM showing the most inhibition. The IκB-α expression 12 hpi (Fig 4 D) shows to be elevated in lithium-treated cells in a dose dependent manner. IκB-α is the inhibitory molecule that keeps NF-κB in the cytoplasm and is known to regulate activity of this transcription factor (Garcia et al., 2009). Discussion In Page 10/26 Page 10/26 Page 10/26 this study lithium has shown to stimulate production of the primary pro-inflammatory cytokine, TNF-α, in Raw 264.7 cells as early as 3 hrs post infected with RVFV. All three concentration of lithium were shown to significantly stimulate production of this primary pro-inflammatory cytokine. this study lithium has shown to stimulate production of the primary pro-inflammatory cytokine, TNF-α, in Raw 264.7 cells as early as 3 hrs post infected with RVFV. All three concentration of lithium were shown to significantly stimulate production of this primary pro-inflammatory cytokine. Kleinerman et al, have observed TNF-α increment in LPS-stimulated macrophages treated with lithium as early as 10 min post stimulation with the production plateau reached within 12 hrs post stimulation. Kleinerman and colleagues hypothesised that lithium induced production of TNF-α by macrophages and the produced TNF-α subsequently stimulate production of the granulocyte-macrophage CSF (GM-CSF) from the endothelial cells. These observation can be associated with the observed lithium-induced leukocytosis and granulocytosis as a result of GM-CSF (Merendino et al., 1994; Kleinerman et al., 1989). The secondary pro-inflammatory cytokine, IL-6, and a chemokine, RANTES, were shown to be produced during the late hours of infection 12 and 24 hrs with 1.25 mM LiCl being the most effective (fig 1 B & D). These findings coincide with observations by Maes et al which showed that lithium did not induce significant production of the IL-6 in both stimulated and unstimulated cells (Maes at al., 1999). Moreover, Makola et al showed inhibitory properties of 10 mM lithium on RANTES production 24 hrs post stimulation with lipopolysaccharide (LPS) in a GSK-independent manner (Makola et al., 2020). This could suggest that lithium may not possess sufficient ability to stimulate IL-6 and RANTES production. In vitro studies by van Vuren showed a 10 times elevated production of IL-6 in fatal cases as compared to non- fatal patients. This observation suggests that elevated production of this cytokine could be favouring virus survival as opposed to host defence (van Vuren et al., 2015). Interestingly, lithium was shown to reverse the elevated production of this pro-inflammatory cytokine in RVFV-infected cells. In another study, Maes et al has shown that lithium enhance production of another secondary pro-inflammatory cytokine IL-8 in both LPS and phytohemagglutinin (PHA) stimulated and unstimulated cells (Maes at al., 1999). Discussion Innate immune response plays a central role in the immune system as the first line of defence against foreign and infectious agents. Innate immunity, although non-specific, has ability to orchestrate humoral immune system through antigen presentation to the CD+4 T-cells (Xiao, 2017). It facilitates the first line of defence systems through inflammation, an ontogenetically old defence mechanism regulated by cytokines, products of the plasma enzyme systems, lipid mediators released from different cells, and vasoactive mediators released from mast cells, basophils, platelets and macrophages (Ross et al., 2002). Macrophages are antigen presenter cells (APC) that produce cytokines as inflammatory mediators, which recruitment other immune cells to the inflamed site and link the innate and adaptive immune response (McElroy and Nichol, 2012). Inflammation pays a pivotal role in eliminating infections. However, deregulated inflammation can lead to tissue damage and various adverse conditions that include neurodegeneration disorders, diabetes, cancer and endothelial leakage (Koriyama et al., 2013; Jope et al., 2007; Wang et al., 2004). Viruses such as RVFV target macrophages to invade the innate immune system and use them as a vehicle to target tissues such as brain and liver (McElroy and Nichol, 2012). This virus is known to inhibit production of the IFNs as targeted by the NSs virulence factor. This is thought to be the mechanism in which RVFV use to circumvent the immune system in favour of viral replication (Nfon et al., 2012). In addition to inhibited IFNs, NSs is shown to induce direct degradation and inhibition of the PKR involved in translational arrest of both cellular and viral mRNA (Habjan et al., 2009). Weakened inflammatory responses from RVFV infection has been suggested to contribute to RVFV pathogenesis and fatality (Nfon et al., 2012). Contrary to these suggestions, a recent body of evidence (Caroline et al., 2016; van Vuren et al., 2015; Gray et al., 2012) suggests that deregulation and prolonged inflammation correlate with viral pathogenesis and fatality. The combination of this contradicting inflammatory evidence and the IFNs inhibitory role of the NSs led to the hypothesis that unbalanced and deregulated inflammation could be central to the RVFV pathogenesis and lethality. This work examined lithium as a potential drug to restore regulatory patterns of inflammation and innate immune system. Discussion An in vitro study by Gray et al observed strong and prolonged expression of IL-6, GCSF and MCP-1 three days pi, this has led to suggestion that these molecules could be involved in endothelial leakage that lead to haemorrhagic fever (Gray et al., 2012). It is suggested that lithium could be restoring the balance in production of inflammatory mediators, as pro-inflammatory molecules are later balanced by regulatory cytokines to limit over production of pro- inflammatory molecules. Lithium remains an effective and preferred treatment option for bipolar disorders despite the sparse and limited understanding of its mechanism of action (Nassar and Azab, 2014). Under-regulated Inflammation has been linked to pathological processes behind manic depression and bipolar disorders. Hence, studies suggest that lithium could be restoring inflammatory deregulation as the mechanism underlying its anti-depressant property (Nassar and Azab, 2014; Maes at al., 1999). An in vitro study by Gray et al observed strong and prolonged expression of IL-6, GCSF and MCP-1 three days pi, this has led to suggestion that these molecules could be involved in endothelial leakage that lead to haemorrhagic fever (Gray et al., 2012). The RVFV-infected lithium treated cells have shown to lower production of the reactive oxygen and nitrogen species. The lowered production of this reactive molecules has been depicted in figure 2 A and 3 A in a qualitative assay. Quantitative findings (fig 2 B and 3 B) show the same trend as in the pictures. As represented in Figure 1 B and 2B, there is a significant difference in production of these reactive species 24 hrs post infection. Previous work has shown lithium at 10 mM to reduce ROS while 5 mM being effective in reduction of NO production in LPS-stimulated Raw 264.7 cells (Makola et al., 2020). More interestingly, in the current study, lithium down-regulated expression of iNOS enzyme (fig 3 C), which correlate with lowered NO production. In addition to the inhibited iNOS, lithium stimulate HO-1 expression, an antioxidant enzyme (fig 2 C). This work aligns inflammation regulatory properties of lithium with activation of the NF-κB transcription factor. Lithium-treated cells show the presence of the NF-κB in both the cytoplasm and the nucleus, suggesting the reversal/ inhibition of the transcription factor from translocating to the nucleus (fig 4 A). Molecular translocation of NF-κB into the nucleus is observed to be lowered by lithium treatments in a concentration dependent manner (fig 4 B & C). Discussion This current work demonstrated significant up-regulation of IFN-γ by lithium from 3 hrs post infection in a concentration-dependent manner (Fig 1, A). This work shows that lithium stimulates production of some pro-inflammation cytokines which is the most important phenomenon since Nfon et al link weakened inflammation with pathogenesis and lethality. A review by Nassar and Azab, support findings from this current study as they are in agreement with previous reports. However, most of the reports show the inhibitory role of lithium on this cytokine rather than stimulation (Nassar and Azab, 2014). Nfon et al have linked elevated levels of IFN-γ to survival of infected goats in animal experimental models. IFN-γ is suggested to inhibit viral replication and stimulate cytotoxic activity of the NK cells since lowered viremia has been observed in surviving infected goats (Nfon et al., 2012). In the current in vitro model system, lithium has been suggested to inhibit viral replication through induction of early apoptosis in virus- infected cells, leading to abortion of replicating viral progeny. Elevated IFN-γ levels could be another mechanism used by lithium to lower viral replication. In addition to pro-inflammatory cytokines, lithium stimulated production of the anti-inflammatory cytokine, IL-10, and the cytokine production reached its peak as early as 12 hpi (fig 1 C). Similar findings have been reported in other studies (Maes at al 1999; Rapaport and Manji, 2001). These studies showed that lithium Page 11/26 Page 11/26 stimulate expression of IL-10 and IL-1R anti-inflammatory molecules. This is suggested to be a regulatory mechanism as a result of overwhelming production of inflammatory mediators known to have deleterious outcomes. Lithium is shown to stimulate both the pro and anti-inflammatory cytokines in the current and previous studies (Nassar and Azab, 2014; Maes at al., 1999). It is suggested that lithium could be restoring the balance in production of inflammatory mediators, as pro-inflammatory molecules are later balanced by regulatory cytokines to limit over production of pro- inflammatory molecules. Lithium remains an effective and preferred treatment option for bipolar disorders despite the sparse and limited understanding of its mechanism of action (Nassar and Azab, 2014). Under-regulated Inflammation has been linked to pathological processes behind manic depression and bipolar disorders. Hence, studies suggest that lithium could be restoring inflammatory deregulation as the mechanism underlying its anti-depressant property (Nassar and Azab, 2014; Maes at al., 1999). Discussion Previous studies (Narayanan et al., 2014) have shown that RVFV stimulate NF-κB nuclear translocation, culminating in production of inflammatory mediators and resulting in oxidative stress. Oxidative stress is a condition emanating from excessive production of oxidants and free radicals, leading to imbalance between oxidants and antioxidants. Studies (Christen, 2000; Reuter et al., 2010; Narayanan et al., 2014) have shown that oxidative stress conditions elicit biomolecules deformation that lead to altered cell function and then cell demise. Narayanan et al, hypothesise that RVFV prevalent liver disease emanate from oxidative stress that lead to hepatic cell demise (Narayanan et al., 2014). Thus, inflammatory deregulation and oxidative stress has been linked with a number of pathogenic outcomes. This study suggest that lithium could ameliorate detrimental outcomes emanating from this viral infection. Figure 4 D, show that lithium concentrations Page 12/26 Page 12/26 upregulate the inhibitory molecules, IκB-α. IkB-α inhibit the translocation of the NF-κB by masking its nuclear translocation domain (Garcia et al., 2009). Our previous work at high lithium concentration (10 mM) showed expression of the NF-κB inhibitors IκB-α, TRAF3, Tollip and NF-κB1/p50 to be lithium inhibition biomarkers (Makola et al., 2020). What remains profound about lithium is that in as much as it was shown to promote expression of some pro-inflammatory cytokines it stimulates anti-inflammatory cytokines in an attempt to avoid oxidative stress and nonspecific damage to host cell biomolecules. Previous studies show that NSs selectively tempers with the type I IFN signalling while sparing the other inflammation mediators such as ROS, NOS and Pro/ anti-inflammation cytokines/chemokines. On a signalling level this could mean that NSs inhibit nuclear translocation of IRF3 and 7 as the transcription factors involved in production of type I IFNs or perhaps targeting the transcription of ISGs, leading to silencing of antiviral molecules (Ghaemi-Bafghi and Haghparast, 2013) (fig 5). Since NSs selectively inhibit IFNs which are linked to IRFs transcription factors, it then implies that other inflammatory mediators expressed by other transcription factors such as AP-1 and NF-κB will continually be produced leading elevated inflammatory mediators and oxidative stress. Thus, this work link regulatory mechanism of lithium with inhibition of the NF-κB signalling pathway as the inflammatory transcription factor that is not targeted by NSs. The NF-κB signalling pathway is suggested to be stimulated by the glycol proteins detected by TLR-4 or ssRNA detected by TLR-7 or dsRNA detected by the RIG-I. Discussion All these PRRs are linked to the NF-κB signalling pathway in as much as others stimulate IRF signalling as well (fig 5). The hypothesis that lithium restore balance in the inflammatory system emanates from its regulatory mechanism on the NF-κB pathway as NSs inhibit translocation of IRFs and not other transcription factors. The in vitro and ex vivo studies have shown cytokine and chemokines production excluding type I IFN during RVFV infection (Nfon et al., 2012; van Vuren et al., 2015). The activated NF-κB pathway continue producing these inflammatory mediators that are suggested to participate in the RVFV pathogenesis. Therefore, lithium restores production of excessive inflammatory mediators as it has been observed to limit NF-κB translocation through upregulation of the IκB molecule. Abbreviations MyD88: Myeloid differentiation factor 88 TLR: Toll Like Receptors TRIF: TIR-domain-containing adaptor protein-inducing IFN-β Tirap: TIR Domain containing adaptor protein γ-GCS: γ- glutamylcysteine synthetase Traf: TNF receptor-associated factor FDA: US Food and Drug Administration NaCl Sodium Chloride RNS Reactive Nitrogen species RIG-1: Retinoic acid-indicible gene 1 Tollip: Toll interacting protein NSs: 78-kDa non-structural protein TRAF3: TNF receptor-associated factor 3 LPS: Lipopolysaccharide HO: Haem Oxygenase RTCA: real time cell analyser system (rtca) iNOS: Inducible nitric Oxide Synthase TNF-α: Tumor necrosis alpha IκB-α: Inhibitor of kappaB kinase alpha IFNs: Interferons MTT: 3-(4,5-dimethylthiazol-2-yl)-2,5 diphenyltetrazolium bromide RANTES: Regulated on activation, normal T cell expressed and secreted DAF- 2DA: 5,6-Diaminofluorescein diacetate IL-6: Interleukine-6 H2DCF- DA: 2',7'-dichlorodihydrofluorescein diacetate IRF: Interferon Regulatory Factor GSK-3: Glycogen Synthase Kinase-3 NOS: Reactive nitrogen species FBS: Fetal Bovine Serum ROS: Reactive oxygen species Declarations All th h d l d th t th i fli t f i t t di bli ti f thi k Conclusion The NF-κB transcription factor is shown to be the targeted molecule behind the anti-inflammation properties displayed by lithium. Results from this work show that lithium inhibit NF-κB-activity and that is linked to the observed inhibition of production of the inflammatory mediators at various concentrations. Although additional work is required, the current findings suggest that lithium could be used as an anti- haemorrhagic fever agent since RVFV-induced oxidative stress, which is suggested to be the critical factor that lead to haemorrhagic fever, which is shown to be reversed by lithium treatment. This study predicts that the RVFV virulence factor NSs inhibits production of the type I IFN at a transcription factor level (IRF) since production of other inflammatory mediators such as RNS, ROS, cytokines and chemokines are observed with the exception of the type I IFN. Page 13/26 Page 13/26 Page 13/26 Consent to publication Not applicable Funding This study was funded by National Research Foundation. The role of this funding body was only providing finds for execution of the experiments. Authors’ contribution RT Makola, TM Matsebatlela, JT Paweska and PJ van Vuren were involved in experimental design and project conceptualisation. RT Makola, PJ van Vuren, GK More and J Kgaladi were involved in running the experiments. RT Makola, TM Matsebatlela, JT Paweska and PJ van Vuren were involved in data analysis. This manuscript was written by RT Makola. While RT Makola and all the co-authors reviewed the manuscript. Data Availability The raw data are available upon reasonable request. Page 14/26 Page 14/26 Competing interests There is no financial and non-financial competing interests. Acknowledgements We would like to appreciate the help with laboratory equipments and scientific imputations from Dr Nadia Storm, Dr Gaby ER Monteiro, Antoinette Grobler, Dr Nazneen Moola, Dr Jacqueline Weyer and Prof MP Mokgotho. The funding bodies for this work include Poliomyelitis Research foundation and National Research Foundation. References 1. 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Le May N, Dubaele S, De Santis LP, Billecocq AS, le Bouloy M, Egly JM (2004) TFIIH Transcription Factor, a Target for the Rift Valley Hemorrhagic Fever Virus. Cell Press. 116: 541–550 13. Maes M, Song C, Lin A H, Pioli R, Kenis G, Kubera M, Bosmans E (1999) In vitro immunoregulatory effects of lithium in healthy volunteers. Psychopharmacology (Berl).143(4):401-407. 14. Makola RT, Mbazima VG, Mokgotho MP, Gallicchio VS, Matsebatlela TM (2020) The Effect of Lithium on Inflammation-Associated Genes in Lipopolysaccharide-Activated Raw 264.7 Macrophages. International Journal of Inflammation. 2020: 18 14. Makola RT, Mbazima VG, Mokgotho MP, Gallicchio VS, Matsebatlela TM (2020) The Effect of Lithium on Inflammation-Associated Genes in Lipopolysaccharide-Activated Raw 264.7 Macrophages. International Journal of Inflammation. 2020: 18 15. McElroy AK, Nichol ST, (2012) Rift Valley fever virus inhibits a pro-inflammatory response in experimentally infected human monocyte derived macrophages and a pro-inflammatory cytokine response may be associated with patient survival during natural infection. Virology. 422(1):6-12 15. McElroy AK, Nichol ST, (2012) Rift Valley fever virus inhibits a pro-inflammatory response in experimentally infected human monocyte derived macrophages and a pro-inflammatory cytokine response may be associated with patient survival during natural infection. Virology. 422(1):6-12 16. Merendino RA, Mancuso G, Tomasello F, Gazzara D, Cusumano V, Chillemi S, Spadaro P, Mesiti M (1994) Effects of lithium carbonate on cytokine production in patients affected by breast cancer. Biol. Regul. Homeostatic Agents. 8:88−91. 16. Merendino RA, Mancuso G, Tomasello F, Gazzara D, Cusumano V, Chillemi S, Spadaro P, Mesiti M (1994) Effects of lithium carbonate on cytokine production in patients affected by breast cancer. Biol. Regul. Homeostatic Agents. 8:88−91. 17. Narayanan A, Amaya M, Voss K, Chung M, Benedict A, Sampey G, Kehn-Hall K, Luchini A, Liotta L, Bailey C, Kumar A, Bavari S, Hakami RM, Kashanchi F (2014) Reactive oxygen species activate NFκB (p65) and p53 and induce apoptosis in RVFV infected liver cells. Virology. 449: 270–286 17. Narayanan A, Amaya M, Voss K, Chung M, Benedict A, Sampey G, Kehn-Hall K, Luchini A, Liotta L, Bailey C, Kumar A, Bavari S, Hakami RM, Kashanchi F (2014) Reactive oxygen species activate NFκB (p65) and p53 and induce apoptosis in RVFV infected liver cells. Virology. 449: 270–286 18. References Nassar A, Azab AN (2014) Effects of Lithium on Inflammation. ACS Chem Neurosci. 5(6): 451–458. 18. Nassar A, Azab AN (2014) Effects of Lithium on Inflammation. ACS Chem 18. Nassar A, Azab AN (2014) Effects of Lithium on Inflammation. ACS Chem Neurosci. 5(6): 451–458. 19. Nfon CK, Marszal P, Zhang S, Weingartl HM (2012) Innate Immune Response to Rift Valley Fever Virus in Goats. PLoS Negl Trop Dis 6(4): e1623 19. Nfon CK, Marszal P, Zhang S, Weingartl HM (2012) Innate Immune Response to Rift Valley Fever Virus in Goats. PLoS Negl Trop Dis 6(4): e1623 20. Plowden J, Renshaw-Hoelscher M, Engleman C, Katz J, Sambhara S (2004) Innate immunity in aging: impact on macrophage function. Aging Cell. 3(4):161-167. 21. Rapaport M, H, Manji HK (2001) The effects of lithium on ex vivo cytokine production. Biol Psychiatry. 50(3):217-224 22. Reuter S, Gupta SC, Chaturvedi MM, Aggarwal (2010) Oxidative stress, inflammation, and cancer: How are they linked? Free Radical Bio Med. 49: 1603–1616 23. Ross JA, Auger MJ (2002) The biology of the macrophage. Burke B and Lewis CE, editors. Oxford: Medical Publications. 2nd1–72. 23. Ross JA, Auger MJ (2002) The biology of the macrophage. Burke B and Lewis CE, editors. Oxford: Medical Publications. 2nd1–72. Page 16/26 Page 16/26 24. van Vuren PJ, Shalekoff S, Grobbelaar AA, Archer BN, Thomas J, Tiemessen CT, Paweska JT (2015) Serum levels of inflammatory cytokines in a Rift Valley fever patients are indicative of severe disease. Virol J. 12:159. 25. Wang L, Zhang L, Zhao X, Zhang M, Zhao W, Gao C (2013) Lithium Attenuates IFN-β Production and Antiviral Response via Inhibition of TANK-Binding Kinase 1 Kinase Activity. J Immunol. 191:4392- 4398. 26. Wang T, Town T, Alexopoulou L, Anderson JF, Fikrig E, Flavell RA (2004) Toll-like receptor 3 mediates West Nile virus entry into the brain causing lethal encephalitis. Nat Med. 10(12):1366-1373 27. Wood ZA, Sabatini RS, Hajduk SL (2004) Targeting TFIIH to Inhibit basal transcription factor THIIH to induce shut-off of host cell transcription. Mol Cell. 13(4):456-458 28. Xiao TS (2017) Innate immunity and inﬂammation. Cell & Mol Immunol. 14: 1–3. 28. Xiao TS (2017) Innate immunity and inﬂammation. Cell & Mol Immunol. Figures Page 17/26 Figure 1 Figure 1 Determination of the effects lithium on TNF-α production after inoculation with the RVFV. In order to measure effects of lithium in TNF-α, IL-6, IL-10, IFN-γ and RANTES production, Raw 264.7 cells where seeded at the 2.4x106 cells per T 25 flask for 3 hrs inoculated with 1x104.8 viral tite for an hour. The excess virus was washed and the cells were treated with various concentration of lithium and then supernatant was collected in 3, 6, 12 and 24 hrs time intervals. The Sandwich Elisa (PeproTech, USA) was Page 18/26 Page 18/26 executed to measure the amount of these cytokines from various samples. The data points represent mean + standard deviation (error bar). The plot was developed with Graph pad prism-6 software and instat-3 was used to establish the statistical analysis. instat-3 was used to establish the statistical analysis. Figure 2 Determination of the effects of lithium on oxidative burst after Raw 264.7 cell are challenged with RVFV and expression of levels of antioxidant enzyme. (A) Cells were seeded at 4x105 cells/well in a 6 well plate Determination of the effects of lithium on oxidative burst after Raw 264.7 cell are challenged with RVFV and expression of levels of antioxidant enzyme. (A) Cells were seeded at 4x105 cells/well in a 6 well plate Page 19/26 for 3 hrs then pre-treated with various concentration of lithium and 5 mg/ml LPS. Later the some wells were inoculated with RVFV at 1x104.8 viral titer for 24 hrs. After 24 hrs of inoculation, cells were staining with permeant H2DCF-DA at RT for 30 min in the dark then cell were fixed with 3.7% paraformaldehyde for an hour. The pictures where captured with EVOS FL Colour imaging system (Life technologies, USA) Ex: 495nm; Em: 515nm. (B) Cells were seeded at 1x106 cells/well for 3 hrs then inoculated with RVFV at 103.8 viral titter/100uL and then treated with lithium concentrations and stimulated with 5 mg/ml LPS for 12 and 24 hrs. After the incubation hours the cells were stained with H2DCF-DA for 30 min in the dark, and then the fluorescence intensity was measured with Fluoroskan Ascent FL (Thermo Fisher Scientific, USA) at ex (485 nm)-em (538 nm). The graphs were developed with Graph pad prism-6 software and instat-3 was used to establish the statistical analysis. (C) In order to determine the expression of HO-1 protein, Raw 264.7 cell where seeded at 1x106 cell/ml for 3 hrs then treated as above, and then cells were inoculated with 104.8 viral titer/mL RVFV for 12 hrs. This was then followed by isolation of proteins and then western blotting assay. The pictures were captured with ChemiDoc XRS+ (Bio-RAD, USA). for 3 hrs then pre-treated with various concentration of lithium and 5 mg/ml LPS. Later the some wells were inoculated with RVFV at 1x104.8 viral titer for 24 hrs. After 24 hrs of inoculation, cells were staining with permeant H2DCF-DA at RT for 30 min in the dark then cell were fixed with 3.7% paraformaldehyde for an hour. The pictures where captured with EVOS FL Colour imaging system (Life technologies, USA) Ex: 495nm; Em: 515nm. Figure 2 (B) Cells were seeded at 1x106 cells/well for 3 hrs then inoculated with RVFV at 103.8 viral titter/100uL and then treated with lithium concentrations and stimulated with 5 mg/ml LPS for 12 and 24 hrs. After the incubation hours the cells were stained with H2DCF-DA for 30 min in the dark, and then the fluorescence intensity was measured with Fluoroskan Ascent FL (Thermo Fisher Scientific, USA) at ex (485 nm)-em (538 nm). The graphs were developed with Graph pad prism-6 software and instat-3 was used to establish the statistical analysis. (C) In order to determine the expression of HO-1 protein, Raw 264.7 cell where seeded at 1x106 cell/ml for 3 hrs then treated as above, and then cells were inoculated with 104.8 viral titer/mL RVFV for 12 hrs. This was then followed by isolation of proteins and then western blotting assay. The pictures were captured with ChemiDoc XRS+ (Bio-RAD, USA). Page 20/26 Figure 3 Determination of the effects of lithium on production of inflammatory reactive nitrogen species 24 hrs post RVFV inoculation and expression levels of the NOS enzyme. (A) Cells were seeded at 4x105 cells/well in a 6 well plate for 3 hrs then pre-treated with various concentration of lithium and 5 mg/ml LPS. Later the some wells were inoculated with RVFV at 1x104.8 viral titer for 24 hrs. After 24 hrs of inoculation, cells were staining with permeant DAF-2 DA at RT for 30 min in the dark then cell were fixed Page 21/26 Page 21/26 with 3.7% paraformaldehyde for an hour. The pictures where captured with EVOS FL Colour imaging system (Life technologies, USA). (B) Cells were seeded at 1x106 cells/well for 3 hrs then inoculated with RVFV at 103.8 viral titter/100uL and then treated with lithium concentrations and stimulated with 5 mg/ml LPS for 12 and 24 hrs. After the incubation hours the cells were stained with DAF-2 DA for 30 min in the dark, and then the fluorescence intensity was measured with Fluoroskan Ascent FL (Thermo Fisher Scientific, USA) at ex (485 nm)-em (538 nm). The plot were developed with Graph pad prism-6 software and instat-3 was used to establish the statistical analysis. (C) In order to determine the expression of NOS-2 protein, Raw 264.7 cell where seeded at 1x106 cell/ml for 3 hrs then treated with 2.5, 1.25, and 0.625 mM LiCl, and then cells were inoculated with 104.8 viral titer/mL RVFV for 12 hrs. This was then followed by isolation of proteins and then western blotting assay. The pictures were captured with ChemiDoc XRS+ (Bio-RAD, USA). with 3.7% paraformaldehyde for an hour. The pictures where captured with EVOS FL Colour imaging system (Life technologies, USA). (B) Cells were seeded at 1x106 cells/well for 3 hrs then inoculated with RVFV at 103.8 viral titter/100uL and then treated with lithium concentrations and stimulated with 5 mg/ml LPS for 12 and 24 hrs. After the incubation hours the cells were stained with DAF-2 DA for 30 min in the dark, and then the fluorescence intensity was measured with Fluoroskan Ascent FL (Thermo Fisher Scientific, USA) at ex (485 nm)-em (538 nm). The plot were developed with Graph pad prism-6 software and instat-3 was used to establish the statistical analysis. Figure 3 (C) In order to determine the expression of NOS-2 protein, Raw 264.7 cell where seeded at 1x106 cell/ml for 3 hrs then treated with 2.5, 1.25, and 0.625 mM LiCl, and then cells were inoculated with 104.8 viral titer/mL RVFV for 12 hrs. This was then followed by isolation of proteins and then western blotting assay. The pictures were captured with ChemiDoc XRS+ (Bio-RAD, USA). with 3.7% paraformaldehyde for an hour. The pictures where captured with EVOS FL Colour imaging system (Life technologies, USA). (B) Cells were seeded at 1x106 cells/well for 3 hrs then inoculated with RVFV at 103.8 viral titter/100uL and then treated with lithium concentrations and stimulated with 5 mg/ml LPS for 12 and 24 hrs. After the incubation hours the cells were stained with DAF-2 DA for 30 min in the dark, and then the fluorescence intensity was measured with Fluoroskan Ascent FL (Thermo Fisher Scientific, USA) at ex (485 nm)-em (538 nm). The plot were developed with Graph pad prism-6 software and instat-3 was used to establish the statistical analysis. (C) In order to determine the expression of NOS-2 protein, Raw 264.7 cell where seeded at 1x106 cell/ml for 3 hrs then treated with 2.5, 1.25, and 0.625 mM LiCl, and then cells were inoculated with 104.8 viral titer/mL RVFV for 12 hrs. This was then followed by isolation of proteins and then western blotting assay. The pictures were captured with ChemiDoc XRS+ (Bio-RAD, USA). Page 22/26 Figure 4 Effects of lithium on translocation of NF-kB between the cytoplasm and nucleus, and IkB. (A) The cells where seeded Cells were seeded at 4x105 cells/well in a 6 well plat treated with 2.5, 1.25, and 0.625 mM LiCl concentration of lithium, 5 mg/ml LPS and Figure 4 Figure 4 Effects of lithium on translocation of NF-kB between the cytoplasm and nucleus, and expression levels of IkB. (A) The cells where seeded Cells were seeded at 4x105 cells/well in a 6 well plate for 3 hrs then treated with 2.5, 1.25, and 0.625 mM LiCl concentration of lithium, 5 mg/ml LPS and inoculated with RVFV at 1x104.8 viral titer for 24 hrs. After 24 hrs of inoculation, cells were fixed with 4% paraformaldehyde for an hour, and then permeabilized with (0.1% Triton X-100, 1%BSA) for 30 min. Figure 4 Effects of lithium on translocation of NF-kB between the cytoplasm and nucleus, and expression levels of IkB. (A) The cells where seeded Cells were seeded at 4x105 cells/well in a 6 well plate for 3 hrs then treated with 2.5, 1.25, and 0.625 mM LiCl concentration of lithium, 5 mg/ml LPS and inoculated with RVFV at 1x104.8 viral titer for 24 hrs. After 24 hrs of inoculation, cells were fixed with 4% paraformaldehyde for an hour, and then permeabilized with (0.1% Triton X-100, 1%BSA) for 30 min. Page 23/26 Page 23/26 Permeabilised cells were incubated for 60 min with rabbit anti-p65 antibody (1:500). The primary antibody was followed by FITC-labelled goat anti-rabbit secondary Ab incubation for 60 min. After 5 min nuclear staining with DAPI cells were mounted on slides using 50 % glycerol and analysed usingusing fluorescent inverted Nikon Ti-E microscope at 20x magnification. (B&C) In order to determine the translocation quantity of the NF-κB, Raw 264.7 cell where seeded at 1x106 cell/ml for 3 hrs in the T25 cell culture flasks and then treated with various concentration of lithium and other cells were inoculated with 104.8 viral titer/mL RVFV for 24 hrs. This was then followed by isolation of cytoplasmic proteins as well the nucleus proteins and then western blotting assay followed. The pictures were captured with ChemiDoc XRS+ (Bio-RAD, USA). The ChemiDoc XRS+ image lab 5.2.1software was used to measure band volume (Bio-RAD, USA). (C) The plot was developed with Graph pad prism-6 software and instat-3 was used to establish the statistical analysis.(D) In order to determine the expression of the above depicted of Ikb-α, protein, Raw 264.7 cell where seeded and inoculated as above for 12 hrs. This was then followed by isolation of proteins and then western blotting assay. The pictures were captured with ChemiDoc XRS+ (Bio-RAD, USA) Page 24/26 Figure 5 Figure 5 Determination of the canonical NF-kB and IRF3/7 signalling pathways and the effects of lithium post RVFV infection. TLR 2 and 4 are stimulated by the viral glycoproteins that in turn recruit adapter molecule Myd88 via tirap. The adapter molecules recruit Irak4 which phosphorylate recruit irak-1 which then associate with Traf-6. Traf-6 recruit Tak1 and Tab2. Tak1 phosphorylate IΚΚ-β, which then phosphorylate IkB which is then tagged for ubiquitination and then degradation by cytoplasmic proteases. Figure 4 This then Determination of the canonical NF-kB and IRF3/7 signalling pathways and the effects of lithium post RVFV infection. TLR 2 and 4 are stimulated by the viral glycoproteins that in turn recruit adapter molecule Myd88 via tirap. The adapter molecules recruit Irak4 which phosphorylate recruit irak-1 which then associate with Traf-6. Traf-6 recruit Tak1 and Tab2. Tak1 phosphorylate IΚΚ-β, which then phosphorylate IkB which is then tagged for ubiquitination and then degradation by cytoplasmic proteases. This then Determination of the canonical NF-kB and IRF3/7 signalling pathways and the effects of lithium post RVFV infection. TLR 2 and 4 are stimulated by the viral glycoproteins that in turn recruit adapter molecule Myd88 via tirap. The adapter molecules recruit Irak4 which phosphorylate recruit irak-1 which then associate with Traf-6. Traf-6 recruit Tak1 and Tab2. Tak1 phosphorylate IΚΚ-β, which then phosphorylate IkB which is then tagged for ubiquitination and then degradation by cytoplasmic proteases. This then Page 25/26 Page 25/26 allows translocation of NF-kB to the nucleus and inflammatory genes expression. The RIG-1 is known to be stimulated by dsRNA from replicating viral genome, which is said to be hidden from the TLR-3. This cytoplasmic receptor is shown to be essential for viral IFN expression. The RIG-1 is shown to associate with IPS-1 with its N-terminal card domain. The IPS-1 and RIG-1 association activate TBK1 and IΚΚ-ε which phosphorylate IRF-3 and 7. The NSs is suggested to interfere with the IFN signalling at the transcription factor level since there is an expression of other inflammatory mediators except for IFNs. Since, the NSs inhibit the interferon production via IRF inhibition other transcription factors such NF-kB continue to produce inflammatory mediators, hence, elevated production of other inflammatory mediators except the IFN. This diagram suggests that NF-kB inhibition as a result of upregulated IkB could be the, mechanism in which lithium restore dysregulated inflammation after RVFV infection leading to haemorrhagic fever pathogeneses observed during this viral infection. allows translocation of NF-kB to the nucleus and inflammatory genes expression. The RIG-1 is known to be stimulated by dsRNA from replicating viral genome, which is said to be hidden from the TLR-3. This cytoplasmic receptor is shown to be essential for viral IFN expression. The RIG-1 is shown to associate with IPS-1 with its N-terminal card domain. The IPS-1 and RIG-1 association activate TBK1 and IΚΚ-ε which phosphorylate IRF-3 and 7. Figure 4 The NSs is suggested to interfere with the IFN signalling at the transcription factor level since there is an expression of other inflammatory mediators except for IFNs. Since, the NSs inhibit the interferon production via IRF inhibition other transcription factors such NF-kB continue to produce inflammatory mediators, hence, elevated production of other inflammatory mediators except the IFN. This diagram suggests that NF-kB inhibition as a result of upregulated IkB could be the, mechanism in which lithium restore dysregulated inflammation after RVFV infection leading to haemorrhagic fever pathogeneses observed during this viral infection. Page 26/26
https://openalex.org/W2971611548	https://www.nature.com/articles/s41598-019-47442-8.pdf	English	null	Neonicotinoid seed treatments of soybean provide negligible benefits to US farmers	Scientific reports	2,019	cc-by	5,979	OPEN Received: 31 January 2019 Accepted: 17 July 2019 Published: xx xx xxxx Received: 31 January 2019 Accepted: 17 July 2019 Published: xx xx xxxx Spyridon Mourtzinis1, Christian H. Krupke2, Paul D. Esker 3, Adam Varenhorst4, Nicholas J. Arneson1, Carl A. Bradley 6, Adam M. Byrne7, Martin I. Chilvers7, Loren J. Giesler5, Ames Herbert8, Yuba R. Kandel9, Maciej J. Kazula10, Catherine Hunt9, Laura E. Lindsey11, Sean Malone8, Daren S. Mueller9, Seth Naeve10, Emerson Nafziger12, Dominic D. Reisig13, William J. Ross14, Devon R. Rossman7, Sally Taylor8 & Shawn P. Conley1 Neonicotinoids are the most widely used insecticides worldwide and are typically deployed as seed treatments (hereafter NST) in many grain and oilseed crops, including soybeans. However, there is a surprising dearth of information regarding NST effectiveness in increasing soybean seed yield, and most published data suggest weak, or inconsistent yield benefit. The US is the key soybean-producing nation worldwide and this work includes soybean yield data from 194 randomized and replicated field studies conducted specifically to evaluate the effect of NSTs on soybean seed yield at sites within 14 states from 2006 through 2017. Here we show that across the principal soybean-growing region of the country, there are negligible and management-specific yield benefits attributed to NSTs. Across the entire region, the maximum observed yield benefits due to fungicide (FST = fungicide seed treatment) + neonicotinoid use (FST + NST) reached 0.13 Mg/ha. Across the entire region, combinations of management practices affected the effectiveness of FST + NST to increase yield but benefits were minimal ranging between 0.01 to 0.22 Mg/ha. Despite widespread use, this practice appears to have little benefit for most of soybean producers; across the entire region, a partial economic analysis further showed inconsistent evidence of a break-even cost of FST or FST + NST. These results demonstrate that the current widespread prophylactic use of NST in the key soybean-producing areas of the US should be re-evaluated by producers and regulators alike. In the US, the most recent published estimates reflect that approximately 34–44% of planted soybean hectares are treated with neonicotinoid seed treatments (NST)1. Based upon inferences drawn from trendlines shown in that work, the current estimate for NST use in soybeans is very likely to exceed 50%. Despite the prevalence of this practice nationally, the work we report here is the first large-scale analysis of soybean yield data. www.nature.com/scientificreports www.nature.com/scientificreports www.nature.com/scientificreports Scientific Reports \| (2019) 9:11207 \| https://doi.org/10.1038/s41598-019-47442-8 OPEN Insecticidal seed treatments of soybean belong to the neonicotinoid class of insecticides that include the active ingredients 1Department of Agronomy, University of Wisconsin-Madison, Madison, WI, 53706, United States. 2Department of Entomology, Purdue University, West Lafayette, IN, 47907, United States. 3Department of Plant Pathology and Environmental Microbiology, Pennsylvania State University, State College, PA, 16801, United States. 4Department of Agronomy, Horticulture & Plant Science, Brookings, SD, 57007, United States. 5Department of Plant Pathology, University of Nebraska-Lincoln, Lincoln, NE, 68583, United States. 6Department of Plant Pathology, University of Kentucky Research & Education Center, Princeton, KY, 42445, United States. 7Department of Plant, Soil and Microbial Sciences, Michigan State University, East Lansing, MI, 48824, United States. 8Department of Entomology, Virginia Tech Agricultural Research and Extension Center, Suffolk, VA, 23437, United States. 9Department of Plant Pathology and Microbiology, Iowa State University, Ames, IA, 50011, United States. 10Department of Agronomy and Plant Genetics, University of Minnesota, St. Paul, MN, 55108, United States. 11Department of Horticulture and Crop Science, The Ohio State University, Columbus, OH, 43210, United States. 12Department of Crop Sciences, University of Illinois, Urbana, IL, 61801, United States. 13Department of Entomology and Plant Pathology, North Carolina State University, Vernon James Research and Extension Center, Plymouth, NC, 27962, United States. 14Department of Crop, Soil, and Environmental Sciences, University of Arkansas, Little Rock, AR, 72204, United States. Correspondence and requests for materials should be addressed to Spyridon Mourtzinis (email: agstat001@ gmail.com) Scientific Reports \| (2019) 9:11207 \| https://doi.org/10.1038/s41598-019-47442-8 www.nature.com/scientificreports/ clothianidin, imidacloprid, and thiamethoxam. Corn and soybean seed treatments represent the largest uses of neonicotinoids nationally, and the higher seeding rate of soybeans mean that they are responsible for higher lev- els of active ingredient per unit area2. It is notable that current NST use rates far exceed historic benchmarks for insecticide use in soybeans; in the decade prior to introduction of neonicotinoid seed treatments, only about 5% of soybean hectares received insecticides3. This benchmark reflects that the region where most of US soybeans are grown, the upper Midwest, benefits from a temperate climate and relatively few insect pests, particularly in the early season when NST would provide most crop protection. Recent reviews of insect pest abundance in soybean re-confirm this assessment – early season pests of soybean are still infrequently encountered across the region4,5. OPEN Soybean aphid, a relatively recent invader to US soybean production, is a notable exception, but it’s abundance and phenology are a poor fit for the early-growing season, when NST are most effective6,7. p gy pi y g gf Recent studies report weak relationships between NST use and effectiveness in preserving crop yield. Specifically for soybean, in a recent multi-environment study in Wisconsin, yield benefit due to the use of insec- ticide seed treatments was variable8. In a comprehensive review conducted by the Environmental Protection Agency - EPA, NSTs were categorized as offering negligible overall benefits to soybean production in the Midwest9. A recent multi-state study of management tactics for the key pest in the region, the soybean aphid (Aphis glycines Matsumura) demonstrated that crop yield benefits and overall economic returns were marginally affected by NST, while an integrated pest management (IPM) approach, which combined scouting for the pest with foliar insecticide sprays only when the established economic threshold is reached, proved superior in all metrics outlined above6. Additionally, other management practices, such as planting date10, seeding rates11, and possibly region4, may affect the seed yield response of insecticide seed treatments. These results suggest that responses are unpredictable and support the notion that prophylactic application of NST across the region may be largely unnecessary. Aside from the fact that a farmer may be incurring unnecessary input costs, a growing body of research suggests that the use of NST in this manner can lead to a host of negative effects upon non-target organisms. It has been reported that neonicotinoids are increasingly detected in terrestrial and aquatic environ- ments12,13. Furthermore, studies in the US and elsewhere have evaluated impacts of neonicotinoid on nontarget organisms such as honey bees13–15 wild bees16,17, monarch butterflies18, vertebrates19,20, terrestrial and aquatic invertebrates21,22 and overall declines in ecosystem function23. Although each of these concerns are relevant to the US soybean-producing regions, it is worthwhile to note that key soybean producing states represented in our study include ND, SD, and MN, which rank 3rd, 4th and 5th, respectively in honey bee colonies ranked by state24; many of these are migratory colonies used for pollination of key fruit and nut crops. This presents a key intersec- tion between NST exposure and our principal managed pollinator species with demonstrated sensitivity to this class of compounds. Results and Discussion For this work, soybean seed yield data from 194 studies were assembled and stratified in four growing environ- ments (Fig. 1) based on soil pH and in-season weather conditions. There were differences in average growing sea- son temperatures and total precipitation among the four clusters (Table S1). The greatest precipitation occurred in locations in clusters 2 and 3. Locations in cluster 4 had the lowest precipitation and greatest average yields were observed in cluster 2. FST, FST + NST, and untreated controls (UTC) were applied in all locations (Table S2). Across the entire region, concurrent use of FST + NST effectively increased soybean yield compared to FST and UTC seed (Fig. 2). Nevertheless, the maximum yield difference compared with fungicide only and from untreated seed was small and reached only 0.04 and 0.06 Mg/ha, respectively. Similar magnitudes of yield differences were observed within clusters 1, 2 and 4 where the effect of seed treatment was significant (Fig. S1). fi When repeating the analysis with seed treatments separated by neonicotinoid active ingredients (imidaclo- prid, thiamethoxam, and clothianidin), across the entire region, concurrent thiamethoxam-based FST + NST resulted in the highest yield (4.3 Mg/ha), and differences compared with the other seed treatments did not exceed 0.13 Mg/ha (Fig. S2). A similar magnitude of yield differences due to seed treatments, separated by neonicotinoid active ingredients, was observed within each cluster (Fig. S3). These results suggest that the yield benefit due to neonicotinoid seed treatments was small but relatively consistent across the entire study area.f Conditional inference tree analysis was used to identify conditional effects of seed treatments with grow- ing environments (clusters) and management practices. Irrigation, followed by cluster, were the most important yield limiting factors followed by the effect of row spacing and seeding rate (Fig. 3). In cluster 1, narrow rows in non-irrigated experiments were associated with yield increase by up to 0.3 Mg/ha whereas in cluster 2, seeding rate greater than 297,000 seeds/ha resulted in the greatest yield. When repeating the analysis, with treatments separated by neonicotinoid active ingredient (imidacloprid, thiamethoxam, and clothianidin), the results were identical to Fig. 3. This analysis demonstrates that seed treat- ments, with and without neonicotinoids, have a negligible effect on soybean yield. In all experiments included in this study, the effectiveness of NST was examined concurrently with FST. OPEN p When implementing an IPM approach, an insecticide is used only when pest populations are expected to reach economically important populations and other management tools are not available or effective25. Using NST under an IPM strategy is admittedly challenging due to a lack of secondary pest predictive tools and thus, limited prediction power regarding early season pest populations. Consequently, the approach to NST use in North American annual crops since their introduction in the early 2000’s has been a continent-wide test of an “insurance-based” approach to insect pest management, where the risk of pests across the entire soybean-growing region was assumed to be sufficient to justify the use of insecticide over tens of millions of hectares annually, with- out corroborating monitoring or real-time yield assessments. Scientific Reports \| (2019) 9:11207 \| https://doi.org/10.1038/s41598-019-47442-8 Results and Discussion This is a common practice (51% of treated fields) among farmers across the North-central Midwestern US26, and our results suggest that such a practice is unlikely to significantly increase yields across the region. Based on these analyses, we conclude www.nature.com/scientificreports/ Figure 1. Location of individual experiments that were included in the study. Experiments with the same color belong to a cluster with similar growing environments, as were described in methods and Supplementary Table S1. Figure 1. Location of individual experiments that were included in the study. Experiments with the same color belong to a cluster with similar growing environments, as were described in methods and Supplementary Table S1. Figure 2. Soybean yield (Mg/ha) due to the applied seed treatments across the entire region. The black rectangles show the mean yield for each treatment and the lines extend to the lower and upper 95% confidence limits. Note: FST, fungicide only; FST + NST, fungicide plus neonicotinoid insecticide; UTC, untreated control. Means with the same letter are not significantly different at α = 0.05. Figure 2. Soybean yield (Mg/ha) due to the applied seed treatments across the entire region. The black rectangles show the mean yield for each treatment and the lines extend to the lower and upper 95% confidence limits. Note: FST, fungicide only; FST + NST, fungicide plus neonicotinoid insecticide; UTC, untreated control. Means with the same letter are not significantly different at α = 0.05. that prophylactic use of seed treatments (with and without neonicotinoids) are not necessary to maximize yield returns across the region, and other management practices that have a more direct impact on soybean seed yield, are much more important considerations27, these include sowing date, and cultivar maturity group.hff The effectiveness of the combined FST + NST compared with the FST alone appeared to be affected mainly by the use of row spacing, irrigation, and the cultivar’s maturity group (Fig. S4A). The greatest yield benefit of NSTs was observed in 12% of cropping systems that included non-irrigated plants in narrow rows (38 cm) and cultivars with maturity group ≤2 (+0.19 Mg/ha).ff y g p g Effectiveness of concurrent use of FST + NST compared to the UTC was mainly affected by row spacing and seeding rate (Fig. S4B). The yield benefit in these cropping systems reached 0.22 Mg/ha. Scientific Reports \| (2019) 9:11207 \| https://doi.org/10.1038/s41598-019-47442-8 Results and Discussion It appears that seed treat- ments including both FST + NST may be more effective in narrow row production systems, measuring 38 cm, and sub-optimal (<198,000 seeds/ha) seeding rates. However, across the Midwestern and North-central US, prevalent row spacings in non-irrigated production systems are 38 cm27. Our analysis demonstrates that the optimal man- agement practices are already applied in farmer’s fields, and thus, no additional yield benefit should be expected from FST + NST applications.f pp Sowing date within a region has a large effect on soybean seed yield27. Sowing date (early vs. late) has also been reported as a risk factor for pest infestation in various crops and US regions28. Early sowing in cold and wet soil can increase the risk for pest infestation and yield reduction4. In early and medium sown trials concurrent FST + NST use resulted in 0.06 and 0.1 Mg/ha greater yield than UTC seeds, respectively, whereas no yield benefit was observed in late sown fields across the entire region (Fig. S5). When repeating the analysis by cluster × sowing window, in only half of the early and one fourth of the medium sown clusters FST + NST use resulted in greater yield (between 0.07 to 0.12 Mg/ha) than UTC seeds (Fig. S6). Scientific Reports \| (2019) 9:11207 \| https://doi.org/10.1038/s41598-019-47442-8 www.nature.com/scientificreports/ Figure 3. Conditional inference tree for soybean yields (Mg/ha) as affected by environment (clusters) and management practices. In each boxplot, the central rectangle spans the first to the third yield quartiles. The solid line inside the rectangle is the mean which is also numerically shown at the bottom (Y). The number of data points comprising each mean is shown on top of each boxplot (n). The white circles show outlier yields. Figure 3. Conditional inference tree for soybean yields (Mg/ha) as affected by environment (clusters) and management practices. In each boxplot, the central rectangle spans the first to the third yield quartiles. The solid line inside the rectangle is the mean which is also numerically shown at the bottom (Y). The number of data points comprising each mean is shown on top of each boxplot (n). The white circles show outlier yields. The results in our study show an environmental- and management-specific soybean seed yield response due to the use of neonicotinoid seed treatments. Results and Discussion In general terms, these small yield benefits call into question the economic return on investment of prophylactic applications of neonicotinoid seed treatments. Partial eco- nomic analysis of the observed yield increases under 294, 404, 514, 625, and 735 $/Mg soybean price scenarios at 250,000, 350,000, and 450,000 seeds/ha seeding rates showed that both FST and FST + NST seed should not cost more than UTC seed (Fig. 4). For all price scenarios, breakeven cost of FST + NST was significant only at 350,000 seeds/ha (P = 0.034). Hypothetically, a higher treatment cost would be justified if soybean prices were greater than 735 $/Mg. However, this is extremely unlikely; the average monthly soybean price during the last 10 years was 472 $/Mg and the maximum price has never reached this threshold (maximum of 684 $/Mg in Aug 2012, a year when drought impacted many states in the soybean-growing region)29.hi The lack of consistent yield benefits attributable to NST, coupled with mounting reports of potential environ- mental risks, highlight that the current default approach of prophylactic applications of NST in soybeans in the US should be re-evaluated. Adjusting other soybean management practices, such as sowing date, row spacing and seed- ing rate, appear to have a greater potential to increase soybean yields across the entire examined region compared to neonicotinoid use26,27. Such practices represent a net-zero environmental burden compared with the prophylactic use of neonicotinoid treated seeds. IPM, a decision-making process based on scientific data to identify and reduce both yield limiting risks from pests and from pest-management related strategies, can be followed as an alternative to some extent. Although sporadic yield limiting pests are difficult to predict in advance, our data demonstrate that yield-limiting populations of these pests are uncommon across our growing region and that current use rates of NST are likely to far outpace their utility for soybean pest management. This observation is supported by previous anal- yses9, and by recent reviews of the prevalence and population dynamics of soybean insect pests across the region4,5. I t h i ht d b t th t t ff t f NST i l th E In response to heightened concerns about the non-target effects of NST use in annual crops, the European Commission restricted the use of clothianidin, imidacloprid and thiamethoxam neonicotinoid insecticides. Scientific Reports \| (2019) 9:11207 \| https://doi.org/10.1038/s41598-019-47442-8 Methods Soybean seed yield data from 194 randomized and replicated field studies, which were conducted specifically to evaluate the effect of seed treatments on soybean seed yield at sites within each of 14 states from 2006 through 2017, were assembled for this study. To include an individual experiment in the combined database, presence of replicated and randomized neonicotinoid seed treatments was essential. The final database included 11,146 plot-specific soybean seed yields. For all experiments, soil pH and information about nine major management practices, including irrigation, sowing date, cultivar maturity group, tillage operations, previous year crop, row spacing, seeding rate, double crop system, and manure application were recorded. p g g p y pp For each study, weather data were obtained from the PRISM dataset32. Weather variables included daily min- imum and maximum temperatures (Tmin and Tmax, respectively), and precipitation. In all studies, sowing date as day of year was set to zero and the 30-d specific weather conditions, beginning 30-d before sowing (DBS) up to 150 days after sowing (DAS), and season-wide (0–150 DAS) were calculated.ff yt g Since individual experiments were located in different regions, the effect of environment on soybean yield was assumed to be significant. Therefore, to account for non-management-related effects on yield, cluster analysis was used to stratify experiments into similar growing environments based on soil pH and the aforementioned weather varia- bles. Additionally, to enhance the clustering model, cumulative precipitation from sowing to 60 DAS, from sowing to 90 DAS, from sowing to 120 DAS, and use of irrigation were included as independent variables. Finally, coordinates (latitude and longitude), and sowing date were also included in the model to capture additional non-weather-related information (e.g., photoperiod). Variables were then standardized to mean = 0 and standard deviation = 1 and clusters were created using PROC FASTCLUS in SAS 9.4 (SAS Institute Inc., 2016). In this method, the iterative algorithm minimizes the sum of squared distances from the cluster means. The clustering is done using Euclidean distances com- puted from numeric variables. This kind of clustering method is often called a k-means model, since the cluster centers are the means of the observations assigned to each cluster. In each iteration, the least-squares criterion is reduced until convergence is achieved. We used adaptive training by using the DRIFT option in which the cluster seed is updated as the current mean of the cluster each time an observation is added. Results and Discussion Initially a moratorium, these restrictions were renewed in 2018 and expanded to a complete ban on all out- door uses of the compounds in 201830. The restriction in neonicotinoids initially resulted in the use of alterna- tive insecticide seed treatments or foliar applications by farmers31. Thus, an important issue is the anticipated response of farmers to a similar use restriction in the US. Such action may lead to increased use of alternative treatments and products which in turn, can result in different environmental issues. Our data provide some measure of security for soybean producers and other agricultural professionals that pest pressure is low across the key soybean-growing regions of the US. This provides empirical data for researchers, regulators, and seed www.nature.com/scientificreports/ Figure 4. Breakeven cost of fungicide only (F - circles), fungicide + insecticide (FI - triangles) seeds compared to untreated (line at 0 $/ha) for 294 $/Mg (yellow), 404 $/Mg (green), 514 $/Mg (blue), 625 $/Mg (red), and 735 $/Mg (black) soybean price scenarios. The lines extend to the lower and upper 95% confidence limits of each income difference (FST = fungicide − untreated and FST + NST = fungicide + insecticide − untreated seed). Figure 4. Breakeven cost of fungicide only (F - circles), fungicide + insecticide (FI - triangles) seeds compared to untreated (line at 0 $/ha) for 294 $/Mg (yellow), 404 $/Mg (green), 514 $/Mg (blue), 625 $/Mg (red), and 735 $/Mg (black) soybean price scenarios. The lines extend to the lower and upper 95% confidence limits of each income difference (FST = fungicide − untreated and FST + NST = fungicide + insecticide − untreated seed). sales staff to inform producers about the likelihood of measurable pest management and yield benefits associated with NST use, and we can infer that other, similar pest management approaches would be equally unnecessary in the absence of pests. This affords the industry an opportunity for a correction where NST use rates align more closely with pest incidence and risk factors. Given the demonstrable non-target issues associated with the current approach to NST use, we argue that this correction is not only advisable, but necessary if these pest management tools are to be preserved for occasions where they can provide benefit. Conclusions Our analysis, spanning 12 years and 14 soybean-producing states, provides no empirical support for continuing the current approach of blanket NST use in soybeans. On the contrary, our data suggest that this approach pro- vides little to zero net benefit in most cases, and that meaningful (i.e. significant) gains are likely to be realized by site-specific management practices, independent of NST use. Although we do not have site-specific pest data to identify the mechanisms behind our lack of observed pest management benefits, our results are given context by historical data that reflect the scarcity of soybean pests targeted by this approach. This means that throughout most soybean-producing regions of the US, the period of pest protection provided by NSTs does not align with economically significant pest populations. Absent economic infestations of pests, there is no opportunity for this plant protection strategy to provide benefit to most producers. www.nature.com/scientificreports/ practices, continuous variables (sowing date, seeding rate, cultivar maturity group, and row space) were trans- formed to categorical. Sowing date and seeding rate had three levels, (early, medium, and late sowed fields and sparse, medium, and dense sowed, respectively) that corresponded to three percentiles (<30th, 30th to 70th, and >70th). The median was used to create two levels for maturity group whereas for row spacing, two spacings were used across all studies (38 and 76 cm). Then, a combined management practice variable (mgm) was created as a nine-way combination of the levels of the nine recorded management practices. Thus, random effects included clusters, experiments within clusters, replication nested within experiments and clusters, the seed treatment nested within replications, mgm, the seed treatment nested within mgm, and the seed treatment nested within mgm and clusters. Degrees of freedom were calculated using the Kenward-Rodger approximation, 95% confidence limits were calculated, and the adjdfe = row and adjust = simulate adjustments were used for multiple pairwise means comparisons at 5% confidence level. These adjustments were used to take into account the fact that observations are not equal at all levels of the independent variables and thus, degrees of freedom are subject to variability.if q p g j y When the analysis was repeated for seed treatments separated by active ingredient, the fixed effect variable had six levels: fungicide only, fungicide plus thiamethoxam (application rate range: 0.0756 to 0.1512 mg. a.i. per seed.), fungicide plus imidacloprid (application rate range: 0.10 to 0.2336 mg. a.i. per seed), fungicide plus clothianidin (application rate range: 0.081 to 0.13 mg. a.i. per seed), fungicide plus both imidacloprid and clothianidin (appli- cation rates: 0.1013 mg a.i. per seed and 0.1056 mg a.i. per seed, respectively), and an untreated control (UTC). All fungicides were applied according to labeled rates. The aforementioned model was used for this analysis.ff g pp gh y To assess the seed treatment-related yield differences within each cluster, random effects included experi- ments, replication nested within experiments, the seed treatment nested within replications, mgm, and the seed treatment nested within mgm. The same model was also used when the analysis was repeated for seed treatments separated by active ingredient. p y g In our study, the levels of the nine major management practices were not replicated or randomized across all individual experiments. www.nature.com/scientificreports/ Therefore, evaluation of the levels of individual management practices with the greatest effect on seed treatment performance using traditional linear models (e.g., analysis of variance, multiple linear regression) are not appropriate. Consequently, we used the conditional inference regression trees methodology, within the “partykit” package in R (R development Core team, 2016). To evaluate which management practices had the greatest impact on the effectiveness of insecticide only and FST + NST, in every individual experiment (n = 194) and for every nine-way management combination, we calculated the following respective yield differ- ences: FST + NST minus FST and FST + NST minus UTC. In these analyses, the criterion for the independence test was based on a univariate p-value of alpha = 0.01. Additionally, to ensure adequate power at all steps, each intermediate node had to account for >25% of total observations and a terminal node had to consist of >10% of total observations. To avoid overfitting and enhance interpretability, the maximum tree depth was set to 5 nodes. i g p y p For the partial economic analysis, yield in every plot in every trial with seeding rate of 250,000, 350,000, and 450,000 seeds/ha were converted to profit for five soybean price scenarios: 294, 404, 514, 625, and 735 $/Mg. Then, the profit for each scenario (seeding rate × seed treatment (FST, FST + NST, UTC) × soybean price) was used as dependent variable in a mixed model analysis as was described earlier. References p p y p 3. Fernandez-Cornejo, J. et al. Pesticide use in US agriculture: 21 selected crops, 1960–2008. Economic Information Bulletin 124 USDA Economic Research Service, Washington, DC (2014). g 4. Hesler, S. L., Allen, C. K., Luttrell, R. G., Sappington, T. W. & Papiernik, S. K. Early-season pests of soybean in the United States and factors that affect their risk of infestation. Journal of Integrated Pest Management. 9(1), 19, https://doi.org/10.1093/jipm/pmx028 (2018) 4. Hesler, S. L., Allen, C. K., Luttrell, R. G., Sappington, T. W. & Papiernik, S. K. Early-season pests of soybean in the United States and factors that affect their risk of infestation. Journal of Integrated Pest Management. 9(1), 19, https://doi.org/10.1093/jipm/pmx028 (2018). 5. Papiernik, S. K., Sappington, T. W., Luttrell, R. G., Hesler, L. S. & Allen, K. C. Overview: Risk Factors and Historic Levels of Pressure From Insect Pests of Seedling Corn, Cotton, Soybean, and Wheat in the United States. Journal of Integrated Pest Management, 9(1), 1, 18, https://doi.org/10.1093/jipm/pmx026 (2018). f J f g g ( ), , p g j p p ( ) 5. Papiernik, S. K., Sappington, T. W., Luttrell, R. G., Hesler, L. S. & Allen, K. C. Overview: Risk Factors and Historic Levels of Pressure From Insect Pests of Seedling Corn, Cotton, Soybean, and Wheat in the United States. Journal of Integrated Pest Management, 9(1) 1, 18, https://doi.org/10.1093/jipm/pmx026 (2018). p g j p p 6. Krupke, C. H. et al. Assessing the value and pest management window provided by neonicotinoid seed treatments for managemen of soybean aphid (Aphis glycines Matsumura) in the Upper Midwestern United States. Pest. Manag. Sci 73, 2184–2193, https://doi org/10.1002/ps.4602 (2017). g 7. Ragsdale, D. W., Landis, D. A., Brodeur, J., Heimpel, G. 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Estimated Annual Agricultural Pesticide Use (accessed at, https://water.usgs.gov/nawqa/pnsp/usage/maps/show_map php?year=2014&map=THIAMETHOXAM&hilo=L) (2014). Methods We specified LEAST = 2 which minimizes the root mean square difference between the data and the corresponding cluster means. Using canonical analysis, visual evaluation of the clusters showed a high degree of separation and small overlap among the clusters (Fig. S7).i g g p p g g In the first analysis, a multilevel model, as described previously33, was used in PROC MIXED in SAS 9.4 to quantify the effect of seed treatments on soybean seed yield across clusters and the nine major aforementioned management practices. The seed treatment variable was used as a fixed effect and included three levels: fungicide only (FST), fungicide + neonicotinoid insecticide (FST + NST), and untreated control (UTC). The stratification of environments and management practices were introduced in the model as random effects. 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Additional Information Supplementary information accompanies this paper at https://doi.org/10.1038/s41598-019-47442-8.h Supplementary information accompanies this paper at https://doi.org/10.1038/s41598-019-4 Competing Interests: The authors declare no competing interests. Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Cre- ative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. 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https://openalex.org/W4254967593	https://biosignaling.biomedcentral.com/track/pdf/10.1186/s12964-020-00644-4	English	null	Rabies virus phosphoprotein P5 binding to BECN1 regulates self-replication by BECN1-mediated autophagy signaling pathway	Research Square (Research Square)	2,020	cc-by	9,449	© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. RESEARCH Open Access Abstract Background: Rabies virus (RABV) is reported to encode five phosphoproteins (P), which are involved in viral genomic replication, axonal transport, oxidative stress, interferon antagonism, and autophagy induction. However, the functions of the different P proteins are poorly understood. Methods: Immunofluorescence staining and western blot were performed to detect the autophagy activity, the form of ring-like structure, and the colocalization of BECN1 and P. Co-immunoprecipitation was performed to detect the interaction between P and BECN1. QRT-PCR and TCID50 assay were performed to detect the replication level of RABV. Small interfering RNA was used to detect the autophagy signaling pathway. Results: We found that P5 attaches to N-terminal residues 1–139 of BECN1 (beclin1) on the BECN1 ring-like structure through amino acid residues 173–222 of P5. Subsequently, we found that P5-induced autophagosomes did not fuse with lysosomes. Becn1 silencing did not recover P5 overexpression-induced promotion of RABV replication. Mechanistically, RABV protein PΔN82 (P5) induced incomplete autophagy via the BECN1-mediated signaling pathway. Conclusions: Our data indicate that P5 binding to the BECN1 ring benefits RABV replication by inducing BECN1 signaling pathway-dependent incomplete autophagy, which provides a potential target for antiviral drugs against RABV. Keywords: Rabies virus phosphoprotein P5, Beclin1, Binding domain, Incomplete autophagy, Viral replication Keywords: Rabies virus phosphoprotein P5, Beclin1, Binding domain, Incomplete autophagy Liu et al. Cell Communication and Signaling (2020) 18:153 https://doi.org/10.1186/s12964-020-00644-4 Liu et al. Cell Communication and Signaling (2020) 18:153 https://doi.org/10.1186/s12964-020-00644-4 (2020) 18:153 Liu et al. Cell Communication and Signaling https://doi.org/10.1186/s12964-020-00644-4 Juan Liu1, Min Liao1, Yan Yan1, Hui Yang1, Hailong Wang1 and Jiyong Zhou1,2 Juan Liu1, Min Liao1, Yan Yan1, Hui Yang1, Hailong Wang1 and Jiyong Zhou1,2 Background induces apoptosis by targeting mitochondria [3]. The viral protein P is a multifunctional protein that is in- volved in viral transcription and replication [4]. The P protein–dynein LC8 interaction is involved in the axonal transport of rabies virus along microtubules through neuronal cells [5]. The interaction of RABV P protein with complex I in mitochondria causes mitochondrial dysfunction, increased generation of reactive oxygen spe- cies (ROS), and oxidative stress [6]. In addition, the interaction of RABV P protein with the focal adhesion kinase and nucleolin positively regulates viral replication [7]. However, RABV P protein also directly binds to the interferon-induced promyelocytic leukemia protein, Rabies is associated with severe neurological symptoms and a high mortality rate, causing over 59,000 human deaths worldwide each year [1]. Rabies virus (RABV), be- longing to the Rhabdoviridae family, is a single nonseg- mented negative-stranded RNA virus with genome of 12 kb. The RABV genome encodes a nucleoprotein (N), phosphoprotein (P), matrix protein (M), glycoprotein (G), and RNA polymerase (L) [2]. The RABV M protein * Correspondence: liaomin4545@zju.edu.cn 1MOA Key Laboratory of Animal Virology, Center for Veterinary Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China Full list of author information is available at the end of the article ina l list of author information is available at the end of the article * Correspondence: liaomin4545@zju.edu.cn 1MOA Key Laboratory of Animal Virology, Center for Veterinary Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China Full list of author information is available at the end of the article Adenovirus expressing mCherry-GFP-LC3B fusion protein (C3011), cell lysis buffer NP-40 (50 mM Tris pH 7.4, 150 mM NaCl, 1% NP-40) (P0013F) and phenyl- methyl sulfonylfluoride protease inhibitor (ST505) were purchased from Beyotime (Shanghai, China). Earle’s balanced salt solution (EBSS) (14155–063) was pur- chased from Gibco. The jetPRIME cell transfection kit (PT-114-07) was purchased from Polyplus Transfection (Sébastien Brant, Illkirch, France). which inhibits viral replication [8]. P protein’s interaction with both cell division cycle 37 (CDC37) and heat shock pro- tein 90 (HSP90) promoted self-stability [9]. RABV P binding to beclin1 (BECN1) can induce incomplete autophagy through the caspase2 (CASP2)-mediated signaling pathways to promote viral genome replication [10]. RABV P also inter- acts with signal transducer and activator of transcription 1 (STAT1) to counteract interferon (IFN) signaling by creating both cytoplasmic and nuclear blocks for STAT1 [11]. RABV P protein, via an interferon antagonist interaction with acti- vated STAT3, inhibits membrane glycoprotein 130 (GP130) receptor signaling to generate optimal cellular conditions for viral replication and spread [12]. The RABV P protein is phosphorylated by a RABV pro- tein kinase and protein kinase C, forming different phos- phorylated versions of the P protein [13]. The full length P and small P proteins P2, P3, P4, and P5, are translated from downstream in-frame AUG initiation codons by a leaky scanning mechanism [14]. These small P proteins have different subcellular localizations. The small P pro- teins P3, P4, and P5 are located in the nucleus because of the nuclear localization signal (NLS) located in the C- terminal part of the protein (amino acids 172–297), whereas the cytoplasmic distributions of P and P2 result from a CRM1 nuclear export signal (NES) in the N- terminal part of the protein [15]. Thus, the functions of these small P proteins have not been fully determined. In the present study, we aimed to determine the func- tion of the small P protein PΔN82 (P5). The results showed that P5 binding to the BECN1 ring-like structure induced incomplete autophagy via the BECN1 mediated signaling pathway, which promotes RABV replication. Our study highlights the role of viral protein P5 in modulating RABV replication. Liu et al. Cell Communication and Signaling (2020) 18:153 Page 2 of 12 (2532), anti-p-ERK (4370), anti- ERK (4695), anti-p-P38 (4511), and anti-P38 (9212) antibodies were purchased from Cell Signaling Technology (Beverly, MA, USA). Rabbit anti-P62 (3340–1) antibody was purchased from Epitomics (Burlingame, CA, USA). Rabbit anti-CASP2 (ab179520), anti-ULK1 (ab128859), and anti-ATG5 (ab108327) antibodies were purchased from Abcam (Cambridge, MA, USA). Mouse anti-ATG7 (sc-376,212) and anti-BECN1 (sc-48,341) antibodies were purchased from Santa Cruz Biotechnology (Santa Cruz, CA, USA). Mouse anti-Flag (clone M2) (F1804) mAb, wortmannin (W1628), and 3-MA (M9281) were purchased from Sigma-Aldrich (St. Louis, MO, USA). Rabbit anti-MYC (R1208–1) and anti-GAPDH/glyceraldehyde-3-phos- phate dehydrogenase (EM1101) antibodies were purchased from Huaan Biological Technology (Hangzhou, China). Mouse monoclonal antibodies (mAbs) recognizing the N/P proteins of RABV were produced in our laboratory [16]. Fluorescein isothio- cyanate (FITC)-labeled goat anti-mouse IgG (62–6511) and Alexa Fluor 546-conjugated anti-rabbit IgG (A10036) were obtained from Thermo Scientific (Wal- tham, MA, USA). Secondary antibodies comprising horseradish peroxidase-labeled anti-mouse (074–1806) or anti-rabbit (074–1506) IgG were purchased from Kirkegaard & Perry Laboratories (Millford, MA, USA). Adenovirus expressing mCherry-GFP-LC3B fusion protein (C3011), cell lysis buffer NP-40 (50 mM Tris pH 7.4, 150 mM NaCl, 1% NP-40) (P0013F) and phenyl- methyl sulfonylfluoride protease inhibitor (ST505) were purchased from Beyotime (Shanghai, China). Earle’s balanced salt solution (EBSS) (14155–063) was pur- chased from Gibco. The jetPRIME cell transfection kit (PT-114-07) was purchased from Polyplus Transfection (Sébastien Brant, Illkirch, France). (2532), anti-p-ERK (4370), anti- ERK (4695), anti-p-P38 (4511), and anti-P38 (9212) antibodies were purchased from Cell Signaling Technology (Beverly, MA, USA). Rabbit anti-P62 (3340–1) antibody was purchased from Epitomics (Burlingame, CA, USA). Rabbit anti-CASP2 (ab179520), anti-ULK1 (ab128859), and anti-ATG5 (ab108327) antibodies were purchased from Abcam (Cambridge, MA, USA). Mouse anti-ATG7 (sc-376,212) and anti-BECN1 (sc-48,341) antibodies were purchased from Santa Cruz Biotechnology (Santa Cruz, CA, USA). Mouse anti-Flag (clone M2) (F1804) mAb, wortmannin (W1628), and 3-MA (M9281) were purchased from Sigma-Aldrich (St. Louis, MO, USA). Rabbit anti-MYC (R1208–1) and anti-GAPDH/glyceraldehyde-3-phos- phate dehydrogenase (EM1101) antibodies were purchased from Huaan Biological Technology (Hangzhou, China). Mouse monoclonal antibodies (mAbs) recognizing the N/P proteins of RABV were produced in our laboratory [16]. Fluorescein isothio- cyanate (FITC)-labeled goat anti-mouse IgG (62–6511) and Alexa Fluor 546-conjugated anti-rabbit IgG (A10036) were obtained from Thermo Scientific (Wal- tham, MA, USA). Secondary antibodies comprising horseradish peroxidase-labeled anti-mouse (074–1806) or anti-rabbit (074–1506) IgG were purchased from Kirkegaard & Perry Laboratories (Millford, MA, USA). Plasmids construction and transfection Mouse neuroblastoma N2a cells (CCL-131) and human embryonic kidney 293 T cells (CRL-3216) from ATCC were maintained in Dulbecco’s modified Eagle’s medium (DMEM; Gibco, Carlsbad, CA, USA) supplemented with 10% heat-activated fetal bovine serum (Gibco/Invitrogen, Carlsbad, CA, USA), 100 U of penicillin mg/ml, and 100 mg of streptomycin/ml. RABV strains HEP-Flury and CVS-11 were stored in our laboratory and were propa- gated in N2a cells. Briefly, N2a cells were infected with RABV at a multiplicity of infection (MOI) of 2. The in- fected cells were grown in fresh medium at 37 °C and 5% CO2 for the indicated times. The specific primers used to make the constructs gener- ated in this study are listed in Table S1. The truncated P genes were amplified from the cDNA of HEP-Flury (Ac- cession: AB085828.1) and cloned into pCMV-N-Flag (Clontech, Mountain View, CA, USA, 635688) or pCMV-N-Myc (Clontech, 635,689). The truncated Becn1 genes were amplified from the cDNA of Mus musculus Becn1 (Accession: NM_019584.3) and cloned into pCMV-N-Myc. The other plasmids Flag-P (full-length) and Myc-BECN1 were stored in our laboratory. The siRNA targeting mouse Becn1 gene and shRNA targeting mouse Akt, Mtor, Ampk, Mapk genes were also synthe- sized by Genepharma (Suzhou, China). The siRNA or shRNA and all the plasmids were transfected into HEK293T or N2a cells using the jetPRIME kit according to the manufacturer’s instructions. Co-immunoprecipitation Residues 173–222 of the RABV P protein form an autophagy-inducing domain Confocal microscopy cDNAs using a RevertAid RT Reverse Transcription Kit (Thermo Scientific, K1691). The qRT-PCR specific primers used are as follows: upstream primer 5′-AAG- GAGTTGAATGACAGGGTGCCA-3′ and downstream primer 5′-ACT TGGGATGGTTCGAAAGGAGGA-3′ for the RABV anti-genome (115 bp in length), upstream primer 5′-AGCAGCAATGCAGTTCTTTGAGGG-3′ and downstream primer 5′-TTGTCAGTTCCATGCC TCCTGT CA-3′ for the RABV N gene (164 bp in length), and upstream primer 5′ -TCAACAGCAACTCC CACTCTTCCA-3′ and downstream primer5′-ACCCTG TTGCTGTAGCCGTATTCA-3′ for Gapdh gene (92 bp in length). The qPCR reaction was performed using ChamQ™Universal SYBR® qPCR Master Mix (Vazyme Biotechnology, Q711–02, Nanjing, China) and a Light- Cycler96 real-time PCR system (Roche, Basel, Switzerland). The qPCR conditions were as follows: 95 °C for 300 s; 40 cycles of 95 °C for 10 s and 60 °C for 30 s; 95 °C for 10 s, 65 °C for 60 s and 97 °C for 1 s; 37 °C for 30 s. Quantitative analysis was performed using the LightCycler96 software with a relative quantification method (ΔΔCt) to analyze the levels of viral N mRNA and anti-genomic RNA. py HEK293T or N2a cells were grown to 70% confluence on a confocal plate (In Vitro Scientific, Sunnyvale, CA, USA) and then transfected with the indicated plasmids or infected with RABV (MOI = 2) for 24 h. The cells were washed with phosphate-buffered saline (PBS), fixed, and permeabilized with 4% paraformaldehyde in PBS at 4 °C for 20 min, and then incubated with the appropriate primary and secondary antibodies. The nuclei were stained with 4, 6-diamidino-2- phenylindole (DAPI). Fluorescence signals were scanned under a Zeiss LSM 780 laser confocal microscopy (Zeiss, Oberkochen, Baden-Württemberg, Germany). Antibodies and reagents Antibodies and reagents Rabbit anti-LC3A/B (4108), anti-p-AKT (Ser473) (4060), anti-AKT (4691), and anti-p-MTOR (Ser2448; 5536), anti-MTOR (2983), anti-p-AMPK (4185), anti- AMPK Page 3 of 12 Liu et al. Cell Communication and Signaling (2020) 18:153 Page 3 of 12 Liu et al. Cell Communication and Signaling (2020) 18:153 Western blotting Cells were harvested and lysed with NP-40 buffer con- taining phenylmethyl sulfonyl fluoride at 4 °C for 2 h. Protein samples were separated by 12% sodium dodecyl sulfate polyacrylamide-gel electrophoresis and were transferred onto nitrocellulose membranes. 5% nonfat dry milk containing 0.1% Tween 20 was used to block the nonspecific binding sites for 1 h at room temperature, and then the membranes were incubated with primary antibody at 4 °C overnight, followed by the appropriate secondary antibody for 1 h at room temperature. The blots were developed using a Super- Signal West Femto Substrate Trial Kit (Thermo Scien- tific, 34,096) according to the manufacturer’s protocol. Images were captured using FluorChemm M chemilu- minescent imaging system (Protein Simple, Santa Clara, CA, USA) and ImageJ software (National Institutes of Health, Bethesda, MD, USA) was used to quantify the intensity of the immunoreactive protein bands. Statistical analysis Statistically significant differences between groups were determined using one-way analysis of variance (ANOVA) with the Tukey Multiple Comparison Test and using GraphPad Prism 5 software (GraphPad Software, Inc., La Jolla, CA, USA). A P value of less than 0.05 was consid- ered statistically significant. Residues 173–222 of the RABV P protein form an autophagy-inducing domain Transfected HEK293T cells were lysed for 2 h with NP- 40 buffer containing 1 mM phenylmethyl sulfonylfluor- ide protease inhibitor at 4 °C. The insoluble fractions were removed after the cell lysates were centrifuged at 12,000 g for 10 min at 4 °C. The soluble fractions were incubated with the indicated antibodies overnight at 4 °C. Fresh protein A/G agarose (Santa Cruz Biotechnol- ogy, sc-2003) was then added at 4 °C for 8 h before washing with PBS. The eluted proteins were subjected to western blotting analysis. Our previous report discovers that the RABV P protein induces incomplete autophagy [10], however, the do- main responsible for this incomplete autophagy induc- tion is unknown. To identify the functional domain of the P protein required for autophagy induction, we con- structed six truncated P protein mutants (Fig. 1a). 293 T cells were transfected with the plasmids pCMV-N-Flag- tagged P, PΔC75, PΔC125, PΔN19 (P2), PΔN52 (P3), PΔN68 (P4), and PΔN82 (P5), respectively. Western blotting assay revealed that the level of endogenous LC3-phosphatidylethanolamine conjugate (LC3-II) was dramatically increased in cells transfected with all trun- cated P mutants except for those transfected with PΔC125 compared with the empty vector transfected cells, and chloroquine (CQ), a lysosomal proteolysis in- hibitor, as a control for autophagic flux (Fig. 1b; P < 0.05, P < 0.001). Moreover, all truncated P proteins caused no significant increases in autophagy associated proteins au- tophagy related (ATG)5, ATG7, Unc-51 like autophagy QRT-PCR Quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) analyses of the mRNA tran- scripts and anti-genomic RNA were performed as previ- ously described [17]. Briefly, Total RNA was extracted from N2a cells using the TRIZOL Reagent (Superfec- TRI™, 3101–100; Shanghai Pufei Biotech Co., Ltd., Shanghai, China) according to the manufacturer’s in- structions. The total RNA was reverse transcribed into Liu et al. Cell Communication and Signaling (2020) 18:153 Page 4 of 12 Fig. 1 Truncated P proteins induce autophagy. a Schematic diagram of the full-length and truncated P proteins. b HEK293T Cells were transfected with the plasmids containing the truncated P genes for 48 h, harvested, and analyzed using western blotting using mouse anti-ATG7, anti-Flag mAb, rabbit anti-LC3A/B, anti-ATG5, anti-BECN1, anti-P62, anti-ULK1, and anti-GAPDH antibodies. c HEK293T cells were cotransfected with GFP-LC3B and the plasmids containing the truncated P genes for 24 h, fixed, and immunostained with mouse anti-Flag antibodies (red), and then visualized using confocal microscopy. DAPI (blue) was used to stain nuclear DNA. Scale bar: 10 μm. d The graph shows the quantification of autophagosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; *, P < 0.001) Fig. 1 Truncated P proteins induce autophagy. a Schematic diagram of the full-length and truncated P proteins. b HEK293T Cells were transfected with the plasmids containing the truncated P genes for 48 h, harvested, and analyzed using western blotting using mouse anti-ATG7, anti-Flag mAb, rabbit anti-LC3A/B, anti-ATG5, anti-BECN1, anti-P62, anti-ULK1, and anti-GAPDH antibodies. c HEK293T cells were cotransfected with GFP-LC3B and the plasmids containing the truncated P genes for 24 h, fixed, and immunostained with mouse anti-Flag antibodies (red), and then visualized using confocal microscopy. DAPI (blue) was used to stain nuclear DNA. Scale bar: 10 μm. d The graph shows the quantification of autophagosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; , P < 0.001) activating kinase 1 (ULK1), BECN1, and autophagic deg- radation substrate sequestome 1 (also known as P62) levels (Fig. 1b). QRT-PCR Consistently, confocal observation also revealed green fluorescent protein (GFP)-LC3B punctas were dramatically increased in cells transfected with all truncated P mutants except for those transfected with PΔC125 compared with the empty vector transfected cells (Fig. 1c and d; P < 0.001), however, there were no significant differences in GFP-LC3B punctas caused by all truncated P proteins after these cells were treated with CQ (Fig. S1). Therefore, these data showed that a P protein containing C-terminal residues aa 173–222 was responsible for autophagic activity. Phosphoprotein P5 forming ring-like structures induces autophagosomes accumulation Small phosphoprotein P5 contains residues aa 83–172, 173–222, and 223–297 of full-length P protein. Page 5 of 12 Liu et al. Cell Communication and Signaling (2020) 18:153 Liu et al. Cell Communication and Signaling (2020) 18:153 Interestingly, a ring circle-like structure was observed in N2a cells transfected only with the P5 mutant but not in N2a cells either transfected individually with other P protein mu- tants or co-transfected with P5 and other P protein mutants (Fig. 1c, Fig. 2a and Fig. S2). Similarly, the ring circle-like structure was observed in N2a cells co-transfected with both Flag-P5 and Myc-P5 (Fig. 2b), indicating that only P5 could form the ring-like structure. Moreover, the number of GFP- LC3B puncta autophagosomes surrounded by the P5 ring- like structure increased significantly in N2a cells cotrans- fected with GFP-LC3B and Flag-P5 in comparison with N2a cells cotransfected with Flag-vector and GFP-LC3B (Fig. 2c). Collectively, these data demonstrated that the P5 ring-like structure induced autophagosomes accumulation. Fig. 2 Accumulated autophagosomes are surrounded by a ring-like structure comprising P5. a-c N2a cells were transfected with Flag-P or Flag- P5, or cotransfected with Flag-P5 and Myc-P5 or GFP-LC3B plasmids for 24h, fixed, and immunostained with mouse anti-Flag antibodies and rabbit anti- Myc antibodies, and then visualized using confocal microscopy. DAPI (blue) was used to stain nuclear DNA. Scale bar: 10 or 20 μm. The graph shows the quantification of autophagosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P<0.05; , P< 0.01; , P< 0.001) Incomplete autophagic vesicles are induced by P5 protein To further investigate the relationship between autopha- gosomes and P5, N2a cells were cotransfected with Flag- P5 and GFP-LC3B, and labeled with LysoTracker Red. As expected, the number of GFP-LC3B puncta autopha- gosomes increased markedly and did not colocalize with LysoTracker Red in Flag-P5-transfected N2a cells com- pared with EBSS-treated N2a cells (Fig. 3a), indicating that the autophagosomes did not fuse with acidic com- partments after P5 transfection. To rule out the possibil- ity that autophagosomes fused with lysosomes but were not efficiently acidified in the transfected cells, we inves- tigated the colocalization of GFP-LC3B with lysosomal associated membrane protein 1 (LAMP1) in Flag-P5- transfected N2a cells. GFP-LC3B puncta did not colocal- ize with LAMP1 in Flag-P5-transfected N2a (Fig. S3). Phosphoprotein P5 forming ring-like structures induces autophagosomes accumulation These data suggested that autophagosomes did not effi- ciently fuse with lysosomes in Flag-P5-transfected cells. In addition, we used adenovirus that expressed mCherry-GFP-LC3B, which was used to discriminate autophagosomes (expressing both mCherry and GFP fluorescent) from acidified autolysosomes (expressing red fluorescentonly) to determine the function of P5 in autophagosome maturation. N2a cells were transfected with Flag-P5 plasmids for 12 h, and infected with the adenovirus. In Flag vector transfected cells, few yellow puncta autophagosomes could be detected after adeno- virus infection (Fig. 3b). In contrast, in Flag-P5 trans- fected cells, we observed the accumulation of yellow puncta autophagosomes but a low number of mcherry puncta autophagosomes, suggesting impaired autopha- gosome fusion with lysosomes. These results implied that P5 protein was responsible for the observed incom- plete autophagic induction. Fig. 2 Accumulated autophagosomes are surrounded by a ring-like structure comprising P5. a-c N2a cells were transfected with Flag-P or Flag- P5, or cotransfected with Flag-P5 and Myc-P5 or GFP-LC3B plasmids for 24h, fixed, and immunostained with mouse anti-Flag antibodies and rabbit anti- Myc antibodies, and then visualized using confocal microscopy. DAPI (blue) was used to stain nuclear DNA. Scale bar: 10 or 20 μm. The graph shows the quantification of autophagosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P<0.05; , P< 0.01; , P< 0.001) Fig. 2 Accumulated autophagosomes are surrounded by a ring-like structure comprising P5. a-c N2a cells were transfected with Flag-P or Flag- P5, or cotransfected with Flag-P5 and Myc-P5 or GFP-LC3B plasmids for 24h, fixed, and immunostained with mouse anti-Flag antibodies and rabbit anti- Myc antibodies, and then visualized using confocal microscopy. DAPI (blue) was used to stain nuclear DNA. Scale bar: 10 or 20 μm. The graph shows the quantification of autophagosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P<0.05; , P< 0.01; , P< 0.001) The protein P5 attaches to the BECN1 ring-like structure by interaction with BECN1 We previously demonstrated that the RABV P protein could interact with BECN1 [10]. To identify whether Liu et al. Cell Communication and Signaling (2020) 18:153 Page 6 of 12 Fig. 3 Autophagosomes fail to fuse with lysosomes in Flag-P5-transfected cells. a N2a cells were cotransfected with Flag-P5 and GFP-LC3B for 24 h, and were treated with EBSS or CQ for 4 h. Cells were incubated with LysoTracker Red (50 nM) for 15 min, and then were fixed, and immunostained with mouse anti-Flag mAb (blue), and observed using confocal microscopy to analyze fusion of autophagosomes with lysosomes. Scale bars: 10 μm. The graph shows the quantification of autolysosomes by taking the average number of dots in 50 cells. b N2a cells were transfected with Flag-P5 for 8 h, and infected with the adenovirus expressing mCherry-GFP-LC3B protein for 24 h, and were treated with EBSS or CQ for 4 h. Cells were fixed, and immunostained with mouse anti-Flag mAb (blue), and observed using confocal microscopy to analyze fusion of autophagosomes with lysosomes. Scale bars: 10 μm. The graph shows the quantification of autophagosomes by taking the average numberof dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; , P < 0.001) Fig 3 Autophagosomes fail to fuse with lysosomes in Flag P5 transfected cells a N2a cells were cotransfected with Flag P5 and GFP LC3B for 24 Fig. 3 Autophagosomes fail to fuse with lysosomes in Flag-P5-transfected cells. a N2a cells were cotransfected with Flag-P5 and GFP-LC3B for 24 h, and were treated with EBSS or CQ for 4 h. Cells were incubated with LysoTracker Red (50 nM) for 15 min, and then were fixed, and immunostained with mouse anti-Flag mAb (blue), and observed using confocal microscopy to analyze fusion of autophagosomes with lysosomes. Scale bars: 10 μm. The graph shows the quantification of autolysosomes by taking the average number of dots in 50 cells. b N2a cells were transfected with Flag-P5 for 8 h, and infected with the adenovirus expressing mCherry-GFP-LC3B protein for 24 h, and were treated with EBSS or CQ for 4 h. Cells were fixed, and immunostained with mouse anti-Flag mAb (blue), and observed using confocal microscopy to analyze fusion of autophagosomes with lysosomes. Scale bars: 10 μm. The graph shows the quantification of autophagosomes by taking the average numberof dots in 50 cells. The protein P5 attaches to the BECN1 ring-like structure by interaction with BECN1 Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; , P < 0.001) Fig. 3 Autophagosomes fail to fuse with lysosomes in Flag-P5-transfected cells. a N2a cells were cotransfected with Flag-P5 and GFP-LC3B for 24 h, and were treated with EBSS or CQ for 4 h. Cells were incubated with LysoTracker Red (50 nM) for 15 min, and then were fixed, and immunostained with mouse anti-Flag mAb (blue), and observed using confocal microscopy to analyze fusion of autophagosomes with lysosomes. Scale bars: 10 μm. The graph shows the quantification of autolysosomes by taking the average number of dots in 50 cells. b N2a cells were transfected with Flag-P5 for 8 h, and infected with the adenovirus expressing mCherry-GFP-LC3B protein for 24 h, and were treated with EBSS or CQ for 4 h. Cells were fixed, and immunostained with mouse anti-Flag mAb (blue), and observed using confocal microscopy to analyze fusion of autophagosomes with lysosomes. Scale bars: 10 μm. The graph shows the quantification of autophagosomes by taking the average numberof dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; , P < 0.001) Page 7 of 12 Page 7 of 12 Liu et al. Cell Communication and Signaling (2020) 18:153 BECN1 binding to the P protein involves P5, N2a cells were cotransfected with Myc-BECN1 and Flag-P5 or Flag-PΔC75, Flag-PΔC125, Flag-PΔN19, Flag-PΔN52, and Flag-PΔN68, respectively. Confocal microscopy showed that the BECN1 colocalized with the full-length P and the P mutants except for PΔC125P5 mutant, notably, the P5 formed ring-like structure had stronger localization with BECN1 ring-like structure compared with P ring-like structure (Fig. 4a, and Fig. S4). Similarly, endogenous P protein colocalized with BECN1 to form the ring-like structure in RABV infected cells, and interestingly, the ring-like structure was not observed after Becn1 gene was knocked down, suggesting that BECN1 was necessary for RABV infection to form the ring-like structure (Fig. 4b). Subsequently, a co-immunoprecipitation assay (Co-IP) was performed to further analyze whether the colocaliza- tion involves protein-protein interactions. The Co-IP data demonstrated that full-length and all truncated P proteins except PΔC125 could immunoprecipitate BECN1, and that P5 showed stronger binding to BECN1 than the other truncated P mutants (Fig. 4c). P5 binding to the BECN1 ring-like structure regulates RABV replication via the BECN1-mediated signaling pathway To further investigate the BECN1-dependent signaling pathway through which P5 regulates RABV replication, we examined whether BECN1, AMP-activated protein kinase (AMPK), CASP2, protein kinase B (AKT), mammalian tar- get of rapamycin (MTOR), and mitogen activated protein kinases MAPKs [extracellular signal-regulated kinase (ERK), P38] levels changed during overexpression of P5. Western blotting analysis showed that P5 dramatically up- regulated the phosphorylation (p) level of AKT, MTOR, AMPK, ERK1/2, and P38, and reduced the CASP2 level; however, it did not affect the total amount of these proteins nor BECN1 levels (Fig. 6a). Moreover, we knocked down cellular Becn1 using siBecn1 to further show whether the P5 protein affected the expression of BECN1, AMPK, CASP2, AKT, MTOR, and MAPK (ERK, P38). The results showed that there was a significant downregulation of CASP2 and p-AMPK, p-AKT, p-MTOR, and p-MAPK (ERK1/2, P38) levels, and an insignificant alteration of the total amount of these proteins in Becn1-knockdown cells with viral gene P5 transfection (Fig. 6b). To investigate whether P5 regulated RABV replication depends on the downstream of BECN1-dependent sig- naling pathway, next we knocked down cellular Akt, Mtor, Ampk, Mapk respectively, and examined the NP expression levels in the absence or presence of P5. The results showed that there was a significant decrease of NP in absence or presence of P5, suggesting that the RABV replication was dependent of the AKT, MTOR, AMPK, MAPK proteins (Fig. 6c). Collectively, these data demonstrated that the BECN1 binding to P5 was re- sponsible for regulating RABV replication via a BECN1- mediated signaling pathway. The protein P5 attaches to the BECN1 ring-like structure by interaction with BECN1 In addition, surprisingly, P5’s binding ability to BECN1 was stronger than that of the full-length protein (Fig. 4c). To identify the P protein bind- ing domain of BECN1, Myc-tagged truncation mutants of BECN1 (1–351aa, 139–351aa, and 139–448aa) were con- structed and transfected into 293 T cells (Fig. 4d). Confocal microscopy analysis showed that only the 1–351aa BECN1 mutant formed the ring-like structure, and the P protein colocalized with the ring-like structure and the 1–351aa BECN1 mutant (Fig. 4e). Further co-IP experiments showed that only 1–351aa BECN1, but not 139–351aa BECN1 and 139–448aa BECN1, interacted with P protein (Fig. 4f), revealing that first 139 N-terminal residues of BECN1 are responsible for interacting with P. Collectively, these data confirmed that RABV protein P attached to the BECN1 ring-like structure by residues 173–222 of P bind- ing to N-terminal residues 1–139 of BECN1. to further confirm whether the effect of the ring-like structure on RABV replication was dependent of au- tophagy induction, we also detected the level of viral N protein in presence of protein P5 together with the au- tophagy inhibitor 3-methyladenine (3-MA), or wortman- nin treatment. The results showed 3-MA or wortmannin treatment significantly inhibited the level of viral N pro- tein compared with that in non-treated P5 group (Fig. 5f and g, P < 0.01 or 0.001). Collectively, these data demon- strated that RABV replication hijacked BECN1 by P5 binding to the BECN1 ring-like structure. P5 binding to BECN1 ring-like structure promoted RABV replication To determine the effect on RABV replication of P5 bind- ing to the BECN1 ring-like structure, we investigated the dynamics of RABV infection under condition of P5 over- expression. N2a cells transfected with Flag-P5 for 12 h were infected with RABV. We found that the level of viral N protein, viral N mRNA, viral anti-genomic RNA, and infectious RABV progeny were all significantly in- creased; however, when Becn1 was knocked down using two short interfering RNAs (siBecn1), there was a detect- able downregulation of viral N protein, viral N mRNA, viral anti-genomic RNA, and infectious RABV progeny in the absence or presence of P5 (Fig. 5a-e, P < 0.05, 0.01, or 0.001), suggesting a positive role of P5 in regu- lating RABV infection dependent of BECN1. In addition, Discussion Previous studies showed that full-length P protein and at least four additional shorter products P2 (PΔN19), P3 (PΔN52), P4 (PΔN68), and P5 were detected in RABV- infected cells, viral gene P transfected cells, and purified RABV virions [14]. BECN1 plays an interacting partner Page 8 of 12 Liu et al. Cell Communication and Signaling (2020) 18:153 Fig. 4 Truncated protein P5 interacted with BECN1. a, b N2a cells were cotransfected with Flag-P5 and Myc-BECN1 (a) or singly transfected with siBecn1 RNA for 12 h and infected with RABV strain HEP-Flury at MOI = 2 for 24 h (b), and the viral P/P5 protein (green), BECN1 (red), and DAPI (blue) were detected using the indicated antibodies via confocal microscopy. White arrows indicate the colocalization of the ring-like structure. Scale bar: 10 μm. The graph shows the quantification of the percentage of BECN1 localization with P5 ring-like structure. c HEK 293 T cells were cotransfected with the plasmids containing the truncated P genes and Myc-BECN1 for 48 h, and the interactions between the truncated P protein and BECN1 were determined using the indicated antibodies. IP, immunoprecipitation. The asterisk indicates the heavy chains. d Schematic diagram of the full-length and truncated BECN1 proteins. e N2a cells were singly transfected or cotransfected with the plasmids encoding the truncated BECN1 genes and Flag-P for 24 h, and the viral P protein (red), BECN1 (green), and DAPI (blue) were detected using the indicated antibodies via confocal microscopy. White arrows indicate the colocalization of the ring-like structure. Scale bar: 10 μm. The graph shows the quantification of the ring-like structures formed with BECN1 deletion mutants. f HEK 293 T cells were cotransfected with the plasmids containing the truncated Becn1 genes and Flag-P for 48 h, and the interactions between the truncated BECN1 proteins and P were determined using the indicated antibodies. IP, immunoprecipitation. The asterisk indicates the heavy chains. Means and SD (error bars) of three independent experiments are indicated (, P < 0.001) Fig. 4 Truncated protein P5 interacted with BECN1. a, b N2a cells were cotransfected with Flag-P5 and Myc-BECN1 (a) or singly transfected with siBecn1 RNA for 12 h and infected with RABV strain HEP-Flury at MOI = 2 for 24 h (b), and the viral P/P5 protein (green), BECN1 (red), and DAPI (blue) were detected using the indicated antibodies via confocal microscopy. White arrows indicate the colocalization of the ring-like structure. Discussion Scale bar: 10 μm. The graph shows the quantification of the percentage of BECN1 localization with P5 ring-like structure. c HEK 293 T cells were cotransfected with the plasmids containing the truncated P genes and Myc-BECN1 for 48 h, and the interactions between the truncated P protein and BECN1 were determined using the indicated antibodies. IP, immunoprecipitation. The asterisk indicates the heavy chains. d Schematic diagram of the full-length and truncated BECN1 proteins. e N2a cells were singly transfected or cotransfected with the plasmids encoding the truncated BECN1 genes and Flag-P for 24 h, and the viral P protein (red), BECN1 (green), and DAPI (blue) were detected using the indicated antibodies via confocal microscopy. White arrows indicate the colocalization of the ring-like structure. Scale bar: 10 μm. The graph shows the quantification of the ring-like structures formed with BECN1 deletion mutants. f HEK 293 T cells were cotransfected with the plasmids containing the truncated Becn1 genes and Flag-P for 48 h, and the interactions between the truncated BECN1 proteins and P were determined using the indicated antibodies. IP, immunoprecipitation. The asterisk indicates the heavy chains. Means and SD (error bars) of three independent experiments are indicated (, P < 0.001) Liu et al. Cell Communication and Signaling (2020) 18:153 Page 9 of 12 Fig. 5 A ring-like structure containing P5 was beneficial to virus replication. a, b N2a cells were transfected with Flag-P5 (a) or cotransfected with Flag-P5 and two siRNAs targeting Becn1 (b) for 12 h, and infected with RABV strain HEP-Flury or CVS-11 at an MOI = 2 for 36 h, and then harvested for western blotting analysis with mouse anti-NP, anti-BECN1, anti-Flag mAbs, and rabbit anti-GAPDH antibodies. c The ratio of viral protein N to GAPDH was normalized to that of the control conditions. d N2a cells were treated as described for panels A and B. qRT-PCR analysis of cellular viral N mRNA, and the anti-genomic RNA level. All qRT-PCR data were normalized to the expression of Gapdh and the control group was used as a reference. e Cellular supernatant in panels (a and b) were harvested for virus titer detection. Virus titers in N2a cells were determined using a TCID50 assay. Discussion f N2a cells were transfected with Flag-P5 for 12 h and were pretreated with 5 mM 3-MA or 1 mM wortmannin for 2 h, and then infected with RABV HEP-Flury strain at an MOI = 2 and incubated in the absence or presence of 5 mM 3-MA or 1 mM wortmannin for 24 h, and the cells were harvested for western blotting analysis using the indicated antibodies. g The ratio of viral protein N to GAPDH was normalized to that of the control conditions. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; , P < 0.001) Fig. 5 A ring-like structure containing P5 was beneficial to virus replication. a, b N2a cells were transfected with Flag-P5 (a) or cotransfected with Flag-P5 and two siRNAs targeting Becn1 (b) for 12 h, and infected with RABV strain HEP-Flury or CVS-11 at an MOI = 2 for 36 h, and then harvested for western blotting analysis with mouse anti-NP, anti-BECN1, anti-Flag mAbs, and rabbit anti-GAPDH antibodies. c The ratio of viral protein N to GAPDH was normalized to that of the control conditions. d N2a cells were treated as described for panels A and B. qRT-PCR analysis of cellular viral N mRNA, and the anti-genomic RNA level. All qRT-PCR data were normalized to the expression of Gapdh and the control group was used as a reference. e Cellular supernatant in panels (a and b) were harvested for virus titer detection. Virus titers in N2a cells were determined using a TCID50 assay. f N2a cells were transfected with Flag-P5 for 12 h and were pretreated with 5 mM 3-MA or 1 mM wortmannin for 2 h, and then infected with RABV HEP-Flury strain at an MOI = 2 and incubated in the absence or presence of 5 mM 3-MA or 1 mM wortmannin for 24 h, and the cells were harvested for western blotting analysis using the indicated antibodies. g The ratio of viral protein N to GAPDH was normalized to that of the control conditions. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; , P < 0.001) Liu et al. Cell Communication and Signaling (2020) 18:153 Page 10 of 12 Fig. 6 The protein P5 binding to the BECN1 ring-like structure regulates RABV replication via the BECN1-mediated signaling pathway. Discussion a, b N2a cells were transfected with Flag-P5 (a) or cotransfected with Flag-P5 and two siRNAs targeting Becn1 (b) for 48 h, and then harvested for western blotting analysis with the indicated antibodies. c N2a cells were cotransfected with Flag-P5 and the shRNA/siRNA targeting Akt or Mtor or Ampk or Mapk for 12 h, and infected with RABV HEP-Flury strain at an MOI = 2 for 36 h. Cells were harvested for western blotting analysis with the indicated antibodies. d Proposed model showing how P5 protein regulates RABV replication. Data are representative of 3 independent experiments replication via the BECN1-mediated signaling pathway. a, b N2a siRNAs targeting Becn1 (b) for 48 h, and then harvested for western with Flag-P5 and the shRNA/siRNA targeting Akt or Mtor or Ampk 6 h. Cells were harvested for western blotting analysis with the ABV replication. Data are representative of 3 eplication via the BECN1-mediated signaling pathway. a, b N2a RNAs targeting Becn1 (b) for 48 h, and then harvested for western with Flag-P5 and the shRNA/siRNA targeting Akt or Mtor or Ampk Fig. 6 The protein P5 binding to the BECN1 ring-like structure regulates RABV replication via the BECN1-mediated signaling pathway. a, b N2a cells were transfected with Flag-P5 (a) or cotransfected with Flag-P5 and two siRNAs targeting Becn1 (b) for 48 h, and then harvested for western blotting analysis with the indicated antibodies. c N2a cells were cotransfected with Flag-P5 and the shRNA/siRNA targeting Akt or Mtor or Ampk or Mapk for 12 h, and infected with RABV HEP-Flury strain at an MOI = 2 for 36 h. Cells were harvested for western blotting analysis with the indicated antibodies. d Proposed model showing how P5 protein regulates RABV replication. Data are representative of 3 independent experiments Fig. 6 The protein P5 binding to the BECN1 ring-like structure regulates RABV replication via the BECN1-mediated signaling pathway. a, b N2a cells were transfected with Flag-P5 (a) or cotransfected with Flag-P5 and two siRNAs targeting Becn1 (b) for 48 h, and then harvested for western blotting analysis with the indicated antibodies. c N2a cells were cotransfected with Flag-P5 and the shRNA/siRNA targeting Akt or Mtor or Ampk or Mapk for 12 h, and infected with RABV HEP-Flury strain at an MOI = 2 for 36 h. Cells were harvested for western blotting analysis with the indicated antibodies. Authors’ contributions JZ, JL and ML designed the research. JL performed the experiments, analyzed and interpreted data. JL, ML and JZ wrote the manuscript. ML, YY, HW and HY provide the experimental materials. All authors read and approved the final manuscript. Discussion d Proposed model showing how P5 protein regulates RABV replication. Data are representative of 3 independent experiments proteins (PΔC75, PΔN19, PΔN52, PΔN68, and P5), residues 173–222 induced autophagy by interacting with N-terminal residues 1–139 of BECN1. Mean- while, only the full-length P protein and P5 were vis- ibly colocalized with the BECN1 ring-like structure (Fig. 4). Notably, in co-IP experiments, P5 showed stronger binding than full length P protein. Therefore, we concluded that RABV small phosphoprotein P5 is responsible for binding to the BECN1 ring-like structure. role for the mammalian phosphatidylinositol 3-kinase catalytic subunit type 3 (PIK3C3) involving macroauto- phagy, in which it is an essential chaperone or adaptor [18–20]. However, in the relationship between the virus and autophagy, although it has been reported that BECN1 interacts with a virus protein to regulate autophagy, the specific domain responsible for the BECN1 interaction is not clear [21, 22]. The present study showed that BECN1 exists in a ring-like struc- ture, and identified that among five truncated P Page 11 of 12 Page 11 of 12 Liu et al. Cell Communication and Signaling (2020) 18:153 Liu et al. Cell Communication and Signaling (2020) 18:153 As an essential cofactor of RABV RNA polymerase, P may participate in additional physiological processes [23]. Our previous research reports incomplete autophagy in- duced by the RABV phosphoprotein [10]. In this study, we demonstrated that the P proteins with, but not without, amino acid segment 173–222 are involved in increasing the level of endogenous lipidated LC3-II. In particular, the LC3-II was surrounded by the P5 protein (Figs. 1 and 2). However, P5 did not change the levels of autophagy associ- ated proteins ATG5, ATG7, ULK1, BECN1, and P62, markedly. In addition, the P5-induced autophagosome did not colocalize with lysosomes (Figs. 1, 2 and 3 and S2). Nonetheless, we observed that P5 upregulated the phos- phorylation of AMPK, MAPK (P38, ERK1/2), AKT, and MTOR, and decreased BECN1-dependent CASP2 levels (Fig. 6). Collectively, our data demonstrated that amino acid residues 173–222 of the viral P protein are responsible for inducing incomplete autophagy, and the binding of P5 to the BECN1 ring-like structure induced this incomplete au- tophagy by activating the BECN1 signaling pathway. RABV P5 protein interacted with the BECN1 ring-like structure to induce incomplete autophagy through a BECN1 signaling pathway. P5 attached to the BECN1 ring- like structure promoted RABV self-replication (Fig. 6d). Acknowledgments f We gratefully acknowledge Ms. Yunqin Li for technical assistance on laser confocal microscopy. Supplementary information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12964-020-00644-4. Supplementary information accompanies this paper at https://doi.org/10. 1186/s12964-020-00644-4. Additional file 1: Table S1. Primer used for the truncated P or BECN1 protein constructs. p Additional file 2: Figure S1. HEK293T cells were cotransfected with GFP-LC3B and the plasmids containing the truncated P genes for 24 h, and further treated with CQ for 4 h. These cells were fixed, and immuno- stained with mouse anti-Flag antibodies (red), and then visualized using confocal microscopy. DAPI (blue) was used to stain nuclear DNA. Scale bar: 10 μm. The graph shows the quantification of autophagosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05. Figure S2. The truncated protein P5 is required for a ring-like structure. N2a cells were cotransfected with Flag and Myc tagged plasmids encoding the truncated P genes for 24 h, fixed, and immunostained with mouse anti- Flag antibody (green) and rabbit anti-Myc (red), and then visualized by confocal microscopy. DAPI (blue) stained nuclear DNA. Scale bar: 10 μm. Figure S3. Autophagosomes fail to fuse with lysosomes in Flag-P5- transfected cells. N2a cells were cotransfected with Flag-P5 and GFP-LC3B for 24 h, and were treated with EBSS or CQ for 4 h. Cells were fixed, and immunostained with rabbit anti-LAMP1 mAb (red), and mouse anti-Flag mAb (blue), and observed using confocal microscopy to analyze fusion of autophagosomes with lysosomes. Scale bar: 10 μm. The graph shows the quantification of autolysosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; *, P < 0.001). Figure S4. The trun- cated P proteins colocalize with BECN1. N2a cells were cotransfected with the plasmids encoding the truncated P genes and Myc-BECN1 for 24 h, and Flag (green), BECN1 (red) and DAPI (blue) were detected by using the indicated antibodies in confocal microscopy. Scale bar: 10 μm. Additional file 2: Figure S1. HEK293T cells were cotransfected with GFP-LC3B and the plasmids containing the truncated P genes for 24 h, and further treated with CQ for 4 h. These cells were fixed, and immuno- stained with mouse anti-Flag antibodies (red), and then visualized using confocal microscopy. DAPI (blue) was used to stain nuclear DNA. Scale bar: 10 μm. Supplementary information The graph shows the quantification of autolysosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05; , P < 0.01; , P < 0.001). Figure S4. The trun- cated P proteins colocalize with BECN1. N2a cells were cotransfected with the plasmids encoding the truncated P genes and Myc-BECN1 for 24 h, and Flag (green), BECN1 (red) and DAPI (blue) were detected by using the indicated antibodies in confocal microscopy. Scale bar: 10 μm. Abbreviations k AKT: Protein kinase B; AMPK: AMP-activated protein kinase; ANOVA: Analysis of variance; ATG: Autophagy related; BECN1: Beclin1; CASP2: Caspase2; Co- IP: Co-immunoprecipitation; DAPI: 6-diamidino-2-phenylindole; ERK: Extracellular signal-regulated kinase; GAPDH: Glyceraldehyde-3- phosphate dehydrogenase; GFP: Green fluorescent protein; LAMP1: Lysosomal associated membrane protein 1; LC3: Microtubule associated protein 1 light chain 3 alpha; mAbs: Mouse monoclonal antibodies; MAPKs: Mitogen activated protein kinases; MOI: Multiplicity of infection; MTOR: Mammalian target of rapamycin; P: Phosphoprotein; RABV: Rabies virus; siRNA: Small interfering RNA Discussion Thus, the results of the present study identified potential antiviral drug targets against RABV. Supplementary information The graph shows the quantification of autophagosomes by taking the average number of dots in 50 cells. Means and SD (error bars) of three independent experiments are indicated (, P < 0.05. Figure S2. The truncated protein P5 is required for a ring-like structure. N2a cells were cotransfected with Flag and Myc tagged plasmids encoding the truncated P genes for 24 h, fixed, and immunostained with mouse anti- Flag antibody (green) and rabbit anti-Myc (red), and then visualized by confocal microscopy. DAPI (blue) stained nuclear DNA. Scale bar: 10 μm. Autophagy can remove intracellular pathogens, includ- ing bacteria and viruses, by activating various cellular defense responses, including direct digestion of intracy- toplasmic virions [21, 24], recognition of pathogen- associated molecular patterns through the delivery of viral genomes to endosomal toll-like receptors [25], acti- vation of innate immune signaling [26], and regulation of the inflammatory response [27–31]. However, many viruses also subvert the autophagic machinery to en- hance viral replication [32–37]. In this study, we demon- strated that P5 overexpression increased the level of viral N protein, viral N mRNA, viral anti-genomic RNA, and infec- tious RABV progeny, and these indexes were significantly inhibited in the absence or presence of P5 and knockdown of Becn1 (Fig. 5). In addition, we also demonstrated that the P5 still increased the RABV replication when autophagy was inhibited (Fig. 5). These results suggested that RABV replication was regulated by the binding of P5 to the BECN1 ring-like structure. In our previous study, RABV P binding to BECN1 can induce incomplete autophagy through the pathways BECN1-CASP2-AMPK-MAPK and BECN1-CASP2-AMPK-AKT-MTOR and RABV-induced incomplete autophagy provides the scaffolds for the replica- tion of RABV genome. However, in this study, we found that small phosphoprotein P5 binding to BECN1 formed a ring-like structure to induce incomplete autophagy through a BECN1 signaling pathway. 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Availability of data and materials suckling mouse brain antigen. Monoclonal Antibodies Immunodiagnosis Immunother. 2014;33:94–100. suckling mouse brain antigen. Monoclonal Antibodies Immunodiagnosis Immunother. 2014;33:94–100. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. 17. Zhang J, Wu X, Zan J, Wu Y, Ye C, Ruan X, et al. Cellular chaperonin CCTgamma contributes to rabies virus replication during infection. J Virol. 2013;87:7608–21. Ethics approval and consent to participate Not applicable. Publisher’s Note 14. Chenik M, Chebli K, Blondel D. Translation initiation at alternate in-frame AUG codons in the rabies virus phosphoprotein mRNA is mediated by a ribosomal leaky scanning mechanism. J Virol. 1995;69:707–12. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 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https://openalex.org/W4311584126	https://ro-journal.biomedcentral.com/counter/pdf/10.1186/s13014-022-02172-6	English	null	Knowledge-based DVH estimation and optimization for breast VMAT plans with and without avoidance sectors	Radiation oncology	2,022	cc-by	9,408	Abstract Background: To analyze RapidPlan knowledge-based models for DVH estimation of organs at risk from breast cancer VMAT plans presenting arc sectors en-face to the breast with zero dose rate, feature imposed during the optimization phase (avoidance sectors AS). Methods: CT datasets of twenty left breast patients in deep-inspiration breath-hold were selected. Two VMAT plans, PartArc and AvoidArc, were manually generated with double arcs from ~ 300 to ~ 160°, with the second having an AS en-face to the breast to avoid contralateral breast and lung direct irradiation. Two RapidPlan models were generated from the two plan sets. The two models were evaluated in a closed loop to assess the model performance on plans where the AS were selected or not in the optimization. Results: The PartArc plans model estimated DVHs comparable with the original plans. The AvoidArc plans model estimated a DVH pattern with two steps for the contralateral structures when the plan does not contain the AS selected in the optimization phase. This feature produced mean doses of the contralateral breast, averaged over all patients, of 0.4 ± 0.1 Gy, 0.6 ± 0.2 Gy, and 1.1 ± 0.2 Gy for the AvoidArc plan, AvoidArc model estimation, Rapid- Plan generated plan, respectively. The same figures for the contralateral lung were 0.3 ± 0.1 Gy, 1.6 ± 0.6 Gy, and 1.2 ± 0.5 Gy. The reason was found in the possible incorrect information extracted from the model training plans due to the lack of knowledge about the AS. Conversely, in the case of plans with AS set in the optimization generated with the same AvoidArc model, the estimated and resulting DVHs were comparable. Whenever the AvoidArc model was used to generate DVH estimation for a plan with AS, while the optimization was made on the plan without the AS, the optimizer evidentiated the limitation of a minimum dose rate of 0.2 MU/°, resulting in an increased dose to the contralateral structures respect to the estimation. Conclusions: The RapidPlan models for breast planning with VMAT can properly estimate organ at risk DVH. Atten- tion has to be paid to the plan selection and usage for model training in the presence of avoidance sectors. rds: RapidPlan, Knowledge-based planning, Avoidance sector, Breast, VMAT, DVH estimation model © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Open Access Open Access Knowledge‑based DVH estimation and optimization for breast VMAT plans with and without avoidance sectors Antonella Fogliata1, Sara Parabicoli1, Lucia Paganini1, Giacomo Reggiori1, Francesca Lobefalo1, Luca Cozzi1,2, Ciro Franzese1,2, Davide Franceschini1, Ruggero Spoto1 and Marta Scorsetti1,2 Fogliata et al. Radiation Oncology (2022) 17:200 https://doi.org/10.1186/s13014-022-02172-6 Fogliata et al. Radiation Oncology (2022) 17:200 https://doi.org/10.1186/s13014-022-02172-6 Background Breast cancer is one of the most commonly diagnosed tumours. It contributes conspicuously to the use of the resources of a radiotherapy department in all aspects, from diagnosis to treatment preparation, delivery and follow-up. © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Page 2 of 11 Fogliata et al. Radiation Oncology (2022) 17:200 Fogliata et al. Radiation Oncology (2022) 17:200 Over the last decade, many publications have proven the dosimetric advantages of using the volumetric mod- ulated arc therapy (VMAT) technique for breast cancer treatment, particularly in terms of target dose homogene- ity and conformity, and homolateral organs at risk (OAR) dose reduction [1–4]. However, its clinical application did not find the same diffusion as it did for most other anatomical sites. The main reason is related to the possi- ble larger low-dose bath delivered with such a technique, with the associated increase of secondary cancer risk induction [5–7]. The conventional irradiation, with the classical two tangential fields, is the beam arrangement delivering the lowest dose to the contralateral struc- tures (particularly breast and lung) since no direct beam crosses them. Such an arrangement allows these struc- tures to receive only dose scattered from the primary treatment fields. Several studies approached different VMAT solutions, aiming to lower the dose to the con- tralateral structures. The classical VMAT arc geometry of about 240° long arc(s) has been modified over the years to solve the problem: a more tangential VMAT approach with one or two partial arcs covering all the directions from the classical medial entrance to an almost posterior position was implemented. Methods Twenty left breast patients were selected. Patients were simulated in the supine position with the arms above the head and in deep-inspiration breath-hold (DIBH) to bet- ter spare the heart. The contoured structures included the lungs, the left Lung_Homolat and the right Lung_Contralat, the heart and the right breast (Breast_Contralat). The clinical tar- get volume (CTV) was delineated to include the whole mammary gland. The PTV was defined as CTV plus an additional 5 mm margin, cropped inside the outer con- tour by 4 mm. On each patient, two different plans were optimized for VMAT on a 6 MV (flattened) photon beam generated by a Varian TrueBeam linac equipped with Millennium MLC (5 mm leaf width at isocentre, in the central 20 cm of the field, 1 cm outside) to deliver 40.05 Gy in 15 frac- tions as mean dose to the PTV. The version 15.6.03 of the Eclipse treatment planning system was used. The Photon Optimizer (PO) engine and the Acuros algorithm were used for the plan optimization process and the final dose calculation, respectively. y Two sets of plans were generated for each patient: • Plan PartArc: two or three partial arcs with the same start/end angles, starting from a classical medial entrance (around 300° gantry angle for the left-sided breast) and ending to a gantry value of approximately 160–170°. The collimator was set around ± 15° (com- plimentary), tuned on the target shape and patient anatomy. The X field size (direction of the MLC motion) was imposed to be less than 15 cm. The use of knowledge-based planning (KBP) allowed an improvement of the department’s efficiency while main- taining (or leveraging) the quality of the treatment plans. RapidPlan (Varian Medical Systems, USA) is a KBP solu- tion that allows implementing models based on depart- mental knowledge, bringing in the routine practice the plan quality according to the specific institutional goals. It allows developing DVH predictive models trained on high-quality historical plan data. These models can be used to prospectively estimate the DVHs of all the OAR included in the model training for any new patient with their anatomical characteristics. The most explored technique reduced the breast en-face entrance, with the so-called “butterfly” or “bow-tie” technique, using short arcs mim- icking a more tangential approach [8–19]. Other pro- posals have been hybrid techniques (VMAT and IMRT, or more common VMAT and 3DCRT) [20, 21] or non- coplanar settings [22–24].h Methods In the training phase, for the "in-field" OAR volume, a Principal Component Analysis (PCA) is conducted to find the geometric feature that best correlates with the dosimetric principal component score 1. With those two components, a regression model is applied to obtain the regression between the anatomical/geometrical and the dosimetric features. The OAR regions not belong- ing to the “in-field” category are modelled with simple models as means-and-std to estimate the dose. The final estimated DVH is a combination of the different parts according to the sub-volume partitioning.i setting does not include control point intensity informa- tion. This experiment was designed with two objectives. The first one was to verify if the optimization engine could autonomously reduce the dose rate in the sectors where the contralateral structures are seen in the beam’s- eye-view beyond the target, using only the DVH estima- tion information translated into optimization objectives. The second objective was to analyze the ability of the model to generate the DVH estimations according to the AvoidArc dose distribution without the information on the avoidance sector’s presence. For each patient, the two plans were named RP_PartArc and RP_AvoidArc, gener- ated by PartArcModel and AvoidArcModel, respectively. The choice of the same set of patients in a closed-loop setting was intended to focus the attention on the model’s capabilities by eliminating any possible variance induced by the use of different patients. This approach did not focus on the clinical application or the robustness of the models as done in an open-loop validation experiment. A schematic diagram of the plans and models is shown in Fig. 1.hi To evaluate the models, the goodness-of-fit (the regres- sion) is given as the coefficient of determination R2 and the average chi-square χ2 . The first metric measures the proportion of the variance in the dependent variable (the dose, as the DVH principal component score) that is predictable from the independent variable (the geo- metrical feature). The second metric is related to Pear- son’s chi-squared test, which results from the residuals (the difference between the original and the estimated data). Also the potential outliers have to be evaluated. An outlier is an observation whose value is markedly differ- ent from the other values in the sample data. Among the metrics identifying a structure as a possible outlier, there is the modified Z-score (mZ), with a value greater than the threshold of 3.5. Methods The RapidPlan estima- tions can then be translated into individualized optimiza- tion objectives based on the quality of the historical data used for the training [25–27].h • Plan AvoidArc: the same as above, with an additional avoidance sector (arc sector with MU = 0 selecta- ble inside the optimization window) defined in the optimization process for all the arcs. This tool forces the dose rate to drop to zero in the arc sector along which the contralateral structures (breast and lung) are visible, in the beam’s-eye-view projection (the fields had the same size as the PartArc plan), beyond the target. The avoidance sectors thus prevent the primary beams’ irradiation of the contralateral struc- tures. The intention of AvoidArc plans thanks to the avoid- ance sector, is to maximally reduce the contralateral structures dose, going in that way to receive no dose from direct beams. The skin flash (procedure first proposed in [28]) was not adopted in this planning work to avoid con- founding factors in the optimisation and in the calcula- tion processes.h The present study aims to analyze the combination of the RapidPlan models and the solutions from the VMAT optimizer implemented in the Eclipse planning system (Varian Medical Systems, Palo Alto, CA, USA) when the VMAT technique with an avoidance sector en-face to the treating breast is set. The work intends to understand possible weaknesses in the model configuration and its implementation in clinical practice. The generation of a RapidPlan DVH estimation model foresees an extraction and a training phase [25]. During Fogliata et al. Radiation Oncology (2022) 17:200 Page 3 of 11 Fogliata et al. Radiation Oncology (2022) 17:200 Fogliata et al. Radiation Oncology (2022) 17:200 Table 1 Optimization objectives in the RapidPlan models Structure Parameter type Objective Priority PTV Upper objective Dmax,0% < 101% of prescription 95 Lower objective Dmin,100% > 99% of prescription 95 Heart Line objective Generated Generated Lung_Homolat Line objective Generated Generated Lung_Contralat Line objective Generated Generated Breast_Contralat Line objective Generated Generated Table 1 Optimization objectives in the RapidPlan models the extraction phase, several anatomical and dosimetric features are obtained from the patient’s anatomy and the plan. Each OAR is partitioned into sub-volumes accord- ing to its position in relation to the beam and the target. Methods This metric measures the difference of an individual geometric parameter from the median value in the training set, normalized with the median absolute difference, and it is an indicator of potential geo- metric outliers. The plans generated, as described above, were finally compared with the original plans used to train the two RapidPlan models. The comparison included a variety of dose-volume metrics. For the target V95%, V105% and D98% were scored. For the OARs, mean doses for the homolat- eral structures as well as V20Gy for the left lung and V18Gy for the heart, and the mean doses for the contralateral structures (right breast and lung) were used. A general focus of the planning efforts was to maximize the con- tralateral structures sparing. The 20 PartArc plans were used to generate a Rapid- Plan model called PartArcModel, while the 20 Avoid- Arc plans were used to obtain a RapidPlan model called AvoidArcModel. The OARs considered in the models were the heart, lungs and contralateral breast.h The same optimization objectives were selected for both models, according to Table 1.h The two models were then used to generate dose dis- tributions on the same 20 patients executing the opti- mization process with the objectives determined by the model, without any human modification or interaction. Intermediate dose calculation was performed with Acu- ros during the optimization process to refine the dose accuracy. These test plans were optimized using the same plan geometry as the PartArc plans, i.e. without select- ing the avoidance sectors inside the optimizer. The choice is supported by the fact that the arc geometry, as trans- ferred to the model generation process, is technically the same in both PartArc and AvoidArc plans, as the beam Dosimetric data were obtained from the DVHs, while the statistical significance of the differences was tested with the Wilcoxon Signed Rank test, a paired non-para- metric test; differences were considered significant with p < 0.05. In the second part of the study, a RapidPlan model named ButterflyModel was generated from plans (called Butterfly) similar to the AvoidArc plans. These Butter- fly plans were optimized according to a beam geometry Fogliata et al. Radiation Oncology (2022) 17:200 Page 4 of 11 Fig. 1 Diagram of the plans and models the beams irradiating the target. The counter-balance is an increased dose to the homolateral lung and a slightly reduced, although significant, target dose homogeneity. Methods obtained by splitting each arc into two short arcs instead of setting an avoidance sector in the optimization phase. No different collimator rotation was applied to mimic the AvoidArc plans fully. The motivation for this further step derives from the implementation of a similar VMAT technique for treating breast cancer in some radiotherapy centres (called "butterfly" or "bow-tie" techniques [8– 19]). As expected, the differences between the AvoidArc and the Butterfly plans were minimal and insignificant.hl The models Table 3 summarises the model training results from the configuration information in terms of goodness-of-fit (coefficient of determination R2 and average chi-square χ2). li The ButterflyModel was used to generate plans, named RP_Butterfly, having the same initial geometry as the Butterfly plans for subsequent comparisons. In the table, the number of potential outliers is also reported. All the cases with mZ > 3.5 were evaluated in the single plans. None was judged to be a real outlier: the cohort of patients covered a range of possible anatomical differences.h Plans PartArc and AvoidArc of determination R2 0.887 0.693 0.730 0.873 Average χ2 1.182 1.263 1.188 1.127 Number of Potential Outliers 2 1 5 6 Fig. 2 Regression plots (first row) and residual plots (second row) of the PartArcModel Table 3 Model training results Heart Homolat lung Contralat lung Contral breast PartArcModel Coeff. of determination R2 0.828 0.594 0.768 0.479 Average χ2 1.181 1.146 1.271 1.141 Number of Potential Outliers 1 5 10 1 AvoidArcModel Coeff. of determination R2 0.887 0.693 0.730 0.873 Average χ2 1.182 1.263 1.188 1.127 Number of Potential Outliers 2 1 5 6 Table 3 Model training results Table 3 Model training results Heart Homolat lung Contralat lung Contral breast PartArcModel Coeff. of determination R2 0.828 0.594 0.768 0.479 Average χ2 1.181 1.146 1.271 1.141 Number of Potential Outliers 1 5 10 1 AvoidArcModel Coeff. of determination R2 0.887 0.693 0.730 0.873 Average χ2 1.182 1.263 1.188 1.127 Number of Potential Outliers 2 1 5 6 Fig. 2 Regression plots (first row) and residual plots (second row) of the PartArcModel Fig. 2 Regression plots (first row) and residual plots (second row) of the PartArcModel Fig. 2 Regression plots (first row) and residual plots (second row) of the PartArcModel Fig. 2 Regression plots (first row) and residual plots (second row) of the PartArcModel Fig. 2 Regression plots (first row) and residual plots (second row) of the PartArcModel Fig. 3 Regression plots (first row) and residual plots (second row) of the AvoidArcModel Fig. 3 Regression plots (first row) and residual plots (second row) of the AvoidArcModel one for the AvoidArc. The other cases in the cohort pre- sent similar features to Patient8. second row showed an accurate prediction with a small variance. Table 4 reports the mean doses averaged over the patient cohort of the four OARs for the different plans and estimations. Plans PartArc and AvoidArc f The regression plots and the residual plots related to the four organs at risk are reported in Figs. 2 and 3 for the PartArcModel and AvoidArcModel, respectively. Table 2 reports the dosimetric characteristics of the Par- tArc and AvoidArc plans used to generate the RapidPlan models. The different trade-offs are shown: for Avoid- Arc plans, a lower dose to the contralateral structures and the heart is achieved since no direct beam toward those structures contributes to their dose, while the contribution is only from the scattered radiation from Despite the contralateral breast for both models and the contralateral lung for the PartArcModel showed a regression plot without a clear slope and a large stand- ard deviation (the dashed lines), the residual plots in the Table 2 Dose characteristics of the PartArc and AvoidArc plans selected for the models’ input. Values are the average of the 20 patients cohort. Uncertainty is reported as one standard deviation the goal within brackets is in case of enhanced contralateral structures sparing Structure Dosimetric parameter and goal PartArc plans AvoidArc plans PTV V95% > 95% [%] 97.0 ± 1.2 95.8 ± 0.6 + V105% < 3% [%] 0.7 ± 0.7 2.0 ± 0.8 + D98% > 90% [%] 94.1 ± 1.0 93.4 ± 0.6 + Heart Mean < 4 Gy [Gy] 2.2 ± 0.4 1.9 ± 0.7 + V18Gy < 5% [%] 0.0 ± 0.0 0.1 ± 0.3 Lung_Homolat Mean < 8 Gy [Gy] 5.4 ± 0.5 6.2 ± 0.8 + V20Gy < 10% [%] 6.9 ± 1.0 10.2 ± 2.0 + Lung_Contralat Mean < 2 Gy (1 Gy)* [Gy] 1.4 ± 0.5 0.3 ± 0.1 + Breast_Contralat Mean < 3 Gy (1 Gy)* [Gy] 1.7 ± 0.5 0.4 ± 0.1 + s of the PartArc and AvoidArc plans selected for the models’ input. Values are the average of the 20 is reported as one standard deviation Table 2 Dose characteristics of the PartArc and AvoidArc plans selected for the models’ input. Values are patients cohort. Uncertainty is reported as one standard deviation the goal within brackets is in case of enhanced contralateral structures sparing Fogliata et al. Radiation Oncology (2022) 17:200 Page 5 of 11 Table 3 Model training results Heart Homolat lung Contralat lung Contral breast PartArcModel Coeff. of determination R2 0.828 0.594 0.768 0.479 Average χ2 1.181 1.146 1.271 1.141 Number of Potential Outliers 1 5 10 1 AvoidArcModel Coeff. Comparison This unexpected shape shows that the training phase of the model configuration did not include information on the sectors with zero dose rate, leading to the inconsistency between the plans in the model (with the avoidance sectors) and the arc geom- etry (without the avoidance sectors). improvement of 3.6% (0.1 Gy) in the mean heart dose between the original PartArc and the RP_PartArc plans (p = 0.01). The model for the homolateral lung (low-den- sity structure) resulted in similar DVHs, but the mean lung dose of RP_PartArc was higher by 2.8% (0.2 Gy) than PartArc (p = 0.003). However, the dose differences cannot be considered clinically significant. Mean doses to the contralateral structures were higher in RP_PartArc than PartArc (p = 0.01). Looking at Fig. 4, in RP_PartArc the optimizer seems unable to reduce the very low dose region of the contralateral breast, where the DVH esti- mation is consistent with the original PartArc plan. For the contralateral lung (low-density OAR), the DVH esti- mation is generally of lower quality, and the RP_PartArc is more consistent with the estimated objective.i improvement of 3.6% (0.1 Gy) in the mean heart dose between the original PartArc and the RP_PartArc plans (p = 0.01). The model for the homolateral lung (low-den- sity structure) resulted in similar DVHs, but the mean lung dose of RP_PartArc was higher by 2.8% (0.2 Gy) than PartArc (p = 0.003). However, the dose differences cannot be considered clinically significant. Mean doses to the contralateral structures were higher in RP_PartArc than PartArc (p = 0.01). Looking at Fig. 4, in RP_PartArc the optimizer seems unable to reduce the very low dose region of the contralateral breast, where the DVH esti- mation is consistent with the original PartArc plan. For the contralateral lung (low-density OAR), the DVH esti- mation is generally of lower quality, and the RP_PartArc is more consistent with the estimated objective.i A set of new plans (RP_AvoidArc + Avoid) were opti- mized with the AvoidArcModel, setting the same avoid- ance sector in the optimization phase. The estimated DVHs in these cases reflect the presence of the avoid- ance sectors, leading to different estimates than those resulting from the RP_Avoid (where the avoidance sector was not defined). The first row of Fig. 5, likewise Fig. 3, reports the DVHs for the same Patient8 in this last con- dition. Comparison Figure 4 shows the DVHs of a single case (Patient8) for the four OARs of the original plans, the estimated DVHs from the RapidPlan models and the plans generated with the models: in the first row for the PartArc, in the second For the cases in which the avoidance sectors were not applied, the heart DVHs in the original plans, in the estimations and in the RP plans were similar, with an Fogliata et al. Radiation Oncology (2022) 17:200 Page 6 of 11 Fig. 4 DVH of OARs comparison for Patient 8. First Row: PartArc (original plan), estimated DVH from PartArcModel, RP_PartArc (RapidPlan generated plan). Second Row: AvoidArc (original plan with avoidance sectors), estimated DVH from AvoidArcModel, RP_AvoidArc (RapidPlan generated plan, no avoidance sectors selected) Fig. 4 DVH of OARs comparison for Patient 8. First Row: PartArc (original plan), estimated DVH from PartArcModel, RP_PartArc (RapidPlan generated plan). Second Row: AvoidArc (original plan with avoidance sectors), estimated DVH from AvoidArcModel, RP_AvoidArc (RapidPlan generated plan, no avoidance sectors selected) Table 4 Mean doses (in Gy) for the organs at risk doses, uncertainty is reported as one standard deviation In the first column, the plan generating the dose distribution Heart Homolat lung Contralat breast Contralat lung PartArc 2.2 ± 0.4 Gy 5.4 ± 0.5 Gy 1.6 ± 0.5 Gy 1.4 ± 0.5 Gy PartArcModel estimate 2.0 ± 0.4 Gy 4.8 ± 0.5 Gy 1.2 ± 0.4 Gy 1.3 ± 0.4 Gy RP_PartArc 2.2 ± 0.5 Gy 5.5 ± 0.5 Gy 1.8 ± 0.4 Gy 1.4 ± 0.5 Gy AvoidArc 1.9 ± 0.7 Gy 6.2 ± 0.8 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy AvoidArcModel estimate 2.7 ± 0.6 Gy 5.4 ± 0.6 Gy 0.6 ± 0.2 Gy 1.6 ± 0.6 Gy RP_AvoidArc 2.6 ± 0.7 Gy 6.1 ± 0.6 Gy 1.1 ± 0.2 Gy 1.2 ± 0.5 Gy Table 4 Mean doses (in Gy) for the organs at risk doses, uncertainty is reported as one standard deviation AvoidArc plans. In Fig. 4, the estimated DVHs present an unexpected shape (like a two-step DVH, where two parts of the structure volume receive different dose distribu- tions), making the optimizer unable to spare those struc- tures, as confirmed in Table 4. The ButterflyModel resultsh The results of the mean OARs dose of the Butterfly and RP_Butterfly plans are reported in Table 6. In this case, the avoidance sectors have been translated in the arc geometry, giving a consistency between the plans in the training and the model verification phase. RapidPlan gives here the expected results, outperforming, on aver- age, the original plans (p < 0.01 for mean heart and con- tralateral breast doses, p = 0.014 for contralateral lung mean dose), except for the homolateral lung (not signifi- cant, p = 0.06). Discussionh The interest in the dose reduction to the contralateral structures has been widely explored in the last years, aim- ing to minimize the increased risk of secondary cancer Fig. 5 DVH of OARs comparison for Patient 8. First row: AvoidArc (original plan), estimated DVH from AvoidArcModel for a plan with avoidance sectors, RP_AvoidArc + Avoid (RapidPlan generated plan selecting an avoidance sector in the optimization phase). Second row: AvoidArc (original plan), estimated DVH from AvoidArcModel for a plan with avoidance sector, RP_VMAT (RapidPlan generated plan with no avoidance sector) Fig. 5 DVH of OARs comparison for Patient 8. First row: AvoidArc (original plan), estimated DVH from AvoidArcModel for a plan with avoidance sectors, RP_AvoidArc + Avoid (RapidPlan generated plan selecting an avoidance sector in the optimization phase). Comparison Here, the estimated DVHs for the contralateral structures presented the expected shape, consistent with the original AvoidArc plans, and the plans generated with the model reproduce the original ones. These results show the strong link between the model training and the beam geometry of the plans used in the model. In the cases with the avoidance sectors defined (Avoid- Arc), the homolateral lung model can well reproduce the original plan DVH (p = 0.28). At the same time, the mean heart dose is poorly estimated, and the resulting dose in the RP_AvoidArc plan increased by an average of 0.7 Gy (38%) with respect to AvoidArc. The situation of the con- tralateral structures is more complex. Table 4 reports the mean doses of RP_AvoidArc to the contralateral breast and lung, which is about 3 and 5 times higher than Page 7 of 11 Fogliata et al. Radiation Oncology (2022) 17:200 Fogliata et al. Radiation Oncology (2022) 17:200 Finally, a set of plans, called RP_VMAT, with the PartArc geometry (no avoidance sectors defined) was optimized with the optimization objectives obtained for the RP_AvoidArc + Avoid plans. The results of this experiment are reported in the second row of Fig. 5 as DVHs for Patient 8 and in Table 5 as the mean dose to the OARs averaged over the whole patient cohort. The results show that the optimizer can lower the dose rate significantly in the direction toward the contralateral structures, although not down to zero, delivering some low doses to those structures that might be reduced by further decreasing the dose rate at some gantry directions. Discussionh Radiation Oncology (2022) 17:200 induction due to the low dose bath. The classical VMAT (as PartArc) cannot reduce the low dose at the level of the tangential beam setting. Over the last decade, many authors described the VMAT solution with two short arcs mimicking the tangential treatment fields [8–12]. Fogliata et al. [10] and Rossi et al. [9] implemented this technique using avoidance sectors, as described in the present work. The VMAT approach of reducing the en- face entrance of the primary radiation has been proven to be the most beneficial solution, especially concerning the contralateral structure irradiation. Different authors compared this solution to the classical solution of the dual partial arc of about 200–250° each. The ratio of the mean doses to the contralateral breast and lung between the "butterfly" and the classical VMAT with continuous arc can be determined from different published works. From Pasler et al. [13], the ratios were 0.60 and 0.37 for the contralateral breast and lung, respectively. guide the optimization engine to find the best solution (e.g. zeroing the dose rate where needed) to achieve the clinical aims. This study presented some criticalities related to this approach. On the one hand, we analyzed the ability of the RapidPlan models to estimate the DVH of structures receiving dose purely from scattered radiation with the avoidance sectors application. On the other hand, the study evaluated the ability of PO to optimize the plan toward the estimation in the case where the information of the zero dose rate sector is missing. In the present study, as shown in the regression plots of the RapidPlan models, the contralateral structures did not present a clear correlation between the geometric and the dosimetric features, with an angular coefficient close to zero (Figs. 2 and 3). This might be related to the fact that the most significant component of the dose to those organs is the scattering. In such conditions, the dose estimation accuracy can be inferior in the structures far from the target. Spruijt et al. [36], discussing the out- of-field doses in breast irradiation with flattened and FFF beams, pointed out that there is an underestimation of the out-of-field dose calculated with the AAA algorithm (a type “b” algorithm). Discussionh Considering the dose to the con- tralateral structures, the type of calculation algorithm should be taken into account because it could affect both the DVH estimation and the final dose calculation. Similarly, the results from Maier et al. [14] presented ratios of 0.72 and 0.59, 0.56 and 0.39 in the case of FFF beams; Xi et al. [15] reported data leading to ratios of 0.67 and 0.54; Viren et al. [16] of 0.46 and 0.56, Fogliata et al. [10] had ratios of 0.27 and 0.19, for breast and lung, respectively. This approach, reducing the mean dose to the contralateral structures, can also reduce the risk of secondary cancer induction, as proven by Fogliata et al. [7]. Other studies evaluating the same risk using VMAT for breast treatments showed an increased risk with the classical VMAT technique [5, 6], but in those studies, there was no specific attempt in the contralateral dose reduction, as in Paganetti et al. [6], where among the planning goal there was the mean dose to the contralat- eral breast to be less than 7 Gy. i Moreover, for the DVH estimation, a non-negligible part of the contralateral organs is partitioned as an “out- of-field” region, where the means-and-std concept is used instead of the PCA-regression model, and the final DVH estimation is obtained as the relative sum of each region of the partition, weighted by the corresponding relative volume. In addition, the direct reconstruction from the principal component scores obtained from the regression model in these "extreme" conditions of the OAR far from the target could produce a curve that is not monotonically decreasing. This might also contribute to the unexpected estimated DVH shape of the contralateral structures, as shown in the second row of Fig. 4.h Other solutions aiming to mimic the dose distribu- tion of the tangential beam setting did focus on hybrid solutions with various combinations of tangential 3D conformal or IMRT beams with VMAT [20, 21]. These approaches outlined the difficulty of breast planning, which might be enhanced for particular anatomies, where the full VMAT solution improves the quality of the resulting doses [29].h The mean doses of the contralateral structures (and in part of the heart), estimated by the AvoidArcModel, were higher than the corresponding mean doses of the input plans (AvoidArc). Discussionh Second row: AvoidArc (original plan), estimated DVH from AvoidArcModel for a plan with avoidance sector, RP_VMAT (RapidPlan generated plan with no avoidance sector) Table 5 Mean dose (in Gy) to the organs at risk; uncertainty is expressed at one standard deviation In the first column, the plan generating the dose distribution with the avoidance sector defined in the optimization phase before the DVH estimation Heart Homolat lung Contralat breast Contralat lung AvoidArc 1.9 ± 0.7 Gy 6.2 ± 0.8 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy AvoidArcModel estimate* 1.5 ± 0.7 Gy 5.5 ± 0.7 Gy 0.2 ± 0.1 Gy 0.2 ± 0.1 Gy RP_AvoidArc + Avoid 1.8 ± 0.8 Gy 6.4 ± 0.9 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy RP_VMAT 2.0 ± 1.8 Gy 6.3 ± 0.8 Gy 0.9 ± 0.2 Gy 0.7 ± 0.2 Gy Table 6 Mean dose (in Gy) to the organs at risk doses; uncertainty is expressed at one standard deviation In the first column, the plan generating the dose distribution Heart Homolat lung Contralat breast Contralat lung Butterfly 2.1 ± 0.8 Gy 6.2 ± 0.9 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy ButterflyModel estimate 1.7 ± 0.6 Gy 5.3 ± 0.9 Gy 0.2 ± 0.1 Gy 0.1 ± 0.1 Gy RP_Butterfly 1.9 ± 0.8 Gy 6.3 ± 1.0 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy Table 5 Mean dose (in Gy) to the organs at risk; uncertainty is expressed at one standard deviation In the first column, the plan generating the dose distribution with the avoidance sector defined in the optimization phase before the DVH estimation Heart Homolat lung Contralat breast Contralat lung AvoidArc 1.9 ± 0.7 Gy 6.2 ± 0.8 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy AvoidArcModel estimate 1.5 ± 0.7 Gy 5.5 ± 0.7 Gy 0.2 ± 0.1 Gy 0.2 ± 0.1 Gy RP_AvoidArc + Avoid 1.8 ± 0.8 Gy 6.4 ± 0.9 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy RP_VMAT 2.0 ± 1.8 Gy 6.3 ± 0.8 Gy 0.9 ± 0.2 Gy 0.7 ± 0.2 Gy Table 5 Mean dose (in Gy) to the organs at risk; uncertainty is expressed at one standard deviation Table 6 Mean dose (in Gy) to the organs at risk doses; uncertainty is expressed at one standard deviation In the first column, the plan generating the dose distribution Heart Homolat lung Contralat breast Contralat lung Butterfly 2.1 ± 0.8 Gy 6.2 ± 0.9 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy ButterflyModel estimate 1.7 ± 0.6 Gy 5.3 ± 0.9 Gy 0.2 ± 0.1 Gy 0.1 ± 0.1 Gy RP_Butterfly 1.9 ± 0.8 Gy 6.3 ± 1.0 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy Table 6 Mean dose (in Gy) to the organs at risk doses; uncertainty is expressed at one standard deviation In the first column, the plan generating the dose distribution Heart Homolat lung Contralat breast Contralat lung Butterfly 2.1 ± 0.8 Gy 6.2 ± 0.9 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy ButterflyModel estimate 1.7 ± 0.6 Gy 5.3 ± 0.9 Gy 0.2 ± 0.1 Gy 0.1 ± 0.1 Gy RP_Butterfly 1.9 ± 0.8 Gy 6.3 ± 1.0 Gy 0.4 ± 0.1 Gy 0.3 ± 0.1 Gy Page 8 of 11 Fogliata et al. Discussionh This is not the case for the homolateral lung and all the PartArc structures estimated by the Par- tArcModel, where the mean estimated dose is generally lower than the original plans. The inability of the Avoid- ArcModel to estimate mean doses to the contralateral OARs as low as those of the input plans derives from the missing information on the avoidance sector. The control points in that sector are used, during the model genera- tion, to determine the OAR in-field region (where the PCA-regression model is used), while a large portion of The application of KBP planning with RapidPlan to breast treatments has been explored by different groups, particularly in the last few years [30–35], showing inter- est in such an approach. It is clear that, since the best selection of the portion of the arc en-face the breast depends on the patient’s anatomy, there is interest in benefitting from the pre- dictive power of the knowledge-based planning models. The ideal scenario is to define a workflow where, starting from simple geometry (e.g. the classical continuous par- tial VMAT arcs), the model predicts DVH estimations, especially for the contralateral structures, and then can Page 9 of 11 Fogliata et al. Radiation Oncology (2022) 17:200 Fogliata et al. Radiation Oncology (2022) 17:200 free-breathing condition to 0.16 g/cm3 in DIBH. In such a case, the dose calculation algorithm used during the opti- mization iterations is not sufficiently accurate to account for scattering. the OAR volume should instead be managed as an out- of-field region, with the simplified mean-and-std model. The presence of the avoidance sectors in the original plans seems to determine an inconsistency in the data extraction phase. The RP_Butterfly cases instead show consistency between the geometric and the dosimetric information leading to a DVH estimation that is compat- ible with the actual beam arrangement (the sectors with zero dose rate in the AvoidArc plans are sectors with no beam in Butterfly and RP_Butterfly plans).h The Photon Optimizer in Eclipse has a tool, other than the avoidance sector, called avoidance structure. Those structures where the tool is activated will be shielded by closed MLC when the structure is before the target in the beam’s-eye-view or whenever its projection is in the beam’s-eye-view (as different options). Discussionh However, due to MLC limitations, there could be some unexpected aper- tures or small beams irradiating the selected contralateral structures, and the transmitted dose increases the struc- ture dose. For that reason, in the presented study, the used avoidance tool was in terms of the sector (with no radiation in a defined gantry rotation interval) instead of structure (with MLC closing toward the specified struc- tures). However, it could also be of interest to evaluate a model generated by plans using that avoidance tool.l ll The case of RP_VMAT, where the avoidance sector was not included in the optimization while the optimi- zation objectives did, is particularly interesting. Here the contralateral structures were better spared than the RP_ AvoidArc plans, although not as much as in RP_Avoid- Arc + Avoid. The reasons for these differences could be a too low priority generated by the model, combined with the fact that PO does not reduce the dose rate below 0.2 MU/°, limiting the possibility of decreasing the contralat- eral doses. In this work, no skin flash was applied, although breast VMAT plans in the clinical practice have to include it by adding a virtual bolus (or body expansion) and optimiz- ing on a target expanded inside the bolus to take into account the missing CTV to PTV margin in the skin direction. The rationale for not applying this important step was to evaluate the optimizer’s ability to reduce the dose rate without confounding factors arising from the skin flash adoption. The clinical need for the skin flash in VMAT planning remains clear. The RapidPlan mod- els used in clinical practice should be generated starting from plans with virtual bolus and target expansion. The beam geometry influences the DVH estimation. A proof also comes from the mean doses estimated for the contralateral structures (where this fact is more pro- nounced) by the same AvoidArcModel in the two con- ditions of the avoidance sector defined or not in the optimization phase for the same initial beam geometry. In the first case, with the avoidance sector, the mean esti- mated doses to contralateral breast and lung were 0.4 and 0.3 Gy, respectively. Values to compare with 0.6 and 1.6 Gy, respectively, of the estimations in the case of no avoidance sector defined. Discussionh The limited number of patients used in this study was sufficient for the scope of the work, which was not a clini- cal use of the presented models. It is important to men- tion that a model configured for clinical purposes should better include a larger number of patients adequately selected. i In summary, the model is able to produce good and consistent DVH estimations relative to the input data only in the case where the beam geometry information is correctly extracted and used in the model training or if the planner manually adjusts the beam geometry (avoid- ance sector), but this confirms the need of such informa- tion to the DVH estimator. Regarding the homolateral structures, once the proper geometrical information is assigned, as in the PartArc or Butterfly cases, the plans generated with RapidPlan out- perform the original plans only for the structure with soft tissue density (heart), while this is not the case for the low-density organ (lung), as shown for example in Table 4. This reduced performance in low-density struc- tures is not generated by the RapidPlan process (the DVH estimation is, in fact, lower than the input plans), while it should be sought inside the optimization. A possible reason might be related to the fact that the irradiation of the lung presents an important scatter component. This is mainly in DIBH patients, as in this work, where the lung density is lower, as shown in [37], where the mean mass density is reported to reduce from 0.27 g/cm3 in Received: 31 May 2022 Accepted: 30 November 2022 Received: 31 May 2022 Accepted: 30 November 2022 17. Karpf D, Sakka M, Metzger M, Grabenbauer GG. Left breast irradiation with tangential intensity modulated radiotherapy (t-IMRT) versus tan- gential volumetric modulated arc therapy (t-VMAT): trade-offs between secondary cancer induction risk and optimal target coverage. Radiat Oncol. 2019;14(1):156. https://doi.org/10.1186/s13014-019-1363-4. Conclusion b In breast cancer treatments, the avoidance sectors can be used to limit the en-face beam entrance. In plans selected to train a RapidPlan model, this fact gives inconsistency between the dosimetric and the geometric data extracted for the model training process. The effect is a lower qual- ity of the RapidPlan model.h The Photon Optimizer properly attempts to achieve the DVHs estimated by the RapidPlan models; however, it cannot reduce the dose rate below a threshold, thus limit- ing the possibility of reducing the dose to the contralat- eral structures as it would be done using the avoidance sectors. Page 10 of 11 Fogliata et al. Radiation Oncology (2022) 17:200 Fogliata et al. 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Radiother Oncol. 2007;85:346–54. https://doi.org/10.1016/j.radonc.2007.10.006. • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: Publisher’s Note S i N t i Flattening filter free vs flattened beams for breast irradiation. Int J Radiat Oncol Biol Phys. 2013;85(2):506–13. https://doi.org/10.1016/j. ijrobp.2012.03.040. 37. Fogliata A, Nicolini G, Vanetti E, Clivio A, Winkler P, Cozzi L. The impact of photon dose calculation algorithms on expected dose distributions in
https://openalex.org/W4246503777	https://www.qeios.com/read/13IIZH/pdf	English	null	Horehound Oil	Definitions	2,020	cc-by	58	Qeios · Definition, February 2, 2020 Open Peer Review on Qeios Open Peer Review on Qeios Horehound Oil National Cancer Institute Qeios ID: 13IIZH · https://doi.org/10.32388/13IIZH Source National Cancer Institute. Horehound Oil. NCI Thesaurus. Code C107316. The essential oil of Marrubium vulgare. Horehound oil is used typically in expectorants and cough suppressants. Qeios ID: 13IIZH · https://doi.org/10.32388/13IIZH 1/1
https://openalex.org/W2781979037	https://europepmc.org/articles/pmc5757235?pdf=render	English	null	Changes in smoking prevalence and cessation support, and factors associated with successful smoking cessation in Swedish patients with asthma and COPD	European clinical respiratory journal	2,018	cc-by	5,947	ABSTRACT ARTICLE HISTORY Received 19 July 2017 Accepted 16 December 2017 KEYWORDS Smoking prevalence; smoking cessation support; primary care; secondary care; cardiovascular risk factors; high educational level ABSTRACT Introduction: Our aim was to investigate changes in smoking prevalence, smoking cessation support and factors associated with successful smoking cessation in patients with asthma and COPD. Methods: Questionnaires about available smoking cessation resources were completed by 54 primary health-care centers and 14 hospitals in central Sweden in 2005 and 2012. Patient data were collected using record reviews and patients questionnaires for two cohorts of randomly selected asthma and COPD patients in 2005 (n = 2306; with a follow up in 2012), and in 2014/ 2015 (n = 2620). Smoking prevalence, available individual and group smoking cessation support, and factors associated with successful smoking cessation were explored. g p Results: Smoking prevalence decreased from 11% to 6% (p < 0.0001) in patients with asthma but was almost unchanged in patients with COPD (28 to 26%, p = 0.37). Smoking cessation support increased from 53% to 74% (p = 0.01). A high cardiovascular risk factor level, including diabetes mellitus and hypertension was associated with improved smoking cessation in patients with asthma (OR (95% CI) 3.87 (1.04–14.4), p = 0.04). A higher magnitude success was observed in men with asthma (OR (95% CI) 27.9 (1.73–449), p = 0.02). More highly educated women with asthma had successful greater smoking cessation (4.76 (1.22–18.7), p = 0.04). No significant associations were found in COPD. Conclusions: The smoking prevalence in patients with asthma but not in COPD has almost halved in Sweden during a 7-year period. The availability of smoking cessation support has increased. Suggested factors related to successful smoking cessation are higher level of education in women with asthma and cardiovascular risk factors in men and women with asthma. asthma and COPD in 2016, 40% of patients with COPD were smokers. The proportion of smokers in patients diagnosed with asthma was 12% [8]. CONTACT Josefin Sundh josefin.sundh@oru.se © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. EUROPEAN CLINICAL RESPIRATORY JOURNAL, 2018 VOL. 5, 1421389 https://doi.org/10.1080/20018525.2017.1421389 EUROPEAN CLINICAL RESPIRATORY JOURNAL, 2018 VOL. 5, 1421389 https://doi.org/10.1080/20018525.2017.1421389 Changes in smoking prevalence and cessation support, and factors associated with successful smoking cessation in Swedish patients with asthma and COPD Marcus Stegberga, Mikael Hasselgren a, Scott Montgomeryb,c,d, Karin Lissperse, Björn Ställberg e, Christer Jansonf and Josefin Sundh g Marcus Stegberga, Mikael Hasselgren a, Scott Montgomeryb,c,d, Karin Lissperse, Björn Ställberg e, Christer Jansonf and Josefin Sundh g n a, Scott Montgomeryb,c,d, Karin Lissperse, Björn Ställberg e, aSchool of Medical Sciences, Örebro University, Örebro, Sweden; bClinical Epidemiology and Biostatistics, Örebro University, Örebro, Sweden; cClinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; dDepartment of Epidemiology and Public Health, University College, London, UK; eDepartment of Public Health and Caring Sciences, Family Medicine and Preventive medicine, Uppsala University, Uppsala, Sweden; fDepartment of Medical Sciences, Respiratory, Allergy & Sleep Research, Uppsala University, Uppsala, Sweden; gDepartment of Respiratory Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden ARTICLE HISTORY Received 19 July 2017 Accepted 16 December 2017 by Informa UK Limited, trading as Taylor & Francis Group. ributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted n in any medium, provided the original work is properly cited. ARTICLE HISTORY Received 19 July 2017 Accepted 16 December 2017 KEYWORDS Smoking prevalence; smoking cessation support; primary care; secondary care; cardiovascular risk factors; high educational level Introduction Tobacco smoking is an important risk factor for several diseases, such as chronic obstructive pulmonary disease (COPD), lung cancer, other forms of malignancies and cardiovascular diseases [1]. Tobacco smoking is also associated with a worse prognosis in asthma, as well as in COPD [2,3]. There are several interventions used for smoking cessation, including pharmacological therapy and counseling. Pharmacological options are nicotine replacement therapy (NRT), varenicline and bupro- pion, and counseling includes motivational interview- ing and behavioral support performed as individual or group therapy. In a recent meta-analysis the combina- tion of counseling and pharmacological therapy was most successful for smoking cessation compared with a minimal intervention or usual care [9]. According to the international recommendations Global initiative on Obstructive Lung Disease (GOLD) and Global Initiative for Asthma (GINA), smoking cessation is of The mean prevalence of tobacco smoking in adults in Europe was estimated as 28% in 2015 [4]. In Sweden, a decreasing trend has been seen in both men and women over recent decades, and was esti- mated as 9%, in 2016 [5]. The custom of using moist snuff (‘snus’) in Sweden has been suggested as one of the explanations for the lower smoking prevalence [6,7]. According to the Swedish national register of CONTACT Josefin Sundh M. STEGBERG ET AL. 2 support in terms of individual support, group support or both) and access to an asthma/COPD nurse at the participating centers were reported in the resources questionnaires from 2005 and 2012. For analyses of factors associated with smoking cessation between 2005 and the follow-up in 2012, information on sex, age, smoking habits, height, weight, educational level, exacerbations defined as number of emergency visits due to the obstructive disease in the last 6 months, and self-rated severity level of their disease was obtained from the 2005 patient questionnaire, and information about current smoking habits and received smoking cessation support from the follow-up questionnaire in 2012. In addition, data on the comorbid conditions hypertension, heart disease, diabetes and depression at baseline were collected in 2005 by review of records for the period 2000–2003. great importance. Subsequently, smoking cessation has acquired the highest priority level in the Swedish National Board of Health and Welfare guidelines for asthma and COPD care [10]. Factors associated with successful smoking cessation in the general population are older age, male sex and higher educational level [11,12]. Statistical analysis Analyses were performed using SPSS software version 23 (SPSS Inc., Chicago). Cross-tabulation and Pearson’s chi- square test were used to compare the smoking prevalence in the 2005 and 2014/15 cohorts, with stratification for sex and obstructive disease. McNemar’s test was used to investigate differences in available tobacco prevention support resources in the participating centers in 2005 compared with 2012. Logistic regression analysis with no daily smoking in 2012 as the dependent variable was performed among smokers from the 2005 population Data collection Patient data were collected from the PRAXIS study, an observational study involving seven county councils in central Sweden [16–26]. In the first PRAXIS-cohort, each county council was represented by the department of respiratory medicine in their central hospital, the department of internal medicine from one randomly selected district hospital and eight randomly selected primary health care centers (PHCCs). From the parti- cipating centers, a total of 3223 patients above 18 years of age with a doctor’s diagnosis of COPD (ICD-10, J44) or asthma (ICD-10, J45) were randomly selected. The first data collection was performed in 2005, using patient questionnaires and record reviews as well as resources questionnaires to the heads of the centers about available resources in asthma and COPD care. In 2012, follow-up questionnaires were sent to the patients from 2005 that were still alive. In 2012 new resources questionnaires were sent to the same centers, and new second cohorts were randomly selected in 2014 (COPD) and 2015 (asthma) from the same cen- ters as in 2005. The data collection is summarized in the flow chart in Figure 1. Introduction In COPD, a lower frequency of cessation has been found in patients who are younger, or have lower income, milder disease, high nicotine dependence and low self-efficacy [13–15]. However, there are still limited data on factors asso- ciated with successful smoking cessation in patients with asthma and COPD. The aim of this study was therefore to investigate whether the prevalence of smoking in asthma and COPD patients and availability of smoking cessation support have changed over a 10- year period in Sweden, and to identify factors asso- ciated with successful smoking cessation in patients with asthma and COPD. Smoking history was categorized as current daily smok- ing or not. Body mass index was calculated as weight (kg)/ height (m)2. Obesity was defined as body mass index (BMI) ≥30, overweight as BMI <30 and ≥25, normal weight as BMI <25 and ≥20 and underweight as BMI <20. The dichotomous educational variable identified the most highly educated group as 2 years or more beyond the Swedish compulsory schooling of 9 years. Exacerbations were grouped as 0, 1 or ≥2 during the previous 6 months. Self-estimated severity of disease included seven steps from mild to very severe disease. Heart disease was defined as having the diagnoses of ischemic heart disease or heart failure, and these, along with type 1 or type 2 diabetes were identified from records for the period 2000–2003. Depression was defined as having a diagnosis of depression in combination with antidepressant drug treatment during the period 2000–2003. A high cardiovascular risk factor level was defined as presence of both hypertension and diabetes diagnoses. Because of differences in the age dis- tributions between patients with asthma or COPD, patients with asthma were categorized as ≤55, 56–65 and >65 years and patients with COPD were categorized as ≤65, 66–70 and >70 years. General smoking prevalence The prevalence of smoking in patients diagnosed with asthma decreased from 11% to 6% (p = <0.0001) between 2005 and 2015, whereas no statistically sig- nificant change was found in patients with COPD (28–26%, p = 0.37) between 2005 and 2014. In ana- lyses with stratification for sex and obstructive dis- ease, a statistically significant decrease in smoking prevalence was found in the youngest women diag- nosed with asthma, and a statistically significant increase was shown in the youngest men diagnosed with COPD (Figure 2). Patient characteristics Patient characteristics are shown in Table 1. In both cohorts, women were more common, and patients with asthma were generally younger and less often current daily smokers than the COPD patients. Results (n = 436), stratified by obstructive disease and sex. The independent variables were age (four groups), level of education, number of exacerbations (three groups), BMI (four categories), heart disease, depression, hypertension, diabetes, the variable for a high cardiovascular risk factor level, any smoking cessation support, access to asthma/ COPD nurse and level of healthcare. Multivariable logis- tic regression analysis included statistically significant variables from the univariate analysis. Interaction analysis used interaction terms for sex with each relevant variable with adjustment for the main effects and the potential cofounding factors. An attrition analysis using the chi square test compared patients included in the regression analyses with patients smoking in 2005 but excluded due to missing data in 2012. A p-value below 0.05 was con- sidered statistically significant. (n = 436), stratified by obstructive disease and sex. The independent variables were age (four groups), level of education, number of exacerbations (three groups), BMI (four categories), heart disease, depression, hypertension, diabetes, the variable for a high cardiovascular risk factor level, any smoking cessation support, access to asthma/ COPD nurse and level of healthcare. Multivariable logis- tic regression analysis included statistically significant variables from the univariate analysis. Interaction analysis used interaction terms for sex with each relevant variable with adjustment for the main effects and the potential cofounding factors. An attrition analysis using the chi square test compared patients included in the regression analyses with patients smoking in 2005 but excluded due to missing data in 2012. A p-value below 0.05 was con- sidered statistically significant. Patient characteristics and measures For comparison between the 2005 and 2014/15 cohorts, the patient questionnaires provided information on sex, age and smoking habits. Available smoking cessation resources (pharmacological treatment and behavioral 3 EUROPEAN CLINICAL RESPIRATORY JOURNA 3 Figure 1. Flow chart. Flow chart of cohorts and data collection for the three major research questions of the study. PRAXIS I is referring to the first cohort from 2005, PRAXIS IB to the follow-up in 2012 of the first cohort, and PRAXIS II to the second cohort from 2014/2015. PHCCs = primary health care centers. Figure 1. Flow chart. g Flow chart of cohorts and data collection for the three major research questions of the study. PRAXIS I is referring to the first cohort from 2005, PRAXIS IB to the follow-up in 2012 of the first cohort, and PRAXIS II to the second cohort from 2014/2015. PHCCs = primary health care centers. g Flow chart of cohorts and data collection for the three major research questions of the study. PRAXIS I is referring to the first cohort from 2005, PRAXIS IB to the follow-up in 2012 of the first cohort, and PRAXIS II to the second cohort from 2014/2015. PHCCs = primary health care centers. Flow chart of cohorts and data collection for the three major research questions of the study. PRAXIS I is referring PRAXIS IB to the follow-up in 2012 of the first cohort, and PRAXIS II to the second cohort from 2014/2015. PHCCs Ethical considerations The study was approved by the Regional Ethical Review Board in Uppsala (Dnr:s 2004:M-445 and 2010/090). Written informed consent was given by all patients. M. STEGBERG ET AL. Table 1. Patient characteristics. Table 1. Patient characteristics. Asthma COPD Characteristics PRAXIS I N = 1195 PRAXIS II N = 1291 Characteristics PRAXIS I N = 1089 PRAXIS II 1329 Sex n (%) Sex, n (%) Male 475 (40) 498 (39) Male 451 (41) 584 (44) Female 720 (60) 793 (61) Female 638 (59) 745 (56) Age, n (%) Age, n (%) ≤55 685 (57) 605 (47) ≤65 549 (50) 416 (31) 56–65 294 (25) 279 (22) 66–70 281 (26) 408 (31) >65 216 (18) 407 (31) >70 259 (24) 505 (38) Age mean (SD) 50 (15) 54 (16) Age mean (SD) 64 (8) 61 (14) Smokers, n (%) 125 (11) 74 (6) Smokers, n (%) 308 (28) 345 (26) Data presented as numbers and column percentages. PRAXIS I is referring to the first cohort in 2005, and PRAXIS II to the second cohort in 2014/2015. The alternative age intervals refer to the different age intervals in the asthma and respectively COPD cohorts. COPD: chronic obstructive pulmonary disease; SD: standard deviations; Smokers: current daily smokers. Data presented as numbers and column percentages. PRAXIS I is referring to the first cohort in 2005, and PRAXIS II to the second cohort in 2014/2015. The alternative age intervals refer to the different age intervals in the asthma and respectively COPD cohorts. COPD: chronic obstructive pulmonary disease; SD: standard deviations; Smokers: current daily smokers. Figure 2. Smoking prevalence stratified by sex and obstructive disease. Prevalence of smoking in the two cohorts 2005 and 2014/15 stratified by sex and obstructive disease with 95% confidence interval. COPD: chronic obstructive pulmonary disease. Figure 2. Smoking prevalence stratified by sex and obstructive disease. Figure 2. Smoking prevalence stratified by sex and obstructive disease. Prevalence of smoking in the two cohorts 2005 and 2014/15 stratified by sex and obstructive disease with 95% confidence interval. COPD: chronic obstructive pulmonary disease. Figure 2. Smoking prevalence stratified by sex and obstructive disease. Prevalence of smoking in the two cohorts 2005 and 2014/15 stratified by sex and obstructive disease with 95% confidence interval. COPD: chronic obstructive pulmonary disease. Prevalence of smoking in the two cohorts 2005 and 2014/15 stratified by sex and obstructive disease with 95% confidence interval. COPD: chronic obstructive pulmonary disease. General smoking prevalence The adverse effects of smoking in asthma and COPD are well known. Bronchial hyper responsiveness is a risk factor for developing COPD [27], and smoking cessation is of substantial importance in patients with asthma. In COPD, the disease progression in smokers compared with never smokers and ex-smokers is well established, and implies a benefit from stopping smoking regardless of the degree of lung function limitation [28]. The overall smoking prevalence in Sweden decreased from 14% to 11% between 2006 and 2012 [5]. In the seven county councils in Sweden represented in our study, the mean prevalence was between 12% and 16% over the 3 year period between 2004 and 2007 and from 9% to 12% over the period 2011–2014 [5]. Thus, current smoking prevalence is generally lower in patients with Change of smoking habits and factors associated with quitting smoking The availability of smoking cessation support at the participating centers increased between 2005 and 2012 in the PHCCs, whereas no significant change was found in secondary care. However, in both pri- mary and secondary care, the proportion of centers with individual therapy increased over time, and access to this type of support was more common than access to both individual and group support in 2012. Having only group therapy support was uncommon in primary care, and did not exist at all in hospitals in 2012 (Figure 3). In total, 210 patients that were current daily smokers in 2005 were followed up in 2012. Of these, 112 (53%) remained smokers and 98 (47%) ceased smoking between 2005 and 2012. Most of the patients (62%) who ceased smoking between 2005 and 2012 used pharmacological therapy of some type. Only 27% ceased smoking with individual or group support from the health-care system. NRT was used by 29% and 22% had been prescribed bupropion or varenicline. Some 8% used both nicotine replacement therapy and bupropion or varenicline. In EUROPEAN CLINICAL RESPIRATORY JOURNAL Figure 3. Smoking support. Available smoking cessation support in primary health care and in secondary care, 2005 vs. 2012. Figure 3. Smoking support. Available smoking cessation support in primary health care and in secondary care, 2005 vs. 2012. has increased in primary care between 2005 and 2012. A high cardiovascular risk factor level was associated with greater chance of smoking cessation in asthma. addition, 6% replaced smoking by using snuff. There were no statistically significant differences in using phar- macological smoking cessation support between patients with asthma and COPD. In multivariable analysis, a high cardiovascular risk factor level was associated with successful smoking cessa- tion in with asthma (OR (95% CI) 3.87 (1.04–14.4), p = 0.04). No significant associations were found in COPD. Results from multivariate logistic regression ana- lysis with stratification for both sex and obstructive dis- ease are shown in Table 2. The attrition analysis showed that among the patients who smoked in 2005, statistically significantly more with heart disease and aged over 65 years were lost to follow-up in 2012 (data not shown). Change of smoking habits and factors associated with smoking cessation Previous studies have explored factors associated with successful smoking cessation attempts in the general population [11,12], and a study of more than 3000 hospital based patients with COPD has shown that older age, higher income and more severe disease are associated with a higher chance of stopping smoking. However, to our knowledge there are still limited data on factors associated with smoking cessation in patients with asthma, and in patients with obstructive disease managed in primary care. Our results show an association between having combined hypertension and diabetes mellitus with successful smoking cessation in asthma. There were also clear indications that hyper- tension and diabetes alone were factors of importance for smoking cessations, although most often not statis- tically significant due to small numbers. This may indicate the importance of improving the quality of discussion with patients about cardiovascular risk fac- tors and the benefits of giving up smoking. We spec- ulate that these patients have health care visits more regularly which may give more opportunities for brief intervention concerning smoking and thus influence their motivation to cease smoking. We speculate that the decreased smoking prevalence in asthma but not in COPD could be because patients with COPD have a longer smoking history and a more severe nicotine dependence and so are less likely to be successful in smoking cessation. The current smokers in the baseline COPD cohort already represent a selected sample of patients who haven’t managed to stop smoking at the time of their diagnosis. Previous studies have shown that a lower nicotine dependence and high self-efficacy are associated with higher chance of smoking cessation [14,15]. The decrease in smoking prevalence in our study was greatest among women below age 55 years diag- nosed with asthma, which might be an effect of the general decline in smoking prevalence among younger women in Sweden [5]. The increased smoking preva- lence among men below age 65 years with COPD is interesting because it is not consistent with previous studies where patients with COPD were more likely to cease smoking compared with smokers in the general population [30,31]. The general prevalence of mild COPD at younger ages may have increased during the last decade due to higher awareness of the need to perform spirometry, and in this group of patients the rate of smoking cessation is lower [32]. Discussion The main findings of this multicenter observational study were that the prevalence of smoking decreased in asthma but was unchanged in COPD patients during the last decade. The availability of smoking cessation support Table 2. Factors associated with successful smoking cessation. Men with asthma Women with asthma Variables Adjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value P for interaction High cardiovascular risk factor level 27.9 (1.73–450) 0.02 2.47 (0.48–12.8) 0.28 0.07 Higher level of education 0.33 (0.02–4.56) 0.41 4.76 (1.22–18.7) 0.03 0.04 High cardiovascular risk factor level 5.26 (0.94–29.6) 0.060 1.23 (0.49–3.08) 0.65 0.14 Higher level of education 0.49 (0.12–2.01) 0.32 0.78 (0.33–1.87) 0.58 0.53 Multivariable analysis stratified for sex and obstructive disease. The multivariable models included the explanation variables high cardiovascular risk factor level and higher educational level, as they were statistically significant in univariable analysis. OR: Odds Ratio; COPD: chronic obstructive pulmonary disease. Table 2. Factors associated with successful smoking cessation. Multivariable analysis stratified for sex and obstructive disease. The multivariable models included the explanation variables high cardiovascular risk factor level and higher educational level, as they were statistically significant in univariable analysis. OR: Odds Ratio; COPD: chronic obstructive pulmonary disease. M. STEGBERG ET AL. 6 asthma and higher in patients with COPD compared with the general population. for both asthma and COPD and for methods of pre- venting disease from the Swedish National Board of Health and Welfare, resulting in a more developed organization for smoking support in primary care. Our study shows a lower tobacco smoking preva- lence in patients with asthma and COPD compared with the report from the Swedish national register of asthma and COPD [8]. This could be because that the register is rather new and does not yet have sufficient coverage for all severity stages, and smoking patients may be prioritized for visits and thus for registrations. In addition, patients who ceased smoking during the previous 6 months are registered as current smokers. In our study, the random selection of patients corre- sponds to the distribution of severity stages of COPD in a large population-based Swedish study [29], and the patient questionnaires report the current smoking status. Change of smoking habits and factors associated with smoking cessation The fact that no statistically significant associations were found for cardiovascular risk factors with smok- ing cessation in patients with COPD is of interest. However, the majority of the patients lost between 2005 and 2012 had COPD and most likely died from heart disease, and thus some patients with COPD who ceased smoking due to a high cardiovascular risk factor level may have been excluded. In addition, patients with asthma are generally younger, with lower amount of pack years and may be more receptive for the mes- sage about cardiovascular risk factors. In women with asthma, a higher level of education was associated with greater smoking cessation, consis- tent with the results from previous studies of smokers in the general population [11]. This was not seen in men with asthma, possible due to lower numbers. The association with higher level education was not found in women or men with COPD or in men with asthma. Interaction analysis showed statistically significant effect modification by female sex on the association of higher level of education and smoking cessation in asthma. Availability of resources In our study the majority of the centers in primary care but not in secondary care offered smoking cessation support. Both individual and group counseling have been shown to improve smoking cessation success [33]. Interestingly, the proportion of centers offering only individual therapy has increased in both primary and secondary care. The overall availability of smoking cessation support increased in primary care, and this may be due to implementation of national guidelines 7 EUROPEAN CLINICAL RESPIRATORY JOURNAL 7 Notes on contributor Marcus Stegberg has a medical degree from the School of Medical Sciences, Örebro University, Örebro, Sweden. He has performed the study as a mandatory scientific project during his education. Mikael Hasselgren is a general practitioner, PhD and senior lecturer at the School of Medical Sciences Örebro University, Örebro, Sweden. He is a member of the Swedish and European Respiratory Societies. His research has mainly focused on observational studies of asthma and allergy in primary care. Acknowledgements The authors thank Ulrike Spetz-Nyström and Eva Manell for reviewing the patient records, and all participating centers. Conclusion The general prevalence of smoking in patients with asthma but not in COPD has decreased over the last decade and resources for smoking support increased between 2005 and 2012. Overall and specifically in men with asthma, smoking cessation seems to be more common in patients with a higher cardiovas- cular risk factor level with diabetes and hypertension. In women with asthma smoking cessation is more common among those with a higher level of education. A potentially major limitation is that although the ori- ginal cohort included more than 2000 patients, a rather small proportion of the population were smokers. Some of the statistically significant results from the regression ana- lysis had wide confidence intervals, due to low power. Thus, there may be more factors associated with smoking cessation, which we were unable to detect in this study due to a small number of patients, and due to missing data for smoking support. Between the 2005 cohort and the 2012 follow up there was a loss of patients. This was expected since the patients, mostly those diagnosed with COPD, have a higher mortality rate and more likely to die during follow up. Patients with more severe COPD are more likely to cease smoking because of their symptoms and are also more likely to die from their disease. In addition, most of the lost patients had heart disease which is the most common cause of death in COPD. Comorbid conditions may also have developed during the follow-up, and thus not included as independent factors at baseline. We find it interesting that a high cardiovascular risk factor level although not heart disease was associated with successful smoking cessation in COPD, and speculate that this may be because people with cardiovascular risk factors but no existing heart disease may be more motivated to stop smoking. Another limitation is that we have no data on the patients’ motivation or self-efficacy for smoking cessa- tion. Finally, patients in this study were included based on a doctor’s diagnosis of COPD or asthma, which may be incorrectly recorded and thereby influence the results in our study. Geolocation information The study was performed in central Sweden. Disclosure statement No potential conflict of interest was reported by the authors. Strengths and limitations Finally, an important implication is that better smoking cessation support is needed, especially in hospitals. The major strengths of our study include that it is a multicenter study of both primary and secondary care including both data on patient characteristics and on available resources, and with analysis of prevalence and factors associated with successful smoking cessation. The study was conducted using real world data ensur- ing a high external validity and generalizability. Funding The authors did not receive any grants for this specific study. M. STEGBERG ET AL. 8 [6] Rodu B, Jansson JH, Eliasson M. The low prevalence of smoking in the Northern Sweden MONICA study, 2009. Scand J Public Health. 2013;41:808–811. Björn Ställberg is a general practitioner and associate pro- fessor at the Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden. He is a member of the Swedish and European Respiratory Societies. His research has focused on asthma and COPD. [7] Ramstrom L, Borland R, Wikmans T. Patterns of smok- ing and snus use in sweden: implications for public health. Int J Environ Res Public Health. 2016Nov 9;13 (11). [8] The Swedish National Register of COPD. Annual report 2016. [Cited 2017 Nov 11]. Available from: http://www. registercentrum.se/sites/default/files/dokument/luftvags registret_arsrapport_2016.pdf Karin Lisspers is a general practitioner and associate profes- sor at the Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden. She is a member of the European Respiratory Society. Her research has focused on asthma and COPD. g pp p [9] Stead LF, Koilpillai P, Fanshawe TR, et al. Combined phar- macotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;3:Cd008286. y [10] The Swedish National Board of Health and Welfare. Vård vid astma och KOL 2015. [Cited 2017 Nov 11]. Available from: http://www.socialstyrelsen.se/Lists/ Artikelkatalog/Attachments/19949/2015-11-3.pdf Christer Janson is a pulmonologist and professor in Respiratory Medicine at the Department of Medical Sciences for Respiratory; Allergy and Sleep Research, Uppsala University, Uppsala, Sweden. He is a member of the Swedish and European Respiratory Societies. His research has focused on asthma and COPD. g p [11] Lee CW, Kahende J. Factors associated with successful smoking cessation in the USA, 2000. Am J Public Health. 2007;97:1503–1509. [12] Yang JJ, Song M, Yoon HS, et al. What are the major determinants in the success of smoking cessation: results from the health examinees study. PloS One. 2015;10:e0143303. Josefin Sundh is a pulmonologist and PhD at the Department of Respiratory Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden. She is a member of the Swedish and European Respiratory Societies. Her research has mainly focused on observational studies in COPD, but also includes studies of asthma, dyspnea and hypoxia. She has been super- visor to Marcus Stegberg in the present study. [13] Tottenborg SS, Thomsen RW, Johnsen SP, et al. Determinants of smoking cessation in patients with COPD treated in the outpatient setting. Chest. 2016;150:554–562. ORCID Mikael Hasselgren http://orcid.org/0000-0003-4241-7851 Björn Ställberg http://orcid.org/0000-0001-8497-7326 Josefin Sundh http://orcid.org/0000-0003-1926-8464 [15] van Eerd EA, Van Rossem CR, Spigt MG, et al. Do we need tailored smoking cessation interventions for smo- kers with COPD? A comparative study of smokers with and without COPD regarding factors associated with tobacco smoking. Respiration. 2015;90:211–219. M. STEGBERG ET AL. [14] Lindberg A, Niska B, Stridsman C, et al. Low nicotine dependence and high self-efficacy can predict smoking cessation independent of the presence of chronic obstructive pulmonary disease: a three year follow up of a population-based study. Tob Induc Dis. 2015;13:27. Clinical implications and need of further research The results in this study are of importance to patients who smoke and are diagnosed with asthma or COPD and managed in either primary health care or hospitals. We also believe it is of substantial benefit to clarify to patients the increased risk of tobacco use when other cardiovascular risk factors are present. Future studies might investigate the importance of frequent health care visits in this context. A comparison of the impact of different types of smoking cessation support would also be of great interest, and should be performed in a study with more complete data on these factors. Scott Montgomery is a clinical epidemiologist at Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University in Sweden; also affiliated to the Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet; and the Department of Epidemiology and Public Health, University College London, where he is honorary professor. Research interests include etiology and outcomes in diseases with an immune-mediated/inflammatory compo- nent. M. STEGBERG ET AL. References g [16] Spruit MA, Polkey MI, Celli B, et al. Predicting outcomes from 6-minute walk distance in chronic obstructive pul- monary disease. J Am Med Dir Assoc. 2012;13:291–297. [1] Onor IO, Stirling DL, Williams SR, et al. Clinical effects of cigarette smoking: epidemiologic impact and review of pharmacotherapy options. Int J Environ Res Public Health. 2017 Sept 28;14(10). [17] Arne M, Lisspers K, Stallberg B, et al. How often is diagnosis of COPD confirmed with spirometry? Respir Med. 2010;104:550–556. [2] Colak Y, Afzal S, Nordestgaard BG, et al. Characteristics and prognosis of never-smokers and smokers with asthma in the copenhagen general population study. A prospective cohort study. Am J Respir Crit Care Med. 2015;192:172–181. [18] Sundh J, Stallberg B, Lisspers K, et al. Co-morbidity, body mass index and quality of life in COPD using the Clinical COPD Questionnaire. Copd. 2011;8:173–181. [19] Sundh J, Janson C, Lisspers K, et al. The Dyspnoea, Obstruction, Smoking, Exacerbation (DOSE) index is predictive of mortality in COPD. Prim Care Respir J. 2012;21:295–301. [3] Anthonisen NR, Connett JE, Murray RP. Smoking and lung function of lung health study participants after 11 years. Am J Respir Crit Care Med. 2002;166:675–679. [20] Sundh J, Janson C, Lisspers K, et al. Clinical COPD Questionnaire score (CCQ) and mortality. Int J Chron Obstruct Pulmon Dis. 2012;7:833–842. y p [4] World Health Organization E. 2017. [Cited 2017 Nov 11]. Available from: http://www.euro.who.int/en/health- topics/disease-prevention/tobacco/data-and-statistics. [21] Lisspers K, Stallberg B, Janson C, et al. Sex-differences in quality of life and asthma control in Swedish asthma patients. J Asthma. 2013. p p [5] The Public Health Agency of Sweden 2017. [Cited 2017 Nov 11]. Available from: https://www.folkhalsomyndigh eten.se/folkhalsorapportering-statistik/statistikdataba ser-och-visualisering/nationella-folkhalsoenkaten/lev nadsvanor/tobaksvanor/ [22] Sundh J, Osterlund Efraimsson E, Janson C, et al. Management of COPD exacerbations in primary care: 9 9 EUROPEAN CLINICAL RESPIRATORY JOURNAL 9 a clinical cohort study. Prim Care Respir J. 2013;22:393–399. an analysis of the Framingham offspring cohort. Am J Respir Crit Care Med. 2009;180:3–10. p [29] Lundback B, Eriksson B, Lindberg A, et al. A 20-year follow-up of a population study-based COPD cohort-report from the obstructive lung dis- ease in Northern Sweden studies. Copd. 2009;6:263–271. [23] Kampe M, Lisspers K, Stallberg B, et al. Determinants of uncontrolled asthma in a Swedish asthma population: cross- sectional observational study. Eur Respir J. 2014 Sep 12;1. y p p [24] Sundh J, Stallberg B, Lisspers K, et al. References Comparison of the COPD Assessment Test (CAT) and the Clinical COPD Questionnaire (CCQ) in a Clinical Population. COPD. 2016;13(1):57-65. [30] Stratelis G, Molstad S, Jakobsson P, et al. The impact of repeated spirometry and smoking cessation advice on smokers with mild COPD. Scand J Prim Health Care. 2006;24:133–139. [25] Sundh J, Montgomery S, Hasselgren M, et al. Change in health status in COPD: a seven-year follow-up cohort study. NPJ Prim Care Respir Med. 2016;26:16073. [31] Bednarek M, Gorecka D, Wielgomas J, et al. Smokers with airway obstruction are more likely to quit smoking. Thorax. 2006;61:869–873. y [26] Sundh J, Lindgren H, Hasselgren M, et al. Pulmonary rehabilitation in COPD - available resources and utiliza- tion in Swedish primary and secondary care. Int J Chron Obstruct Pulmon Dis. 2017;12:1695–1704. [32] Stallberg B, Janson C, Johansson G, et al. Management, morbidity and mortality of COPD during an 11-year period: an observational retrospective epidemiological register study in Sweden (PATHOS). Prim Care Respir J. 2014;23:38–45. [27] Rijcken B, Schouten JP, Weiss ST, et al. The relationship of nonspecific bronchial responsiveness to respiratory symptoms in a random population sample. Am Rev Respir Dis. 1987;136:62–68. [33] Stead LF, Lancaster T. Group behaviour therapy pro- grammes for smoking cessation. Cochrane Database Syst Rev. 2017 Mar 31;3:CD001007. p [28] Kohansal R, Martinez-Camblor P, Agusti A, et al. The natural history of chronic airflow obstruction revisited:
https://openalex.org/W2216950070	https://f1000research.com/articles/4-1313/pdf	English	null	Advances in understanding and managing bullous pemphigoid	F1000Research	2,015	cc-by	5,632	Abstract Bullous pemphigoid (BP) is the commonest subtype of autoimmune blistering disease in most countries of the world. It occurs most frequently in elderly patients and is characterised clinically by large, tense blisters in the skin preceded by urticarial plaques and pruritus. Immunopathologically, it is characterised by autoantibodies directed against the 180 kD antigen (BP180) and the 230 kD antigen (BP230). New knowledge regarding BP is being continually uncovered. This article reviews the recent advances in BP, including newer diagnostic tests, standardised outcome measures and emerging therapeutic options, as well as the evidence supporting their use. Advances in understanding and managing bullous pemphigoid [version 1; peer review: 2 approved] Open Peer Review Approval Status 1 2 version 1 20 Nov 2015 F1000Research 2015, 4(F1000 Faculty Rev):1313 Last updated: 06 SEP 2024 F1000Research 2015, 4(F1000 Faculty Rev):1313 Last updated: 06 SEP 2024 Keywords Keywords Bullous pemphigoid, blisters, urticarial plaques, pruritus Bullous pemphigoid, blisters, urticarial plaques, pruritus Zhi Liu, University of North Carolina at Chapel Hill, Chapel Hill, USA 1. Cassian Sitaru, University Medical Centre Freiburg, Freiburg, Germany 2. Any comments on the article can be found at the end of the article. Zhi Liu, University of North Carolina at Chapel Hill, Chapel Hill, USA 1. Zhi Liu, University of North Carolina at Chapel Hill, Chapel Hill, USA 1. Page 1 of 7 F1000Research 2015, 4(F1000 Faculty Rev):1313 Last updated: 06 SEP 2024 Corresponding author: Dedee F. Murrell (d.murrell@unsw.edu.au) Competing interests: The senior author of the article (Dedee F. Murrell) was involved in the development and validation of the BPDAI mentioned in the article. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2015 Zhao CY and Murrell DF. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Zhao CY and Murrell DF. Advances in understanding and managing bullous pemphigoid [version 1; peer review: 2 approved] F1000Research 2015, 4(F1000 Faculty Rev):1313 https://doi.org/10.12688/f1000research.6896.1 First published: 20 Nov 2015, 4(F1000 Faculty Rev):1313 https://doi.org/10.12688/f1000research.6896.1 Corresponding author: Dedee F. Murrell (d.murrell@unsw.edu.au) Competing interests: The senior author of the article (Dedee F. Murrell) was involved in the development and validation of the BPDAI mentioned in the article. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2015 Zhao CY and Murrell DF. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Zhao CY and Murrell DF. Advances in understanding and managing bullous pemphigoid [version 1; peer review: 2 approved] F1000Research 2015, 4(F1000 Faculty Rev):1313 https://doi.org/10.12688/f1000research.6896.1 First published: 20 Nov 2015, 4(F1000 Faculty Rev):1313 https://doi.org/10.12688/f1000research.6896.1 Introduction Bullous pemphigoid (BP) is the commonest subtype of autoim- mune blistering disease (AIBD), a rare but potentially fatal group of skin diseases. BP usually affects the elderly and has an incidence of 12.1 to 66 new cases per million per year in epidemiological studies conducted in Europe1–4. Clinically, it can present heterogeneously but typically manifests with large, tense blisters in the skin preceded by urticarial plaques and intense pruritus. Immunopathologically, it is characterised by subepidermal autoantibodies directed against the 180 kD antigen (BP180) and the 230 kD antigen (BP230), two components of adhesion complexes promoting dermo-epidermal cohesion5. Medical knowledge regarding BP has progressed considerably in recent years. An important area of progress is newer BP labora- tory testing methods, allowing a faster, cheaper and more feasible diagnosis of BP to be established. Another important area is the validation of BP outcome measures, allowing more accurate assess- ment of disease severity, facilitating the optimal therapy choice and dosage to be administered, and true disease responsiveness to be monitored. As BP usually affects the elderly (over 70 years of age), therapy choice is complicated and needs to be tailored to suit this frail population, balancing between efficacy, practicality and safety. Insights into BP therapies, especially systemic antibody-modulating agents, have increased significantly with regard to both efficacy and safety. This article reviews the recent advances in BP, including diagnostic techniques, outcome measures and therapeutic options, as well as the evidence supporting their use. Developed in Germany in 2012, the BIOCHIP IF mosaic is a new IIF method for the diagnosis of AIBDs and allows both antibody screening and antigen-specific substrate testing in a single mini- ature incubation field. So far, four validation studies have been performed, showing that for BP180 testing, it has good sensitivities, varying from 77–100%, and even superior specificities of 84–100% (Table 1)17–20. However, for BP230, the sensitivities were much lower, varying from 39–94%, although the specificities were gener- ally good (100% in three studies)18–20. These cumulative findings suggest that the BIOCHIP IF mosaic in detecting BP180 autoanti- bodies may be comparable to ELISA, and therefore may be used as a faster and cheaper screening test for patients with suspected BP. However, given the low sample size of the studies, the validities of the findings are compromised. A future study with large sample size and inter-rater reliability evaluation may be indicated for the BIOCHIP mosaic IF test. Corresponding author: Dedee F. Murrell (d.murrell@unsw.edu.au) Corresponding author: Dedee F. Murrell (d.murrell@unsw.edu.au) : The senior author of the article (Dedee F. Murrell) was involved in the development and validation of the BPDAI cle. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2015 Zhao CY and Murrell DF. This is an open access article distributed under the terms of the Cre Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the cited. How to cite this article: Zhao CY and Murrell DF. Advances in understanding and managing bullous pemphigoid [version 1; peer review: 2 approved] F1000Research 2015, 4(F1000 Faculty Rev):1313 https://doi.org/10.12688/f1000research.6896.1 First published: 20 Nov 2015, 4(F1000 Faculty Rev):1313 https://doi.org/10.12688/f1000research.6896.1 Page 2 of 7 F1000Research 2015, 4(F1000 Faculty Rev):1313 Last updated: 06 SEP 2024 The diagnosis of BP may be further confirmed by the characterisa- tion of circulating autoantibodies by using methods such as indirect immunofluorescence (IIF), enzyme-linked immunosorbent assay (ELISA), Western blotting and immunoprecipitation. Developed in the 1980s, IIF is the most commonly used method of autoanti- body characterisation, which has a sensitivity of 60–80% in detect- ing IgG autoantibodies that typically bind to the epidermal side of the salt-split human skin10. The substrate may be obtained commer- cially or alternatively prepared in the laboratory, the latter of which has the disadvantage of being potentially very time-consuming11. On the other hand, introduced in 2002, ELISA for BP using recombinant protein of BP180 NC16 (the extracellular domain harbouring immunodominant epitopes of BP autoantibodies) is a more sophisticated method of autoantibody characterisation12. It has the advantages of allowing multiple-sample testing, is easily reproducible, and provides a quantitative analysis13. Various valida- tion studies have shown the sensitivity of the commercially avail- able BP180 ELISAs to be 70–90%, which increases when using the NC16A domain and other extracellular portions of BP180 or BP230 together6,12,14,15. However, ELISA has two disadvantages: the cost is high and the recombinant proteins used may not contain all of the epitopes present in vivo. In addition, autoantibodies to BP180 and BP230 may be found usually in low levels by ELISA in about 7% of patients with other unrelated diseases or in healthy subjects16. Western blotting and immunoprecipitation are less commonly used given that these methods are often tedious and time-consuming, and have low availability. Outcome measures Overall, introducing an immunosuppressive medica- tion depends on several factors, including the efficacy of the first- line topical clobetasol or oral corticosteroids, the patient’s disease extent and co-morbidities, the dermatologist’s experiences, and cost considerations. In this era of biological therapies, new antibody modulators, includ- ing rituximab and omalizumab, have been suggested for the treat- ment of BP. It was proposed that they would have a more benign adverse event profile and more selective mechanisms of action. Rituximab is a humanised chimeric monoclonal antibody that tar- gets CD20+ B cells. So far, rituximab has shown promising evidence for other AIBDs such as pemphigus; however, in BP, the evidence for rituximab has been limited to case reports and case series34–36. In a retrospective case series involving five patients with refractory BP, rituximab was administered as 375 mg/m2 given weekly over 4 weeks, resulting in complete remission in three of the five patients, and partial remission in one patient34. However, one other patient died shortly after rituximab therapy. Despite the potential serious adverse events of rituximab, its efficacy for refractory BP was implicated. In a more recent retrospective study, rituximab’s role as first therapy was evaluated37. In this study, a group of 13 patients received 4 weekly infusions of rituximab 500 mg along with oral prednisolone, and a group of 19 patients received oral prednisolone only. The study had a follow-up period of 1 year. It found that the rituximab group had significantly higher rates of complete remission (92% versus 53%) and lower rates of mortality (15% versus 37%). However, there were no significant differences in the patient’s mean BPDAI scores or the cumulative oral corticosteroid dose. The study supported the safety and effectiveness of rituximab but was limited by its retrospective nature and its small sample size. A future RCT with a longer follow-up period, larger sample, and a comparison of various rituximab protocols, may be indicated. Other than disease severity, the BP patient’s quality of life (QOL) may be measured by the Autoimmune Bullous Disease Quality of Life (ABQOL) and Treatment of Autoimmune Bullous Disease Quality of Life (TABQOL) questionnaires. These two questionnaires were developed in 2013, as dermatology disease-specific QOL measures were shown to be more sensitive to changes in disease status than generic QOL measures27. Outcome measures The standardisation of BP outcome measures is important for the progress of BP treatment development, as it allows the direct com- parison and meta-analysis of results from different clinical trials. Formed in 2008, the BP Definitions Group consists of many world- wide AIBD experts21. Over a period of 2 years, the group held seven consensus meetings to establish definitions for the various stages of BP disease activity, therapeutic end-points and the first BP-specific severity outcome measure, called the Bullous Pemphigoid Disease Area Index (BPDAI)22. The BPDAI consists of two components: objective and pruritus. Its objective component has up to 360 points and includes blisters or erosions, urticarial or erythematous lesions, and mucosal involvement, each worth up to 120 points. Its separate subjective pruritus component has up to 30 points and takes into account the subjective severity of pruritus in the last 24 hours, week and month. The BPDAI has been validated in terms of its sensi- tivity to change, accuracy, and external validity by two separate studies23,24. The studies showed that the BPDAI correlated well with the patient’s erythematous/eczematous/urticarial skin surface, number of daily new blisters, and anti-BP180 titres tested by using ELISA, but not with the anti-BP230 titres. The BPDAI’s inter-rater and intra-rater reliabilities have also been reported to be excellent, and high intra-class correlation coefficients were detailed by a con- ference abstract summarising their preliminary results25. Future studies to evaluate the interpretability and cross-cultural validity of BPDAI may be indicated in order to complete its validation accord- ing to the COSMIN (Consensus-Based Standards for the Selection of Health Status Measurement Instruments) checklist manual26. The use of immunosuppressive medications for BP has been con- troversial. Their efficacy is generally inconclusive with significant potential adverse events, given prolonged use31. The most well-established immunosuppressive medication is aza- thioprine, a purine analogue, typically given at 0.5–2.5 mg/kg per day, followed by mycophenolate mofetil, a DNA-synthesis inhibi- tor, and methotrexate, a folate antagonist28. There have been a few RCTs evaluating immunosuppressive agents32,33. One study found azathioprine to have worse hepatotoxicity than mycophenolate32. However, the evidence for efficacy, measured by disease control and remission, was inconclusive. Furthermore, none of the studies used a placebo, which is a control that may be difficult to justify ethically31. Outcome measures Furthermore, these two questionnaires have been validated as having acceptable levels of construct validity, internal consistency and test-retest reliability, leading to their expan- sion and further validations in other languages21. Diagnosis Th di i The diagnosis of BP is based on a combination of clinical, histopatho- logical and immunological criteria6. In the setting of tense bullae with dermal-epidermal separation on histology, or of prodromal separations and positive direct immunofluorescence (DIF) for IgG or C3, the diagnosis of BP can be made if three of the following four criteria are present: age of more than 70 years, absence of atrophic scars, absence of mucosal involvement, and absence of predominant bullous lesions on the neck and head7,8. This has a sensitivity of 90%, specificity of 83%, and positive predicative value of 95% when vali- dated using immunoelectron microscopy and a sensitivity of 86%, specificity of 90%, and positive predicative value of over 95% when validated using immunoblotting as the gold standard. Therefore, it is recommended to perform a DIF and serological analysis to exclude a BP in all pruritic skin lesion patients who are at least 65 years old9. Table 1. Validation studies evaluating the specificity and sensitivity of biochip indirect immunofluorescence for bullous pemphigoid. Reference Country Number of patients with BP Gold standard BP180 BP230 Sensitivity Specificity Sensitivity Specificity Tampoia et al.20 Italy 36 ELISA 85% 100% 44% 100% van Beek et al.18 Germany 42 ELISA 100% 98% 55% 100% Zarian et al.19 Italy 18 ELISA 83% 100% 39% 100% Chiang et al.17 Australia 18 ELISA 77% 84% 94% 63% Study in progress. ELISA, enzyme-linked immunosorbent assay. Validation studies evaluating the specificity and sensitivity of biochip indirect immunofluorescence for pemphigoid. Study in progress. ELISA, enzyme-linked immunosorbent assay. Page 3 of 7 F1000Research 2015, 4(F1000 Faculty Rev):1313 Last updated: 06 SEP 2024 (0.5–1 mg/kg per day), despite its significantly worse adverse event profile, is recommended as the initial therapy instead29,31. Treatment h The treatment of BP should be aimed at decreasing blistering for- mation and pruritus, promote the healing of blisters and improve QOL while having a minimally adverse profile28. The therapeu- tic options for BP have been transformed significantly in the past decade. Topical clobetasol propionate 0.05% (40 grams per day) has been shown to be superior to oral prednisolone (0.5 mg/kg per day) in terms of overall survival, disease control and adverse event profile for patients with extensive BP. It is equally effective for patients with moderate BP, as shown in a randomised controlled trial (RCT)29. For this reason, topical clobetasol has taken over the previous benchmark of BP therapy, oral corticosteroids, as the first-line treatment for BP. This is supported by the consensus statement from the European Dermatology Forum in collaboration with the European Academy of Dermatology and Venereology28,30. However, topical clobetasol has the disadvantages of poor practi- cality in bedridden patients, higher rates of incompliance, and poor accessibility in certain countries. In these cases, oral prednisolone Omalizumab is a humanised monoclonal antibody that inhibits the binding of IgE to its receptors. It has been previously used for asthma and chronic urticaria, and is postulated to be effective for BP as IgE antibodies specific for the BP180 autoantigen have been detected in sera and biopsy samples from the majority of patients with BP38. In an uncontrolled case series of six patients with refrac- tory BP, omalizumab was administered subcutaneously in doses of 300–375 mg from fortnightly to every 6 weeks39. Overall, five of the Page 4 of 7 F1000Research 2015, 4(F1000 Faculty Rev):1313 Last updated: 06 SEP 2024 recent years. Standardised outcome measures such as the BPDAI have been developed to facilitate the comparison and meta-analysis of clinical trial results. This would likely lead to higher-quality clin- ical studies evaluating BP treatments, especially immunosuppres- sives and antibody modulators, with the aim of reducing adverse events associated with oral corticosteroids. six patients demonstrated clinical improvements from the omalizu- mab, and the sixth patient terminated treatment because of inter- current comorbidities. Three of the six patients had their BP180 and BP230 autoantibodies measured by ELISA and showed signifi- cant reductions after the use of omalizumab. None of the patients had any significant adverse events. 1. Marazza G, Pham HC, Schärer L, et al.: Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study. Br J Dermatol. 2009; 161(4): 861–8. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation Competing interests The senior author of the article (Dedee F. Murrell) was involved in the development and validation of the BPDAI mentioned in the article. References Kobayashi M, Amagai M, Kuroda-Kinoshita K, et al.: BP180 ELISA using bacterial recombinant NC16a protein as a diagnostic and monitoring tool for bullous pemphigoid. J Dermatol Sci. 2002; 30(3): 224–32. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 13. Lee EH, Kim YH, Kim S, et al.: Usefulness of Enzyme-linked Immunosorbent Assay Using Recombinant BP180 and BP230 for Serodiagnosis and Monitoring Disease Activity of Bullous Pemphigoid. Ann Dermatol. 2012; 24(1): 45–55. PubMed Abstract \| Publisher Full Text \| Free Full Text 14. Di Zenzo G, Thoma-Uszynski S, Fontao L, et al.: Multicenter prospective study of the humoral autoimmune response in bullous pemphigoid. Clin Immunol. 2008; 128(3): 415–26. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 14. Di Zenzo G, Thoma-Uszynski S, Fontao L, et al.: Multicenter prospective study of the humoral autoimmune response in bullous pemphigoid. Clin Immunol. 2008; 128(3): 415–26. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 2. Langan SM, Smeeth L, Hubbard R, et al.: Bullous pemphigoid and pemphigus vulgaris--incidence and mortality in the UK: population based cohort study. BMJ. 2008; 337: a180. PubMed Abstract \| Publisher Full Text \| Free Full Text \| F1000 Recommendation 15. Sitaru C, Dähnrich C, Probst C, et al.: Enzyme-linked immunosorbent assay using multimers of the 16th non-collagenous domain of the BP180 antigen for sensitive and specific detection of pemphigoid autoantibodies. Exp Dermatol. 2007; 16(9): 770–7. PubMed Abstract \| Publisher Full Text 3. Gudi VS, White MI, Cruickshank N, et al.: Annual incidence and mortality of bullous pemphigoid in the Grampian Region of North-east Scotland. Br J Dermatol. 2005; 153(2): 424–7. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 4. Bertram F, Bröcker EB, Zillikens D, et al.: Prospective analysis of the incidence of autoimmune bullous disorders in Lower Franconia, Germany. J Dtsch Dermatol Ges. 2009; 7(5): 434–40. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 16. Wieland CN, Comfere NI, Gibson LE, et al.: Anti-bullous pemphigoid 180 and 230 antibodies in a sample of unaffected subjects. Arch Dermatol. 2010; 146(1): 21–5. 16. Wieland CN, Comfere NI, Gibson LE, et al.: Anti-bullous pemphigoid 180 and 230 antibodies in a sample of unaffected subjects. Arch Dermatol. 2010; 146(1): 21–5. Treatment h Although the study suggested the efficacy of omalizumab, it was limited by its significantly small sample size, its variation in omalizumab dosage between patients, and its use of non-standardised outcome measures. Future RCTs evaluating omalizumab as a potential treatment for BP may be indicated. ; ( ) PubMed Abstract \| Publisher Full Text 10. Gammon WR, Briggaman RA, Inman AO 3rd, et al.: Differentiating anti- lamina lucida and anti-sublamina densa anti-BMZ antibodies by indirect immunofluorescence on 1.0 M sodium chloride-separated skin. J Invest Dermatol. 1984; 82(2): 139–44. PubMed Abstract \| Publisher Full Text 22. Murrell DF, Daniel BS, Joly P, et al.: Definitions and outcome measures for bullous pemphigoid: recommendations by an international panel of experts. J Am Acad Dermatol. 2012; 66(3): 479–85. PubMed Abstract \| Publisher Full Text \| Free Full Text 23. Patsatsi A, Kyriakou A, Giannakou A, et al.: Clinical significance of anti-desmoglein-1 and -3 circulating autoantibodies in Pemphigus Patients Measured by Area Index and Intensity Score. Acta Derm Venereol. 2014; 94(2): 203–6. PubMed Abstract \| Publisher Full Text 11. Mascaró JM Jr: Histological and Immunofluorescence Diagnosis of Autoimmune Blistering Diseases. In: Murrell D, ed. Blistering Diseases. Sydney: Springer; 2015; 161–191. P bli h F ll T t Conclusions Knowledge regarding AIBD is rapidly advancing. The diagnosis of BP requires a combination of clinical, histopathological and immu- nological testing via the detection of tissue-bound and circulating autoantibodies, the latter being the main area of development in Grant information The author(s) declared that no grants were involved in supporting this work. F1000 recommended References 1. Marazza G, Pham HC, Schärer L, et al.: Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study. Br J Dermatol. 2009; 161(4): 861–8. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 2. Langan SM, Smeeth L, Hubbard R, et al.: Bullous pemphigoid and pemphigus vulgaris--incidence and mortality in the UK: population based cohort study. BMJ. 2008; 337: a180. PubMed Abstract \| Publisher Full Text \| Free Full Text \| F1000 Recommendation 3. Gudi VS, White MI, Cruickshank N, et al.: Annual incidence and mortality of bullous pemphigoid in the Grampian Region of North-east Scotland. 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Di Zenzo G, Della Torre R, Zambruno G, et al.: Bullous pemphigoid: from the clinic to the bench. Clin Dermatol. 2012; 30(1): 3–16. PubMed Abstract \| Publisher Full Text 18. van Beek N, Rentzsch K, Probst C, et al.: Serological diagnosis of autoimmune bullous skin diseases: prospective comparison of the BIOCHIP mosaic-based indirect immunofluorescence technique with the conventional multi-step single test strategy. Orphanet J Rare Dis. 2012; 7: 49. PubMed Abstract \| Publisher Full Text \| Free Full Text \| F1000 Recommendation 18. van Beek N, Rentzsch K, Probst C, et al.: Serological diagnosis of autoimmune bullous skin diseases: prospective comparison of the BIOCHIP mosaic-based indirect immunofluorescence technique with the conventional multi-step single test strategy. Orphanet J Rare Dis. 2012; 7: 49. PubMed Abstract \| Publisher Full Text \| Free Full Text \| F1000 Recommendation 7. Vaillant L, Bernard P, Joly P, et al.: Evaluation of clinical criteria for diagnosis of bullous pemphigoid. French Bullous Study Group. Arch Dermatol. 1998; 134(9): 1075–80. PubMed Abstract \| Publisher Full Text 19. Zarian H, Saponeri A, Michelotto A, et al.: Biochip technology for the serological diagnosis of bullous pemphigoid. ISRN Dermatol. 2012; 2012: 237802. PubMed Abstract \| Publisher Full Text \| Free Full Text 19. Zarian H, Saponeri A, Michelotto A, et al.: Biochip technology for the serological diagnosis of bullous pemphigoid. ISRN Dermatol. 2012; 2012: 237802. PubMed Abstract \| Publisher Full Text \| Free Full Text 8. Joly P, Courville P, Lok C, et al.: Clinical criteria for the diagnosis of bullous pemphigoid: a reevaluation according to immunoblot analysis of patient sera. Dermatology. 2004; 208(1): 16–20. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 20. Tampoia M, Zucano A, Villalta D, et al.: Anti-skin specific autoantibodies detected by a new immunofluorescence multiplex biochip method in patients with autoimmune bullous diseases. Dermatology. 2012; 225(1): 37–44. PubMed Abstract \| Publisher Full Text 9. Schmidt E, Goebeler M, Hertl M, et al.: S2k guideline for the diagnosis of pemphigus vulgaris/foliaceus and bullous pemphigoid. J Dtsch Dermatol Ges. 2015; 13(7): 713–27. PubMed Abstract \| Publisher Full Text 9. Schmidt E, Goebeler M, Hertl M, et al.: S2k guideline for the diagnosis of pemphigus vulgaris/foliaceus and bullous pemphigoid. J Dtsch Dermatol Ges. 2015; 13(7): 713–27. PubMed Abstract \| Publisher Full Text 21. Zhao CY, Murrell DF: Outcome measures for autoimmune blistering diseases. J Dermatol. 2015; 42(1): 31–6. PubMed Abstract \| Publisher Full Text 21. PubMed Abstract \| Publisher Full Text 5. Labib RS, Anhalt GJ, Patel HP, et al.: Molecular heterogeneity of the bullous pemphigoid antigens as detected by immunoblotting. J Immunol. 1986; 136(4): 1231–5. PubMed Abstract 5. Labib RS, Anhalt GJ, Patel HP, et al.: Molecular heterogeneity of the bullous pemphigoid antigens as detected by immunoblotting. J Immunol. 1986; 136(4): 1231–5. PubMed Abstract 17. Chiang YZ, Zhao CY, Melbourne W, et al.: Biochip immunofluorescence microscopy as a new diagnostic tool for autoimmune blistering skin diseases in Australia. World Congress of Dermatology; Vancouver, Canada; 2015. Reference Source PubMed Abstract Zhao CY, Murrell DF: Outcome measures for autoimmune blistering diseases. J Dermatol. 2015; 42(1): 31–6. PubMed Abstract \| Publisher Full Text 12. Kobayashi M, Amagai M, Kuroda-Kinoshita K, et al.: BP180 ELISA using bacterial recombinant NC16a protein as a diagnostic and monitoring tool for bullous pemphigoid. J Dermatol Sci. 2002; 30(3): 224–32. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation PubMed Abstract \| Publisher Full Text 12. Kobayashi M, Amagai M, Kuroda-Kinoshita K, et al.: BP180 ELISA using bacterial recombinant NC16a protein as a diagnostic and monitoring tool for bullous pemphigoid. J Dermatol Sci. 2002; 30(3): 224–32. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 24. Lévy-Sitbon C, Barbe C, Plee J, et al.: Assessment of bullous pemphigoid disease area index during treatment: a prospective study of 30 patients. Dermatology. 2014; 229(2): 116–22. PubMed Abstract \| Publisher Full Text Page 5 of 7 F1000Research 2015, 4(F1000 Faculty Rev):1313 Last updated: 06 SEP 2024 25. Wijayanti A, Zhao CY, Boettiger D, et al.: The Validity, Reliability and Responsiveness of the Bullous Pemphigoid Disease Area Index (BPDAI). Cutaneous Biologic Meeting; North Stradbroke Island, Australia. 2014. Reference Source 26. Mokkink LB, Terwee CB, Patrick DL, et al.: COSMIN checklist manual. Amsterdam, Netherlands: COSMIN; 2012. Reference Source 27. Finlay AY, Khan GK, Luscombe DK, et al.: Validation of Sickness Impact Profile and Psoriasis Disability Index in Psoriasis. Br J Dermatol. 1990; 123(6): 751–6. PubMed Abstract \| Publisher Full Text 28. Ramirez-Quizon MN, Borradori L, Hall RP III, et al.: Management of Bullous Pemphigoid. In: Murrell DF, ed. Blistering Diseases. Sydney, Australia: Springer; 2015; 543–550. Publisher Full Text 29. Joly P, Roujeau JC, Benichou J, et al.: A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med. 2002; 346(5): 321–7. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 30. Feliciani C, Joly P, Jonkman MF, et al.: Management of bullous pemphigoid: the European Dermatology Forum consensus in collaboration with the European Academy of Dermatology and Venereology. Br J Dermatol. 2015; 172(4): 867–77. PubMed Abstract \| Publisher Full Text 31. Kirtschig G, Middleton P, Bennett C, et al.: Interventions for bullous pemphigoid. Cochrane Database Syst Rev. 2010; (10): CD002292. PubMed Abstract \| Publisher Full Text 32. Beissert S, Werfel T, Frieling U, et al.: A comparison of oral methylprednisolone plus azathioprine or mycophenolate mofetil for the treatment of bullous pemphigoid. Arch Dermatol. 2007; 143(12): 1536–42. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 33. Guillaume JC, Vaillant L, Bernard P, et al.: Controlled trial of azathioprine and plasma exchange in addition to prednisolone in the treatment of bullous pemphigoid. Arch Dermatol. 1993; 129(1): 49–53. PubMed Abstract \| Publisher Full Text 34. PubMed Abstract \| Publisher Full Text Lourari S, Herve C, Doffoel-Hantz V, et al.: Bullous and mucous membrane pemphigoid show a mixed response to rituximab: experience in seven patients. J Eur Acad Dermatol Venereol. 2011; 25(10): 1238–40. PubMed Abstract \| Publisher Full Text 35. Kasperkiewicz M, Shimanovich I, Ludwig RJ, et al.: Rituximab for treatment- refractory pemphigus and pemphigoid: a case series of 17 patients. J Am Acad Dermatol. 2011; 65(3): 552–8. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 36. Shetty S, Ahmed AR: Treatment of bullous pemphigoid with rituximab: critical analysis of the current literature. J Drugs Dermatol. 2013; 12(6): 672–7. PubMed Abstract 37. Cho YT, Chu CY, Wang LF: First-line combination therapy with rituximab and corticosteroids provides a high complete remission rate in moderate-to-severe bullous pemphigoid. Br J Dermatol. 2015; 173(1): 302–4. PubMed Abstract \| Publisher Full Text 38. Messingham KA, Holahan HM, Fairley JA: Unraveling the significance of IgE autoantibodies in organ-specific autoimmunity: lessons learned from bullous pemphigoid. Immunol Res. 2014; 59(1–3): 273–8. PubMed Abstract \| Publisher Full Text 39. Yu KK, Crew AB, Messingham KA, et al.: Omalizumab therapy for bullous pemphigoid. J Am Acad Dermatol. 2014; 71(3): 468–74. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation treatment of bullous pemphigoid. Arch Dermatol. 2007; 143(12): 1536–42. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 25. Wijayanti A, Zhao CY, Boettiger D, et al.: The Validity, Reliability and Responsiveness of the Bullous Pemphigoid Disease Area Index (BPDAI). Cutaneous Biologic Meeting; North Stradbroke Island, Australia. 2014. Reference Source 33. Guillaume JC, Vaillant L, Bernard P, et al.: Controlled trial of azathioprine and plasma exchange in addition to prednisolone in the treatment of bullous pemphigoid. Arch Dermatol. 1993; 129(1): 49–53. PubMed Abstract \| Publisher Full Text 26. Mokkink LB, Terwee CB, Patrick DL, et al.: COSMIN checklist manual. Amsterdam, Netherlands: COSMIN; 2012. Reference Source 34. Lourari S, Herve C, Doffoel-Hantz V, et al.: Bullous and mucous membrane pemphigoid show a mixed response to rituximab: experience in seven patients. J Eur Acad Dermatol Venereol. 2011; 25(10): 1238–40. PubMed Abstract \| Publisher Full Text 27. Finlay AY, Khan GK, Luscombe DK, et al.: Validation of Sickness Impact Profile and Psoriasis Disability Index in Psoriasis. Br J Dermatol. 1990; 123(6): 751–6. P bM d Ab t t \| P bli h F ll T t F1000Research 2015, 4(F1000 Faculty Rev):1313 Last updated: 06 SEP 2024 Editorial Note on the Review Process Faculty Reviews are review articles written by the prestigious Members of Faculty Opinions. The articles are commissioned and peer reviewed before publication to ensure that the final, published version is comprehensive and accessible. The reviewers who approved the final version are listed with their names and affiliations. PubMed Abstract \| Publisher Full Text 28. Ramirez-Quizon MN, Borradori L, Hall RP III, et al.: Management of Bullous Pemphigoid. In: Murrell DF, ed. Blistering Diseases. Sydney, Australia: Springer; 2015; 543–550. Publisher Full Text Publisher Full Text 29. Joly P, Roujeau JC, Benichou J, et al.: A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med. 2002; 346(5): 321–7. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 30. Feliciani C, Joly P, Jonkman MF, et al.: Management of bullous pemphigoid: the European Dermatology Forum consensus in collaboration with the European Academy of Dermatology and Venereology. Br J Dermatol. 2015; 172(4): 867–77. PubMed Abstract \| Publisher Full Text 31. Kirtschig G, Middleton P, Bennett C, et al.: Interventions for bullous pemphigoid. Cochrane Database Syst Rev. 2010; (10): CD002292. PubMed Abstract \| Publisher Full Text 32. Beissert S, Werfel T, Frieling U, et al.: A comparison of oral methylprednisolone plus azathioprine or mycophenolate mofetil for the 29. Joly P, Roujeau JC, Benichou J, et al.: A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med. 2002; 346(5): 321–7. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 30. Feliciani C, Joly P, Jonkman MF, et al.: Management of bullous pemphigoid: the European Dermatology Forum consensus in collaboration with the European Academy of Dermatology and Venereology. Br J Dermatol. 2015; 172(4): 867–77. PubMed Abstract \| Publisher Full Text 38. Messingham KA, Holahan HM, Fairley JA: Unraveling the significance of IgE autoantibodies in organ-specific autoimmunity: lessons learned from bullous pemphigoid. Immunol Res. 2014; 59(1–3): 273–8. PubMed Abstract \| Publisher Full Text 31. Kirtschig G, Middleton P, Bennett C, et al.: Interventions for bullous pemphigoid. Cochrane Database Syst Rev. 2010; (10): CD002292. PubMed Abstract \| Publisher Full Text 39. Yu KK, Crew AB, Messingham KA, et al.: Omalizumab therapy for bullous pemphigoid. J Am Acad Dermatol. 2014; 71(3): 468–74. PubMed Abstract \| Publisher Full Text \| F1000 Recommendation 32. Beissert S, Werfel T, Frieling U, et al.: A comparison of oral methylprednisolone plus azathioprine or mycophenolate mofetil for the Page 6 of 7 The reviewers who approved this article are: Version 1 Cassian Sitaru Department of Dermatology, University Medical Centre Freiburg, Freiburg, Germany Competing Interests: No competing interests were disclosed. 1. Zhi Liu Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Competing Interests: No competing interests were disclosed. 2. The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com Page 7 of 7
https://openalex.org/W3131096325	https://eprints.soton.ac.uk/447052/1/Reproducibility_and_Concurrent_Validity_of_Manual_Palpation_with_Rehabilitative_Ultrasound_Imaging_for_assessing_Deep_Abdominal_Muscle_Activity.pdf	English	null	Reproducibility and Concurrent Validity of Manual Palpation with Rehabilitative Ultrasound Imaging for Assessing Deep Abdominal Muscle Activity: Analysis with Preferential Ratios	Diagnostics	2,021	cc-by	15,146	For publication in: 1 Diagnostics 2 3 Please note: this is the final draft of the accepted article: 4 5 Valentín-Mazarracin I, Nogaledo-Martín M, López-de-Uralde-Villanueva I, 6 Fernández-de-las-Peñas C, Stokes M, Arias-Buría JL, Díaz-Arribas MJ, Plaza- 7 Manzano G. Reproducibility and Concurrent Validity of Manual Palpation 8 with Rehabilitative Ultrasound Imaging for assessing Deep Abdominal Muscle 9 Activity: Analysis with Preferential Ratios. Diagnostics In press; 10 Accepted 10th February 2021 11 12 13 Please use the following link for the final, fully proofed and peer-reviewed 14 journal 15 article online: https:// www.mdpi.com/journal/diagnostics 16 17 For publication in: 1 Diagnostics 2 3 Please note: this is the final draft of the accepted article: 4 5 Valentín-Mazarracin I, Nogaledo-Martín M, López-de-Uralde-Villanueva I, 6 Fernández-de-las-Peñas C, Stokes M, Arias-Buría JL, Díaz-Arribas MJ, Plaza- 7 Manzano G. Reproducibility and Concurrent Validity of Manual Palpation 8 with Rehabilitative Ultrasound Imaging for assessing Deep Abdominal Muscle 9 Activity: Analysis with Preferential Ratios. Diagnostics In press; 10 Accepted 10th February 2021 11 12 13 Please use the following link for the final, fully proofed and peer-reviewed 14 journal 15 article online: https:// www.mdpi.com/journal/diagnostics 16 17 Article 18 Reproducibility and Concurrent Validity of Manual 19 Palpation with Rehabilitative Ultrasound Imaging 20 for assessing Deep Abdominal Muscle Activity: 21 Analysis with Preferential Ratios 22 Analysis with Preferential Ratios 22 Irene Valentín-Mazarracin 1, Miriam Nogaledo-Martín 2, Ibai López-de-Uralde-Villanueva 3, 23 César Fernández-de-las-Peñas 4,5,, María Stokes 6,7, José L. Arias-Buría 4,5, María J. Díaz-Arribas 3 24 and Gustavo Plaza-Manzano 3 25 1 Complete Health of Lawrenceville, Princeton, New Jersey, USA. vm.irene@hotmail.com 26 2 Centro de Fisioterapia Qsana, Madrid, Spain. miriam.nogaledo@gmail.com 27 3 Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, 28040 28 Madrid, Spain gusplaza@ucm.es (G.P.-M); mjdiazar@med.ucm.es (M.J.D.-A); ibailope@ucm.es (I.L.-d.-U.- 29 V) 30 4 Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, 31 Universidad Rey Juan Carlos, 28922 Alcorcón, Spain; joseluis.arias@urjc.es 32 5 Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y 33 Ejercicio Terapéutico, Universidad Rey Juan Carlos,28922 Madrid, Spain. 34 6 School of Health Sciences University of Southampton United Kingdom m stokes@soton ac uk 35 Abstract The abdominal drawing-in maneuver (ADIM) is a clinical tool used for identifying 39 preferential activity of deep abdominal muscles. However, concurrent validity and reproducibility 40 of palpation during the ADIM has not been formally investigated. The aims of this study were: 1, 41 To assess intra- and inter-rater reliability of manual palpation during the ADIM; and, 2, to determine 42 the concurrent validity of manual palpation during the ADIM by calculating preferential activation 43 ratio cut-off as assessed with ultrasound imaging (RUSI). Thirty-two subjects (n = 16 patients with 44 non-specific low back pain and 16 comparable healthy individuals) performed the ADIM in a supine 45 hook-lying position. Two experienced assessors evaluated the presence or absence of preferential 46 contraction of the deep abdominal muscles by palpation during the ADIM on 2-different days. Intra- 47 rater (test-retest) and inter-rater reliability of palpation were calculated using Cohen’s kappa 48 coefficients. Muscle thickness of the transverse abdominis (TrA), internal oblique (IO), and external 49 oblique (EO) muscles at rest and during the ADIM were also measured. TrA-Contraction Ratio 50 (TrA-CR), TrA-Preferential Activation Ratio (TrA-PAR) and Modified-TrA-PR (M-TrA-PAR) were 51 calculated. The concurrent validity of manual palpation was determining by correlation between 52 manual palpation and imaging, by calculating ROC curve (operating characteristics curve), Youden 53 index, and sensitivity and specificity. Intra-rater and inter-rater reliability of manual palpation 54 during the ADIM was excellent (κ: 0.82–1.00) and good to excellent (κ: 0.71–1.00), respectively. Inter- 55 rater reliability for muscle thickness ranged from good to excellent (ICC3,1 0.79–0.91). Diagnostics When evaluating the 57 diagnostic accuracy of manual palpation, the best predictive model (ROC value: 0.89; p < 0.001) for 58 correct a preferential contraction of TrA was obtained when the M-TrA-PAR was ≥0.08 (Sensitivity 59 0.95–1.00; specificity: 0.62). 60 Article 18 Reproducibility and Concurrent Validity of Manual 19 Palpation with Rehabilitative Ultrasound Imaging 20 for assessing Deep Abdominal Muscle Activity: 21 Analysis with Preferential Ratios 22 Article 18 Reproducibility and Concurrent Validity of Manual 19 Palpation with Rehabilitative Ultrasound Imaging 20 for assessing Deep Abdominal Muscle Activity: 21 Analysis with Preferential Ratios 22 Irene Valentín-Mazarracin 1, Miriam Nogaledo-Martín 2, Ibai López-de-Uralde-Villanueva 3, 23 César Fernández-de-las-Peñas 4,5,, María Stokes 6,7, José L. Arias-Buría 4,5, María J. Díaz-Arribas 3 24 and Gustavo Plaza-Manzano 3 25 1 Complete Health of Lawrenceville, Princeton, New Jersey, USA. vm.irene@hotmail.com 26 2 Centro de Fisioterapia Qsana, Madrid, Spain. miriam.nogaledo@gmail.com 27 3 Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, 28040 28 Madrid, Spain gusplaza@ucm.es (G.P.-M); mjdiazar@med.ucm.es (M.J.D.-A); ibailope@ucm.es (I.L.-d.-U.- 29 V) 30 4 Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, 31 Universidad Rey Juan Carlos, 28922 Alcorcón, Spain; joseluis.arias@urjc.es 32 5 Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y 33 Ejercicio Terapéutico, Universidad Rey Juan Carlos,28922 Madrid, Spain. 34 6 School of Health Sciences, University of Southampton, United Kingdom m.stokes@soton.ac.uk 35 7 Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, Nottingham, UK 36 * Correspondence: cesar.fernandez@urjc.es; Tel.: + 34 91 488 88 84 37 Received: 9 December 2020; Accepted: date; Published: date 38 Abstract The abdominal drawing-in maneuver (ADIM) is a clinical tool used for identifying 39 preferential activity of deep abdominal muscles. However, concurrent validity and reproducibility 40 of palpation during the ADIM has not been formally investigated. The aims of this study were: 1, 41 To assess intra- and inter-rater reliability of manual palpation during the ADIM; and, 2, to determine 42 the concurrent validity of manual palpation during the ADIM by calculating preferential activation 43 ratio cut-off as assessed with ultrasound imaging (RUSI). Thirty-two subjects (n = 16 patients with 44 non-specific low back pain and 16 comparable healthy individuals) performed the ADIM in a supine 45 hook-lying position. Two experienced assessors evaluated the presence or absence of preferential 46 contraction of the deep abdominal muscles by palpation during the ADIM on 2-different days. Diagnostics www.mdpi.com/journal/diagnostics www.mdpi.com/journal/diagnostics 2 of 18 Diagnostics Accepted Article 18 Reproducibility and Concurrent Validity of Manual 19 Palpation with Rehabilitative Ultrasound Imaging 20 for assessing Deep Abdominal Muscle Activity: 21 Analysis with Preferential Ratios 22 Irene Valentín-Mazarracin 1, Miriam Nogaledo-Martín 2, Ibai López-de-Uralde-Villanueva 3, 23 César Fernández-de-las-Peñas 4,5,, María Stokes 6,7, José L. Arias-Buría 4,5, María J. Díaz-Arribas 3 24 and Gustavo Plaza-Manzano 3 25 1 Complete Health of Lawrenceville, Princeton, New Jersey, USA. vm.irene@hotmail.com 26 2 Centro de Fisioterapia Qsana, Madrid, Spain. miriam.nogaledo@gmail.com 27 3 Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, 28040 28 Madrid, Spain gusplaza@ucm.es (G.P.-M); mjdiazar@med.ucm.es (M.J.D.-A); ibailope@ucm.es (I.L.-d.-U.- 29 V) 30 4 Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, 31 Universidad Rey Juan Carlos, 28922 Alcorcón, Spain; joseluis.arias@urjc.es 32 5 Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y 33 Ejercicio Terapéutico, Universidad Rey Juan Carlos,28922 Madrid, Spain. 34 6 School of Health Sciences, University of Southampton, United Kingdom m.stokes@soton.ac.uk 35 7 Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, Nottingham, UK 36 Correspondence: cesar.fernandez@urjc.es; Tel.: + 34 91 488 88 84 37 Received: 9 December 2020; Accepted: date; Published: date 38 Abstract The abdominal drawing-in maneuver (ADIM) is a clinical tool used for identifying 39 preferential activity of deep abdominal muscles. However, concurrent validity and reproducibility 40 of palpation during the ADIM has not been formally investigated. The aims of this study were: 1, 41 To assess intra- and inter-rater reliability of manual palpation during the ADIM; and, 2, to determine 42 the o u e t alidity of a ual al atio du i the ADIM by al ulati efe e tial a ti atio 43 Article 18 Reproducibility and Concurrent Validity of Manual 19 Palpation with Rehabilitative Ultrasound Imaging 20 for assessing Deep Abdominal Muscle Activity: 21 Analysis with Preferential Ratios 22 Irene Valentín-Mazarracin 1, Miriam Nogaledo-Martín 2, Ibai López-de-Uralde-Villanueva 3, 23 César Fernández-de-las-Peñas 4,5,, María Stokes 6,7, José L. Arias-Buría 4,5, María J. Díaz-Arribas 3 24 and Gustavo Plaza-Manzano 3 25 1 Complete Health of Lawrenceville, Princeton, New Jersey, USA. vm.irene@hotmail.com 26 2 Centro de Fisioterapia Qsana, Madrid, Spain. Diagnostics miriam.nogaledo@gmail.com 27 3 Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, 28040 28 Madrid, Spain gusplaza@ucm.es (G.P.-M); mjdiazar@med.ucm.es (M.J.D.-A); ibailope@ucm.es (I.L.-d.-U.- 29 V) 30 4 Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, 31 Universidad Rey Juan Carlos, 28922 Alcorcón, Spain; joseluis.arias@urjc.es 32 5 Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y 33 Ejercicio Terapéutico, Universidad Rey Juan Carlos,28922 Madrid, Spain. 34 6 School of Health Sciences, University of Southampton, United Kingdom m.stokes@soton.ac.uk 35 7 Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, Nottingham, UK 36 Correspondence: cesar.fernandez@urjc.es; Tel.: + 34 91 488 88 84 37 Received: 9 December 2020; Accepted: date; Published: date 38 Abstract The abdominal drawing-in maneuver (ADIM) is a clinical tool used for identifying 39 preferential activity of deep abdominal muscles. However, concurrent validity and reproducibility 40 of palpation during the ADIM has not been formally investigated. The aims of this study were: 1, 41 To assess intra- and inter-rater reliability of manual palpation during the ADIM; and, 2, to determine 42 the concurrent validity of manual palpation during the ADIM by calculating preferential activation 43 ratio cut-off as assessed with ultrasound imaging (RUSI). Thirty-two subjects (n = 16 patients with 44 non-specific low back pain and 16 comparable healthy individuals) performed the ADIM in a supine 45 hook-lying position. Two experienced assessors evaluated the presence or absence of preferential 46 contraction of the deep abdominal muscles by palpation during the ADIM on 2-different days. Intra- 47 rater (test-retest) and inter-rater reliability of palpation were calculated using Cohen’s kappa 48 coefficients. Muscle thickness of the transverse abdominis (TrA), internal oblique (IO), and external 49 oblique (EO) muscles at rest and during the ADIM were also measured. TrA-Contraction Ratio 50 (TrA-CR), TrA-Preferential Activation Ratio (TrA-PAR) and Modified-TrA-PR (M-TrA-PAR) were 51 calculated. The concurrent validity of manual palpation was determining by correlation between 52 manual palpation and imaging, by calculating ROC curve (operating characteristics curve), Youden 53 index, and sensitivity and specificity. Intra-rater and inter-rater reliability of manual palpation 54 during the ADIM was excellent (κ: 0.82–1.00) and good to excellent (κ: 0.71–1.00), respectively. Inter- 55 rater reliability for muscle thickness ranged from good to excellent (ICC3,1 0.79–0.91). Manual 56 palpation and TrA ratio showed low to moderate correlations (r: 0.36–0.60). Diagnostics Intra- 47 rater (test-retest) and inter-rater reliability of palpation were calculated using Cohen’s kappa 48 coefficients. Muscle thickness of the transverse abdominis (TrA), internal oblique (IO), and external 49 oblique (EO) muscles at rest and during the ADIM were also measured. TrA-Contraction Ratio 50 (TrA-CR), TrA-Preferential Activation Ratio (TrA-PAR) and Modified-TrA-PR (M-TrA-PAR) were 51 calculated. The concurrent validity of manual palpation was determining by correlation between 52 manual palpation and imaging, by calculating ROC curve (operating characteristics curve), Youden 53 index, and sensitivity and specificity. Intra-rater and inter-rater reliability of manual palpation 54 during the ADIM was excellent (κ: 0.82–1.00) and good to excellent (κ: 0.71–1.00), respectively. Inter- 55 rater reliability for muscle thickness ranged from good to excellent (ICC3,1 0.79–0.91). Manual 56 palpation and TrA ratio showed low to moderate correlations (r: 0.36–0.60). When evaluating the 57 diagnostic accuracy of manual palpation, the best predictive model (ROC value: 0.89; p < 0.001) for 58 correct a preferential contraction of TrA was obtained when the M-TrA-PAR was ≥0.08 (Sensitivity: 59 0.95–1.00; specificity: 0.62). 60 1. Introduction 66 One hypothesis associated with development and 74 recurrence of LBP is a potential dysfunction in the motor control of the muscles of the thoracic cage, 75 e.g., deep abdominal, pelvic floor, multifidus and diaphragm. Among the abdominal musculature, 76 particular attention has been placed to the deep muscles, e.g., transverse abdominis (TrA) and lumbar 77 multifidi. In fact, training of the TrA and the lumbar multifidi has been advocated to be a relevant 78 component within rehabilitation programs of individuals with LBP; although no linear association 79 between the changes in morphometry or activity of deep abdominal muscles (TrA) and clinical 80 outcomes has been observed [7]. In fact, exercise programs including training of the deep abdominal 81 muscles, are recommended (moderate quality evidence) for the management of patients with chronic 82 low back pain in clinical practice guidelines [8]. 83 The abdominal drawing-in maneuver (ADIM) is commonly used as a foundational basis of 84 lumbar stabilization training programs. It is hypothesized that the ADIM is able to facilitate coactivity 85 of the deep abdominal musculature and could play a supportive role for the spine during functional 86 activities [9]. In fact, a recent review has concluded that ultrasound imaging and electromyographic 87 activity of the TrA and internal oblique (IO) muscles are highly correlated during the ADIM 88 supporting the use of this maneuver [10]. 89 Ultrasound (US) imaging is a noninvasive method that allows both the clinician and the patient 90 to observe changes in thickness of the deep abdominal muscles. In fact, the use of rehabilitative 91 ultrasound imaging (RUSI) for visual assessment of deep trunk muscles function, particularly the 92 TrA and lumbar multifidi, and as a biofeedback tool has become increasingly popular [11], 93 particularly in the physical therapy profession [12]. Different systematic reviews have been published 94 about the reliability of RUSI. Hebert et al. concluded that the majority of studies indicate that RUSI 95 exhibits acceptable to good reliability for assessing the TrA; however, they concluded that more high- 96 quality studies are needed [13]. Costa et al. found that current literature reported good to excellent 97 reliability for single measures of TrA thickness but poor to good reliability for measures of thickness 98 changes (reflecting the muscle activity) supporting TrA activity [14]. 1. Introduction 66 In fact, the use of rehabilitative 91 ultrasound imaging (RUSI) for visual assessment of deep trunk muscles function, particularly the 92 TrA and lumbar multifidi, and as a biofeedback tool has become increasingly popular [11], 93 particularly in the physical therapy profession [12]. Different systematic reviews have been published 94 about the reliability of RUSI. Hebert et al. concluded that the majority of studies indicate that RUSI 95 exhibits acceptable to good reliability for assessing the TrA; however, they concluded that more high- 96 quality studies are needed [13]. Costa et al. found that current literature reported good to excellent 97 reliability for single measures of TrA thickness but poor to good reliability for measures of thickness 98 changes (reflecting the muscle activity) supporting TrA activity [14]. 99 It should be noted that many clinicians do not have access to US imaging in routine clinical 100 practice and, therefore, manual evaluation remains the most common form of evaluating deep 101 abdominal muscle activity [15]. An important step before a maneuver can be regularly used in 102 research or clinical practice is to know if it is reproducible and valid. This is particularly relevant for 103 manual assessment during the ADIM, since palpation is operator-dependent. A previous study 104 evaluated inter-rater reliability of manual palpation during the ADIM in healthy participants 105 reporting a mean kappa value of 0.52 [16]. The methodology of this small study was poor since no 106 clear analysis was provided. Kaping et al. evaluated the ability of the ADIM for differentiating 107 between people with LBP and healthy participants, and found that neither the ADIM nor US imaging 108 Low back pain (LBP) represents a medical problem for the current society showing a worldwide 67 prevalence ranging from 1.4% to 20% and an incidence from 0.024% to 7%, depending on the 68 diagnostic criteria used [1]. In athletes, the one-year prevalence of LBP can reach 84% and the life- 69 time prevalence till 94% [2]. In addition, the pooled prevalence rate of healthcare use of LBP patients 70 is up to 67% supporting high healthcare costs [3]. In fact, the estimated annual total cost of LBP in the 71 USA was 100 billion of dollars [4]. In the Global Burden of Disease Study, LBP was ranked as the 72 fourth leading cause of disability-adjusted life years (DALYs) globally [5,6]. 73 The etiology of LBP is multifactorial. Article 18 Reproducibility and Concurrent Validity of Manual 19 Palpation with Rehabilitative Ultrasound Imaging 20 for assessing Deep Abdominal Muscle Activity: 21 Analysis with Preferential Ratios 22 Manual 56 palpation and TrA ratio showed low to moderate correlations (r: 0.36–0.60). When evaluating the 57 diagnostic accuracy of manual palpation, the best predictive model (ROC value: 0.89; p < 0.001) for 58 correct a preferential contraction of TrA was obtained when the M-TrA-PAR was ≥0.08 (Sensitivity: 59 0.95–1.00; specificity: 0.62). 60 3 of 18 Diagnostics Accepted g p Good to excellent intra- and inter-rater reliability of manual palpation was found during the ADIM 61 in both patients and healthy groups. Manual palpation showed concurrent validity for identifying 62 the preferential activity of the TrA muscle supporting its use in clinical practice. 63 Keywords: rehabilitative ultrasound imaging; transversus abdominis; reliability; core stability. 64 65 Good to excellent intra- and inter-rater reliability of manual palpation was found during the ADIM 61 in both patients and healthy groups. Manual palpation showed concurrent validity for identifying 62 the preferential activity of the TrA muscle supporting its use in clinical practice. 63 Keywords: rehabilitative ultrasound imaging; transversus abdominis; reliability; core stability 64 Good to excellent intra- and inter-rater reliability of manual palpation was found during the ADIM 61 in both patients and healthy groups. Manual palpation showed concurrent validity for identifying 62 the preferential activity of the TrA muscle supporting its use in clinical practice. 63 Good to excellent intra- and inter-rater reliability of manual palpation was found during the ADIM 61 in both patients and healthy groups. Manual palpation showed concurrent validity for identifying 62 the preferential activity of the TrA muscle supporting its use in clinical practice. 63 Keywords: rehabilitative ultrasound imaging; transversus abdominis; reliability; core stability. 64 1. Introduction 66 Low back pain (LBP) represents a medical problem for the current society showing a worldwide 67 prevalence ranging from 1.4% to 20% and an incidence from 0.024% to 7%, depending on the 68 diagnostic criteria used [1]. In athletes, the one-year prevalence of LBP can reach 84% and the life- 69 time prevalence till 94% [2]. In addition, the pooled prevalence rate of healthcare use of LBP patients 70 is up to 67% supporting high healthcare costs [3]. In fact, the estimated annual total cost of LBP in the 71 USA was 100 billion of dollars [4]. In the Global Burden of Disease Study, LBP was ranked as the 72 fourth leading cause of disability-adjusted life years (DALYs) globally [5,6]. 73 The etiology of LBP is multifactorial. One hypothesis associated with development and 74 recurrence of LBP is a potential dysfunction in the motor control of the muscles of the thoracic cage, 75 e.g., deep abdominal, pelvic floor, multifidus and diaphragm. Among the abdominal musculature, 76 particular attention has been placed to the deep muscles, e.g., transverse abdominis (TrA) and lumbar 77 multifidi. In fact, training of the TrA and the lumbar multifidi has been advocated to be a relevant 78 component within rehabilitation programs of individuals with LBP; although no linear association 79 between the changes in morphometry or activity of deep abdominal muscles (TrA) and clinical 80 outcomes has been observed [7]. In fact, exercise programs including training of the deep abdominal 81 muscles, are recommended (moderate quality evidence) for the management of patients with chronic 82 low back pain in clinical practice guidelines [8]. 83 The abdominal drawing-in maneuver (ADIM) is commonly used as a foundational basis of 84 lumbar stabilization training programs. It is hypothesized that the ADIM is able to facilitate coactivity 85 of the deep abdominal musculature and could play a supportive role for the spine during functional 86 activities [9]. In fact, a recent review has concluded that ultrasound imaging and electromyographic 87 activity of the TrA and internal oblique (IO) muscles are highly correlated during the ADIM 88 supporting the use of this maneuver [10]. 89 Ultrasound (US) imaging is a noninvasive method that allows both the clinician and the patient 90 to observe changes in thickness of the deep abdominal muscles. 1. Introduction 66 Abdominal Drawing-In Maneuver (ADIM) 146 Participants received a training session, where they were taught how to properly perform an 147 abdominal drawing-in maneuver (ADIM). The ADIM involves the drawing-in of the abdominal wall 148 eliciting a concentric contraction of the deep abdominal muscles. It is claimed that ADIM allows for 149 an efficient and measurable contraction of the TrA [21]. The training session was conducted in 150 quadruped. First, participants were manually assisted in finding their neutral spine position and 151 were instructed to perform the ADIM by drawing the umbilicus towards their lumbar spine. This 152 contraction was performed 5 times holding each contraction for the duration of two normal breaths 153 (10s). 154 1. Introduction 66 99 It should be noted that many clinicians do not have access to US imaging in routine clinical 100 practice and, therefore, manual evaluation remains the most common form of evaluating deep 101 abdominal muscle activity [15]. An important step before a maneuver can be regularly used in 102 research or clinical practice is to know if it is reproducible and valid. This is particularly relevant for 103 manual assessment during the ADIM, since palpation is operator-dependent. A previous study 104 evaluated inter-rater reliability of manual palpation during the ADIM in healthy participants 105 reporting a mean kappa value of 0.52 [16]. The methodology of this small study was poor since no 106 clear analysis was provided. Kaping et al. evaluated the ability of the ADIM for differentiating 107 between people with LBP and healthy participants, and found that neither the ADIM nor US imaging 108 4 of 18 Diagnostics Accepted was able to discriminate between patients with LBP and healthy participants [17]. No previous study 109 has investigated the validity of manual assessment during the ADIM when compared with a US 110 imaging by determining cut-off values of identifying deep abdominal muscle activity. Therefore, the 111 objectives of the present study were: 1) to assess the reliability of manual assessment during the 112 ADIM; and 2) to investigate the concurrent validity of manual assessment by calculating cut-off 113 values assessed with US imaging. 114 was able to discriminate between patients with LBP and healthy participants [17]. No previous study 109 has investigated the validity of manual assessment during the ADIM when compared with a US 110 imaging by determining cut-off values of identifying deep abdominal muscle activity. Therefore, the 111 objectives of the present study were: 1) to assess the reliability of manual assessment during the 112 ADIM; and 2) to investigate the concurrent validity of manual assessment by calculating cut-off 113 values assessed with US imaging. 114 g g 2. Materials and Methods 115 2.1. Participants 116 Consecutive participants with LBP symptoms were recruited via local advertisement and 117 screened for eligible criteria between December 2018 and December 2019. To be included, they had 118 to have a history of non-specific LBP without lower extremity referral for longer than 1 year. 1. Introduction 66 119 Exclusion criteria included: 1) current pregnancy; 2) LBP with a specific underlying pathology such 120 as tumor, infection, inflammatory disorders, hernia disc, prolapsed disc; 3) signs consistent with 121 nerve root compression, e.g., positive straight-leg-raise test < 45°, diminished lower-extremity force, 122 or diminished reflexes; 4, lumbar spine surgery; 5) history of osteoporosis; 6) spinal fracture; 7) 123 abdominal pain; or, 8) obesity (BMI > 30). The medical history from each patient was solicited from 124 their primary care physician to assess the presence of the exclusion criteria. 125 In addition, a sample of comparative healthy participants were also recruited. To be eligible to 126 participate, they had to be between 18 and 65 years old and with no history of recurrent LBP and no 127 episode of pain in the previous year. The same exclusion criteria as for the LBP group were applied. 128 The study design was approved by the Review Ethical Committee of Universidad Alcalá de Henares, 129 Spain (CEIM/HU/2017/20). Participants provided written informed consent prior to their inclusion in 130 the study. 131 Participants were asked: 1) to avoid eating or drinking at least two hours prior to each data 132 collection session; 2) to empty their bladder immediately before each assessment; and 3) to avoid any 133 physical activity, particularly, exercising the abdominal muscles, the day before the assessment. 134 2.2. Clinical Data 135 Demographic data including age, gender, body mass (kg), height (cm), body mass index (BMI), 136 past medical history and location, and nature of symptoms were collected. Pain intensity and pain- 137 related disability were also assessed throughout questionnaires. A 100mm visual analogue scale 138 (VAS, 0: no pain; 100: maximum pain) was used to assess current intensity of LBP [18]. The Oswestry 139 Disability Index (ODI) was used to determine related-disability [19]. The ODI has 10 items referring 140 to activities of daily living that might be disrupted due to LBP. Each item is answered on a 6-point 141 Likert scale ranging from “no problem at all” [0] to “not possible” [5]. The total score arises from 142 summing all answers (0–50), multiplied by 2 to obtain a final index ranging from 0 (no disability) to 143 100 (maximum disability). The Spanish version of the ODI has shown good reliability and internal 144 consistency [20]. 145 2.3. 2.1. Participants 116 Consecutive participants with LBP symptoms were recruited via local advertisement and 117 screened for eligible criteria between December 2018 and December 2019. To be included, they had 118 to have a history of non-specific LBP without lower extremity referral for longer than 1 year. 119 Exclusion criteria included: 1) current pregnancy; 2) LBP with a specific underlying pathology such 120 as tumor, infection, inflammatory disorders, hernia disc, prolapsed disc; 3) signs consistent with 121 nerve root compression, e.g., positive straight-leg-raise test < 45°, diminished lower-extremity force, 122 or diminished reflexes; 4, lumbar spine surgery; 5) history of osteoporosis; 6) spinal fracture; 7) 123 abdominal pain; or, 8) obesity (BMI > 30). The medical history from each patient was solicited from 124 their primary care physician to assess the presence of the exclusion criteria. 125 In addition, a sample of comparative healthy participants were also recruited. To be eligible to participate, they had to be between 18 and 65 years old and with no history of recurrent LBP and no episode of pain in the previous year. The same exclusion criteria as for the LBP group were applied. The study design was approved by the Review Ethical Committee of Universidad Alcalá de Henares, Spain (CEIM/HU/2017/20). Participants provided written informed consent prior to their inclusion in the study. Participants were asked: 1) to avoid eating or drinking at least two hours prior to each data 132 collection session; 2) to empty their bladder immediately before each assessment; and 3) to avoid any 133 physical activity, particularly, exercising the abdominal muscles, the day before the assessment. 134 Demographic data including age, gender, body mass (kg), height (cm), body mass index (BMI), 136 past medical history and location, and nature of symptoms were collected. Pain intensity and pain- 137 related disability were also assessed throughout questionnaires. A 100mm visual analogue scale 138 (VAS, 0: no pain; 100: maximum pain) was used to assess current intensity of LBP [18]. The Oswestry 139 Disability Index (ODI) was used to determine related-disability [19]. The ODI has 10 items referring 140 to activities of daily living that might be disrupted due to LBP. Each item is answered on a 6-point 141 Likert scale ranging from “no problem at all” [0] to “not possible” [5]. 2.1. Participants 116 The total score arises from 142 summing all answers (0–50), multiplied by 2 to obtain a final index ranging from 0 (no disability) to 143 100 (maximum disability). The Spanish version of the ODI has shown good reliability and internal 144 consistency [20]. 145 Diagnostics Accepted 5 of 18 After the training session, participants were in supine hook-lying and performed the ADIM 155 twice as real testing 1) for manual palpation and 2) for ultrasound assessment. The assessor provided 156 the following verbal feedback during the ADIM: “take a relaxed breath in and out, hold the breath 157 out, and then draw the belly button towards your lumbar spine as you did previously while kneeling 158 on all fours (Supplementary Video).” Participants were advised about avoiding any compensatory 159 pattern including holding the breath, backward movement of the pelvis, visual costal movement 160 suggestive of superficial abdominal muscles (external oblique, OE) contraction or pressing the heels 161 down towards the table [22]. Each subject was given a rest period of 2 min between each trial (by 162 different assessors) and a rest period of 10 min between the type of assessments (manual palpation 163 or ultrasound). 164 2.4. Rehabilitative Ultrasound Imaging Assessment 165 Ultrasound images were obtained with participants in the supine hook-lying position, using a 166 real-time ultrasound scanner (Shenzhen Mindray Co, M7 model), with a 10-MHz curvilinear probe. 167 For assessing muscle thickness, the probe was placed transversely just above the iliac crest in the mid- 168 axillary line (Figure 1A). The focal depth was manually adjusted on each participant, focusing on the 169 OI muscle to maximize optimal visualization of the three abdominal muscles (EO, IO, TrA). Three 170 images were obtained bilaterally at rest and on muscle contraction during the ADIM (at the end of 171 exhalation) [23], and the mean of the three measurements was used for analysis. For images taken at 172 rest, participants were instructed to breathe normally, and the image was acquired at the end of a 173 regular/normal inspiration to prevent TrA activation [24]. Since all LBP patients exhibited bilateral 174 symptoms, the mean value of both sides was considered in the statistical analysis. 175 176 Figure 1. Ultrasound probe placed transversely just above the iliac crest in the mid-axillary line (A). 177 Manual palpation of the transversus abdominis by placing the index and middle fingers just 2cm (B) 178 medial to the anterior superior iliac spine (C). 179 176 Figure 1. Ultrasound probe placed transversely just above the iliac crest in the mid-axillary line (A). 177 Manual palpation of the transversus abdominis by placing the index and middle fingers just 2cm (B) 178 medial to the anterior superior iliac spine (C). 179 2.5. Data Imaging and Management 180 Once the image was captured, it was transferred to offline ImageJ 1.8® Software for calculatin 181 muscle thickness of the TrA, IO, and EO muscles at rest and during the ADIM (muscle contraction 182 Muscle thickness was measured as the distance between the inside borders of hyperechoic fasci 183 layers of each muscle separately, but without including fascia thickness. To consistently measure ove 184 the same point along all the muscles, measurements were conducted in a vertical line located 3cm 185 lateral to the rectus sheath muscle-fascia junction (semilunaris line) as previously described (Figur 186 2) [25]. 187 176 Figure 1. Ultrasound probe placed transversely just above the iliac crest in the mid-axillary line (A). 177 Manual palpation of the transversus abdominis by placing the index and middle fingers just 2cm (B) 178 medial to the anterior superior iliac spine (C). 179 2.5. 2.4. Rehabilitative Ultrasound Imaging Assessment 165 Data Imaging and Management 180 Once the image was captured, it was transferred to offline ImageJ 1.8® Software for calculating 181 muscle thickness of the TrA, IO, and EO muscles at rest and during the ADIM (muscle contraction). 182 Muscle thickness was measured as the distance between the inside borders of hyperechoic fascial 183 layers of each muscle separately, but without including fascia thickness. To consistently measure over 184 the same point along all the muscles, measurements were conducted in a vertical line located 3cm 185 lateral to the rectus sheath muscle-fascia junction (semilunaris line) as previously described (Figure 186 2) [25]. 187 Figure 1. Ultrasound probe placed transversely just above the iliac crest in the mid-axillary line (A). 177 Manual palpation of the transversus abdominis by placing the index and middle fingers just 2cm (B) 178 medial to the anterior superior iliac spine (C). 179 6 of 18 Diagnostics Accepted Figure 2. Ultrasound image of the deep abdominal muscles (A). Colour mark of the deep abdominal muscles (B). Ultrasound measurements conducted in a vertical line located 3cm lateral to the rectus heath muscle-fascia junction (semilunaris line) (C). 188 Figure 2. Ultrasound image of the deep abdominal muscles (A). Colour mark of the deep abdominal 189 muscles (B). Ultrasound measurements conducted in a vertical line located 3cm lateral to the rectus 190 sheath muscle-fascia junction (semilunaris line) (C). 191 Figure 2. Ultrasound image of the deep abdominal muscles (A). Colour mark of the deep abdominal muscles (B). Ultrasound measurements conducted in a vertical line located 3cm lateral to the rectus sheath muscle-fascia junction (semilunaris line) (C). The change in muscle thickness from rest to contraction during the ADIM was reported as an 192 absolute value in millimeters (mm), and as a percentage of change. In addition, the TrA contraction 193 ratio (TrA thickness contracted/TrA thickness at rest) and the TrA preferential activation ratio [(TrA 194 thickness contracted/TrA + OE + OI thickness contracted) − (TrA thickness at rest/TrA + OE + OI 195 thickness at rest)] were also calculated [26]. It has been described that the preferential activation ratio 196 determines the relative coactivation of the TrA in relation to EO and IO muscles. 2.6. Assessors and Reliability Calculation 229 A 2-way mixed-model, consistency-type intraclass correlation coefficient (ICC3,1) was used to 230 evaluate the inter-rater reliability of muscle thickness (TrA, IO and EO) measurements on the total 231 sample (as a group and by gender), as well as independently for each group (patients or controls). 232 Based on the ICC2,1 value, reliability was considered excellent (ICC ≥ 0.90), good (0.90 > ICC ≥ 0.70), 233 fair (0.70 > ICC ≥ 0.40), or poor (ICC < 0.40) [30]. The standard error of measurement (SEM) was 234 calculated as follows: SEM (%) = (SDx√1−ICC) × 100. The 90 and 95 minimal detectable change (MDC) 235 were also calculated: MDC90: SEM × 1.64 × √2; MDC95: SEM × 1.96 × √2 [31]. 236 The inter-rater and test-retest reliability of clinical palpation of the ADIM was evaluated using 237 the Cohen’s kappa (κ) coefficients with their respective 95% Cis, again in the total sample (as a group 238 and by gender) as well as independently for each group (patients or controls). To better understand 239 reliability, observed and expected agreements are also reported along with prevalence and bias 240 indices. Additionally, given that the kappa value is sensitive to imbalances in prevalence and bias, 241 the prevalence-adjusted and bias-adjusted kappa (PABAK) was also calculated [31]. The PABAK 242 calculation is a more restrictive reliability analysis performed by adjusting for high or low prevalence 243 by computing the average of cells a and d in a cross table, substituting this value for the actual values 244 in those cells. Similarly, an adjustment for bias is achieved by substituting the mean of cells b and c 245 for the actual cell values [32]. Reliability was defined according to the classification system proposed 246 by Landis and Koch: excellent (0.81–1.0), good (0.61–0.80), moderate (0.41–0.60), fair (0.21–0.40), or 247 poor (0.0–0.2) [33]. 248 249 Two assessors, who received 60 h of education on US imaging and manual palpation, 203 participated. For manual palpation, the assessor placed the index and middle fingers just 2cm medial 204 to the anterior superior iliac spine, in the anatomical projection of the deep abdominal muscles as is 205 commonly done in clinical practice (Figure 1B). Each assessor determined the presence and/or 206 absence of preferential contraction of the deep abdominal muscles during the ADIM on each subject 207 without knowing the participant’s condition (patient or control). 2.4. Rehabilitative Ultrasound Imaging Assessment 165 However, since 197 simultaneous activation of the OI and the TrA has been reported [27,28], we created the Modified 198 Preferential Activation Ratio [(TrA thickness contracted/(TrA + OE thickness contracted) − (TrA 199 thickness at rest/TrA + OE thickness at rest)]. 200 201 7 of 18 Diagnostics Accepted 2.6. Assessors and Reliability Calculation The contraction was considered 208 positive when the assessor perceived a slow, deep, and bilateral tension in the anatomical projection 209 of the deep abdominal muscles, without any compensatory pattern as previously described. Manual 210 palpation was conducted by each assessor on two different days with 7-days between. Each day, 211 manual palpation was repeated 3 times by each assessor. A positive contraction was considered when 212 two of three trials were perceived as having involved contraction. Intra-rater reliability was 213 calculated from the assessment of each assessor on both days (test-retest), whereas inter-rater 214 reliability was calculated from assessment of both assessors on each day. 215 In addition, ultrasound assessment was conducted once by each assessor to assess inter-rater 216 reliability of muscle thickness the first day of assessment. Participants were repositioned on each 217 assessment and the order of assessment and raters was numerically randomized. Every image was 218 coded to blind the assessors by using alphanumerical codes. We assessed inter-rater reliability of 219 ultrasound imaging of muscle thickness with the mean data obtained the first day by each assessor. 220 A sample of 16 participants per group was calculated for obtaining κ agreement data (proportion 222 of positive ratings: 0.5; Kappa to detect: 0.7; significance level: 0.05; power: 80%; 2 tailed test) as 223 recommended in reliability statistics [29]. 224 Data analysis was performed using SPSS version 21.0 (SPSS Inc., Chicago, Ill, USA). For all the 226 analyses, a p value <0.05 was considered as statistically significant. Demographics and clinical 227 characteristics data were assessed for normality by Shapiro-Wilks test and visual inspection of 228 histograms. 229 A 2-way mixed-model, consistency-type intraclass correlation coefficient (ICC3,1) was used to 230 evaluate the inter-rater reliability of muscle thickness (TrA, IO and EO) measurements on the total 231 sample (as a group and by gender), as well as independently for each group (patients or controls). 232 Based on the ICC2,1 value, reliability was considered excellent (ICC ≥ 0.90), good (0.90 > ICC ≥ 0.70), 233 fair (0.70 > ICC ≥ 0.40), or poor (ICC < 0.40) [30]. The standard error of measurement (SEM) was 234 calculated as follows: SEM (%) = (SDx√1−ICC) × 100. The 90 and 95 minimal detectable change (MDC) 235 were also calculated: MDC90: SEM × 1.64 × √2; MDC95: SEM × 1.96 × √2 [31]. 2.6. Assessors and Reliability Calculation y Two assessors, who received 60 h of education on US imaging and manual palpation, 203 participated. For manual palpation, the assessor placed the index and middle fingers just 2cm medial 204 to the anterior superior iliac spine, in the anatomical projection of the deep abdominal muscles as is 205 commonly done in clinical practice (Figure 1B). Each assessor determined the presence and/or 206 absence of preferential contraction of the deep abdominal muscles during the ADIM on each subject 207 without knowing the participant’s condition (patient or control). The contraction was considered 208 positive when the assessor perceived a slow, deep, and bilateral tension in the anatomical projection 209 of the deep abdominal muscles, without any compensatory pattern as previously described. Manual 210 palpation was conducted by each assessor on two different days with 7-days between. Each day, 211 manual palpation was repeated 3 times by each assessor. A positive contraction was considered when 212 two of three trials were perceived as having involved contraction. Intra-rater reliability was 213 calculated from the assessment of each assessor on both days (test-retest), whereas inter-rater 214 reliability was calculated from assessment of both assessors on each day. 215 In addition, ultrasound assessment was conducted once by each assessor to assess inter-rater 216 reliability of muscle thickness the first day of assessment. Participants were repositioned on each 217 assessment and the order of assessment and raters was numerically randomized. Every image was 218 coded to blind the assessors by using alphanumerical codes. We assessed inter-rater reliability of 219 ultrasound imaging of muscle thickness with the mean data obtained the first day by each assessor. 220 2.7. Sample Size Calculation 221 A sample of 16 participants per group was calculated for obtaining κ agreement data (proportion 222 of positive ratings: 0.5; Kappa to detect: 0.7; significance level: 0.05; power: 80%; 2 tailed test) as 223 recommended in reliability statistics [29]. 224 2.8. Statistical Analysis 225 Data analysis was performed using SPSS version 21.0 (SPSS Inc., Chicago, Ill, USA). For all the 226 analyses, a p value <0.05 was considered as statistically significant. Demographics and clinical 227 characteristics data were assessed for normality by Shapiro-Wilks test and visual inspection of 228 histograms. 2.6. Assessors and Reliability Calculation 282 Asymptomatic Controls (n = 16) Low Back Pain (n = 16) p-value Mean ± SD/n (%) Mean ± SD/n (%) Age (years) 29.5 ± 4.5 28.5 ± 4.0 0.648 Gender (female) 8 (50%) 8 (50%) 1.00 Body mass (kg) 68.0 ± 9.5 67.0 ± 13.0 0.854 Height (m) 1.75 ± 0.1 1.70 ± 0.1 0.266 BMI (kg/m2) 22.3 ± 2.0 22.9 ± 2.4 0.418 VAS (0–100, mm) – 39.5 ± 15.9 – ODI (0–100, %) – 24.5 ± 14.5 – BMI: Body Mass Index; VAS: Visual Analog Scale; ODI: Oswestry Disability Index. 283 284 p p y The current gold standard to determine activation of the TrA during the test is fine wire 258 electromyography, which is invasive and was not used. To calculate the optimal cut-off point for TrA 259 preferential activation ratio, we, therefore, generated a new dichotomous variable based on the 260 relative MDC obtained from the present study data repeated from different days for the total sample. 261 Accordingly, we considered a positive performance of the ADIM if the participant generated a 262 contraction of deep abdominal muscle, i.e., TrA, that exceeded the relative value of the MDC (i.e., 263 error of measurement on repeated testing) established for this muscle at rest but did not exceed the 264 MDC established for the OI and EO muscles. Therefore, by means of a ROC curve (operating 265 characteristics curve) the optimum point for the original and modified preferential activation ratio 266 was established, which can be used as a criterion variable to qualitatively determine the correct 267 performance, as identified by manual palpation, of the ADIM. This cut-off point was determined by 268 means of the Youden index, and the diagnostic precision was evaluated according to the area under 269 the ROC curve, with values above 0.7 being considered acceptable [35]. Finally, using the calculated 270 criterion variable, sensitivity and specificity data of manual palpation of the ADIM applied by each 271 assessor was established. Validity was considered acceptable when at least 70% sensitivity and 50% 272 specificity values were obtained [36]. 273 Table 1. Demographic and Clinical Characteristics of the Sample. Table 1. Demographic and Clinical Characteristics of the Sample. 2.6. Assessors and Reliability Calculation 236 [ ] The inter-rater and test-retest reliability of clinical palpation of the ADIM was evaluated using 237 the Cohen’s kappa (κ) coefficients with their respective 95% Cis, again in the total sample (as a group 238 and by gender) as well as independently for each group (patients or controls). To better understand 239 reliability, observed and expected agreements are also reported along with prevalence and bias 240 indices. Additionally, given that the kappa value is sensitive to imbalances in prevalence and bias, 241 the prevalence-adjusted and bias-adjusted kappa (PABAK) was also calculated [31]. The PABAK 242 calculation is a more restrictive reliability analysis performed by adjusting for high or low prevalence 243 by computing the average of cells a and d in a cross table, substituting this value for the actual values 244 in those cells. Similarly, an adjustment for bias is achieved by substituting the mean of cells b and c 245 for the actual cell values [32]. Reliability was defined according to the classification system proposed 246 by Landis and Koch: excellent (0.81–1.0), good (0.61–0.80), moderate (0.41–0.60), fair (0.21–0.40), or 247 poor (0.0–0.2) [33]. 248 249 Diagnostics Accepted 8 of 18 Concurrent validity was analyzed by evaluating the correlation between the manual palpation 250 with muscle thickness ratios. The correlation was evaluated using Spearman correlation coefficients: 251 very high correlation (0.9–1.0), high correlation (0.70–0.89), moderate correlation (0.50–0.69), low 252 correlation (0.26–0.49), or small/no-correlation (0.00–0.25) [34]. Furthermore, the validity of the 253 manual palpation during the ADIM to perceive the positive contraction of the deep abdominal 254 muscles was evaluated by comparing the results obtained by palpation by the assessors during the 255 ADIM with muscle thickness ratios. For the analysis, the average of the original and modified 256 preferential activation ratios provided by each assessor was used. 257 with muscle thickness ratios. The correlation was evaluated using Spearman correlation coefficients: 251 very high correlation (0.9–1.0), high correlation (0.70–0.89), moderate correlation (0.50–0.69), low 252 correlation (0.26–0.49), or small/no-correlation (0.00–0.25) [34]. Furthermore, the validity of the 253 manual palpation during the ADIM to perceive the positive contraction of the deep abdominal 254 muscles was evaluated by comparing the results obtained by palpation by the assessors during the 255 ADIM with muscle thickness ratios. For the analysis, the average of the original and modified 256 preferential activation ratios provided by each assessor was used. 2.6. Assessors and Reliability Calculation 257 The current gold standard to determine activation of the TrA during the test is fine wire 258 electromyography, which is invasive and was not used. To calculate the optimal cut-off point for TrA 259 preferential activation ratio, we, therefore, generated a new dichotomous variable based on the 260 relative MDC obtained from the present study data repeated from different days for the total sample. 261 Accordingly, we considered a positive performance of the ADIM if the participant generated a 262 contraction of deep abdominal muscle, i.e., TrA, that exceeded the relative value of the MDC (i.e., 263 error of measurement on repeated testing) established for this muscle at rest but did not exceed the 264 MDC established for the OI and EO muscles. Therefore, by means of a ROC curve (operating 265 characteristics curve) the optimum point for the original and modified preferential activation ratio 266 was established, which can be used as a criterion variable to qualitatively determine the correct 267 performance, as identified by manual palpation, of the ADIM. This cut-off point was determined by 268 means of the Youden index, and the diagnostic precision was evaluated according to the area under 269 the ROC curve, with values above 0.7 being considered acceptable [35]. Finally, using the calculated 270 criterion variable, sensitivity and specificity data of manual palpation of the ADIM applied by each 271 assessor was established. Validity was considered acceptable when at least 70% sensitivity and 50% 272 specificity values were obtained [36]. 273 274 3. Results 275 3.1. Participants 276 From 25 participants with back pain symptoms responding to the announcement, nine were 277 excluded due to previous lumbar fusion (n = 3), pain radiating to a lower extremity (n = 2), pregnancy 278 (n = 2), and obesity (n = 2), leaving a total of sixteen patients. In addition, 16 comparative healthy 279 participants were also included. Demographic and clinical features are shown in Table 1. 280 281 Table 1. Demographic and Clinical Characteristics of the Sample. 2.6. Assessors and Reliability Calculation 282 Asymptomatic Controls (n = 16) Low Back Pain (n = 16) p-value Mean ± SD/n (%) Mean ± SD/n (%) Age (years) 29.5 ± 4.5 28.5 ± 4.0 0.648 Gender (female) 8 (50%) 8 (50%) 1.00 Body mass (kg) 68.0 ± 9.5 67.0 ± 13.0 0.854 Height (m) 1.75 ± 0.1 1.70 ± 0.1 0.266 BMI (kg/m2) 22.3 ± 2.0 22.9 ± 2.4 0.418 VAS (0–100, mm) – 39.5 ± 15.9 – ODI (0–100, %) – 24.5 ± 14.5 – BMI: Body Mass Index; VAS: Visual Analog Scale; ODI: Oswestry Disability Index. 283 9 of 18 Diagnostics Accepted 3.2. Reliability of US Imaging between Assessors 287 The inter-rater reliability for muscle thickness ranged from good to excellent for the total sample 288 (ICC ranging from 0.84 to 0.90) without significant differences between males (ICC ranging from 0.77 289 to 0.90) and females (ICC ranging from 0.78 to 0.90) and also separately for patients (ICC from 0.79 290 to 0.90) and healthy participants (ICC from 0.86 to 0.91). In general, inter-rater reliability was slightly 291 higher in the healthy group than in the LBP patient group. The TrA exhibited the lowest SEM and 292 MDC (SEM: 0.36–0.75; MDC90–95: 0.84–2.08), followed by the EO (SEM: 0.36–0.88; MDC90–95: 0.84– 293 2.44) and IO (SEM: 0.61–1.66; MDC90–95: 1.42–3.22). Again, no significant gender differences were 294 found. In general, the SEM and MDC for muscle thickness during the ADIM were higher than at rest 295 and also slightly higher in patients than in controls. The descriptive statistics, ICCs and associated 296 95% confidence intervals, SEM, MDC90 and MDC95 are shown in Table 2. 297 298 3.3. Reliability of Manual Palpation during the ADIM 299 The inter-rater reliability of the ADIM ranged from good to excellent regardless of the total 300 sample, gender or group (κ: 0.71–1.00), while the test-retest (intra-rater) reliability was excellent (κ: 301 0.82–1.00). Inter-rater reliability was good (κ: 0.71) in patients with LBP while it was almost perfect 302 (κ: 0.82–1.00) in controls. Importantly, reliability was not affected by the prevalence and sample bias 303 indices since PABAK and kappa index values were practically identical (Table 3). 304 3.2. Reliability of US Imaging between Assessors 287 3.2. 2.6. Assessors and Reliability Calculation Reliability of US Imaging between Assessors 287 y f g g The inter-rater reliability for muscle thickness ranged from good to excellent for the total sample 288 (ICC ranging from 0.84 to 0.90) without significant differences between males (ICC ranging from 0.77 289 to 0.90) and females (ICC ranging from 0.78 to 0.90) and also separately for patients (ICC from 0.79 290 to 0.90) and healthy participants (ICC from 0.86 to 0.91). In general, inter-rater reliability was slightly 291 higher in the healthy group than in the LBP patient group. The TrA exhibited the lowest SEM and 292 MDC (SEM: 0.36–0.75; MDC90–95: 0.84–2.08), followed by the EO (SEM: 0.36–0.88; MDC90–95: 0.84– 293 2.44) and IO (SEM: 0.61–1.66; MDC90–95: 1.42–3.22). Again, no significant gender differences were 294 found. In general, the SEM and MDC for muscle thickness during the ADIM were higher than at rest 295 and also slightly higher in patients than in controls. The descriptive statistics, ICCs and associated 296 95% confidence intervals, SEM, MDC90 and MDC95 are shown in Table 2. 297 298 3.3. Reliability of Manual Palpation during the ADIM 299 The inter-rater reliability of the ADIM ranged from good to excellent regardless of the total 300 sample, gender or group (κ: 0.71–1.00), while the test-retest (intra-rater) reliability was excellent (κ: 301 0.82–1.00). Inter-rater reliability was good (κ: 0.71) in patients with LBP while it was almost perfect 302 (κ: 0.82–1.00) in controls. Importantly, reliability was not affected by the prevalence and sample bias 303 indices since PABAK and kappa index values were practically identical (Table 3). 304 10 of 18 Diagnostics Accepted Table 2. Inter-rater Reliability of Ultrasound Muscle Thickness at Rest and during the ADIM. Table 2. Inter-rater Reliability of Ultrasound Muscle Thickness at Rest and during the ADIM. 2.6. Assessors and Reliability Calculation a e y g TRANSVERSUS ABDOMINIS (TrA) Mean ± SD ICC (95 CI) SEM (mm) MDC90 (mm; %) MDC95 (mm; %) Rater A Rater B Total Sample (n = 32) Rest (mm) ADIM (mm) Change (mm; %) 3.5 ± 0.8 6.2 ± 1.4 2.7 ± 1.4; 77% 3.4 ± 0.8 6.2 ± 1.5 2.8 ± 1.3; 84% 0.84 (0.67 to 0.92) 0.86 (0.71 to 0.93) 0.43 0.72 1.01; 29% 1.68; 27% 1.20; 35% 1.99; 32% Male Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 3.9 ± 0.6 6.4 ± 1.3 2.5 ± 1.5; 64% 3.8 ± 0.5 6.5 ± 1.4 2.7 ± 1.3; 71% 0.77 (0.36 to 0.92) 0.89 (0.69 to 0.96) 0.33 0.61 0.76; 20% 1.42; 22% 0.90; 23% 1.69; 26% Female Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 3.1 ± 0.9 5.9 ± 1.5 2.8 ± 1.3; 90% 3.0 ± 0.9 5.9 ± 1.5 2.9 ± 1.4; 97% 0.78 (0.36 to 0.92) 0.83 (0.50 to 0.94) 0.54 0.83 1.26; 41% 1.95; 33% 1.50; 49% 2.31; 39% Asymptomatic Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 3.6 ± 0.8 6.3 ± 1.6 2.7 ± 1.5; 77% 3.4 ± 0.8 6.3 ± 1.6 2.8 ± 1.5; 83% 0.89 (0.68 to 0.96) 0.89 (0.68 to 0.96) 0.36 0.75 0.84; 24% 1.75; 28% 1.00; 29% 2.08; 33% Low Back Pain Patients (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 3.4 ± 0.8 6.0 ± 1.1 2.6 ± 1.3; 76% 3.3 ± 0.9 6.12± 1.3 2.8 ± 1.2; 85% 0.79 (0.40 to 0.93) 0.81 (0.47 to 0.94) 0.51 0.070 1.19; 35% 1.64; 27% 1.41; 42% 1.95; 32% INTERNAL OBLIQUE (IO) Total Sample (n = 32) Rest (mm) ADIM (mm) Change (mm; %) 6.6 ± 1.3 8.0 ± 2.1 1.5 ± 2.0; 22% 6.6 ± 1.5 8.3 ± 2.2 1.7 ± 1.9; 26% 0.90 (0.80 to 0.95) 0.85 (0.69 to 0.93) 0.62 1.10 1.44; 22% 2.58; 32% 1.71; 26% 3.06; 37% 11 of 18 Diagnostics Accepted Male Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 7.1 ± 1.0 8.2 ± 2.3 1.2 ± 1.4; 15% 7.1 ± 1.3 8.5 ± 1.9 1.2 ± 1.1; 20% 0.86 (0.60 to 0.95) 0.83 (0.52 to 0.94) 0.57 1.15 1.34; 19% 2.67; 32% 1.59;22% 3.17; 38% Female Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 6.0 ± 1.4 7.9 ± 2.1 1.9 ± 1.3; 32% 6.0± 1.6 8.1 ± 2.4 2.1 ± 1.9; 35% 0.90 (0.70 to 0.96) 0.87 (0.62 to 0.95) 0.68 1.10 1.58; 26% 2.56; 32% 1.87; 31% 3.04; 38% Asymptomatic Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 7.0 ± 1.3 8.5 ± 2.2 1.5 ± 2.3; 22% 7.1 ± 1.5 8.6 ± 2.1 1.5 ± 2.1; 22% 0.90 (0.70 to 0.96) 0.86 (0.60 to 0.95) 0.64 1.07 1.49; 21% 2.50; 29% 1.77;25% 2.97; 35% Low Back Pain Patients (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 6.2 ± 1.3 7.6 ± 2.0 1.4 ± 1.7; 23% 6.1 ± 1.4 7.9 ± 2.3 1.9 ± 1.8; 31% 0.89 (0.68 to 0.96) 0.83 (0.52 to 0.94) 0.61 1.16 1.42; 23% 2.71; 35% 1.68; 27% 3.22;41% EXTERNAL OBLIQUE (EO) Total Sample (n = 32) Rest (mm) ADIM (mm) Change (mm; %) 4.7 ± 1.1 5.6 ± 1.5 0.9 ± 1.4; 19% 4.6 ± 1.2 5.6 ± 1.6 1.0 ± 1.5; 23% 0.90 (0.80 to 0.95) 0.84 (0.68 to 0.92) 0.45 0.83 1.06; 23% 1.94; 35% 1.26; 27% 2.31; 41% Male Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 5.0 ± 1.0 5.6 ± 1.4 0.6 ± 1.4; 12% 4.8 ± 1.2 5.7 ± 1.8 0.9 ± 1.8; 19% 0.90 (0.72 to 0.96) 0.89 (0.68 to 0.96) 0.47 0.73 1.09; 22% 1.70; 30% 1.30; 26% 2.02; 36% Female Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 4.4 ± 1.1 5.6 ± 1.7 1.2 ± 1.4; 27% 4.3 ± 0.9 5.5 ± 1.6 1.2 ± 1.1; 28% 0.89 (0.69 to 0.96) 0.81 (0.44 to 0.93) 0.45 0.94 1.05; 24% 2.20; 40% 1.24; 29% 2.61; 47% 12 of 18 Diagnostics Accepted Asymptomatic Subjects (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 4.9 ± 1.0 5.9 ± 1.6 1.0 ± 1.6; 20% 4.6 ± 1.0 5.8 ± 1.8 1.2 ± 1.6; 25% 0.91 (0.72 to 0.97) 0.88 (0.65 to 0.96) 0.36 0.80 0.84; 18% 1.87; 32% 1.00; 21% 2.22; 38% Low Back Pain Patients (n = 16) Rest (mm) ADIM (mm) Change (mm; %) 4.5 ± 1.2 5.2 ± 1.4 0.8 ± 1.2; 17% 4.5 ± 1.2 5.4 ± 1.5 0.9 ± 1.4;20% 0.90 (0.71 to 0.97) 0.79 (0.41 to 0.93) 0.52 0.88 1.21; 27% 2.05; 38% 1.44; 32% 2.44;46% ADIM: Abdominal Drawing-In Maneuver; CI: Confidence Interval; ICC: Intraclass Correlation Coefficient; MDC: Minimal Detectable Change; SEM: Standard Error of the Measurement. 2.6. Assessors and Reliability Calculation Discussion 35 The present results revealed a good to excellent intra- and inter-rater reliability of palpation and 36 inter-rater reliability for muscle thickness assessment during the ADIM in patients with LBP and 37 healthy controls. Manual palpation showed concurrent validity for identifying the preferential 38 Table 4. Correlations between Manual Palpation and Muscle Thickness assessing Transversus 18 Abdominis (TrA) Muscle Contraction. 19 TrA-CR TrA-PAR M-TrA-PAR Rater A 0.39* 0.48* 0.60** Rater B 0.36* 0.39* 0.51** TrA-CR: Transversus Abdominis-Contraction Ratio; TrA-PAR: Transversus Abdominis-Preferential 20 Activation Ratio; M-TrA-PAR: Modified-Transversus Abdominis-Preferential Activation Ratio. * p < 21 0.05. ** p < 0.01. 22 Concurrent validity data from manual palpation during the ADIM can be found in Table 5. The 23 transformation of continuous to dichotomous US imaging measurement to determine the selective 24 contraction of TrA, showed significant and acceptable models for the preferential activation indices 25 [TrA-PAR (ROC value = 0.86; p = 0.001); and M-TrA-PAR (ROC value = 0.89; p < 0.001)]. When 26 evaluating the diagnostic accuracy of manual palpation, the best result was obtained when a value 27 equal to or greater than 0.08 is observed in the M-TrA PAR index, and used as a criterion variable for 28 correct selective contraction of TrA (Sensitivity: 0.95–1.00; specificity: 0.62). 29 Table 5. Concurrent Validity of Manual Palpation to Determine the Contraction of the Transversus 30 Abdominis using USI measurements transformed into dichotomous ones as a criterion variable. 2.6. Assessors and Reliability Calculation 13 of 18 Diagnostics Accepted Table 3. Inter-rater and Intra-rater Test-retest Reliability of Manual Palpation during the Abdominal 1 Drawing-In Maneuver (ADIM). 2 INTER-RATER RELIABILITY Observed agreement Expected agreement Prevalence Index Bias Index Kappa (95%CI) PABAK Day 1 Total Sample (n=32) Males (n=16) Females (n=16) Asymptomatic (n=16) Low Back Pain (n=16) 0.91 0.61 0.47 0.03 0.76 (0.50 to 1.00) 0.81 0.94 0.88 0.94 0.59 0.63 0.66 0.44 0.50 0.56 0.06 0.01 0.06 0.85 (0.55 to 1.00) 0.67 (0.23 to 1.00) 0.82 (0.47 to 1.00) 0.88 0.75 0.88 0.88 0.56 0.38 0.13 0.71 (0.34 to 1.00) 0.75 Day 2 Total Sample (n=32) Males (n=16) Females (n=16) Asymptomatic (n=16) Low Back Pain (n=16) 0.94 0.63 0.50 0.00 0.83 (0.61 to 1.00) 0.88 0.94 0.94 1.00 0.59 0.66 0.70 0.44 0.56 0.63 0.06 0.06 0.00 0.85 (0.55 to 1.00) 0.82 (0.47 to 1.00) 1.00 (1.00 to 1.00) 0.88 0.88 1.00 0.88 0.57 0.38 0.00 0.71 (0.33 to 1.00) 0.75 INTRA-RATER TEST-RETEST RELIABILITY Observed agreement Expected agreement Prevalence Index Bias Index Kappa (95%CI) PABAK Rater A Total Sample (n=32) Males (n=16) Females (n=16) Asymptomatic (n=16) Low Back Pain (n=16) 0.94 0.63 0.50 0.00 0.83 (0.61 to 1.00) 0.88 0.94 0.94 0.94 0.59 0.66 0.66 0.44 0.56 0.56 0.06 0.06 0.06 0.85 (0.55 to 1.00) 0.82 (0.47 to 1.00) 0.82 (0.47 to 1.00) 0.88 0.88 0.88 0.94 0.59 0.44 0.06 0.85 (0.55 to 1.00) 0.88 Rater B Total Sample (n=32) Males (n=16) Females (n=16) Asymptomatic (n=16) Low Back Pain (n=16) 0.97 0.61 0.47 0.03 0.92 (0.77 to 1.00) 0.94 0.94 1.00 1.00 0.59 0.63 0.70 0.44 0.50 0.63 0.06 0.00 0.00 0.85 (0.55 to 1.00) 1.00 (1.00 to 1.00) 1.00 (1.00 to 1.00) 0.88 1.00 1. 00 0.94 0.55 0.31 0.06 0.86 (0.60 to 1.00) 0.88 CI: Confidence Interval; PABAK: Prevalence-Adjusted and Bias-Adjusted Kappa;. 3 ble 3. Inter-rater and Intra-rater Test-retest Reliability of Manual Palpation during the Abdominal awing-In Maneuver (ADIM). INTER-RATER RELIABILITY Transformation of muscle thickness to activation ratios provided the following data: 6 Transversus Abdominis-Contraction Ratio (TrA-CR): 1.88 (0.49); TrA-Preferential Activation Ratio 7 (TrA-PAR): 0.08 (0.05); Modified-TrA-Preferential Activation Ratio (M-TrA-PAR): 0.09 (0.1). 8 Manual palpation during the ADIM showed acceptable concurrent validity as it showed low to 9 moderate correlations with ratios of the US imaging measurement (Table 4). In fact, manual 0 evaluation during the ADIM showed the highest association with the M-TrA-PAR (Table 4). 2.6. Assessors and Reliability Calculation 1 2 14 of 18 14 of 18 Diagnostics Accepted Table 4. Correlations between Manual Palpation and Muscle Thickness assessing Transversus 18 Abdominis (TrA) Muscle Contraction. 19 TrA-CR TrA-PAR M-TrA-PAR Rater A 0.39* 0.48* 0.60** Rater B 0.36* 0.39* 0.51** TrA-CR: Transversus Abdominis-Contraction Ratio; TrA-PAR: Transversus Abdominis-Preferential 20 Activation Ratio; M-TrA-PAR: Modified-Transversus Abdominis-Preferential Activation Ratio. * p < 21 0.05. ** p < 0.01. 22 Concurrent validity data from manual palpation during the ADIM can be found in Table 5. The 23 transformation of continuous to dichotomous US imaging measurement to determine the selective 24 contraction of TrA, showed significant and acceptable models for the preferential activation indices 25 [TrA-PAR (ROC value = 0.86; p = 0.001); and M-TrA-PAR (ROC value = 0.89; p < 0.001)]. When 26 evaluating the diagnostic accuracy of manual palpation, the best result was obtained when a value 27 equal to or greater than 0.08 is observed in the M-TrA PAR index, and used as a criterion variable for 28 correct selective contraction of TrA (Sensitivity: 0.95–1.00; specificity: 0.62). 29 Table 5. Concurrent Validity of Manual Palpation to Determine the Contraction of the Transversus 30 Abdominis using USI measurements transformed into dichotomous ones as a criterion variable. 31 TrA-CR Proposed model for the dichotomous transformation of USI measurements: ROC value (95%CI) = 0.60 (0.39– 0.82); p = 0.33 Youden Index = 0.25 TrA-CR Cut-off point = 1.32 TrA-PAR* Proposed model for the dichotomous transformation of USI measurements: ROC value (95%CI) = 0.86 (0.71 - 1.00); p = 0.001 Youden Index = 0.73 TrA-PAR Cut-off point = 0.06 Sensitivity (95%CI) Specificity (95%CI) LR + (95%CI) LR - (95%CI) ADIM Rater A 0.90 (0.77–1.00) 0.33 (0.12–0.55) 1.35 (1.00–1.93) 0.30 (0.07–1.00) Rater B 0.85 (0.69–1.00) 0.50 (0.22–0.78) 1.70 (1.00–3.08) 0.30 (0.09–0.98) M-TrA-PAR* Proposed model for the dichotomous transformation of USI measurements: ROC value (95%CI) = 0.89 (0.74–1.00); p < 0.001 Youden Index = 0.78 M-TrA-PAR Cut-off point = 0.08 Sensitivity (95%CI) Specificity (95%CI) LR + (95%CI) LR - (95%CI) ADIM Rater A 1.00 (1.00–1.00) 0.62 (0.35–0.88) 2.60 (1.31–5.17) 0.00 (0.00–0.00) Rater B 0.95 (0.85–1.00) 0.62 (0.35–0.88) 2.46 (1.23–4.94) 0.09 (0.01–0.60) ADIM: Abdominal Drawing-In Manoeuvre; TrA-CR: Transversus Abdominis-Contraction Ratio; 32 TrA-PAR: Transversus Abdominis-Preferential Activation Ratio; M-TrA-PAR: Modified-Transversus 33 Abdominis-Preferential Activation Ratio. * Model statistically significant. 34 4. 4.1. Reliability of Manual Palpation during ADIM and RUSI Imaging 1 53 This is the first study using PABAK calculations for determining reliability of manual palpation 54 during the ADIM, which increase the precision of statistical analysis. Nevertheless, we should 55 consider that both assessors of our study received 60 h of education on RUSI and manual palpation 56 during the ADIM, which could explain their positive results. This is a relevant topic since manual 57 palpation and RUSI assessment are operator dependent. Future studies should investigate the role of 58 proper education and clinical experience in reproductivity of manual palpation during the ADIM to 59 determine if reliability is related to the assessor experience. 60 We also found good to excellent inter-rater reliability of RUSI assessment of the deep abdominal 61 muscles in both LBP patients (ICC 0.79–0.90) and healthy participants (ICC 0.86–0.91). Two 62 systematic reviews have previously investigated reliability of RUSI of the abdominal muscles [13,14]. 63 Hebert et al. concluded that most studies investigating intra-rater reliability showed moderate to 64 excellent score (ICC from 0.48 to 1.0); however, 60% of the studies were of poor methodological 65 quality [13]. Inter-rater reliability was investigated in only two studies reporting excellent scores (ICC 66 from 0.91 to 1.0); however, data were mainly based on healthy populations [13]. Similar results were 67 reported by the Costa et al. review [14]. This review observed good to excellent reliability (ICC 0.81 68 to 0.92) for single measures of TrA thickness but poor to good reliability (ICC 0.48 to 0.78) for 69 measures of thickness changes, reflecting TrA muscle activity [14]. The present results showing good 70 to excellent inter-rater reliability of muscle thickness measurements agree with these previous 71 reviews [13,14]. Importantly, our study also observed that inter-rater reliability was good-to-excellent 72 in LBP (ICC 0.79 to 0.90). 73 This is the first study using PABAK calculations for determining reliability of manual palpation 54 during the ADIM, which increase the precision of statistical analysis. Nevertheless, we should 55 consider that both assessors of our study received 60 h of education on RUSI and manual palpation 56 during the ADIM, which could explain their positive results. This is a relevant topic since manual 57 palpation and RUSI assessment are operator dependent. Future studies should investigate the role of 58 proper education and clinical experience in reproductivity of manual palpation during the ADIM to 59 determine if reliability is related to the assessor experience. 4.1. Reliability of Manual Palpation during ADIM and RUSI Imaging 1 60 y p We also found good to excellent inter-rater reliability of RUSI assessment of the deep abdominal 61 muscles in both LBP patients (ICC 0.79–0.90) and healthy participants (ICC 0.86–0.91). Two 62 systematic reviews have previously investigated reliability of RUSI of the abdominal muscles [13,14]. 63 Hebert et al. concluded that most studies investigating intra-rater reliability showed moderate to 64 excellent score (ICC from 0.48 to 1.0); however, 60% of the studies were of poor methodological 65 quality [13]. Inter-rater reliability was investigated in only two studies reporting excellent scores (ICC 66 from 0.91 to 1.0); however, data were mainly based on healthy populations [13]. Similar results were 67 reported by the Costa et al. review [14]. This review observed good to excellent reliability (ICC 0.81 68 to 0.92) for single measures of TrA thickness but poor to good reliability (ICC 0.48 to 0.78) for 69 measures of thickness changes, reflecting TrA muscle activity [14]. The present results showing good 70 to excellent inter-rater reliability of muscle thickness measurements agree with these previous 71 reviews [13,14]. Importantly, our study also observed that inter-rater reliability was good-to-excellent 72 in LBP (ICC 0.79 to 0.90). 73 2.6. Assessors and Reliability Calculation 31 TrA-CR Proposed model for the dichotomous transformation of USI measurements: ROC value (95%CI) = 0.60 (0.39– 0.82); p = 0.33 Youden Index = 0.25 TrA-CR Cut-off point = 1.32 TrA-PAR* Proposed model for the dichotomous transformation of USI measurements: ROC value (95%CI) = 0.86 (0.71 - 1.00); p = 0.001 Youden Index = 0.73 TrA-PAR Cut-off point = 0.06 Sensitivity (95%CI) Specificity (95%CI) LR + (95%CI) LR - (95%CI) ADIM Rater A 0.90 (0.77–1.00) 0.33 (0.12–0.55) 1.35 (1.00–1.93) 0.30 (0.07–1.00) Rater B 0.85 (0.69–1.00) 0.50 (0.22–0.78) 1.70 (1.00–3.08) 0.30 (0.09–0.98) M-TrA-PAR* Proposed model for the dichotomous transformation of USI measurements: ROC value (95%CI) = 0.89 (0.74–1.00); p < 0.001 Youden Index = 0.78 M-TrA-PAR Cut-off point = 0.08 Sensitivity (95%CI) Specificity (95%CI) LR + (95%CI) LR - (95%CI) ADIM Rater A 1.00 (1.00–1.00) 0.62 (0.35–0.88) 2.60 (1.31–5.17) 0.00 (0.00–0.00) Rater B 0.95 (0.85–1.00) 0.62 (0.35–0.88) 2.46 (1.23–4.94) 0.09 (0.01–0.60) ADIM: Abdominal Drawing-In Manoeuvre; TrA-CR: Transversus Abdominis-Contraction Ratio; 32 TrA-PAR: Transversus Abdominis-Preferential Activation Ratio; M-TrA-PAR: Modified-Transversus 33 Abdominis-Preferential Activation Ratio. * Model statistically significant. 34 Table 5. Concurrent Validity of Manual Palpation to Determine the Contraction of the Transversus y p Abdominis using USI measurements transformed into dichotomous ones as a criterion variable. The present results revealed a good to excellent intra- and inter-rater reliability of palpation and 36 inter-rater reliability for muscle thickness assessment during the ADIM in patients with LBP and 37 healthy controls. Manual palpation showed concurrent validity for identifying the preferential 38 activity of the deep abdominal muscles, potentially the TrA and IO, supporting its use in clinical 39 practice. 40 15 of 18 Diagnostics Accepted 15 of 18 4.1. Reliability of Manual Palpation during ADIM and RUSI Imaging 1 4.1. Reliability of Manual Palpation during ADIM and RUSI Imaging 41 This is the first study investigating both intra- and inter-rater reliability of manual palpation 42 during ADIM. We found excellent intra-rater reliability on different days (κ: 0.82–1.00) and good to 43 excellent inter-rater reliability (κ: 0.71–1.00). Current results are better than those previously reported 44 by an earlier study evaluating inter-rater reliability of manual palpation during the ADIM in healthy 45 subjects (κ: 0.52) [16]. The previous study included students and the statistical analysis only included 46 single kappa coefficients [16]. More recently, Kaping et al. investigated the inter-rater reliability of 47 manual palpation during the ADIM and reported substantial agreement (κ: 0.71, 95%CI 0.41 to 1.00) 48 [17]. Current and previous findings would suggest that manual palpation during the ADIM seems to 49 be a reliable procedure for identifying deep abdominal muscles activity. In addition, an important 50 topic of the present analysis is that reliability values were not affected when the PABAK test, a more 51 restrictive reliability statistical analysis, was applied. The application of PABAK has been shown to 52 increase the reliability of clinical tests for identifying shoulder instability [37]. 53 This is the first study investigating both intra- and inter-rater reliability of manual palpation 42 during ADIM. We found excellent intra-rater reliability on different days (κ: 0.82–1.00) and good to 43 excellent inter-rater reliability (κ: 0.71–1.00). Current results are better than those previously reported 44 by an earlier study evaluating inter-rater reliability of manual palpation during the ADIM in healthy 45 subjects (κ: 0.52) [16]. The previous study included students and the statistical analysis only included 46 single kappa coefficients [16]. More recently, Kaping et al. investigated the inter-rater reliability of 47 manual palpation during the ADIM and reported substantial agreement (κ: 0.71, 95%CI 0.41 to 1.00) 48 [17]. Current and previous findings would suggest that manual palpation during the ADIM seems to 49 be a reliable procedure for identifying deep abdominal muscles activity. In addition, an important 50 topic of the present analysis is that reliability values were not affected when the PABAK test, a more 51 restrictive reliability statistical analysis, was applied. The application of PABAK has been shown to 52 increase the reliability of clinical tests for identifying shoulder instability [37]. 4.2. Concurrent Validity of Manual Palpation compared with RUSI Imaging 4 One of the main objectives of this study was to determine the concurrent validity of palpation 75 during the ADIM for evaluating deep abdominal muscle activity. We found low to moderate 76 association between manual palpation with the different US ratios (see Table 4). We used three 77 different preferential activation US ratios (TrA-CR, TrA-PAR, M-TrA-PAR) to asses concurrent 78 validity of manual palpation. The highest association between palpation and US ratios was observed 79 for the M-TrA-PAR (r: 0.60), whereas the lowest association was reported for the TrA-CR (r: 0.36). In 80 fact, the application of the Youden index identified that TrA-CR was not a significant predictor of 81 TrA contraction perceived during the ADIM by the assessor. On the contrary, both preferential 82 activation ratios (TrA-PAR, M-TrA-PAR) showed acceptable models. These present results would 83 support that preferential activation ratios, instead the TrA contraction ratio, should be used in clinical 84 practice for evaluating deep abdominal muscle activity. These results would agree with those 85 previously reported by Pulkovski et al. who also found that the TrA-CR was not able to distinguish 86 between patients with LBP and controls (discriminant validity) [38]. 87 Interestingly, although both preferential activation ratios (TrA-PAR and M-TrA-PAR) showed 88 concurrent validity with manual palpation, the best predictive model was obtained with the M-TrA- 89 PAR. This modified preferential activation ratio considers the simultaneous contraction of the TrA 90 Interestingly, although both preferential activation ratios (TrA-PAR and M-TrA-PAR) showed 88 concurrent validity with manual palpation, the best predictive model was obtained with the M-TrA- 89 PAR. This modified preferential activation ratio considers the simultaneous contraction of the TrA 90 Diagnostics Accepted 16 of 18 and IO muscles [26,27], which could explain its better concurrent validity with manual palpation. 91 One potential explanation maybe the anatomical association between the TrA and IO muscles and, 92 therefore, the inability to directly palpate the TrA [39]. Future studies should investigate the 93 discriminant validity of this preferential activation ratio (M-TrA-PAR) for identifying patients with 94 LBP from healthy controls. 95 and IO muscles [26,27], which could explain its better concurrent validity with manual palpation. 91 One potential explanation maybe the anatomical association between the TrA and IO muscles and, 92 therefore, the inability to directly palpate the TrA [39]. 4.3. Strengths and Limitations 96 Additionally, data by gender showed in the current study 120 should be considered with caution at this stage, since it was not possible to determine reliability of 121 the data by gender on each group (patients or controls) due to the sample size. 122 Current results should be considered attending to the strengths and limitations of the study. A 97 strength of the present study was to include most of the methodological flaws identified by Costa et 98 al. [14]. This review identified that inappropriate description of the sample and the assessors, 99 inadequate statistics, lack of blinding or lack of controlling measures order were the most common 100 methodological weaknesses of published studies [14]. The current study was conducted considering 101 these weaknesses to improve the methodological quality. Additionally, we conducted a deep analysis 102 of reproducibility and concurrent validity of manual palpation of deep abdominal muscles activity 103 during the ADIM as compared with RUSI measures. Although we followed previous guidelines for 104 reliability studies [28], the total sample size could be considered relatively small. Naturally, this could 105 affect presence of positive and negative findings to 50%. However, to overcome this situation, 106 PABAK calculations were also included and reported along with kappa, to show transparently how 107 data would have been with equal distributions of positive and negative test results. 108 q p g Among the potential limitations, manual palpation and RUSI measurements were not conducted 109 simultaneously. This situation could affect the results considering a possible learning effect on the 110 participants. The topic of manual palpation of the deep abdominal muscles is currently debatable, 111 since it is not possible to directly palpate the TrA muscle due to its deep anatomical location. 112 Therefore, it should be comprehensible that manual palpation during the ADIM aims to identify 113 preferential activity of the deep abdominal muscles, that is, TrA and IO, against activity of the most 114 superficial muscle, i.e., the EO muscle. Additionally, it should be noted that MCD and SEM data from 115 muscle thickness data used in this study to calculate the optimal cut-off point for TrA preferential 116 activation ratio were based on inter-rater, and not intra-rater, reliability. The reason for not assessing 117 intra-rater reliability of US imaging muscle thickness is that it has been well established in the 118 literature as being good to excellent [13,14]. 4.2. Concurrent Validity of Manual Palpation compared with RUSI Imaging 4 Future studies should investigate the 93 discriminant validity of this preferential activation ratio (M-TrA-PAR) for identifying patients with 94 LBP from healthy controls. 95 4.3. Strengths and Limitations 96 Current results should be considered attending to the strengths and limitations of the study. A 97 strength of the present study was to include most of the methodological flaws identified by Costa et 98 al. [14]. This review identified that inappropriate description of the sample and the assessors, 99 inadequate statistics, lack of blinding or lack of controlling measures order were the most common 100 methodological weaknesses of published studies [14]. The current study was conducted considering 101 these weaknesses to improve the methodological quality. Additionally, we conducted a deep analysis 102 of reproducibility and concurrent validity of manual palpation of deep abdominal muscles activity 103 during the ADIM as compared with RUSI measures. Although we followed previous guidelines for 104 reliability studies [28], the total sample size could be considered relatively small. Naturally, this could 105 affect presence of positive and negative findings to 50%. However, to overcome this situation, 106 PABAK calculations were also included and reported along with kappa, to show transparently how 107 data would have been with equal distributions of positive and negative test results. 108 Among the potential limitations, manual palpation and RUSI measurements were not conducted 109 simultaneously. This situation could affect the results considering a possible learning effect on the 110 participants. The topic of manual palpation of the deep abdominal muscles is currently debatable, 111 since it is not possible to directly palpate the TrA muscle due to its deep anatomical location. 112 Therefore, it should be comprehensible that manual palpation during the ADIM aims to identify 113 preferential activity of the deep abdominal muscles, that is, TrA and IO, against activity of the most 114 superficial muscle, i.e., the EO muscle. Additionally, it should be noted that MCD and SEM data from 115 muscle thickness data used in this study to calculate the optimal cut-off point for TrA preferential 116 activation ratio were based on inter-rater, and not intra-rater, reliability. The reason for not assessing 117 intra-rater reliability of US imaging muscle thickness is that it has been well established in the 118 literature as being good to excellent [13,14]. Finally, the rigid inclusion criteria used in the study may 119 limits the generalizability of the results. 4.3. Strengths and Limitations 96 Finally, the rigid inclusion criteria used in the study may 119 limits the generalizability of the results. Additionally, data by gender showed in the current study 120 should be considered with caution at this stage, since it was not possible to determine reliability of 121 the data by gender on each group (patients or controls) due to the sample size. 122 References 138 1. Fatoye, F., Gebrye, T., Odeyemi, I. Real-world incidence and prevalence of low back pain using routinely 139 collected data. Rheumatol Int 2019; 39: 619-626. 140 2. Farahbakhsh, F., Rostami, M., Noormohammadpour, P., et al Prevalence of low back pain among athletes: 141 A systematic review. J Back Musculoskelet Rehabil 2018; 31: 901-916 142 3. Beyera, G.K., O’Brien, J., Campbell, S. Health-care utilisation for low back pain: a systematic review and 143 meta-analysis of population-based observational studies. Rheumatol Int 2019; 39: 1663-1679. 144 4. 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Conclusions 123 The current study reported good to excellent intra- and inter-rater reliability of manual palpation 124 and inter-rater reliability of muscle thickness assessment during the ADIM in patients with LBP and 125 healthy controls. Manual palpation during the ADIM showed concurrent validity with RUSI 126 measures for identifying preferential activity of the deep abdominal muscles, supporting use of 127 palpation in clinical practice. Future studies should investigate if the inclusion of preferential 128 activation ratios provides better information of changes during the course of treatment in patients 129 with LBP. 130 Author Contributions: Conceptualization, all authors; methodology, I.V.-M., M.N.-M., and J.L.A.-B.; software, 3 I.L.d.-U.-V.; validation, all authors; formal analysis, C.F.d.l.-P., and I.L.d.-U.-V.; investigation, all authors; 4 writing—original draft preparation, all authors; writing—review and editing, all authors; supervision, M.S. 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Intertester reliability of clinical 218 shoulder instability and laxity tests in subjects with and without self-reported shoulder problems. BMJ 219 Open 2018; 8: e018472. 220 38. Pulkovski, N., Mannion, A.F., Caporaso, F., Toma, V., Gubler, D., Helbling, D., Sprott, H. Ultrasound 221 assessment of transversus abdominis muscle contraction ratio during abdominal hollowing: a useful tool 222 to distinguish between patients with chronic low back pain and healthy controls? Eur Spine J 2012; 21: S750- 223 9. 224 39. Mannion, A.F., Pulkovski, N., Toma, V., Sprott, H. Abdominal muscle size and symmetry at rest and during 225 abdominal hollowing exercises in healthy control subjects. J Anat 2008; 213: 173-82. 226 © 2020 by the authors. Submitted for possible open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/). 227 © 2020 by the authors. Submitted for possible open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/). 227 228
https://openalex.org/W1989893359	https://hess.copernicus.org/articles/19/1307/2015/hess-19-1307-2015.pdf	English	null	Documentary evidence of historical floods and extreme rainfall events in Sweden 1400–1800	Hydrology and earth system sciences	2,015	cc-by	13,185	Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 D. Retsö Received: 25 June 2014 – Published in Hydrol. Earth Syst. Sci. Discuss.: 5 September 2014 Revised: 30 January 2015 – Accepted: 4 February 2015 – Published: 9 March 2015 Received: 25 June 2014 – Published in Hydrol. Earth Syst. Sci. Discuss.: 5 September 2014 Revised: 30 January 2015 – Accepted: 4 February 2015 – Published: 9 March 2015 2 Basic orographical and hydrological characteristics Abstract. This article explores documentary evidence of ﬂoods and extreme rainfall events in Sweden in the pre- instrumental period (1400–1800). The survey shows that two sub-periods can be considered as ﬂood-rich, 1590–1670 and the early 18th century. The result related to a low degree of human impact on hydrology during the period, suggests that climatic factors, such as lower temperatures and increased precipitation connected to the so-called Little Ice Age rather than large-scale atmospheric circulation patterns, should be considered as the main driver behind ﬂood frequency and magnitude. The Scandinavian mountain range (with a maximum altitude of 2469 m above sea level) runs in a north–south direction on the western side of the Scandinavian Peninsula. The conti- nental divide largely coincides with the border between Swe- den and Norway. Most rivers in Sweden ﬂow down on the eastern slopes of the mountain range in a southeasterly di- rection through the largely ﬂat lands into the Bothnian Sea and the Gulf of Bothnia. In south-central Sweden a number of large lakes are found – Vänern, Vättern, Mälaren and Hjäl- maren – which catch waters to constitute the main basins of large catchment areas (see Fig. 1). In the southernmost part of the country the modestly elevated Småland highlands, with a maximum altitude of 377 m, is the source of a number of smaller rivers that run both into the Baltic Sea to the east and the south and into the Kattegatt–Skagerrak of the North Sea in the west. 1 Introduction The purpose of this article is to give an overview of major his- torical ﬂood events in Sweden in the pre-instrumental period (1400–1800) based on documentary sources. A few data con- cern Finland. Focus will be on river ﬂoods driven by rainfall (summer and autumn) and snowmelt (spring). First, a gen- eral presentation of the basic orographical and hydrological features of Sweden will be given, followed by a presenta- tion and critical evaluation of available sources in terms of reliability and validity. An indexation on magnitude will be given and an attempt to identify ﬂood-rich and ﬂood-poor sub-periods will be made. A catalogue of ﬂoods and extreme rainfall events 1400–1800 is found in Table A1, and a cata- logue of possible ﬂood-related harvest failures 1200–1600 is found in Table B1. The study intends to align with prevalent recommendations in methodology and observation periods in order to enhance the possibilities of synoptic reconstruction, calibration and general conclusions on ﬂood regimes in Eu- rope in the pre-instrumental period. The most important catchment areas are Dalälven, Norrström, Göta älv and Motala ström (see Fig. 1). Dalälven is Sweden’s longest river with a total extension of 520 km. The total catchment area is 28 954 km2. Lake Mälaren con- stitutes a basin collecting water from a wide range of smaller rivers, totalling a catchment area of 22 650 km2, all ﬂow- ing into the Baltic Sea at Stockholm. The main outlet is Norrström, north of the Old Town of Stockholm, which has given the name of the entire catchment area. Sweden’s largest lake, Vänern, catches waters running down from the higher altitudes in the province of Värmland as well as in Norway and lets its waters continue to the North Sea by the Göta älv River. At its mouth, the second largest city of modern Swe- den, Gothenburg, is located, though only founded as late as 1628. The total area of the catchment is 50 229 km2. The Mo- tala ström catchment area with 15 481 km2, is constituted by sö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–180 Södertälje and the two narrow canals Norrström and Söder- ström in Stockholm, founded around AD 1250 and later to become the capital of Sweden. The combination of these three factors – the importance of mining to the Swedish econ- omy, the location of the mines near rivers subjected to spring ﬂoods and the location of Sweden’s most prominent early city – produce a number of hydrological data in contempo- rary historical sources. Figure 1. Catchment areas and major lakes in Sweden mentioned in the text. Although many catchment areas in Sweden are quite large (15–50 000 km2), most rivers in south-central Sweden are, with a few exceptions, not suitable for navigation due to their small size and the presence of rapids. It led authorities at an early point to explore the possibilities of building canals and locks, but such projects were never carried out on any signiﬁcant scale before the 19th century (Meyersson, 1943; Bring, 1911). Also dredging projects were few and limited before the 19th century. The only systematic dredging of Swedish rivers seems to have been a consequence of in- creased log driving, predominantly in the northern provinces and in the ﬁrst half of the 18th century (Ahlbäck and Alberts- son, 2006; Wik, 1950). Serious alterations of runoff through engineered modiﬁcations only occurred in the second half of the 20th century with the development of hydropower plants in the north. The hydrological events prior to the 19th cen- tury are therefore to a large extent the result of natural fac- tors. The hydrologically most vulnerable point was the city of Stockholm. It is located at the outlet of Lake Mälaren, where a ﬂoodgate was constructed already before the 16th century to control the spring-ﬂood water and where most works of this kind were carried out (see e.g. Almquist, 1903, 241 pp.; Handl. rör. Skand. hist. 19, 1834, 183 pp.; Almquist, 1913, p. 82). In the early 15th century some dredging works were carried out at the outlet of Södertälje and again in the late 17th century but had little impact on the hydrology of the lake (Bring, 1924). Figure 1. Catchment areas and major lakes in Sweden mentioned in the text. the waters running from Lake Vättern to the Baltic Sea at Norrköping. The geographical distribution of hydrological data in doc- umentary sources mirrors the economic geography of me- dieval and early modern Sweden. Published by Copernicus Publications on behalf of the European Geosciences Union. Published by Copernicus Publications on behalf of the European Geosciences Union. 1308 3 The documentary sources whole individual letter suites (e.g. Sjöberg, 1911, 1915; Wi- jkmark, 1995), and a number of institutional records such as letters from bailiffs and civil servants throughout the country (Retsö, 2002; Almquist 1868, 1875, 1877, 1893, 1902, 1903, 1913; Styffe, 1893; Edén, 1905; Ahnlund, 1930). The present study has been mainly based on printed letters, diaries, travel notes, annals and chronicles, as well as sec- ondary sources such as regional topographical descriptions. Some data have been found in the Swedish National Archives (Riksarkivet) in Stockholm. There are also some compila- tions of general weather data from the 18th century (Ferner, 1756; Falkengren, 1781; Ekman, 1783). Further data could still be found e.g. for the 18th century in newspapers but it is argued here that the main trends would not change sub- stantially. The survey covers the period up to 1800, approx- imately a century before the beginning of systematic instru- mental hydrographic measurements (Lindström and Alexan- dersson, 2004). The period has been chosen in order to avoid complications in the analysis due to the increased interfer- ence of anthropogenic factors in the 19th century. ; y , ; , ; , ) Hydrological data are limited to statements on extreme ﬂood events or general characterizations of an entire year. The approach chosen here is the threshold approach (Hall et al., 2014), i.e. only ﬂoods and rainfall events that have been perceived by contemporaries to be beyond normality have been included. Concerning ﬂoods, the sources tell us about two cases: ﬂoods due to excessive precipitation and extreme spring ﬂoods. However, it is most often impossible to assess the magnitude of ﬂoods in quantitative terms. Some excep- tions are the ﬂoods at Uppsala in 1622, at Söderköping in 1684 – for which the only known ﬂoodmark has been found (Broocman, 1760, p. 149) – at Holmen in 1646, at Ekby 1709, and at Stockholm and Uppsala in 1780. p g y As for most of Europe, the amount of documentary sources in Sweden is meagre for the Middle Ages but increases dra- matically from ca. 1520 due to successful centralization ef- forts of the central authorities by King Gustavus Vasa (1523– 1560) as well as fortunate preservation circumstances (Retsö and Söderberg, 2015a). 3 The documentary sources Thus, for the 12th and 13th centuries, most climatological and parameteorological proxy data are found in chronicles and annals, written long after the events were described and most often of Danish or north German origin. This type of source material is notoriously difﬁcult to use for historical reconstruction, but with speciﬁed method- ology it is not useless especially concerning spectacular and severe events like ﬂoods (Wetter et al., 2011; Retsö and Söderberg, 2015b). Geographical speciﬁcity is not very great – in earlier sources it is conﬁned to general terms (Sweden, Norway, Denmark). The earliest mentioning of a hydrolog- ical extreme found in Scandinavian sources possibly rele- vant for Sweden is from a Danish annal written sometime after 1288, which states that the year 1195 was character- ized by “extreme wetness” (yuerwætis vædher) (Jørgensen, 1930, p. 179). The only primary sources of a uniform kind from the Swedish Middle Ages are the diaries of the Birgit- tine monastery in Vadstena and the Franciscan order of Visby (Gejrot, 1996; Odelman and Melefors, 2008), but they con- tain very little of hydrological data. The magnitude is normally described in vague qualitative terms, e.g. as the worst “in living memory” (mannaminne). It is argued here that such implicit comparisons with previ- ous ﬂoods are indications of perceived absolute magnitude and not relative to real magnitude. The threshold approach inevitably involves an element of interpretation based on an analysis of terminology, the basic understanding of which may have varied somewhat over time and between persons but has nevertheless been mainly constant. For example, “se- vere spring ﬂood” (svår vårﬂod) must have meant a spring ﬂood above normal expectations, and the same is the case with “much wetness” (mycket väta). The data used have thus been restricted to such data that can be conﬁrmed to be reliable and valid and above the threshold of perceived normality. A commonly recom- mended 3-scale indexation of the magnitude is used here, based on the criteria of duration, spatial extension and ma- terial damage/human casualties (Sturm et al., 2001; Llasat et al., 2005; Glaser et al., 2010; Wetter et al., 2011): (1) ﬂoods on a regional scale with little material damage and/or short duration, (2) ﬂoods of signiﬁcant regional or supra-regional magnitude with considerable material damage and/or aver- age duration, and (3) ﬂoods of regional or supra-regional magnitude with disastrous material damage and/or long dura- tion. Following Hall et al. 3 The documentary sources (2014), the survey intends to iden- tify ﬂood-rich periods in order to facilitate cross-continental comparisons. Due to lack of reliable data at this stage no at- tempt will be made to assess discharge. All dates are adjusted according to the Gregorian calendar (New Style), introduced in Sweden in 1753. The quantitative increase of documentary sources in gen- eral after 1520 also implies greater reliability since the num- ber of independent data also increases and the basic require- ments for documentary sources such as nearness in time and space and neutrality are better complied with, as well as the speciﬁc requirements on data for the study of long-term structures and parameteorological phenomena such as ﬂoods, namely, regularity, frequency, uniformity, high time resolu- tion and geographical speciﬁcity (Bell and Ogilvie, 1978; Brázdil et al., 2005, 2010). In addition, the degree of de- tail as to the causes and impact on society is greater. There are several uniform individual records produced by the same person (e.g. Brahe, 1920; Hausen, 1880; Lewenhaupt, 1903), sö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–180 Population density was highest in southern Sweden where consequently agriculture, the most important economic activity and especially sensi- tive to variations in hydrological patterns, was concentrated. Mining, the second most important economic activity, was concentrated in the less populated areas of Bergslagen in the provinces of Västmanland and Dalarna in the areas north and west of Lake Mälaren. Already in the Bronze Age rich mineral resources were found here, giving rise to an early mining activity which used the streaming rivers as a source of power for the roasting and smelting of the raw ore. The mining area predictably became an important zone for the Swedish economy. The rivers are often subject to intense spring ﬂoods when the snow in the mountains to the north- west melts rapidly. The seasonality of ﬂoods in the mining area is therefore concentrated to the spring season and is explained by a combination of snow storage in the moun- tains and the rate of melting in the spring. Lake Mälaren was originally a bay of the Baltic Sea but was separated from it and transformed into a lake by the continuous postglacial re- bound around 1000 BC. The outlet was for long conﬁned to g Consequently, the human impact on river streambeds and ﬂoodplains has been limited during the period in concern here. The pressure of urbanization, population increase, de- forestation, and other land use changes as well as surface al- terations and irregularities in channel alignment can be con- sidered to be negligible due to the sparse population of Swe- den and the low-intensity utilization of rivers. Hypotheti- cally, climate, i. e. precipitation and temperature, would be the main driver behind any observable ﬂood regime change before 1800 (Glaser et al., 2010; Wetter et al., 2011). Excep- tionally, other natural factors than climate explain ﬂoods. For example, according to locals changes in the water levels of Lake Vänern were due to winds over the large lake surface rather than ﬂoods in the tributary rivers or drought (Elvius, 1751–1752, p. 39). www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 1309 4 Results With all these prior observations of the source material, the result of the survey is as follows. A total of 157 ﬂoods or extreme rainfall events have been found for the period 1400– www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 al ﬂoods and extreme rainfall events in Sweden 1400–1800 Figure 3. Documentary evidence of ﬂoods and extreme rainfall events in Sweden, 1400–1800, with levels of magnitude. D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1310 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 Figure 2. Decadal frequency of ﬂoods and extreme rainfall events in Sweden, 1400–1800, according to documentary sources. 1800 of which 107 can be unambiguously deﬁned as ﬂoods Figure 3. Documentary evidence of ﬂoods and extreme rainfall events in Sweden, 1400–1800, with levels of magnitude. 1310 Figure 2. Decadal frequency of ﬂoods and extreme rainfall events in Sweden, 1400–1800, according to documentary sources. Figure 2. Decadal frequency of ﬂoods and extreme rainfall events in Sweden, 1400–1800, according to documentary sources. Figure 3. Documentary evidence of ﬂoods and extreme rainfall events in Sweden, 1400–1800, with levels of magnitude. 1800, of which 107 can be unambiguously deﬁned as ﬂoods (see Table A1). Catchments particularly hit by ﬂoods were Norrström, Göta älv and Dalälven (see Fig. 1). As for magnitude, 32 % of all events were of the third cate- gory (ﬂoods of regional or supraregional magnitude with dis- astrous material damage and/or long duration), and 44 % of the second category (ﬂoods of signiﬁcant regional or suprare- gional magnitude with considerable material damage and/or average duration) (Fig. 3). The impression of the period 1591–1670 as one of dramatic hydrology is substantiated by the fact that almost one-sixth, or 27, of all third category events occurred during that period. ( g ) There is no clear picture of ﬂood frequency during this period. Yet, the data are clearly sufﬁcient to make a prelim- inary identiﬁcation of ﬂood-rich and ﬂood-poor periods (see Figs. 2 and 3). There is a clear tendency to more frequent ﬂoods in the 17th and 18th centuries in general. Especially two periods stand out as particularly ﬂood-rich: 1591–1670 with two intermediate sub-periods with fewer ﬂoods in the 1610s and the 1650s, and the early 18th century. 4 Results On a decadal timescale the highest number of ﬂoods is found in the 1640s (12 events), the 1700s and the 1720s (11 each), followed by the 1630s (10) and the 1620s (9). Years of signiﬁcantly severe ﬂoods were 1649 (6 events), 1622 and 1780 (5 each), and 1596, 1640, 1661, 1677, 1707, 1709 and 1728 (4 each). Par- ticularly serious was the ﬂood in the province of Östergötland in August 1649 (the so-called Olsmässoﬂoden). According to one assessment considerably more than 100 mm, perhaps as much as 200–300 mm of rain may have fallen over certain locations in the southern and central parts of Östergötland in a few days (Alexandersson and Vedin, 2001). The ﬂood in May 1650 seems to have been equally serious; the situation caused the authorities to initiate works to widen the outlet at Stockholm and also to investigate the possibilities to widen the outlet through the Södertälje Canal. The same happened in the spring of 1661 and the authorities sped up the work at Södertälje (Bring, 1924, p. 16). 5.2 Relation to quantity of source data The ﬁrst question to address is whether this can be explained by a deﬁciency in the Swedish source material. It is held here that more documentary sources could doubtlessly improve the picture in its details but not substantially change the gen- eral pattern. For example, the increase in reliable ﬂood data in the 17th and 18th centuries is not entirely a reﬂection of a total increase in documentary sources. Indeed, the total quan- tity of preserved documentary sources rises considerably al- ready in the 1520s but the rising frequency of ﬂoods does not occur until the 1590s. It can thus be concluded that the data most probably reﬂect a real increase in ﬂood events towards the late 16th century. Consequently, it can also be presumed that ﬂoods really were more rare in the source-poor late Mid- dle Ages. As has been pointed out by Wetter et al. (2011), it is highly improbable that spectacular events like major ﬂoods would pass unnoticed by chroniclers. ( ) Previous attempts have failed to establish an unambiguous connection between NAO, winter precipitation and ﬂoods, in general, particularly for northern Europe (Bouwer et al., 2006; Uvo, 2003; Casty et al., 2005). One reason for that is undoubtedly that NAO operates on a great variety of timescales and is interfered with by other local conditions as well as other circulation patterns (Jacobeit et al., 2003; Lavers et al., 2012). Also changes in ﬂood frequencies are obviously the result of the workings of several driving forces at the same time but to different degrees at different times and places, particularly in colder climates as in Sweden. For example, it seems that NAO-related precipitation patterns east of the Scandinavian mountains, i.e. in Sweden, are over- played by other climatic factors (Uvo, 2003; Linderholm et al., 2003). However, it is conspicuous that the great major- ity of the worst ﬂood events have been recorded in catch- ments that are particularly subjected to spring ﬂoods fuelled by melting snow from high altitudes or latitudes (Norrström, Göta älv, Dalälven, Torneälven, Piteälven, Ljungan, Indal- sälven) and where lake evapotranspiration is lower and water storage capacity higher (see Fig. 1). Furthermore, if the av- erage winter temperature of Stockholm (Leijonhufvud et al., 2010) is taken as a proxy for a general meteorological pattern in southern and central Sweden, the frequency of ﬂoods has a clear correlation with cold and snowy winters. 5.2 Relation to quantity of source data Although the correlation of winter precipitation with NAO is gener- ally weaker in Sweden than on the Atlantic coast of Norway D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1311 it would seem that a tendency to a 10–12 years cycle, a timescale which is close to one of the suggested NAOs (Hur- rell and Van Loon, 1997; Cook et al., 1998), could be seen in the Swedish sources between 1620 and 1661 there is no sign of it after that. Similarly, one NAO winter index recon- struction (Cook et al., 2002) identiﬁes a positive phase until about 1640 whereafter it went into a neutral or negative phase which would not be able to explain the ﬂood peaks in Sweden in the following decades. If the chronology of Swedish ﬂood events is compared with the NAO index found in Luterbacher et al. (2002), then no correlation at all can be seen. According to expectations, the NAO would have a marked inﬂuence on precipitation and streamﬂow, particularly in its positive mode when westerly winds bring moist and warm air over Scandi- navia. NAO is also expected to have a stronger effect in the winter than in the summer, and a stronger effect in northern Sweden than in the south (Uvo, 2003). However, the docu- mented ﬂoods are slightly more frequent in negative NAO phases (83 events) than in positive NAO phases (64 events). Furthermore, ﬂoods related to the winter season, i.e. spring ﬂoods, are about as many (70) as those related to the summer season (77). There is no clear tendency in either high altitude or high latitude catchments (deﬁned as catchments no. 1–5 and 7–8 in Fig. 1): the number of events (106) in the former catchments is indeed greater than the number of events (34) in the low latitude/altitude catchments but exhibits a perfectly equal distribution between positive and negative NAO phases (53 events each). land until the ﬁrst decades of the 18th century (Pﬁster, 1999; Schmocker-Fackel and Naef, 2010). The latter half of the century was again a period of high frequency, which only partially coincides with the documentary data from Sweden. There are no traces of similarities with Sweden on single ex- treme years in the same region (Wetter et al., 2011) or in cen- tral Europe at a larger scale (Glaser et al., 2010). There are only slight similarities with the ﬂood chronology of Spain, in particular for the Llobregat and Tagus catchments in the ex- tended period 1580–1620 (Llasat et al., 2005; Benito et al., 2003). 5.1 Comparison with ﬂood-rich and ﬂood-poor periods in continental Europe The result does not neatly coincide nor with tendencies in ﬂood frequency or particular events observed in continental Europe (compare e.g. Wetter et al., 2011; Benito et al., 2003; Glaser et al., 2010; Glaser and Stangl, 2004; Elleder, 2013; De Kraker, 2006). For example, both Brázdil et al. (1999) and Schmocker-Fackel and Naef (2010) found few ﬂoods in northern Switzerland in the ﬁrst half of the 16th century but there was a ﬂood frequency peak in 1560–1590, whereas a ﬁrst peak in Sweden is found only in the following 2 decades. As for the 17th century, there was a low in Switzer- www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 5.3 Comparison with North Atlantic Oscillation (NAO) reconstructions The meteorological/climatological causes behind these Swedish ﬂood data require further research to be identi- ﬁed. In a number of studies the great variability in ﬂood frequencies in Europe has been explained by large-scale atmospheric circulation patterns, particularly on a decadal timescale (Schmocker-Fackel and Naef, 2010; Casanueva et al., 2014). In particular, the NAO together with other, related atmospheric circulation patterns is normally seen as the main explanation for climatic variability in northern Europe (Lind- holm et al., 2009), especially winter precipitation in the NAO positive phases (Hurrell and Van Loon, 1997; Barker et al., 2004; Casanueva et al., 2014) as well as for river discharges, snow accumulation and ﬂooding (Prudhomme and Genevier, 2011). However, there is no clear connection between the existing NAO reconstructions and ﬂood frequency in Sweden. In one reconstruction (Luterbacher et al., 1999) a few winter NAO indices coincide with ﬂood peaks in Sweden (early 18th cen- tury, the 1770s and perhaps also the 1740s), while in oth- ers the picture is somewhat different (see e.g. Luterbacher et al., 2002; Glueck and Stockton, 2001). For example, while www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1312 1949, p. 417; Lindblom, 1793, p. 121; Strömbeck, 1993, p. 170). Some medieval data tell about severe harvest failures and famine without stating the causes (see Table B1). At the present stage no details can be found to support that these extreme events were caused by ﬂoods and undoubtedly some of them are connected to drought. But it is also clear that sev- eral of them may have been caused by ﬂoods. Already Em- manuel Le Roy Ladurie warned about the difﬁculty to estab- lish a strict causal connection between climate and crop fail- ures unless the precise cause is stated or the data can be sup- ported by other contemporary data (Le Roy Ladurie, 1971, 275–6 pp.). The purpose of presenting the Swedish data here is to furnish a point of departure for future research and com- parative analyses that can shed more light on the matter. 6 Conclusions Two periods stand out as particularly ﬂood-rich in the pre- instrumental period in Sweden according to documentary records: 1591–1670 and the early 18th century. In particu- lar, there are clusters of ﬂoods in the 1640s, the 1700s and the 1720s. One-third of all events were ﬂoods of regional or supra-regional magnitude with disastrous material dam- age and/or long duration, and half of them occurred in the period 1591–1670. p The spatial scale of spring ﬂoods and their temporal con- centration in clusters suggest causality on a large timescale, i.e. meteorological conditions connected with the Little Ice Age rather than atmospheric circulation patterns such as the North Atlantic Oscillation (NAO) and a reﬂection of regional response to climatic variability. NAO could very well explain winter precipitation patterns as well as the ﬂood peaks be- tween 1591 and 1650 but only in combination with a Lit- tle Ice Age cooling, which in turn is the more plausible ex- planation for the peaks in the early 18th century. Given the high degree of continuity in demographic and economic con- ditions in the 1400–1800 period, it therefore seems reason- able to conclude that among the potential drivers of ﬂood regime change are the changes in precipitation and temper- ature, i.e. climatic change, that mainly account for the long- term variability of historical ﬂoods in this period. Although there is a natural time lag in relation to temperature, there is a clear correlation between the seasonality and the chronol- ogy of spring ﬂoods, on the one hand, and, on the other, rapid and late melting of larger snow storages in combination with spring precipitation from ca. 1600. This is further conﬁrmed by the observable spatial coherence of major ﬂood events. 5.3 Comparison with North Atlantic Oscillation (NAO) reconstructions (Uvo, 2003) and although temperature tends to increase un- der positive NAO, precipitation in the winter at northern lat- itudes would under all conditions and NAO modes come as snow and therefore generate a larger storage of water in the mountains. Thus, the melting of large amounts of snow in the spring would affect Sweden as well and thereby contribute to spring ﬂoods whose intensity would depend on the evolution of temperature in the spring. Plausibly, a decline in evaporation due to decreasing mean temperatures, probably in connection with heavy winter pre- cipitation in the form of snow and increased spring precipi- tation due to NAO, generated considerably higher levels of runoff, notably at higher altitudes (cf. Burt and Howden, 2013) where the wellsprings of most Swedish catchments are located. The combination of soil saturation, huge snow amounts and spring rain has been pointed out a an important trigger for spring ﬂoods (Wetter et al., 2011). This allows for the conclusion that the NAO can account for precipitation patterns, mainly in the winter, but not necessarily all ﬂood peaks, whereas climate plays the main role for the frequency of ﬂoods. The peaks in Sweden’s ﬂood history would then be characterized as cases of “complex extremes” (Benestad and Haugen, 2007), involving both temperature and precipi- tation. In some cases, the correlation between snow-rich win- ters and spring ﬂoods is explicit in contemporary sources; for example, the winters of 1543, 1544, 1601 and 1780 and the following disastrous spring ﬂoods. This correlation between ﬂood frequencies and the so-called Little Ice Age has also been noted for other areas of Europe (Brázdil et al., 1999; Pﬁster, 1999; Glaser, 2008). Appendix A Table A1. Documentary evidence of ﬂoods and extreme rainfall events in Sweden 1400–1800 (bf – before). Year Date Location River Catchment Index Type Source Comment 1400 after 26 July Söderköping Storån Storån 2 rainfall Fant (1818) p. 95, great ﬂood caused by sudden, violent raining; Paulsson (1974) p. 289, people ﬂed the town in fear of a Deluge; knee- 398 pp. high water inundated cemeteries and streets; bridges and mills destroyed 1405 7 August (Denmark, Sweden) – – 3 rainfall Rørdam (1873) p. 555 continuous raining from early August to Christmas 1421 summer Vadstena Lake Vättern Motala ström 2 rainfall Gejrot (1996) p. 174f “so great quantities of rain that corn rotted . .. followed by plague” 1495 7 November Stockholm (Norrström) Norrström 2 rainfall, sea ﬂood Fant (1818) p. 68 great storm and sea ﬂood destroyed several ships in the harbour 1506 April Arboga Arbogaån Norrström 1 snowmelt Sjödin (1937) p. 205 unusually great spring ﬂood, “a thousand men could not go against it” 1513 July (Sweden) – – 2 rainfall Retsö (2002) p. 148 the greatest rainfall in 6–8 years 1523 January Markaryd 1 snowmelt Larsson (2002) p. 69f great inundations hindered warfare 1526 autumn Västergötland – Göta älv 1 rainfall Almquist (1868) 74 pp. much rain and wetness Province 1530 summer Uppsala bishopric NA Norrström 2 rainfall Almquist (1877) p. 207 very wet summer and autumn, crops endangered 1533 5 August Sala NA Norrström 1 rainfall Riksarkivet, great torrential rain, miners refused to enter the Kammararkivet, mines due to the excessive water Bergsbruk, Sala gruva 1533–1537 1534 8 September Sala NA Norrström 1 rainfall Riksarkivet, great torrential rain, miners refused to enter the Kammararkivet, mines due to the excessive water Bergsbruk, Sala gruva 1533–1537 1543 summer (Sweden) – – 2 rainfall Ekman (1783) p. 143 very wet and cold summer 1544 summer (Sweden) – – 2 rainfall Forssell (1884) Appendix A very wet and cold summer p. 157 1549 23 April Uppsala Fyrisån Norrström 2 snowmelt Almquist (1902) 13/4 1549 spring ﬂood ﬂushed away a mill dam 1550 bf 21 May Lake Mälaren – Norrström 3 snowmelt Almquist (1903) 241 pp., great spring ﬂood causing “mighty great damages Handl. rör. Skand. hist. on ﬁelds and meadows” 19 pp., 183 pp. 1557 bf 15 May Lake Mälaren – Norrström 3 snowmelt Almquist (1913) p. www.hydrol-earth-syst-sci.net/19/1307/2015/ 5.4 Medieval ﬂoods and harvest failures without stated causes There are no unambiguously reliable data on ﬂoods in Swedish medieval sources before the 15th century. In Dan- ish and German chronicles reports are found of heavy raining and/or ﬂoods in 1287, 1315, 1336, 1347, 1357 and 1381 that could possibly have affected Sweden (Holder-Egger, 1880, p. 546; Rørdam, 1873, p. 318, 589, 592 pp.; Langebek, 1772, p. 303; Langebek and Suhm, 1786, p. 532), but the only indication in Swedish sources is a blunt general statement about “evil and wet weather” in 1313 in the Erik chroni- cle, written in the 1330s (Jansson, 2003, p. 148). It should be noted that there are no indications in Swedish medieval sources, as in central Europe, for ﬂoods in the 1340s or in 1501 (cf. Rokoengen et al., 2001; Brázdil et al., 2005; Rohr, 2007; Kiss, 2009; Elleder et al., 2013). It is also uncertain whether the statements in Danish chronicles are relevant for Sweden. The same is the case with the report in Heinrich of Balsee’s chronicle on a ﬂood in northern Germany in Decem- ber 1374 (Crull, 1878, 165 pp.). In many cases the magnitude of ﬂoods in the early modern period is related to the damage on crops (see e.g. Jämtl. räk., 1564–1571, 38 pp.; Sommarström, 1935, p. 285; Ekström, www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1313 Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 Appendix A 82 great spring ﬂood and rapidly rising water levels due to large quantities of ice and snow melting causing great damages on meadows, dams, bridges and mills 1559 July (Västmanland – Norrström 2 rainfall Dalin (1760–1761) p. 485 great rainfall; all hay ﬂushed away Province) 1560 9 July Arboga Arbogaån Norrström 1 torrential Ekström (1949) p. 265 sudden torrential rain causing such a darkness that rain the priest needed a light in the middle of the day and people thought Doomsday was at hand 1571 summer Ragunda Indalsälven Indalsälven 2 rainfall Jämtl. räk. (1564–1571) small harvest due to great wetness 38 pp. 1573 summer Linköping Motala ström 3 rainfall Granlund (1876) p. 45 the cathedral at Linköping damaged by rain 1580 summer (south Västergötland Viskan, Viskan, Ätran 2 rainfall Österberg (1971) p. 219 “terrible wetness”, peasants unable to pay taxes Province) Ätran 1581 spring Gliehammaren – Norrström 2 snowmelt Noraskogs arkiv water wheel damaged beyond repair (1889–1891) p. 173 1589 autumn Skerike Svartån Norrström 3 rainfall Ekström (1949) p. 78 great wetness destroyed the crops 1589 summer Romfartuna Lillån Norrström 2 rainfall Ekström (1949) p. 663 damages on crops due to wetness 1595 bf 7 July Finland – – 2 rainfall Sommarström (1935) p. 285 bad harvest and rotten hay due to excessive rains 1595 summer (Sweden) – – 2 rainfall Brahe (1920), p. 15 unprecedented extreme rains 1596 10 August Örslösa Söneån Göta älv 3 rainfall Silvén-Garnert and great deluge-like rainfall, ﬂushing away bridges, Söderlind (1980) p. 158f water covering ﬁelds and meadows destroying crops and killing goats and sheep 1596 ca. 25 June–ca. 25 July (northern – Norrström 2 rainfall Lewenhaupt (1903) p. 109 raining almost every day for 1 month Södermanland Province) 1596 summer Orsa Oreälven Dalälven 3 rainfall Ekström (1949) p. 417 “severe wetness destroyed the harvest” Table A1. Documentary evidence of ﬂoods and extreme rainfall events in Sweden 1400–1800 (bf – before). www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1314 Table A1. Continued. Year Date Location River Catchment Index Type Source Comment 1596 July Lönneberga, Ålem Silverån, Emån, 3 rainfall Hallendorff (1902) p. 77, ﬂood caused by heavy rainfall; all meadows Alsterån Alsterån Edman (1985) p. Appendix A 72 covered by water so that they looked like lakes; bad damages on hay and corn crops, and animals died of food shortage, hay ﬂushed away from meadows and the crop failure created hunger among peasants 1597 22 May Ålem Alsterån Alsterån 3 torrential rain Edman (1985) p. 72 torrential rain brought by northerly winds; all crops ﬂushed away and the ﬁelds looked like lakes 1597 27 June Ålem Alsterån Alsterån 3 torrential rain Edman (1985) p. 72 torrential rain for 24 hours; corn plants drowned in water and crops ﬂushed away 1600 summer (Östergötland – – 2 rainfall Wennberg (1947) p. 197 no. 3 crops partly destroyed by wetness Province) 1600 20 September– Ålem Alsterån Alsterån 3 rainfall Lindblom (1793) p. 121 continuous raining for 3 weeks from 10 October 20 September, harvests ruined 1601 April Ålem Alsterån Alsterån 3 snowmelt Edman (1985) p. 75, great spring ﬂood caused by sudden warmth Collmar (1960) p. 85, following a severe winter with much snow; all Utterström (1955) p. 29 bridges and most mills destroyed, next year’s seeds destroyed 1602 summer Fresta, Hammarby – Norrström 2 rainfall Strömbeck (1993) p. 170 excessive rains destroyed most of the harvest 1602 summer, Ålem Alsterån Alsterån 2 rainfall Edman (1985) p. 76, “mighty severe autumn wetness” damaged hay autumn Collmar (1960) p. 85, crops and other crops Palme (1942) p. 391 1603 bf 25 February Kumogård, Birkkala Kumo älv Kumo älv 1 snowmelt Waaranen (1864) 9, 12 pp. “superﬂuous water”, “waterﬂow and unnatural (Finland) wetness” 1604 spring Nykroppa Kroppaälven Göta älv 2 snowmelt Furuskog (1924) p. 80 water dams busted by spring ﬂood, requiring 354 days of work to repair 1606 spring Lillfors Storfors-älven Göta älv 2 snowmelt Furuskog (1924) p. 83 water dam busted by spring ﬂood; it took 4 weeks to repair it 1607 autumn Ålem Alsterån Alsterån 2 rainfall Edman (1985) p. 84 “extreme autumn wetness” 1608 May Ålem Alsterån Alsterån 2 rainfall Edman (1985) p. 84 “two mighty great waterﬂoods in May and in August” with much damages on hay and corn crops 1608 August Ålem Alsterån Alsterån 2 rainfall Edman (1985) p. 84 “two mighty great waterﬂoods in May and in August” with damages on hay and corn 1610 16–18 March Visby, Gotland – – 2 rainfall Strelow (1633) p. 298 “severe ﬂood”, water high in the streets 1610 spring (Sweden) – – 1 snowmelt Ekman (1783) p. Appendix A 149 great waterﬂood 1613 spring (Dalarna Province) – Dalälven 1 snowmelt Sillén (1865) p. 84 “strong waterﬂow” 1614 autumn Växjö – Mörrumsån 2 rainfall Ahnlund (1930) p. 363 harvest “badly damaged” by rain 1617 spring Kuivakangas Torne älv Torne älv 3 snowmelt Olofsson and Stille The Särkilax chapel ﬂoated away with the (1965) p. 213 spring ﬂood 1618 spring Uppsala Fyrisån Norrström 2 snowmelt Falkengren (1781) “much damage” by spring ﬂood 1622 spring Löfsta, Uppsala Fyrisån Norrström 3 snowmelt Swederus (1911) p. 238, dams damaged at the Löfsta mill and in Uppsala Falkengren (1781) town, ice blocks thrown up on the main square 1622 spring Norrköping Norrköpings Motala ström 3 snowmelt Helmfrid (1959) p. 21 all water dams swept away by the spring ﬂood ström 1622 spring Piteå Pite älv Pite älv 3 snowmelt Olofsson and Stille dams at Piteå sawmill damaged (1965) p. 273 1622 1 August Stockholm – Norrström 2 rainfall Ahnlund (1920) p. 40f much rain, breaking down the corn 1622 bf 28 October Gothenburg Göta älv Göta älv 2 rainfall Cronholm (1864) p. 67 the harbour damaged by much rain 1623 ca. 30 June eastern Värmland – Göta älv 2 rainfall Hausen (1880) p. 270 a statement on a severe spring ﬂood in 1663 says that an equally destructive ﬂood took place 40 years earlier 1625 bf 5 April– Säter Dalälven Dalälven 3 snowmelt Edén (1905) 206 pp., spring ﬂood unusually violent, destroying the mint 10 May Wittrock (1919) p. 57, at Säter on 10 May, nine people went missing Wolontis (1936) p. 63, Falkengren (1781) 1626 bf 28 April Nyköping Nyköpings-ån Nyköpingsån 1 snowmelt Wittrock (1919) p. 74f the copper minting hindered by spring ﬂood 1628 summer (Sweden) – – 3 rainfall Ekman (1783) p. 136, very rainy summer, ﬂooded ﬁelds and meadows, Falkengren (1781) damaged harvests 1632 bf 28 October Stockholm (Norrström) Norrström 1 rainfall Styffe (1893) p. 504 “continuous wetness” 1632 summer Öland – – 1 rainfall Ilmoni (1849) p. 185, continuous raining Sillén (1865) p. 84, Ahlqvist (1825) p. 295 Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1315 Table A1. Continued. Year Date Location River Catchment Index Type Source Comment 1632 July northern Sweden – – 1 rainfall Olofsson and Stille cold and wet (1965) p. Appendix A 311 1633 summer Öland – – 2 rainfall Sillén (1865) p. 84 continuous raining, famine and dear times 1633 summer (Sweden) – – 3 rainfall Ekman (1783) p. 136 rainy summer with poor harvests in the south and harvest failures in the north 1638 spring Västerbotten – – 3 snowmelt, Göthe (1929) p. 67, spring ﬂood and raining destroyed ﬁelds and rainfall Falkengren (1781), meadows Riksregistraturet 19/3 1639 1640 spring Sala Sagån Norrström 2 snowmelt Edén (1905) p. 267 great spring ﬂood stopped silver mining for 1 month 1640 spring – Lake Mälaren Norrström 1 snowmelt Bring (1924) p. 16 unusually high water levels on lakes 1640 bf 28 May Kopparberget Faluån Dalälven 2 snowmelt Edén (1905) p. 269 f water dams have barely been saved from the spring ﬂood which is expected to last another 14 days 1640 28 June Karlstad Klarälven Göta älv 3 snowmelt Hausen (1880) p. 53 mighty high water levels on the lakes; boats could be rowed across the ﬁelds 1641 summer, northern Sweden, – – 2 rainfall Wittrock (1948) p. 311, “rain almost every day” during the summer, autumn northern Finland Lundkvist (1986) damaging the harvests seriously 1646 10–18 December Holmens bruk Motala ström Motala ström 2 rainfall Helmfrid (1959) p. 67 the water in Motala ström began to rise rapidly around 10 December, to a level only 30 cm below the furnaces on 18 December 1647 19 July Väsby – Norrström 2 rainfall Edén (1905) p. 245 mines ﬁlled with water after great and continuous rainfall, causing a stop for mining for 14 days 1648 – (Sweden) – – 1 rainfall Hausen (1880) p. 135 very wet year 1649 spring Baggetorp – Norrström 2 snowmelt Edén (1905) p. 183 mill dam destroyed by spring ﬂood 1649 spring Stockholm (Norrström), Norrström 3 rainfall Tigerstedt (1888) p. 45, “much wetness and continuous raining” caused Lake Bring (1924) p. 16 harvest failure and poverty among peasants; Lake Mälaren Mälaren high above its banks 1649 summer, autumn (Västergötland, – – 3 rainfall Hausen (1880) p. 143 “so much water that the ears of the corn could not Öland) be seen” 1649 7 August (Östergötland) – Motala ström 3 rainfall Ilmoni (1849) p. Appendix A 196, the “Olsmässa ﬂood”: severe ﬂoods all over the and Rydberg (1997), province, mills, dams, houses, fences, crops and following Alexandersson and trees ﬂushed away, cattle and people died, Vedin (2001) destroyed harvests for 3 years afterwards 1649 autumn (Dalarna Province) – Dalälven 3 rainfall Ilmoni (1849) p. 196 inundations all over the province 1649 bf 16 October Stockholm (Norrström) Norrström 2 rainfall Sjöberg (1911) p. 16 “horrible weather ... it has rained and is still raining tremendously ... this city [of Stockholm] must be the potty of the sky” 1650 bf 19 May – Lake Norrström 2 snowmelt Handl. rör. Skand. hist., rapidly rising water levels in the lake, damaging Mälaren Vol. 9, p. 394, the surroundings Lilienberg (1891) p. 35 1650 autumn – Lake Mälaren Norrström 1 rainfall Bååth (1916) p. 234 rising water levels 1656 bf 21 May Avesta Dalälven Dalälven 3 snowmelt Norberg (1956) p. 32 no. 33 “a tremendous spring ﬂood with so much water that some who live near the river have seen their beds ﬂoating inside their houses” 1658 bf 24 November Småland Province – – 3 snowmelt Holm (1906) p. 346 much snow in November melted and became a ﬂood so great that bridges were destroyed and the water “stood above the back of the horse” 1659 summer Stola Lake Vänern Göta älv 2 rainfall Sjöberg (1911) 146, 149 pp. “great wetness” 1660 spring Skedvi, Säter, (Stora) Dalälven Dalälven 3 snowmelt Riksarkivet, three mines and all water wheels severely Tuna Bergskollegium, damaged by violent spring ﬂood huvudarkivet, Bergverksrelationer EII:a vol. 2 fol 172, 175, 177 1661 spring Skedvi, Säter, (Stora) Dalälven Dalälven 3 snowmelt Riksarkivet, all water wheels severely damaged by violent Tuna Bergskollegium, spring ﬂood huvudarkivet, Bergverksrelationer EII:a vol. 2 fol 175 1661 early spring Stockholm Norrström, Norrström 3 snowmelt Bring (1924) p. 16 extremely high water due to large quantities of Söderström snow and ice melting, covering the Munkbro bridge and entering houses; other bridges and the new lock threatened by the water www.hydrol-earth-syst-sci.net/19/1307/2015/ www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 1316 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 Table A1. Continued. Appendix A Year Date Location River Catchment Index Type Source Comment 1661 spring Västland and Tolfta Tämnarån Tämnarån 3 snowmelt Landshövdingars great damage from spring ﬂood that covered ﬁelds parishes skrivelse t K M:t, for a long time Uppsala län (RA) 1661 bf 17 August Stockholm (Norrström) Norrström 2 rainfall Sjöberg (1915) p. 270 “tremendously great wetness” 1662 autumn Södermanland – Nyköpingsån 1 rainfall Tilander (1968) p. 109 wet and ﬂooded roads Province 1663 bf 10 April Stockholm (Norrström) Norrström 1 snowmelt Sjöberg (1915) p. 369 great spring ﬂood 1663 July, esp. eastern Värmland Göta älv 3 rainfall Hausen (1880) p. 270 terribly much rain on certain locations; heavy 20–21 rainfall on 20–21 July “as if the sky had opened”, followed by ﬂood which destroyed bridges, dams, sawmills etc., the meadows were like lakes, the hay ﬂoated away and the water covered the crops, many pigs drowned 1664 14–16 September Värmland Province Göta älv 2 rainfall Hausen (1880) 302, 303 pp. heavy daily rain and storm with ﬂood and rising river levels 1677 spring Falun Faluån Dalälven 1 snowmelt Hildebrand (1946) p. 331 material damages 1677 spring Stöpsjöhyttan Stöpsjön Göta älv 2 snowmelt Danielson (1974) 19 pp. severe spring ﬂood, damages at the furnace facilities 1677 spring Njurunda Ljungan Ljungan 3 snowmelt Hülphers (1780) p. 30 great ﬂood, causing much damage 1677 5 June – Torne älv Torne älv 3 snowmelt Hellant (1747), Keksi great ﬂood, causing much damage on buildings (1936–1945), Olofsson and killing cattle and Liedgren (1974) p. 93, Fahlgren (1956) p. 48 1680 spring Hännickehammaren Stampbäc-ken Göta älv 2 snowmelt Furuskog (1924) p. 133 violent spring ﬂood destroyed the furnace 1684 bf 27 April Vaksala Lillån Norrström 2 snowmelt letter from the peasants bridges destroyed by spring ﬂood in Vaksala 17 April 1684, RA, Landshövdingens i Uppsala län skrivelser till K. M.:t 1684 spring Söderköping Storån Storån 3 snowmelt Broocman (1760) p. 149 severe spring ﬂood; the water rose to 0.5 m above the benches in the St. Laurentii church and 0.5 m above the ﬂoor, watermark on wall in church 1686 spring Nordhallen, Indalsälven Indalsälven 1 snowmelt Hildebrand (1918) p. 115, great spring ﬂood (Jämtland) Lundström (1912) p. 249 1686 bf 15 June Lundby – Tyresån 2 rainfall Wijkmark (1995) p. Appendix A 436 continuous rain and storms for several days 1691 bf 1 March Vaxholm – Åkersström 2 snowmelt letter from the governor barrier damaged by spring ﬂood of Uppsala Province 19 February 1691, RA, Landshövdingens i Uppsala län skrivelser till K. M.:t 1697 bf 1 May Nykvarn Brants- Norrström 2 snowmelt letter from the governor damages on ferry and mill hammarsån of Uppsala Province 4 April 1697, RA, Landshövdingens i Uppsala län skrivelser till K. M.:t 1697 spring Rytterne Åbäcken Norrström 1 snowmelt Hülphers (1793) p. 319 great spring ﬂood 1703 6–7 July Ydre – Motala ström 2 rainfall Rääf (1875) p. 350 “great rainfall . .. hardly any spring ﬂood could be greater than the ﬂood that followed” 1705 27 May Gotland – – 2 rainfall Kellgren (1931) p. 18 f “snowing all day followed by much rain and great waterﬂood”, not so much damage on crops as on hay 1707 bf 2 January Ljustorp, Medelpad Ljustorpsån Indalsälven 3 rainfall, Hülphers (1771) p. 112 enduring rain and great waterﬂood destroyed snowmelt bridges and water dams 1707 summer Rytterne Åbäcken Norrström 2 rainfall Hülphers (1793) p. 321 “wet summer”, hay and rye crops damaged 1707 summer – Lake Vänern Göta älv 1 rainfall Wallén (1910) p. 13 much raining 1707 summer, Gotland – – 2 rainfall Kellgren (1931) p. 20 violent and enduring rain, wetness continued until autumn New Year 1709 13 March Ekby Tidan Göta älv 3 snowmelt Bergstrand (1934) p. 188 severe winter followed by spring ﬂood which almost reached the parish church (2 km from the river) D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1316 1316 Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 www.hydrol-earth-syst-sci.net/19/1307/2015/ D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1317 Table A1. Continued. Year Date Location River Catchment Index Type Source Comment 1709 spring Norrköping Norrköpings Motala ström 3 snowmelt Ringborg (1920) p. 92, great spring ﬂood causing poverty among peasants ström, Lake Stille (1903) p. 146 f Roxen 1709 spring Uppsala Fyrisån Norrström 3 snowmelt Annerstedt (1912) p. 128 water dams completely ruined by great spring ﬂood 1709 spring Gotland – – 3 snowmelt Kellgren (1931) p. 25 great spring ﬂood causing much damage on sawmills and other mills 1710 May Hälsingland Province – – 1 snowmelt Hægermarck and quite great but not enduring spring ﬂood Grape (1911–1949) p. 340 1711 12, 13, Hälsingland Province – – 1 rainfall Hægermarck and great ﬂood caused by much rain; hay ruined, mill 16 July Grape (1911–1949) p. 348 channels full, as in spring 1712 21 October– Hälsingland Province – – 2 rainfall Hægermarck and “the month of October all wet ... continuous 11 November Grape (1911–1949) p. 353 raining, wind and fog so that, contrary to the usual, creeks and rivers swelled even more than in the spring ... caused much damage” 1714 15–16 September Hälsingland Province – – 3 rainfall Hægermarck and in two days “fell so terribly much rain that all Grape (1911–1949) p. 360 creeks, lakes, meadows were covered. No spring ﬂood could be greater”, great damages; bridges, millhouses, barns, boats destroyed and great slides of chunks of earth 1717 early May Hälsingland Province – – 1 snowmelt Hægermarck and unusually great spring ﬂood Grape (1911–1949) p. 366 1720 24–30 October Hälsingland Province – – 1 rainfall Hægermarck and much rain on 24 and even more on 27, and again Grape (1911–1949) p. 380 on 28–30 October; rising sea level 1721 spring Västerbotten – – 2 snowmelt Lundmark (1990) p. 155 great spring ﬂood ruined ﬁshing of the season Province 1724 20 April Örebro Svartån Norrström 2 snowmelt Linder (1916) p. 25 the excessive water submerged poles in the harbour 1724 spring Långared Säveån Göta älv 2 snowmelt Bergstrand (1954) p. 24 great spring ﬂood causing inundations 1725 summer Västergötland – Göta älv 2 rainfall Bergstrand (1934) p. 1316 154 extremely rainy summer Province 1728 spring Mora southwards Dalälven Dalälven 3 snowmelt Norberg (1956) p. 325 great spring ﬂood damaged all bridges between Mora and the provincial border 1728 spring Järbo Jädraån Dalälven 2 snowmelt Norberg (1958–1959) p. 243 iron furnace destroyed by spring ﬂood 1728 spring Jämtland Province – Indalsälven 1 snowmelt Hasselberg (1930) high waters due to spring ﬂood 1728 spring Njurunda Ljungan Ljungan 1 snowmelt Hülphers (1780) p. 30 great spring ﬂood 1729 spring Jämtland Province – Indalsälven 1 snowmelt Hasselberg (1930) high waters due to spring ﬂood 1730 spring Säter Dalälven Dalälven 2 snowmelt Ericsson (1970) p. 73 the mill severely damaged by spring ﬂood 1730 spring Holmen Hällestadsån Motala ström 2 snowmelt Helmfrid (1954) p. 109, water dam at Säter damaged by spring ﬂood Ericsson (1970) p. 73 1733 August Hälsingland Province – – 3 rainfall Hægermarck and continuous rain day and night throughout the Grape (1911–1949) p. 380 month of August; swamps and meadows ﬁlled with water and streams and creeks greater than in spring ﬂoods so that one could travel over them in boats; hay and corn destroyed. High sea level 1740 summer – Lake Vänern Göta älv 1 rainfall Wallén (1910) p. 13 “wet year” 1740 summer southern and – – 1 rainfall Utterström (1957), Vol. 2 “much wetness” southeastern Sweden p. 429 1743 spring Jämtland Province – Indalsälven 1 snowmelt Hasselberg (1930) high waters due to spring ﬂood 1743 28 May Avesta Dalälven Dalälven 2 snowmelt Norberg (1956) p. 683 river bridge broken down by great spring ﬂood and storm 1743 May Avesta Dalälven Norrström 2 snowmelt Norberg (1956) Vol. 2 river bridge destroyed by spring ﬂood p. 683 1745 spring Uppland – Norrström 1 snowmelt Utterström (1957) p. 430 great spring ﬂood 1745 spring (Västergötland – Göta älv 1 snowmelt Utterström (1957) Vol. 2 great spring ﬂood Province) p. 430, Ny journal (1776–1813) p. 33 1745 15 July Stöde Indalsälven Indalsälven 1 torrential Nordenström (1894) p. 43 “great rain on the 14th, as if the sky had opened rain with a great rainﬂood” 1753 13 August Stöde Indalsälven Indalsälven 1 rainfall Nordenström (1894) p. 44 great ﬂood caused by rain 1754 August Uppsala Fyrisån Norrström 2 rainfall Ferner (1756) 287 pp. wet; much hay and corn destroyed by wetness 1755 spring Stöde Indalsälven Indalsälven 1 snowmelt Nordenström (1894) p. 44 great spring ﬂood www.hydrol-earth-syst-sci.net/19/1307/2015/ Hydrol. Earth Syst. Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 Appendix B Table B1. Documentary data on harvest failures related to Sweden, 1200–1600, without speciﬁed cause. Year Location Source Comment 1283 Denmark Rørdam (1873) p. 587 “a severe dear time” 1291 Sweden Sylvius (1678) p. 211 “dear times” 1310 Denmark Strelow (1633) p. 154 “such a dear time that has not hitherto been known” 1314 Sweden Sylvius (1678) p. 279 “great famine in Sweden” 1319 Denmark Rørdam (1873) p. 589 “a severe dear time” 1360 Denmark Langebek (1772) p. 220 great food shortage 1375 Gotland Strelow (1633) p. 180 “dear times on corn and ﬁsh” 1442 Finland Hausen (1921) no. 2512, 2517, harvest failure on hops and rye 2521, 2528, 2529, 2535 1445 Vadstena Riksarkivet A21 fol. 89r.-v. a letter from May 1447 speaks of food shortage and two consecutive years of harvest failures 1446 Vadstena Riksarkivet A21 fol. 89r.-v. a letter from May 1447 speaks of food shortage and two consecutive years of harvest failures 1455 Sweden, Östergötland Gejrot (1996) 286, 292 pp., Styffe “famine ravaged in all of Sweden so violently that many died of starvation, and (1870) no. 44, Fant (1818) 173, many of the plague”, “so great was the famine this year [1457] and in the past 175 pp., Cod. dipl. lub. (1893), 9 no. 328, two years in Sweden and Östergötland that nobody among the living could Ropp (1883) 378, 383 pp. remember such starvation” 1456 Sweden, Östergötland Gejrot (1996) p. 292 f “so great was the famine this year [1457] and in the past two years in Sweden and Östergötland that nobody among the living could remember such starvation” 1457 Sweden, Östergötland Gejrot (1996) p. 292 f “so great was the famine this year [1457] and in the past two years in Sweden and Östergötland that nobody among the living could remember such starvation” 1470 Finland Hausen (1890) no. 625 “a greatly difﬁcult year” referring to 1470 1542 Finland Almquist (1893) p. 1316 Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 Appendix B 1319 1316 Sci., 19, 1307–1323, 2015 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 1318 D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 Table A1. Continued. Year Date Location River Catchment Index Type Source Comment 1756 11 June Stöde Indalsälven Indalsälven 2 snowmelt Nordenström (1894) p. 44 great spring ﬂood, water rising above the ﬁelds 1759 ca. 15 June Stöde Indalsälven Indalsälven 2 rainfall Nordenström (1894) p. 45 rain ﬂood greater than this year’s spring ﬂood 1763 20 July Stöde Indalsälven Indalsälven 2 rainfall Nordenström (1894) p. 45 rain ﬂood destroying hay harvest 1777 summer Västergötland – Göta älv 2 rainfall Bergstrand (1934) p. 154 continuous rains, few persons could remember Province anything similar 1778 31 March Söderköping Storån Storån 3 rainfall Ny journal (1776–1813) p. 115 great rainfall, ﬂooding the river which covered seven bridges, waters entered church and streets 1780 March Västmanland Lake Norrström 2 snowmelt Utterström (1957) p. 435 unprecedented great spring ﬂood following a Province Mälaren severe, snow-rich and long winter 1780 March Stockholm (Norrström) Norrström 3 snowmelt Ny journal (1776–1813)l p. 231 great spring ﬂood in creeks and streams, unprecedented water levels of the Lake Mälaren, rising up to 4 ft. higher than usual 1780 May Uppsala Fyrisån Norrström 3 snowmelt Ny journal (1776–1813) p. 163 great spring ﬂood following an “unnaturally” snow-rich winter; the waters rose to the windows of the houses and into the gardens which were destroyed 1780 early May Nordmarks hytta Nordmarks- Göta älv 3 snowmelt Danielson (1974) p. 38f the iron furnace at Nordmark destroyed by sudden älven and great spring ﬂood 1780 spring Jämtland Province – Indalsälven 1 snowmelt Hasselberg (1930) high waters due to spring ﬂood 1782 autumn Närke Province – Norrström 2 rainfall Ny journal (1776–1813) p. 224 1 entire month of continuous raining 1785 autumn Uddevalla Bäveån Strömsån 3 rainfall Ny journal (1776–1813) p. 33 extreme autumn rains rose the waters of the river to the highest in 40 years; four bridges, six grainmills and other facilities destroyed 1788 March Norrköping Norrköpings Motala ström 1 snowmelt Ny journal (1776–1813) p. 88 great spring ﬂood with some damage ström 1318 Table A1. Continued. Hydrol. Earth Syst. Sci., 19, 1307–1323, 2015 www.hydrol-earth-syst-sci.net/19/1307/2015/ D. Retsö: Documentary evidence of historical ﬂoods and extreme rainfall events in Sweden 1400–1800 D. Appendix B 292 f “quite small harvest” 1568 Västergötland Riksarkivet Riksregistraturet (1569) “small harvest in Västergötland, the subjects are destitute and impoverished” 5/4 1569 1571 Östergötland Riksarkivet Riksregistraturet (1572) “people in Östergötland are in misery and in need of seed and assistance” 11/5 1572 1586 Uppland, Västmanland Riksarkivet Riksregistraturet (1587) “bad harvest last year” and other provinces 5/4 1587 1587 Uppland, Kalmar, Riksarkivet Riksregistraturet (1588) “hard and dear times”, “bad harvest last year [1587]” Småland, Finland, 15/2 1588, 2/4 1588 northern Sweden 1588 northern Sweden and Hildebrand (1899) p. 811 “small harvest, particularly in northern Sweden and Finland Finland Table B1. 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https://openalex.org/W4311505046	https://bmcpsychology.biomedcentral.com/counter/pdf/10.1186/s40359-022-01007-z	English	null	Sex differences in the sustained attention of elementary school children	BMC psychology	2,022	cc-by	7,803	© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom- mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Abstract Background: The study investigates sex differences in sustained attention among children. Methods: Forty-five children (23 girls) from Grades 2–5 (mean age of 7.47 ± 0.73 years) wore an actigraph for a continuous five to seven days including school and non-school days. Sustained attention using the psychomotor vigilance test (PVT) was measured twice a day on two school days and on one non-school day. Results: No sex differences were found for sleep patterns. However, sex differences in PVT performance were documented. While boys were faster (shorter reaction time) and showed fewer lapses than girls, they showed higher number of false starts than girls, on both weekdays and weekends. Conclusions: The findings suggest that sex differences should been taken into account in studies investigating neu- robehavioral functioning, particularly, sustained attention across various age groups. Keywords: Sleep, Actigraph, Children, Psychomotor vigilance test (PVT), Sex differences of sleep loss on PVT performance, which causes an over- all slowing of response time, increasing lapses of atten- tion, and modestly increasing false starts (e.g., [4]). Apart from its sensitivity to circadian and homeostatic modula- tion, sustained attention is also susceptible to the effects of age [5] and sex [5, 6]. Open Access Sex differences in the sustained attention of elementary school children Barel Efrat* and Tzischinsky Orna Introduction Sustained attention, also called vigilant attention, refers to the attention control processes needed to preserve attention and task engagement over time [1]. It relates to a collection of cognitive processes which enable individu- als to organize their behavior in response to current situ- ational demands and future directions and is an essential part of executive function. Sustained attention is usually measured via computerized performance tasks requiring responses to target signals. The most widely used meas- ure of sustained attention is the psychomotor vigilance test (PVT) due to its psychometric advantages over other cognitive measures [2]. Sustained attention has been shown to be influenced by the interaction between the circadian timing system and the homeostatic sleep regu- latory system [3]. Studies have demonstrated the impact Sex differences in sustained attention have been stud- ied across various age groups. Venker et al. [7] inves- tigated sex differences in the mean and median PVT reaction time (RT) of children aged 6–11. They showed that boys were faster than girls; however, these differ- ences tended to disappear with age. Beijamini et al. [6] evaluated the influence of gender on the PVT perfor- mance of adolescents. They found that boys were faster and had fewer lapses than girls. Blatter et al. [5] examined sex differences in the PVT performance of young adults (aged 20–31) and older adults (aged 57–74). They found that men were faster than women, but women were more likely to avoid false starts. They suggested that these pat- terns of sex differences may imply the use of different strategies to achieve optimal results: women aim to avoid errors, while men aim to be as fast as possible. Department of Behavioral Sciences and the Center for Psychobiological Research, The Max Stern Academic College of Emek Yezreel, Emek Yezreel, Israel Efrat and Orna BMC Psychology (2022) 10:307 https://doi.org/10.1186/s40359-022-01007-z Efrat and Orna BMC Psychology (2022) 10:307 https://doi.org/10.1186/s40359-022-01007-z Department of Behavioral Sciences and the Center for Psychobiological Research, The Max Stern Academic College of Emek Yezreel, Emek Yezreel, Israel . Open Access T d i di i Efrat and Orna BMC Psychology (2022) 10:307 Efrat and Orna BMC Psychology (2022) 10:307 Efrat and Orna BMC Psychology (2022) 10:307 Page 2 of 8 Such a suggestion begs the question of whether sex dif- ferences in achievement strategies are apparent in early stages of development, and the present study therefore chose to investigate sex differences in the sustained atten- tion of children. Previous studies have found differences between boys and male adolescents and girls and female adolescents, showing the former to present shorter reac- tion times, lower error rates, and higher risk-taking ten- dencies (e.g., [7–9]). Similar to the premise regarding sex differences in achievement strategies among adults [5], it has been suggested that sex differences in perfor- mance among children correspond to sex differences in response styles [8]. It has been suggested that girls tend to adopt a more cautious approach to selecting answers than boys which, in a limited time frame, would lead to less accurate response patterns. Studies have provided support for this assertion by showing that girls display more conscientiousness [10] and cautiousness [11, 12] than boys. Further support has come from neuroimaging studies. For example, Cornblath et al. [13] investigated the neurobiological basis of sex differences in executive functions, specifically regarding impulsivity among chil- dren. They measured sex differences in network control- lability and impulse control using the false positive rate in the continuous performance test (CPT) and found that local sex differences in controllability predict false positive responses. Furthermore, superior parietal modal controllability was higher in females and found negatively associated with impulsivity, leading the authors to sug- gest that these regions are involved in impulse control in females. [7, 18]); they did not, however, control for sleep qual- ity. Given that sustained attention is highly sensitive to sleep loss, the present study controlled for this variable through multiple observations of sleep via actigraphic recording. Previous studies explored the relationship between sleep quality and cognitive performance among children. For example, Astill et al. [19] conducted a meta-analysis and found a modest association between sleep duration and cognition among children. They reported that even sustained attention and memory, both of which are sensi- tive to poor sleep, showed no significant association with sleep duration. A possible explanation of these results is that brain immaturity may prevent children from feel- ing poor sleep and fatigue. Recently, Short et al. . Open Access T d i di i [20] showed in a meta-analytic review that only a few studies have examined the association between the sleep dura- tion and optimal cognitive performance of school-age children. Both of these meta-analyses demonstrated that sleep duration is associated with specific cognitive func- tion but not with others and that sleep duration was not associated with sustained attention. Sleep duration may vary between weekend and weekdays nights; however, given that it was not found associated with attention, we assumed that the role of sex differences in sustained attention will not differ between weekend and weekday nights. The present study therefore looked to measure sleep patterns but did not expect sex differences in sus- tained attention to depend on sleep. Regarding sex differences in sleep patterns and sleep- related difficulties, data from several studies suggested that among adolescent, girls tend to report sleep dif- ficulties more frequently than boys [21–24]. In contrast to adolescents, the results among children are inconsist- ent. Whereas some studies observed different sleep pat- terns between boys and girls with more sleep difficulties among boys than girls [25], others found no gender dif- ferences [24] or more frequent difficulties among girls than boys [26]. Recently, Lewien et al. [27] indicated that sleep-related difficulties were more frequent among boys in the child sample and among girls in the adolescent sample. It is important to note, however, that not all studies showed consistent findings. Some found no sex differ- ences (children aged 6–14) (e.g., [14]), and one study demonstrated that girls had greater attentional capacity than boys (aged 3–7) [15]. This inconsistency may be due to the different stimuli used. The most frequent test used is the PVT, followed by the CPT and its many versions. It has been suggested that sustained attention may con- stitute multiple distinct constructs and the PVT and the CPT are not pure measures of sustained attention [16]. Furthermore, the CPT requires longer duration and most of the assessment versions were used among adults [17]. The present study therefore hypothesized that: 1. there are no sex differences in sleep patterns; and 2. there are sex differences in PVT performance, with boys being faster (shorter RT) and showing fewer lapses than girls but showing a higher number of false starts than girls both on weekdays and at weekends. Numerous studies have shown that sustained attention is highly influenced by sleep quality. . Open Access T d i di i This is, to the best of our knowledge, the first study to examine sex differ- ences in the PVT performance of children by controlling for sleep quality via objective measurements (actigra- phy). In the present home-based study, sex differences in PVT performance were evaluated in a natural setting via multiple observations (several weeknights and weekend nights) of 45 children. Only a few studies have addressed sex differences in the sustained attention of children (e.g., Sleep measures Objective sleep patterns were measured using an acti- graph (Mini-Act, AMA-32, AMI)—a small movement sensor that continuously records body mobility, accu- mulates movement over one minute, and causes the sensor signal to cross a fixed reference signal. Sleep/ wake measures were estimated from actigraphy data using a validated algorithm [34]. g g [ ] Participants wore the actigraph on the wrist of their non-dominant hand for one week including weekdays (four–five nights) and weekends (one night before non- school day) in a natural environment (home). Actigraph recordings were scored using the event marker button for subjective sleep and wake times. The analysis of the actigraph recoding (using the program Action) pro- vided an estimation of participants’ sleep onset times and wake-up times, sleep latency, time in bed (from sleep onset to wake-up time), true sleep minutes (only minutes of sleep), wake after sleep onset (WASO), and sleep efficiency. Participants Study participants included 45 children (23 girls; mean age 7.43 ± 0.90 years; 22 boys; mean age Efrat and Orna BMC Psychology (2022) 10:307 Efrat and Orna BMC Psychology (2022) 10:307 Efrat and Orna BMC Psychology (2022) 10:307 Page 3 of 8 Page 3 of 8 Page 3 of 8 7.50 ± 0.51 years) from normative elementary schools, Grades 2–5 (most in Grades 3 and 4), in urban and rural middle-class communities in northern Israel (mean age 7.47 ± 0.73 years). All participants began school between 7:45 and 8:50 in the morning, 42.4% had 2 days off a week (Friday and Saturday), and 57.8% had only one day off (Saturday). Of all participants, 82.2% did sport between one and seven times a week and 8.9% reported drinking coffee during the day. While 15.6% were diagnosed with ADHD (6 boys, 1 girl), no dif- ferences were found between children with/without ADHD in sleep or cognitive measures, and they were therefore taken as one group. Cognitive performance Participants completed a visual PVT twice a day: in the morning after wake-up and before bedtime. We exam- ined their cognitive functioning in the morning and the evening because sleepiness is affected by the combina- tion of circadian phase and time awake, as was quanti- fied in laboratory sleep deprivation studies [28]. In field studies the daily time course of sleepiness was found to be U-shaped: moderate levels upon awakening which decrease and reach a minimum in the early evening and then increase in the evening hours (before bedtime) to levels that were higher than those upon awakening [29]. The PVT task is sensitive to sleep loss and circa- dian phase [30, 31] and has been employed for the last 30 years as a sensitive test of sustained attention [32]. This simple measure of reaction time (RT) to repetitive stimuli has become recognized as a highly sensitive and effective tool for measuring degradation of sustained attention performance under sleep deprivation or par- tial sleep deprivation or changes in circadian phases [30, 31]. Procedure P i i Participants were collected using the snowball method. The research assistant met with potential participants and their parents at home. The parents of those chil- dren who agreed to participate in the study signed an informed consent. Participants wore the actigraph con- tinuously for five to seven days, on both school and non-school days, and completed the PVT for three minutes. Participants were required to maintain a regu- lar sleep pattern on school and non-school days.h The ethics committee at Emek Yezreel College (no: EMEK YVC 2018-48) approved this study. Statistical analysis S Scores were averaged per individual on weekdays. PVT measures were not normally distributed and were therefore subject to a log 10 transformation that nor- malized their distribution. Independent sample t-tests were calculated for sex differences in actigraph sleep patterns between weekday and weekend measures. Bivariate correlations were conducted between sleep duration (calculated as time in bed multiplied by sleep efficiency) and PVT measures. Bonferroni corrections for multiple comparisons were calculated. PVT perfor- mance tests were analyzed via repeated-measures anal- ysis of variance (sex × day × time) with age, ADHD, and mean sleep duration as covariates. For all the ANOVA tests, whenever Mauchly’s test indicated a violation of sphericity assumption, Greenhouse–Geisser correc- tions were used. Effect-size analyses for t-tests were calculated based on Cohen’s d, whereas effect-size for The PVT-B (Joggle Research, Seattle, WA) is a three- minute long sustained attention RT task, which, in the present study, was performed on an iPad. It is a validated measure of sustained attention with high test–retest reli- ability and low learning effects [1]. Participants were instructed to maintain vigilant attention on a target box and to respond as quickly as possible to the appearance of a stimulus while avoiding premature responses. The outcome measures of the present study were mean RT, lapses, and false starts. Participants were requested to press on the screen to stop the counter, responding as quickly as possible but avoiding pressing on the screen when the counter was not displayed (i.e., false starts). The interstimulus interval, defined as the period between the last response and the appearance of the next stimulus, varied randomly from 2 to 10 s [33]. Efrat and Orna BMC Psychology (2022) 10:307 Page 4 of 8 Table 1 Means (SD), F, and η2 p for actigraph sleep measures, boys vs. Statistical analysis S There was no significant sex × day interaction [F (1, 25) = 0.13, p > 0.05; η2 p = 0.01], day × time interaction [F (1, 25) = 0.48, p > 0.05; η2 p = 0.02], or sex × day × time [F (1, 25) = 2.04, p > 0.05; η2 p = 0.08]. There was no sig- nificant main effect for day [F (1, 25) = 0.33, p > 0.05; η2 p = 0.01] or time [F (1, 25) = 0.00, p > 0.05; η2 p = 0.00].if shorter mean RTs than girls (see Table 3). A signifi- cant sex × time interaction [F (1, 25) = 8.17, p < 0.01; η2 p = 0.28] was also found. Further analyses revealed a significant effect of sex for morning [t (42) = 1.70, p < 0.05 1-tailed; Cohen’s d = 0.48] with boys (M = 2.57, SD = 0.13) being faster than girls (M = 2.64, SD = 0.16); no significant difference was found for evening [t (43) = 1.53, p > 0.05; Cohen’s d = 0.71]. There was no significant sex × day interaction [F (1, 25) = 0.13, p > 0.05; η2 p = 0.01], day × time interaction [F (1, 25) = 0.48, p > 0.05; η2 p = 0.02], or sex × day × time [F (1, 25) = 2.04, p > 0.05; η2 p = 0.08]. There was no sig- nificant main effect for day [F (1, 25) = 0.33, p > 0.05; η2 p = 0.01] or time [F (1, 25) = 0.00, p > 0.05; η2 p = 0.00].if Statistical analysis S Further analyses revealed a significant effect of sex for morning [t (42) = 1.70, p < 0.05 1-tailed; Cohen’s d = 0.48] with boys (M = 2.57, SD = 0.13) being faster than girls (M = 2.64, SD = 0.16); no significant difference was found for evening [t (43) = 1.53, p > 0.05; Cohen’s d = 0.71]. There was no significant sex × day interaction [F (1, 25) = 0.13, p > 0.05; η2 p = 0.01], day × time interaction [F (1, 25) = 0.48, p > 0.05; η2 p = 0.02], or sex × day × time [F (1, 25) = 2.04, p > 0.05; η2 p = 0.08]. There was no sig- nificant main effect for day [F (1, 25) = 0.33, p > 0.05; η2 p = 0.01] or time [F (1, 25) = 0.00, p > 0.05; η2 p = 0.00]. For PVT lapses, a significant effect of sex was found [F (1, 25) = 5.04, p < 0.05; η2 p = 0.18] with boys having fewer lapses than girls. A significant sex × day interaction [F (1, 25) = 4.48, p < 0.05; η2 p = 0.16] was also found. Fur- ther analysis revealed that sex differences in PVT lapses were found for weekends [F (1, 35) = 13.77, p < 0.01; η2 p = 0.28] with boys having fewer lapses than girls. How- ever, for weekdays no significant differences were found [F (1, 37) = 0.80, p > 0.05; η2 p = 0.02]. There was no sig- nificant sex × time interaction [F (1, 25) = 1.10, p > 0.05; η2 p = 0.05], day × time interaction [F (1, 25) = 0.00, p > 0.05; η2 p = 0.00], or sex × day × time [F (1, 25) = 3.25, p > 0.05; η2 p = 0.12]. There was no significant main effect shorter mean RTs than girls (see Table 3). A signifi- cant sex × time interaction [F (1, 25) = 8.17, p < 0.01; η2 p = 0.28] was also found. Further analyses revealed a significant effect of sex for morning [t (42) = 1.70, p < 0.05 1-tailed; Cohen’s d = 0.48] with boys (M = 2.57, SD = 0.13) being faster than girls (M = 2.64, SD = 0.16); no significant difference was found for evening [t (43) = 1.53, p > 0.05; Cohen’s d = 0.71]. Statistical analysis S girls, weekdays and weekends (N = 45) WASO minutes of wake after sleep onset p < 0.05 The correlation did not remain significant after performing Bonferroni corrections for multiple comparisons Weekdays (WD) Weekend (WE) F η2 p Boys Girls Boys Girls Bedtime (hh:mm) 21:19 (0:19) 21:38 (0:32) 23:04 (1:04) 22:37 (1:37) 2.13 0.06 Wake-up time (hh:mm) 6:53 (0:31) 6:49 (0:25) 7:58 (1:09) 8:18 (1:12) 1.32 0.04 Time in bed 575.18 (34.33) 551.07 (49.42) 535.70 (66.25) 581.21 (80.62) 6.49 0.16 WASO 27.41 (15.87) 24.98 (19.65) 24.58 (14.16) 38.18 (28.58) 3.56 0.10 Sleep latency 19.56 (14.94) 17.24 (9.56) 15.23 (10.01) 14.38 (12.96) 0.00 0.00 Sleep efficiency 95.31 (3.00) 95.44 (3.53) 95.24 (2.68) 93.27 (5.13) 2.12 0.06 Table 1 Means (SD), F, and η2 p for actigraph sleep measures, boys vs. girls, weekdays and weekends (N = 45) p < 0.05 The correlation did not remain significant after performing Bonferroni corrections for multiple comparisons Table 3 Means (SE) for PVT, weekdays vs. weekend (N = 42) WD = weekdays; WE = weekend; Mean RTlog10 = log transformed PVT mean RT; Lapseslog10 = log transformed PVT number of lapses Weekdays (WD) Weekend (WE) Boys Girls Boys Girls Mean RTlog10 2.55 (0.02) 2.57 (0.02) 2.51 (0.04) 2.65 (0.04) Lapseslog10 0.91 (0.07) 1.01 (0.07) 0.86 (0.06) 1.14 (0.06) False starts 9.36 (1.14) 8.07 (1.14) 13.77 (1.95) 8.13 (1.95) Table 3 Means (SE) for PVT, weekdays vs. weekend (N = 42) Table 2 Correlations between PVT measures and sleep duration in morning and evening, weekdays and weekends (N = 45) Table 2 Correlations between PVT measures and sleep duration in morning and evening, weekdays and weekends (N = 45) p < 0.05 The correlation did not remain significant after performing Bonferroni corrections for multiple comparisons Weekdays (WD) Weekend (WE) Morning Evening Morning Evening Mean RTlog10 0.08 0.23 − 0.02 − 0.03 Lapseslog10 0.04 − 0.01 − 0.15 0.14 False starts − 0.26 0.14 0.43 0.09 The correlation did not remain significant after performing Bonferroni corrections for multiple comparisons shorter mean RTs than girls (see Table 3). A signifi- cant sex × time interaction [F (1, 25) = 8.17, p < 0.01; η2 p = 0.28] was also found. Discussion Based on earlier observations regarding sex differences in sustained attention across various age groups, we investi- gated performance differences among children. Further- more, given that sustained attention is sensitive to sleep loss, we objectively evaluated sleep quality and time in bed using actigraphic objective measurements. The time in bed of weekdays and weekend reflected the recom- mended time in bed (more than 9.5 h) [35].ii Our findings supported the first hypothesis by show- ing no sex differences in sleep patterns. These findings are in line with previous reports suggesting no sex dif- ferences before puberty. For example, Jenni and LeBour- geois [36] reported no sex differences in sleep EEG power bands in prepubescent boys and girls, and Feinberg et al. [37] reported no sex differences in NREM delta power between ages 9 and 11. The authors suggested that the emergence of sex differences at puberty are due to sexual maturation. Furthermore, the authors also suggested that sex hormone regulatory mechanisms may play a role in the decline of NREM delta power density. We further found that sex difference in PVT RT was moderated by the time of day. Sex differences favor- ing boys were apparent at morning, while no sex differ- ence was found in the evening. We turned to literature on individual differences in chronotype to shed light on these results. A meta-analysis suggested a significant effect of sex on morningness, with men tending to score significantly more toward eveningness than women [40]. Other studies focused on the role of chronotype on cog- nitive abilities. For example, Preckel et al. [41] reported a positive association between eveningness and cogni- tive ability, while Roberts and Kyllonen [42] found that higher scores on eveningness were associated with higher scores on a working memory task, even though the task was performed in the morning. These results suggest that there may be an interaction between sex and chronotype on cognitive performance. To address this Escribano and Díaz-Morales [43] examined the role of sex and chrono- type on sustained attention among adolescents. They found that boys presented higher attention levels than girls and that evening type boys tended to perform bet- ter than morning type boys and evening type girls even though they were tested in the morning. While the pre- sent study did not include chronotype, it should, in our opinion, be considered in future studies. Results Sleep patterns as measured through actigraph recordings are presented in Table 1. A series of two-way repeated- measures ANOVAs with sex (boys, girls) and day (WD, WE) as the independent variables was conducted. A sig- nificant sex × day interaction was found for sleep dura- tion. Further analyses revealed no significant effect of sex on weekdays [t (35) = 1.89, p > 0.05; Cohen’s d = 0.62] or weekends [t (40) = 1.84, p > 0.05; Cohen’s d = 0.57]. No other significant interactions were found. No significant main effect for either sex or day was found for sleep pat- terns (Table 1). p p For PVT lapses, a significant effect of sex was found [F (1, 25) = 5.04, p < 0.05; η2 p = 0.18] with boys having fewer lapses than girls. A significant sex × day interaction [F (1, 25) = 4.48, p < 0.05; η2 p = 0.16] was also found. Fur- ther analysis revealed that sex differences in PVT lapses were found for weekends [F (1, 35) = 13.77, p < 0.01; η2 p = 0.28] with boys having fewer lapses than girls. How- ever, for weekdays no significant differences were found [F (1, 37) = 0.80, p > 0.05; η2 p = 0.02]. There was no sig- nificant sex × time interaction [F (1, 25) = 1.10, p > 0.05; η2 p = 0.05], day × time interaction [F (1, 25) = 0.00, p > 0.05; η2 p = 0.00], or sex × day × time [F (1, 25) = 3.25, p > 0.05; η2 p = 0.12]. There was no significant main effect We also checked for associations between sleep dura- tion and PVT measures. Bivariate correlations did not demonstrate significant results (see Table 2). i For PVT measures (mean RT, lapses, false starts), a series of three-way repeated-measures ANOVAs with sex (boys, girls), day (WD, WE), and time (M, E) as the independent variables was conducted, with age, ADHD, and mean sleep duration as covariates. A signifi- cant effect of sex was found [F (1, 25) = 4.34, p < 0.05; η2 p = 0.16] for mean RT, with boys demonstrating Efrat and Orna BMC Psychology (2022) 10:307 Page 5 of 8 test (CPT) of children aged 6–15, while Venker et al. [7] examined performance on the PVT of children aged 6–11. Results Both studies documented sex differences in sus- tained attention in favor of boys. However, not all stud- ies yielded this pattern of differences between boys and girls (e.g. [14, 15]). These two studies, for example, used different versions of the CPT. Their inconsistency may be due to differences in the measures of each stimulus used; for example, the nature of commission errors and time length of administration for the PVT are different from the CPT [38]. Recently, Rouse et al. [39] used both PVT and CPT to evaluate the effects of medication on attention and other aspects of cognitive function- ing among children diagnosed with excessive daytime sleepiness. They found that specific measures of each test indicated other aspects of improved attention in the medicated group. Specifically, the PVT false starts indicated an increase in attention, vigilance, and alert- ness, and CPT omissions indicated a decrease in the failure to respond to stimuli while children were medi- cated. These findings call for further research directly comparing PVT and CPT among children to deepen our understanding of the multiple aspects of sustained attention. for day [F (1, 25) = 0.59, p > 0.05; η2 p = 0.03] or time [F (1, 25) = 0.42, p > 0.05; η2 p = 0.02]. p For PVT false starts, a significant effect of sex was found [F (1, 25) = 3.31, p < 0.05 1-tailed; η2 p = 0.13]. The average level of false starts was lower among girls than boys. There was no significant sex × day interaction [F (1, 25) = 2.56, p > 0.05; η2 p = 0.03], sex × time interaction [F (1, 25) = 2.07, p > 0.05; η2 p = 0.08], day × time interac- tion [F (1, 25) = 0.01, p > 0.05; η2 p = 0.00], or sex × day × time [F (1, 25) = 3.30, p > 0.05; η2 p = 0.13]. There was no significant main effect for day [F (1, 25) = 0.00, p > 0.05; η2 p = 0.00] or time [F (1, 25) = 0.18, p > 0.05; η2 p = 0.01]. Discussion The current preliminary results among children call for replication in future studies including variables such as chronotype, sex, age, and time of day and their interaction exploring their role in attention performance. Next, we examined the association between sleep dura- tion and PVT performance. In accordance with previous meta-analyses [19, 20], we did not find any correlation. While among adults and adolescents sleep loss results in inattention, among children domains typically sensitive to sleep loss, such as sustained attention, show no sig- nificant relationship with sleep duration. Astill et al. [19] suggested that sustained attention requires activation of the frontoparietal networks that are compromised fol- lowing sleep loss among adolescents and adults, whereas in children this network is still quite immature.f Our second hypothesis regarding sex differences in PVT performance was also confirmed. Under sleep sati- ation, boys presented shorter PVT RT and fewer lapses than girls, while girls showed fewer false starts than boys. This is in accordance with previous studies which demonstrated that boys are faster and have fewer lapses on sustained attention tasks. For example, Lin et al. [18] examined performance on the continuous performance Efrat and Orna BMC Psychology (2022) 10:307 Efrat and Orna BMC Psychology (2022) 10:307 Page 6 of 8 Page 6 of 8 We also detected sex differences in the number of PVT false starts, with girls having less false starts than boys. This finding is consistent with previous studies among adults, showing that women commit fewer false starts in vigilance performance than men (e.g., [44]). Blatter et al. [5] explored sex and age differences in the PVT and showed that women tended to inhibit their PVT response to maintain accuracy while men demonstrated faster RT than women. The authors suggested that women and men may use different strategies to achieve optimal results. This is in line with sex differences found in other cognitive domains. For example, Adam et al. [45] demonstrated sex differences in choice RT. Participants performed RT tasks that required a verbal response to a spatial location target stimulus. Men and women showed different RT patterns as a function of stimulus location, and the authors suggested that this may reflect differ- ences in processing strategy. Conclusions Th This is, to our knowledge, the first home-based study (field study) to document sex differences in the PVT per- formance of children using objective measurements to control for sleep quality. Our study supports previous suggestions regarding differential cognitive strategies for girls and boys. Future studies might deepen our under- standing of the differential strategies used by females and males across developmental landmarks by also using neuroimaging to unravel sex differences in activation patterns throughout development. An understanding of the mechanisms underlying sex differences in sustained attention will provide insight into sex-related differences in other functioning domains, such as recreational and occupational preferences and functioning. Furthermore, a growing body of research on sex differences in cogni- tive performance and sustained attention in particu- lar, unraveling the similarities and differences between females and males, will enable the development of dif- ferential training programs and evaluation methods for girls and boys, with an emphasis on the strengths and weaknesses of both sexes based on the principles of brain plasticity. As expected, our results showed sex differences in PVT measures for weekend and weekend nights. While pre- vious meta-analyses [19, 20] did not find an association between sleep duration and sustained attention among children, they did document an association with other cognitive domains (e.g., executive function). We there- fore hypothesized that a sex difference effect would be found for both weekend and weekday nights regardless of sleep duration. Investigating differences in sleep pat- terns in the present sample revealed no significant effect; in other words, our participants had sufficient sleep dura- tion [35] on both weekend and weekday nights. As a result, we had no further opportunity to explore the role of sleep loss in the association between sex differences and sustained attention. Future studies should pursue this objective by including various populations with a range of sleep duration. Despite its important findings, certain limitations of this study should be noted. First, despite the fact that studies investigating characteristics that may vary sig- nificantly within populations often require larger sample sizes, the current study has a small sample size. Inter- pretations should thus be made with caution. Second, regarding sample characteristics, the children partici- pating in the present study were healthy and were good sleepers. The extent to which our findings can be gener- alized to other populations is therefore unknown. Discussion Support for this assertion comes from neuroimaging studies that showed increased activation in temporo-occipital, posterior cingulate, and cerebellar cortices in females in comparison to males during cognitive control and sustained attention contrast tasks [46].f supervision has been found essential for the mainte- nance of healthy sleep habits over time [47]. Future stud- ies should examine other populations to assess the role of sleep deprivation on sex differences in sustained atten- tion. Lastly, the present study did not include an exami- nation of personality traits. A few studies have found a correlation between sustained attention and personality traits, such as the Big Five conscientiousness [48]. Fur- thermore, previous studies exploring sex differences in cognitive performance and controlling for personality variables have documented the mediating role of person- ality traits in the relationship between sex differences and cognitive performance (e.g., [49]). However, there is, to the best of our knowledge, no previous report on the role of personality traits in the association between sex dif- ferences and sustained attention. We recommend future studies to explore the mechanisms underlying sex differ- ences in sustained attention. Abbreviations PVT: Psychomotor vigilance test; RT: Reaction time; CPT: Continuous perfor- mance test; ADHD: Attention deficit/hyperactivity disorder; WASO: Wake after sleep onset; EEG: Electroencephalogram; NREM: Non rapid eye movement. Conclusions Th Third, the children were recruited from middle-class commu- nities with sleep regimes that supported sufficient time in bed on both weekend and weekday nights. 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https://openalex.org/W3123272276	https://research.abo.fi/ws/files/27199882/Jaiswal2021_Article_RheologicalBehaviorOfHighConsi.pdf	English	null	Rheological behavior of high consistency enzymatically fibrillated cellulose suspensions	Cellulose	2,021	cc-by	10,479	Please cite the original version: Jaiswal, A. K., Kumar, V., Khakalo, A., Lahtinen, P., Solin, K., Pere, J., & Toivakka, M. (2021). Rheological behavior of high consistency enzymatically fibrillated cellulose suspensions. Cellulose, 28(4), 2087-2104. https://doi.org/10.1007/s10570-021-03688-y This is an electronic reprint of the original article. This reprint may differ from the original in pagination and typographic detail. Rheological behavior of high consistency enzymatically fibrillated cellulose suspensions Please cite the original version: Jaiswal, A. K., Kumar, V., Khakalo, A., Lahtinen, P., Solin, K., Pere, J., & Toivakka, M. (2021). Rheological behavior of high consistency enzymatically fibrillated cellulose suspensions. Cellulose, 28(4), 2087-2104. https://doi.org/10.1007/s10570-021-03688-y General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. This document is downloaded from the Research Information Portal of ÅAU: 24. Oct. 2024 Cellulose https://doi.org/10.1007/s10570-021-03688-y (0123456789().,-volV)( 01234567 89().,-volV) Cellulose https://doi.org/10.1007/s10570-021-03688-y (0123456789().,-volV)( 01234567 89().,-volV) ORIGINAL RESEARCH Rheological behavior of high consistency enzymatically ﬁbrillated cellulose suspensions Aayush Kumar Jaiswal . Vinay Kumar . Alexey Khakalo . Panu Lahtinen . Katariina Solin . Jaakko Pere . Martti Toivakka Introduction Enzymatic treatment of cellulose to obtain CNMs has been studied extensively in the past where efforts have been devoted towards identifying enzymes for efﬁcient ﬁbrillation, studying their mechanisms, and developing processes for controlled unraveling of the ﬁbre cell wall to obtain ﬁbrillated cellulosic materials (Karim et al. 2017). Cellulases, especially endoglu- canases have been previously used for cellulose ﬁbrillation (Henriksson et al. 2007; Pa¨a¨kko¨ et al. 2007). It is well-known that endoglucanase activity is selective to b-1,4-glucosidic bonds in cellulose (Liu et al. 2009). Earlier work also describes that the endoglucanase activity preferentially takes place at dislocations along the ﬁbre (Ander et al. 2008; Thygesen et al. 2011). Such dislocations comprise of only a small portion of the total accessible surface of the ﬁbre and hence, might get saturated at a certain enzyme loading. Thus, an increase in endoglucanase dosage above the saturation point might not be effective (Gourlay et al. 2018). On the other hand, exoglucanases, such as cellobiohydrolases are known to attack the cellulose chains from either end, releasing cellobiose units (Quinlan et al. 2010). The presence of lignin and hemicelluloses has been found to reduce the extent of cellulase activity due to inaccessibility of cellulose for the enzyme to bind upon (Igarashi et al. 2011; Laureano-Perez et al. 2005; Mosier et al. 2005). Hence, a combination of cellulases or hemicellulases, Lignocellulosic biomass is considered as one of the most promising and sustainable natural resources due to its abundance and renewable nature. Biomass has traditionally been utilized poorly as a fuel but is now rapidly becoming an important raw material for manufacturing biofuels and chemicals, and the need for high-value products obtained from biomass keeps growing (Song et al. 2014). g g g One among many of such high-value products are cellulose nanomaterials (CNMs), which have been studied for numerous applications such as, in packag- ing, cell culture, drug delivery, 3D printing, rheology modiﬁcations, and electronics (Abitbol et al. 2016; Dufresne 2019; Fang et al. 2019; Plackett 2014). While some applications aim at replacing nonrenew- able fossil fuel-based materials in existing products, others target totally novel products. Cellulose nanoﬁb- ril (CNF) and Cellulose nanocrystal (CNC), the two major grades of nanocellulosic materials, are manu- factured by either purely mechanical treatments, or a combination of chemical and mechanical treatment (Abdul Khalil et al. 2014). Aayush Kumar Jaiswal . Vinay Kumar . Alexey Khakalo . Panu Lahtinen . Katariina Solin . Jaakko Pere . Martti Toivakka Received: 28 September 2020 / Accepted: 7 January 2021 The Author(s) 2021 found to decrease with increasing enzyme dosage while the water retention increased. The shear viscos- ity followed power law relationship with the power law index varying in the range 0.11–0.73. The shear- thinning behavior decreased with increasing consis- tency. Moreover, suspension viscosity (l) was found to be highly dependent on the consistency (cÞ as l cm, with m ranging from 2.75 to 4.31 for different samples. Yield stress (sy) of the HefCel suspensions was measured at 7 and 10% consistencies. The performance of the ﬁbrillated cellulose grades in a typical application was demonstrated by casting ﬁlms, which were characterized for their mechanical properties. Abstract High-consistency processing of ﬁbrillated cellulose materials is attractive for commercial appli- cations due to potential for lowered production costs, energy savings and easier logistics. The current work investigated structure–property relationships of ﬁbril- lated cellulose suspensions produced at 20% consis- tency using VTT HefCel (High-consistency enzymatic ﬁbrillation of cellulose) technology. Morphological examination of the ﬁbrillated materials revealed that enzymatic action on the cellulose substrates was not a direct function of enzyme dosage but rather was dependent on the raw material composition. Further- more, shear viscosity of the HefCel suspensions was Supplementary Information The online version of this article (https://doi.org/10.1007/s10570-021-03688-y) contains supplementary material, which is available to authorized users. A. K. Jaiswal (&) V. Kumar A. Khakalo P. Lahtinen J. Pere Biomass Processing and Products, VTT Technical Research Centre of Finland Ltd, Tietotie 4E, 02044 Espoo, Finland e-mail: aayush.jaiswal@vtt.ﬁ A. K. Jaiswal (&) V. Kumar A. Khakalo P. Lahtinen J. Pere Biomass Processing and Products, VTT Technical Research Centre of Finland Ltd, Tietotie 4E, 02044 Espoo, Finland e-mail: aayush.jaiswal@vtt.ﬁ A. K. Jaiswal M. Toivakka Laboratory of Natural Materials Technology, A˚ bo Akademi University, Porthaninkatu 3, 20500 Turku, Finland K. Solin Department of Bioproducts and Biosystems, School of Chemical Engineering, Aalto University, Vuorimiehentie 1, 00076 Espoo, Finland 123 123 Cellulose Cellulose Graphic abstract Graphic abstract Keywords Cellulose Enzymatic hydrolysis Rheology HefCel Nanocellulose Keywords Cellulose Enzymatic hydrolysis Rheology HefCel Nanocellulose obtain CNMs from biomass is biological, via enzy- matic pre-treatment of cellulose. Enzymatic pretreat- ment on pulp ﬁbres has been shown to be an energy efﬁcient method to derive CNMs (Henriksson et al. 2007; Pa¨a¨kko¨ et al. 2007). Aayush Kumar Jaiswal . Vinay Kumar . Alexey Khakalo . Panu Lahtinen . Katariina Solin . Jaakko Pere . Martti Toivakka obtain CNMs from biomass is biological, via enzy- matic pre-treatment of cellulose. Enzymatic pretreat- ment on pulp ﬁbres has been shown to be an energy efﬁcient method to derive CNMs (Henriksson et al. 2007; Pa¨a¨kko¨ et al. 2007). Introduction Chemical pre-treatments reduce energy consumption during the production of CNFs and improve the degree of ﬁbrillation when compared to solely mechanical processes (Malucelli et al. 2019; Siro´ and Plackett 2010). Another route to 12 123 Cellulose Cellulose and a loss in crystallinity. Moreover, the redispersibil- ity of the CNF powder in water might be challenging due to ﬁbre horniﬁcation. Baati et al. (2017) also used a TSE to ﬁbrillate pulp ﬁbres after TEMPO-mediated oxidation. The extrusion process yielded strong CNF gels at up to 10% solids with carboxyl content ranging from 300 to 900 lmol/g. In a separate work, Rol et al. (2017) utilized a TSE to demonstrate the ﬁbrillation of enzymatically pretreated bleached kraft pulp to pro- duce a paste-like material at approximately 20% solids. The energy consumption during the production of CNFs at 20% solids using TSE (7 passes) was approximately 5000 kWh/t which was 63% lower than production using a grinder. acting synergistically, is typically required to achieve efﬁcient hydrolysis via a purely enzymatic route (de Campos et al. 2013). As an alternative route, mechan- ical reﬁning of cellulose before enzymatic treatment can be used to increase the number of dislocations and the available surface area of ﬁbres for enzymatic action (Gao et al. 2015; Hoeger et al. 2013). Multicomponent cellulase cocktails composed of a mixture of endoglucanases and exoglucanases (cel- lobiohydrolases) to obtain CNMs were studied by Siqueira et al. (Siqueira et al. 2010, 2011). Hu et al. termed the enzymes/proteins, such as xylanases and lytic polysaccharide monooxygenases (LPMO), which enhance the action of cellulases, as ‘accessory enzymes’ and reported the use of those in pulp ﬁbrillation (Hu et al. 2013, 2018). In another work, de Campos et al. reported the use of endoglucanase along with an accessory pectinase and hemicellulases (de Campos et al. 2013). Apart from the TSE-based technologies, an enzy- matic approach named high-consistency enzymatic ﬁbrillation of cellulose (HefCel) was developed at VTT (Hiltunen et al. 2015). The HefCel method uses a reactor equipped with a sigma-type mixer that enables precise temperature control, uniform mixing of the enzyme cocktail with the cellulose substrate and employing ﬁbre–ﬁbre friction to obtain ﬁbrillation in synergy with the enzymatic action. After all unit operations, a high-consistency ﬁbrillated material can be produced at 10–25% solids. The energy demand for the HefCel process was calculated to be roughly 900 kWh/t in our previous investigation (Lehmonen et al. 2017). Introduction Thus, the HefCel method has a lower energy consumption compared to other manufacturing meth- ods such as reﬁning, grinding, homogenization, ball milling, and extrusion because it only requires a simple mixing process. In most studies, the enzymatic treatment has been followed by mechanical ﬁbrillation processes such as soniﬁcation (de Campos et al. 2013; Hu et al. 2018), homogenization (Henriksson et al. 2007), and ﬂu- idization (Pa¨a¨kko¨ et al. 2007) to obtain nanoscale ﬁbres. However, all three processes are highly energy intensive, requiring material dilution to low consis- tencies, typically below 5%, in order to yield ﬁne ﬁbres. The use of low consistency CNMs increases logistics costs and limits applications in areas that demand low water amount during processing. For instance, the presence of water in conjugation with hot-melt polymers during compression molding, injection molding, and ﬁlm extrusion limits CNMs use as reinforcement in composites. In food packaging applications, a considerable obstacle for use of CNMs as a gas barrier ﬁlm or coating is the required excessive drying capacity during processing, which inhibits high-speed production (Kumar et al. 2016). It is evident that high-consistency ﬁbrillation leads to advantages such as low production costs, energy savings, easier logistics and better suitability of CNF for industrial applications. Previous studies have focused on optimizing process parameters, such as TSE screw geometry, shear proﬁle, and number of TSE passes, for production of high-consistency mate- rials (Ho et al. 2015; Rol et al. 2017). However, there is still a lack of information regarding the effect of varying factors such as enzyme dosage and the role of cellulose substrate composition on the properties of the resultant material in high-consistency processes. Understanding such a relationship could pave the ways to produce CNMs with properties tuned for optimal performance in speciﬁc applications. Several studies have addressed the need to over- come the obstacles related to the high energy consumption of CNM manufacturing and low solids content of the resulting material. Mechanical ﬁbrilla- tion of never-dried bleached kraft pulp ﬁbres was demonstrated by Ho et al. (2015) using a twin-screw extruder (TSE) where the resultant product was moist CNF powder at 33–45% solids. However, the process faced practical challenges due to excessive heat generation in the TSE after 10 passes leading to excessive depolymerization of the cellulose chains The present work investigates the structure–prop- erty relationship in ﬁbrillated cellulose materials 12 3 3 Cellulose produced using the HefCel process. Introduction For this, the effects of enzyme dosage and raw material composi- tion on the morphological and rheological properties of the resultant ﬁbrillated cellulose material (hereafter termed as HefCel grades) were studied. Three differ- ent wood pulps were used as raw materials and three different enzyme dosages were studied for each pulp, giving nine grades of ﬁbrillated cellulose materials at 17–23% solids content. To demonstrate the perfor- mance of the grades in a typical application, ﬁlms were casted using dilute suspensions and were characterized for their mechanical properties. observe the effect of enzyme dosage level on the resultant HefCel quality. These enzyme dosage levels have been selected based on our prior experience with the HefCel process, where all three levels lie within the operational window of the process. Further details concerning the HefCel process have been reported elsewhere (Pere et al. 2020). The treatment time was ﬁxed at 6.5 h for all samples. After 6.5 h, the enzyme activity was stopped by increasing the temperature in the reactor to 90 C for 30 min. Subsequently, the obtained HefCel was washed with deionized water to remove any remaining enzyme. Water added during the washing stage was then ﬁltered out from the HefCel under mild vacuum to obtain a ﬁnal consistency of approximately 20%. The obtained materials were stored at 4 C until use in experiments. The wash water from the process was analyzed for carbohydrates using the dinitrosalicylic acid (DNS) assay of reducing sugars as suggested by Rahikainen et al. (2020) and originally developed by Sumner and Noback (1924). Materials Three different bleached kraft pulps were used in the study, namely once-dried softwood pulp, never-dried softwood pulp, and once-dried hardwood pulp. The softwood pulps were procured from Metsa¨ Fibre Bioproduct Mill (A¨ a¨nekoski, Finland). The never- dried pulp was received at ca. 37% solids content and the once-dried pulp at 95% solids. Hardwood pulp was obtained in once-dried state from a Finnish pulp mill. All pulps were bleached at the production site. The used enzyme cocktail (EcoPulp Energy, AB Enzymes, Finland) was a multicomponent cellulase with both endo-and- exoglucanase activity and minor back- ground hemicellulase activities. Characterization of HefCel A high speed mixer (DispermatTM LC) was used to make dilute suspensions from the high consistency HefCel suspensions. The suspensions were homoge- nized for at least 15 min at 2000 RPM before performing any experiments. pH measurements were performed directly on the high consistency HefCel suspensions obtained after the ﬁltration stage using a standard portable pH meter (Mettler Toledo SG2). The conductivity of the HefCel suspensions, diluted to 2% consistency, was measured at room temperature using a Jenway 4510 conductivity meter. Fibrillated cellulose production Fibrillated cellulose suspensions were produced from pulps using HefCel technology developed at VTT. Once-dried pulps were slushed in water at 25% consistency, and the pulp suspension was then trans- ferred to a reactor equipped with a temperature controller and a two-shaft sigma-type mixer (Wink- worth Machinery Ltd., UK) as shown in Fig. 1. The never-dried pulp was used as such. The enzyme mixture was dosed to the pulp suspensions in the reactor while keeping the mixing speed constant at 25 RPM and the temperature at 70 8C. The enzyme type, dosage amount, and treatment time are parameters critical to the ﬁnal HefCel quality. Three different enzyme dosage levels viz. 6, 8, and 10 mg/g (on dry ﬁbre mass) were used with each type of pulp to Carbohydrate analysis and molar mass measurements To determine the carbohydrate composition, the source pulps and ﬁbrillated samples were hydrolyzed with sulphuric acid and the resulting monosaccharides were determined by High-performance anion exchange chromatography (HPAEC) with pulse amperometric detection (Dionex ICS 3000A equipped with CarboPac PA-1 column) according to the NREL method (Sluiter et al. 2012; Pettersen 1991). The polysaccharide content in the samples was calculated from the corresponding monosaccharides using an 123 Cellulose Fig. 1 The setup for HefCel production (left), inside view of the mixer after opening the mixer lid (right) Fig. 1 The setup for HefCel production (left), inside view of the mixer after opening the mixer lid (right) production (left), inside view of the mixer after opening the mixer lid (right) ColorView 12 camera) was used to analyze the HefCel samples. To obtain sufﬁcient contrast in the images, each sample was dyed with 1% Congo red solution in 1:1 ratio by volume before imaging. Atomic force microscopy (AFM) was performed to analyze the nanoscale ﬁbril fraction. HefCel samples were diluted to 0.5 wt.% solids using deionized water and cen- trifuged (5804 R Centrifuge, Eppendorf AG) at 10,400 RPM for 45 min. Then approximately 5 ml of the supernatant was taken for spin coating. AFM (Mul- tiMode 8 Scanning Probe Microscope, Bruker AXS Inc.) was used to analyze the surface topography of spin-coated samples on polyethyleneimine-coated SiO2 wafers. Tapping mode in air and silicon cantilevers (NSC15/ALBS, MikroMasch) were used to scan 3 9 3 lm2 and 5 9 5 lm2 surface areas. At least three sample areas were imaged and ﬂattening was used in image processing by using Nanoscope Analysis 8.15 software. anhydro correction of 0.88 for pentoses and 0.9 for hexoses. For the molar mass measurements, solid samples were dissolved in DMAc/8% LiCl according to the solvent exchange method described by Berggren et al. (2003). This method includes activation of the sample with water, solvent exchange with methanol and DMAc, followed by ethyl isocyanate derivatization assisted dissolution into DMAc/8% LiCl. After com- plete dissolution, the samples were diluted with DMAc providing ﬁnal LiCl concentration of 0.8% as in the eluent. In all cases, the samples were ﬁltered (0.45 lm mesh) before the measurement. For all samples, size exclusion chromatography (SEC) mea- surements were performed using PLgel MiniMIX A columns with a precolumn in DMAc/0.8% LiCl eluent (0.36 ml/min, T = 80 C). Two parallel samples of each pulp and HefCel were studied. Rheology and water retention The morphology of the HefCel ﬁbres were investi- gated with a Kajaani FibreLab analyzer (Metso Automation, Kajaani, Finland) equipped with Fibre- Lab 4Core. Fibre samples (approx. 0.1 g oven-dry mass) were taken to the automated ﬁbre analysis device to measure ﬁbre parameters such as ﬁbre length (weight-weighted average ﬁbre length), curl, kinks, and ﬁnes content. All rheology measurements were performed using a stress-controlled rotational rheometer Physica MCR 301 (Anton Paar GmbH). Shear ﬂow measurements were performed using a Couette-type smooth-walled concentric cylinder geometry. The diameters of the inner and the outer cylinder were 27.00 mm and 29.29 mm respectively, and the vertical gap between the two cylinders was kept at 1 mm. For all measure- ments, samples were pre-sheared at 100 s-1 for 60 s and were then left idle for 120 s before starting data recording, according to the protocol suggested by Film casting and testing In order to study the self-assembling behavior of the HefCels, standalone ﬁlms were prepared by casting a calculated amount of 2 wt.% HefCel suspension in Petri dishes placed on a horizontal surface. The target basis weight was 50 g/m2. Five parallel samples were prepared for each grade of HefCel. The ﬁlms were dried and tested in a conditioned environment, regu- lated at 23 C and 50% relative humidity (RH). Basis weight of the ﬁlms was measured by weighing a ﬁlm sample of known size. Dry ﬁlm thickness was measured using an L&W Micrometer 051 (Lorentzen & Wettre AB) following the TAPPI T411 standard. Tensile tests were performed using a Lloyd LS5 materials testing device (AMETEK Inc., USA) equipped with a load cell of 100 N. The strain rate Static gravimetric dewatering of HefCel suspen- sions was studied using A˚ bo Akademi Gravimetric Water Retention (A˚ A-GWR) method, originally developed by Sanda˚s et al. (1989). Dewatering was studied at four different concentrations viz. 2, 5, 7, and 10% for each type of HefCel. For measurement, 10 ml of sample was inserted into a measurement cylinder of known diameter, placed above a 5 lm polycarbonate Table 1 Composition of the source pulps and the prepared ﬁbrillated materials Sample code Enzyme dosage (mg/g) Glucose (%) Xylan (%) Cellulose (%) Liberated reducing sugars (%) SW ND 0 82.9 ± 1.3 7.8 ± 0.2 71.3 ± 1.1 – SW ND6 6 81.3 ± 0.6 7.7 ± 0.2 69.6 ± 0.5 9.7 SW ND8 8 81.5 ± 2.0 7.7 ± 0.2 69.8 ± 1.7 10.3 SW ND10 10 77.4 ± 3.8 7.3 ± 0.3 66.3 ± 3.3 14.0 SW 1D 0 82.6 ± 1.2 8.9 ± 0.2 71.5 ± 1.1 – SW 1D6 6 81.8 ± 0.5 9.3 ± 0.1 70.6 ± 0.4 9.4 SW 1D8 8 81.0 ± 0.9 9.3 ± 0.1 69.9 ± 0.8 11.5 SW 1D10 10 81.2 ± 0.4 9.3 ± 0.1 70.0 ± 0.3 13.5 HW 1D 0 71.4 ± 2.2 19.6 ± 0.7 63.6 ± 1.9 – HW 1D6 6 70.9 ± 0.5 19.6 ± 0.1 63.1 ± 0.4 9.7 HW 1D8 8 71.6 ± 0.4 19.7 ± 0.2 63.7 ± 0.3 12.6 HW 1D10 10 71.3 ± 0.4 19.7 ± 0.2 63.4 ± 0.3 13.9 Abbreviations: Once-dried hardwood (HW 1D), Once-dried softwood (SW 1D), Never-dried softwood (SW ND). Morphology Optical microscope (Olympus BX61 equipped with WH4X-H eyepieces, ﬂuorite objectives and a 12 123 Cellulose Naderi et al. (Naderi and Lindstro¨m 2016). This protocol ensures homogeneity in the sample. membrane (GE Water & Process Technologies, USA) and backed by multiple sheets of absorbent blotter papers of known mass. After a ﬁxed duration of 15 s of placing the sample into the measurement cylinder, the cylinder was sealed and constant air pressure of 50 kPa was applied for 90 s. After depressurization, the sample was kept in contact with the membrane and blotter papers for 15 s and weighed. GWR value represents the amount of water released by the suspension per unit area. The reported results are an average of three parallel measurements. The shear rate sweeps were performed in the interval of 0.1–1000 s-1 and data was collected at 40 different points with 10 s measurement duration per point. Oscillatory measurements were performed using a vane-and-cup geometry (vane span: 22 mm, cup diameter 29.29 mm) to avoid wall-slip effects on measurements results, as suggested by Mohtaschemi et al. (Mohtaschemi et al. 2014). Oscillatory strain sweeps were performed in order to determine the linear viscoelastic (LVE) region with strain ranging from 0.1–100% while the frequency was kept constant at 10 rad/s. The strain sweeps were followed by frequency sweeps in the range of 0.1–100 Hz, while keeping the strain within the LVE region of the sample. Three parallel measurements were conducted. Yield stress for the suspensions was calculated using the strain sweep data. The shear stress at which the value of storage modulus dropped to 90% of its initial value was deﬁned as the yield stress. Film casting and testing The number after the pulp name indicates the enzyme dosage in mg/g, based on dry ﬁbre mass. Reducing sugars were measured in the ﬁltrate after washing the produced HefCel grades and are reported as mass percentage of the total dry pulp mass used Abbreviations: Once-dried hardwood (HW 1D), Once-dried softwood (SW 1D), Never-dried softwood (SW ND). The number after the pulp name indicates the enzyme dosage in mg/g, based on dry ﬁbre mass. Reducing sugars were measured in the ﬁltrate after washing the produced HefCel grades and are reported as mass percentage of the total dry pulp mass used 12 Cellulose Cellulose was set to 10 mm/min and the gauge length was 50 mm. Tensile strength, Young’s Modulus, and Strain at Break (SaB) are reported as a mean of ﬁve measurements per sample. Fibre characterization process. Three different wood pulps were used as raw materials and three different enzyme dosages were studied for each pulp, giving nine grades of ﬁbrillated cellulose (termed as HefCel grades) in total. All production process parameters were kept constant except for the enzyme dosage level. Table 1 lists all the samples with their abbreviated codes used in further discussion along with their carbohydrate composition, and liberated reducing sugars content in the wash water obtained from each grade. Abbreviations to the sample codes are listed in the table footnote. The pH of all HefCel samples was found to be in the range of 5–6. The used enzyme cocktail exhibits the highest activity level in the same pH range and thus, the measurement ensured that the ﬁbrillation was done under optimum conditions. Electrical conductivity values were found to be quite low in all samples, below approximately 20 lS/cm, which was an indicator of no additional free ions being released to the suspensions during the production process. The extent of enzymatic degradation of the ﬁbres was studied by four different methods, viz. optical microscopy, an optical ﬁbre analyzer, molar mass measurement, and AFM imaging. Figure 2 (a) illus- trates a compilation of optical microscope images for all three pulps and nine grades of HefCel, along with their mean length-weighted ﬁbre length and mean ﬁbre width. The optical microscope images show the micro-sized fraction of the HefCel materials and the ﬁbre size analysis done via FibreLab is only valid for this fraction. The enzymatic treatment causes a signiﬁcant reduction in the ﬁbre length, whereas the ﬁbre diameter was not much affected since some ﬁbres were not ﬁbrillated during the process. Such behavior has been previously reported for monocomponent endoglucanase treatment on cellulose substrates (Gourlay et al. 2018). An interesting observation is that the hydrolysis action was not a direct function of enzyme dosage but rather dependent on the raw material composition. The increase in enzyme dosage did not universally correlate with the change in aspect ratio of the ﬁbres. For instance, the lowest aspect ratio of 6.4 was found in the HW 1D10 sample, whereas in the case of softwood-derived grades, the lowest aspect ratio of 7.3 was found in the SW 1D6 sample. Results and discussion The present work studies the effect of enzyme dosage and raw material composition on the properties of the resultant ﬁbrillated cellulose material from the HefCel p p p p p resultant ﬁbrillated cellulose material from the HefCel Images of the source pulps and HefCel suspensions ng an optical microscope. The scale bar denotes length. The table underneath enlists the length- average ﬁbre length and mean diameter for the same measured using an optical analyzer (standard deviations can be found in the Online Resource 1. b Average molar mass and dispersity of the same samples. Mn = number average molecular weight, Mw = weight average molecular weight and dispersity = Mw/Mn Fig. 2 a Images of the source pulps and HefCel suspensions taken using an optical microscope. The scale bar denotes 500 lm length. The table underneath enlists the length- weighted average ﬁbre length and mean diameter for the same samples measured using an optical analyzer (standard deviations can be found in the Online Resource 1. b Average molar mass and dispersity of the same samples. Mn = number average molecular weight, Mw = weight average molecular weight and dispersity = Mw/Mn 123 12 3 Cellulose 123 12 Cellulose bFig. 3 AFM images of four HefCel grades taken from an area of 3 9 3 lm2. The horizontal lines over the images indicate the lines along which the ﬁbril width was analyzed. The graphs underneath each image show the ﬁbril width proﬁle (denoted as height) across the image along the marked line amount of xylans in the initial pulps and the respective HefCel grades did not differ much. The full carbohy- drate composition data can be found in the supple- mentary information (Online Resource 1). bFig. 3 AFM images of four HefCel grades taken from an area of 3 9 3 lm2. The horizontal lines over the images indicate the lines along which the ﬁbril width was analyzed. The graphs underneath each image show the ﬁbril width proﬁle (denoted as height) across the image along the marked line Fibre characterization Since the HefCel method takes advantage of the interﬁbre friction generated by mixing at high consistency to unravel ﬁbrils in combination with cellulase action, the HefCel grades had lower ﬁbre widths than source pulps. The ﬁnes content in all HefCel grades was found to be more than 90% whereas the softwood pulps contained roughly 25% ﬁnes and the hardwood pulp contained approximately 10% ﬁnes. Table 1 lists glucose, xylan, and cellulose content of the source pulps and the HefCel samples. The fairly constant glucose and cellulose content in the source pulps and in the HefCel grades derived from those respectively, indicates that the enzymatic hydrolysis occurred randomly in the cellulose chains and the cleaved cellulose chains were not fully converted to soluble sugars. Additionally, it shows that the chem- ical composition of the pulps was not signiﬁcantly altered during enzymatic hydrolysis. The residual sugar analysis done on the ﬁltrate after washing the produced HefCel grades indicates the loss of raw material in form of soluble sugars during processing. A common trend can be observed for all raw materials: as the enzyme dosage increased, the amount of soluble sugars in the ﬁltrate also increased, suggesting more hydrolysis on the reducing end and ultimately, losses in process yield. The hardwood pulp and the hard- wood-derived HefCel grades were found to contain a high amount of xylans, which is typical for hardwood ﬁbres. The used enzyme cocktail had only minor background hemicellulase activity and thus, the As expected, the softwood pulp ﬁbres had a higher aspect ratio than the hardwood counterparts, however, the softwood-derived HefCel grades showed a lower aspect ratio than the hardwood-derived grades. This peculiar observation can be explained by the presence of a high amount of hemicelluloses in the hardwood pulp that affects the hydrolysis behavior. Hemicellu- loses, such as xylan, restrict the interaction of enzymes with the cellulose chains and consequently, decrease 12 3 3 Cellulose Cellulose Fig. 4 a Schematic description of the setup for the A˚ A-GWR measurements. Dewatering values, measured as liquid transferred to the blotter papers, as a function of concentration for HefCel suspensions obtained from SW ND (b), SW 1D (c), and HW 1D (d) pulps Fig. 4 a Schematic description of the setup for the A˚ A-GWR measurements. 123 Fibre characterization Dewatering values, measured as liquid transferred to the blotter papers, as a function of concentration for HefCel suspensions obtained from SW ND (b), SW 1D (c), and HW 1D (d) pulps the extent of enzymatic action (Igarashi et al. 2011; Penttila¨ et al. 2013; Zhang et al. 2012). Thus, almost similar ﬁbre dimensions were observed for the hard- wood-derived HefCel grades HW 1D6 and HW 1D8. In general, cellulase action can be inhibited by the presence of any non-cellulosic material in the raw material, such as, lignin, ink pigments, glues, or resins, which restrict the enzyme access to cellulose. It must be noted that the optical methods were only used to study the micro-sized fraction of the HefCel materials. enzyme dosage, while keeping the treatment duration and conditions constant, did not lead to a decrease in the average molar mass. A similar observation has been reported in earlier work by Gourlay et al. (2018) where it was postulated that beyond a certain enzyme loading, the dislocations on the ﬁbre surface get saturated and the endoglucanase action is restricted due to inaccessibility to the substrate. Such explana- tion holds merit as the preferential action of endoglu- canase on dislocations on cellulose ﬁbres along the ﬁbre length is well-described in earlier work (Hidayat et al. 2012, 2015; Thygesen et al. 2011). The results from the optical measurements were found to be in agreement with the SEC results. The average molar mass of cellulose chains in the ﬁbril- lated suspensions was found to be much lower than the source pulps (Fig. 2b). Moreover, the increase in Since the optical analyses dealt only with the microscale fraction of the HefCel grades, AFM imaging was performed to analyze the nanoscale ﬁbril 123 123 Cellulose Cellulose fraction. The presence of nanoscale fraction, separated via centrifugation, indicated the occurrence of ﬁbril- lation of pulp ﬁbres during processing. Figure 3 shows AFM images comparing the lowest and the highest enzyme dosages for both softwood and hardwood derived HefCel grades. The ﬁbrils have high aspect ratios, a ‘‘curly’’ appearance, and diameters in the range of 5–20 nm. For instance, at an average length of 1 lm, 5–20 nm diameter corresponds to an aspect ratio of 50–200. Similar studies have reported that CNF produced via the enzymatic route using a twin screw extruder had an average diameter of 25.4 ± 7.1 nm (Rol et al. 2017). Fibre characterization (2019) described that the typical low consistency of CNF suspensions was detrimental to shape ﬁdelity of 3D printed structures due to high shrinkage upon drying. Thus, a ﬁbrillated cellulose material which possesses low viscosity while maintaining a pseudo- plastic nature, used at high consistency (5–15%), could be useful for applications in coatings and 3D printing. In the current work, the shear viscosity of the HefCel grades was studied as a function of suspension consistency, ranging from 2 to 10%. Water retention and rheology Water retention values of HefCel suspensions were measured using the A˚ A-GWR method. A˚ A-GWR is an indirect measurement method where static gravimetric dewatering of a material is studied under mild overpressure. The method was originally developed to study water retention of paper coating colors and is relevant for studying the dewatering of cellulosic materials for applications in thin-ﬁlm structures such as self-standing ﬁlms and coatings, where the material layer lies in contact with an absorbent substrate (Dimic-Misic et al. 2013; Kumar et al. 2016). The results from the measurements are illustrated in Fig. 4, where a higher amount of liquid transferred to the blotter paper indicates lower water retention by the material. For the used measurement setup, a water retention value of 3000 g/m2 corresponded to 20% dewatering of the suspension when calculated on the basis of total water present in the suspension. All HefCel suspensions, quite expectedly, exhib- ited an increasing trend in water retention as the concentration of the suspension was increased. The lower amount of water present in more concentrated suspensions directly correlated to the lower dewater- ing tendency. HefCel grades derived from never-dried softwood pulp were observed to retain water better than their counterparts derived from once-dried soft- wood pulp at all tested concentrations and at all enzyme dosage levels. This behaviour can be under- stood to be resulting from horniﬁcation of ﬁbres in the once-dried pulp. The lower water retention of horni- ﬁed ﬁbres compared to virgin ﬁbres due to a lower number of free hydroxyl groups available for hydro- gen bonding with water molecules is well-known (Fernandes Diniz et al. 2004). For all HefCel grades, an increase in the enzyme dosage level resulted in lower dewatering. Dewatering rate is associated with the rate of water diffusion through the ﬁlter cake formed on top of the absorbent paper. Fibre characterization Forward shear rate ramps for SW ND6 sample at es of 2, 5, 7, and 10%. b Shear rate ramps for HefCel ived from SW ND pulp using 6, 8, and 10 mg/g Subﬁgures (b), (c) and (d) show curves for labell 10% consistency. e The table below lists the powe (n) for each ﬂow curve in the high shear reg Subﬁgures (b), (c) and (d) show curves for labelled samples at 10% consistency. e The table below lists the power law indices (n) for each ﬂow curve in the high shear regime and the parameter m denoting the correlation between suspension viscosity and consistency calculated at shear rate of 1 s-1 Fig. 5 a Forward shear rate ramps for SW ND6 sample at consistencies of 2, 5, 7, and 10%. b Shear rate ramps for HefCel grades derived from SW ND pulp using 6, 8, and 10 mg/g enzyme dosage. c Effect of changing pulp type on the viscosity of grades containing 6 mg/g and d 10 mg/g respectively. Fig. 5 a Forward shear rate ramps for SW ND6 sample at consistencies of 2, 5, 7, and 10%. b Shear rate ramps for HefCel grades derived from SW ND pulp using 6, 8, and 10 mg/g enzyme dosage. c Effect of changing pulp type on the viscosity of grades containing 6 mg/g and d 10 mg/g respectively. 12 3 3 3 Cellulose Cellulose prominent in ﬁbrillated CNM grades, such as CNFs than in CNCs due to physical entanglement between ﬁbrils. Applications of ﬁbrillated cellulose materials in coatings, 3D printing and rheology modiﬁcation require overcoming the challenges associated with high yield stress and viscosity along with the typical low solids content. For instance, Kumar et al. used a slot-die to shear a 2% CNF suspension in order to apply a uniform coating layer on paperboard moving at speed of 3 m/min (Kumar et al. 2016). Applying CNF coatings was not straightforward using conven- tional methods like blade and rod coating at such low speeds and the shear-thinning (power law index 0.2) in the slot was crucial for the process. Even if the coating was made possible with such high viscosity gels (ca. 80,000 mPa.s at 1 s-1 for 2% CNF suspension), high- speed processing was still limited by the excessive drying demand. In 3D printing applications, Klar et al. 123 Fibre characterization There was no signiﬁcant difference in the average ﬁbre dimen- sions upon varying the enzyme dosage, however, the difference in viscosity was substantial. No straight- forward correlation between the ﬁbre aspect ratio and viscosity of the suspensions could be identiﬁed. A possible explanation of the decrease in the suspension viscosity with increasing enzyme dosage could be the one described by Gourlay et al. who reported in two separate works that the surface of cellulose ﬁbres contained isolated and highly accessible cellulosic strands, which contributed towards interﬁbre entan- glement and increased the suspension viscosity (Gourlay et al. 2015). In a later work, it was reported that the 1 mg/g enzyme dosage for 30 min resulted in a 75% viscosity drop (compared at 0.1 s-1) while the aspect ratio of ﬁbres decreased by only 5% (Gourlay et al. 2018). This behavior was attributed to the hydrolysis of the accessible cellulosic strands, which lowered the possibility of interﬁbre entanglement. Thus, in these studies as well, ﬁbre dimensions remained almost similar but a drop observed in viscosity could be attributed to the same phenomenon. The forward shear rate ramps illustrated in Fig. 5 show the presence of a ‘kink’ in the curves at shear rates of approximately 10 s-1. Such a viscosity plateau is a typical feature in shear ﬂow curves for ﬁbrillar CNMs and has been described frequently in literature (Hubbe et al. 2017a, b). Karppinen et al. (2012) and Saarinen et al. (2014) imaged the ﬂow of CNF suspensions at 0.1–2% and 0.5–1% consistencies respectively, and showed that soft ﬁbrillar ﬂocs are present in the suspensions at low shear rates. As the shear rate increases, the ﬂocs grow in size, thus offering a greater resistance to the ﬂow, increasing the viscosity, and leading to the plateau in the ﬂow curve. With further increase in shearing, the ﬂocs get broken and ﬁbrils get aligned with ﬂow streamlines, causing a rapid decrease in viscosity subsequent to the plateau region. Hence, due to microstructural changes in the suspensions, the shear ﬂow curve follows different power law models in different shear rate regimes before and after the ‘kink. The ﬂow indices shown in Fig. 5e are calculated for the high shear rate regime (after the plateau) in each suspension. All values for the consistency index and the ﬂow indices for the low shear rate regime can be found in the Online Resource 1. Fibre characterization Higher water retention was expected to be resulted from a combined effect of high degree of ﬁbrillation, increasing the ﬁbre surface area and amount of ﬁnes in the system, which allow the formation of a dense ﬁlter cake. In the present study, the produced HefCel grades had a wide ﬁbre size distribution, ranging from unﬁbrillated microsized ﬁbres to nanoscale ﬁbrils. Due to such mixed size distribution, the ﬁbre network entanglement, which governs the suspension viscos- ity, varied greatly. The HefCel grades were found to have much lower viscosities than typical CNMs (Fig. 5). For instance, viscosities of 2% CNF suspen- sions at shear rate of 1 s-1, were measured to be approximately 60,000 mPa s by Turpeinen et al. (2020) and 80,000 mPa s by Kumar et al. (2016). For the HefCel grades, the viscosities at 2% solids were several orders of magnitude lower and fell in the range of 20–200 mPa s. However, viscosities compa- rable to CNFs was found for several HefCel grades at 7% and 10% solids. Hence, these HefCel grades could prove suitable in ﬁlm forming, coating and printing applications without the employment of ultra-high shear rates and could reduce the drying energy requirements signiﬁcantly. This is evident from the fact that a ﬁlm (at same basis weight) made from a Fibrillated cellulose materials are known to possess a complex rheology. CNM suspensions, even at low consistencies of 1–3%, possess high yield stress but also exhibit a steep shear-thinning behavior (Hubbe et al. 2017a, b). Such behavior is found to be more 123 Cellulose Cellulose material at 10% solids contains 82% less water as compared to one made at 2% solids. data for the HefCel grades at different consistencies was ﬁtted to the power law equation s ¼ K: _cn. Values for K and n were derived from the power law ﬁts and the dependence of both parameters on suspension consistency was analyzed. All values reported for the ﬁtting parameters correspond to models with correla- tion (R-squared) values greater than 0.99 with the experimental curve. The viscosity of HefCel suspensions generally appeared to decrease with increasing enzyme dosage. The only outlier to this trend was the SW1D10 sample, for which the viscosity seemed to increase when compared to the SW1D8 sample (see supplementary information for data (Online Resource 1)). Fibre characterization The power law indices decreased with increasing suspension consistency, denoting a higher shear-thinning character at higher consistency but the drop tended to saturate in some samples beyond 5% solids. The increase of shear thinning tendency, manifested in decrease of the ﬂow index, with an increasing solids content has been reported previously (Schenker et al. 2018). In a separate work, Schenker et al. (2019) offered a possible explanation underlying this behavior where they suggested that at high consistencies, the attractive interactions between ﬁbres are more pronounced than at low consistencies due to the lower distance between ﬁbres. This causes higher aggregation at high consis- tencies which, when broken down under shear, leads to enhanced pseudoplastic behavior. Recently, Koponen (2019) prepared a review on the dependency of viscosity (lÞ and yield stress (sy) of CNFs on suspension consistency (c). Rheology data for a wide range of CNF grades was analyzed and it was shown to obey similar scaling laws when ﬁtted to the power law equation, s ¼ K: _cn, where s is shear stress, K is consistency index, _c is shear rate, and n is the ﬂow index (power law index). The data was found to universally ﬁt well to the power law relationship and the following correlations were derived, (i) n / c0:43, (ii) K / c2:43, and (iii) sy / c2:26. Clearly, rheological parameters were highly dependent on the suspension consistency. It must be noted the above relationships were derived from rheology data of suspensions having consistencies of 0.01–7% solids, but most of the data was in the consistency range of 0.5–3. In the present work, following a similar methodol- ogy as described by Koponen (2019), the shear ﬂow 123 123 Cellulose Cellulose . 6 a Strain sweeps at 7 and 10% consistencies for SW 1D6 b SW 1D10 samples. Similarly, subﬁgures (c) and (d) show in sweeps for HW 1D6 and HW1D 10 samples respectively. Curves for all other samples can be found in supplementary information. Subﬁgure (e) shows the yield stress values for the HefCel samples Curves for all other samples can be found in supplementary information. Subﬁgure (e) shows the yield stress values for the HefCel samples Fig. 6 a Strain sweeps at 7 and 10% consistencies for SW 1D6 and b SW 1D10 samples. Similarly, subﬁgures (c) and (d) show strain sweeps for HW 1D6 and HW1D 10 samples respectively. Fibre characterization The dependence of suspension viscosity on the consistency was analyzed in terms of the parameter m, which was calculated using the relation l / cm as described earlier by Hubbe et al. (2017a, b). Figure 5e shows that the viscosity was found to be strongly dependent on the consistency with m values ranging from 2.75 to 4.31 for different HefCel grades. In an earlier work, this value was derived to be approxi- mately 2.5 for ﬁbrillar CNMs, where the analysis was limited to the consistency range of 0.3–3% (Koponen 2019). It must be noted herein that the parameter m is not unique but dependent on the shear rate. Koponen (2019) modeled the value of m at various shear rates and the value of 2.5 was calculated at shear rate of 1 s-1 and for comparison, the values have been calculated at the same shear rate in the current work. All the HefCel grades had extremely low viscosity at 2% solids. Thus, at shear rates of 200–1000 s-1, secondary ﬂows (Taylor vortices) were generated, causing ﬂow resistance and therefore, the viscosity seemed to increase at high shear rates. Therefore, the data at 2% solids at high shear rates is not accurate but still has been presented to show the lower limit of consistency for such measurements. Fibre characterization This data was also 123 123 123 Cellulose Table 2 Results from tensile testing of casted ﬁlms Sample Basis weight (g/m2) Film density (kg/m3) Tensile strength (MPa) Young’s modulus (GPa) Strain at break (%) SW ND6 48.9 ± 0.3 1083 ± 7 45.7 ± 0.8 5.2 ± 0.4 1.0 ± 0.1 SW ND8 50.2 ± 0.3 1173 ± 68 50.8 ± 4.1 7.6 ± 0.3 1.0 ± 0.1 SW ND10 45.3 ± 0.6 966 ± 17 30.9 ± 4.9 4.6 ± 0.7 0.6 ± 0.2 SW 1D6 46.2 ± 0.1 1067 ± 30 42.9 ± 2.4 7.4 ± 0.9 0.8 ± 0.1 SW 1D8 51.1 ± 0.8 1056 ± 27 37.3 ± 3.4 4.7 ± 0.3 0.9 ± 0.2 SW 1D10 54.4 ± 1.3 1138 ± 28 36.0 ± 3.3 7.3 ± 0.9 0.6 ± 0.1 HW 1D6 53.8 ± 0.1 1062 ± 34 50.2 ± 6.8 4.3 ± 0.2 1.7 ± 0.3 HW 1D8 50.4 ± 0.9 1092 ± 28 42.0 ± 3.6 6.4 ± 0.7 0.9 ± 0.2 HW 1D10 46.2 ± 1.2 992 ± 55 46.6 ± 2.6 5.8 ± 0.4 1.1 ± 0.1 Abbreviations: Once-dried hardwood (HW 1D), Once-dried softwood (SW 1D), Never-dried softwood (SW ND) Table 2 Results from tensile testing of casted ﬁlms Film density (kg/m3) Tensile strength (MPa) Young’s modulus (GPa) Strain at break (%) quantiﬁed using several different methods (Nazari et al. 2016). In another work, Mohtaschemi et al. reported sy value of 33.9 Pa for a CNF suspension at 2.3% consistency, when measured using a vane geometry (Mohtaschemi et al. 2014). Therefore, in comparison of CNMs produced via mechanical grind- ing (or homogenization), HefCel grades possess much lower yield stress. Yield stress is an important rheological parameter for CNM suspensions when dealing with their mixing and pumping and lower sy values make HefCel a promising material for appli- cations in coating and 3D printing. excluded while calculating ﬁtting parameters for the power law equation. Since the HefCel grades were not completely ﬁbrillated, the viscosity of the suspensions at low consistencies was quite low, and it was observed that those suspensions did not form gels below 5% consistency. Hence, the oscillatory studies were made for samples only at 7 and 10% solids. Amplitude (strain) sweep curves for all HefCel grades are not shown but can be accessed from the supplementary information along with respective frequency sweep curves. Fibre characterization Selected results from the amplitude (strain) sweeps can be found in Fig. 6. The linear viscoelastic region (LVE) varied between samples but was typi- cally found to be below 1% strain. Moreover, many samples exhibited no ﬂow point until 100% strain. Both the storage and loss moduli increased with an increase in suspension consistency. It was observed that for the SW ND pulp, 6 mg/g enzyme dosage was sufﬁcient to produce a stable gel above 7% solids but as the dosage was increased to 10 mg/g, the gel strength reduced with crossover occurring at roughly 2% strain for 10% SW 1D 10 sample. On the other hand, for hardwood-derived grades, an increase in enzyme dosage was found to enhance the gelling tendency of the suspensions. Film properties Finally, the performance of the HefCel grades was tested in a typical application for ﬁbrillated celluloses, i.e. as standalone ﬁlms. Extensive analysis of the prepared ﬁlms was not undertaken as ﬁlm formation was only used to demonstrate the self-assembling nature of HefCel grades. Therefore, any barrier tests were not in the scope of the current work. The ﬁlms were found to be formed homogeneously but exhibited poor mechanical properties ( \* MERGEFORMAT Table 2). Both the tensile strength and strain at break of the ﬁlms were much lower when compared to CNF ﬁlms, where values greater than 100 MPa and 5%, respectively, have been reported (Syverud and Stes- nius 2009). However, such behavior was expected as the ﬁbril dimensions are vastly different and a similar result has previously been reported by Rol et al. (2017). Comparison within HefCel grades shows that ﬁlms made from SW ND10, SW 1D8 and SW 1D10 Yield stress (sy) of the HefCel grades is shown in Fig. 6e at 7 and 10% consistencies. Data regarding yield stress of ﬁbrillar CNMs at such high consisten- cies is rare in literature; however, numerous studies have reported sy values in the 0–1-3% consistency range. Nazari et al. reported sy values in the order of 1000 Pa at 7% consistency for CNF suspensions when 12 3 3 3 Cellulose Cellulose 10% consistencies and was found to be much lower than typical CNF grades. Future work on the topic could focus on studying different enzyme cocktails and investigate the performance of the HefCel grades in end-use applications such as 3D printing, coatings, and rheology modiﬁcation. Moreover, future work could focus of studying the thixotropic nature of HefCel materials as thixotropy plays an important role in printing stability and object resolution during 3D printing and coating consolidation during coating processes. The behavior of various HefCel grades during subsequent mechanical processing, such as homogenization and ﬂuidization, could also be explored where the mechanical processing would allow the production of CNMs with narrow size distribution from HefCel grades. had lower tensile strength than other ﬁlms while elongation at break remained similar. The overall low tensile strength of the HefCel ﬁlms could pose challenges towards their industrial applicability. However, the ﬁlm strength and elastic properties could be improved by using strength or plasticizing additives such as carboxymethylcellulose (CMC), hydroxyethylcellulose (HEC), sorbitol, etc. (Herrera et al. 2017; Hubbe et al. 2017a, b; Spoljaric et al. Film properties 2015). Conclusions Understanding the role of process parameters and raw materials could pave ways to produce cellulose nanomaterials with properties tuned for optimal per- formance in speciﬁc applications. The present work investigated the effect of enzyme dosage on the structure–property relationship in ﬁbrillated cellulose materials produced via enzymatic treatment of wood pulp. The enzymatic treatment was done using the HefCel process developed at VTT, which produced ﬁbrillated cellulose at 20% consistency. The effect of enzyme dosage level in the HefCel process was studied using three different types of pulp ﬁbres as substrates, namely, never-dried softwood, once-dried softwood, and once-dried hardwood. Acknowledgments The authors would like to acknowledge Janika Hart for assisting in microscopy and rheological characterization and Ulla Salonen for optical ﬁbre analysis. We would also like to thank Atte Mikkelson for performing the SEC measurements. Funding Open Access funding provided by Technical Research Centre of Finland (VTT). This work was part of the Academy of Finland Flagship Programme under project numbers 318890 and 318891 (Competence Center for Materials Bioeconomy, FinnCERES). References Hidayat BJ, Felby C, Johansen KS, Thygesen LG (2012) Cel- lulose is not just cellulose: a review of dislocations as reactive sites in the enzymatic hydrolysis of cellulose microﬁbrils. Cellulose 19(5):1481–1493 Abdul Khalil HPS et al (2014) Production and modiﬁcation of nanoﬁbrillated cellulose using various mechanical pro- cesses: a review. Carbohyd Polym 99:649–665 Hidayat BJ et al (2015) The binding of cellulase variants to dislocations: a semi-quantitative analysis based on CLSM (Confocal Laser Scanning Microscopy) images. AMB Express 5(1):1–14 Abitbol T et al (2016) Nanocellulose, a tiny ﬁber with huge applications. Curr Opin Biotechnol 39:76–88. https:// www.sciencedirect.com/science/article/pii/ S0958166916000045. 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An increase in enzyme dosage did not universally corre- late with the change in aspect ratio of the ﬁbres and neither did it lead to a decrease in the average cellulose molar mass. Fibres in the softwood-derived HefCel grades showed a lower aspect ratio than the hardwood- derived grades. The different enzymatic action for softwood and hardwood substrates is hypothesized to be due to the presence of high amount of hemicellu- loses in the hardwood pulp. Conﬂict of interest The authors declare that they have no conﬂict of interest. Conﬂict of interest The authors declare that they have no conﬂict of interest. Open Access This article is licensed under a Creative Com- mons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any med- ium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Both viscosity and water retention values of the HefCel suspensions were found to decrease with increasing enzyme dosage. The shear viscosity data was ﬁtted with the power law equation s ¼ K: _cn where the power law index n was found to vary from 0.11 to 0.73. The shear-thinning behavior decreased with increasing consistency. The suspension viscosity was found to be highly dependent on the consistency as l cm, with m ranging from 2.75 to 4.31. 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https://openalex.org/W3159141917	https://www.researchsquare.com/article/rs-421231/latest.pdf	English	null	Safety of 0.5% hydrogen peroxide mist used in the disinfection gateway for COVID-19	Environmental science and pollution research international	2,021	cc-by	7,423	Safety of 0.5% hydrogen peroxide mist used in the disinfection gateway for COVID-19 Parayanthala Valappil Mohanan (  mohanpv10@gmail.com ) SCTIMST Parayanthala Valappil Mohanan SCTIMST Vijayan Sangeetha SCTIMST Arumugham Sabareeswaran SCTIMST Vayalappil Muraleedharan SCTIMST Krishnan Jithin SCTIMST Unnikrishnan Vandana SCTIMST Sheela Bhasi Varsha SCTIMST Research Article DOI: https://doi.org/10.21203/rs.3.rs-421231/v1 DOI: https://doi.org/10.21203/rs.3.rs-421231/v1 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Version of Record: A version of this preprint was published at Environmental Science and Pollution Research on July 7th, 2021. See the published version at https://doi.org/10.1007/s11356-021-15164-y. Page 1/19 Page 1/19 Page 1/19 Abstract Hydrogen peroxide (H2O2) is a reactive chemical used in a wide range of applications. Most importantly, it is used for sterilization process in health care environment. In the present study, safety assessment of 0.5% of H2O2or its mist intended to be used in the disinfection gateway for Covid-19 was evaluated. Skin irritation and repeated dose inhalation toxicity studies were carried out in rabbits and rats respectively. Skin irritation study revealed no observable oedema and erythema in rabbits after tropical application of 0.5% H2O2. Wistar rats (both male and female) were exposed (whole body exposure) to0.5% of H2O2 mist, at a concentration of 11.022 (low dose-2 min exposure), 22.044 (medium dose-4 min exposure) and 55.11mg/kg (high dose/high doe recovery-10 min exposure) body weight, daily for seven days. Rats in the high dose recovery group (55.11mg/kg-10 min exposure) were kept for another 7 days without any exposure. A toxicological evaluation was done based on general health parameters, haematology, serum biochemistry, gross necropsy and histopathological data. The results of the study indicated that there was no skin irritation potential induced on exposure of 0.5% of H2O2to rabbits. Similarly, the inhalation toxicity of 0.5% of H2O2 mist, imparts no evidence of haematological, biochemical, gross pathology or histopathological abnormalities in rats. Further, at the laboratory condition stimulated, the NOEL was found to be 55.11mg/kg body weight. Hence, the present study concluded that 0.5% H2O2 or its mist used in the disinfection gateway for COVID-19, failed to induce any skin irritation in rabbits or inhalation toxicity in rats. 1. Introduction Hydrogen peroxide, colourless liquid easily decompose to oxygen and water in the presence of most metals and alkaline solutions. Itwas first synthesized by Louis Jacques Thénard in 1818 by reaction of nitric acid with barium peroxide. Hydrogen peroxide (H2O2) generally used and available in concentrations ranging from 3%-90%.H2O2, an oxidizing agent is actively used in wide range of applications, mainly in medicinal and house hold purposes (3–30%). Industries mostly use concentrated hydrogen peroxide (30–70%) for the purpose of bleaching (Ernstgard et al. 2012). Aqueous solutions of hydrogen peroxide in the range of 3–6% in water demonstrate broad-spectrum antimicrobial activity depending on the concentration and exposure time; hence it is also included in cosmetics, toothpaste, and detergents (McDonnell, 2009). H2O2both in liquid and gaseous form is widely used for biocidal applications. In health care facilities, vaporized hydrogen peroxide is used in sterilization of medical devices (Rutala and Weber 2015) and hydrogen peroxide-based automated room disinfection systems are utilized in pharmaceutical environments (Murdoch et al. 2016). Recently vaporized hydrogen peroxide (VHP) as a rapid sterilization technology is used as broad spectrum antimicrobial with virucidal, bactericidal, fungicidal and sporicidal activity (Lerouge et al. 2012). Virucidal effect of hydrogen peroxide vapour disinfection against poliovirus, rotavirus, adenovirus, MNV1 and influenza A virus has been documented (Tuladhar et al. 2012). Concern raised on the toxic effect of hydrogen peroxide due to its wide spread application. It has been documented that hydrogen peroxide once entered the blood circulation; it is rapidly decomposed in blood and remains unavailable systemically. Hydrogen peroxide induces toxicity depending on the route and concentration of Hydrogen peroxide, colourless liquid easily decompose to oxygen and water in the presence of most metals and alkaline solutions. Itwas first synthesized by Louis Jacques Thénard in 1818 by reaction of nitric acid with barium peroxide. Hydrogen peroxide (H2O2) generally used and available in concentrations ranging from 3%-90%.H2O2, an oxidizing agent is actively used in wide range of applications, mainly in medicinal and house hold purposes (3–30%). Industries mostly use concentrated hydrogen peroxide (30–70%) for the purpose of bleaching (Ernstgard et al. 2012). Aqueous solutions of hydrogen peroxide in the range of 3–6% in water demonstrate broad-spectrum antimicrobial activity depending on the concentration and exposure time; hence it is also included in cosmetics, toothpaste, and detergents (McDonnell, 2009). H2O2both in liquid and gaseous form is widely used for biocidal applications. 1. Introduction In health care facilities, vaporized hydrogen peroxide is used in sterilization of medical devices (Rutala and Weber 2015) and hydrogen peroxide-based automated room disinfection systems are utilized in pharmaceutical environments (Murdoch et al. 2016). Recently vaporized hydrogen peroxide (VHP) as a rapid sterilization technology is used as broad spectrum antimicrobial with virucidal, bactericidal, fungicidal and sporicidal activity (Lerouge et al. 2012). Virucidal effect of hydrogen peroxide vapour disinfection against poliovirus, rotavirus, adenovirus, MNV1 and influenza A virus has been documented (Tuladhar et al. 2012). Concern raised on the toxic effect of hydrogen peroxide due to its wide spread application. It has been documented that hydrogen peroxide once entered the blood circulation; it is rapidly decomposed in blood and remains unavailable systemically. Hydrogen peroxide induces toxicity depending on the route and concentration of Page 2/19 Page 2/19 exposure. The permissible exposure limit as per Occupational Safety and Health Administration (OSHA) is found to be 1 ppm (averaged over an 8-hour work shift) (ATSDR, 2012). The 8 hour limit value of hydrogen peroxide was decreased from 1ppm to down to 0.05ppm by MAK commission. Among the routes of exposure (Ingestion, inhalation and dermal contact), inhalation is considered to be the major route for gaseous form exposure resulting in toxicity. Studies on human have reported, industrial workers exposed to hydrogen peroxide 1.2 to 2.4 ml/m3 with peak exposures of 8 ml/m3 caused irritation of the eyes and throat, nasal congestion, coughing and asthma symptoms revealing severe signs of inhalation toxicity (Hartwig et al. 2019). A Animal studies have reported, dermal LD50 of 90 % hydrogen peroxide solution, between 700 and 5000 mg/kg body weight in various species, among them the rat was the least sensitive (EC, 2003).Earlier studies also reported thatworkers exposed to H2O2 concentrations, less than 1 ppm showedrough skin on the hands and decolorized hairs (Suenaka et al. 1984). Studies on rodents documented that the oral LD50 of hydrogen peroxide (30%-70%) is found to be 694–1270 mg/kg body weight in rats (EU, 2012). In a 28-day, study Wistar rats exposed to hydrogen peroxide vapour in concentrations of 0, 2, 10 or 25 ml/m3 for 6 hours per day and 5 days per week (nose-only exposure) showed concentration depended lung toxicity (ECIC, 2002).Studies also documented hydrogen peroxide as a well-known irritant to the mucous membranes and the airways (Watt et al. 2004). 2.1 Animals Wistar rats, both male and female of 8 weeks old with body weight range 170–250g was selected for inhalation toxicity study and New Zealand white rabbit weighing 2.0-2.6 kg was chosen for skin irritation test. The animals were selected from an inbred colonymaintained under the controlled conditions of 22 ± 3oC, humidity of 30–70 % and 12 h photoperiod with sterile food and water. Experiments were performed after obtaining approval by the Institutional Animal Ethics Committee. The animal care and handling were according to the The Committee for the Purpose of Control and Supervision of Experiments on Animals (CPCSEA) guide-lines for animal experimentation. 1. Introduction Even though numerous studies on hydrogen peroxide are available in literature, consistent and accurate toxicity studies remain elusive. Recently, exploiting virucidal, bactericidal and disinfectant activity of 0.5% of hydrogen peroxide mist, a disinfectant gate way was developed intended to be used for Covid-19 to control the extent of exposure to the viral load (Krishnan et al. 2020). In the present study, safety assessment of 0.5% H2O2 mist used in the disinfection gateway for COVID-19 was evaluated for skin irritation and repeated dose inhalation toxicity studies in New Zealand white rabbits and Wistar rats. 2.2 Skin irritation Skin irritation potential was carried out as per International organization for standardization (ISO 10993-10, 2010). Three New Zealand white rabbits were used for the study. 0.5% H202 solution (3%H202IP-Pharmacy Page 3/19 grade) and physiological saline (control) were exposed topically on the upper left and right hand side of the clipped skin of 3 Rabbits (0.5mL/site). Application sites were covered with occlusive bandage for 4h.The test sample and control application sites were observed at 1h, 24h, 48h and 72h after removal of patches and observed for any tissue reactions. Skin irritation responses of rabbits were scored and recorded as ISO 10993-10. 2.3 Repeated-dose inhalation toxicity Repeated-dose inhalation toxicity study was performed based on OECD guidelines 412 (OECD, 2018). Wistar rats of either sex (20 male and 20 female) were randomly assigned to five different groups: low dose, medium dose, high dose, high dose recovery and control group respectively (n = 4). Wistar rats (both male and female) were exposed (whole body exposure) to 0.5% of H2O2 mist (2–10 micron diameter), at a concentration of 11.022 (low dose-2 min exposure), 22.044 (medium dose-4 min exposure) and 55.11mg/kg body weight (high dose/high dose recovery-10 min exposure), daily for seven days. Rats in the high dose recovery group (55.11mg/kg-10 min exposure) were kept for another 7 days without any exposure. Control animals received only normal environmental conditions or exposure. All animals in each group (control, low, medium, and high) were sacrificed after 7 days. Recovery group animals were kept further 7 more days and sacrificed on 14th day.The justification for selection of dose/exposure is based on the multiple dose of human exposure (dose human exposure X6, X12 and X30 times) as shown in Table 1. All animals were subjected to daily observations for mortality and behavioural changes. Body weight of the animals before and after exposure was also recorded. Table 1 Experimental design: Repeated dose inhalation toxicity of 0.5% H2O2 mist No Group No of animals (Rats) Duration of exposure Dose mg/kg body weight of H2O2 mist Male Female 1 Control 4 4 0 min 0 2 Low dose 4 4 2 min 11.022mg/kg 3 Medium dose 4 4 4 min 22.044mg/kg 4 High dose 4 4 10 min 55.11mg/kg 5 High dose recovery 4 4 10 min 55.11mg/kg Table 1 2.7 Gross necropsy At the end of observation period, all the animals in control and test groups were sacrificed by cervical dislocation. All the animals were subjected to gross pathological evaluations. Organs, such as lungs, cerebrum, cerebellum, liver, spleen, pancreas, kidneys, heart, thymus, adrenal, testes, epididymis, ovaries, uterus, cervix, nasal cavity, pharynx, larynx and trachea were subjected to gross pathological evaluations. 2.4 Body weight In the repeated-dose inhalation toxicity study, the body weight of Wistar rats exposed to hydrogen peroxide mist (0.5%) and control animals were recorded before and after completion of exposure. 2.5 Haematology Page 4/19 Page 4/19 Wistar rats were anesthetized (diethyl ether) and blood was collected from retro-orbital venous plexus in sample tubes containing ethylene diamine tetra acetic acid (EDTA) and examined for the following parameters: white blood cell counts (WBC), red blood cell counts (RBC), haemoglobin concentration (Hb), haematocrit (HCT), MCV, mean corpuscular volume (MCHC) and platelets (PLT) using a haematology analyser (Abc VET, New Delhi). 2.6 Serum biochemistry Blood samples were collected from retro-orbital venous plexus of rats and allowed to clot. The serum samples of both 0.5% of H2O2 mist exposed and non-exposed was separated after centrifugation at 3,000 rpm for 5 min. The serum was subjected to use for the estimation of alanine amino transferase (ALT), aspartate amino transferase (AST), Alkaline phosphatase (ALP), Triglycerides, albumin, total protein, total bilirubin, creatinine, glucose, cholesterol and urea using an automated biochemical analyser (ERBA XL 300,Germany) and as per the manufacturer’s instructions. 2.8 Histopathology All the animals were scarified at the end of the experimental period. Following organs from the control and test groups were subjected to histopathological evaluations. Organs such as lungs, cerebrum, cerebellum, liver, spleen, pancreas, kidneys, heart, thymus, adrenal, testes, epididymis, ovaries, uterus, cervix, nasal cavity, pharynx, larynx and trachea. All the above organs were collected and preserved in 10% buffered formalin. Blocks of tissue were processed in automatic tissue processor and embedded in molten paraffin. Five micrometer (3–5µm) thick sections were cut from the block and stained with Haematoxylin and Eosin and subjected to microscopical examinations. 2.9.1Preparation tissue homogenate Liver homogenate was prepared as follows, liver tissues of Wistar rats exposed to 0.5% of H2O2mist at varying doses and control animals were dissected and washed with saline (0.9%) to remove excess blood. The tissues were homogenized in 0.1M phosphate buffer using a tissue homogenizer (Polytron P3100) at 1000 rpm and subsequently centrifuged to pellet cell debris. The supernatant was collected and stored at -80°c until used for antioxidant assays. 2.9.3 Reduced glutathione level (GSH) The amount of reduced glutathione (GSH) in the liver homogenate of Wistar rats exposed to 0.5% H2O2mist was determined with slight modifications of the method of Moron, Depierre, and Mannervik (Moron et al. 1979). The thiol reagent DTNB (5, 5’-dithiobis- (2-nitrobenzoic acid), reacts with GSH to form a chromophore, 5-thionitrobenzoic acid (TNB) and it is measured using UV/Vis spectrophotometer (Perkin Elmer, USA) at 412 nm. 2.9.2 Total protein assessment Page 5/19 Page 5/19 Total protein concentration of liver homogenate was determined (Lowry et al. 1951) with bovine serum albumin as standard in a UV/Vis spectrophotometer (Perkin Elmer, USA) at 690 nm. 2.9.4 Glutathione peroxidase (GPx) GPx activity in liver tissue homogenate of Wistar rats exposed to 0.5% H2O2mist was analysed (Rotruck et al.1973). Glutathione peroxidase (GPx) resulting in the formation of glutathione disulfide (GSSG). GSH remaining after enzyme catalyzed reaction complexes with DTNB, which absorbs at maximum wavelength of 412 nm. Enzyme activity was expressed as mg of GSH consumed /min/mg protein. 3.2.1Clinical signs and survival No mortality or morbidity was found in both control or tested groups throughout the experimental period. No clinical signs of toxicity were observed on exposure to 0.5% hydrogen peroxide mist in all study groups. 3 2 2 Body weight 3.2.2 Body weight Gain in body weight was observed in all groups (low dose, medium dose, high dose and high dose recovery) exposed to 0.5% H2O2mist. Significant increase in body weight observed when compared to initial body weight, as shown in Table 3. 3.1 Skin irritation test Skin irritation potential on exposure to 0.5% H2O2was determined and depicted in table 2. Rabbits showed no signs of skin irritation after exposure to 0.5% H2O2. The treated skin remained intact, no oedema and erythema compared to control site was observed. Enema and erythema score was categorised (ISO 10993- 10) and recorded as ‘0’ in each rabbit on removing the test material and at the end of observation period. 3.2.3Haematology Haematological parameters were analysed separately for males and females. The results (Table 4) revealed that, all the haematological parameters were comparable with the control group, both in males and females. The RBC count and percentage of HCT of control animal was found to be less than the Page 6/19 Page 6/19 normal range. It is suggested that the alternation observed in the RBC count or percentage of HCT is not related with the test sample exposure. There is a statistical significance observed in MCV and MCHV values, but the values are within the normal range. 3.2.7 Antioxidant assay The results depicted in Table.6 revealed that no significant difference was observed in the levels reduced glutathione and glutathione peroxidase with respect to control. 3.2.6 Histopathology Histopathological examination of lungs, cerebrum, cerebellum, liver, spleen, pancreas, kidneys, heart, thymus, adrenal, testes, epididymis, ovaries, uterus and cervix did not revealed any abnormality in low, medium, high dose and high dose recovery group in comparison to control group. Similarly, no pathological lesions were evident in nasal cavity, pharynx, larynx and trachea in low, medium, high dose and high dose recovery group. Histopathology of control and 0.5% of H2O2mistexposed tissues of both male and female are shown in Figure 1 (a-f), Figure 2 (a-f) and Figure 3 (A-B). 3.2.4 Serum biochemistry Biochemical analysis revealed serum ALT, bilirubin, creatinine, triglycerides, total protein and albumin in both female and male Wistar rats exposed to0.5% H2O2 mist for a period of 7 days were comparable with that of control (Table5a, 5b). However, slight variation was observed in the creatinine, ALT, total protein, albumin and ALP level of control animals in comparison with normal reference range. Significant increase was observed in serum cholesterol and urea levels compared to control in hydrogen peroxide mist exposed Male Wistar rats (P<0.01, P<0.05), but all are within the reference range. Similarly serum glucose levels were also found be increased in Wistar rats (Female) (Table 5a). Moreover, serum AST (SGOT) levels were decreased in both male (high dose) and female Wistar rats (Low, medium, high) with respect to control. It was also noted that an increased level of triglycerides occurred in the low and medium dose group of males and high dose group of females. Significant difference was observed in urea, AST, Glucose, and cholesterol levels in recovery group in comparison with control and high dose (p<0.01) 3.2.5 Gross necropsy Necropsy examination of lungs, cerebrum, cerebellum, liver, spleen, pancreas, kidneys, heart, thymus, adrenal, testes, epididymis, ovaries, uterus, cervix, nasal cavity, pharynx, larynx and trachea in low, medium, high dose and high dose recovery group (both male and female) did not reveal any treatment (0.5% H2O2mist) related gross findings in comparison to control group. Statistical analysis Data were expressed as mean ± SD. Statistical comparisons between and control exposed groups was done using one-way ANOVA followed by Tukey’sposthoc test (SPSS ver 22, IBM Corp) and significant Page 7/19 difference between initial and final body weight by paired T-test. The p values (p< 0.01, p< 0.05) are considered as significant. 5. Discussion Hydrogen peroxide, its oxidising nature enabled it to be a part of wide range of applications. Among the various applications, both aqueous and gaseous form of H2O2 plays a key role in the process of sterilization. Recently the concept of vapour phase H2O2 (VPHP) sterilization has been developed as a replacement for EO and formaldehyde sterilants (McEvoy et al. 2019). The rationale of the study is to assess the safety of 0.5% hydrogen peroxide used as a disinfectant compound in the disinfectant gateway developed in concern with current virus pandemic. In the disinfected gate way the hydrogen peroxide mist is used as a disinfectant to decontaminate the personnel entering a cleaner private space from a public space (Krishnan et al. 2020) In the present study, acute skin irritation and repeated dose inhalation toxicity was carried out to assess safety assessment. Notably, 0.5% of hydrogen peroxide mist was used in disinfectant gateway by exploiting its application as a disinfectant to reduce the microbial and viral load. Skin irritation is considered to be one of the relevant end points of chemicals and therefore skin irritation test is critical, if dermal contact is intended (Chandra et al. 2015). A study on New Zealand rabbits, reported that severity of skin irritation increases within the increase in concentration of hydrogen peroxide solution (10 %< 35 %< 50%). No signs of skin irritation were observed in New Zealand white rabbits administered with 3% aqueous hydrogen peroxide to intact and abraded skin under occlusion for 24 h (ECHA, 2003). In this study, skin irritation test in rabbits was done to screen any potential hazards of hydrogen peroxide on skin and no evidence of erythema and oedema was observed for 0.5% of hydrogen peroxide. In the present study, acute skin irritation and repeated dose inhalation toxicity was carried out to assess safety assessment. Notably, 0.5% of hydrogen peroxide mist was used in disinfectant gateway by exploiting its application as a disinfectant to reduce the microbial and viral load. Skin irritation is considered to be one of the relevant end points of chemicals and therefore skin irritation test is critical, if dermal contact is intended (Chandra et al. 2015). A study on New Zealand rabbits, reported that severity of skin irritation increases within the increase in concentration of hydrogen peroxide solution (10 %< 35 %< 50%). 5. Discussion These variation exist may be due to age, reproductive status, housing, starvation, environmental factors, stress and transportation (Waziri et al. The pathological of condition of internal organs after exposure to hydrogen peroxide mist was revealed by serum biochemistry. Variation observed in the creatinine, ALT, total protein, albumin and ALP levels of control animals in comparison with the normal reference range suggested by CPCSEA (CPCSEA, 2003). A significant decrease in serum AST levels was observed in female Wistar rats exposed to hydrogen peroxide (low, high, medium and recovery groups) with respect to control. Whereas in male Wistar rats significant difference was observed at medium and recovery groups with respect to control but all are within the reference range. It was also found that alkaline phosphatase levels (ALP) increased in male Wistar rats at low dose but no such increase was observed at high dose with respect to control. It has been reported that breed, sex, age, reproductive status; time of feeding, diurnal variations, nutritional state and management; and geographical/climatic factors influence serum parameters (Stockham et al. 2013). It was also documented that many of the haematological and biochemical parameters are in association with developmental changes (Lillie et al.1996). So the alternations in serum AST and ALP levels may be due to such variation than the effect of hydrogen peroxide. Significant difference was observed in serum urea and cholesterol levels in male Wistar rats exposed to hydrogen peroxide, in comparison with control but all are within the reference range. In recovery groups, most of the test parameters were found to be comparable with that of control. Nonetheless, significant decreases in urea levels were observed in male Wistar rat. Further, negligible differences observed with regard to haematological and biochemical parameters may not be considered as toxicological or biological significance as the results were comparable to that of control and most of the changes were not related to the exposure. Histopathological results revealed no abnormalities or pathological alternations in the tissues examined. All the tissues like lungs, cerebrum, cerebellum, liver, spleen, pancreas, kidneys, heart, thymus, adrenal, testes, epididymis, ovaries, uterus, cervix, nasal cavity, pharynx, larynx and trachea examined after H2O2 exposure remains intact, similar to that of control. Studies have documented on the morphological complexity and the importance of upper respiratory tract in inhalation toxicity studies (Herbert et al. 2018). 5. Discussion No signs of skin irritation were observed in New Zealand white rabbits administered with 3% aqueous hydrogen peroxide to intact and abraded skin under occlusion for 24 h (ECHA, 2003). In this study, skin irritation test in rabbits was done to screen any potential hazards of hydrogen peroxide on skin and no evidence of erythema and oedema was observed for 0.5% of hydrogen peroxide. Inhalation of chemicals in many industrial workplaces can be a trigger of respiratory tract disorders as well as systemic diseases, depending on the type of inhaled substance and exposure time (Bakand et al. 2005; Camus et al. 1998). It has been documented that male Wistar rats were exposed to hydrogen vapour (90%) in glass chamber for 8h, sacrificed after 14 days showed alveolar emphysema together with severe congestion (ECHA,2003).A sub-chronic toxicity study on rats exposed to aerosolized hydrogen peroxide (50% aq.) 5 days per week, 6 h per day, for 28 days showed clinical signs such as reddened nose, salivation, irregular breathing, respiratory tract irritation, piloerection, at 14.6 mg/ml (Oberst et al. 1954). In this present repeated dose exposure study, no evidence of mortality, clinical toxicity signs and body weight loss was observed in all study groups compared to control. Haematology and serum biochemical assessments are key tools to assess the physiological and pathological status of the tissue (Stockham et al. 2003). In this study, the haematological parameters of clinical importance, haemoglobin, white blood cell counts and platelets were observed to be similar to that of control in both female and male. Wistar rats exposed to 0.5% of hydrogen peroxide mist. Alternations were observed in red blood cell (RBC) counts with respect to control, in male Wistar rats exposed to hydrogen peroxide mist (low, medium dose). But it may not be consider as a sign of hydrogen peroxide induced toxicity, since these changes were not observed in high exposure level. However, haematological Page 8/19 Page 8/19 indices HCT, MCV, MCHC were significantly decreased in male Wistar rats at low and medium dose exposure of hydrogen peroxide mist and at high dose in females. These variation exist may be due to age, reproductive status, housing, starvation, environmental factors, stress and transportation (Waziri et al. 2010). indices HCT, MCV, MCHC were significantly decreased in male Wistar rats at low and medium dose exposure of hydrogen peroxide mist and at high dose in females. Funding No funding from other sources. Consent to Participate and Publish All authors read and approved the manuscript and have no conflict in participation and publishing the manuscript. All authors read and approved the manuscript and have no conflict in participation and publishing the manuscript. 5. Discussion Studies have documented that inhalation of chemicals may affect the pulmonary epithelium of the respiratory tract (Gorguner et al. 2010).Toxicants or irritant chemicals induce frequent lesions such as necrosis, erosion and ulceration of the respiratory epithelium. In this study, no hydrogen peroxide induced alternations were observed, even though few infrequent lesions observed in control rats, may be due to microbial infections. Histopathological results revealed no abnormalities or pathological alternations in the tissues examined. All the tissues like lungs, cerebrum, cerebellum, liver, spleen, pancreas, kidneys, heart, thymus, adrenal, testes, epididymis, ovaries, uterus, cervix, nasal cavity, pharynx, larynx and trachea examined after H2O2 Oxidative stress, an imbalance between reactive oxygen species (ROS)and the antioxidant defence mechanism of cells or tissues, lead to rapid glutathione depletion, decreasing antioxidant enzyme, lipid peroxidation and DNA damage (Valko et al. 2016). Antioxidant enzyme system play key role in defence against free radical induced oxidative damage. It has been reported that hydrogen peroxide (100 mg/kg body weight) induced alternations in antioxidant enzyme activity in mice (Yalçın et al. 2020). In normal Page 9/19 Page 9/19 conditions the glutathione/glutathione peroxidase system maintains the hydrogen peroxide levels by breaking down to oxygen and water (Reid et al. 2011).In this study no significant difference was observed in reduced glutathione and GPx activity with respect to control. conditions the glutathione/glutathione peroxidase system maintains the hydrogen peroxide levels by breaking down to oxygen and water (Reid et al. 2011).In this study no significant difference was observed in reduced glutathione and GPx activity with respect to control. The results of the present study suggest that, there was no skin irritation potential such as oedema or erythema or necrosis on exposure to 0.5% H2O2 in rabbits. Similarly the inhalation toxicity of 0.5% of H2O2 mist, intended to be used for disinfection gateway for COVID-19, was well tolerated by wistar rats (both male and female).Further, at the laboratory condition stimulated, the NOEL was found to be 55.11mg/kg body weight. Hence, the present study concluded that 0.5% H2O2 or its mist used in the disinfection gateway for COVID-19, failed to induce any skin irritation in rabbits or inhalation toxicity in rats. Ethical Approval Experiments were conducted after obtaining approval from the Institutional animal ethics committee. The animal care and handling was done according to the CPCSEA guidelines for animal experimentation. Acknowledgments Authors express their thanks to the Director and Head, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology (Govt. of India), Trivandrum, Kerala, India for their support and providing the infrastructure to carry out this work. Authors Contributions Moahan: design of the study, experiment done, data collection, drafting, interpretation and final approval. Sangeetha, Sabareeswaran, Muraleedharan, Jithin, Vandana, Varsha: data collection, drafting and experimental support. Conflicts of interest The authors declare that they have no conflict of interests. Data Availability Page 10/19 Page 10/19 The authors declared that the research data referred correctly cited in the manuscript’s reference section. References The authors declared that the research data referred correctly cited in the manuscript’s reference section. The authors declared that the research data referred correctly cited in the manuscript’s reference section. References Agency for Toxic Substances and Disease Registry (ATSDR) (2002) Managing Hazardous Materials Incidents. Volume III - Medical Management Guidelines for Acute Chemical Exposures: Hydrogen Peroxide. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. 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Table 4: Haematological values of rats exposed to 0.5% H2O2 mist Tables *p< 0.01; p< 0.05 compared to initial body weight.(Final body weight after 7 days of exposure), $Final bodyweight after14days Page 14/19 Groups Hb (g/dl) RBC(x 106/mm3) WBC (x103/mm3) PLT(x103/mm3) HCT (%) MCV (um3) MCHC (g/dL) Male Control 15.07± 0.58 5.23± 0.19 10.00± 2.80 836.3± 41.30 34.20± 1.12 65.30± 1.71 44.13± 0.61 Low dose 15.10± 0.49 5.98± 0.15* 8.40± 2.30 815.3± 60.11 37.10± 1.36* 61.80± 2.50* 40.60± 0.24** Medium dose 15.63± 0.79 6.00± 0.22* 8.15± 1.90 847.5± 26.30 37.53± 1.94* 61.30± 1.50 41.70± 0.58 High dose 14.50± 0.61 4.85± 0.12 8.68± 1.40 848.5± 22.65 32.03± 1.68 66.00± 1.63 45.30± 0.77 High dose Recovery 15.00± 0.64 6.20± 0.19# 10.50± 4.48 888.7± 19.63 38. 90± 2.97# 59.80± 1.50# 37.88± 1.46# Female Control 14.65± 0.43 4.85± 0.05 6.35± 2.70 824.5± 66.54 31.78± 0.54 65.30± 0.50 45.58± 0.85 Low dose 14.70± 0.82 5.13± 0.17 6.18± 1.29 776.3± 50.26 32.45± 1.76 63.30± 2.06* 45.35± 0.85 Medium dose 14.18± 0.45 4.85± 0.21 6.02 ± 0.58 862.0± 18.13 31.23± 1.41 64.80± 0.50 45.33± 0.84 High dose 14.65± 0.17 5.68± 0.22 6.03± 0.59 852.3± 35.03 33.93± 1.38 60.00± 0.50 43.25± 1.09* High dose Recovery 15.30± 0.49 6.74± 0.44# 6.53± 0.55 888.3± 20.02 39.20± 2.18# 58.00± 0.82# 38.98± 0.87# Data expressed as mean ± SD, n = 4. Statistical significance was determined using one way ANOVA followed by Tukeys post hoc test.p< 0.05; p < 0.01 compared to control, #p < 0.01 compared to high dose Data expressed as mean ± SD, n = 4. Tables Table 1: Experimental design: Repeated dose inhalation toxicity of 0.5% H2O2 mist No Group No of animals (Rats) Duration of exposure Dose mg/kg body weight of H2O2 mist Male Female 1 Control 4 4 0 min 0 2 Low dose 4 4 2 min 11.022mg/kg 3 Medium dose 4 4 4 min 22.044mg/kg 4 High dose 4 4 10 min 55.11mg/kg 5 High dose recovery 4 4 10 min 55.11mg/kg Table 1: Experimental design: Repeated dose inhalation toxicity of 0.5% H2O2 mi Table 2: Skin irritation score of Rabbits exposed to 0.5% H2O2 Table 2: Skin irritation score of Rabbits exposed to 0.5% H2O2 Page 13/19 Animal Group Irritation score 24h Irritation score 48h Irritation score 72h 1♀ Control Erythema OedemaErythemaOedemaErythemaOedema Test 0 0 0 0 0 0 2♂ Control 0 0 0 0 0 0 Test 0 0 0 0 0 0 3♂ Control 0 0 0 0 0 0 Test 0 0 0 0 0 0 Primary irritation score 0 Irritation Index 0 Table 3: Body weight of Wistar rats before and after exposure to 0.5% H2O2 mist Groups Initial body weight (g) Final body weight (g) Initial body weight (g) Final body weight (g) Male Female Control 242.33 ± 9.54 280.92 ± 11.41* 179.71 ± 6.18 195.72 ± 2.93* Low dose 171.50 ± 13.82 263.02 ± 7.76** 171.82 ± 11.50 199.80 ± 7.74* Medium dose 233.11 ± 10.99 262.15 ± 18.14 183.55 ± 9.33 192.26 ± 5.65 High dose 217.28 ± 33.86 252.53 ± 45.53 183.96 ± 9.28 190.31 ± 11.94 High recovery$ dose 195.50 ± 18.53 285.00 ± 26.52 176.70 ± 5.80 200.80 ± 10.17 Table 3: Body weight of Wistar rats before and after exposure to 0.5% H2O2 mist Data expressed as mean ± SD. Statistical significance was determined using paired T-test. Tables Statistical significance was determined using one way ANOVA followed by Tukeys post hoc test.p< 0.05; p < 0.01 compared to control, #p < 0.01 compared to high dose Table 5a: Serum biochemistry of rats exposed to 0.5% H2O2 mist Groups Urea Mg/dL Creatinine (mg/dL) SGPT (ALT) (IU/L) SGOT (IU/L) Glucose (mg/dL) Male Control 43.17± 1.50 0.90± 0.19 83.43± 4.48 215.9± 26..89 77.10± 10.27 Low dose 38.79± 3.50 0.89± 0.02 66.55± 33.64 199.0± 4.32 77.20± 11.43 Medium dose 38.10± 1.00* 0.62± 0.18 64.40± 18.15 153.5± 41.8* 79.38± 10.81 High dose 39.23± 3.96 1.00± 0.14 66.83± 19.28 176.3± 55.57 56.32± 7.40* High dose recovery 15.32± 2.25# 1.03± 0.20 71.78± 4.80 128.4± 12.14# 97.40± 9.00*# Female Control 40.63± 1.07 0.94± 0.12 81.38± 18.76 221.4± 27.7 48.38± 3.12 Low dose 31.43± 5.20 1.00± 0.12 82.93± 25.29 170.7± 47.78* 44.60± 19.46 Medium dose 37.34± 1.35 1.10± 0.12 69.93± 18.62 173.5± 17.28* 53.10± 18.88* High dose 38.56± 0.33 1.10± 0.12 65.38± 6.29 152.2± 54.39 76.40± 8.63 High dose recovery 23.35± 5.68# 0.91± 0.11 66.05± 7.53 134.2± 5.96 82.63± 11.87# Table 5a: Serum biochemistry of rats exposed to 0.5% H2O2 mist Page 15/19 Page 15/19 Data expressed as mean ± SD, n = 4. Statistical significance was determined using one way ANOVA followed by Turkey’spost hoc test. p< 0.01; p < 0.05 compared to control,#p< 0.01 compared to high dose Table 5b: Serum biochemistry of rats exposed to 0.5% H2O2 mist Groups Cholesterol (mg/dL) TG mg/dL ALP IU/L Total Bilirubin (mg/dL) Total Protein (g/dL) Albumin g/dL Male Control 112.3± 8.73 155.8± 3.30 227.0± 103.6 0.25± 0.09 11.07± 4.18 5.30± 1.17 Low dose 73.50± 13.00 198.8± 26.74 336.0± 90.00* 0.25± 0.05 9.45± 1.60 5.15± 0.26 Medium dose 81.20± 8.75* 185.5± 84.86 336.2± 84.26 0.27± 0.09 10.80± 0.59 5.33± 0.48 High dose 89.00± 38.9 154.8± 48.53 364.1± 7.66 0.28± 0.08 10.87± 2.43 5.50± 1.00 High dose recovery 61.41± 5.56# 120.3± 21.09 185.9± 68.20# 0.34± 0.85 9.90± 1.62 5.07± 0.26 Female Control 80.0± 11.92 100.0± 8.04 181.3± 16.70 0.29± 0.09 10.75± 2.90 5.63± 1.07 Low dose 90.3± 22.4 101.5± 27.74 186.3± 18.15 0.34± 0.34 11.90± 2.28 4.98± 0.56 Medium dose 84.08± 6.08 150.0± 58.09 190.8± 28.8 0.33± 0.07 10.63± 0.62 5.40± 0.91 High dose 78.25± 26.72 214.0± 58.09 203.0± 82.32 0.33± 0.09 11.85± 0.94 5.88± 0.45 High dose recovery 56.40± 5.6# 102.3± 18.25# 110.6± 39.43 0.37± 0.05 10.40± 2.84 5.50± 0.43 Data expressed as mean ± SD, n = 4. ta expressed as mean ± SD.Gpx : Glutathione peroxidase, GSH: Reduced glutathion Tables Statistical significance was determined using one way ANOVA followed by Tukeys post hoc test. p< 0.01; p < 0.05 compared to control, #p< 0.01 compared to high dose Table 5b: Serum biochemistry of rats exposed to 0.5% H2O2 mist Data expressed as mean ± SD, n = 4. Statistical significance was determined using one way ANOVA followed by Tukeys post hoc test. p< 0.01; p < 0.05 compared to control, #p< 0.01 compared to high dose able 6: Effect of antioxidant enzymes on exposure of 0.5% H2O2 mist to male wistarrats Groups Reduced GSH (nmol/mg protein) GPx (units/mg protein) Control 1.03 ± 0.02 0.11 ± 0.60 Low 1.04 ± 0.29 0.11 ± 0.91 Medium 1.10 ± 0.25 0.12 ± 0.92 High 0.87 ± 0.03 0.20 ± 0.17 High recovery 0.90 ± 0.13 0.24 ± 0.043 Table 6: Effect of antioxidant enzymes on exposure of 0.5% H2O2 mist to male wistarrats Table 6: Effect of antioxidant enzymes on exposure of 0.5% H2O2 mist to ma Data expressed as mean ± SD.Gpx : Glutathione peroxidase, GSH: Reduced glutathione Figures Page 16/19 Page 16/19 Page 16/19 Figure 1 Histopathology of rats (male) exposed to 0.5% H2O2 mist: Brain (a): Neuron (N), Glial cells(GC); Kidney(b): Glomeruli (G), Proximal convoluted tubule (PCT), Distal convoluted tubule (DCT); Lung (c): Alveolar space (AS); Liver (d): Central vein (CV), Hepatocyte (H), Sinosoids (S); Testis (f): Seminiferous tubule (SF). Magnification (400x). Histopathology of rats (male) exposed to 0.5% H2O2 mist: Brain (a): Neuron (N), Glial cells(GC); Kidney(b): Glomeruli (G), Proximal convoluted tubule (PCT), Distal convoluted tubule (DCT); Lung (c): Alveolar space (AS); Liver (d): Central vein (CV), Hepatocyte (H), Sinosoids (S); Testis (f): Seminiferous tubule (SF). Magnification (400x). Page 17/19 Page 17/19 Page 17/19 Figure 2 Histopathology of rats (female) exposed to 0.5% H2O2 mist: Brain (a): Neuron (N), Glial cells (GC); Kidney (b): Glomeruli (G), Proximal convoluted tubule (PCT), Distal convoluted tubule (DCT); Lung (c): Alveolar space (AS); Liver (d): Central vein (CV), Hepatocyte (H), Sinosoids (S); Ovary (f): Primary follicle (PF).Magnification:400x. Figure 2 Histopathology of rats (female) exposed to 0.5% H2O2 mist: Brain (a): Neuron (N), Glial cells (GC); Kidney (b): Glomeruli (G), Proximal convoluted tubule (PCT), Distal convoluted tubule (DCT); Lung (c): Alveolar space (AS); Liver (d): Central vein (CV), Hepatocyte (H), Sinosoids (S); Ovary (f): Primary follicle (PF).Magnification:400x. Tables Page 18/19 Figure 3 Histopathology of rats (male and female) exposed to 0.5% H2O2 mist: (A) Respiratory epithelial, (B) Olfactory epithelial areas of the nasal cavity. RE: Respiratory epithelium, OE: Olfactory epithelium. Magnification: 400x Figure 3 Histopathology of rats (male and female) exposed to 0.5% H2O2 mist: (A) Respiratory epithelial, (B) Olfactory epithelial areas of the nasal cavity. RE: Respiratory epithelium, OE: Olfactory epithelium. Magnification: 400x Histopathology of rats (male and female) exposed to 0.5% H2O2 mist: (A) Respiratory epithelial, (B) Olfactory epithelial areas of the nasal cavity. RE: Respiratory epithelium, OE: Olfactory epithelium. Magnification: 400x Supplementary Files This is a list of supplementary files associated with this preprint. Click to download. ResponsestoTechnicalCheckResults.docx ResponsestoTechnicalCheckResults.docx Page 19/19
https://openalex.org/W4386874461	https://egusphere.copernicus.org/preprints/2023/egusphere-2023-1382/egusphere-2023-1382.pdf	English	null	Comment on egusphere-2023-1382	null	2,023	cc-by	21,338	Abstract. In summary, our 2-part study points to future changes in the relative importance of different processes for the dynamics of intense North Atlantic cyclones in a warming climate, with important consequences for the near-surface wind pattern. In particular, a larger role of cloud diabatic processes is projected affecting the cyclones through PV production in the lower troposphere. The role of other mechanisms, in particular radiative changes near the tropopause, should be investigated 20 lower troposphere. The role of other mechanisms, in particular radiative changes near the tropopause, should be investigated 20 in more detail in future studies. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Future changes in North Atlantic winter cyclones in CESM-LE Part 2: A Lagrangian analysis Edgar Dolores-Tesillos1,2 and Stephan Pfahl1 1Institute of Meteorology, Freie Universität Berlin, Berlin, Germany 2Institute of Geography, Oeschger Centre for Climate Change Research, University of Bern, Bern, Switzerland Correspondence: Edgar Dolores-Tesillos (edgar.dolores@unibe.ch) Abstract. Future changes in extratropical cyclone structure and dynamics may lead to important impacts, but are not yet fully under- stood. In the first part of this study, we have applied a composite approach together with potential vorticity (PV) inversion to study such changes in the dynamics of North Atlantic cyclones. Here, this is complemented with the help of a Lagrangian perspective, making use of air parcel trajectories to investigate the causes of altered PV anomalies as well as the role that 5 cyclone airstreams play in shaping these changes. Intense cyclones in the extended winter seasons of two periods, 1990-2000 and 2091-2100, are studied in Community Earth System Model Large Ensemble (CESM-LE) simulations, and backward tra- jectories are calculated from the cyclone area as a basis to construct cyclone-centered composites of Lagrangian tendencies and their projected future changes. Our results show that diabatic processes on a timescale of 24 hours shape the cyclones’ low- 5 level PV distribution and corroborate that the increasing moisture content along with enhanced ascent in warm conveyor belts 10 leads to amplified latent heat release and larger low- and mid-level PV anomalies near the cyclone center in a warmer climate. In contrast, projected upper-level PV changes are due to a combination of several processes, in addition to cloud-diabatic PV changes mainly anomalous PV advection and likely also radiative PV generation in the lower stratosphere above the cyclone center. For instance, enhanced poleward advection is the primary reason for a projected decrease in upper-level PV anomalies level PV distribution and corroborate that the increasing moisture content along with enhanced ascent in warm conveyor belts 10 leads to amplified latent heat release and larger low- and mid-level PV anomalies near the cyclone center in a warmer climate. In contrast, projected upper-level PV changes are due to a combination of several processes, in addition to cloud-diabatic PV changes mainly anomalous PV advection and likely also radiative PV generation in the lower stratosphere above the cyclone center. For instance, enhanced poleward advection is the primary reason for a projected decrease in upper-level PV anomalies south of the cyclone center. Warm conveyor belt outflow regions are projected to shift upward, but there is not robust change 15 in the associated upper-level PV anomalies due to compensation between enhanced low-level PV generation and upper-level PV destruction. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Laurila et al., 2021; Ulbrich et al., 2009). The strong winds associated with these storms can result in large societal impacts and 25 economic losses (Klawa and Ulbrich, 2003; Roberts et al., 2014). For instance, the death of 65 people across Europe has been attributed to the extratropical cyclone Xynthia (Kolen et al., 2010). Cyclones, through damaging winds, also cause 53% of all damages to European forests (Schelhaas et al., 2003). To be able to adapt to potential future changes in European windstorm intensities, it is thus crucial to understand and predict changes in extratropical cyclone dynamics (cf. Shaw et al., 2016; Catto Laurila et al., 2021; Ulbrich et al., 2009). The strong winds associated with these storms can result in large societal impacts and 25 economic losses (Klawa and Ulbrich, 2003; Roberts et al., 2014). For instance, the death of 65 people across Europe has been attributed to the extratropical cyclone Xynthia (Kolen et al., 2010). Cyclones, through damaging winds, also cause 53% of all damages to European forests (Schelhaas et al., 2003). To be able to adapt to potential future changes in European windstorm intensities, it is thus crucial to understand and predict changes in extratropical cyclone dynamics (cf. Shaw et al., 2016; Catto et al., 2019). 30 In part 1 of this study (Dolores-Tesillos et al., 2022, , in the following simply referred to as part 1), we have analyzed such changes in cyclone dynamics based on Community Earth System Model Large Ensemble (CESM-LE) simulations for the RCP8.5 scenario and found an intensification of near-surface wind speed and an extended wind footprint in the warm sector southeast of the cyclone center during the mature cyclone stage. Such an extended footprint has also been found for et al., 2019). 30 In part 1 of this study (Dolores-Tesillos et al., 2022, , in the following simply referred to as part 1), we have analyzed such changes in cyclone dynamics based on Community Earth System Model Large Ensemble (CESM-LE) simulations for the RCP8.5 scenario and found an intensification of near-surface wind speed and an extended wind footprint in the warm sector southeast of the cyclone center during the mature cyclone stage. 1 Introduction European windstorms are typically associated with extratropical cyclones traveling over the North Atlantic towards Europe, with higher cyclone frequencies and intensities in the winter compared to the summer half-year (Leckebusch et al., 2006; 1 1 Such an extended footprint has also been found for several CMIP6 models and other climate scenarios (Priestley and Catto, 2022). Furthermore, based on the analysis of potential 35 vorticity (PV) anomalies and PV inversion, we have demonstrated that both enhanced diabatic heating and changes in upper- level dynamics (represented by lower- and upper-level PV anomalies, respectively) contribute to the near-surface wind changes. In part 2, we go one step further by investigating the processes leading to changes in these PV anomalies through a Lagragian analysis of cyclone airstreams. Several studies have used the concept of cyclone-relative airstreams to describe the cloud organization in extratropical 40 cyclones (Harrold, 1973; Carlson, 1980; Browning, 1990). By analyzing the system-relative flow on isentropic surfaces around mid-latitude cyclones, the presence of three distinct airstreams has been demonstrated: the warm conveyor belt (WCB), the dry intrusion (DI), and the cold conveyor belt (CCB) (Harrold, 1973; Carlson, 1980; Browning, 1986; Madonna et al., 2014). Fig. 1 shows the region and typical trajectory of the three airstreams. A detailed perspective on these airstreams and their Several studies have used the concept of cyclone-relative airstreams to describe the cloud organization in extratropical 40 cyclones (Harrold, 1973; Carlson, 1980; Browning, 1990). By analyzing the system-relative flow on isentropic surfaces around mid-latitude cyclones, the presence of three distinct airstreams has been demonstrated: the warm conveyor belt (WCB), the dry intrusion (DI), and the cold conveyor belt (CCB) (Harrold, 1973; Carlson, 1980; Browning, 1986; Madonna et al., 2014). Fig. 1 shows the region and typical trajectory of the three airstreams. A detailed perspective on these airstreams and their Several studies have used the concept of cyclone-relative airstreams to describe the cloud organization in extratropical 40 cyclones (Harrold, 1973; Carlson, 1980; Browning, 1990). By analyzing the system-relative flow on isentropic surfaces around mid-latitude cyclones, the presence of three distinct airstreams has been demonstrated: the warm conveyor belt (WCB), the dry intrusion (DI), and the cold conveyor belt (CCB) (Harrold, 1973; Carlson, 1980; Browning, 1986; Madonna et al., 2014). Fig. 1 shows the region and typical trajectory of the three airstreams. A detailed perspective on these airstreams and their 40 climatological characteristics can be obtained from air parcel trajectory calculations (e.g., Wernli and Davies, 1997; Wernli, 45 1997; Madonna et al., 2014; Raveh-Rubin, 2017). WCBs are moist airstreams originating from near the surface ahead of cold fronts and experiencing rapid slantwise ascent with latent heat release. In this way, they provide a major contribution to cloud and precipitation formation in extratropical cyclones (Madonna et al., 2014). Furthermore, they play a crucial role in extreme precipitation events in the mid-to-high climatological characteristics can be obtained from air parcel trajectory calculations (e.g., Wernli and Davies, 1997; Wernli, 45 1997; Madonna et al., 2014; Raveh-Rubin, 2017). WCBs are moist airstreams originating from near the surface ahead of cold fronts and experiencing rapid slantwise ascent with latent heat release. In this way, they provide a major contribution to cloud and precipitation formation in extratropical cyclones (Madonna et al., 2014). Furthermore, they play a crucial role in extreme precipitation events in the mid-to-high latitudes (Pfahl et al., 2014). Embedded convection in the WCB may contribute to such high precipitation rates (Oertel et al., 50 2020). Joos (2019) demonstrate the relevance of WCBs for modulating the radiative budget in mid-latitudes. For instance, they contribute around 10 Wm2 to the net cloud radiative forcing over the central North Atlantic in winter. In the Northern Hemisphere, WCBs are more frequent in winter than in summer, with two preferential regions of ascent in the western North Atlantic and western North Pacific (Madonna et al., 2014), typically fueled by moisture from nearby ocean evaporation (Pfahl latitudes (Pfahl et al., 2014). Embedded convection in the WCB may contribute to such high precipitation rates (Oertel et al., 50 2020). Joos (2019) demonstrate the relevance of WCBs for modulating the radiative budget in mid-latitudes. For instance, they contribute around 10 Wm2 to the net cloud radiative forcing over the central North Atlantic in winter. In the Northern Hemisphere, WCBs are more frequent in winter than in summer, with two preferential regions of ascent in the western North Atlantic and western North Pacific (Madonna et al., 2014), typically fueled by moisture from nearby ocean evaporation (Pfahl et al., 2014). 55 WCBs influence the tropospheric PV distribution in different ways. Before the ascent, the airstreams, on average, have rel- atively low PV, followed by a steep PV increase during the first part of the ascent and a decrease in the second part (Madonna et al., 2014). This PV ascent and descent are due to the latent heating during various microphysical processes, such as con- densation of water vapor at low levels and depositional growth of snow at upper levels (Binder et al., 2016; Joos and Wernli, et al., 2014). 55 WCBs influence the tropospheric PV distribution in different ways. Before the ascent, the airstreams, on average, have rel- atively low PV, followed by a steep PV increase during the first part of the ascent and a decrease in the second part (Madonna et al., 2014). This PV ascent and descent are due to the latent heating during various microphysical processes, such as con- densation of water vapor at low levels and depositional growth of snow at upper levels (Binder et al., 2016; Joos and Wernli, 2 2 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. 2012). WCB-related cloud-diabatic processes thus produce positive PV anomalies in the lower and middle troposphere, which 60 can reinforce the cyclone’s intensification (Dacre and Gray, 2013; Binder et al., 2016) and also affect other dynamical fea- tures, such as the low-level jet ahead of the cold front (Lackmann, 2002). At upper levels, diabatic PV destruction leads to negative PV anomalies in the WCB outflow near the tropopause level, which can interact with the extratropical waveguide and thereby substantially influence the downstream flow (Binder et al., 2016; Grams et al., 2011). Additionally, this process mayl 2012). WCB-related cloud-diabatic processes thus produce positive PV anomalies in the lower and middle troposphere, which 60 can reinforce the cyclone’s intensification (Dacre and Gray, 2013; Binder et al., 2016) and also affect other dynamical fea- tures, such as the low-level jet ahead of the cold front (Lackmann, 2002). At upper levels, diabatic PV destruction leads to negative PV anomalies in the WCB outflow near the tropopause level, which can interact with the extratropical waveguide and thereby substantially influence the downstream flow (Binder et al., 2016; Grams et al., 2011). Additionally, this process may also influence the formation of atmospheric blocking downstream (Steinfeld and Pfahl, 2019; Steinfeld et al., 2020). 65 The CCB is characterized by a westward flow relative to the cyclone propagation at low levels parallel to and on the cold side of the warm front (Catto et al., 2010; Schemm and Wernli, 2014). It often consists of two branches. The main branch slopes cyclonically at low levels around the cyclone center (Schultz, 2001) and is often related to strong winds along the bent-back front, forming a low-level jet (Schemm and Wernli, 2014; Slater et al., 2017). A second branch turns anticyclonically and also influence the formation of atmospheric blocking downstream (Steinfeld and Pfahl, 2019; Steinfeld et al., 2020). 65 The CCB is characterized by a westward flow relative to the cyclone propagation at low levels parallel to and on the cold side of the warm front (Catto et al., 2010; Schemm and Wernli, 2014). It often consists of two branches. The main branch slopes cyclonically at low levels around the cyclone center (Schultz, 2001) and is often related to strong winds along the bent-back front, forming a low-level jet (Schemm and Wernli, 2014; Slater et al., 2017). A second branch turns anticyclonically and also influence the formation of atmospheric blocking downstream (Steinfeld and Pfahl, 2019; Steinfeld et al., 2020). 65 The CCB is characterized by a westward flow relative to the cyclone propagation at low levels parallel to and on the cold side of the warm front (Catto et al., 2010; Schemm and Wernli, 2014). It often consists of two branches. The main branch slopes cyclonically at low levels around the cyclone center (Schultz, 2001) and is often related to strong winds along the bent-back front, forming a low-level jet (Schemm and Wernli, 2014; Slater et al., 2017). A second branch turns anticyclonically and ascends into the cloud head. Schultz (2001) mentioned that this branch represents a transition airstream between the WCB and 70 the cyclonic branch of the CCB. Similar to the WCB, cloud-diabatic processes in the CCB can produce positive PV anomalies in the lower and middle troposphere (Schemm and Wernli, 2014). ascends into the cloud head. Schultz (2001) mentioned that this branch represents a transition airstream between the WCB and 70 the cyclonic branch of the CCB. Similar to the WCB, cloud-diabatic processes in the CCB can produce positive PV anomalies in the lower and middle troposphere (Schemm and Wernli, 2014). ascends into the cloud head. Schultz (2001) mentioned that this branch represents a transition airstream between the WCB and 70 the cyclonic branch of the CCB. Similar to the WCB, cloud-diabatic processes in the CCB can produce positive PV anomalies in the lower and middle troposphere (Schemm and Wernli, 2014). Figure 1. Satellite image of the extratropical cyclone Eunice (February 18, 2022) with the three airstreams WCB, DI and CCB indicated by colored arrows. The red and blue lines show the cyclone’s warm and cold front, respectively. Modified from: EUMETSAT Eumetview (https://view.eumetsat.int/productviewer). ©EUMETSAT 2022. Figure 1. Satellite image of the extratropical cyclone Eunice (February 18, 2022) with the three airstreams WCB, DI and CCB indicated by colored arrows. The red and blue lines show the cyclone’s warm and cold front, respectively. Modified from: EUMETSAT Eumetview (https://view.eumetsat.int/productviewer). ©EUMETSAT 2022. Figure 1. Satellite image of the extratropical cyclone Eunice (February 18, 2022) with the three airstreams WCB, DI and CCB indicated by colored arrows. The red and blue lines show the cyclone’s warm and cold front, respectively. Modified from: EUMETSAT Eumetview (https://view.eumetsat.int/productviewer). ©EUMETSAT 2022. (2023), this enhanced latent heating and the associated increase in diabatic PV production lead to an increased relative importance of diabatic processes for rapid cyclone intensification in a warmer climate. However, at least in the Northern Hemisphere, this is not associated with a general 90 intensification of cyclones compared to present-day climate, most probably due to compensating changes in dry-dynamical processes. These results are consistent with previous findings based on idealized models (Pfahl et al., 2015; Büeler and Pfahl, 2019; Sinclair et al., 2020) and our results from part 1. In this part 2, we extend the analysis of future changes in cyclone airstreams by combining Lagrangian trajectory calculations cyclone intensification in a warmer climate. However, at least in the Northern Hemisphere, this is not associated with a general 90 intensification of cyclones compared to present-day climate, most probably due to compensating changes in dry-dynamical processes. These results are consistent with previous findings based on idealized models (Pfahl et al., 2015; Büeler and Pfahl, 2019; Sinclair et al., 2020) and our results from part 1. In this part 2, we extend the analysis of future changes in cyclone airstreams by combining Lagrangian trajectory calculations with the Eulerian composite perspective applied in part 1. The main goal is to explicitly identify the processes contributing to 95 the composite PV anomaly changes identified in part 1 and link them to the properties of airstreams, in particular the WCB and DI. In this way, we test the hypothesis (also formulated in part 1) that cloud-diabatic processes are mainly responsible for low-level PV changes, but additional factors have to be considered for explaining the upper-level changes. In sections 2 and 3 below, we describe the CESM-LE dataset as well as the trajectory calculations and generation of Lagrangian composites, respectively. The results are presented and discussed in section 4, and conclusions are provided in section 5. 100 DIs are cold, dry airstreams descending behind the cyclone from near the tropopause to middle and low levels (Browning, 1997; Catto et al., 2010; Raveh-Rubin, 2017). At lower levels, DIs tend to fan out cyclonically or anticyclonically. A cloud-free DIs are cold, dry airstreams descending behind the cyclone from near the tropopause to middle and low levels (Browning, 1997; Catto et al., 2010; Raveh-Rubin, 2017). At lower levels, DIs tend to fan out cyclonically or anticyclonically. A cloud-free region is generated due to the low moisture content in DIs (Catto et al., 2010; Raveh-Rubin, 2017), which can be identified in 75 satellite images as a "dry slot" with a hammer-head shape (Fig. 1). The cyclonically descending air parcels might travel along region is generated due to the low moisture content in DIs (Catto et al., 2010; Raveh-Rubin, 2017), which can be identified in 75 satellite images as a "dry slot" with a hammer-head shape (Fig. 1). The cyclonically descending air parcels might travel along region is generated due to the low moisture content in DIs (Catto et al., 2010; Raveh-Rubin, 2017), which can be identified in 75 satellite images as a "dry slot" with a hammer-head shape (Fig. 1). The cyclonically descending air parcels might travel along 75 3 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. the cold front and produce instability and potential for severe weather (Browning, 1997). Convection associated with the DIs is found in regions where they overrun moist air and potential instability is released, favoring strong winds, precipitation, and thunderstorms (e.g., Raveh-Rubin and Wernli, 2016). However, DIs can also weaken the WCB rain band if they underrun the northern part of the WCB leading to evaporation of precipitation from the cloud head (Raveh Rubin 2017) DIs influence the 80 the cold front and produce instability and potential for severe weather (Browning, 1997). Convection associated with the DIs is found in regions where they overrun moist air and potential instability is released, favoring strong winds, precipitation, and thunderstorms (e.g., Raveh-Rubin and Wernli, 2016). However, DIs can also weaken the WCB rain band if they underrun the northern part of the WCB, leading to evaporation of precipitation from the cloud head (Raveh-Rubin, 2017). DIs influence the 80 PV distribution mainly through advection of air masses with relatively high PV from upper layers downwards (Raveh-Rubin, 2017). 80 Only very recently, first studies have started to investigate changes of cyclone-related airstreams, in particular, the WCB, in a warmer climate from a Lagrangian perspective. Based on the same CEMS-LE simulations as applied here (see section 2), Joos et al. (2023) and Binder et al. (2023) studied projected future changes in WCB airstreams as well as their role in cyclone 85 intensification. Joos et al. (2023) concluded that projected shifts in the spatial distribution of WCBs are mostly consistent with shifts in the storm tracks and that the larger atmospheric moisture content in a warmer climate causes a systematic increase in WCB-related precipitation, latent heat release and outflow level. According to Binder et al. (2023), this enhanced latent heating and the associated increase in diabatic PV production lead to an increased relative importance of diabatic processes for rapid Joos et al. (2023) and Binder et al. (2023) studied projected future changes in WCB airstreams as well as their role in cyclone 85 intensification. Joos et al. (2023) concluded that projected shifts in the spatial distribution of WCBs are mostly consistent with shifts in the storm tracks and that the larger atmospheric moisture content in a warmer climate causes a systematic increase in WCB-related precipitation, latent heat release and outflow level. According to Binder et al. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. 3 Methods are projected on the initialization time step and interpolated on a radial grid centered on the cyclone center, as described for 120 other cyclone-centered composites in section 3.1 of part 1. Finally, the Lagrangian tendencies are averaged over all extreme cyclones to construct the Lagrangian tendency composites. are projected on the initialization time step and interpolated on a radial grid centered on the cyclone center, as described for 120 other cyclone-centered composites in section 3.1 of part 1. Finally, the Lagrangian tendencies are averaged over all extreme cyclones to construct the Lagrangian tendency composites. 4 Results The results of this study are presented in three subsections. In order to obtain a general idea of the evolution of key parameters along the backward trajectories and the relevant time scales, in the first subsection time series are presented pooling all trajecto- 125 ries from specific pressure levels. Subsequently, in the second subsection, the Lagrangian composites on two selected pressure levels are discussed, supplemented by time series of trajectories from individual locations that facilitate linking the composites to the classical airstream concept. Finally, in the third subsection Lagrangian composite cross sections are presented to provide a more comprehensive view on the spatial structure of the Lagrangian transport patterns. 2 Data We have selected ten members from the CESM-LE-ETH ensemble, which were restarted from CESM-LE simulations (Kay et al., 2015) proving 6 hourly output fields on model levels that are required for our trajectory calculations (see section 3). The periods 1990-2000 (present-day climate) and 2091-2100 (future climate, under the RCP8.5 scenario) are analyzed. More details are provided in Sect. 2 of part 1. 105 4 3 Methods We study Lagrangian airstreams in the 1% strongest cyclones in the 10-member CESM-LE dataset for the extended winter season. This cyclone dataset is described in detail in part 1. For the calculation of air parcel trajectories, we apply the Lagrangian Analysis Tool (LAGRANTO; Wernli and Davies, 1997; Sprenger and Wernli, 2015), which uses the three-dimensional CESM- LE wind field for kinematic forward and backward calculations of air parcel trajectories. 7-day backward trajectories are 110 initialized on a horizontal equidistant grid (∆x = 200 km) centered at the cyclone center (sea level pressure (SLP) minimum) and covering the storm area with a fixed radius of 1500 km at the time of maximum intensity of each selected extreme cyclone. They are initialized at 8 vertical levels: 850, 800, 700, 600, 500, 400, 300, and 250 hPa. Along the trajectories, several variables are traced, together with the trajectory position (longitude, latitude) and pressure. These physical parameters include specific LE wind field for kinematic forward and backward calculations of air parcel trajectories. 7-day backward trajectories are 110 initialized on a horizontal equidistant grid (∆x = 200 km) centered at the cyclone center (sea level pressure (SLP) minimum) and covering the storm area with a fixed radius of 1500 km at the time of maximum intensity of each selected extreme cyclone. They are initialized at 8 vertical levels: 850, 800, 700, 600, 500, 400, 300, and 250 hPa. Along the trajectories, several variables are traced, together with the trajectory position (longitude, latitude) and pressure. These physical parameters include specific humidity q, potential temperature θ, and potential vorticity PV. The time axis is defined such that the initialization time (time 115 of maximum cyclone intensity) is t = 0, and negative times correspond to periods before the trajectories reach the cyclone. Composites of Lagrangian tendencies of air mass properties are computed as outlined in the following. The Lagrangian tendency is defined as the change in magnitude of any variable between the initialization time and a previous time step along the backward trajectory for each grid point at a given pressure level and each selected cyclone .These Lagrangian tendencies are projected on the initialization time step and interpolated on a radial grid centered on the cyclone center, as described for 120 other cyclone-centered composites in section 3.1 of part 1. Finally, the Lagrangian tendencies are averaged over all extreme cyclones to construct the Lagrangian tendency composites. 4.1 Time series of parameters along trajectories 130 In this section, we analyze the temporal evolution of different key parameters along the backward trajectories, providing insights into the times during which the parameters experience a significant change, which eventually determines the cyclone intensity and structure. The temporal change of PV and θ along the trajectories can be associated with diabatic processes due to their conservation for adiabatic and frictionless motion (Hoskins et al., 1985; Madonna et al., 2014, e.g.). A comparison b h l l i f h d d f j i id i i h i h i fl f di b i In this section, we analyze the temporal evolution of different key parameters along the backward trajectories, providing insights into the times during which the parameters experience a significant change, which eventually determines the cyclone intensity and structure. The temporal change of PV and θ along the trajectories can be associated with diabatic processes due to their conservation for adiabatic and frictionless motion (Hoskins et al., 1985; Madonna et al., 2014, e.g.). A comparison between the temporal evolution of the present-day and future trajectories may provide insights into the influence of diabatic 135 and advective processes that shape the cyclone structure in the simulated future climate. 5 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. As the first step, we evaluate various parameters averaged over all trajectories initialized in the cyclone area, in a radius of 10o around the SLP minimum, at the time of maximum cyclone intensity. In the following, the temporal evolution of a) pressure, latitude, longitude, b) specific humidity, c) θ and d) PV is discussed for trajectories from two pressure levels, 700 and 250 hPa. 140 140 a) Pressure, latitude, longitude Figs. 2a,b show the temporal evolution of pressure along backward trajectories initialized at 700 and 250 hPa, respectively. Trajectories from both levels indicate ascent in the 24 hours before the air parcels reach the cyclones at the time of maximum intensity. At low levels, the mean ascent is about 30 hPa, while at upper levels, it is larger, around 50 hPa. This ascent is 145 associated with specific airstreams such as the WCB (Binder et al., 2016; Madonna et al., 2014), as will be discussed in the following subsections. The relatively moderate pressure changes in the mean are due to the fact that, in Fig. 2, data are averaged over the entire cyclone area, leading to partial cancellation between ascending and descending airstreams. On average, the trajectories experience an equatorward displacement before the ascent and a poleward movement during the ascent phase (Figs. 2c,d). The temporal evolution of longitude (Figs. 2e,f) shows that the trajectories move eastward. 150 Furthermore, trajectories ending at upper levels travel larger distances, which is due to the typically larger wind velocities at higher altitudes. In the simulated future climate, the trajectories initialized at 700 hPa are projected to follow a similar zonal, meridional and vertical displacement as in the present-day reference period (Figs. 2a,c,e). In particular, the ascent in the last 24 hours is very In the simulated future climate, the trajectories initialized at 700 hPa are projected to follow a similar zonal, meridional and vertical displacement as in the present-day reference period (Figs. 2a,c,e). In particular, the ascent in the last 24 hours is very similar, while the mean descent in the phase before these last 24 hours is slightly more pronounced in the future. Trajectories 155 initialized at 250 hPa also follow a similar zonal and meridional path in present-day and future climate (Figs. 2d,f), but origi- nate at lower levels in the future, associated with a larger ascent in the last 24 hours (Fig. 2b). similar, while the mean descent in the phase before these last 24 hours is slightly more pronounced in the future. Trajectories 155 initialized at 250 hPa also follow a similar zonal and meridional path in present-day and future climate (Figs. 2d,f), but origi- nate at lower levels in the future, associated with a larger ascent in the last 24 hours (Fig. 2b). 6 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Figure 2. Temporal evolution of (a,b) pressure, (c,d) latitude, (e,f) longitude, (g,h) specific humidity, (i,j) potential temperature and (k,l) PV averaged over all trajectories initialized within a 10° radius around the cyclone center of all selected cyclones and at (left column) 700 hPa and (right column) 250 hPa. The average for present-day climate is shown as blue, dashed line, the average over the future time slice as red line. Shading shows the 5. and 95. percentiles. Figure 2. Temporal evolution of (a,b) pressure, (c,d) latitude, (e,f) longitude, (g,h) specific humidity, (i,j) potential temperature and (k,l) PV averaged over all trajectories initialized within a 10° radius around the cyclone center of all selected cyclones and at (left column) 700 hPa and (right column) 250 hPa. The average for present-day climate is shown as blue, dashed line, the average over the future time slice as red line. Shading shows the 5. and 95. percentiles. b) Specific humidity b) Specific humidity ) pi y Figs. 2g,h show the temporal evolution of specific humidity along the backward trajectories. There are marked differences 160 between the moisture evolution along trajectories reaching the 700 hPa and 250 hPa levels. During the 6-day pre-ascent phase, trajectories reaching the 700 hPa level typically gain moisture. In present-day climate the average specific humidity increases from 1.5 to more than 2 g kg−1. During the ascent phase, water vapor condenses, and the specific humidity decreases to 1.5 Figs. 2g,h show the temporal evolution of specific humidity along the backward trajectories. There are marked differences 160 between the moisture evolution along trajectories reaching the 700 hPa and 250 hPa levels. During the 6-day pre-ascent phase, trajectories reaching the 700 hPa level typically gain moisture. This is examined in more detail in the following subsection. ascent phase in the last 24 hours is similar in future and present-day climate for lower-level trajectories, but there is an amplified 180 heating in the future (corresponding to the amplified moisture loss) along the 250 hPa trajectories. This is examined in more detail in the following subsection. In present-day climate the average specific humidity increases from 1.5 to more than 2 g kg−1. During the ascent phase, water vapor condenses, and the specific humidity decreases to 1.5 160 7 7 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. g kg−1. In contrast, trajectories reaching the upper levels experience a constant decrease of moisture with values only slightly above 0 g kg−1 at 250 hPa. g kg−1. In contrast, trajectories reaching the upper levels experience a constant decrease of moisture with values only slightly above 0 g kg−1 at 250 hPa. In the future climate, the moisture content increases for both trajectories initialized at upper and lower levels. The moisture ncrease for trajectories reaching the cyclones at 700 hPa is constant over time (0.5 gKg−1 in the mean). However, trajectories nitialized at 250 hPa converge towards 0 g kg−1 when they reach the cyclones, similar to present-day. Accordingly, the mois- ure decrease in the ascent phase is larger in future than in present-day climate for the upper-level trajectories. specific humidity discussed before. The trajectories reach the level of 700 hPa with a potential temperature of 285 K in the 175 mean, while the mean θ is 321 K for trajectories reaching 250. However, there is a large spread of around 20 K. In the future, the potential temperature along backward trajectories generally increases in the 7 days before maximum cy- clone intensity. An increase of around 5 K is projected for both trajectories ending at 700 hPa and at 250 hPa. Note that this increase corresponds to the global mean warming of 5 K. In line with the specific humidity changes, the heating during the In the future, the potential temperature along backward trajectories generally increases in the 7 days before maximum cy- clone intensity. An increase of around 5 K is projected for both trajectories ending at 700 hPa and at 250 hPa. Note that this increase corresponds to the global mean warming of 5 K. In line with the specific humidity changes, the heating during the clone intensity. An increase of around 5 K is projected for both trajectories ending at 700 hPa and at 250 hPa. Note that this increase corresponds to the global mean warming of 5 K. In line with the specific humidity changes, the heating during the ascent phase in the last 24 hours is similar in future and present-day climate for lower-level trajectories, but there is an amplified 180 heating in the future (corresponding to the amplified moisture loss) along the 250 hPa trajectories. d) Potential vorticity Figs. 2k,l show the temporal evolution of PV along the backward trajectories. There are again structural differences between 185 trajectories initialized at 700 hPa and 250 hPa. Trajectories reaching the cyclones at 700 hPa experience a clear PV increase in the 24 h before. Such an increase due to diabatic processes is expected for trajetories below the level of maximum diabatic heating (Binder et al., 2016; Madonna et al., 2014). The mean PV along the 250 hPa trajectories, in contrast, stays relatively constant. Most likely, these small mean changes are related to opposing PV tendencies along individual trajectories, with some Figs. 2k,l show the temporal evolution of PV along the backward trajectories. There are again structural differences between 185 trajectories initialized at 700 hPa and 250 hPa. Trajectories reaching the cyclones at 700 hPa experience a clear PV increase in the 24 h before. Such an increase due to diabatic processes is expected for trajetories below the level of maximum diabatic heating (Binder et al., 2016; Madonna et al., 2014). The mean PV along the 250 hPa trajectories, in contrast, stays relatively constant. Most likely, these small mean changes are related to opposing PV tendencies along individual trajectories, with some Figs. 2k,l show the temporal evolution of PV along the backward trajectories. There are again structural differences between 185 trajectories initialized at 700 hPa and 250 hPa. Trajectories reaching the cyclones at 700 hPa experience a clear PV increase in the 24 h before. Such an increase due to diabatic processes is expected for trajetories below the level of maximum diabatic heating (Binder et al., 2016; Madonna et al., 2014). The mean PV along the 250 hPa trajectories, in contrast, stays relatively constant. Most likely, these small mean changes are related to opposing PV tendencies along individual trajectories, with some of them experiencing PV destruction due to their location above the region of maximum diabatic heating. In addition, radiative 190 cooling and heating may affect the upper-level PV tendencies (Chagnon et al., 2013; Cavallo and Hakim, 2013). In the simulated future climate, the PV increase along the 700 hPa trajectories is more pronounced than for present-day. Although there is no indication of an amplified heating in these air parcels (see again Fig. 2i), the heating is likely enhanced at higher altitudes (see section 4.2 below), as indicated also by an increase in surface precipitation (not shown). https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. explained by a decrease in the climatological PV at upper levels (see Supplementary Fig. S1). The impact of this PV decrease on the upper PV anomalies differs between cyclone subregions, as demonstrated in more detail in the following. explained by a decrease in the climatological PV at upper levels (see Supplementary Fig. S1). The impact of this PV decrease on the upper PV anomalies differs between cyclone subregions, as demonstrated in more detail in the following. d) Potential vorticity The more pronounced PV increase is thus likely related to a larger vertical gradient in diabatic heating in the future. On the contrary, 195 the trajectories ending at 250 hPa are projected to have an almost constant mean PV, similar to the present-day trajectories. Nevertheless, the PV of the future trajectories remains lower than for present-day during the entire 7-day period. This can be pronounced PV increase is thus likely related to a larger vertical gradient in diabatic heating in the future. On the contrary, 195 the trajectories ending at 250 hPa are projected to have an almost constant mean PV, similar to the present-day trajectories. Nevertheless, the PV of the future trajectories remains lower than for present-day during the entire 7-day period. This can be 8 8 4.2 Lagrangian tendency composites 200 In the previous section, we have identified that the last 24 hours before the air parcels arrive in the cyclone area at the time of maximum cyclone intensity are a period of particular changes in the physical parameters along the backward trajectories. During this period, both air parcels arriving at 700 and 250 hPa typically ascend, accompanied by latent heat release and, for the lower-level trajectories, a PV increase. However, as demonstrated in part 1, the spatial distribution of PV anomalies as well the lower-level trajectories, a PV increase. However, as demonstrated in part 1, the spatial distribution of PV anomalies as well as its projected future changes vary across the cyclone area, with important consequences for cyclone dynamics and winds. 205 To link such local PV anomalies to the Lagrangian tendencies outlined above, we analyze Lagrangian tendency composites showing the spatial distributions of changes in physical parameters along the backward trajectories in the last 24 hours (see section 3). In the following, we examine such composites of Lagrangian tendencies in latitude, longitude, pressure, θ and PV. To facilitate the interpretation of these Lagrangian composites, we also show time series averaged over trajectories that arrive at specific locations in the cyclone composite, namely at the cyclone center as well as 8o to the north and 5o south of the 210 center Note that these locations correspond to strongly positive (center and northward point) respectively strongly negative as its projected future changes vary across the cyclone area, with important consequences for cyclone dynamics and winds. 205 To link such local PV anomalies to the Lagrangian tendencies outlined above, we analyze Lagrangian tendency composites showing the spatial distributions of changes in physical parameters along the backward trajectories in the last 24 hours (see section 3). In the following, we examine such composites of Lagrangian tendencies in latitude, longitude, pressure, θ and PV. To facilitate the interpretation of these Lagrangian composites, we also show time series averaged over trajectories that arrive at specific locations in the cyclone composite, namely at the cyclone center as well as 8o to the north and 5o south of the 210 center. Note that these locations correspond to strongly positive (center and northward point), respectively strongly negative (southward point) projected future changes in the upper-level PV anomaly (see Fig. 8c in part 1). https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Figure 3. Composites of Lagrangian tendencies along backward trajectories initialized at 700 hPa in the last 24 hours before arrival in the cyclone area of (a) latitude, (b) longitude, (c) pressure, (d) potential temperature and (e) PV. Contours show present-day Lagrangian tendencies and the color shading indicates the response to future climate change (difference in the Lagrangian tendencies between future and present-day climate). Figure 3. Composites of Lagrangian tendencies along backward trajectories initialized at 700 hPa in the last 24 hours before arrival in the cyclone area of (a) latitude, (b) longitude, (c) pressure, (d) potential temperature and (e) PV. Contours show present-day Lagrangian tendencies and the color shading indicates the response to future climate change (difference in the Lagrangian tendencies between future and present-day climate). 4.2 Lagrangian tendency composites 200 The time series thus also help understanding the complex projected upper-level PV anomaly changes in more detail. arrive at specific locations in the cyclone composite, namely at the cyclone center as well as 8o to the north and 5o south of the 210 center. Note that these locations correspond to strongly positive (center and northward point), respectively strongly negative (southward point) projected future changes in the upper-level PV anomaly (see Fig. 8c in part 1). The time series thus also help understanding the complex projected upper-level PV anomaly changes in more detail. arrive at specific locations in the cyclone composite, namely at the cyclone center as well as 8o to the north and 5o south of the 210 center. Note that these locations correspond to strongly positive (center and northward point), respectively strongly negative (southward point) projected future changes in the upper-level PV anomaly (see Fig. 8c in part 1). The time series thus also help understanding the complex projected upper-level PV anomaly changes in more detail. 9 9 4.2.1 Lower levels (700 hPa) Fig. 3a shows the composite of latitude tendencies along trajectories reaching the cyclone area at 700 hPa during the 24 h be- 215 fore the cyclone maximum intensity. The contours indicate the present-day meridional displacement, color shading shows the projected future change in this displacement. Positive values indicate trajectories originating from the south, negative values trajectories from the north. Trajectories from the south dominate the region downstream of the cyclone, with the maximum northward transport near the mean position of the warm front. Trajectories from the north are found southwest of the cyclone center, with smaller absolute meridional displacements compared to the southerly flow downstream. The composite of lon- 220 gitude tendencies (Fig. 3b) shows that most trajectories move eastward (positive longitude tendency). The largest eastward displacement is found in the warm sector to the south and southeast of the cyclone center. A small region of westward dis- placement is located northwest of the cyclone center, in the area of the occlusion, indicative of cyclonic wrap-up of the air around the cyclone center. In Fig. 3c, a clear zone of ascent is identified in the warm sector and particularly around the cyclone center. A maximum rate of ascent of 250 hPa in 24 h, averaged over all trajectories, is found at the cyclone center, whereas 225 10 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. a wedge-shaped region of descent is located to the southwest of the cyclone center. The northward, ascending flow in the cyclones’ warm sector can be linked to WCB activity. The descending branch from northwest towards the south of the cyclone center is related to the dry intrusion, as also shown exemplarily in the time series along backward trajectories initialized south of the cyclone center shown in Fig. 4 (left column). These trajectories show the southward transport and descent (particularly in the last 24 h) of relatively dry air masses from mid-levels. The linkages to the classical air stream concept will be further 230 discussed in section 4.3. Figure 4. Temporal evolution of (a,b) pressure, (c,d) latitude, (e,f) longitude, (g,h) specific humidity, (i,j) potential temperature and (k,l) PV averages along backward trajectories initialized 5o south of the cyclone center and at (left column) 700 hPa and (right column) 250 hPa. Figure 4. Temporal evolution of (a,b) pressure, (c,d) latitude, (e,f) longitude, (g,h) specific humidity, (i,j) potential temperature and (k,l) PV averages along backward trajectories initialized 5o south of the cyclone center and at (left column) 700 hPa and (right column) 250 hPa. 11 11 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. The ascent in the warm sector and near the cyclone center is associated with diabatic heating, as shown by the positive potential temperature tendencies in the same region (Fig. 3d), most probably due to latent heat release during cloud formation. This is further illustrated by the time series initialized in the cyclone center shown in Fig. 5 (left column). In the last 24 hours, these air parcels experience a strong decrease in water vapor specific humidity along with the ascent, northward transport and 235 diabatic heating. The Lagrangian tendency of θ is also positive in most other parts of the cyclone composite, except for the western boundary (see again Fig. 3d). The ascent in the warm sector and near the cyclone center is associated with diabatic heating, as shown by the positive potential temperature tendencies in the same region (Fig. 3d), most probably due to latent heat release during cloud formation. This is further illustrated by the time series initialized in the cyclone center shown in Fig. 5 (left column). In the last 24 hours, these air parcels experience a strong decrease in water vapor specific humidity along with the ascent, northward transport and 235 diabatic heating. The Lagrangian tendency of θ is also positive in most other parts of the cyclone composite, except for the western boundary (see again Fig. 3d). Lagrangian PV tendencies are positive in the northern and eastern part of the cyclone area, with the largest PV production at the cyclone center and extending towards the warm front (Fig. 3e). The spatial pattern is similar to the pattern of ascent and diabatic heating As mentioned above diabatic PV production due to latent heat release in clouds is expected in these low level 240 The ascent in the warm sector and near the cyclone center is associated with diabatic heating, as shown by the positive potential temperature tendencies in the same region (Fig. 3d), most probably due to latent heat release during cloud formation. This is further illustrated by the time series initialized in the cyclone center shown in Fig. 5 (left column). In the last 24 hours, these air parcels experience a strong decrease in water vapor specific humidity along with the ascent, northward transport and 235 diabatic heating. The Lagrangian tendency of θ is also positive in most other parts of the cyclone composite, except for the western boundary (see again Fig. 3d). Lagrangian PV tendencies are positive in the northern and eastern part of the cyclone area, with the largest PV production at the cyclone center and extending towards the warm front (Fig. 3e). The spatial pattern is similar to the pattern of ascent and diabatic heating. As mentioned above, diabatic PV production due to latent heat release in clouds is expected in these low-level 240 air parcels since they are likely located below the vertical maximum of heat release. A region of PV reduction is found to the south of the cyclone center, albeit with much smaller magnitude compared to the PV generation in other regions. The largest reduction occurs near the expected region of the DI (see also the example in Fig. 4k), which might be related to turbulent mixing (Attinger et al., 2021). at the cyclone center and extending towards the warm front (Fig. 3e). The spatial pattern is similar to the pattern of ascent and diabatic heating. As mentioned above, diabatic PV production due to latent heat release in clouds is expected in these low-level 240 air parcels since they are likely located below the vertical maximum of heat release. A region of PV reduction is found to the south of the cyclone center, albeit with much smaller magnitude compared to the PV generation in other regions. The largest reduction occurs near the expected region of the DI (see also the example in Fig. 4k), which might be related to turbulent mixing (Attinger et al., 2021). diabatic heating. As mentioned above, diabatic PV production due to latent heat release in clouds is expected in these low-level 240 air parcels since they are likely located below the vertical maximum of heat release. A region of PV reduction is found to the south of the cyclone center, albeit with much smaller magnitude compared to the PV generation in other regions. The largest reduction occurs near the expected region of the DI (see also the example in Fig. 4k), which might be related to turbulent mixing (Attinger et al., 2021). 12 12 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Figure 5. Temporal evolution of (a,b) pressure, (c,d) latitude, (e,f) longitude, (g,h) specific humidity, (i,j) potential temperature and (k,l) PV averages along backward trajectories initialized at the cyclone center and at (left column) 700 hPa and (right column) 250 hPa. Figure 5. Temporal evolution of (a,b) pressure, (c,d) latitude, (e,f) longitude, (g,h) specific humidity, (i,j) potential temperature and (k,l) PV averages along backward trajectories initialized at the cyclone center and at (left column) 700 hPa and (right column) 250 hPa. Projected future changes of the Lagrangian composites at 700 hPa are shown with color shading in Fig. 3. In the cyclones’ 245 warm sector, both the northward motion and ascent are projected to intensify, in particular near the warm front and south of the cyclone center (Fig. 3a,c). Also, the descent in the southern part of the cyclone area intensifies, and on the northwestern flank, enhanced descent is projected in a region of small mean vertical displacement in present-day climate. The mean westerly flow weakens slightly in most regions, in particular southwest of the cyclone center. The spatial pattern of future changes in diabatic heating (Fig. 3d) corresponds relatively well to the change in vertical motion, with regions of stronger ascent experiencing more 250 heating and vice versa. In addition to the enhanced ascent, the larger atmospheric moisture content in a warmer climate explains 13 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. the increase in diabatic heating through increasing latent heat release, as shown exemplarily for the cyclone center in Fig. 5g. Finally, Fig. 3e shows that the PV generation in the last 24 hours before maximum cyclone intensity increases in most of the cyclone area, except for the northwestern part. The strongest intensification is found at the cyclone center, extending along the warm front and towards the southwest. This also corresponds to the region of enhanced ascent and diabatic heating, but the 255 relative changes in PV generation are even larger and spatially more extended than the increase in heating (see also Fig. 5i,k). As already discussed in section 4.1, this amplified PV generation can be explained by the increased latent heat release also at higher altitudes (see Supplementary Fig. S2 for the composite change at 500 hPa), leading to a larger vertical heating gradient. The region of an increasing Lagrangian PV tendency in a warmer climate also extends into the southern sector of the cyclone the increase in diabatic heating through increasing latent heat release, as shown exemplarily for the cyclone center in Fig. 5g. Finally, Fig. 3e shows that the PV generation in the last 24 hours before maximum cyclone intensity increases in most of the cyclone area, except for the northwestern part. The strongest intensification is found at the cyclone center, extending along the warm front and towards the southwest. This also corresponds to the region of enhanced ascent and diabatic heating, but the 255 relative changes in PV generation are even larger and spatially more extended than the increase in heating (see also Fig. 5i,k). As already discussed in section 4.1, this amplified PV generation can be explained by the increased latent heat release also at higher altitudes (see Supplementary Fig. S2 for the composite change at 500 hPa), leading to a larger vertical heating gradient. The region of an increasing Lagrangian PV tendency in a warmer climate also extends into the southern sector of the cyclone composite where air parcels, on average, descend and the Lagrangian PV tendency is negative in present day climate. This thus 260 indicates a reduced PV destruction in this region (see also Fig. 4k). It may point towards a role of other processes beyond latent heating, in particular turbulent mixing, for future changes in near-surface PV anomalies. Nevertheless, the magnitude of these PV tendency changes is much smaller than the changes near the cyclone center induced by latent heating. In summary the most apparent future changes in PV generation occur around the cyclone center These PV generation composite where air parcels, on average, descend and the Lagrangian PV tendency is negative in present day climate. This thus 260 indicates a reduced PV destruction in this region (see also Fig. 4k). It may point towards a role of other processes beyond latent heating, in particular turbulent mixing, for future changes in near-surface PV anomalies. Nevertheless, the magnitude of these PV tendency changes is much smaller than the changes near the cyclone center induced by latent heating. In summary, the most apparent future changes in PV generation occur around the cyclone center. These PV generation In summary, the most apparent future changes in PV generation occur around the cyclone center. These PV generation changes in the last 24 hours explain a substantial part of the total future composite changes in the cyclones’ low-level PV 265 anomalies, also in a quantitative manner (see Fig. 8a in part 1). Our Lagrangian analysis thus provides strong evidence that these PV anomaly changes can be explained by amplified latent heating, driven by both a larger moisture content and enhanced ascent in a warmer climate. This thus corroborates the first part of our hypothesis formulated in section 1. Changes in PV generation further away from the cyclone center are smaller and thus of minor importance for the cyclones’ dynamics, as also illustrated exemplarily in the time series along trajectories initialized south and north of the cyclone center shown in Figs. 4 270 and 6 (left columns), respectively. 14 14 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Figure 6. Temporal evolution of (a,b) pressure, (c,d) latitude, (e,f) longitude, (g,h) specific humidity, (i,j) potential temperature and (k,l) PV averages along backward trajectories initialized 8o north of the cyclone center and at (left column) 700 hPa and (right column) 250 hPa. Figure 6. Temporal evolution of (a,b) pressure, (c,d) latitude, (e,f) longitude, (g,h) specific humidity, (i,j) potential temperature and (k,l) PV averages along backward trajectories initialized 8o north of the cyclone center and at (left column) 700 hPa and (right column) 250 hPa. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. streak (see Fig. 8d in part 1). The spatial pattern of the regions of ascent and descent shown in Fig. 7c is indicative of cyclonic wrap-up. Ascending trajectories are located northeast of the cyclone center, with the strongest ascent in the north, which is in streak (see Fig. 8d in part 1). The spatial pattern of the regions of ascent and descent shown in Fig. 7c is indicative of cyclonic wrap-up. Ascending trajectories are located northeast of the cyclone center, with the strongest ascent in the north, which is in contrast to the pattern at 700 hPa (see again Fig. 3c). These poleward ascending trajectories are related to the WCB outflow, as 280 also shown in the time series in Fig. 6 (righ column) and discussed further in section 4.3. The descent of trajectories located to the southwest of the cyclone center is weaker than the ascent in the northeastern part. Similar to th composite at 700 hPa, also at upper levels the spatial pattern of the Lagrangian tendencies of θ (Fig. 7d) is similar to the pattern of vertical displacement (Fig. 3c). Trajectories arriving over the northern and eastern part of the composite region experience diabatic heating, with the strongest θ increase in the area of largest ascent, the WCB outflow region. As exemplarily shown in Fig. 6b,h,j, this ascent 285 from the middle to the upper troposphere goes along with a decrease in specific humidity, indicating that the diabatic heating, as for the lower level, is most probably due to latent heat release during cloud formation. Descending trajectories southwest of the cyclone center experience a slight decrease of θ, likely because of longwave radiative cooling. contrast to the pattern at 700 hPa (see again Fig. 3c). These poleward ascending trajectories are related to the WCB outflow, as 280 also shown in the time series in Fig. 6 (righ column) and discussed further in section 4.3. The descent of trajectories located to the southwest of the cyclone center is weaker than the ascent in the northeastern part. Similar to th composite at 700 hPa, also at upper levels the spatial pattern of the Lagrangian tendencies of θ (Fig. 7d) is similar to the pattern of vertical displacement (Fig. 3c). 4.2.2 Upper levels (250 hPa) The Lagrangian tendency composites at 250 hPa are shown in Fig. 7. In present-day climate, most of the cyclone area is dominated by trajectories coming from the south (Fig. 7a) and west (Fig. 7b). The largest northward displacement occurs northeast of the cyclone center. Near the western boundary of the composite there is a small region with northerly flow, located 275 above a more extended area with northerlies at lower levels (see again Fig. 3a). The maximum eastward displacement southeast of the cyclone center (with a longitude change of more than 45o in 24 h) is co-located with the exit region of an upper-level jet The Lagrangian tendency composites at 250 hPa are shown in Fig. 7. In present-day climate, most of the cyclone area is dominated by trajectories coming from the south (Fig. 7a) and west (Fig. 7b). The largest northward displacement occurs do ated by t ajecto es co g o t e sout ( g. 7a) a d west ( g. 7b). e a gest o t wa d d sp ace e t occu s northeast of the cyclone center. Near the western boundary of the composite there is a small region with northerly flow, located 275 above a more extended area with northerlies at lower levels (see again Fig. 3a). The maximum eastward displacement southeast of the cyclone center (with a longitude change of more than 45o in 24 h) is co-located with the exit region of an upper-level jet northeast of the cyclone center. Near the western boundary of the composite there is a small region with northerly flow, located 275 above a more extended area with northerlies at lower levels (see again Fig. 3a). The maximum eastward displacement southeast of the cyclone center (with a longitude change of more than 45o in 24 h) is co-located with the exit region of an upper-level jet 15 Trajectories arriving over the northern and eastern part of the composite region experience diabatic heating, with the contrast to the pattern at 700 hPa (see again Fig. 3c). These poleward ascending trajectories are related to the WCB outflow, as 280 also shown in the time series in Fig. 6 (righ column) and discussed further in section 4.3. The descent of trajectories located to the southwest of the cyclone center is weaker than the ascent in the northeastern part. Similar to th composite at 700 hPa, also at upper levels the spatial pattern of the Lagrangian tendencies of θ (Fig. 7d) is similar to the pattern of vertical displacement (Fig. 3c). Trajectories arriving over the northern and eastern part of the composite region experience diabatic heating, with the strongest θ increase in the area of largest ascent the WCB outflow region As exemplarily shown in Fig 6b h j this ascent 285 280 strongest θ increase in the area of largest ascent, the WCB outflow region. As exemplarily shown in Fig. 6b,h,j, this ascent 285 from the middle to the upper troposphere goes along with a decrease in specific humidity, indicating that the diabatic heating, as for the lower level, is most probably due to latent heat release during cloud formation. Descending trajectories southwest of the cyclone center experience a slight decrease of θ, likely because of longwave radiative cooling. Figure 7. Composites of Lagrangian tendencies along backward trajectories initialized at 250 hPa in the last 24 hours before arrival in the cyclone area of (a) latitude, (b) longitude, (c) pressure, (d) potential temperature and (e) PV. Contours show present-day Lagrangian tendencies and the color shading indicates the response to future climate change (difference in the Lagrangian tendencies between future and present-day climate). Figure 7. Composites of Lagrangian tendencies along backward trajectories initialized at 250 hPa in the last 24 hours before arrival in the cyclone area of (a) latitude, (b) longitude, (c) pressure, (d) potential temperature and (e) PV. Contours show present-day Lagrangian tendencies and the color shading indicates the response to future climate change (difference in the Lagrangian tendencies between future and present-day climate). The Lagrangian PV tendency in the 24 h before the trajectories reach the cyclone area is shown in Fig. 7e. In contrast to the lower levels (cf. Fig. 3), here the spatial pattern of the PV tendencies does not correspond to the pattern of heating and vertical 90 The Lagrangian PV tendency in the 24 h before the trajectories reach the cyclone area is shown in Fig. 7e. In contrast to the lower levels (cf. Fig. 3), here the spatial pattern of the PV tendencies does not correspond to the pattern of heating and vertical 290 290 16 The trajectories thus arrive 320 at the cyclone center with almost the same PV in present-day and future climate, but, because of the decrease in climatological PV (Supplementary Fig. S1), this leads to a larger positive PV anomaly in the future climate, explaining the positive signal at the cyclone center in Fig. 8c of part 1. Finally, the projected increase of PV anomalies northeast of the cyclone center (see again Fig. 8c in part 1), which cannot be explained by our Lagrangian diagnostic (Fig. 6, right column), should be interpreted with care, as it is not robust across vertical levels (in a region of large vertical PV gradients) and (at least at many grid points) 325 future reduction in the mean PV climatology (Supplementary Fig. S1), but also a mean downward and, in particular, southward 315 shift in the location of the origin (Figs. 4b,d). The reduced PV anomalies in this southern region are thus primarily caused by enhanced meridional transport of low-PV air from more southerly regions, which is consistent with the mean wind changes shown in Fig. 8d of part 1. Also for trajectories arriving at the cyclone center, the PV at their origin seven days before is slightly lower in the simulated future climate (Fig. 5l), but this difference is compensated mostly by enhanced PV production in the future reduction in the mean PV climatology (Supplementary Fig. S1), but also a mean downward and, in particular, southward 315 shift in the location of the origin (Figs. 4b,d). The reduced PV anomalies in this southern region are thus primarily caused by enhanced meridional transport of low-PV air from more southerly regions, which is consistent with the mean wind changes shown in Fig. 8d of part 1. Also for trajectories arriving at the cyclone center, the PV at their origin seven days before is slightly lower in the simulated future climate (Fig. 5l), but this difference is compensated mostly by enhanced PV production in the last 24 h. As discussed above, this diabatic PV change is likely associated with radiative processes. The trajectories thus arrive 320 at the cyclone center with almost the same PV in present-day and future climate, but, because of the decrease in climatological PV (Supplementary Fig. S1), this leads to a larger positive PV anomaly in the future climate, explaining the positive signal at the cyclone center in Fig. 8c of part 1. Most likely, this is related to varying be diabatically produced by radiative processes near the lowered tropopause above the cyclone center. In particular, longwave 295 radiative cooling is expected to peak in the tropopause region, where vertical humidity gradients are large, leading to a positive vertical heating gradient and thus PV generation above. Farther away from the cyclone center, the mean PV tendency in the last 24 h is close to zero (see again Fig. 7e). This is also the case in the WCB outflow region north of the cyclone center, in spite of substantial latent heat release in these ascending air parcels (see also Fig. 6j,l). Most likely, this is related to varying 295 positions of the air parcels relative to the spatial maximum of diabatic heating, leading to PV generation in some of them, or in 300 the earlier period of the ascent, and PV destruction in others (those located above the heating maximum), which compensate each other. Projected future changes in the Lagrangian tendencies at 250 hPa (color shading in Fig. 7) indicate a strengthening of the ascent as well as enhanced northward and reduced eastward transport in the WCB outflow region north of the cyclone positions of the air parcels relative to the spatial maximum of diabatic heating, leading to PV generation in some of them, or in 300 the earlier period of the ascent, and PV destruction in others (those located above the heating maximum), which compensate each other. Projected future changes in the Lagrangian tendencies at 250 hPa (color shading in Fig. 7) indicate a strengthening of the ascent as well as enhanced northward and reduced eastward transport in the WCB outflow region north of the cyclone positions of the air parcels relative to the spatial maximum of diabatic heating, leading to PV generation in some of them, or in 300 the earlier period of the ascent, and PV destruction in others (those located above the heating maximum), which compensate each other. Projected future changes in the Lagrangian tendencies at 250 hPa (color shading in Fig. 7) indicate a strengthening ofl the ascent as well as enhanced northward and reduced eastward transport in the WCB outflow region north of the cyclone center. This corresponds to an intensification of the WCB outflow that wraps around the cyclone center. This enhanced ascent 305 and WCB activity goes along with amplified diabatic heating (Fig. 7d). https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. motion. The strongest PV generation occurs in trajectories reaching the cyclone center. As shown in the time series in Fig. 5 (right column), these trajectories are located in the lower stratosphere (PV > 6 PVU) and are very dry (specific humidity < 0.1 g Kg−1). The modest increase in θ (Fig. 5j) and the diabatic PV generation (Fig. 5l) can thus not be explained by latent heat release. As shown by Chagnon et al. (2013) and Cavallo and Hakim (2013), such lower-stratospheric positive PV anomalies can motion. The strongest PV generation occurs in trajectories reaching the cyclone center. As shown in the time series in Fig. 5 (right column), these trajectories are located in the lower stratosphere (PV > 6 PVU) and are very dry (specific humidity < 0.1 g Kg−1). The modest increase in θ (Fig. 5j) and the diabatic PV generation (Fig. 5l) can thus not be explained by latent heat release. As shown by Chagnon et al. (2013) and Cavallo and Hakim (2013), such lower-stratospheric positive PV anomalies can be diabatically produced by radiative processes near the lowered tropopause above the cyclone center. In particular, longwave 295 radiative cooling is expected to peak in the tropopause region, where vertical humidity gradients are large, leading to a positive vertical heating gradient and thus PV generation above. Farther away from the cyclone center, the mean PV tendency in the last 24 h is close to zero (see again Fig. 7e). This is also the case in the WCB outflow region north of the cyclone center, in spite of substantial latent heat release in these ascending air parcels (see also Fig. 6j,l). Most likely, this is related to varying be diabatically produced by radiative processes near the lowered tropopause above the cyclone center. In particular, longwave 295 radiative cooling is expected to peak in the tropopause region, where vertical humidity gradients are large, leading to a positive vertical heating gradient and thus PV generation above. Farther away from the cyclone center, the mean PV tendency in the last 24 h is close to zero (see again Fig. 7e). This is also the case in the WCB outflow region north of the cyclone center, in spite of substantial latent heat release in these ascending air parcels (see also Fig. 6j,l). The region south of the cyclone center experiences decreasing northward and enhanced easteward transport, which is, however, not related to pronounced changes in vertical motion or diabatic heating. Finally, there are no pronounced future changes in Lagrangian PV tendencies in the last 24 h before the cyclones’ maximum intensity (Fig. 7e). The PV tendencies slightly decrease northeast of the cyclone center, but this decrease is small compared to the projected change in PV advection in this region (see example in Fig. 6l). 310 Hence, again, in contrast to the 700 hPa level, the 24 h Lagrangian PV tendency changes do not explain the projected changes in PV anomalies at 250 hPa (Fig. 8c in part 1). The projected PV anomaly reduction south of the cyclone center can be explained by a strong PV reduction at the origin of the air parcels seven days before arriving in the cyclone area (Fig. 4l). These lower PV values at the origin, which are approximately conserved during transport (at least in the mean over all trajectories), are due to a Hence, again, in contrast to the 700 hPa level, the 24 h Lagrangian PV tendency changes do not explain the projected changes in PV anomalies at 250 hPa (Fig. 8c in part 1). The projected PV anomaly reduction south of the cyclone center can be explained by a strong PV reduction at the origin of the air parcels seven days before arriving in the cyclone area (Fig. 4l). These lower PV values at the origin, which are approximately conserved during transport (at least in the mean over all trajectories), are due to a future reduction in the mean PV climatology (Supplementary Fig. S1), but also a mean downward and, in particular, southward 315 shift in the location of the origin (Figs. 4b,d). The reduced PV anomalies in this southern region are thus primarily caused by enhanced meridional transport of low-PV air from more southerly regions, which is consistent with the mean wind changes shown in Fig. 8d of part 1. Also for trajectories arriving at the cyclone center, the PV at their origin seven days before is slightly lower in the simulated future climate (Fig. 5l), but this difference is compensated mostly by enhanced PV production in the last 24 h. As discussed above, this diabatic PV change is likely associated with radiative processes. 4.3 Lagrangian composite cross sections The Lagrangian composite analysis has shown that transport and diabatic processes along trajectories shape future changes in 335 cyclonic PV anomalies on specific pressure levels. To better understand the three-dimensional structure of such Lagrangian tendency changes and further link these tendencies to the classical airstream concept (see section 1), in the following, this analysis is extended with the help of vertical cross sections of Lagrangian pressure and PV tendencies. More specifically, four cross sections are studied: (1) west to east through the cyclone center, (2) south to north through the cyclone center, (3) south to north 8o east of the center (WCB region), and (4) west to east 4o south of the center (dry intrusion region). 340 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. ensemble members. An increase in PV anomalies in the northeast is thus not apparent in the upper-tropospheric vertical mean change in Fig. 9b of part 1, and is thus not thought to substantially affect future changes in cyclone dynamics. ensemble members. An increase in PV anomalies in the northeast is thus not apparent in the upper-tropospheric vertical mean change in Fig. 9b of part 1, and is thus not thought to substantially affect future changes in cyclone dynamics. g g p , g y g y y In summary, several processes shape future changes in cyclonic PV anomalies at upper levels, in particular, changes in PV advection, but possibly also radiative processes in the lower stratosphere near the cyclone center. The latter should be investi- gated in more detail in future studies. Amplified latent heat release affects the WCB outflow region and is linked to enhanced 0 vertical motion there, but this does not go along with consistent changes in PV anomalies, likely due to a compensation between a strengthening of both diabatic PV generation and reduction. All together, this corroborates the second part of our hypothesis formulated in section 1. In summary, several processes shape future changes in cyclonic PV anomalies at upper levels, in particular, changes in PV advection, but possibly also radiative processes in the lower stratosphere near the cyclone center. The latter should be investi- gated in more detail in future studies. Amplified latent heat release affects the WCB outflow region and is linked to enhanced vertical motion there, but this does not go along with consistent changes in PV anomalies, likely due to a compensation between a strengthening of both diabatic PV generation and reduction. All together, this corroborates the second part of our hypothesis formulated in section 1. Finally, the projected increase of PV anomalies northeast of the cyclone center (see again Fig. 8c in part 1), which cannot be explained by our Lagrangian diagnostic (Fig. 6, right column), should be interpreted with care, as it is not robust across vertical levels (in a region of large vertical PV gradients) and (at least at many grid points) 325 17 4.3.1 Cyclone center cross sections Figure 8 shows the two cross-sections (1) and (2), which are located at the center of the composite cyclone. The west-east section indicates the presence of two regions of strong ascent in present-day climate (Fig. 8a). The first region is located above the cyclone center, with the most vigorous ascent at mid-levels. This region extends further to the north of the center and to higher altitudes, as shown in Fig. 8c. The second region is located in the eastern part of the cross section, with the strongest 345 ascent around 400 hPa. Both the ascent at high levels north of the cyclone center and the ascent in the eastern part of the cross section are likely associated with WCBs, more specifically with a cyclonic WCB branch wrapping around the cyclone center and an anticyclonic branch extending further downstream, respectively, as already described in previous studies (Martínez- Alvarado et al., 2014; Binder et al., 2016). An area of descent is located to the south of the cyclone center, peaking around 700-650 hPa (Fig. 8c), which is probably linked to the dry intrusion. 350 higher altitudes, as shown in Fig. 8c. The second region is located in the eastern part of the cross section, with the strongest 345 ascent around 400 hPa. Both the ascent at high levels north of the cyclone center and the ascent in the eastern part of the cross section are likely associated with WCBs, more specifically with a cyclonic WCB branch wrapping around the cyclone center and an anticyclonic branch extending further downstream, respectively, as already described in previous studies (Martínez- Alvarado et al., 2014; Binder et al., 2016). An area of descent is located to the south of the cyclone center, peaking around 18 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Figure 8. (a,b) West-east and (c,d) south-north vertical cross sections through the cyclone center. Contours show present-day Lagrangian endencies along backward trajectories in the last 24 hours before arrival in the cyclone area of (a,c) pressure and (b,d) PV. Color shading Figure 8. (a,b) West-east and (c,d) south-north vertical cross sections through the cyclone center. Contours show present-day Lagrangian tendencies along backward trajectories in the last 24 hours before arrival in the cyclone area of (a,c) pressure and (b,d) PV. Color shading Figure 8. 4.3.1 Cyclone center cross sections (a,b) West-east and (c,d) south-north vertical cross sections through the cyclone center. Contours show present-day Lagrangian tendencies along backward trajectories in the last 24 hours before arrival in the cyclone area of (a,c) pressure and (b,d) PV. Color shading shows the response to future climate change. 19 Figure 8. (a,b) West-east and (c,d) south-north vertical cross sections through the cyclone center. Contours show present-day Lagrangian tendencies along backward trajectories in the last 24 hours before arrival in the cyclone area of (a,c) pressure and (b,d) PV. Color shading shows the response to future climate change. 19 19 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. The strongest PV production occurs along trajectories initialized near the cyclone center at low levels (Figs. 8b,d), with a maximum PV increase of more than 1.2 PVU in 24 h. It extends up to mid-levels. This PV production, as described above, is due to latent heat release during cloud formation. A second maximum in PV production is located above the cyclone center at upper levels, peaking around 300 hPa, above the region of strong ascent. As discussed in section 4.2.2, the diabatic PV generation in this region near and above the tropopause is likely due to radiative heating and cooling (Chagnon et al., 2013; 355 Cavallo and Hakim, 2013). Together, the PV generation by these diabatic processes at lower and upper levels contributes to the formation of a PV tower above the cyclone center. The PV tendencies in the air parcels associated with the WCB are positive in the mid-level region of strong ascent above the cyclone center, contributing to cyclone intensification (see again Binder et al., 2016), and small to slightly negative in the upper-level outflow regions to the north and east of the cyclone center. The latter, as discussed above, is due to the compensation between PV generation below and PV destruction above the heating 360 maximum (Madonna et al., 2014; Methven, 2015). In spite of these small Lagrangian PV tendencies, WCB outflow typically leads to negative PV anomalies in the upper troposphere due to net upward transport of low-PV air from lower levels (Steinfeld and Pfahl, 2019; Grams et al., 2011). In the region of mean descent south of the cyclone center, Lagrangian PV tendencies are negative (see also the example in Fig. 4k), possibly associated with turbulent mixing of the descending air parcels with latter, as discussed above, is due to the compensation between PV generation below and PV destruction above the heating 360 maximum (Madonna et al., 2014; Methven, 2015). In spite of these small Lagrangian PV tendencies, WCB outflow typically leads to negative PV anomalies in the upper troposphere due to net upward transport of low-PV air from lower levels (Steinfeld and Pfahl, 2019; Grams et al., 2011). In the region of mean descent south of the cyclone center, Lagrangian PV tendencies are negative (see also the example in Fig. 4k), possibly associated with turbulent mixing of the descending air parcels with lower-tropospheric, low-PV air (Attinger et al., 2021). 365 In the simulated future climate, the ascent in the cyclones’ core region near the center is projected to intensify over the entire column (blue shading in Figs. 8a,c), with a maximum intensification at upper levels slightly west of the center that corresponds to an upward extension of the region of strong ascent in the cyclonic branch of the WCB outflow. This enhanced ascent goes along with amplified PV production at low- and mid-levels due to stronger latent heat release (red shading in Figs. 8b,d). Two lower-tropospheric, low-PV air (Attinger et al., 2021). 365 In the simulated future climate, the ascent in the cyclones’ core region near the center is projected to intensify over the entire column (blue shading in Figs. 8a,c), with a maximum intensification at upper levels slightly west of the center that corresponds to an upward extension of the region of strong ascent in the cyclonic branch of the WCB outflow. This enhanced ascent goes along with amplified PV production at low- and mid-levels due to stronger latent heat release (red shading in Figs. 8b,d). Two regions are identified where the PV tendency increases by more than 0.2 PVU: the lower levels above the cyclone center (see 370 also Fig. 5, left column) and the core region of the WCB ascent between 600 and 500 hPa slightly west of the center. On the contrary, there is no clear future change in the radiative PV generation at upper levels above the cyclone center. The increase observed at 250 hPa in Fig. 5l is thus not representative for the altitudes slightly below. This apparently complex response of such radiative processes near the tropopause to climate warming warrants future investigation. In the upper-tropospheric regions are identified where the PV tendency increases by more than 0.2 PVU: the lower levels above the cyclone center (see 370 also Fig. 5, left column) and the core region of the WCB ascent between 600 and 500 hPa slightly west of the center. On the contrary, there is no clear future change in the radiative PV generation at upper levels above the cyclone center. The increase observed at 250 hPa in Fig. 5l is thus not representative for the altitudes slightly below. This apparently complex response of such radiative processes near the tropopause to climate warming warrants future investigation. In the upper-tropospheric outflow region of the cyclonic branch of the WCB north of the cyclone center, the ascent intensifies above 300 hPa and also 375 shifts upwards (dipole pattern in Fig. 8c). The changes in PV tendencies in this region are relatively small, but consistently negative in the upper part (300 hPa and above). Such a reduction of PV generation may be partly explained by the upward shift of the tropopause and WCB outflow in a warmer climate, leading to weaker PV tendencies in a region characterized by radiative PV production in the lower stratosphere in present-day climate. In the anticyclonic branch of the WCB in the eastern outflow region of the cyclonic branch of the WCB north of the cyclone center, the ascent intensifies above 300 hPa and also 375 shifts upwards (dipole pattern in Fig. 8c). The changes in PV tendencies in this region are relatively small, but consistently negative in the upper part (300 hPa and above). Such a reduction of PV generation may be partly explained by the upward shift of the tropopause and WCB outflow in a warmer climate, leading to weaker PV tendencies in a region characterized by radiative PV production in the lower stratosphere in present-day climate. In the anticyclonic branch of the WCB in the eastern part of the cross section, the ascent is projected to weaken at mid- and upper-levels, without a clear effect on PV tendencies. 380 Finally, the region of descent south of the cyclonce center shifts upward, associated with intensified descent at mid-levels. PV tendency changes in this area are again small, but positive, indicating a weakening of the PV reduction in the descending air parcels. In the next two subsections, two additional cross sections are analyzed to better characterize the changes in the eastern WCB branch as well as the dry intrusion region of descent south of the center. part of the cross section, the ascent is projected to weaken at mid- and upper-levels, without a clear effect on PV tendencies. 380 Finally, the region of descent south of the cyclonce center shifts upward, associated with intensified descent at mid-levels. PV tendency changes in this area are again small, but positive, indicating a weakening of the PV reduction in the descending air parcels. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. 4.3.2 WCB cross section 385 As described above, we have identified two WCB branches. The evolution of the first, cyclonic branch has been described in detail with the vertical cross sections at the cyclone center. To analyze the second branch, we have constructed the south-north cross-section (3), 8o east of the center, as shown in Fig. 9. Figure 9. South-north vertical cross section through the WCB region 8o east of the cyclone center. Contours show present-day Lagrangian tendencies along backward trajectories in the last 24 hours before arrival in the cyclone area of (a) pressure and (b) PV. Color shading shows the response to future climate change. Figure 9. South-north vertical cross section through the WCB region 8o east of the cyclone center. Contours show present-day Lagrangian tendencies along backward trajectories in the last 24 hours before arrival in the cyclone area of (a) pressure and (b) PV. Color shading shows the response to future climate change. The cross section is dominated by ascending trajectories (Fig. 9a), with the strongest ascent of more than 240 hPa in 24 h at upper levels in the northern part associated with the WCB outflow. A dipole pattern is apparent in the Lagrangian PV 390 tendencies (Fig. 9b), with PV generation below 500 hPa (albeit with a smaller magnitude compared to the cyclone center, cf. Fig. 8b,d) and PV destruction above, in particular in the northern part. This large area of negative PV tendencies may contribute to ridge building downstream of the cyclones (see again Steinfeld and Pfahl, 2019; Grams et al., 2011). In future climate the ascent of this WCB branch is projected to shift poleward associated with reduced ascent on the In future climate, the ascent of this WCB branch is projected to shift poleward, associated with reduced ascent on the southern flank of the present-day maximum (peaking at 400 hPa) and enhanced ascent on its northern flank (throughout the 395 entire column). The strongest increase in ascent is found above 300 hPa near the northern edge of the cross section, implying an upward extension of the WCB outflow, similar to the cyclonic branch. Figure 9a also shows that the reduced ascent observed for the eastern WCB branch in Fig. 8a does not imply a weakening of the entire branch, but, as discussed above, rather a spatial shift. In the next two subsections, two additional cross sections are analyzed to better characterize the changes in the eastern WCB branch as well as the dry intrusion region of descent south of the center. 20 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. some areas around 400 hPa, this changes the sign of the tendency, from PV destruction in present-day to PV generation in 400 future climate. The strongest PV tendency increase is found above the area of the strongest mid-level amplification of ascent, which is consistent with enhanced PV generation by latent heat release in the ascending air masses. It also coincides with increasing precipitation in the region of the warm front (not shown). some areas around 400 hPa, this changes the sign of the tendency, from PV destruction in present-day to PV generation in 400 future climate. The strongest PV tendency increase is found above the area of the strongest mid-level amplification of ascent, which is consistent with enhanced PV generation by latent heat release in the ascending air masses. It also coincides with increasing precipitation in the region of the warm front (not shown). 4.3.2 WCB cross section 385 PV tendencies are projected to increase across most of the vertical section from the surface up to 300 hPa (Fig. 9b). In southern flank of the present-day maximum (peaking at 400 hPa) and enhanced ascent on its northern flank (throughout the 395 entire column). The strongest increase in ascent is found above 300 hPa near the northern edge of the cross section, implying an upward extension of the WCB outflow, similar to the cyclonic branch. Figure 9a also shows that the reduced ascent observed for the eastern WCB branch in Fig. 8a does not imply a weakening of the entire branch, but, as discussed above, rather a spatial shift. PV tendencies are projected to increase across most of the vertical section from the surface up to 300 hPa (Fig. 9b). In 21 4.3.3 DI cross section The Lagrangian tendency composite at 700 hPa, the north-south vertical cross-section through the cyclone center and the time 405 series in Fig. 4 (left column) show a descending airstream south of the center with characteristics of a dry intrusion (Raveh- Rubin, 2017). To study the spatial pattern of this DI in more detail, we analyze the west-east vertical cross-section (4) 4o south of the cyclone center, as shown in Fig. 10. In this cross section, there is a broad region of descent in the western part and ascent in the eastern part (Fig. 10a), the The Lagrangian tendency composite at 700 hPa, the north-south vertical cross-section through the cyclone center and the time 405 series in Fig. 4 (left column) show a descending airstream south of the center with characteristics of a dry intrusion (Raveh- Rubin, 2017). To study the spatial pattern of this DI in more detail, we analyze the west-east vertical cross-section (4) 4o south of the cyclone center, as shown in Fig. 10. In this cross section, there is a broad region of descent in the western part and ascent in the eastern part (Fig. 10a), the In this cross section, there is a broad region of descent in the western part and ascent in the eastern part (Fig. 10a), the latter being associated with the WCB. The transition between these two regimes around 5o east of the cyclone center is likely 410 associated with the mean position of the cold front. The two areas of strongest descent are located at the western boundary at low levels (∼800 hPa) and east of the cyclone center at middle levels (∼550 hPa). Apparently, some DI trajectories arrive to the west of the cyclone moving southeastward at low levels and others to the east of the cyclone, moving northeastward close to the cyclone center. This is consistent with the fanning out of DI trajectories as they descend behind the cold front described latter being associated with the WCB. The transition between these two regimes around 5o east of the cyclone center is likely 410 associated with the mean position of the cold front. The two areas of strongest descent are located at the western boundary at low levels (∼800 hPa) and east of the cyclone center at middle levels (∼550 hPa). 4.3.3 DI cross section In a warmer climate, the descent of the DI trajectories at low levels in the western part is projected to weaken. In contrast, at the mid-level maximum east of the cyclone center, the descent is amplified. PV tendencies increase in most areas below 500 hPa, weakening the PV destruction in most regions, but amplifying PV generation below the area of maximum descent south of the cyclone center. These projected changes in DI descent and PV tendencies may have implications for severe weather events 420 associated with the DI, which should be investigated in more detail in future studies. hPa, weakening the PV destruction in most regions, but amplifying PV generation below the the cyclone center. These projected changes in DI descent and PV tendencies may have implications for severe weather events 420 associated with the DI, which should be investigated in more detail in future studies. 420 4.3.3 DI cross section Apparently, some DI trajectories arrive to the west of the cyclone moving southeastward at low levels and others to the east of the cyclone, moving northeastward close to the cyclone center. This is consistent with the fanning out of DI trajectories as they descend behind the cold front described in previous studies (Browning, 1997). Lagrangian PV tendencies are negative in the regions of strongest descent and positive 415 below the maximum descent east of the cyclone center (Fig. 10b). in previous studies (Browning, 1997). Lagrangian PV tendencies are negative in the regions of strongest descent and positive 415 below the maximum descent east of the cyclone center (Fig. 10b). 22 Figure 10. West-east vertical cross section through the dry intrusion region 4o south of the cyclone center. Contours show present-day Lagrangian tendencies along backward trajectories in the last 24 hours before arrival in the cyclone area of (a) pressure and (b) PV. Color shading shows the response to future climate change. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Figure 10. West-east vertical cross section through the dry intrusion region 4o south of the cyclone center. Contours show present-day Lagrangian tendencies along backward trajectories in the last 24 hours before arrival in the cyclone area of (a) pressure and (b) PV. Color shading shows the response to future climate change. In a warmer climate, the descent of the DI trajectories at low levels in the western part is projected to weaken. In contrast, at the mid-level maximum east of the cyclone center, the descent is amplified. PV tendencies increase in most areas below 500 In a warmer climate, the descent of the DI trajectories at low levels in the western part is projected to weaken. In contrast, at the mid-level maximum east of the cyclone center, the descent is amplified. PV tendencies increase in most areas below 500 hPa, weakening the PV destruction in most regions, but amplifying PV generation below the area of maximum descent south of the cyclone center. These projected changes in DI descent and PV tendencies may have implications for severe weather events 0 associated with the DI, which should be investigated in more detail in future studies. 5 Conclusions In this study, we have used a Lagrangian perspective based on air parcel trajectory calculations to investigate projected future changes of air streams in intense North Atlantic extratropical winter cyclones as well as their role for PV anomaly changes. Lagrangian tendency composites have been constructed to link this Lagrangian perspective to the Eulerian composite analysis 25 of part 1 of this study. In this study, we have used a Lagrangian perspective based on air parcel trajectory calculations to investigate projected future changes of air streams in intense North Atlantic extratropical winter cyclones as well as their role for PV anomaly changes. Lagrangian tendency composites have been constructed to link this Lagrangian perspective to the Eulerian composite analysis 425 of part 1 of this study. Our results show that lower-tropospheric air parcel properties, in particular PV, are driven by changes happening in the last 24 hours before the air parcels arrive in the cyclone area. This period is strongly affected by diabatic heating associated with cloud formation in ascending air streams, which leads to diabatic PV production maximizing at and around the center of the composite cyclone. Primarily due to the increasing atmospheric moisture content in a warming climate, this diabatic 430 Our results show that lower-tropospheric air parcel properties, in particular PV, are driven by changes happening in the last 24 hours before the air parcels arrive in the cyclone area. This period is strongly affected by diabatic heating associated with cloud formation in ascending air streams, which leads to diabatic PV production maximizing at and around the center f h i l P i il d h i i h i i i i li hi di b i of the composite cyclone. Primarily due to the increasing atmospheric moisture content in a warming climate, this diabatic 430 23 Enhanced vertical and especially meridional trans- port of low-PV air masses explain the decrease of PV anomalies south of the cyclone center. An increase in the stratospheric anomaly above the center is related to a combination of altered transport, diabatic PV generation likely due to radiative pro- cesses, and changes in the background PV climatology. In particular the complex changes in radiative PV production near the tropopause level warrants further investigation. Air parcels arriving in the WCB outflow regions north (cyclonic branch) and 450 northeast (anticyclonic branch) of the cyclone center experience enhanced ascent, leading to an elevated WCB outflow level, and a modest intensification of diabatic PV destruction. However, this is not associated with robust and consistent changes in PV anomalies in the outflow regions, most likely because the enhanced PV destruction is partly compensated by enhanced PV generation during an earlier period, when the air parcels are located at lower altitudes, and also by the complex interplay of changes in other processes (advection, radiation) and the spatial pattern of the WCB outflow that may mask the relatively 455 small cloud-diabatic tendency changes. Nevertheless, note that the lack of robust changes in PV anomalies on the 250 hPa level does not implicate that the enhanced WCB ascent and diabatic heating may not have an effect on the persistence and intensity (through the elevated outflow level) of downstream ridges and atmospheric blocking (cf. Steinfeld et al., 2022). Limitations of our study are related to the fact that it is based on a single climate model only. As shown previously, the CESM simulations applied here capture WCB properties and their connection to cyclones reasonably well, but still underesti- 460 mate the magnitude of positive low-level PV anomalies associated with the WCB (Joos et al., 2023; Binder et al., 2023). Future investigations should thus focus on the robustness of the conclusions obtained here when using more than one model. Further- more, the relatively coarse spatial and temporal resolution (time step of 6 hours) limits the ability of the trajectory calculations to resolve ascending motion. This implies that, for instance, convection embedded in the WCB is not captured (Oertel et al., 2020), and the influence of diabatic changes on future cyclone dynamics may be underestimated (Willison et al., 2015). https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. PV generation on the day before the cyclones’ maximum intensity is projected to intensify, which quantitatively explains the increase in low-level cyclonic PV anomalies that has been identified in part 1 and that has a strong impact also on low-level wind changes, in particular, in the cyclones’ warm sector. The amplified latent heating is also associated with enhanced ascent and PV generation in WCB airstreams (in agreement with previous studies based on the same CESM simulations, see Joos et al 2023; Binder et al 2023) which further contributes to the intensification of midlevel PV anomalies in the cyclones’ 435 PV generation on the day before the cyclones’ maximum intensity is projected to intensify, which quantitatively explains the increase in low-level cyclonic PV anomalies that has been identified in part 1 and that has a strong impact also on low-level wind changes, in particular, in the cyclones’ warm sector. The amplified latent heating is also associated with enhanced ascent and PV generation in WCB airstreams (in agreement with previous studies based on the same CESM simulations, see Joos et al., 2023; Binder et al., 2023), which further contributes to the intensification of midlevel PV anomalies in the cyclones’ 435 PV tower. Accordingly, our Lagrangian analysis corroborates the hypothesis that the relative importance of moist processes, especially latent heat release during cloud formation, for cyclone dynamics increases in a warmer climate compared to other, dry-dynamical mechanisms, which has already been formulated in part 1 and other previous studies (Pfahl et al., 2015; Büeler and Pfahl, 2019; Sinclair et al., 2020; Binder et al., 2023). Changes in low-level PV tendencies and anomalies in regions further et al., 2023; Binder et al., 2023), which further contributes to the intensification of midlevel PV anomalies in the cyclones’ 435 PV tower. Accordingly, our Lagrangian analysis corroborates the hypothesis that the relative importance of moist processes, especially latent heat release during cloud formation, for cyclone dynamics increases in a warmer climate compared to other, dry-dynamical mechanisms, which has already been formulated in part 1 and other previous studies (Pfahl et al., 2015; Büeler and Pfahl, 2019; Sinclair et al., 2020; Binder et al., 2023). Changes in low-level PV tendencies and anomalies in regions further 435 away from the cyclone center, including the DI region to the south, are of smaller magnitude and thus likely of secondary 440 importance for general aspects of the cyclones’ dynamics. Nevertheless, projected changes in DI descent and diabatic PV destruction (likely associated with turbulence) may have implications for more localized, smaller-scale severe weather events that should be investigated in future studies. away from the cyclone center, including the DI region to the south, are of smaller magnitude and thus likely of secondary 440 importance for general aspects of the cyclones’ dynamics. Nevertheless, projected changes in DI descent and diabatic PV destruction (likely associated with turbulence) may have implications for more localized, smaller-scale severe weather events that should be investigated in future studies. Future changes in air parcel properties at upper-level are more complex and affected by several processes also operating on time scales longer than 24 hours. Accordingly, the upper-level composite PV anomaly changes identified in part 1 do not 445 correspond to the 24 h Lagrangian PV change composite shown in Fig. 7e). Enhanced vertical and especially meridional trans- port of low-PV air masses explain the decrease of PV anomalies south of the cyclone center. An increase in the stratospheric anomaly above the center is related to a combination of altered transport, diabatic PV generation likely due to radiative pro- cesses, and changes in the background PV climatology. In particular the complex changes in radiative PV production near the on time scales longer than 24 hours. Accordingly, the upper-level composite PV anomaly changes identified in part 1 do not 445 correspond to the 24 h Lagrangian PV change composite shown in Fig. 7e). Enhanced vertical and especially meridional trans- port of low-PV air masses explain the decrease of PV anomalies south of the cyclone center. An increase in the stratospheric anomaly above the center is related to a combination of altered transport, diabatic PV generation likely due to radiative pro- cesses, and changes in the background PV climatology. In particular the complex changes in radiative PV production near the on time scales longer than 24 hours. Accordingly, the upper-level composite PV anomaly changes identified in part 1 do not 445 correspond to the 24 h Lagrangian PV change composite shown in Fig. 7e). 465 CESM simulations applied here capture WCB properties and their connection to cyclones reasonably well, but still underesti- 460 mate the magnitude of positive low-level PV anomalies associated with the WCB (Joos et al., 2023; Binder et al., 2023). Future investigations should thus focus on the robustness of the conclusions obtained here when using more than one model. Further- more, the relatively coarse spatial and temporal resolution (time step of 6 hours) limits the ability of the trajectory calculations to resolve ascending motion. 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The model output of the CESM-LENS re-runs used here is available upon request from the authors. Author contributions. S.P. and E.D.-T. designed the study. E.D.-T. performed the analysis, produced the figures and drafted the manuscript. Both authors discussed the results and edited the manuscript. 470 470 Competing interests. Stephan Pfahl is executive editor of WCD. Acknowledgements. We are grateful to Urs Beyerle (ETH Zurich) for performing the CESM-LENS re-runs. S.P. acknowledges support by Deutsche Forschungsgemeinschaft through Grant CRC 1114 ‘Scaling Cascades in Complex Systems’, project C06. We acknowledge the HPC service of ZEDAT, Freie Universität Berlin, for providing computational resources (Bennett et al., 2020). 25 https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. https://doi.org/10.5194/egusphere-2023-1382 Preprint. Discussion started: 14 July 2023 c⃝Author(s) 2023. CC BY 4.0 License. Grams, C. 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https://openalex.org/W3015043779	http://komunikacie.uniza.sk/index.php/communications/article/download/1556/1500	English	null	Formation and Optimization of Transport Networks in the Conditions of the Digital Integral Environment for Transportation	Komunikácie	2,020	cc-by	6,399	FORMATION AND OPTIMIZATION OF TRANSPORT NETWORKS IN THE CONDITIONS OF THE DIGITAL INTEGRAL ENVIRONMENT FOR TRANSPORTATION The article provides a brief description of the digital integrated transportation support environment. The methods of choosing the base route in the formation of transport networks in the conditions of the formation of a digital integrated environment are presented. It is shown that the means of solving the problem of optimization of transport networks is a developed modeling complex, which consists of a set of models with the necessary degree of detail. The paper presents a functional diagram and a brief description of the complex. The complex functions taking into account the replenishment, improvement and updating of models, allow you to combine different types of models and use the necessary of them when solving specific problems of transport network optimization. The modeling complex allows to significantly simplify the optimization of transportation networks. On the basis of the proposed mathematical apparatus, the software of an automated system has been developed, which is designed to function in a digital integrated environment, a brief theoretical description of which is given. Keywords: digital integrated environment, basic route, route criteria and parameters, transport network, optimization, models, modeling complex Lieberman, Arak, Ligum, Levinson, Black, Vuchic, Schnabel, Lohse, Fernandez and other scientists. Boris Zhelenkov1, Irina Safonova1,, Yakov Goldovsky1, Elizaveta I. Dmitrieva2 1Department “Computing systems and networks” of the Russian University of Transport (RUT - MIIT), Russia 2Department “Foreign Languages 5” of the Russian University of Transport (RUT - MIIT), Russia E-mail of corresponding author: iesafonova@yandex.ru 1 Introduction The problem is the organization of the information space in which both carriers and customers would feel comfortable is very urgent now. To solve this problem, it is necessary to create a digital integrated environment - which is the main component of a unified information space to meet the needs of the transportation of passengers and goods, where user work is positioned as an electronic service. The digital integrated environment should have a modular structure that will enable the connection of new routes, new carriers, as well as representatives of related organizations to provide additional services. When creating new routes, it is necessary to evaluate the parameters of the routes and optimize the movement of route vehicles. Consequently, an important step in the development of a digital integrated environment for transportation is the optimization of route transportation networks. Today there are many mathematical models of optimization of transport networks [1- 2]. However, all these models are separated and presented in different ways, have a different form of recording, different representation of input and output parameters, the same parameters in different models have different units of measurement, etc. At the moment there is no single unified form, a single method of representation of such models, while individual models do not allow to fully solve the necessary optimization problems in a digital integrated environment. Therefore, the development of new more effective models, approaches and software to optimize transport networks applicable in the digital integrated environment is an urgent scientific problem. 115 115 O R I G I N A L R E S E A R C H A R T I C L E https://doi.org/10.26552/com.C.2020.2.115-122 Boris Zhelenkov - Irina Safonova - Yakov Goldovsky - Elizaveta I. Dmitrieva Boris Zhelenkov - Irina Safonova - Yakov Goldovsky - Elizaveta I. Dmitrieva 2 Transport network design and optimization The digital integrated environment for transportation is a single information space implemented by software and hardware, which provides the opportunity for interaction between carriers and consumers. The digital integrated transport environment is designed to provide information on all types of transport networks, including urban, regional, intercity, personal and freight transport A single information space for transportation is a space for interaction between participants in the transportation process: employees of transport companies, customers, authorities and other parties interested in the quality of transportation. A single information space for transport provision arises as a result of the formation of an appropriate digital integrated environment, including [3-4]: The tasks of modeling and optimizing route transportation networks were taken up by many specialists. A great contribution to the mathematical formulation of optimization problems and the development of models of the movement of route vehicles made Varelopulo, automated control systems of transport companies; clients of transport companies and authorities; governmental institutions; Boris Zhelenkov1, Irina Safonova1,, Yakov Goldovsky1, Elizaveta I. Dmitrieva2 1Department “Computing systems and networks” of the Russian University of Transport (RUT - MIIT), Russia 2Department “Foreign Languages 5” of the Russian University of Transport (RUT - MIIT), Russia E-mail of corresponding author: iesafonova@yandex.ru C O M M U N I C A T I O N S 2 2 ( 2 ) 115-122 I S S N 1335-4205 (Print), ISSN 2585-7878 (Online) / © 2 0 2 0 U N I V E R S I T Y O F Z I L I N A 116 Z H E L E N K O V e t a l . Figure 1 Scheme for transport networks design Figure 1 Scheme for transport networks design • corporate and local telecommunication networks, expert systems, technological databases and reference books; • corporate and local telecommunication networks, expert systems, technological databases and reference books; • corporate and local telecommunication networks, expert systems, technological databases and reference books; • corporate and local telecommunication networks, expert systems, technological databases and reference books; • a system of reference books, classifiers, registers and other regulatory reference information. The concept of using such a space involves registering a participant in the transportation process on the service portal, either as a client or as a representative of the carrier. The client should be given the opportunity to choose transportation services based on their preferences. 2 Transport network design and optimization For example, if cargo is transported, the determining factors should be the parameters of the cargo, as well as the customer’s preferences - price, speed of delivery, etc. Based on these and other input data, the route is built. On the way of the cargo, the points of trans-shipment are determined, and the client receives information about the route and the final cost of the service. When implementing passenger transportation, it is necessary to take into account not only price and time parameters, client preferences for choosing possible intermediate points (cities, attractions), with an opportunity of creating a route map with the necessary transport documents, up to booking hotel rooms and excursions. • regulatory databases; • specialized data processing centers that provide timely processing of large volumes of information; • on-board devices and mobile devices that collect data directly during transportation; • digital communications in the form of global telecommunication networks, connecting all the listed components into the information environment. However, the digital integrated environment is not yet a single information space. A single information space, in addition to solving other important tasks, requires the development of standards and protocols that ensure a wide exchange of information between its components. To do this, the digital integrated environment must be provided for joint work and efficient data exchange between: • automated transport management systems; digital interfaces of clients of transport companies; To implement a digital integrated environment, it is necessary to solve a number of problems: development of a methodology for creating a digital integrated environment for transport; development of standardization methodology in the field of digital transportation management; development of a set of models for the implementation of a digital integrated environment; development of the concept of connecting carrier modules; development of an intelligent interactive interface with a digital integrated environment (carrier/customer). C O M M U N I C A T I O N S 2 / 2 0 2 0 3 Choosing the optimal route for the transport network Stage 2. Formation of the transport network. Passenger or cargo can be moved between two endpoints using several modes of transport. Each type of transport has its own network of routes that are already formed and regularly used in various geographical areas. When you include any type of transport in the integrated transportation system, all its routes in the corresponding geographical territory are added to the database and can be used to build the necessary integral (composite) route. By integral route we mean a route using various modes of transport. When creating a digital integrated transport support environment, existing routes can be completely transferred to the digital integrated environment, and new routes will be added taking into account the existing ones. R M A T I O N A N D O P T I M I Z A T I O N O F T R A N S P O R T N E T W O R K S I N T H E C O N D I T I O N S O F T H E D I G I T A L . . . 117 important task in creating a digital integrated environment for providing transportation is the task of forming and optimizing transportation networks. A transport network is a set of possible routes of all modes of transport included in the process of transporting passengers or goods between two endpoints. Since several modes of transport can be used for one route, such a system can be called an integrated transport infrastructure or environment. The process of creating transport networks is presented as a diagram in Figure 1. important task in creating a digital integrated environment for providing transportation is the task of forming and optimizing transportation networks. A transport network is a set of possible routes of all modes of transport included in the process of transporting passengers or goods between two endpoints. Since several modes of transport can be used for one route, such a system can be called an integrated transport infrastructure or environment. The process of creating transport networks is presented as a diagram in Figure 1. of video processing is carried out using innovative technologies in the field of artificial intelligence. When analyzing the video sequence, additional opportunities arise for the control of emergency situations. The processing of information received from video monitoring systems can be performed locally or centrally. Local processing of information requires the presence of an on-board specialized computer on a vehicle or traffic control means (traffic lights). The result will be transferred to the dispatch center. Centralized processing of information reduces the requirements for local computing facilities, but increases the load on data transmission channels. At this stage, a set of measures to ensure reliability and information security is being developed. The process of design of transportation networks includes three main stages: Stage 1. Collection and analysis of initial information. Information is collected from video monitoring systems and DVR systems. They also include video monitoring of public transport and outdoor security cameras. To collect and analyze initial information, the following are needed: systematization and standardization of video recording systems; systematization of information processing. It is necessary for the control system to include the means of satellite navigation. The result is a transport network - an electronic map with complete information about the state of traffic flows, emergency situations and the loading of vehicles on routes. 2.1 Choosing the best route for inclusion in the transport network At this stage it is necessary to make an informed decision about which route should really be included in the transport network, using the method of choosing the optimal route (it is reasonable to call it a base route) from a variety of alternatives. Generally, when there is an ambiguity in the choice of a route (usually this occurs under conditions of uncertainty in the initial information), i.e. the only best option cannot be found. You can get only a few («area») rational options. Considering this circumstance, one should first identify this set of rational routes, the final choice of the optimal (base) route that will be included in the transport network is made by applying various expert procedures. With such a final choice, certain formalized techniques can be applied (for example, expert assessment methods, hierarchy analysis method), however, the main role belongs to the person - the expert. To determine new routes, it is necessary to evaluate the parameters of routes and optimize transport networks. Estimation of route parameters and optimization of transport networks leads to increased profitability and quality of services of transport companies. When choosing the best route one should use an appropriate method of selecting the best option from a variety of alternatives. The choice of a route is a multi- criteria task, and many of these criteria are difficult to describe accurately. It is necessary to determine and take into account all the requirements for the route, parameters and criteria for its evaluation. Route parameters are - mode of transport, traffic fluctuations, peak loads, risks, cargo parameters, infrastructure condition, range, time delays of the route, tax rates, volume and condition of the fleet of transport companies, quality of delivery and many others. V O L U M E 2 2 2 Transport network design and optimization In addition to the above, an • a single portal of public services for the access of employees and customers of transport companies to information; • geographic information systems, including electronic maps, 3D-terrain models and decrypted satellite photos; • geographic information systems, including electronic maps, 3D-terrain models and decrypted satellite photos; • a unified system of identification, authentication and authorization of users of the digital platform; • a unified system of identification, authentication and authorization of users of the digital platform; • payment service to pay for transportation, mutual settlements of participants in the transportation process, payment of taxes and fees; C O M M U N I C A T I O N S 2 / 2 0 2 0 V O L U M E 2 2 F O R M A T I O N A N D O P T I M I Z A T I O N O F T R A N S P O R T N E T W O R K S I N T H E C O N D I T I O N S O F T H E D I G I T A L . . . 2.2 Optimization of transport networks The study of modern methods for optimizing transport networks has shown that since the beginning of the 2000s, new approaches to building and optimizing transport networks have been actively introduced in European countries [5]. Existing optimization models should be considered here and/or completely new ones should be developed. Under the conditions of the formation of a digital integrated environment, when choosing a base route to form a transport network, it is advisable to use interactive decision-making methods, since this allows using the creative capabilities of a person - decision-maker (DM) [6-7]. An expert acts as a decision maker, for example, he can be a transport company manager, government official, Stage 3. Evaluation of the results obtained is also carried out by collecting information from video monitoring systems, from entrance and exit turnstiles, etc. Analysis C O M M U N I C A T I O N S 2 / 2 0 2 0 118 Z H E L E N K O V e t a l . route to be included in the transport network can be represented as follows: route to be included in the transport network can be represented as follows: etc. However, in the process of developing the digital integral medium of transportation, there will be a tendency to unite the means of neural networks, expert systems in creating multi-stage decision support systems for the formation of route networks. A. Data input. A. Data input. B. Criteria analysis. C. The definition of a set of rational routes based on the method of analysis of payment matrices with the selection of the main criterion. C. The definition of a set of rational routes based on the method of analysis of payment matrices with the selection of the main criterion. The choice of the base route should be made taking into account all the factors that determine the quality of such a decision, including technical and organizational, as well as cost, and time ones. This requires the use of specific techniques and methods involving the use of intuition and the decision-maker’s experience. Decisions made must be steady and regular. Stability of solutions should be understood as the property to remain unchanged with respect to changes in a priori probabilities affecting the values of the estimated functionals. Decision stability analysis allows DM to identify solutions with a certain guaranteed level. 4 Optimization of transport networks based on the modeling complex When modeling transportation in Russia, the software packages PTV Vision, AIM Sun and others are mainly used. Their main disadvantage is the closed architecture, that is, the impossibility of adding fundamentally new designs (calculation models). Existing modeling tools use only separate models and methods that do not allow to fully and adequately solve the tasks set for transport workers. A means of solving the task of optimizing transport networks is a modeling complex, which consists of many models that have the necessary degree of detail: A study of decision making methods showed that for conditions of certainty of initial information about routes, it is advisable to use the lexicographic method of organizing a variety of alternative options when choosing a base route [10]. The essence of the method is to streamline the decisions in order of criteria importance. In the process of choosing a base route from the set of route parameters, you should choose the one that, in the specific application conditions, reflects the necessary route properties, for example, time delays, and gives it a criterion function. , , , , M M M M i s 1 f f = " , , (1) with M1, Mi, Ms being specific models. Th l i l d b h l i l d i l i , , , , M M M M i s 1 f f = " , , (1) (1) , , , , M M M M i s 1 f f = " , , As practice shows, the majority of decision-making tasks on choosing a route to include it in the transport network are solved under conditions of uncertainty of the initial information. Analysis of existing approaches to solving the problem of choosing the base route in the face of uncertainty of the initial information showed the feasibility of a two-stage decision-making process. At the first stage, a set of rational routes is determined on the basis of formal methods, on the second, a basic route is adopted on the basis of expert procedures. Effective ones are the methods of analysis of payment matrices with the allocation of the main criterion and the method of analysis of hierarchies, respectively [11-12]. with M1, Mi, Ms being specific models. with M1, Mi, Ms being specific models. The complex can include both analytical and simulation models for optimizing route networks. 2.2 Optimization of transport networks A stable solution is different in that it is resistant to DM errors in terms of a priori probabilities. Regularity of decisions means that a complete regular solution has the property that it is optimal for all criteria considered, but this is extremely rare. In this case, it is advisable to use the set with partial regularity of the solution, which is optimal only for individual criteria. C.1 Selection of representative combinations of source data. C.1 Selection of representative combinations of source data. C.2 Search and preliminary analysis of solutions. C.2 Search and preliminary analysis of solutions. C.3 Calculation of the payment matrix. C.4 Analysis of the payment matrix and the choice of rational decisions. C.4 Analysis of the payment matrix and the choice of rational decisions. D. Selecting the base route using the hierarchy analysis method. D.1 Assessing the importance of criteria by pairwise comparisons. D.2 Calculation of criteria weights. D.2 Calculation of criteria weights. D.3 Comparison of the importance of alternatives by criteria. D.4 Calculate the weights of alternatives for each criterion. E. The end of the algorithm. In formal terms, the following decision-making conditions that arise when choosing a base route during the formation of a transportation network [8-9] can be distinguished: certain conditions when all the information for forming a base route is precisely known; conditions of uncertainty, when, in addition to unambiguous source data, there are random variables with precisely known probabilistic characteristics, as well as quantities for which their probabilistic description is not precisely known or not known at all. For the analysis of routes, the selection criteria proposed for the conditions of uncertainty are used - Wald, Laplace, Savage, Hurwitz criteria or their combination [13]. C O M M U N I C A T I O N S 2 / 2 0 2 0 V O L U M E 2 2 4 Optimization of transport networks based on the modeling complex The functional diagram of the modeling complex is presented in Figure 2. The fundamental properties of the modeling complex: - property of integration, that is, the complex must integrate models depending on the specific situation (task); The fundamental properties of the modeling complex: - property of integration, that is, the complex must integrate models depending on the specific situation (task); the property of evolution, which consists in the fact that the modeling complex, in fact, should be a working space for the gradual improvement of the transport network; - the property of duality, reflecting the possibility of representing the complex, on the one hand, as a model For the conditions of uncertainty of the initial information, the general algorithm for choosing the base C O M M U N I C A T I O N S 2 / 2 0 2 0 V O L U M E 2 2 F O R M A T I O N A N D O P T I M I Z A T I O N O F T R A N S P O R T N E T W O R K S I N T H E C O N D I T I O N S O F T H E D I G I T A L 119 Figure 2 Functional diagram of the modeling complex Figure 2 Functional diagram of the modeling complex of large dimensions; effective software implementation; reliability; convenient visual perception. of the object under study, and, on the other hand, as a model, reflecting the process itself of optimizing the transport network; In order to overcome the current diversity of the representation of the existing models for optimizing transportation networks, a single form and a unified methodology for presenting models, their input and output parameters, and units of measurement of parameters have been developed for the modeling complex. 4 Optimization of transport networks based on the modeling complex versatility or applicability for solving an unlimited set of various problems of optimizing transport networks, taking into account the necessary parameters, criteria and restrictions; versatility or applicability for solving an unlimited set of various problems of optimizing transport networks, taking into account the necessary parameters, criteria and restrictions; the property of development, which consists in the fact that the complex is created and operates taking into account the replenishment, improvement and updating of optimization problems and models of their solutions; the complex allows you to combine different types of models and use the necessary ones in solving specific problems of optimization of transport networks in a digital integrated environment of transport. the property of development, which consists in the fact that the complex is created and operates taking into account the replenishment, improvement and updating of optimization problems and models of their solutions; the complex allows you to combine different types of models and use the necessary ones in solving specific problems of optimization of transport networks in a digital integrated environment of transport. The models of the complex should be presented in the form of the following dependence: model model number: {input parameters} & {output parameters} (2) model model number: {input parameters} & {output parameters} (2) or , X X M pri pri in out i & \| (3) (3) with , , X x x pri in pri in prin in 1 f = # - being input parameters for the Mi model, Requirements for the modeling complex: adequacy; the possibility of refining the model when developing the transport network and the possibility of multi-level modeling; correctness of work; the ability to process data i , , X x x pri out pri out pril out 1 f = " , being output parameters (parameter) Mi. C O M M U N I C A T I O N S 2 / 2 0 2 0 V O L U M E 2 2 120 Z H E L E N K O V e t a l . Taking into account Equations (2) and (3), Equation (1) is represented as a system of models as follows: when solving a specific task, to establish a quantitative relation between the input and output parameters of the models. The module implements the preparation and analysis of model data. , , , , , , , , , , , ; , ; . M M x x x x M x x x x M x x x x pr in pr in pr in pr pr in in pr in pr out pr in in pr in pr out i s s prs sn s f out i ij i 1 11 1 1 1 1 2 1 2 2 & & & \| \| \| f f h f f h f f = Z [ \ ]]]]]]]]]]]]]]]] # " # " " " _ ` a bbbbbbbbbbbbbbbb - , - , , , , (4) Results analysis module. According to the results of the analysis of the data obtained during the operation of the modeling complex, a message is displayed containing an assessment of the results obtained and, if necessary, recommendations for correcting them or adjusting the initial task of optimizing route networks. (4) The output parameters of one model / models can be input parameters for another or other models. The number and types of models are determined by the nature of the problems of optimization of route transport networks. The modeling complex functions as follows. model model number: {input parameters} & {output parameters} (2) Based on the data entered by the user (this may be an optimization problem, a set of route parameters, conditions and optimization criteria), the input information is analyzed. Next, we determine the necessary optimization tasks for transportation networks (available in the task table or completely new), the parameters to be obtained; necessary for solving selected problems of the model from the database. It is checked whether this initial information is sufficient, if not, then these data are taken from the corresponding tables, database or requested from the user. Selection and analysis of models (from the database models) is carried out in the required order. Then, the organization of the interaction of the selected models, calibration models (if necessary). Next, the resulting solution is analyzed. As a result, a model will be chosen to solve the problem of optimizing transport route networks, corresponding to specified conditions. It must be emphasized that Equations (2) and (3) determine only the form of representation of models, i.e. how various models for calculation should be presented in the base of complex models. This is necessary to simplify the work with various models of the complex, and to implement the fundamental properties of the modeling complex. The composition of the modeling complex. Interface of user allows for problem-oriented communication between the user and the system that implements the operation of the complex. In the databases (DB), the models and parameters of the models are presented, as well as the optimization criteria for transport networks. The tables contain a list of specific optimization problems and statistical information. Depending on the tasks to be solved and the initial conditions (initial information), various mathematical models and methods that are presented in the model database, for example, methods based on OD-matrices, can be used in the calculations. In interactive mode, the modeling complex offers the user appropriate models for solving problems, and the user himself can specify the necessary models and methods that he will need in the calculations. The module analysis of input data. The functional purpose of the module is to form a data structure. Data entry and selection of the optimization task is carried out at the user’s request, while reading information from the corresponding tables and the database. The composition of the input data used may vary from one task to another. The module of the organization of the interaction of models. model model number: {input parameters} & {output parameters} (2) Here processes of the organization of interaction of models are realized. On the basis of existing tables and databases, statistical processing of information about objects takes place - reduction of the dimension of the feature space, i.e. the selection of such a subsystem of features that would be smaller in volume than the prior space of features, and provided an acceptable solution. The analysis of the characteristics of models, analysis and coordination of units of measurement of input and output parameters of models in the process of solving each specific problem of optimization of transport networks, for example, the problem of calculating the coefficient of imposing passenger traffic on the transport network [14-15]. C O M M U N I C A T I O N S 2 / 2 0 2 0 5 Software for the system of formation and optimization of transport networks On the basis of the proposed mathematical apparatus, software of an automated system for the formation and optimization of route transportation networks, designed to work in a digital integrated environment, has been developed. The automated system was developed by the staff of the department “Computing Systems, Networks and Information Security” of the Russian University of Transport. Programming language is C ++; OS are Ms. Windows 8x and above. Module for analysis of relation between parameters and models. Functional purpose - determination of the necessary parameters to solve specific problems and the construction of criteria dependence. The software complies with the following basic principles necessary for functioning in the conditions of the digital integrated environment for the provision of transport: systemic unity, development, compatibility and standardization. The principle of systemic unity in the creation, operation and development of software Calculation module. The values of parameters obtained on the basis of theoretical calculation methods (by criteria) can be the initial data for subsequent calculations when optimizing transportation networks. Module for assessing the accuracy of models. It is intended to assess the accuracy of each model considered C O M M U N I C A T I O N S 2 / 2 0 2 0 V O L U M E 2 2 121 F O R M A T I O N A N D O P T I M I Z A T I O N O F T R A N S P O R T N E T W O R K S I N T H E C O N D I T I O N S O F T H E D I G I T A L . . . Figure 3 Software Interface Figure 3 Software Interface Table 1 Modelling time reduction with the developed software Modelling Stages Time reduction (%) Information analysis 20 - 30 Estimation of route parameters 10 - 30 Rational options design 10 - 25 Base route selection 15 - 20 Table 1 Modelling time reduction with the developed software should ensure the integrity of the links between system components. The principle of development is that the software must be created and function, taking into account the replenishment, improvement and updating of its components. 5 Software for the system of formation and optimization of transport networks The principle of compatibility ensures the joint functioning of languages, symbols, codes, information and connections between components and preserve the open structure of the system as a whole. The principle of standardization lies in the unification, characterization and standardization of software that is invariant to routes and transport networks. Table 1 shows the reduction in modelling time as a result of using the developed system. As a result of the system operation, an electronic map with full information about the optimal (basic) route, the formed transport network, and information about the state of traffic flows will be obtained. V O L U M E 2 2 References [1] KORYAGIN, M. E. Equilibrium models of urban passenger transport system in the conditions of conflict of interests. Kuzbass State Technical University, Novosibirsk: Science, 2011. ISBN 978-5-02-032236-3. [2] GOLDOVSKIY, Y. M., ZHELENKOV, B. V., SAFONOVA, I. E. Simulation of network database management system with limited circulation of segments. Mir Transporta Journal (MT). 2014, V.12, 4(53), p. 32-44. ISSN 1992-3252. [3] SAFRONOV, E. A., SAFRONOV, K. E., SEMENOVA, E. S. Download management of the city transport network, given the increase in the availability of passenger transport. The Russian Automobile and Highway Industry Journal [online]. 2015, 6(46), p. 38-44 [accessed 2019-02-02]. eISSN 2658-5626. Available from: https://vestnik.sibadi.org/jour/ article/view/237?locale=en_US [4] PONOMAREVA, M. S. Coordination of carrier interests in the regional passenger traffic segment. Science studies [online]. 2015, 7(5). [accessed 2019-06-09]. ISSN 2223-5167. Available from: naukovedenie.ru/PDF/151EVN515.pdf [5] KOLBER, Y. A. Information support of public passenger transport network optimization in major cities: relevance and approaches. The Russian Automobile and Highway Industry Journal [online]. 2018, 15(2), p. 218-228. [accessed 2019-06-09]. eISSN 2658-5626. Available from: https://doi.org/10.26518/2071-7296-2018-2-218-228 [6] SMIRNOV, M. I., KHAIROULLIN, R. Z. Mathematical models used in the optimization system of goods delivery by motor transport DISPATCHER [online]. Moscow: Preprint, Inst. Appl. Math., the Russian Academy of Science, 2002. Available from: http://www.keldysh.ru/papers/2002/prep13/prep2002 13.html [7] SHVETSOV, V. I. Mathematical modeling of traffic flows. Automation and Remote Control. 2003, 11, p. 3-16. ISSN 0005-1179. [8] SAFRONOV, E. A., SAFRONOV, K. E., SEMENOVA, E. S. Prospects of development of light rail transportation in Russian cities. The Russian Automobile and Highway Industry Journal [online]. 2016, 2(48), p. 62-70 [accessed 2019- 09-10]. eISSN 2658-5626. Available from: https://vestnik.sibadi.org/jour/article/view/286?locale=en_US [9] FEDOROV, V. A. On the issue of the possibility of optimizing the route network of urban passenger transport in megalopolises. Young Scientist [online]. 2015, 2(82), p. 331-333 [accessed 2019-09-10]. eISSN 2077-8295. Available from: https://moluch.ru/archive/82/14765/ [10] CHERNORUTSKY, I. G. Decision making methods. Science, St. Petersburg: BHV-Petersburg, 2005. ISBN 5-94157-481-9. [11] SAATY, T. L. Making decisions. Hierarchy analysis method. Translated from English by VACHNADZE, R. G. Moscow: Radio and Communication. ISBN 5-256-00443-3. [12] GONCHAROV, V. A. Optimization methods [online]. MIET, Moscow: Jurait, 2016. ISBN 978-5-9916-3643-8. Available from: https://biblio-online.ru/bcode/378897 [13] SAFONOVA, I. E, TELNOV, G. G. The process of traffic control routing of passenger transport in the regions. In: the XIV International Scientific and Practical Conference : proceedings. Vol. 1. Innovative, Information and Communication Technologies. Moscow: Association of Alumni and Employees VVIA them. prof. Zhukovsky, 2017. 6 Conclusions In the practical application of the developed mathematical apparatus and the developed software, the effect is expected in the following areas: When forming the transport network in the developed system, decision-making methods are implemented both under certain and uncertain conditions of the initial information. The relations between the decision-maker and the computer goes through a series of iterative steps, with two points being significant at each iteration: the computer offers the DM a preliminary decision; the DM expresses his opinion about this decision and, if necessary, sets the direction for finding a solution. Analysis of the proposed solution is carried out in a dialogue with a computer. The route that satisfies the DM is taken as the base route. • increase the capacity of transport systems, for example, regional; • improving the economic efficiency of the use of route rolling stock; • attracting customers by expanding the range of services and customer-oriented approach; • attracting investments from potential partners wishing to provide their services in the digital information environment; • increasing the level of comfort and safety of route traffic. The system interface is shown in Figure 3. The left screen shows the selection and analysis of the parameters of the route for inclusion in the route network. The right screen shows the process of formation and optimization of the route transport network. Unlike the existing ones, the developed system allows taking into account all the parameters and characteristics of routes most fully; carry out calculations and processing of data of large dimensions; enables to solve the problems V O L U M E 2 2 C O M M U N I C A T I O N S 2 / 2 0 2 0 122 Z H E L E N K O V e t a l . functioning of the modeling complex, including the concept of organizing the interaction of models, the algorithm for linking model parameters, the integration technique, as well as the stages of the automated system and experimental testing of the developed mathematical apparatus and System software. of formation and optimization of route transport networks more adequately and at the lowest cost, allowing to reduce the time, while ensuring efficiency of operation. It should be noted that in subsequent articles a more detailed description of the developed mathematical apparatus will be presented, the composition and References ISSN 2500-1248, p. 300-302. [14] SAFONOVA, I. E, TELNOV, G. G. Hierarchical modeling complex as a basic means of optimizing route transport networks. In: the XIV International Scientific and Practical Conference : proceedings. Vol. 1. Innovative, Information and Communication Technologies. Moscow: Association of Alumni and Employees VVIA them. prof. Zhukovsky, 2017. ISSN 2500-1248, p. 295-299. [15] SAFONOVA, I. E, TELNOV, G. G. Selecting the optimal passenger transport routes for inclusion in the region route network. In: the XIV International Scientific and Practical Conference : proceedings. Vol. 1. Innovative, Information and Communication Technologies. Moscow: Association of Alumni and Employees VVIA them. prof. Zhukovsky, 2017. ISSN 2500-1248, p. 290-294. V O L U M E 2 2 C O M M U N I C A T I O N S 2 / 2 0 2 0
https://openalex.org/W2810450925	https://hull-repository.worktribe.com/preview/907885/Article.pdf	English	null	Low serum chloride in patients with chronic heart failure: clinical associations and prognostic significance	European journal of heart failure	2,018	cc-by	14,559	Authors Joseph J. Cuthbert MBBS, MRCP,1 Pierpaolo Pellicori MD, FESC,2 Alan Rigby, 1 Daniel Pan, 1 Syed Kazmi, 1 Parin Shah, 1 Andrew L Clark MA, MD, FRCP.1 All work conducted at Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK JJC, DP, PS are research fellows in the Department of Academic Cardiology PP is a clinical lecturer at the Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK AR and SK are statisticians in the Department of Academic Cardiology P is a clinical lecturer at the Robertson Institute of Biostatistics and Clinical Trials Unit, AR and SK are statisticians in the Department of Academic Cardiology ALC is senior author and Professor of Cardiology in the Department of Academic Cardiology Title Low serum chloride in patients with chronic heart failure: clinical associations and prognostic significance 1 1 1 Affiliations 1. Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK 1. Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham Kingston upon Hull, HU16 5JQ, UK Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham 2. Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK Word Count Corresponding author Dr. Joseph J Cuthbert, Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 2 Cottingham, Kingston upon Hull, HU16 5JQ, UK. Telephone: + 44 (0)1482 461776. Fax: + 44 (0)1482 461779 email: joe.cuthbert@nhs.net Cottingham, Kingston upon Hull, HU16 5JQ, UK. Telephone: + 44 (0)1482 461776. Fax: + 44 (0)1482 461779 email: joe.cuthbert@nhs.net Affiliations 1. Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK 2. Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK Word Count 3135 Affiliations Word Count 3135 This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 3 Abstract Background: Low serum chloride is common in patients with chronic heart failure (CHF) and is associated with worse outcomes. Objectives: We investigated the clinical and prognostic associations, including cause of death associations, of low serum chloride in patients referred to a secondary care clinic with suspected heart failure. Methods: Patients with echocardiogram and serum chloride were evaluated (n=5613). CHF was defined as signs and symptoms of the disease and either left ventricular systolic dysfunction (LVSD) worse than mild: heart failure with reduced ejection fraction (HFREF) or LVSD mild or better and raised NTproBNP levels (>125 ng/L): heart failure with preserved ejection fraction (HFPEF). Hypochloraemia was defined as greater than 2 standard deviations below the mean in the local normal distribution (<96 mmol/L). Results: Of the 5613 patients referred, 908 patients did not have CHF, 1988 had HFREF, and 2717 had HFPEF. Compared to patients in Q4 (median chloride 106 mmol/L), patients in Q1 (median 96 mmol/L) had more severe symptoms (38% NYHA III or IV vs. 25%, P<0.001) and were more likely to take loop diuretics (79% vs. 59%, P<0.001). The annual mortality rate for patients with CHF was 11%. Hypochloraemia was associated with an increased risk of death independent of NTproBNP. Patients in Q1 had a 2-fold increased risk of death compared to patients in Q4 (P<0.001). Sudden death was a common mode of death amongst patients with hypochloraemia. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 4 Conclusions: Hypochloraemia is strongly related to an adverse prognosis and may be a therapeutic target in patients with CHF. Keywords Heart failure, chloride, outcome, hypochloraemia, diuretics, prognosis. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 5 5 Patient population Between September 2000 and October 2016, consecutive referrals (n=6897) from both primary and secondary care were enrolled at a single secondary care clinic serving a local population of about 500,000 people (The Hull LifeLab). The study conforms to the principles outlined in the Declaration of Helsinki and was approved by relevant ethical bodies. All subjects gave their written informed consent. For the purpose of this analysis, CHF was defined as the presence of signs or symptoms consistent with the diagnosis and either left ventricular systolic dysfunction (LVSD) worse than mild, defined as HFREF or LVSD absent or at most mild and abnormal NT-pro-BNP plasma levels (>125 ng/L), defined as HFPEF. Hypochloraemia, hyponatraemia and hypokalaemia were defined as greater than 2 standard deviations below the mean electrolyte level in the normal distribution for the local population (<96 mmol/L, <135 mmol/L and <3.5 mmol/L respectively). Hyperchloraemia was defined as greater than two standard deviations above the mean chloride level in the normal distribution for the local population (>105 mmol/L). investigated the prevalence and clinical and outcome associations of hyper- and hypochloraemia in a large cohort of ambulatory patients with HFREF or HFPEF. investigated the prevalence and clinical and outcome associations of hyper- and hypochloraemia in a large cohort of ambulatory patients with HFREF or HFPEF. investigated the prevalence and clinical and outcome associations of hyper- and hypochloraemia in a large cohort of ambulatory patients with HFREF or HFPEF. Introduction Electrolyte abnormalities are common in patients with chronic heart failure (CHF) and may affect treatment decisions and outcome. Hyponatraemia and both hypo- and hyper-kalaemia are adverse prognostic markers that have been therapeutic targets in some recent trials.1,2 Hyponatraemia is a marker of severe CHF that might prompt consideration of a heart Electrolyte abnormalities are common in patients with chronic heart failure (CHF) and may affect treatment decisions and outcome. Hyponatraemia and both hypo- and hyper-kalaemia are adverse prognostic markers that have been therapeutic targets in some recent trials.1,2 Hyponatraemia is a marker of severe CHF that might prompt consideration of a heart transplant.3 Until very recently, the possible importance of serum chloride levels in patients with CHF had been overlooked. Hyponatraemia is a marker of severe CHF that might prompt consideration of a heart transplant.3 Until very recently, the possible importance of serum chloride levels in patients with CHF had been overlooked. Hypochloraemia (<96 mmol/L) is common in patients with CHF and is associated with a higher risk of mortality in patients with acute or chronic heart failure, independent of prognostic markers such as amino-terminal pro-B-type natriuretic peptide (NTproBNP).4-10 It is not yet clear whether hypochloraemia has a direct pathological effect,5,8 or is merely a consequence of diuretic therapy,11 or a marker of congestion and disease severity.12 Previous studies of chloride in patients with heart failure have either involved patients admitted with acute heart failure4 or myocardial infarction10, or highly selected study populations.5-7,9 Information on the clinical and prognostic significance of abnormal serum chloride levels in unselected out-patients with heart failure, with either reduced (HFREF) or preserved ejection fraction (HFPEF) are lacking. Importantly, there is little data on the mode of death associated with abnormal chloride levels in patients with heart failure. We therefore This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 6 Statistical Analysis Categorical data are presented as percentages, normally distributed continuous data are presented as mean + standard deviation (SD) and non-normally distributed variables are presented as median and interquartile range (IQR). The relationship between chloride and other variables was assessed by Pearson correlation coefficients. Uni- and multi- variable linear regression models were used to identify variables associated with serum chloride. Only variables with p<0.05 in univariable analysis were included in the multivariable model. Log-transformed NTproBNP was used. Patients with CHF were sub-divided as a whole and by phenotype (HFREF or HFPEF) into chloride quartiles and groups depending on the presence of hyponatraemia and / or hypochloraemia: group 1 – hyponatraemia and hypochloraemia, group 2 – normal sodium and hypochloraemia, group 3 – hyponatraemia and normal chloride and group 4 – normal sodium and chloride levels. Chi-squared tests were used to compare categorical variables and one-way analysis of variance (ANOVA) to compare continuous variables across the groups, assumptions of ANOVA (normality or residuals and equal variance) were checked. Kruskal- Wallis tests were used to compare non-normally distributed continuous variables across the quartiles and groups. Associations between variables and outcome were assessed with Cox regression, Associations between variables and outcome were assessed with Cox regression, proportionality of hazards was checked by residual plotting. Univariable analysis was Outcomes This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 7 Patients were followed up until 16/10/2016. The primary outcomes of interest were all-cause mortality and the composite endpoint of mortality or hospitalisation with heart failure. For each patient who died, the cause of death was adjudicated as detailed in the supplement. Statistical Analysis proportionality of hazards was checked by residual plotting. Univariable analysis was This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 8 conducted using all variables in the dataset and variables with P>0.1 in univariable analysis or with more than 10% missing values (an arbitrary threshold) were not included in the multivariable analyses. Kaplan-Meier curves were used to demonstrate outcome by different groups. Harrell’s C-statistic (area under the receiver-operating characteristic curve) was used to highlight the discrimination of different outcome models with and without chloride. 25-fold cross validation was performed on all variables in the database. Statistical analysis was carried out using the Stata 14 and SPSS 23 software packages. The two-tailed level of statistical significance was set at P < 0.05. Results Of the 6897 patients referred to the heart failure service, 5613 had data on echocardiography, NTproBNP and serum chloride at baseline, 908 patients did not have HF and were not included in the analysis. Of the remaining 4705 patients (table 1), 1988 patients had HFREF (supplementary table 1) and 2717 patients had HFPEF (supplementary table 2). The prevalence of hypochloraemia was 10.7% in patients with heart failure, 12.6 % in patients with HFREF and 9.3% in patients with HFPEF (P<0.001). By comparison, the prevalence of hyponatraemia was 11.3% amongst all patients with heart failure, 13.1% in patients with HFREF and 10.1% in patients with HFPEF (P=0.002). The prevalence of dual hypochloraemia and hyponatraemia was 5.9% in all patients, 7.2% in patients with HFREF and 5.0% in patients with HFPEF (P=0.001). This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 9 The prevalence of hyperchloraemia was 13.2% amongst all patients with heart failure, 11.7% in patients with HFREF and 14.3% patients with HFPEF (P=0.001). Patient characteristics by serum chloride levels Median chloride of patients in the first quartile (Q1) was 96 mmol/L (range 76-99 mmol/L) and 106 mmol/L (range 104-117 mmol/L) in the fourth quartile (Q4). Patients in Q1(including those with hypochloraemia (<96 mmol/L)) were older, more likely to have AF or diabetes and had more severe symptoms and a higher rate of loop diuretic prescription compared to patients in Q2-4 (P<0.001) (table 1). 59% of patients in Q1 who were taking loop diuretic were prescribed doses greater than 80mg of furosemide per day (table 1). Patients with hypochloraemia had higher NTproBNP than those with normal chloride levels (P<0.001). There was a general trend towards higher NTproBNP amongst patients in Q1 compared to Q2-4; the relationship was significant (P<0.001) but weak (r2 = 0.021; scatterplot not shown). By contrast, patients with hyperchloraemia (>105 mmol/L) were less likely to have severe symptoms and signs, had lower NTproBNP and had a lower rate of diuretic prescription than patients with hypochloraemia or low-normal chloride (Q1 and Q2) (P<0.001). Similar trends were observed across the quartiles in the HFREF and HFPEF subgroups (supplementary tables 1 and 2). Median NTproBNP was higher (1750 ng/L vs. Patient characteristics by serum chloride and sodium concentrations Patients with hypochloraemia and either low (group 1) or normal (group 2) sodium had similar demographics and disease severity (table 2). Patients with hypochloraemia and either low (group 1) or normal (group 2) sodium had similar demographics and disease severity (table 2). However, there were several biochemical differences between the two groups possibly identifying two distinct groups of patients with hypochloraemia. For example, patients with hypochloraemia and normal sodium had higher bicarbonate, haemoglobin, haematocrit and rate of hypokalaemia than patients with hypochloraemia and hyponatraemia (P<0.001) (table 2). Haemoglobin and haematocrit were similar in those with hyponatraemia regardless of chloride levels (group 1 and 3) (table 2). Disease severity, NTproBNP and rate of high dose diuretic prescription were lower in patients with normal chloride levels regardless of sodium levels (group 3 and 4) compared to those with low chloride levels regardless of sodium levels (group 1 and 2) (table 2) (P<0.001). Results 734 ng/L; P<0.001), and the proportion of patients with NYHA III or IV symptoms (35% vs. 24%; P<0.001) or taking a loop diuretic (75% vs. 54%; P<0.001) was greater amongst patients with This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 10 HeFREF compared to patients with HFPEF. Additionally, the proportion of patients with hypochloraemia who were taking a loop diuretic was higher in patients with HFREF compared to patients with HFPEF (91% vs. 69%; P<0.001). HeFREF compared to patients with HFPEF. Additionally, the proportion of patients with hypochloraemia who were taking a loop diuretic was higher in patients with HFREF compared to patients with HFPEF (91% vs. 69%; P<0.001). Associations with serum chloride This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 11 In all patients with heart failure and in both the HFREF and HFPEF subgroups, there was a strong positive correlation between chloride and sodium and a strong negative correlation with bicarbonate in multivariable analysis (supplementary figure 1). In all patients with heart failure and in both the HFREF and HFPEF subgroups, chloride had a weak negative correlation with log[NTproBNP] in univariable analysis. However, log[NTproBNP] was only associated with chloride after adjustment for other variables amongst patients with HFREF (supplementary figure 1); the association was of borderline significance (correlation co- efficient β = -0.326; t-statistic = -2.81; p=0.05). The strength and direction of other associations with serum chloride were similar between heart failure phenotypes. In all patients with heart failure and in both the HFREF and HFPEF subgroups, there was a strong positive correlation between chloride and sodium and a strong negative correlation with bicarbonate in multivariable analysis (supplementary figure 1). In all patients with heart failure and in both the HFREF and HFPEF subgroups, chloride had a weak negative correlation with log[NTproBNP] in univariable analysis. However, log[NTproBNP] was only associated with chloride after adjustment for other variables amongst patients with HFREF (supplementary figure 1); the association was of borderline significance (correlation co- efficient β = -0.326; t-statistic = -2.81; p=0.05). The strength and direction of other associations with serum chloride were similar between heart failure phenotypes. Predictors of outcome Predictors of outcome During a median follow up of 1691 days (IQR 754-1825), 1643 patients died and there were 919 hospitalisations with heart failure. A total of 1946 patients either died or were hospitalised with heart failure. Low serum chloride was strongly and independently associated with increasing mortality (figure 1) and all-cause mortality or heart failure hospitalisation in all patients with heart failure and in the HFREF and HFPEF subgroups. Other independent predictors of all-cause mortality (ACM) or ACM or hospitalisation with heart failure in both HFREF and HFPEF were increasing age, increasing heart rate, severe symptoms (NYHA III or IV), loop diuretic use, increasing log[NTproBNP], increasing urea and decreasing albumin. No variable was an independent predictor of one endpoint but not the other. the other. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 12 Variables that were independent predictors of outcome in patients with HFPEF and not HFREF were male sex, decreasing haemoglobin and increasing potassium levels. Variables that were independent predictors of outcome in patients with HFREF and not HFPEF were increasing bilirubin and the presence of ischaemic heart disease (IHD) (data not shown). However, neither haemoglobin, potassium, bilirubin or the presence of IHD were associated with outcome in all patients with heart failure (supplementary tables 5 and 6).. Variables that were independent predictors of outcome in patients with HFPEF and not HFREF were male sex, decreasing haemoglobin and increasing potassium levels. Variables that were independent predictors of outcome in patients with HFREF and not HFPEF were increasing bilirubin and the presence of ischaemic heart disease (IHD) (data not shown). i h h l bi i bili bi h f i d Variables that were independent predictors of outcome in patients with HFPEF and not HFREF were male sex, decreasing haemoglobin and increasing potassium levels. Variables that were independent predictors of outcome in patients with HFREF and not HFPEF were increasing bilirubin and the presence of ischaemic heart disease (IHD) (data not shown). However, neither haemoglobin, potassium, bilirubin or the presence of IHD were associated with outcome in all patients with heart failure (supplementary tables 5 and 6).. . Chloride as a predictor of adverse outcome With each unitary decrease in chloride, there was a 4% increase in mortality (hazard ratio (HR) = 1.04 (95% confidence interval (CI) = 1.02 – 1.06, P<0.001) and a 3% increase mortality or hospitalisation with heart failure (HR = 1.03 (95% CI = 1.02 – 1.05, P<0.001) independent of age, sex, body mass index, systolic blood pressure, heart rate, diabetes, IHD, NYHA class, log[NTproBNP], sodium, bicarbonate, calcium, potassium, haemoglobin, creatinine, urea, eGFR, albumin, alkaline phosphatase, alanine transferase, bilirubin, prescription of loop diuretics and CHF phenotype (HFREF vs. HFPEF) (supplementary table 5 and 6). Patients in Q1 had around a 2 fold increased risk of mortality compared to patients in Q4 (figure 2). the other. Patients with hypochloraemia had a similar prognosis, regardless of whether sodium was low (group 1) or normal (group 2); and both groups had a markedly worse prognosis than patients with an isolated low sodium (group 3) or those with both a normal sodium and chloride (group 4) (figure 3). The unadjusted odds ratio for mortality for patients with hypochloraemia was 2.64 compared to 1.71 for patients with hyponatraemia. In 25-fold cross validation using all variables listed in table 1, chloride featured in 22 models (88%) as a predictor of outcome. By comparison, sodium, potassium, bicarbonate and haemoglobin did not feature in any model. However, chloride did not add to the prognostic value of two models: 1) Harrell’s C-statistic for a model including all variables that featured in >80% of cross validation models (age, sex, body mass index, atrial fibrillation, NYHA class, 1) Harrell’s C-statistic for a model including all variables that featured in >80% of cross validation models (age, sex, body mass index, atrial fibrillation, NYHA class, log[NTproBNP], chloride, urea, albumin, ALT, ALP and loop diuretic) was 0.742 without chloride and 0.748 with chloride. validation models (age, sex, body mass index, atrial fibrillation, NYHA class, log[NTproBNP], chloride, urea, albumin, ALT, ALP and loop diuretic) was 0.742 without chloride and 0.748 with chloride. log[NTproBNP], chloride, urea, albumin, ALT, ALP and loop diuretic) was 0.742 without chloride and 0.748 with chloride. 2) C-statistic for an a priori model of age, sex, creatinine, albumin, IHD, NTproBNP, NYHA class, and use of loop diuretics was 0.734 without chloride and 0.738 with chloride. 2) C-statistic for an a priori model of age, sex, creatinine, albumin, IHD, NTproBNP, NYHA class, and use of loop diuretics was 0.734 without chloride and 0.738 with chloride. Cause of death after 1 year follow up the other. With each unitary decrease in chloride, there was a 4% increase in mortality (hazard ratio (HR) = 1.04 (95% confidence interval (CI) = 1.02 – 1.06, P<0.001) and a 3% increase mortality or hospitalisation with heart failure (HR = 1.03 (95% CI = 1.02 – 1.05, P<0.001) independent of age, sex, body mass index, systolic blood pressure, heart rate, diabetes, IHD, NYHA class, log[NTproBNP], sodium, bicarbonate, calcium, potassium, haemoglobin, With each unitary decrease in chloride, there was a 4% increase in mortality (hazard ratio (HR) = 1.04 (95% confidence interval (CI) = 1.02 – 1.06, P<0.001) and a 3% increase mortality or hospitalisation with heart failure (HR = 1.03 (95% CI = 1.02 – 1.05, P<0.001) independent of age, sex, body mass index, systolic blood pressure, heart rate, diabetes, IHD, NYHA class, log[NTproBNP], sodium, bicarbonate, calcium, potassium, haemoglobin, creatinine, urea, eGFR, albumin, alkaline phosphatase, alanine transferase, bilirubin, prescription of loop diuretics and CHF phenotype (HFREF vs. HFPEF) (supplementary table 5 and 6). Patients in Q1 had around a 2 fold increased risk of mortality compared to patients in Q4 (figure 2). There was a tendency for mortality to increase as chloride increased substantially above the normal range (>105 mmol/L). However, there were very few patients with very high chloride levels and thus, the event rate was low. Patients in Q4 were at a slightly higher risk of adverse outcome compared to Q3, but the association was not statistically significant. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 13 Patients with hypochloraemia had a similar prognosis, regardless of whether sodium was low (group 1) or normal (group 2); and both groups had a markedly worse prognosis than patients with an isolated low sodium (group 3) or those with both a normal sodium and chloride (group 4) (figure 3). The unadjusted odds ratio for mortality for patients with hypochloraemia was 2.64 compared to 1.71 for patients with hyponatraemia. Cause of death after 1 year follow up Amongst the 4505 patients with follow up data to one year, 11% died, 60% from cardiovascular causes (table 3). Death due to terminal heart failure was more common for patients in Q1 (including those with hypochloraemia) compared to Q2-4. Sudden death was more common in Q4 compared to Q1-3 but the event rate was much higher in Q1 (table 3). This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 14 Similar trends were seen across the quartiles in the HFREF and HFPEF subgroups although mortality rate was higher in patients with HFREF compared to HFPEF (12% vs. 9%) and cardiovascular death was a more common mode of death amongst patients with HFREF compared to patients with HFPEF (69% vs. 52%) (supplementary table 4). Sudden death was more common among patients with hypochloraemia (groups 1 and 2) compared to those with normal chloride levels and hyponatraemia (group 3) (supplementary table 3). The proportion of sudden deaths was greatest in patients with normal chloride and sodium levels (group 4) but the event rate was low. Discussion Our results add to the validity of findings of other studies:4-10 low serum chloride is associated with increased risk of morbidity and mortality in patients with heart failure regardless of phenotype and independent of more established prognostic variables such as NTproBNP or sodium. There are novel findings from the current study: 1) There may be an association between abnormal chloride levels and sudden death. 2) Hypochloraemia in patients with CHF might exist in two distinct biochemical phenotypes with implications for management. 3) Mortality risk increases substantially with chloride concentrations less than 100 mmol/L Previous studies have either not included NTproBNP,7,10 found no difference,5,6,8,9 or found This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. only a weakly significant difference4 in natriuretic peptides between patients with low and 15 normal serum chloride concentrations. In a very large cohort, we found a significant but weak inverse relation between chloride and NT-proBNP: however, the two were not related when corrections were made for other variables. Hypochloraemia was an indicator of severe disease, regardless of heart failure phenotype, and both decreasing chloride and increasing NTproBNP were strong independent predictors of an adverse outcome, suggesting that they are assessing different aspects of the heart failure syndrome. Chloride and sudden death Low serum chloride concentrations may have a stimulatory effect on a family of enzymes, with-no-lysine (WNK) kinases,13,14 which increase activity of Na+-K+-2Cl- (NKCC) and Na+- Cl- (NC) co-transporters.15,16 NKCC and NC co-transporters have a role in maintaining myocyte volume and pH.17,18 Dysregulation of myocyte intracellular pH is arrhythmogenic,19 and impairs contractility.20 Furthermore, cardiac chloride channels are implicated in sino- atrial pacing ,21 and arrhythmogenesis.22 Thus, there are plausible mechanisms by which abnormal chloride levels might affect cardiac rhythm. However, how serum chloride affects the function of chloride channels or chloride-dependent co-transporters in humans is unknown. Further work is required. Hypochloraemia, regardless of sodium levels, was associated with higher risk of mortality and mortality or heart failure hospitalisation than isolated hyponatraemia. Sodium was not Hypochloraemia, regardless of sodium levels, was associated with higher risk of mortality and mortality or heart failure hospitalisation than isolated hyponatraemia. Sodium was not This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 16 associated with adverse outcome after adjustment for other variables, including chloride. Monitoring serum sodium levels is recommended as an important prognostic marker in patients with heart failure, but it may be that chloride should have similar prominence in guidelines and clinical practice. Our results support the assertions of Ferreira et al (2017) that chloride should be assessed in the context of serum sodium levels.10 There seem to be two biochemical phenotypes: 1) In patients with hypochloraemia and hyponatraemia who have low haemoglobin, haematocrit and mean cell volume: in such patients, haemodilution may be an important contributor to the biochemical abnormalities.23,24 (Group 1 – table 2). 2) In patients with hypochloraemia and normal sodium levels who have higher haemoglobin with higher bicarbonate and a higher rate of hypokalaemia: in such patients, the hypochloraemia may be due to depletion.11,25 (Group 2 – table 2). Metabolic alkalosis is the most common acid-base disturbance in patients with HF,26 and chloride depletion in the context of alkalosis is a well-recognised complication of diuretic treatment.26,27 Both phenotypes have similar prevalence and risk of adverse outcome but the distinction may have implications for treatment, especially considering a similar proportion of patients have clinical signs of congestion in the two groups: while increasing the dose of loop diuretic might be appropriate to treat haemodilution, diuretic might also cause or worsen hypochloraemia. Patients with CHF who are prescribed loop diuretic have a poorer prognosis than those not needing diuretic treatment.28 Electrolyte abnormalities, such as hypochloraemia, may contribute to such findings. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. Redefining the normal limits for serum chloride The U-shaped relation between chloride and mortality shows a substantial increase in risk of death at chloride concentrations less than 100 mmol/L (figure 1). Redefining hypochloraemia as <100 mmol/L would undoubtedly increase the number of patients who might be declared suitable for ‘chloride-sparing diuretics’ such as acetazolamide in future trials and clinical practice. We did find that very high levels of chloride were associated with an adverse outcome. However, the absolute number of patients at the high end of the chloride distribution was small and the absolute number of events smaller still, making it impossible to draw conclusions with certainty. Hypochloraemia, regardless of sodium levels, was associated with higher risk of mortality and mortality or heart failure hospitalisation than isolated hyponatraemia. Sodium was not 17 Acetazolamide, a carbonic anhydrase inhibitor that reduces bicarbonate and sodium re- absorption and increases chloride re-absorption in the proximal tubule, can increase chloride levels whilst also having a diuretic action (a ‘chloride-sparing’ diuretic), and warrants further attention.29 It is important to note that not all patients with hypochloraemia were taking a loop diuretic, suggesting that other aspects of the heart failure syndrome, such as haemodilution, can cause hypochloraemia. This was particularly the case in the HFPEF subgroup; perhaps a reflection of the difficultly of making a clinical diagnosis of heart failure in patients with a normal ejection fraction, leading to a lower rate of diuretic prescription. Limitations This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 18 The limitations of retrospective analyses apply to our study and confounding factors cannot be excluded. A substantial proportion of patients referred to our clinic was naïve to treatment; initiation or adjustments of current treatment might have led to improved electrolyte balance. Our data is a snapshot of a single time-point and no conclusions can be drawn on the importance of changing chloride levels over time. Data on urinary electrolyte concentrations is also missing which would be useful in further delineating the different phenotypes of hypochloraemia. Some might not accept an NTproBNP > 125 pg/ml as diagnostic for heart failure with preserved ejection fraction, although it is consistent with recent European Society of Cardiology guidelines,30 diagnosis of HFPEF remains difficult in most cases. The limitations of retrospective analyses apply to our study and confounding factors cannot be excluded. A substantial proportion of patients referred to our clinic was naïve to treatment; initiation or adjustments of current treatment might have led to improved electrolyte balance. O d i h f i l i i d l i b d h The limitations of retrospective analyses apply to our study and confounding factors cannot be excluded. A substantial proportion of patients referred to our clinic was naïve to treatment; initiation or adjustments of current treatment might have led to improved electrolyte balance. Our data is a snapshot of a single time-point and no conclusions can be drawn on the importance of changing chloride levels over time. Data on urinary electrolyte concentrations is also missing which would be useful in further delineating the different phenotypes of hypochloraemia. Some might not accept an NTproBNP > 125 pg/ml as diagnostic for heart failure with preserved ejection fraction, although it is consistent with recent European Society of Cardiology guidelines,30 diagnosis of HFPEF remains difficult in most cases. Although we recorded cause of death in a carefully prescribed manner, we were not able to use autopsy data to confirm mode and cause of deaths. Conclusion Hypochloraemia is an important adverse prognostic marker in patients with chronic heart failure and sudden death is a common mode of death amongst patients with heart failure and low chloride levels. Whether chloride is a target for treatment is not clear and should be tested in future clinical trials. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 19 Conflicts of interest None. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 20 References 1. Pitt B, Anker SD, Bushinsky DA, Kitzman DW, Zannad F, Huang IZ. Evaluation of the efficacy and safety of RLY5016, a polymeric potassium binder, in a double-blind, placebo-controlled study in patients with chronic heart failure (the PEARL-HF) trial. Eur Heart J. 2011; 32(7):820-8. 2. Konstam MA, Gheorghiade M, Burnett JC Jr, Grinfeld L, Maggioni AP, Swedberg K, Udelson JE, Zannad F, Cook T, Ouyang J, Zimmer C, Orlandi C. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA. 2007; 297(12):1319-31. 3. Banner NR, Bonser RS, Clark AL, Clark S, Cowburn PJ, Gardner RS, Kalra PR, McDonagh T, Rogers CA, Swan L, Parameshwar J, Thomas HL, Williams SG. UK guidelines for referral and assessment of adults for heart transplantation. Heart. 2011; 97:1520e1527. 4. Grodin JL, Simon J, Hachamovitch R, Wu Y, Jackson G, Halkar M, Starling RC, Testani JM, Tang WH.. Prognostic Role of Serum Chloride Levels in Acute Decompensated Heart Failure. J Am Coll Cardiol. 2015; 66(6):659-66. 5. Ter Maaten JM, Damman K, Hanberg JS, Givertz MM, Metra M, O'Connor CM, Teerlink JR, Ponikowski P, Cotter G, Davison B, Cleland JG, Bloomfield DM, Hillege HL, van Veldhuisen DJ, Voors AA, Testani JM.. Hypochloremia, Diuretic Resistance, and Outcome in Patients With Acute Heart Failure. Circ Heart Fail. 2016; 9(8):e003109. 5. Ter Maaten JM, Damman K, Hanberg JS, Givertz MM, Metra M, O'Connor CM, Teerlink JR, Ponikowski P, Cotter G, Davison B, Cleland JG, Bloomfield DM, Hillege HL, van Veldhuisen DJ, Voors AA, Testani JM.. Hypochloremia, Diuretic Resistance, and Outcome in Patients With Acute Heart Failure. Circ Heart Fail. 2016; 9(8):e003109. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 21 6. Grodin JL, Verbrugge FH, Ellis SG, Mullens W, Testani JM, Tang WH. Importance of Abnormal Chloride Homeostasis in Stable Chronic Heart Failure. Circ Heart Fail. 2016; 9(1):e002453. 7. Testani JM, Hanberg JS, Arroyo JP, Brisco MA, Ter Maaten JM, Wilson FP, Bellumkonda L, Jacoby D, Tang WH, Parikh CR.. Hypochloraemia is strongly and independently associated with mortality in patients with chronic heart failure. Eur J Heart Fail. 2016; 18(6):660-8. 8. References Hanberg JS, Rao V, Ter Maaten JM, Laur O, Brisco MA, Perry Wilson F, Grodin JL, Assefa M, Samuel Broughton J, Planavsky NJ, Ahmad T, Bellumkonda L, Tang WH, Parikh CR, Testani JM. Hypochloremia and Diuretic Resistance in Heart Failure: Mechanistic Insights. Circ Heart Fail. 2016; 9(8):e003180. 9. Grodin JL, Sun JL, Anstrom KJ, Chen HH, Starling RC, Testani JM, Tang WH. Implications of Serum Chloride Homeostasis in Acute Heart Failure (from ROSE- AHF). Am J Cardiol. 2017; 119(1):78-83. 10. Ferreira JP, Girerd N, Duarte K, Coiro S, McMurray JJ, Dargie HJ, Pitt B, Dickstein K, Testani JM, Zannad F, Rossignol P. Serum Chloride and Sodium Interplay in Patients With Acute Myocardial Infarction and Heart Failure With Reduced Ejection Fraction An Analysis From the High-Risk Myocardial Infarction Database Initiative. Circ Heart Fail. 2017;10:e003500. 11. Verbrugge FH, Nijst P, Dupont M, Penders J, Tang WH, Mullens W. Urinary composition during decongestive treatment in heart failure with reduced ejection fraction. Circ Heart Fail. 2014; 7:766–772. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 22 12. Vaduganathan M, Pallais JC, Fenves A, Butler J, Gheorghiade M. Serum chloride in heart failure: a salty prognosis Eur J Heart Fail. 2016; 18:669–671 13. Piala AT, Moon TM, Akella R, He H, Cobb MH, Goldsmith EJ. Chloride sensing by WNK1 involves inhibition of autophosphorylation. Sci Signal. 2014; 7(324):ra41. 14. Bazúa-Valenti S, Chávez-Canales M, Rojas-Vega L, González-Rodríguez X, Vázquez N, Rodríguez-Gama A, Argaiz ER, Melo Z, Plata C, Ellison DH, García-Valdés J, Hadchouel J, Gamba G.. The Effect of WNK4 on the Na+-Cl- Cotransporter Is Modulated by Intracellular Chloride. J Am Soc Nephrol. 2015; 26(8):1781-6. 15. Kahle KT, Rinehart J, Lifton RP. Phosphoregulation of the Na-K-2Cl and K-Cl cotransporters by the WNK kinases. Biochim Biophys Acta. 2010; 1802(12):1150-8. 16. Yang CL, Zhu X, Ellison DH. The thiazide-sensitive Na-Cl cotransporter is regulated 15. Kahle KT, Rinehart J, Lifton RP. Phosphoregulation of the Na-K-2Cl and K-Cl cotransporters by the WNK kinases. Biochim Biophys Acta. 2010; 1802(12):1150-8. 16. Yang CL, Zhu X, Ellison DH. The thiazide-sensitive Na-Cl cotransporter is regulated by a WNK kinase signaling complex. J Clin Invest. 2007; 117(11):3403-11. 17. Clemo HF, Feher JJ, Baumgarten CM. References Modulation of rabbit ventricular cell volume and Na+/K+/2Cl− cotransport by cGMP and atrial natriuretic factor. J Gen Physiol. 1992; 100:89–114. 18. Adkins GB, Curtis MJ. Potential role of cardiac chloride channels and transporters as novel therapeutic targets. Pharmacol Ther. 2015; 145:67-75. 19. Orchard CH, Cingolani HE. Acidosis and arrhythmias in cardiac muscle. Cardiovasc Res 1994; 28:1312–1319. 20. Orchard CH, Kentish JC. Effects of changes of pH on the contractile function of cardiac muscle. Am J Physiol. 1990; 27:C967–C981. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 23 21. Huang ZM, Prasad C, Britton FC, Ye LL, Hatton WJ, Duan D. Functional role of CLC-2 chloride inward rectifier channels in cardiac sinoatrial nodal pacemaker cells. J Mol Cell Cardiol. 2009; 47(1):121-32. 22. Duan DY, Liu LL, Bozeat N, Huang ZM, Xiang SY, Wang GL, Ye L, Hume JR. Functional role of anion channels in cardiac diseases. Acta Pharmacol Sin. 2005; 26(3):265-78. 23. Verbrugge FH, Steels P, Grieten L, Nijst P, Tang WH, Mullens W. Hyponatremia in acute decompensated heart failure: depletion versus dilution. J Am Coll Cardiol. 2015; 65(5):480-92. 24. Androne AS, Katz SD, Lund L, LaManca J, Hudaihed A, Hryniewicz K, Mancini DM. Hemodilution is common in patients with advanced heart failure. Circulation. 2003; 107(2):226-9. 25. Frangiosa A, De Santo LS, Anastasio P, De Santo NG. Acid-base balance in heart failure. J Nephrol. 2006;19(suppl 9):S115-S120. 26. Urso C, Brucculeri S, Caimi G. Acid-base and electrolyte abnormalities in heart failure: pathophysiology and implications. Heart Fail Rev. 2015; 20(4):493-503. 27. Luke RG, Galla JH. It is chloride depletion alkalosis, not contraction alkalosis. J Am Soc Nephrol. 2012; 23(2):204-7. 28. Pellicori P, Cleland JG, Zhang J, Kallvikbacka-Bennett A, Urbinati A, Shah P, Kazmi S, Clark AL. Cardiac Dysfunction, Congestion and Loop Diuretics: their Relationship to Prognosis in Heart Failure. Cardiovasc Drugs Ther. 2016; 30(6):599-609. References This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 24 29. Khan MI. Treatment of refractory congestive heart failure and normokalemic hypochloremic alkalosis with acetazolamide and spironolactone. Can Med Assoc J. 1980; 123(9):883-7. 30. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891-975. 30. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891-975. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 25 Title: Association between mortality and serum chloride in patients with heart failure Caption: Probability of all-cause mortality at 5-year follow up by serum chloride levels in patients with heart failure with a reduced ejection fraction or heart failure with a preserved ejection fraction. Frequency bars show the proportion of patients with a specific chloride concentration. The population was divided into quartiles based on serum chloride concentration, denoted by different coloured areas of the figure. Figure 1 Title: Association between mortality and serum chloride in patients with heart failure Figure 3 Title: Kaplan-Meier curve for groups based on the presence of hypochloraemia and/or hyponatraemia Caption: Kaplan-Meier curves for all-cause mortality in patients with heart failure and a reduced ejection fraction or heart failure and preserved ejection fraction divided by groups based on the presence of hypochloraemia and/or hyponatraemia. Group 1 – hypochloraemia and hyponatraemia; group 2 – hypochloraemia and normal sodium levels; group 3 – normal chloride levels and hyponatraemia; group 4 – normal chloride and sodium levels. Unadjusted hazard ratios for different groups compared to group 4 also included. Title: Kaplan-Meier curve for quartiles of serum chloride This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 26 Caption: Kaplan-Meier curves for all-cause mortality in patients with heart failure and a reduced ejection fraction or heart failure and a preserved ejection fraction divided by quartiles of serum chloride. Unadjusted hazard ratios for different quartiles compared to quartile 4 also included. Supplementary figure 1 Title: Univariable correlation matrix for variables associated with serum chloride levels in all patients with heart failure and in the HFREF or HFPEF subgroups. Caption: List of abbreviations used: ALP – alkaline phosphatase; ALT – alanine aminotransferase; BMI – body mass index; eGFR – estimate glomerular filtration rate; HF – heart failure; HFPEF – heart failure with preserved ejection fraction; HFREF – heart failure with reduced ejection fraction; HR – heart rate; LAD – left atrial diameter; LVEF – left ventricular ejection fraction; no. – number; NTproBNP – N-terminal B-type natriuretic This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 27 peptide; SBP – systolic blood pressure. * P<0.05 on multivariable linear regression. ** P>0.05 on multivariable linear regression. Variables entered into the multivariable model for all patients included: age, BMI, sodium, potassium, bilirubin, haemoglobin, ALT, albumin, ALP, Urea, eGFR, bicarbonate, SBP, HR, log[NTproBNP]. Variables entered into the multivariable model for patients with HFREF included: age, BMI, sodium, potassium, bilirubin, haemoglobin, ALT, albumin, ALP, Urea, eGFR, bicarbonate, SBP, HR, log[NTproBNP]. Variables included in the multivariable model for patients with HFPEF included: age, BMI, sodium, potassium, bilirubin, haemoglobin, albumin, ALP, Urea, eGFR, bicarbonate, SBP, HR, log[NTproBNP]. peptide; SBP – systolic blood pressure. * P<0.05 on multivariable linear regression. ** peptide; SBP – systolic blood pressure. * P<0.05 on multivariable linear regression. ** P>0.05 on multivariable linear regression. Variables entered into the multivariable model for all patients included: age, BMI, sodium, potassium, bilirubin, haemoglobin, ALT, albumin, ALP, Urea, eGFR, bicarbonate, SBP, HR, log[NTproBNP]. Variables entered into the multivariable model for patients with HFREF included: age, BMI, sodium, potassium, bilirubin, haemoglobin, ALT, albumin, ALP, Urea, eGFR, bicarbonate, SBP, HR, log[NTproBNP]. Variables included in the multivariable model for patients with HFPEF i l d d di i bili bi h l bi lb i A G P>0.05 on multivariable linear regression. Variables entered into the multivariable model for all patients included: age, BMI, sodium, potassium, bilirubin, haemoglobin, ALT, albumin, ALP, Urea, eGFR, bicarbonate, SBP, HR, log[NTproBNP]. Supplementary figure 1 Variables entered into the multivariable model for patients with HFREF included: age, BMI, sodium, potassium, bilirubin, haemoglobin, ALT, albumin, ALP, Urea, eGFR, bicarbonate, SBP, HR, g[ p ] p included: age, BMI, sodium, potassium, bilirubin, haemoglobin, albumin, ALP, Urea, eGFR, bicarbonate, SBP, HR, log[NTproBNP]. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 28 28 This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. edited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: epted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: rticle may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: his article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versio his is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure followi ttps://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance wi ticle accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online a 7. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived V Tables Table 1 Table 1 Thi i dit d th d d i f ti l t d f bli ti i E J l f H t F il f ll i i Th i f d i il bl li t Patient characteristics by quartile of serum chloride in patients with heart failure. Missing All patients N=4705 Hypochloraemia <96 mmol/L N=503 Q1 N=1177 Q2 N=1176 Q3 N=1176 Q4 N=1176 Hyperchloraemia >105 mmol/L N=622 P for trend mol/L) 0 102 (99 – 104) 93 (91-95) 96 (94-98) 100 (100-101) 103 (102-103) 106 (105-107) 107 (106-108) NA Demographics 0 73 (11) 74 (11) 74 (10) 73 (10) 71 (11) 72 (10) 73 (10) <0.001 o. (%) 0 2885 (61) 262 (52) 628 (53) 737 (63) 742 (63) 778 (66) 414 (67) <0.001 239 3129 (70) 311 (62) 725 (62) 769 (65) 819 (70) 816 (69) 440 (71) <0.001 (%) 0 1152 (25) 146 (29) 339 (29) 306 (26) 22 (25) 252 (21) 126 (20) <0.001 - no. (%) 0 2006 (43) 198 (39) 477 (41) 496 (42) 511 (44) 522 (44) 277 (44) 0.26 e accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: Thi ti l b d f i l i d ith Wil T d C diti f U f S lf A hi d V i This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. uthor-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. Patient characteristics by quartile of serum chloride in patients with heart failure. Patient characteristics by quartile of serum chloride in patients with heart failure. 29 0 2306 (49) 227 (45) 525 (45) 566 (48) 604 (51) 611 (52) 343 (55) 0.001 Signs and symptoms o. (%) 230 1320 (29) 217 (44) 439 (38) 338 (30) 256 (22) 287 (25) 152 (25) <0.001 Blood results 0 2408 (397 – 2535) 1817 (722-4203) 1476 (604-3763) 1040 (422-2439) 871 (334-2000) 873 (333-2206) 917 (346- 2271) <0.001 315 13.3 (12.1 – 14.4) 12.8 (11.7-14.0) 13.0 (11.9-14.2) 13.3 (12.1-14.4) 13.5 (12.4-14.6) 13.4 (12.1-14.5) 13.3 (12.1-14.4) <0.001 280 0.406 (0.374 – 0.438) 0.390 (0.359-0.423) 0.398 (0.366-0.433) 0.406 (0.375-0.438) 0.412 (0.382-0.441) 0.409 (0.377-0.439) 0.408 (0.376-0.438) <0.001 7 139 (137 – 140) 134 (131-136) 136 (133-138) 138 (136-140) 139 (138-141) 140 (139-142) 140 (139-142) <0.001 . (%) 7 533 (11) 279 (56) 407 (35) 100 (9) 20 (2) 6 (1) 3 (1) 38 4.4 (4.1-4.7) 4.3 (3.9-4.6) 4.3 (3.9-4.7) 4.3 (4.0-4.7) 4.4 (4.1-4.7) 4.4 (4.1-4.7) 4.4 (4.1-4.7) <0.001 (%) 38 143 (3) 49 84 27 22 10 4 <0.001 30 (9.7) (7.2) (2.3) (1.9) (0.9) (0.6) mmol/L 0 28 (26 – 30) 30 (28-32) 30 (28-32) 29 (27-30) 28 (26-30) 27 (25-28) 26 (25-28) <0.001 n/1.73m2 152 60 (45 – 74) 55 (41-72) 56 (42-71) 59 (45-73) 64 (51-77) 60 (45-74) 60.0 (45.1-73.4) 0.001 Medications no. (%) 0 2965 (63) 403 (80) 935 (79) 805 (69) 580 (49) 645 (55) 279 (45) <0.001 ose >80 mg/day – no. (%) 0 1212 (41) 246 (61) 549 (59) 322 (40) 175 (30) 166 (35) 75 (27) <0.001 0 950 (20) 177 (35) 366 (31) 251 (21) 170 (15) 163 (14) 84 (14) <0.001 no. (%) 0 3245 (69) 344 (68) 819 (70) 848 (72) 797 (68) 781 (66) 402 (65) 0.02 0 2741 (58) 235 (47) 613 (52) 698 (59) 713 (61) 717 (61) 378 (61) <0.001 Echocardiography e - no. (%) 0 372 (8) 65 (13) 130 (11) 103 (9) 71 (6) 68 (6) 37 (6) <0.001 Legend This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: e may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. Patient characteristics by quartile of serum chloride in patients with heart failure. 31 ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 32 Table 2 Table 2 Patient characteristics by groups based on the presence of hypochloraemia and/or hyponatraemia Patient characteristics by groups based on the presence of hypochloraemia and/or hyponatraemia Variable Missing Group 1 N=279 Group 2 N=224 Group 3 N=254 Group 4 N=3942 P Chloride – (mmol/L) 0 93 (90-94) 94 (93-95) 99 (97-100) 102 (100-104) <0.001 Sodium – mmol/L 0 131 (129-133) 137 (135-139) 133 (132-134) 139 (138-141) <0.001 Demographics Age – years 0 74 (11) 74 (10) 75 (10) 73 (11) 0.001 Sex (male) - no. (%) 0 138 (50) 124 (55) 162 (64) 2456 (62) <0.001 SR – no. (%) 204 186 (66) 128 (57) 175 (69) 2639 (67) 0.60 Diabetes - no. (%) 0 82 (29) 64 (29) 83 (33) 923 (23) 0.001 Hypertension - no. (%) 0 104 (37) 94 (42) 104 (41) 1701 (43) 0.26 IHD -- no. (%) 0 133 (48) 94 (42) 126 (50) 1950 (50) 0.17 33 Symptoms NYHA Class III/IV - no. (%) 108 124 (45) 93 (43) 82 (33) 1018 (26) Blood results NTproBNP – ng/L 0 1816 (777-4298) 1805 (678-4143) 1193 (520-2591) 956 (371-2325) <0.001 Haemoglobin – g/dL 243 12.5 (11.5-13.7) 13.2 (12.0-14.5) 12.5 (11.4-13.8) 13.4 (12.2-14.5) <0.001 Haematocrit 273 0.379 (0.343-0.410) 0.406 (0.372-0.452) 0.378 (0.347-0.408) 0.410 (0.379-0.440) <0.001 Potassium – mmol/L 29 4.4 (4.1-4.7) 4.0 (3.6-4.5) 4.5 (4.2-4.8) 4.4 (4.1-4.7) <0.001 Hypokalaemia – no. (%) 29 8 (3) 41 (18) 3 (1) 90 (2) <0.001 Bicarbonate – mmol/L 0 28 (27-30) 32 (30-35) 26 (25-27) 28 (26-30) <0.001 eGFR – ml/min/1.73m2 128 58 (43-77) 52 (38-67) 59 (40-73) 61 (46-74) <0.001 Medications Loop diuretic- no. (%) 0 207 (74) 196 (88) 167 (66) 2390 (61) <0.001 Furosemide Dose >80 mg/day 0 119 (58) 127 (65) 66 (40) 897 (38) MRA- no. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: e may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: Patient characteristics by quartile of serum chloride in patients with heart failure. (%) 0 104 (37) 73 (33) 89 (35) 682 (17) <0.001 34 ACE-I or ARB- no. (%) 0 204 (73) 140 (63) 196 (77) 2701 (69) 0.002 BB - no. (%) 0 135 (48) 100 (45) 160 (63) 2342 (59) <0.001 Echocardiography Severe LVSD - no. (%) 41 (15) 24 (11) 16 (6) 291 (7) <0.001 This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: htt // li lib il /d i/ b /10 1002/ jhf 1247 Thi ti l b d f i l i d ith Wil T d C diti f U f S lf A hi d V i accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: Legend ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. Group 1 = Na <135mmol/L & Cl <96mmol/L Group 2 = Na >135mmol/L & Cl <96mmol/L Group 3 = Na <135mmol/L & Cl >96mmol/L Group 4 = Na >135mmol/L & Cl >96mmol/ This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 35 Table 3 rticle may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. Table 3 Table 3 Mode of death in patients with heart failure and reduced ejection fraction or heart failure and a preserved ejection fraction by serum chloride quartile and hypo- and hyperchloraemia. All (N=4505) Quartile 1 N=1128 Quartile 2 N=1118 Quartile 3 N=1121 Quartile 4 N=1138 Hypochloraemia (<96 mmol/L) N=483 Chloride levels 96-105 mmol/L N=3421 Hyperchloraemia (>105 mmol/L) N=601 Dead by 12m (All Cause) 481 204 110 78 89 119 312 50 Annual mortality rate 11% 18% 10% 7% 8% 25% 9% 8% Cardiovascular (Primary) 291 (60) 126 (62) 58 (53) 43 (55) 64 (72) 68 (57) 184 (59) 39 (78) Terminal HF (Primary) 103 (21) 55 (27) 20 (18) 12 (15) 16 (18) 31 (26) 63 (20) 9 (18) Sudden Death (Primary) 154 (32) 64 (31) 26 (24) 26 (33) 38 (43) 35 (29) 96 (31) 23 (46) Non CV (Primary Cause) 169 (35) 72 (35) 47 (43) 29 (37) 21 (24) 47 (39) 113 (36) 9 (18) Unknown cause 21 (5) 6 (3) 5 (4) 6 (8) 4 (4) 4 (4) 15 (5) 2 (4) 36 Total of patients with minimum FU of 1 year=4505. Figures in brackets are percentages of all deaths. List of abbreviations used: CV – cardiovascular; HF – Heart failure. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: epted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: rticle may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. his is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure followi ttps://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance wi This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: rticle may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. rtile of serum chloride in patients with heart failure and a reduced ejection fraction This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 37 hi i di d h d d i f i l d f bli i i J l f H il f ll i i h i f d i il bl li Variable Missing All HFREF N=1988 Hypochloraemia N=251 Q1 N=497 Q2 N=497 Q3 N=497 Q4 N=497 Hyperchloraemia N=233 P for trend Chloride – (mmol/L) 0 101 (98-104) 93 (91-95) 95 (93-97) 100 (99-101) 102 (102-103) 105 (104-107 107 (106-108) n/a Demographics Age – years 0 71(11) 71 (11) 72 (11) 71 (11) 70 (12) 70 (11) 70 (11) 0.004 Sex (male) - no. (%) 0 1485 (75) 165 (66) 337 (68) 364 (73) 390 (79) 394 (79) 185 (79) <0.001 SR – no. (%) 118 1368 (69) 158 (63) 312 (63) 352 (71) 345 (69) 359 (72) 169 (73) 0.004 Diabetes - no. (%) 0 472 (24) 86 (34) 151 (30) 132 (27) 98 (20) 91 (18) 41 (18) <0.001 Hypertension - no. (%) 0 651 (33) 78 (31) 151 (30) 168 (34) 163 (33) 169 (34) 80 (34) 0.60 IHD -- no. (%) 0 1278 (64) 150 (60) 297 (60) 32 (65) 327 (66) 332 (67) 154 (66) 0.01 38 Signs and symptoms NYHA Class III/IV - no. (%) 22 686 (35) 123 (50) 217 (44) 181 (37) 149 (30) 139 (29) 75 (33) <0.001 Blood results NTproBNP – ng/L 0 1750 (750-3984) 2731 (1192-5848) 2296 (969-5250) 1716 (746-4014) 1536 (607-3077) 1463 (697-3601) 1593 (733-3844) <0.001 Haemoglobin – g/dL 101 13.5 (12.2-14.6) 13.0 (11.9-14.1) 13.1 (12.0-14.2) 13.5 (12.2-14.5) 13.7 (12.4-14.9) 13.6 (12.5-14.6) 13.5 (12.5-14.7) <0.001 Haematocrit 99 0.411 (0.379-0.443) 0.394 (0.362-0.429) 0.400 (0.370-0.437) 0.410 (0.379-0.441) 0.421 (0.390-0.449) 0.417 (0.384-0.445) 0.419 (0.386-0.444) <0.001 Sodium – mmol/L 5 138 (136-140) 134 (131-136) 135 (133-138) 138 (136-140) 139 (138-141) 140 (139-142) 140 (139-142) <0.001 Hyponatraemia – no. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. edited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: epted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: rticle may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. rtile of serum chloride in patients with heart failure and a reduced ejection fraction (%) 5 259 (13) 142 (57) 198 (36) 47 (9) 9 (2) 5 (1) 3 (1) <0.001 Potassium – mmol/L 13 4.4 (4.1-4.7) 4.3 (3.9-4.6) 4.3 (4.0-4.7) 4.4 (4.1-4.7) 4.4 (4.2-4.7) 4.4 (4.1-4.7) 4.4 (4.1-4.8) 0.004 Signs and symptoms 39 This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: Hypokalaemia – no. (%) 13 58 (2.9) 28 (11.1) 38 (6.9) 10 (2.0) 5 (1.1) 5 (1.1) 7 (3.0) <0.001 Bicarbonate – mmol/L 0 28 (26-30) 30 (28-32) 30 (28-32) 29 (27-31) 28 (27-30) 27 (25-28) 26 (25-28) <0.001 eGFR – ml/min/1.73m2 76 59 (44-73) 55 (41-70) 54 (40-70) 58 (43-73) 62 (47-76) 60 (45-73) 60 (45-75) <0.001 Medications Loop diuretic- no. (%) 0 1490 (75) 229 (91) 449 (90) 399 (80) 338 (68) 302 (61) 133 (57) <0.001 Furosemide Dose >80 mg/day 0 689 (46) 148 (65) 279 (62) 204 (51) 114 (33) 92 (30) 41 (30) <0.001 MRA- no. (%) 0 661 (33) 124 (49) 231 (47) 180 (36) 130 926) 120 (24) 57 (25) <0.001 ACE-I or ARB- no. (%) 0 1614 (81) 198 (79) 402 (81) 405 (82) 407 (82) 400 (81) 186 (80) 0.94 BB - no. (%) 0 1333 (67) 135 (54) 295 (59) 343 (69) 342 (69) 353 (71) 168 (72) <0.001 Echocardiography Severe LVSD - no. (%) 0 372 (19) 65 (26) 100 (20) 130 (26) 67 (14) 75 (15) 37 (16) <0.001 LAD – cm 281 4.4(0.8) 4.4 (0.8) 4.4 (0.8) 4.4 (0.8) 4.3 (0.8) 4.4 (0.7) 4.4 (0.7) 0.37 40 40 ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; HFREF – heart failure with a reduced ejection fraction; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; HFREF – heart failure with a reduced ejection fraction; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. Supplementary Table 2 Patient characteristics by quartile of serum chloride in patients with heart failure and a preserved ejection fraction. Patient characteristics by quartile of serum chloride in patients with heart failure and a p This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. able Missing All HFPEF Hypochloraemia Q1 Q2 Q3 Q4 Hyperchloraemia P for This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 41 41 This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary wiley com/doi/abs/10 1002/ejhf 1247 This article may be used for non commercial purposes in accordance with Wiley Terms and Conditions for Use of Self Archived Versions N=2717 N=252 N=679 N=679 N=679 N=680 N=389 trend mmol/L) 0 102 (99-104) 94 (92-95) 96 (95-98) 101 (100-101) 103 (102-104) 106 (105-107) 107 (106-108) N/A Demographics s 0 75 (10) 77 (9) 77 (9) 75 (10) 74 (10) 73 (10) 74 (9) <0.001 - no. (%) 0 1400 (52) 97 (39) 269 (40) 373 (55) 362 (53) 397 (58) 229 (59) <0.001 ) 86 1761 (65) 153 (61) 414 (61) 426 (63) 438 (65) 483 (71) 271 (70) 0.001 no. (%) 0 680 (25) 60 (24) 182 (27) 186 (27) 165 (24) 147 (22) 85 (22) 0.06 on - no. (%) 0 1355 (50) 120 (48) 345 (51) 330 (49) 338 (50) 342 (50) 197 (51) 0.87 %) 0 1028 (38) 77 (31) 196 (29) 248 (37) 263 (39) 321 (47) 189 (49) <0.001 Signs and symptoms III/IV - no. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary wiley com/doi/abs/10 1002/ejhf 1247 This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions edited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: rticle may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. Supplementary Table 2 (%) 86 634 (24) 94 (39) 211 (32) 152 (23) 142 (21) 129 (19) 77 (20) <0.001 42 Blood results – ng/L 0 734 (289-1672) 1175 (549-2898) 929 (356-2192) 672 (287-1498) 676 (277-1551) 634 (263-1566) 664 (273-1644) <0.001 bin – g/dL 142 13.2 (12.0-14.3) 12.6 (11.5-13.9) 13.0 (11.9-14.1) 13.2 (12.1-14.3) 13.2 (12.1-14.3) 13.3 (12.1-14.4) 13.1 (11.9-14.3) 0.18 it 181 0.403 (0.370-0.435) 0.384 (0.349-0.42) 0.395 (0.363-0.431) 0.404 (0.370-0.435) 0.405 (0.377-0.436) 0.405 (0.372-0.436) 0.401 (0.368-0.433) 0.03 mmol/L 1 139 (137-141) 134 (131-136) 136 (134-138) 139 (137-140) 139 (138-141) 140 (139-142) 140 (139-142) <0.001 emia – no. (%) 1 274 (10) 137 (54) 209 (34) 53 (8) 11 (2) 1 (0) 0 (0) <0.001 – mmol/L 16 4.3 (4.0-4.6) 4.3 (3.9-4.6) 4.3 (3.9-4.6) 4.3 (4.0-4.6) 4.3 (4.1-4.6) 4.4 (4.1-4.7) 4.4 (4.1-4.7) <0.001 mia – no. (%) 16 85 (3.1) 21 (8.3) 46 (6.8) 17 (2.5) 17 (2.5) 5 (0.7) 1 (0.3) <0.001 e – mmol/L 0 28 (26-30) 30 (28-33) 30 (28-32) 28 (27-30) 28 (26-30) 27 (25-28) 26 (24-28) <0.001 43 43 R – ml/min/1.73m2 52 61 (49-75) 55 (41-74) 58 (43-75) 61 (48-75) 62 (49-76) 61 (47-75) 60 (45-73) 0.01 Medications p diuretic- no. (%) 0 1475 (54) 174 (69) 449 (66) 374 (55) 372 (55) 280 (41) 146 (38) <0.001 semide Dose >80 mg/day – no. (%) 0 523 (35) 98 (56) 236 (53) 125 (33) 98 (26) 64 (23) 34 (23) <0.001 A- no. (%) 0 289 (11) 53 (21) 113 (17) 70 (10) 52 (8) 54 (8) 27 (7) <0.001 I or ARB- no. (%) 0 1631 (60) 146 (58) 404 (60) 428 (63) 404 (60) 395 (58) 216 (56) 0.29 no. (%) 0 1408 (52) 100 (40) 306 (45) 343 (51) 387 (57) 372 (55) 210 (54) <0.001 Echocardiography VSD - no. (%) 0 1652 (61) 169 (67) 467 (69) 420 (62) 38 (56) 382 (56) 236 (60) <0.001 ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; HFPEF – heart failure with a preserved ejection fraction; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. Legend This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 44 ACE-I – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta-blocker; BMI – body mass index; eGFR – estimate glomerular filtration rate; no. – number; HFPEF – heart failure with a preserved ejection fraction; IHD – ischaemic heart disease; LVSD – left ventricular systolic dysfunction; MRA – mineralocorticoid receptor antagonist; NYHA – New York Heart Association; SR – sinus rhythm. This is a pre-copyedited, author-produced version of an article accepted for publication in European Journal of Heart Failure following peer review. The version of record is available online at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1247. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. 45 Supplementary Table 3 Mode of death in patients with heart failure and reduced ejection fraction or heart failure and a preserved ejection fraction based on the presence of hypochloraemia and/or hyponatraemia. death in patients with heart failure and reduced ejection fraction or heart failure and a preserved ejection fraction by groups based on the presence of hypochloraemia and/or hyponatraemia. Mode of death in patients with heart failure and reduced ejection fraction or heart failure and a preserved ejection fraction by groups based on the presence of hypochloraemia and/or hyponatraemia. All (N=4502) Group 1 N=265 Group 2 N=218 Group 3 N=235 Group 4 N=3784 Dead by 12m (All Cause) 481 70 49 32 330 Annual mortality rate 11% 26% 22% 14% 9% Cardiovascular (Primary) 291 (60) 40 (57) 28 (57) 21 (65) 202 (61) Terminal HF (Primary) 103 (21) 17 (24) 14 (29) 11 (34) 61 (18) 45 45 46 Sudden Death (Primary) 154 (32) 22 (31) 13 (27) 6 (19) 113 (34) Non CV (Primary Cause) 169 27 20 9 113 Unknown cause 21 3 1 2 15 Legend Total of patients with minimum FU of 1 year=4502. 6 patients were excluded because they did not have sodium available Figures in brackets are percentage of all deaths. List of abbreviations used: CV – cardiovascular; HF – Heart failure. Group 1 = Na <135mmol/L & Cl <96mmol/L Group 2 = Na >135mmol/L & Cl <96mmol/L Group 3 = Na <135mmol/L & Cl >96mmol/L Group 4 = Na >135mmol/L & Cl >96mmol/L 46 47 Supplementary Table 4 Mode of death in patients with heart failure by heart failure phenotype. Patients with HFREF with minimum follow up of 1 year (N = 1901) All (N=1901) Hypochloraemia (<96 mmol/L) N=240 Quartile 1 N=533 Quartile 2 N=494 Quartile 3 N=445 Quartile 4 N=429 Hyperchloraemia (>105 mmol/L) N=224 Dead by 12m (All Cause) 237 65 110 49 34 44 26 Annual mortality rate - % 12 27 21 10 8 10 12 Cardiovascular (Primary) 163 (69) 43 (66) 75 (68) 28 (57) 25 (73) 35 (80) 21 (81) Terminal HF (Primary) 64 (27) 22 (34) 35 (32) 13 (27) 6 (18) 10 (23) 4 (15) Sudden Death (Primary) 85 (36) 21 (32) 36 (33) 13 (27) 15 (44) 21 (48) 13 (50) Non CV (Primary Cause) 65 20 32 18 7 8 5 Mode of death in patients with heart failure by heart failure phenotype. 47 47 48 Unknown cause 9 2 3 3 2 1 0 Patients with HFPEF with minimum follow up of 1 year (N = 2604) All (N=2604) Hypochloraemia (<96 mmol/L) N=243 Quartile 1 N=595 Quartile 2 N=624 Quartile 3 N=676 Quartile 4 N=709 Hyperchloraemia (>105 mmol/L) N=377 Dead by 12m (All Cause) 244 54 94 61 44 45 24 Annual mortality rate - % 9 22 16 10 7 6 6 Cardiovascular (Primary) 128 (52) 25 (46) 51 (54) 30 (49) 18 (41) 29 (64) 18 (75) Terminal HF (Primary) 38 (16) 9 (17) 20 (21) 7 (11) 6 (14) 6 (13) 5 (21) Sudden Death (Primary) 69 (28) 14 (26) 28 (30) 13 (21) 11 (25) 17 (38) 10 (42) Non CV (Primary Cause) 104 27 40 29 22 13 4 Unknown cause 12 2 3 2 4 3 2 48 49 49 brackets are percentages of all deaths. List of abbreviations used: HFREF – heart failure with a reduced ejection fraction; HFPEF – e with a preserved ejection fraction; CV – cardiovascular; HF – Heart failure. Legend Figures in brackets are percentages of all deaths. List of abbreviations used: HFREF – heart failure with a reduced ejection fraction; HFPEF – heart failure with a preserved ejection fraction; CV – cardiovascular; HF – Heart failure. 49 50 Supplementary Table 5 Supplementary Table 5 Supplementary Table 5 50 Univariable and Multivariable analysis for all-cause mortality in all patients with heart failure Variable Univariable Multivariable HR X2 - Wald p HR X2 - Wald p Demographics Age – years 1.06 (1.05- 1.06) 573 <0.001 1.05 (1.04- 1.05) 251 <0.001 Sex (male vs female) - no. Supplementary Table 5 (%) 1.13 (1.05- 1.23) 9 0.002 1.30 (1.18- 1.45) 25 <0.001 BMI – kg/m2 0.97 (0.96- 0.98) 65 <0.001 SBP – mmHg 1.00 (0.99- 1.00) 34 <0.001 Univariable and Multivariable analysis for all-cause mortality in all patients with heart failure 50 51 51 51 HR – bpm 1.01 (1.00- 1.01) 36 <0.001 AF (vs SR) 1.38 (1.27- 1.50) 54 <0.001 Diabetes (vs non-diabetic) 1.26 (1.15- 1.38) 25 <0.001 1.12 (1.01- 1.25) 5 0.033 Hypertension (vs non-hypertensive) 0.95 (0.88- 1.03) 1 0.243 IHD (vs no IHD) 1.16 (1.07- 1.25) 13 <0.001 Signs & Symptoms NYHA Class (III/IV vs I/II) 1.99 (1.83- 2.16) 261 <0.001 1.42 (1.29- 1.57) 53 <0.001 Peripheral oedema (>ankles vs none or trace) 1.84 (1.68- 2.02) 176 <0.001 51 52 52 52 Lung crackles (present vs absent) 1.93 (1.73- 2.16) 141 <0.001 JVP (raised vs not raised) 1.92 (1.72- 2.16) 125 <0.001 Bloods Log(NTproBNP) – ng/L 2.79 (2.60- 3.00) 757 <0.001 1.47 (1.33- 1.63) 53 <0.001 Haemoglobin – g/dL 0.81 (0.80- 0.83) 288 <0.001 Sodium – mmol/L 0.94 (0.93- 0.95) 124 <0.001 Chloride – mmol/L 0.94 (0.93- 0.95) 207 <0.001 0.96 (0.94- 0.98) 17 <0.001 Calcium – mmol/L 0.14 (0.10- 0.18) 180 <0.001 Lung crackles (present vs absent) 52 53 53 Potassium – mmol/L 1.10 (1.00- 1.18) 4 0.045 Bicarbonate – mmol/L 1.01 (1.00- 1.03) 2 0.126 Creatinine-umol/L 1.00 (1.00- 1.00) 265 <0.001 Urea - mmol/L 1.07 (1.06- 1.07) 617 <0.001 1.03 (1.01- 1.04) 15 <0.001 eGFR – ml/min/1.73m2 0.98 (0.98- 0.98) 461 <0.001 Albumin – g/l 0.89 (0.89- 0.90) 451 <0.001 0.95 (0.93- 0.96) 58 <0.001 Bilirubin – umol/L 1.02 (1.01- 1.02) 34 <0.001 ALP – iu/L 1.01 (1.01- 300 <0.001 1.00 (1.00- 47 <0.001 Potassium – mmol/L 53 54 54 54 1.01) 1.00) ALT – iu/L 0.99 (0.99- 0.99) 25 <0.001 0.99 (0.99- 1.00) 18 <0.001 Medications Loop diuretic (vs no loop diuretic) 2.00 (1.84- 2.18) 244 <0.001 1.26 (1.14- 1.40) 19 <0.001 Furosemide Dose (>80mg day vs 1-79mg/day) 1.38 (1.26- 1.52) 47 <0.001 Echocardiography HFrEF vs HFpEF 1.29 (1.19- 1.39) 40 <0.001 LAD – cm 1.30 (1.24- 1.38) 98 <0.001 LVEF by Simpsons – % 0.99 (0.98- 0.99) 57 <0.001 54 55 55 Supplementary Table 5 – Univariable and Multivariable analysis for all-cause mortality in all patients with heart failure Legend Only variables associated with outcome in univariable analysis (p<0.1) were entered in multivariable models. Variables with >10% missing values were excluded. Variables that were non-significant in multivariable analysis were not recorded. Variables included in multivariable model: age, sex, BMI, SBP, HR, diabetes, IHD, NYHA class; log(NT-pro-BNP), sodium, calcium, potassium, haemoglobin, chloride, creatinine, urea, eGFR, albumin, ALP, ALT, bilirubin, loop diuretics, HFrEF, HFpEF. HF – heart failure; HFrEF – heart failure with reduced ejection fraction; HFpEF – heart failure with preserved ejection fraction; no. – number; BMI – body mass index; SBP – systolic blood pressure; HR – heart rate; SR – sinus rhythm; IHD – ischaemic heart disease; NYHA – New York Heart Association; JVP – jugular venous pulse; eGFR – estimate glomerular filtration rate; LAD – left atrial diameter; LVEF – left ventricular ejection fraction 55 56 Supplementary table 6 Univariable and Multivariable analysis for all-cause mortality or heart failure hospitalisation in all patients with heart failure Variable Univariable Multivariable HR X2 - Wald P HR X2 - Wald p Demographics Age – years 1.05 (1.04- 1.05) 434 <0.001 1.04 (1.03- 1.04) 159 <0.001 Sex (male vs female) - no. LVEF by Simpsons – % 0.98 (0.98- 0.99) 103 <0.001 LVEF by Simpsons – % 0.98 (0.98- 0.99) 103 <0.001 Legend (%) 1.14 (1.05- 1.23) 10 0.001 1.25 (1.13- 1.38) 20 <0.001 BMI – kg/m2 0.98 (0.97- 0.99) 40 <0.001 56 56 57 57 57 SBP – mmHg 1.00 (0.99- 1.00) 51 <0.001 HR – bpm 1.01 (1.01- 1.01) 50 <0.001 AF (vs SR) 1.39 (1.28- 1.50) 60 <0.001 Diabetes (vs non-diabetic) 1.28 (1.17- 1.40) 31 <0.001 1.12 (1.01- 1.24) 5 0.027 Hypertension (vs non-hypertensive) 1.01 (0.94- 1.09) 0 0.833 IHD (vs no IHD) 1.17 (1.09- 1.26) 17 <0.001 Signs & Symptoms NYHA Class (III/IV vs I/II) 2.02 (1.87- 2.19) 300 <0.001 1.40 (1.28- 1.53) 53 <0.001 57 58 58 Peripheral oedema (>ankles vs none or trace) 1.98 (1.79- 2.20) 164 <0.001 Lung crackles (present vs absent) 1.99 (1.79- 2.21) 161 <0.001 JVP (raised vs not raised) 1.94 (1.74- 2.17) 139 <0.001 Bloods Log(NTproBNP) – ng/L 2.90 (2.71- 3.11) 893 <0.001 1.63 (1.47- 1.80) 92 <0.001 Haemoglobin – g/dL 0.82 (0.80- 0.84) 294 <0.001 Sodium – mmol/L 0.94 (0.93- 0.95) 111 <0.001 Chloride – mmol/L 0.94 (0.93- 0.95) 208 <0.001 0.97 (0.95- 0.98) 14 <0.001 58 59 59 59 Calcium – mmol/L 0.16 (0.12- 0.21) 166 <0.001 Potassium – mmol/L 1.07 (0.99- 1.16) 3 0.081 Bicarbonate – mmol/L 1.01 (1.00- 1.03) 4 0.038 Creatinine-umol/L 1.00 (1.00- 1.00) 246 <0.001 Urea - mmol/L 1.06 (1.06- 1.07) 565 <0.001 1.02 (1.01- 1.03) 9 0.003 eGFR – ml/min/1.73m2 0.98 (0.98- 0.98) 441 <0.001 Albumin – g/l 0.90 (0.90- 0.91) 394 <0.001 0.96 (0.95- 0.97) 33 <0.001 Bilirubin – umol/L 1.02 (1.01- 48 <0.001 59 60 60 60 1.03) ALP – iu/L 1.01 (1.01- 1.01) 290 <0.001 1.00 (1.00- 1.00) 38 <0.001 ALT – iu/L 0.99 (0.99- 1.00) 12 <0.001 1.00 (0.99- 1.00) 9 0.003 Medications Loop diuretic (vs no loop diuretic) 2.15 (1.98- 2.34) 324 <0.001 1.37 (1.24- 1.51) 37 <0.001 Furosemide Dose (>80mg day vs 1-79mg/day) 1.38 (1.26- 1.51) 51 <0.001 Echocardiography HFrEF vs HFpEF 1.46 (1.35- 1.57) 98 <0.001 LAD – cm 1.35 (1.29- 1.42) 140 <0.001 60 61 LVEF by Simpsons – % 0.98 (0.98- 0.99) 103 <0.001 Legend Only variables associated with outcome in univariable analysis (p<0.1) were entered in multivariable models. Variables with >10% missing values were excluded. Variables that were non-significant in multivariable analysis were not recorded. Variables included in multivariable model: age, sex, BMI, SBP, HR, diabetes, IHD, NYHA class; log(NT-pro-BNP), sodium, calcium, potassium, bicarbonate, haemoglobin, chloride, creatinine, urea, eGFR, albumin, ALP, ALT, bilirubin, loop diuretics, HFREF, HFPEF. HF – heart failure; HFREF – heart failure with reduced ejection fraction; HFPEF – heart failure with preserved ejection fraction; no. – number; BMI – body mass index; SBP – systolic blood pressure; HR – heart rate; SR – sinus rhythm; IHD – ischaemic heart disease; NYHA – New York Heart Association; JVP – jugular venous pulse; eGFR – estimate glomerular filtration rate; LAD – left atrial diameter; LVEF – left ventricular ejection fraction 61 62 62 62 63 63 Figures 63 63 63 63 64 64 65 65 66 66 67 67 67 68 68
https://openalex.org/W4292374088	https://jurnal-assalam.org/index.php/JPMA/article/download/329/187	Indonesian	null	PEMBERDAYAAN PETANI AREN DI DESA TOMPOBULU KECAMATAN TOMPOBULU DALAM PEMBUATAN GULA MERAH MENJADI KOMODITAS USAHA DI ERA DIGITAL	Jurnal Pengabdian Masyarakat As-salam	2,022	cc-by-sa	4,079	anuari - Juni 2022: 1 – 9 Basri, Radiah, Anita M Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022 e-ISSN 2797-7242 anuari - Juni 2022: 1 – 9 Basri, Radiah, Anita M Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022 e-ISSN 2797-7242 PEMBERDAYAAN PETANI AREN DI DESA TOMPOBULU KECAMATAN TOMPOBULU DALAM PEMBUATAN GULA MERAH MENJADI KOMODITAS USAHA DI ERA DIGITAL Syamsuriana Basri1, Radiah2, Anita M3 123Program Studi Pendidikan Fisika, Fakultas Keguruan dan Ilmu Pendidikan, Universitas Muslim Maros, Maros, Indonesia email: syamsuriana@umma.ac.id1,2,3 Abstract: Tompobulu Village is a village located in the Tompobulu sub-district, Maros Regency. Tompobulu village is one of the brown sugar-producing villages with high palm sugar potential. The purpose of this activity is to increase the understanding of sugar palm farmers in the process of packaging and marketing products using digital technology. Participants in this activity consisted of 3 groups of sugar palm farmers, each group consisting of 4 people. The results of the training obtained are 1) increased knowledge of sugar palm farmers from the results of questionnaires filled out by activity participants as respondents, obtained a percentage of 61.11% with an average pretest percentage of 31.67% and 97.78% posttest. 2) produce brown sugar products in various shapes such as rectangles, flowers and semi-circles with attractive packaging, as well as additional products resulting from this activity, namely tenteng products (peanut sugar), ant sugar, and liquid brown sugar, 3) product marketing This is done through social media such as Facebook, WhatsApp, Instagram, blogs and/or websites (Tokopedia, Shopee, Lazada, Bukalapak, dan Tokko) and traditional markets. Keywords: Palm Farmers, Brown Sugar Products Abstrak: Desa Tompobulu merupakan desa yang terletak di kecamatan Tompobulu, Kabupaten Maros. Desa Tompobulu yaitu salah satu desa penghasil gula merah dengan potensi aren yang cukup tinggi. Tujuan dari kegiatan ini adalah untuk meningkatkan pemahaman petani aren dalam proses pengemasan dan pemasaran produk dengan menggunakan teknologi digital. Peserta pada kegiatan ini terdiri atas 3 kelompok petani aren yang masing-masing setiap kelompok petani aren beranggotakan 4 orang. Hasil dari pelatihan yang diperoleh yaitu 1) peningkatan pengetahuan dari petani aren yang diperoleh dari hasil kuesioner oleh peserta kegiatan sebagai responden diperoleh persentasi sebesar 61,11% dengan rata-rata persentasi pretest sebesar 31,67% dan posttest 97,78%. 2) menghasilkan produk gula merah berbagai bentuk seperti persegi panjang, bunga dan setengah lingkaran dengan kemasan yang menarik, serta produk tambahan yang dihasilkan dari kegiatan ini, yaitu produk tenteng (gula kacang), gula semut, dan gula merah cair, 3) pemasaran produk dilakukan melalui media sosial Facebook, Whatshapp, Instagram, Blog dan/atau Website secara online (Tokopedia, Shopee, Lazada, Bukalapak, dan Tokko) dan Pasar- Pasar Tradisional. Kata Kunci: Petani Aren, Produk Gula Merah Pendahuluan Tompobulu merupakan desa yang terletak di wilayah Kecamatan Tompobulu, Kabupaten Maros, Provinsi Sulawesi Selatan yang tercatat sebagai desa definitif dan tergolong sebagai desa swakarya. Desa Tompobulu memiliki luas wilayah 91,98 km2 dan jumlah penduduk sebanyak 3.628 jiwa dan pada tahun 2017 memiliki tingkat kepadatan penduduk sebanyak 39,44 jiwa/km2 (Wikipedia bahasa Indonesia, 2021). Masyarakat di desa Tompobulu memiliki salah satu mata pencarian yakni pengolahan buah aren untuk membuat gula merah. Di desa Tompobulu sebagian besar penduduk tidak memiliki penghasilan tetap sehigga tingkat perekonomian masyarakat masih rendah. Olehnya itu, \| 1 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 - 9 Syamsuriana Basri, Radiah, Anita M dapat dikatakan penduduk desa Tompobulu membutuhkan sumabangan pemikiran dari orang-orang yang mampu memperbaiki kondisi perekonomian dalam hal mengembangkan usaha-usaha yang dilakukan oleh masyarakat desa Tompobulu seperti pembuatan gula merah. Pembuatan gula merah merupakan usaha yang dianggap mudah untuk masyarakat di desa Tompobulu karena di daerah ini banyak yang memelihara pohon aren di pegunungan. Pohon yang dikenal menghasilkan bahan-bahan industri dimana hampir semua bagian fisik serta produksi pada tumbuhan ini dapat dimanfaatkan disebut sebagai pohon aren (Arenga pinnata Merr). Pohon Aren memiliki nilai ekonomi yang cukup tinggi sebab memiliki banyak manfaat. Manfaat aren dapat dirasakan secara langsung oleh masyarakat yang ada disana maupun di sekitar hutan melalui penggunaan secara tradisional (Lempang, 2012). Berdasarkan klasifikasi tanaman, tanaman aren termasuk dalam divisi Spermatophyta, subdivisi Angiospermae, kelas Monocotyledonae, bangsa Spadicitlorae, suku Palmae, marga Arenga dan jenis Arenga pinnata Merr (Perkebunan, 2015). Berdasarkan survey awal dan hasil wawancara menunjukkan bahwa perekonomian masyarakat yang berada di daerah Tompobulu masih rendah, akan tetapi memiliki sumber daya alam (SDA) yang cukup tinggi, hal ini dapat dilihat pada pohon aren. Potensi pengolahan aren sangat bagus sebab pohon aren banyak ditemukan di daerah pegunungan. Terlebih lagi, bertani aren merupakan mata pencarian utama bagi masyarakat desa Tompobulu. Sebagaimana yang kita ketahui bahwa pohon aren memiliki banyak manfaat untuk para petani aren, khususnya pada pembuatan gula merah yang dimana setiap pohon aren dapat menghasilkan kurang lebih 10 kg gula merah yang diproses dalam waktu 1 hari sehingga dapat menjadi gula aren atau biasa juga disebut juga gula merah. Kandungan gula aren terdiri dari unsur senyawa seperti vitamin B kompleks, glukosa, garam mineral dan memiliki kadar kalori yang cukup tinggi serta kadar glisemik gula terendah yaitu 35 Indeks Glisemik (GI) (Lalisang, 2018). Pendahuluan Daerah sasaran PHP2D Himpunan Mahasiswa Pendidikan Fisika FKIP Universitas Muslim Maros yaitu desa Tompobulu Kecamatan Tompobulu Kabupaten Maros. Masyarakat desa Tompobulu Kecamatan Tompobulu disana secara umum memiliki ekonomi yang masih rendah dan rata-rata pendidikannya tidak tamat sekolah dasar. Mayoritas masyarakat di desa Tompobulu Kecamatan Tompobulu bekerja sebagai petani sawah, berkebun sayur-sayuran, petani jagung. Perjalanan ke desa Tompobulu cukup besar tantangannya ketika harus mengendarai motor dengan bebatuan yang cukup banyak dan hanya sebagian jalan yang di beton, dalam perjalannya ditempuh dengan berjalan kaki sejauh lebih kurang 2 km untuk mencapai lokasi pembuatan gula merah. Di dusun Tombolo terdapat 5 (lima) petani aren yang membuat gula merah, di dusun Baddo Ujung terdapat 3 (tiga) petani aren yang membuat gula merah, di dusun Lokayya terdapat 3 (tiga) petani aren yang membuat gula merah, dan di dusun Masale terdapat 3 (tiga) petani aren yang membuat gula merah. Total petani aren yang membuat gula merah di desa Tompobulu sebanyak 14 (empat belas) petani aren. Masalah terbesar yang dihadapi petani aren dalam pembuatan gula merah yaitu produksi gula merah yang belum maksimal sebab terbatasi alat serta pengetahuan yang \| 2 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 – 9 Syamsuriana Basri, Radiah, Anita M lebih mumpuni bagi petani. Pada pengemasan produknya dilakukan dengan menggunakan kantong plastik hitam untuk dipasarkan. Sebelum pengemasan, dilakukan proses pembuatan gula dengan jangka waktu yang lama yaitu terlebih dahulu dilakukan pengambilan nira pada pohon aren kemudian dimasak selama 12 jam. Pengambilan nira dilakukan mulai dari sore hari sampai pagi hari, proses pengambilan nira dilakukan dengan memotong batang buah aren atau enau yang masih muda kemudian menyimpan wadah berupa pipa dengan ukuran besar yang telah disiapkan oleh masyarakat yang membuat gula merah, wadah yang digunakan juga bisa dari jerigen untuk menyimpan nira, setelah wadah tersebut sudah penuh, kemudian diganti dengan wadah yang masih kosong lainnya, setelah semua wadah sudah terisi dengan nira, kemudian wajan besar disiapkan di atas tungku kayu. Proses produksi masih menggunakan cara tradisional yaitu dengan menggunakan wajan besar yang terbuat dari tanah, dan masih menggunakan kayu bakar. Namun dengan cara ini tidak mengurangi rasa dan kualitas produk gula merah yang diproduksi. Kemudian permasalahan yang dihadapi oleh petani aren yaitu jarak dari rumah ke lokasi pembuatan gula merah cukup jauh sekitar 2 km dan jalanan juga masih belum stabil. Pendahuluan Gula aren dapat menjadi lahan bisnis yang baik jika hasil produksi dikelola dan dipasarkan dengan kreatif. Gula aren bisa menjadi tempat untuk berinovasi dan berkreativitas agar produk gula aren ini memiliki nilai tambah untuk menarik konsumen yang dapat memberikan keuntungan bagi para petani aren (Waani & Mangindaan, 2021). Tujuan pelaksanaan kegiatan ini adalah untuk meningkatkan sumber daya manusia di desa Tommpobulu melalui pemberdayaan petani aren, memberikan pemahaman kepada petani aren dalam proses pengemasan dan pemasaran produk gula merah, dan mengembangkan pengetahuan masyarakat mengenai teknologi digital guna meningkatkan nilai jual pada produk gula merah. Metode Bahan baku merupakan kebutuhan pokok dalam melaksanakan proses produksi (Accurate, n.d.). Dalam hal pembuatan gula aren, dibutuhkan bahan agar dapat memproduksi gula aren, bahan yang digunakan yaitu, nira aren yang masih segar, minyak goreng. Adapun alat-alat yang digunakan dalam pembuatan gula aren yaitu, wajan dengan ukuran maksimal, sendok kayu, beberapa cetakan berbagai bentuk. Untuk mengatasi masalah-masalah yang ada pada usaha agroindustri gula aren perlu diperhatikan starategi pengembangan agroindustri gula aren dengan menyesuaikan karakteristik dan permasalahan agroindusti yang bersangkutan. Daya saing dan eksistensi usaha dipengaruhi oleh startegi pengembangan (Purnamasari et al., 2018). Dalam kegiatan pemberdayaan petani aren ini dilakukan dua metode yaitu metode pelaksanaan dan metode pemberdayaan masyarakat, dimana metode pelaksanaan kegiatan terbagi menjadi 3 tahap yaitu, metode pra pelaksanaan yang dilakukan sebelum tim turun langsung ke lapangan untuk melaksanakan kegiatan inti, kemudian metode pelaksanaan, yang dilakukan di lapangan secara langsung, metode pasca pelaksanaan, yang dilakukan setelah pelaksanaan kegiatan inti yakni pemutakhiran data pasca \| 3 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 - 9 Syamsuriana Basri, Radiah, Anita M pelaksanaan. Metode pemberdayaan masyarakat dilakukan dengan bersentuhan secara langsung dengan masyarakat serta kegiatan-kegiatan yang dilakukan oleh masyarakat salah satunya dalam pembuatan gula aren. a. Metode Pra Pelaksanaan Tahap pra pelaksanaan pelatihan yang dilakukan yaitu sebagai berikut: 1) Survei awal Pada tahap survei awal melakukan kunjungan secara langsung ke desa Tompobulu Kecamatan Tompobulu dengan meninjau kondisi alam dan lokasi sasaran program. Kecamatan Tompobulu dengan meninjau kondisi alam dan lokasi sasaran program. 2) Identifikasi potensi dan masalah Pada tahap ini dilakukan identifikasi masalah yang terdapat di desa Tompobulu khususnya pada petani aren yang memproduksi gula merah, seperti teknik pengemasan dan pemasaran masih kurang menarik. 3) Proses dan hasil analisis kebutuhan masyarakat Pada tahap ini tim melaksanakan analisis kebutuhan masyarakat, kebutuhan yang diperoleh yaitu masyarakat khususnya petani aren membutuhkan pengetahuan dan kreasi dalam mengolah dan mengemas produk gula merah agar terlihat menarik dan berdaya saing tinggi di era digital. 4) Penyelarasan dengan kebijakan pembangunan Pada tahap penyelarasan dengan kebijakan pembangunan, tim pelaksana melakukan program ini di lokasi yang jauh dari perkotaan karena perjalanan menuju lokasi juga masih kurang bagus. Metode 5) Penyusunan program bersama masyarakat Pada tahap ini, tim pelaksana melakukan pertemuan bersama masyarakat sasaran guna menyusun program yang akan dilakukan, berikut susunan kegiatannya: 5) Penyusunan program bersama masyarakat Pada tahap ini, tim pelaksana melakukan pertemuan bersama masyarakat sasaran guna menyusun program yang akan dilakukan, berikut susunan kegiatannya: 5) Penyusunan program bersama masyarakat Pada tahap ini, tim pelaksana melakukan pertemuan bersama masyarakat sasaran guna menyusun program yang akan dilakukan, berikut susunan kegiatannya: G b 1 Al P l k K i 5) Penyusunan program bersama masyarakat Pada tahap ini, tim pelaksana melakukan pertemuan bersama masyarakat sasara guna menyusun program yang akan dilakukan, berikut susunan kegiatannya: Gambar 1. Alur Pelaksanaan Kegiatan guna menyusun program yang akan dilakukan, berikut susunan kegiatannya: Gambar 1. Alur Pelaksanaan Kegiatan 6) Penetapan khalayak sasaran Pada tahap ini tim pelaksana bersama kepala desa serta dosen pendamping menetapkan khalayak sasaran, dengan kriteria khalayak sasaran yaitu yang masih kurang produktif, agar dapat ditingkatkan teknik pengemasan dan pemasarannya. 6) Penetapan khalayak sasaran Pada tahap ini tim pelaksana bersama kepala desa serta dosen pendamping menetapkan khalayak sasaran, dengan kriteria khalayak sasaran yaitu yang masih kurang produktif, agar dapat ditingkatkan teknik pengemasan dan pemasarannya. 7) Pengukuran indikator Pada tahap ini tim membuat instrumen indikator keberhasilan program yang akan digunakan pasca pemberdayaan petani aren di desa Tompobulu. b. Metode Pelaksanaan 1) Pelaksanaan program Pada tahap ini, mencakup 3 hal yaitu tahap pelaksanaan, perintisan kemitraan dan penguatan jejaring koordinasi dan komunikasi antar lembaga desa Tompobulu. \| 4 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 – 9 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 – 9 Syamsuriana Basri, Radiah, Anita M Dengan adanya tahap ini, tujuan yang akan dilaksanakan yaitu pemberdayaan desa Tompobulu khususnya pada petani aren dalam pembuatan gula merah dengan Dengan adanya tahap ini, tujuan yang akan dilaksanakan yaitu pemberdayaan desa Dengan adanya tahap ini, tujuan yang akan dilaksanakan yaitu pemberdayaan desa Tompobulu khususnya pada petani aren dalam pembuatan gula merah dengan Dengan adanya tahap ini, tujuan yang akan dilaksanakan yaitu pemberdayaan desa Tompobulu khususnya pada petani aren dalam pembuatan gula merah dengan berbagai bentuk. g y p j y g y p y Tompobulu khususnya pada petani aren dalam pembuatan gula merah dengan berbagai bentuk. Tompobulu khususnya pada petani aren dalam pembuatan gula merah dengan berbagai bentuk. Metode 2) Penguatan dukungan desa Pada tahap ini, tim melaksanakan pertemuan dengan kepala desa untuk keberlanjutan program pemberdayaan petani aren dalam pembuatan gula merah ini agar mendapatkan dukungan positif dari desa Tompobulu. 3) Langkah-langkah pembinaan khalayak sasaran Pada tahapan ini, tim melakukan beberapa metode yang akan diberikan kepada khalayak sasaran, seperti metode pembuatan gula merah dengan berbagai bentuk, metode pengemasan yang menarik minat masyarakat luar, dan metode pemasaran dengan menggunakan teknologi di era digital. 4) Analisis tingkat keberhasilan program Pada tahap ini tim melakukan analisis terhadap produk yang telah dihasilkan agar program ini dapat mencapai keberhasilan yang maksimal. 5) Penguatan jejaring koordinasi dan komunikasi antar kelembagaan Pada tahap ini, tim melakukan pengembangan serta penguatan jejaring koordinasi agar program ini dapat berlanjut dengan baik dan berhasil di desa Tompobulu. . Metode Pasca Pelaksanaan 1) Monitoring dan evaluasi Pada tahap monitoring dan evaluasi ini untuk melihat perkembangan dan mengetahui masalah yang kemungkinan akan terjadi kedepannya, serta mencari solusi atas masalah yang kemungkinan terjadi agar program ini dapat mencapai keberhasilan. 2) Lokakarya hasil Lokakarya hasil yaitu presentasi hasil pelaksanaan program yang akan dilaksanakan dengan mengundang berbagai perangkat desa, masyarakat setempat serta pihak kampus. Lokakarya ini bertujuan agar masyarakat petani aren bisa lebih produktif dalam mengolah aren menjadi gula merah. 3) Pelaporan Pelaporan dilakukan ketika program telah selesai dilaksanakan, laporan ditujukan kepada KEMDIKBUD selaku pelaksana program PHP2D. 4) Pemutakhiran data sasaran Pada tahap ini, dilakukan pemutakhiran data sasaran pasca 2 bulan pelaksanaan program dengan menggunakan form yang telah disediakan. Pelaksanaan Kegiatan PHP2D Kegiatan PHP2D ini bertujuan untuk meningkatkan pengetahuan petani aren di desa Tompobulu, dengan adanya kegiatan ini petani aren diberi pemahaman mengenai teknologi digital dalam proses pengemasan produk dan pemasaran produk gula merah. \| 5 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 - 9 Syamsuriana Basri, Radiah, Anita M Tim PHP2D melakukan pembinaan serta pemberian pengetahuan kepada masyarakat mengenai inovasi bentuk gula merah. Kegiatan PHP2D ini berlangsung selama 4 bulan mulai pada bulan Agustus hingga bulan November tahun 2021. Kegiatan pembukaan dan sosialisasi PHP2D dilaksanakan pada tanggal 28 Agustus 2021 di aula kantor desa Tompobulu, Kecamatan Tompobulu. Pada kegiatan berikutnya, dilakukan pembangunan rumah produksi gula merah yang bertempat di desa Tompobulu. Lokasi kegiatan PHP2D cukup jauh dari pemukiman masyarakat, akan tetapi dalam proses pembuatan produk gula merah cukup mudah karena pohon aren dekat dari rumah produksi yang dibangun oleh Tim PHP2D HIMAPSIKA FKIP UMMA. Gambar 2. Rumah Produksi Yang Telah Terbangun Dalam pelaksanaan kegiatan, Tim PHP2D bekerjasama dengan organisasi karang runa desa Tompobulu untuk membuat produk serta memasarkan produk, dimana jenis oduk yang dihasilkan adalah inovasi bentuk gula merah, gula semut, tenteng (gula acang), dan gula merah cair. Beberapa produk di atas merupakan ide atau saran dari tiap anggota Tim PHP2D HIMAPSIKA FKIP UMMA. Gambar 2. Rumah Produksi Yang Telah Terbangun Gambar 2. Rumah Produksi Yang Telah Terbangun Gambar 2. Rumah Produksi Yang Telah Terbangun Dalam pelaksanaan kegiatan, Tim PHP2D bekerjasama dengan organisasi karang taruna desa Tompobulu untuk membuat produk serta memasarkan produk, dimana jenis produk yang dihasilkan adalah inovasi bentuk gula merah, gula semut, tenteng (gula kacang), dan gula merah cair. Beberapa produk di atas merupakan ide atau saran dari setiap anggota Tim PHP2D HIMAPSIKA FKIP UMMA. Luaran yang Dihasilkan Salah satu luaran yang tercapai yaitu berdirinya rumah produksi dari kayu di dusun Tujua desa Tompobulu sehingga tercapainya luaran yang lain seperti, pembuatan produk inovasi bentuk gula merah, gula semut, gula merah cair, tenteng (gula kacang). Adanya kemasan yang cukup menarik dan tahan lama untuk produk-produk gula merah yang dibuat, tersedia web penjualan produk secara online (Tokopedia, Shopee, Lazada, Bukalapak, dan Tokko), Facebook, Whatshapp, Instagram, Blog, pembuatan profil dan poster hasil pelaksanaan PHP2D, terpublikasinya kegiatan-kegiatan melalui media online dan media cetak, terbentuknya buku panduan produk gula merah serta artikel pada jurnal pengabdian masyarakat. y Gambar 3. Produk Gula Kacang (Tenteng) Gambar 3. Produk Gula Kacang (Tenteng) \| 6 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 – 9 Syamsuriana Basri, Radiah, Anita M Gambar 4. Produk Gula Merah Cair Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 – 9 Syamsuriana Basri, Radiah, Anita M Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 – 9 S i B i R di h A it M Syamsuriana Basri, Radiah, Anita M Syamsuriana Basri, Radiah, Anita M Gambar 4. Produk Gula Merah Cair Gambar 4. Produk Gula Merah Cair Pengemasan Pengemasan sangat penting dalam memasarkan produk, sebab pengemasan berfungsi untuk memudahkan penanganan produk, penyaluran atau distribusi, promosi dan menjadi daya tarik bagi konsumen. Keterangan dan informasi terkait produk seperti berat bersih, kandungan bahan serta keterangan kadaluarsa harus dicantumkan pada kemasan. Keterangan terkait produk biasanya dicantumkan pada kemasan sekunder yaitu yang tidak langsung bersentuhan produk tetapi terletak pada bagian luar kemasan primer. Kemasan tersier digunakan untuk distribusi jarak jauh dimana dapat memuat beberapa kemasan sekunder (EX-SCHOOL, n.d.). Beberapa persyaratan dalam pengemasan produk diantaranya saat pendistribusian kemasan dapat menjaga produk dari pengaruh lingkungan, misalnya kemasan dapat menahan H2O yang masuk melalui pori-pori sehingga gula tidak lembek, pelabelan tercetak dengan jelas sehingga produk harus memiliki kemasan yang menjadi media penandaan terhadap barang, Berdesain atraktif serta kemasan mudah dibuka dan mudah ditutup kembali, melalui kemasan yang menarik akan dengan mudah mempromosikan barang jika dipajang pada etalase toko, kios, swalayan, serta bahan kemasan sebaiknya ramah lingkungan dan dapat di daur ulang. Analisis Tingkat Keberhasilan Untuk mengukur tingkat keberhasilan dalam kegiatan ini, terkait produk yang dihasilkan serta peningkatan penjualan juga disebarkan kuesioner pada responden sebanyak 12 orang mengenai tingkat pengetahuan peserta kegiatan. Kuesioner diberikan sebelum kegiatan dan setelah kegiatan berlangsung, diperoleh data untuk setiap pernyataan yang dapat ditunjukkan pada diagram di bawah ini: Diagram 1. Analisis Tingkat Keberhasilan Setiap Pernyataan Kuesioner Sementara itu, dianalisis pula rata-rata persentasi pre test sebesar 31,67% dan post est sebesar 97,78% dengan peningkatan persentasi pengetahuan sebesar 61,11%. Data dapa dilihat pada diagram di bawah ini: Diagram 1. Analisis Tingkat Keberhasilan Setiap Pernyataan Kuesioner Sementara itu, dianalisis pula rata-rata persentasi pre test sebesar 31,67% dan post test sebesar 97,78% dengan peningkatan persentasi pengetahuan sebesar 61,11%. Data dapa dilihat pada diagram di bawah ini: Di 2 A li i Ti k K b h il P i k P i P h S P Di 1 A li i Ti k K b h il S i P K i Diagram 1. Analisis Tingkat Keberhasilan Setiap Pernyataan Kuesioner Diagram 1. Analisis Tingkat Keberhasilan Setiap Pernyataan Kuesioner Sementara itu, dianalisis pula rata-rata persentasi pre test sebesar 31,67% dan post test sebesar 97,78% dengan peningkatan persentasi pengetahuan sebesar 61,11%. Data dapa dilihat pada diagram di bawah ini: Sementara itu, dianalisis pula rata-rata persentasi pre test sebesar 31,67% dan post test sebesar 97,78% dengan peningkatan persentasi pengetahuan sebesar 61,11%. Data dapa dilihat pada diagram di bawah ini: Diagram 2. Analisis Tingkat Keberhasilan Peningkatan Persentasi Pengetahuan Serta Pre Test Dan Post Test Diagram 2. Analisis Tingkat Keberhasilan Peningkatan Persentasi Pengetahuan Serta Pre Test Dan Post Test Pemasaran Pemasaran produk merupakan hal penting dalam memperoleh laba pada pelaku bisnis. Faktor- faktor yang penting dalam pemasaran produk yaitu tujuan pemasaran, persaingan produk, kebutuhan pasar, jenis produk, serta berkaitan dengan produk seperti kualitas, kemasan dan harga jualnya. Ada beberapa yang harus diperhatikan mengenai produk yaitu kualitas sesuai keinginan konsumen, kuantitas sesuai pemenuhan kebutuhan pasar, inovasi produk, produk memiliki niai tambah, dan produk yang mempunyai produksi dan tingkat kelarisan jangka panjang. Beberapa hal yang mesti dipertimbangkan adalah harga pokok produksi, penyesuaian harga pasar yang ditargetkan dengan produk, membandingkan harga dengan produk sejenis yang ada di pasar. Selain itu kita juga harus mempertimbangkan penetapan tempat menjual produk diantaranya mudah dijangkau oleh konsumen, menyiapkan fasilitas yang dapat memuaskan konsumen serta mempunyai nilai tambah pada pemasaran misalnya dengan pemasaran online. Tentunya setelah memenuhi keseluruhan pertimbanagn di atas perlu dipertimbangkan teknik pemasaran yaitu promosi, hal ini dapat dilakukan melalui berbagai media sosial seperti website, blog pemasaran face to face ke berbagai instansi di lingkungan sekitar. Hal ini dilakukan untuk meningkatkan penjualan produk. \| 7 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 - 9 Syamsuriana Basri, Radiah, Anita M Kesimpulan Kegiatan ini dilaksanakan di desa Tompobulu Kecamatan Tompobulu oleh tim PHP2D. Tim PHP2D memberikan pembinaan kepada masyarakat terkait pengemasan produk dan pemasaran produk gula merah, dengan adanya kegiatan ini, masyarakat dapat lebih mengetahui tentang teknologi digital yang digunakan dalam meningkatkan perekonomian masyarakat di desa Tompobulu. Luaran dari kegiatan pengabdian masyarakat ini diantaranya, pembuatan produk inovasi bentuk gula merah, gula semut, gula merah cair, tenteng (gula kacang), terbentuknya kemasan yang menarik dan tahan lama untuk produk-produk gula merah yang dibuat, tersedia web penjualan produk secara online (Tokopedia, Shopee, Lazada, Bukalapak, dan Tokko), pembuatan profil dan poster hasil pelaksanaan PHP2D, terpublikasinya kegiatan-kegiatan melalui media online dan media cetak, terbentuknya buku panduan produk gula merah serta jurnal kegiatan pengabdian masyarakat serta terciptanya rumah produksi. Ucapan Terima Kasih Tim PHP2D HIMAPSIKA FKIP UMMA mengucapkan terimakasih kepada pihak KEMDIBUDRISTEK yang telah memberikan kesempatan kepada kami dalam \| 8 Jurnal Pengabdian Masyarakat As-Salam (JPMA) Vol. 2 No. 1 Januari - Juni 2022: 1 – 9 Syamsuriana Basri, Radiah, Anita M menjalankan Program Holistik Pembinaan dan Pemberdayaan Desa (PHP2D) dengan judul “Pemberdayaan Petani Aren Di Desa Tompobulu Kecamatan Tompobulu Dalam Pembuatan Gula Merah Menjadi Komoditas Usaha Di Era Digital”. Tim PHP2D juga sangat berterimakasih kepada pihak desa Tompobulu yang telah menerima kami dengan tangan terbuka untuk melaksanakan program ini. Selanjutnya Tim PHP2D HIMAPSIKA FKIP UMMA berterimakasih kepada pihak kampus yang telah banyak berkontribusi dalam kegiatan kami, utamanya memberikan peluang kepada mahasiswa untuk mengembangkan minat dan bakatnya dalam bidang pengabdian masyarakat. Selanjutnya, Tim PHP2D juga sangat berterimakasih kepada Dosen Pendamping yang senantiasa mendampingi kami di lokasi kegiatan serta memberi saran serta masukan yang sangat menyokong terlaksananya PHP2D ini, selanjutnya Tim PHP2D HIMAPSIKA FKIP UMMA berterimakasih kepada masyarakat desa Tompobulu yang telah meluangkan waktunya dalam mensukseskan program PHP2D ini. Yang terakhir, Tim PHP2D juga berterimakasih kepada para pengurus HIMAPSIKA FKIP UMMA karena dengan adanya Himpunan Mahasiswa Pendidikan Fisika, dapat menjadi wadah dalam setiap kegiatan terkhusus pada kegiatan PHP2D. menjalankan Program Holistik Pembinaan dan Pemberdayaan Desa (PHP2D) dengan judul “Pemberdayaan Petani Aren Di Desa Tompobulu Kecamatan Tompobulu Dalam Pembuatan Gula Merah Menjadi Komoditas Usaha Di Era Digital”. Tim PHP2D juga sangat berterimakasih kepada pihak desa Tompobulu yang telah menerima kami dengan tangan terbuka untuk melaksanakan program ini. Selanjutnya Tim PHP2D HIMAPSIKA FKIP UMMA berterimakasih kepada pihak kampus yang telah banyak berkontribusi dalam kegiatan kami, utamanya memberikan peluang kepada mahasiswa untuk mengembangkan minat dan bakatnya dalam bidang pengabdian masyarakat. Selanjutnya, Tim PHP2D juga sangat berterimakasih kepada Dosen Pendamping yang senantiasa mendampingi kami di lokasi kegiatan serta memberi saran serta masukan yang sangat menyokong terlaksananya PHP2D ini, selanjutnya Tim PHP2D HIMAPSIKA FKIP UMMA berterimakasih kepada masyarakat desa Tompobulu yang telah meluangkan waktunya dalam mensukseskan program PHP2D ini. Yang terakhir, Tim PHP2D juga berterimakasih kepada para pengurus HIMAPSIKA FKIP UMMA karena dengan adanya Himpunan Mahasiswa Pendidikan Fisika, dapat menjadi wadah dalam setiap kegiatan terkhusus pada kegiatan PHP2D. Daftar Pustaka Accurate. (n.d.). Proses Produksi: Pengertian, Jenis, Tahapan dan Karakteristiknya. Retrieved November 7, 2021, from https://accurate.id/marketing- manajemen/proses-produksi/ EX-SCHOOL. (n.d.). Pengemasan Dan Pemasaran Pengelolahan Produk Pangan - Your All in One Event Partner Solution. Retrieved November 7, 2021, from https://ex- school.com/artikel/pengemasan-dan-pemasaran-pengelolahan-produk-pangan Lalisang, I. (2018). Pemberdayaan Petani Aren Melalui Diversivikasi Produk Olahan Air Nira. Jurnal Pengabdian Kepada Masyarakat, 23(4), 415. https://doi.org/10.24114/jpkm.v23i4.8938 Lempang, M. (2012). Pohon Aren dan Manfaat Produksinya. Info Teknis EBONI, 9(1), 37–54. http://ejournal.forda-mof.org/ejournal- litbang/index.php/buleboni/article/view/4993/4413 Perkebunan, D. (2015). Prospek Pengembangan Tanaman Aren (Arenga pinnata Merr) Mendukung Kebutuhan Bioetanol di Indonesia. Perspektif: Review Penelitian Tanaman Industri, 9(1), 36–46. https://doi.org/10.21082/p.v9n1.2010 Purnamasari, I., Soetoro, Yuroh, Fitri. (2018). Jurnal Ilmiah Mahasiswa AGROINFO GALUH, 4(2), 718–722. https://jurnal.unigal.ac.id/index.php/agroinfogaluh/article/download/1625/1308 Purnamasari, I., Soetoro, Yuroh, Fitri. (2018). Jurnal Ilmiah Mahasiswa AGROINFO GALUH, 4(2), 718–722. https://jurnal.unigal.ac.id/index.php/agroinfogaluh/article/download/1625/1308 Waani, F., & Mangindaan, J. V. (2021). Analisis Tingkat Kesejaheraan Petani Gula Aren di Desa Tondei Kecamatan Motoling Barat Kabupaten Minahasa Selatan. Productivity, 2(1), 58–62. https://ejournal.unsrat.ac.id/index.php/productivity/article/view/32867 Waani, F., & Mangindaan, J. V. (2021). Analisis Tingkat Kesejaheraan Petani Gula Aren di Desa Tondei Kecamatan Motoling Barat Kabupaten Minahasa Selatan. Productivity, 2(1), 58–62. https://ejournal.unsrat.ac.id/index.php/productivity/article/view/32867 Wikipedia bahasa Indonesia, ensiklopedia bebas. (2021). Tompobulu, Tompobulu, Maros. https://id.wikipedia.org/wiki/Tompobulu,_Tompobulu,_Maros Wikipedia bahasa Indonesia, ensiklopedia bebas. (2021). Tompobulu, Tompobulu, Maros. https://id.wikipedia.org/wiki/Tompobulu,_Tompobulu,_Maros \| 9
https://openalex.org/W3120200263	https://researchonline.gcu.ac.uk/ws/files/42976742/Garcia_Vega_L._et_al_2020_Connexins_and_the_epithelial_tissue_barrier_a_focus_on_Connexin_26.pdf	English	null	Connexins and the Epithelial Tissue Barrier: A Focus on Connexin 26	Biology	2,021	cc-by	16,011	Connexins and the epithelial tissue barrier: a focus on Connexin 26 García-Vega, Laura; O'Shaughnessy, Erin M.; Alboulshi, Ahmad; Martin, Patricia E. Connexins and the epithelial tissue barrier: a focus on Connexin 26 G í V L O Sh h E i M Alb l hi Ah d M i P i Connexins and the epithelial tissue barrier: a focus on Connexin 26 García-Vega, Laura; O'Shaughnessy, Erin M.; Alboulshi, Ahmad; Martin, Pa Document Version Publisher's PDF, also known as Version of record Link to publication in ResearchOnline Citation for published version (Harvard): García-Vega, L, O'Shaughnessy, EM, Alboulshi, A & Martin, PE 2021, 'Connexins and the epithelial tissue barrier: a focus on Connexin 26', Biology, vol. 10, no. 1, 59, pp. 1-18. https://doi.org/10.3390/biology10010059 Citation for published version (Harvard): García-Vega, L, O'Shaughnessy, EM, Alboulshi, A & Martin, PE 2021, 'Connexins and the epithelial tissue barrier: a focus on Connexin 26', Biology, vol. 10, no. 1, 59, pp. 1-18. https://doi.org/10.3390/biology10010059 Citation: Garcia-Vega, L.; O’Shaughnessy, E.M.; Albuloushi, A.; Martin, P.E. Connexins and the Epithelial Tissue Barrier: A Focus on Connexin 26. Biology 2021, 10, 59. https://doi.org/10.3390/biology 10010059 Received: 21 December 2020 Accepted: 12 January 2021 Published: 14 January 2021 Keywords: epithelial tissue; connexin; gap junction; purinergic signaling Publisher’s Note: MDPI stays neu- tral with regard to jurisdictional clai- ms in published maps and institutio- nal afﬁliations. biology biology biology Review ra Garcia-Vega, Erin M. O’Shaughnessy, Ahmad Albuloushi and Patricia E. Martin * Department of Biological and Biomedical Sciences, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow G4 0BA, UK; v.lauramaria.garcia@gmail.com (L.G.-V.); Erinoshaughnessy@rocketmail.com (E.M.O.); albuloushi87@gmail.com (A.A.) * Correspondence: patricia.martin@gcu.ac.uk Simple Summary: Tissues that face the external environment are known as ‘epithelial tissue’ and form barriers between different body compartments. This includes the outer layer of the skin, linings of the intestine and airways that project into the lumen connecting with the external environment, and the cornea of the eye. These tissues do not have a direct blood supply and are dependent on exchange of regulatory molecules between cells to ensure co-ordination of tissue events. Proteins known as connexins form channels linking cells directly and permit exchange of small regulatory signals. A range of environmental stimuli can dysregulate the level of connexin proteins and or protein function within the epithelia, leading to pathologies including non-healing wounds. Mutations in these proteins are linked with hearing loss, skin and eye disorders of differing severity. As such, connexins emerge as prime therapeutic targets with several agents currently in clinical trials. This review outlines the role of connexins in epithelial tissue and how their dysregulation contributes to pathological pathways. Abstract: Epithelial tissue responds rapidly to environmental triggers and is constantly renewed. This tissue is also highly accessible for therapeutic targeting. This review highlights the role of connexin mediated communication in avascular epithelial tissue. These proteins form communication conduits with the extracellular space (hemichannels) and between neighboring cells (gap junctions). Regulated exchange of small metabolites less than 1kDa aide the co-ordination of cellular activities and in spatial communication compartments segregating tissue networks. Dysregulation of connexin expression and function has profound impact on physiological processes in epithelial tissue including wound healing. Connexin 26, one of the smallest connexins, is expressed in diverse epithelial tissue and mutations in this protein are associated with hearing loss, skin and eye conditions of differing severity. The functional consequences of dysregulated connexin activity is discussed and the development of connexin targeted therapeutic strategies highlighted. Citation: Garcia-Vega, L.; O’Shaughnessy, E.M.; Albuloushi, A.; Martin, P.E. Connexins and the Epithelial Tissue Barrier: A Focus on Connexin 26. Biology 2021, 10, 59. https://doi.org/10.3390/biology 10010059 General rights C i ht d General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. Take down policy If you believe that this document breaches copyright please view our takedown policy at https://edshare.gcu.ac.uk/id/eprint/5179 for details of how to contact us. Download date: 24. Oct. 2024 Download date: 24. Oct. 2024 biology 1. Introduction Epithelial tissues line the outer surface of organs and the inner surface of cavities such as the digestive tract and secretory glands, where they project into the lumen connect- ing with the external environment. Thus, the epithelium separates tissue compartments forming barriers, regulates molecule exchange between those compartments and protects from biological, physical and chemical aggressions [1]. The integrity of the epithelium is maintained by intercellular junctional complexes composed of tight junctions (TJs), ad- herens junctions (AJs), and desmosomes [2,3]. These junctions aide in the formation of tight seals or barriers between the external environment. Since the epithelium is avascular, it is believed that the delivery and co-ordination of intercellular signals directly between cell layers is conducted via gap junction intercellular communication channels (GJIC) and paracrine signalling pathways [4,5]. Copyright: © 2021 by the authors. Li- censee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and con- ditions of the Creative Commons At- tribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). https://www.mdpi.com/journal/biology Biology 2021, 10, 59. https://doi.org/10.3390/biology10010059 2 of 18 aining Biology 2021, 10, 59 2 of 18 aining Connexins (CXs) are the structural building blocks of gap junctions, four-transmembrane domain spanning proteins with intracellular N- and C-tails (Figure 1). In humans, con- nexins are encoded by a multigene family containing twenty-one members classiﬁed by their molecular weight ranging from 23 to 62 kDa in size (CX23-CX62) [6]. Six connexins oligomerise forming hemichannels or connexons linking the cytoplasm with the extracellu- lar space. Two connexons from adjacent cells connect head-to-head to form an axial channel or gap junction, thereby allowing the interchange of ions and water-soluble molecules with a relative molecular mass up to 1.2 kDa. They play a central role in control of tissue development, homeostasis and a diverse range of cellular functions [7–10]. y g g g Six connexins oligomerise forming hemichannels or connexons with the extracellular space. Two connexons from adjacent cells co orm an axial channel or gap junction, thereby allowing the intercha oluble molecules with a relative molecular mass up to 1.2 kDa. T n control of tissue development, homeostasis and a diverse range o 0]. igure 1. Topology of Connexin 26 and examples of mutations in CX26 a dysplasia and hearing loss. N amino terminus; E1 extracellular loop 1; E2 Figure 1. Topology of Connexin 26 and examples of mutations in CX26 associated with epidermal dysplasia and hearing loss. igure 1. Topology of Connexin 26 and examples of mutations in CX26 a ysplasia and hearing loss N amino terminus; E1 extracellular loop 1; E2 Figure 1. Topology of Connexin 26 and examples of mutations in CX26 associated with epidermal dysplasia and hearing loss. N amino terminus; E1 extracellular loop 1; E2 extracellular loop 2; TM transmembrane domain. Mutations in red indicate ‘Class 2′ black, ‘Class 3′ and blue ‘Class 4′ mutations (see Section 2.2). igure 1. Topology of Connexin 26 and examples of mutations in CX26 a ysplasia and hearing loss N amino terminus; E1 extracellular loop 1; E2 Figure 1. Topology of Connexin 26 and examples of mutations in CX26 associated with epidermal dysplasia and hearing loss. N amino terminus; E1 extracellular loop 1; E2 extracellular loop 2; TM transmembrane domain. Mutations in red indicate ‘Class 2′ black, ‘Class 3′ and blue ‘Class 4′ mutations (see Section 2.2). 1. Introduction N amino terminus; E1 extracellular loop 1; E2 extracellular loop 2; TM transmembrane domain. Mutations in red indicate ‘Class 2′ black, ‘Class 3′ and blue ‘Class 4′ mutations (see Section 2.2). y p g ansmembrane domain. Mut The Epithelium and the Tissue Barrier mutations (see Section 2.2). The Epithelium and the Tissue Barrier The structure of epithelial tissue depends on its function. In ge re classified by their stratification, being simple, transitional pithelium composes surface-forming epithelia in contact with th e.g., epithelium of nephric tubules, trachea and secretory gla pithelium has some cells in contact with the basement memb orming (e.g., epithelium of urinary bladder). Stratified epithelium ayer, in contact with the basement membrane and the only cells w uperficial stratum, where the cells undergo two process eratinisation non-cornification (e.g., epithelium of oral cavity, o eratinisation and cornification (e g epidermis nail plate) [1] The The structure of epithelial tissue depends on its function. In general, epithelial tis- sues are classiﬁed by their stratiﬁcation, being simple, transitional or stratiﬁed. Simple epithelium composes surface-forming epithelia in contact with the basement membrane (e.g., epithelium of nephric tubules, trachea and secretory glands). The transitional ep- ithelium has some cells in contact with the basement membrane and are surface-forming (e.g., epithelium of urinary bladder). Stratiﬁed epithelium is composed of a basal layer, in contact with the basement membrane and the only cells which can divide, and a su- perﬁcial stratum, where the cells undergo two processes of differentiation: keratinisation non-corniﬁcation (e.g., epithelium of oral cavity, oesophagus, vagina) or keratinisation and corniﬁcation (e.g., epidermis, nail plate) [1]. The epithelium also plays a central role in body ﬂuid secretions including heat and emotional responses via eccrine, apocrine and sebaceous glandular secretions that are tightly regulated and express a range of connexin proteins [11–13]. Skin appendages including the hair follicles and nails also extend from the stratiﬁed epidermis where connexins play a signiﬁcant role in the hair follicle cycle and reviewed elsewhere [13,14]. This review will focus primarily on examples the role of CX26 and CX43 in epithelial tissue including stratiﬁed epithelium such as the epidermis and cornea and simple epithelium including the lining of the respiratory and intestinal tracts. Table 1 summarises the expression proﬁle of CX26 in human tissue. Biology 2021, 10, 59 3 of 18 Table 1. Expression of CX26 in human tissue. System or Organ Tissue or Structure Cell Type References Skin Epidermis Keratinocyte [13,15] Spinous layer Granular layer Appendages Sebaceous gland [13,15] Eccrine sweat gland and ducts Hair follicle. y p g ansmembrane domain. Mut The Epithelium and the Tissue Barrier Outer root sheet Inner root sheet: Henley and Huxlye Hair shaft: Cortex and Medulla Matrix Brain Occipital cortex Astrocyte (glia) [16] Diencephalon Leptomeningeal cells Medulla oblongata Caudate nucleus Digestive system Stomach Epithelial cells [17] Small intestine Muscularis externa cells Colon Endocrine and exocrine glands Salivary glands Acinar cells [18–20] Pancreas (serous acini) Beta cells Pituitary (adenohypophysis) Parathyroid Principal cells Thyroid (follicles) Preputial ducts Lacrimal (serous acini) Parotid (serous acini) Liver Periportal hepatocytes Kidney Proximal tubule [21] Reproductive system Endometrium (luminal epith.) Basal glandular cells [22,23] Preimplantation embryo Blastocysts Placenta Syncytiotrophoblasts Myometrium Uterine myocytes Endocrine system Adrenal cortex [24] Ear Spiral limbus Fibrocytes [25] Spiral ligament Striavascularis Cochlea Claudius cells Hensen’s cells Inner sulcus cells Lung Alveolar epithelium [26] Table 1. Expression of CX26 in human tissue. 2. Connexins and the Skin The skin is the human body’s largest organ and is composed of three layers: the hypodermis, dermis and epidermis. The hypodermis and the dermis are connective tissues, while the epidermis is epidermal tissue composed mainly of epithelial cells known as keratinocytes. Keratinocytes are subclassiﬁed into four layers: basal (proliferative cells), spinous, granular and corneous (anucleated squamous cells) [27]. The skin provides four different types of barrier: physical, redox, bio-chemical (innate immunity) and the adaptive immune barrier. The physical barrier consists of protein enriched cells and is mainly located in the stratum corneum and the granular layer, with strong adhesive interactions via tight, adheren and gap junctions. The bio-chemical or antimicrobial barrier consists of lipids, acids, lysozymes and antimicrobial peptides. These two barriers protect from Biology 2021, 10, 59 4 of 18 crobial external aggressions (outside-inside barrier), while also avoiding loss of water and solutes (inside-outside barrier) [28,29] (Figure 2). protect from external aggressions (outside-inside barrier), while also avoiding loss of water and solutes (inside-outside barrier) [28,29] (Figure 2). Figure 2. Structure of the epidermis indicating connexin expression profile and barriers. Figure 2. Structure of the epidermis indicating connexin expression proﬁle and barriers. Figure 2. Structure of the epidermis indicating connexin expression profile and barriers. Figure 2. Structure of the epidermis indicating connexin expression proﬁle and barriers. The epidermis is composed by four layers of keratinocytes at different stages of differentiation and connexin pattern expression. The epidermis is a two sided barrier: the outside-inside barrier protects from environmental aggression, while inside-outside b i t t f t l The epidermis is composed by four layers of keratinocytes at different stages of differentiation and connexin pattern expression. The epidermis is a two sided barrier: the outside-inside barrier protects from environmental aggression, while inside-outside barrier protects from water loss. barrier protects from water loss. The epidermis, like all other stratified epithelial tissues, is avascular so gap junctions play an important role in cell-to-cell communication and coordination. Up to 10 different connexins are differentially expressed throughout the epidermis, each presenting a characteristic expression profile dependent on the species and conditions. These Connexin profiles allow the establishment of specific gap junction communication compartments in the different strata. Alteration of connexin activity and compatibility may provoke problems in keratinocyte differentiation [5,30,31]. 2. Connexins and the Skin Several studies have demonstrated that connexins are involved in skin conditions such as chronic non-healing wounds, psoriasis d f ll l d k d The epidermis, like all other stratiﬁed epithelial tissues, is avascular so gap junctions play an important role in cell-to-cell communication and coordination. Up to 10 different connexins are differentially expressed throughout the epidermis, each presenting a char- acteristic expression proﬁle dependent on the species and conditions. These Connexin proﬁles allow the establishment of speciﬁc gap junction communication compartments in the different strata. Alteration of connexin activity and compatibility may provoke problems in keratinocyte differentiation [5,30,31]. Several studies have demonstrated that connexins are involved in skin conditions such as chronic non-healing wounds, psoriasis and a variety of genetically related skin syndromes (e.g., [32–34]). and a variety of genetically related skin syndromes (e.g., [32–34]). Within normal healthy human skin CX30.3, CX31 and CX43, and at lower levels CX26, C31.1, CX40 and CX45 are expressed in the granular layer. In the spinous layer, CX26, CX30, CX30.3, CX31, CX31.1, CX40, CX43 and CX45 are expressed with CX43 the predominant CX in the basal layer. [5,30,35] (Figure 2). Cx26 is expressed at low levels in proliferating keratinocytes in tissue culture and readily expressed in stratified 3D d l l b h y g y y ( g ) Within normal healthy human skin CX30.3, CX31 and CX43, and at lower levels CX26, C31.1, CX40 and CX45 are expressed in the granular layer. In the spinous layer, CX26, CX30, CX30.3, CX31, CX31.1, CX40, CX43 and CX45 are expressed with CX43 the predominant CX in the basal layer [5,30,35] (Figure 2). Cx26 is expressed at low levels in proliferating keratinocytes in tissue culture and readily expressed in stratiﬁed 3D epidermal cultures by immunocytochemistry [36–38]. epidermal cultures by immunocytochem 2.1. Connexin 26, Trafﬁcking and Assembly Entire gap junction plaques are removed from the plasma membrane by the formation of annular gap junctions [4,51] (Figure 3). In addition, CX26 is unique to the connexin family as it does not contain phosphorylation sites in its C-terminal tail that play a signiﬁcant role in protein turnover, particularly well characterised for Cx43 [51]. Nevertheless, CX26 presents a variety of putative post-translational modiﬁcations, including carbamylation [52], hydroxylation, phosphorylation and methylation, some of which happen at sites of deafness-causing mutations and may be associated with CX26 biogenesis and channel function [53,54]. Fur- thermore, hemichannels are normally closed during normal conditions; however, human CX26 hemichannels are an exception as they tend to be open under basal conditions. The 3D molecular structure of CX26 suggests this could be because, in contrast to other species, human CX26 presents an asparagine (uncharged) at amino acid position 159 in place of aspartic acid found in other species [55,56]. Golgi-independent trafficking pathway, possibly providing a means for translation on free ribosomes and an ability to be rapidly translated at site specific plasma membrane locations when required [45–50]. Entire gap junction plaques are removed from the plasma membrane by the formation of annular gap junctions [4,51] (Figure 3). In addition, CX26 is unique to the connexin family as it does not contain phosphorylation sites in its C-terminal tail that play a significant role in protein turnover, particularly well characterised for Cx43 [51]. Nevertheless, CX26 presents a variety of putative post- translational modifications, including carbamylation [52], hydroxylation, phosphorylation and methylation, some of which happen at sites of deafness-causing mutations and may be associated with CX26 biogenesis and channel function [53,54]. Furthermore, hemichannels are normally closed during normal conditions; however, human CX26 hemichannels are an exception as they tend to be open under basal conditions. The 3D molecular structure of CX26 suggests this could be because, in contrast to other species, human CX26 presents an asparagine (uncharged) at amino acid position 159 in place of aspartic acid found in other species [55,56]. Figure 3. Life cycle of CX26: CX26 can be co-translated and trafficked through the secretory route (standard life cycle). It can also be post-translationally incorporated into ER microsomes and trafficked by Golgi-independent pathway (alternative CX26 life cycle). GJIC mediated communication is indicated between cells and paracrine signalling permitting ATP release indicated via the open hemichannels. Figure 3. epidermal cultures by immunocytochem 2.1. Connexin 26, Trafﬁcking and Assembly 2.1. Connexin 26, Trafficking and Assembly CX26, a 26 kDa protein consisting of 226 amino acids, is encoded by the GJβ2 gene, located on Chromosome 13q12.11 in Homo sapiens [39]. The gene is formed by the non- coding exon 1 (160 bp), an intron (3 kb) and exon 2 containing the complete connexin coding region and the subsequent 3′-UTR [40]. The promoter P1 (−128 bp:+2 bp) upstream of exon 1 has a number of transcription regulatory domains including SP1/SP3 and AP1 [39]. CX26 is also responsive to the NFkB transcription factor, which plays a role in inflammation and immunity, as well as in cell proliferation, differentiation and survival [41,42]. Human CX26 has a short C-terminal tail, with only 18 amino acids, this characteristic is relevant because it affects its interactome and post-translational modification, where CX26 interacts with a variety of proteins including those associated CX26, a 26 kDa protein consisting of 226 amino acids, is encoded by the GJβ2 gene, located on Chromosome 13q12.11 in Homo sapiens [39]. The gene is formed by the non- coding exon 1 (160 bp), an intron (3 kb) and exon 2 containing the complete connexin coding region and the subsequent 3′-UTR [40]. The promoter P1 (−128 bp:+2 bp) upstream of exon 1 has a number of transcription regulatory domains including SP1/SP3 and AP1 [39]. CX26 is also responsive to the NFkB transcription factor, which plays a role in inﬂammation and immunity, as well as in cell proliferation, differentiation and survival [41,42]. Human CX26 has a short C-terminal tail, with only 18 amino acids, this characteristic is relevant because it affects its interactome and post-translational modiﬁcation, where CX26 interacts with a variety of proteins including those associated with the tight junction network [20]. Gap Junction assembly depends on the oligomerisation of Connexins to form a closed hexameric Connexon or hemichannel in the ER-Golgi environs, which are then escorted and inserted into the plasma membrane via the microtubule network, in association with motor proteins such as consortin [7,43,44]. Evidence suggests that CX26, and closely related CX30, Biology 2021, 10, 59 5 of 18 ane via 43,44]. 5 of 18 ane via ,43,44]. can also follow an alternative Golgi-independent trafﬁcking pathway, possibly providing a means for translation on free ribosomes and an ability to be rapidly translated at site speciﬁc plasma membrane locations when required [45–50]. epidermal cultures by immunocytochem 2.1. Connexin 26, Trafﬁcking and Assembly Life cycle of CX26: CX26 can be co-translated and trafﬁcked through the secretory route (standard life cycle). It can also be post-translationally incorporated into ER microsomes and traf- ﬁcked by Golgi-independent pathway (alternative CX26 life cycle). GJIC mediated communication is indicated between cells and paracrine signalling permitting ATP release indicated via the open hemichannels. Figure 3. Life cycle of CX26: CX26 can be co-translated and trafficked through the secretory route (standard life cycle). It can also be post-translationally incorporated into ER microsomes and trafficked by Golgi-independent pathway (alternative CX26 life cycle). GJIC mediated communication is indicated between cells and paracrine signalling permitting ATP release indicated via the open hemichannels. Figure 3. Life cycle of CX26: CX26 can be co-translated and trafﬁcked through the secretory route (standard life cycle). It can also be post-translationally incorporated into ER microsomes and traf- ﬁcked by Golgi-independent pathway (alternative CX26 life cycle). GJIC mediated communication is indicated between cells and paracrine signalling permitting ATP release indicated via the open hemichannels. 2.2. The Effects of CX26 Mutations 2.2. The Effects of CX26 Mutations Many diseases have been linked with mutations in connexins, commonly termed connexin channelopathies [57–60]. CX43 is the most abundant connexin in the human skin; however, mutations and dysregulation of CX26, which is expressed at very low levels in healthy human epidermis, are related with skin disease characterised by abnormal keratinisation and hyperproliferation of the stratum corneum. Mutations in CX26 are among the most prevalent mutations associated with inherited non syndromic deafness (see Section 4.1) [61–63]. In addition to deafness, dominant mutations are also linked with a range of skin conditions of differing severity, suggesting a complex interrelationship between functional changes in connexin genotype and the phenotypic outcome [59,64–66] (Figure 1). Other mutations in the beta connexin subgroup including CX31 and CX30 cause similar epidermal dysplasia [59]. Many diseases have been linked with mutations in connexins, commonly termed connexin channelopathies [57–60]. CX43 is the most abundant connexin in the human skin; however, mutations and dysregulation of CX26, which is expressed at very low levels in healthy human epidermis, are related with skin disease characterised by abnormal keratinisation and hyperproliferation of the stratum corneum. Mutations in CX26 are among the most prevalent mutations associated with inherited non syndromic deafness (see Section 4.1) [61–63]. In addition to deafness, dominant mutations are also linked with a range of skin conditions of differing severity, suggesting a complex interrelationship between functional changes in connexin genotype and the phenotypic outcome [59,64–66] (Figure 1). Other mutations in the beta connexin subgroup including CX31 and CX30 cause similar epidermal dysplasia [59]. CX31 and CX30 cause similar epidermal dysplasia [59]. p y p Mutations fall into four main classes. Class 1: trafﬁcked to the plasma membrane with non-functional channels; Class 2: non-functional channels and protein trafﬁcking deﬁciencies; Class 3: mutations associated with ‘leaky’ hemichannels and inﬂammatory skin disease; Class 4: trafﬁcking deﬁciency and cell death, associated with mucositis, in- ﬂammatory disease and deafness. Class 1 mutations tend to be linked with non-syndromic deafness and have limited skin pathology and may be related with heterozygous ad- Biology 2021, 10, 59 6 of 18 vantage (see Section 4.1). Class 2 mutations align with non-inﬂammatory skin disorders such as Bart-Pumphrey and Vohwinkel syndrome and deafness. Vohwinkel syndrome (OMIM#124500) is a non-inﬂammatory disorder caused by CX26 mutations located predom- inantly on the ﬁrst portion of EL1 (e.g., D66H). 2.2. The Effects of CX26 Mutations 2.2. The Effects of CX26 Mutations The disease is characterised by keratodermas with constriction bands around the phalanges, which induces autoamputation of the dig- its [67–69]. Class 3, gain of CX26 function mutations, are associated with inﬂammatory disorders such as Keratitis ichthyosis deafness (KID), Hystrix-like ichthyosis-deafness (HID). KID syndrome (OMIM#148210) is caused by CX26 mutations on the N-terminal tail, the EL1 (e.g., G12R, N14Y, G45E and D50N) [70–72]. In addition to hearing loss, the disease is characterised by: hyperkeratosis of the palms and soles, erythrokeratoderma on the ex- tremities and face, follicular hyperkeratosis, photophobia and corneal vascularisation that ultimately leads to blindness. Patients experience severe and chronic bacterial and fungal skin infections and are susceptible to the development of squamous cell carcinoma [73,74]. The molecular mechanisms underlying the condition likely relate to “leaky” hemichannels, with differing sensitivities to pro-inﬂammatory mediators, and ionic sensitivity including calcium and zinc levels thereby altering channel function [66,75–82]. Several mutations induce lethal phenotypes and are associated with loss of cell viability [83–85]. Recently, we proposed a further Class 4 mutation group associated with hyperkeratosis, mucositis and deafness, where cell model studies revealed cell death and a collapse of the microtubule network, but limited connexin channel function (e.g., F142L, CX31G45E) [86,87]. g Accumulating evidence suggests that, in addition to changes in CX26 trafﬁcking and channel behavior, a key pathological trigger in the diverse CX26 mutations is alteration in CX oligomerization compatibility. Normally, oligomerization is CX subtype speciﬁc with ‘alpha’ and ‘beta’ subgroups being incompatible. As such, CX26 and CX43, critical connexins in epithelial tissue are unable to form heterotypic structures [88,89]. Recent studies report changes in CX26 mutation oligomerization compatibility, allowing aberrant interactions with CX43 with exacerbated hemichannel activity but non-functional gap junction channels [78,86,90], with each mutation uniquely altering the 3D structure in terms of charge, pore size, hydrophobicity, etc. It is also conceivable that altered CX43:CX26 heteromeric channels inﬂuence unique metabolic exchange and inﬂuence asymmetric cell division required for the stratiﬁcation of the epidermis, thereby contributing to the hyperproliferative status of the skin [91]. Further characterisation and understanding of the impact of such aberrant CX signalling is required to enhance understanding of these complex conditions. Interestingly, a recent report by Laird and colleagues suggest that hearing loss caused by CX26 mutations does not depend on any interaction with CX43 [92]. 2.3. The Effects of CX26 Dysregulation Up-regulation of CX26 is a characteristic of hyperproliferative epidermis in physiolog- ical conditions, such as vaginal and buccal epithelium, which shows a high proliferation rate, and pathological conditions, such as psoriatic epidermis, chronic non-healing wounds epidermis and viral warts [93–96]. CX26 expression is also induced during wound healing and skin hyperplasia stimulated by tumor promoters [40]. Transgenic mice over-expressing CX26 in the suprabasal layer developed a hyperproliferative phenotype, providing models for several epidermal human CX26 diseases, such as psoriasis [97]. 3. Connexin 26 and Other Epithelial Tissue: A Link with Heterozygous Advantage 3.1. Connexin 26 in Intestinal Epithelia The intestinal epithelium is lined with a single layer of polarized cells where the tight junction network, located at the interface between the apical and basolateral membranes, plays a pivotal role in maintaining the mucosal barrier and regulating selective paracellular transport [112]. The intestinal connexins display cell type-speciﬁc expression patterns, delineating physiological compartments with speciﬁc functions. Up to 11 different isoforms are expressed in the intestinal system: CX26, CX32, CX37 and CX43 are notably expressed in the epithelial cells of the small intestine and colon [17]. CX26-related GJIC plays a role in the maintaining epithelial barrier function by affecting the production of TJ proteins. For example, in Caco-2 cells, a human colorectal epithelial cell line, CX26 expression increased gradually while cells reached conﬂuency. Overexpression of CX26 resulted in enhanced tight junction formation with lower levels of mannitol ﬂux and increased claudin-4 protein expression [113]. Recent studies also indicate that the CX26 interactome includes components of the tight junction network [20]. 2.3.1. Connexins and Wound Repair Connexins are closely involved in normal wound repair and show dynamic changes in expression after wounding. After 6 h of injury, CX43 is down-regulated in keratinocytes and ﬁbroblast at the wound edge to allow cell migration followed by recovery of CX43 levels [95]. In contrast, CX26 and CX30 are up regulated in keratinocytes until the wound is closed [96,98,99] in the granular cell layer near the wound margins and in the basal cell layer at some distance from the wound [95]. Thus, Connexins play a pivotal role in a variety of aspects of the acute wound healing process and each step is associated with a different connexin environment [51]. 7 of 18 7 of 18 Biology 2021, 10, 59 At the edge of chronic wounds, epidermal CX43, CX26 and CX30, and dermal CX43 are strikingly up-regulated around wound margins and at some distance from the chronic wound [95]. The up-regulation of CX43 may disrupt ﬁbroblast migration to the wound bed and as a result failure of granulation tissue formation occurs [100–104]. The up- regulation of CX26 may contribute to the inﬂammatory and hyperproliferative status of the wound [95,105]. The overexpression of Cx26 in mouse skin (under the control of the involucrin promoter) kept wounded epidermis in a hyperproliferative state, blocked the transition to remodelling, and led to an inﬁltration of immune cells. This overexpression also induced ATP release from keratinocytes, which delayed epidermal barrier recovery and promoted an inﬂammatory response in resident immune cells [97]. 2.3.2. Connexins and Psoriasis Psoriasis is a chronic hyperproliferating skin disorder that manifests sporadic skin lesions characterised by loss of the granular layer and incomplete keratinocyte differen- tiation associated with a thickened corniﬁed layer. Overexpression of CX26 in psoriatic lesions was originally reported by Labarthe and Lucke in the late 1990s [93,94]. Subsequent studies in mouse models overexpressing Cx26 in the skin showed a mildly acanthotic and hyperkeratotic skin, with a thicker and more compact corniﬁed layer. Areas with frictional trauma, such as axillary areas, presented with scaling and desquamation and hyperkera- totic plaques developed [97]. Other studies revealed that tape stripping of normal human epidermis induced CX26 expression and hyperproliferation [106]. More recently, publica- tion of the psoriatic transcriptome permitted in depth RNAseq analysis [107] and many of the upregulated genes are related with cell-to-cell adhesion complexes. GJB2, encoding CX26 was the 98th most up-regulated gene detected and its over expression is used as a marker of genetic predisposition in psoriasis [108,109]. A variety of other transcriptomic studies conﬁrm this overall increase in CX26 expression in psoriatic tissue yet no changes in CX43 gene expression are reported [110,111]. 3.4. The Airway Epithelium The air-conducting portion of the lung is lined by a pseudostratiﬁed epithelium, which is referred to as the airway epithelium. CX26 and CX43 are expressed in the undifferenti- ated human airway epithelium in conductive airways, but upon differentiation they rapidly disappear. As with respiratory airways, CX26 and CX43 have been detected in human lung epithelial cells [127,128]. Upon wounding, CX26 expression is transiently induced in activated basal cells and strongly decreased after wound closure. Activation of cell prolifer- ation upon injury is required to trigger CX26 expression in repairing cells. Thus, induction of CX26-mediated intercellular communication by proliferative signals in repairing basal cells may represent a feedback mechanism to repress their proliferation and progressively promote differentiation [129]. Other studies suggest a role for CX26 in barrier adhesive complexes. For example, Calu-3 cells, a human transformed bronchial epithelial cell line, do not express CX26. Treatments with ouabain, a Na+/K+-ATPase inhibitor, disrupted barrier function, causing a down-regulation of occludin, JAM-1, claudin-2, and -4 expres- sion and up-regulation of ZO-1 and claudin-14. However, when the cells were transfected to express CX26 they were not affected by ouabain, TJ proteins remain unchanged and CX26 co-localised with claudin-14. Pre-treatments with GJIC inhibitors did not affect CX26 changes, suggesting that CX26 expression but not GJIC regulates the TJ barrier in human epithelial cells [130]. Some of these concepts were recently reviewed by Chanson et al., 2018 [5]. 3.3. Connexin 26 and Heterozygous Advantage The mutations CX26-R134W and 35delG are reported to produce a thicker epider- mis [119,120]. Organotypic co-culture skin models with keratinocytes expressing CX26- R134W showed a thicker epidermis, suggesting an increase in cell proliferation, a delay in terminal differentiation, and higher cell migration than CX26WT-models, possibly reﬂecting a greater protection against environmental damage [120]. CX26 is also expressed in intesti- nal epithelial cells and several studies suggest that ‘Class 1’ heterozygous CX26-mutation status may decrease susceptibility to enteric pathogens. For example Shigella ﬂexneri causes bacillary dysentery in humans and it invades intestinal epithelial cells inducing an acute inﬂammatory reaction destroying the colonic epithelium [123]. This pathogen can open CX26 hemichannels, in an actin-phospholipase C-dependent manner, allowing ATP release, which induces the retraction of ﬁlopodial extensions, subsequently bringing the bacteria into contact with the cell body being invaded [124]. In vitro experiments with human in- testinal cell lines showed a reduction of both cellular invasion by S. ﬂexneri and adherence by enteropathogenic E. coli following treatment with CX26 siRNA, suggesting that the loss of functional CX26 provides protection against gastrointestinal bacterial pathogens [125]. Further population studies on the health of CX26 carriers in relation to epithelial disorders are certainly warranted, with recent evidence suggesting a link between CX26 and psoriatic hearing loss [126]. 3.2. Connexin 26 in the Auditory System As mentioned in Section 2.2, mutations in CX26 are a leading cause of deafness. The auditory canal surface is covered by a simple nonkeratinized squamous epithelium continuous with the lining of the tympanic cavity where CX29 is the predominant connexin expressed. This protein does not form functional gap junctions and is believed to act as a hemichannel in association with voltage-dependent K+ channels [114]. CX26 is expressed in the organ of Corti, the spiral limbus, the stria vascularis, and ﬁbrocytes of the spiral ligament [114]. The intrical auditory connexin circuit is critical in maintaining the recycling of K+ ions in the endolymph enabling auditory function. As discussed multiple recessive mutations in CX26 are associated with hearing loss with a relatively high carrier frequency Biology 2021, 10, 59 8 of 18 8 of 18 (1–3%), suggesting the possibility of heterozygous advantage [115–122]. Within different ethnic groups there are speciﬁc common recessive mutations that account for most of the CX26-related hearing loss, e.g., 35delG, 235delC and R143W, a typical ‘class 1 mutation’ in the European, Japanese and African populations, respectively [116–118,122]. 4.1. Molecular Mechanisms: ATP, Ca2+ and the Pro-Inﬂammatory Response 4.1. Molecular Mechanisms: ATP, Ca2+ and the Pro-Inﬂammatory Response Formation and maintenance of barrier function is affected by cytokines, ATP and Ca2+ gradients throughout the stratiﬁed layers of the epidermis. Ca2+ levels are highest in the granular layer and almost disappear in the stratum corneum and is an important regulator in epidermal differentiation, protein synthesis and cell-to-cell adhesion [28,139]. Furthermore, keratinocytes in each layer of the epidermis show distinct characteristics in response to ATP. Purinergic signalling, an extracellular signalling pathway triggered by purine nucleotides including ATP passively released via hemichannels, participates in multiple physiological processes (e.g., proliferation and differentiation), activates nerve cells and attracts immune cells. Dysregulation of ATP results in pathological conditions including chronic inﬂammation. Keratinocytes release ATP in a critical gradient depending on the differentiation status of the cell and the distribution of purinergic receptors is different in each layer of the epidermis, thus the response to ATP is different in different epidermal compartments [140,141]. Exposing keratinocytes to stress induced both elevation of intracellular Ca2+ and ATP release [141]. Furthermore, the use of gap junction blockers signiﬁcantly reduced Ca2+ wave propagation in differentiated keratinocytes, suggesting the participation of gap junctions in the induction of Ca2+ waves in response to stress in the epidermis [140,142]. A wide variety of stimuli, including mechanical stimulation, induce ATP release through hemichannels that subsequently interacts with purinergic receptors promoting the propagation of Ca2+ signals, from the ER. These signals can be directly propagated to neighbouring cells via gap junction channels [143] or through the extracellular space via hemichannels [34,144]. The increase in intracellular Ca2+ in response to ATP varies in each layer of the epidermis and is reported to be higher in the basal than in the outer layers [141]. Such events enable a rapid and co-ordinated spatio-temporal signal propagation throughout tissues. Human CX26 hemichannels can be opened under resting conditions [55]. Mutations in CX26 affect hemichannel permeability. As discussed, CX26 KID syndrome mutations provoke ‘leaky’ hemichannels and allow the aberrant formation of CX43-CX26 hetero- hemichannels presenting abnormal permeability [66,78,86,145–147]. Some of these muta- tions also alter CX26 PCO2 gating sensitivity, which may contribute to CO2-dependent regulation of breathing in mammals [148–151]. Other examples of dysregulation of epi- dermal calcium gradients were observed in a transgenic KID syndrome mouse model, Cx26-S17F, where intra- and extracellular Ca2+ levels were maintained in the corneous layer, proposed to be a consequence of hyperactivation of heteromeric hemichannels. 3.5. The Cornea The cornea is a transparent avascular tissue that acts as a barrier protecting the eye from infections. The corneal epithelium is composed of 5–7 layers of three types of non- keratinised stratiﬁed squamous cells: superﬁcial cells, wing cells and basal cells [131]. CX26, CX30, CX31.1 and CX43 are the predominant connexins in human cornea [132,133], their mutation results in ocular disorders such as oculodentodigital dysplasia, produced by mutations in CX43 and KID syndrome related to CX26 mutations, where keratitis is a major pathology [73,134,135]. Zhai et al. determined the connexin expression in 10 human Biology 2021, 10, 59 9 of 18 9 of 18 diseased corneas: ﬁve injured by chemical burns and ﬁve infected [133]. They determined by ﬂow cytometry that only 0.5% cells in normal corneal tissue expressed CX26; however, this percentage increased in chemical burn and infected corneas, being 15.6 and 34.2%, respectively. On the other hand, CX43 was expressed in 3.1% of normal cells, while its expression was 23.4 and 40% in chemically burned and infected cells [133]. As such, Connexins emerge as a prime therapeutic targets and treatments with the synthetic CX43 mimetic peptides and SiRNA technologies are proving successful in clinical trials (see Section 5) [136–138]. 4.1. Molecular Mechanisms: ATP, Ca2+ and the Pro-Inﬂammatory Response The epi- dermis of these mice had altered lipid proﬁles, developed both hyperproliferation and hyperkeratosis which negatively affected epidermal water barrier [152]. TNFα, IL-1 and IL-6 are potent mitogens and stimulators of lipid synthesis crucial to respond to and repair barrier disruption; however, the chronic expression of these cytokines lead to inﬂammation and epidermal proliferation, an end result in epidermal dysplasia including conditions such as dermatitis and psoriasis [28]. ATP induces IL-6 production in HaCaT cells, a model keratinocyte cell line, via P2Y receptors, and it is critical for the wound repair process. Mechanical stimulation of HaCaT cells, such as the change of medium or silica nanoparticle 30, induced release of ATP and the activation of P2Y receptor provoked an increase in intracellular Ca2+ concentration causing the induction Biology 2021, 10, 59 10 of 18 10 of 18 of IL-6 mRNA and protein levels [144,153]. This response was inhibited by suramin (a P2 purinergic receptor antagonist) [154,155]. of IL-6 mRNA and protein levels [144,153]. This response was inhibited by suramin (a P2 purinergic receptor antagonist) [154,155]. The deregulation and persistent production of IL-6 contributes to chronic inﬂammation and autoimmunity. An example is psoriasis, of which transcriptome analysis determined that IL-6 is up-regulated 4.3-fold in psoriatic lesions [107]. In addition, ATP increases proliferation in HaCaT cells and maybe a mechanism for the hyperproliferation that occurs in psoriasis. Both, IL-6 production and proliferation in HaCaT cells were inhibited by blocking purinergic receptors with blockers such as suramin [154–156]. There is extensive evidence to suggest that a double positive feedback between con- nexin channels and purinergic signalling exists. The opening of connexin channels allows the release of ATP which is an agonist of purinergic signalling leading to the opening of hemichannels and the subsequent ampliﬁcation of purinergic signalling (more ATP release and Ca2+ waves) via a positive signalling feedback loop, giving rise to the concept of ATP- induced ATP release [157]. Mugisho and colleagues propose the inﬂammasome pathway is ampliﬁed in an autocrine manner through ATP released via CX43 [158]. Evidence builds that other connexins, including overexpression of CX26 in the epidermis may contribute to this cycle of events with ATP released feeding into purinergic signalling pathways and associated with exacerbated inﬂammation and hyperproliferation linked with psoriasis. 4.2. Connexins and Gram-Positive Bacteria Study of the microbiome have suggested a further contributing trigger to Psoriasis is as a dysbiosis from commensal microﬂora colonisation (e.g., Staphylococcus epidermidis) to opportunistic colonisation (e.g., S. aureus), i.e., an ‘outside-in’ trigger [159,160]. Such a mi- crobiome shift would lead to altered innate immune signalling patterns and may contribute to the pathogenesis. A similar shift is also observed in KID syndrome and chronic wounds where connexin dysregulation is also evident [73]. y g [ ] Peptidoglycan (PGN) from S. aureus regulates connexin gene and protein expression in diverse tissues. In the HaCaT keratinocyte cell model system it induced CX26 gene expres- sion [42,81]. A similar response was observed in mouse astrocytes; however, in microglia and endothelial cells increased Cx43 gene and protein levels were observed [161–163]. PGN is a potent inducer of the innate immune response recognised by Toll-like receptor 2 (TLR2), which is the prime receptor for PGN [164]. PGN interaction with TLR2 triggers a downstream signalling cascade by initiating Ca+2 ﬂuxes which ﬁnally activates NF-kβ and, subsequently, pro-inﬂammatory cytokine expression such IL-6, IL-8, TNF-α and IL- 1β, [165–167]. Gap junctions are involved in the initial spread of Ca+2 ﬂuxes generated by TLR2 in mucosal epithelium. Further, connexin-mediated pathways transduced the signalling triggered by an infection and provoked gene expression changes including cytokine expression. For example, Pseudomonas aeruginosa activated TLR2 and triggered a Ca2+ wave, that passed through gap junction channels, subsequently activating NF-kβ and inducing IL-8 secretion in airway cells [165–167]. Furthermore, in HaCaT cells ex- posed to PGN from S. aureus, there was an increase in ATP release and TLR2 expression. TLR2, via NF-kB, induced the up-regulation of CX26, IL-6 and IL-8, and this response was inhibited by connexin channel blockers [42]. In other studies, PGN evoked hemichan- nel activity and induced a pro-inﬂammatory response in HaCaT cells expressing class 3 CX26 mutations associated with KID syndrome (Section 2.2), events that were inhibited by carbenoxolone, a connexin channel inhibitor. This did not occur in cells expressing non- functional mutations such as D66H associated with the non-inﬂammatory skin disorder Vohwinkel syndrome [81]. 5. Future Directions and Connexins as Therapeutic Targets Informed Consent Statement: Not applicable. Data Availability Statement: Not applicable. Acknowledgments: We thank Malcolm Hodgins for helpful discussion and this review is dedicated to the memory of Howard Evans, a pioneer of the Gap Junction Field. Conﬂicts of Interest: The authors declare no conﬂict of interest. 5. Future Directions and Connexins as Therapeutic Targets Recently antisense technologies targeting CX26 were re- ported to reduce pro-inﬂammatory ATP release within the skin and were beneﬁcial in in vivo wound healing studies, preventing CX26 upregulation at the wound edge, re- ducing inﬂammation, epidermal thickening and improving wound closure events [96]. Short connexin mimetic peptides targeting CX43, based on the original work pioneered by Professor Howard Evans and colleagues during the 1990s, provided a platform for peptide design effectively inhibiting both Gap Junction and Connexin hemichannels ac- tivity. The ‘GAP27’ domain targets amino acid sequence SRPTEKTIFFI located on the distal domain of EXL2. This sequence is highly conserved between Cx43 and Cx37 with a variety of studies revealing Connexin subtype speciﬁcity [37,175–178]. Various platforms have now taken this work forward with the success of extracellular loop peptides, ana- logues of GAP27, targeting CX43 being successful in clinical trials for patients with ocular conditions including diabetic retinopathy and age related macular degeneration [179,180] (https://ocunexus.com/peptagon). Although there is currently no published informa- tion on Cx26 speciﬁc peptides, it is likely that targeting this domain could yield peptides capable of uniquely blocking Cx26 activity. The peptide ACT-1, targeting the carboxyl tail region of CX43 shows exciting possibility in phase 3 clinical trials in wound healing and in tailored targeting of cardiac disease by Prof Rob Gourdie and colleagues [181,182] (https://ﬁrststringresearch.com/). Finally, allele speciﬁc SiRNA therapies, targeting speciﬁc CX26 mutations, show early promise in advancing personalised medicine approached for patients with conditions such as KID syndrome [183,184]. In conclusion, Connexins are dynamically expressed within epithelial tissue with CX26 being highly responsive to environmental stimuli. Further studies are warranted on the interplay of the CX26:CX43 nexus in epithelial networks and may enable tailored targeting of both Connexins to resolve a range of pro-inﬂammatory epithelial conditions. Author Contributions: The authors contributed in the following way. L.G.-V., E.M.O. and A.A. were PhD students with P.E.M. during period 2014–2019 and work reﬂects outputs from their studies. L.G.-V. wrote the original draft of the manuscript with contributions from E.M.O. and A.A. P.E.M. administered the projects and acquired the funding and proof read the ﬁnal version. All authors have read and agreed to the published version of the manuscript. Funding: This research was funded by a GCU PhD studentship to L.G.-V., a PhD studentship from the Psoriasis Association (EO) (grant number ST3 15) and a Kuwaiti Government PhD scholarship to A.A. Institutional Review Board Statement: Not applicable. 5. Future Directions and Connexins as Therapeutic Targets Dysregulation of connexin expression is thus associated with a wide range of ep- ithelial tissue events. This tissue, particularly the stratified epidermis and the cornea, is readily accessible and prime for therapeutic intervention [168,169]. A range of connexin mimetic peptide and SiRNA technologies continue to be developed targeting connex- Biology 2021, 10, 59 11 of 18 11 of 18 ins with evidence amounting of their considerable therapeutic benefit, most of which are based on CX43 [170,171]. Initial studies included antisense oligonucleotides targeted to CX43 [172–174]. This was successfully taken forward by Professor Colin Green and colleagues to clinical trials with exciting evidence in wound healing scenarios (https: //ocunexus.com/nexagon). Recently antisense technologies targeting CX26 were re- ported to reduce pro-inﬂammatory ATP release within the skin and were beneﬁcial in in vivo wound healing studies, preventing CX26 upregulation at the wound edge, re- ducing inﬂammation, epidermal thickening and improving wound closure events [96]. Short connexin mimetic peptides targeting CX43, based on the original work pioneered by Professor Howard Evans and colleagues during the 1990s, provided a platform for peptide design effectively inhibiting both Gap Junction and Connexin hemichannels ac- tivity. The ‘GAP27’ domain targets amino acid sequence SRPTEKTIFFI located on the distal domain of EXL2. This sequence is highly conserved between Cx43 and Cx37 with a variety of studies revealing Connexin subtype speciﬁcity [37,175–178]. Various platforms have now taken this work forward with the success of extracellular loop peptides, ana- logues of GAP27, targeting CX43 being successful in clinical trials for patients with ocular conditions including diabetic retinopathy and age related macular degeneration [179,180] (https://ocunexus.com/peptagon). Although there is currently no published informa- tion on Cx26 speciﬁc peptides, it is likely that targeting this domain could yield peptides capable of uniquely blocking Cx26 activity. The peptide ACT-1, targeting the carboxyl tail region of CX43 shows exciting possibility in phase 3 clinical trials in wound healing and in tailored targeting of cardiac disease by Prof Rob Gourdie and colleagues [181,182] (https://ﬁrststringresearch.com/). ins with evidence amounting of their considerable therapeutic benefit, most of which are based on CX43 [170,171]. Initial studies included antisense oligonucleotides targeted to CX43 [172–174]. This was successfully taken forward by Professor Colin Green and colleagues to clinical trials with exciting evidence in wound healing scenarios (https: //ocunexus.com/nexagon). Abbreviations GJIC: Gap Junction intercellular communication; CX/Cx: human/mouse connexin; ER: endoplasmic reticulum; KID: Keratitis Ichthyosis Deafness syndrome; TJ: Tight junction; ATP: adenosine triphos- phate; IL-6 interleukin 6; PGN: peptidoglycan; TLR2: toll like receptor 2. 12 of 18 12 of 18 Biology 2021, 10, 59 References References 1. Bragulla, H.H.; Homberger, D.G. Structure and functions of keratin proteins in simple, stratiﬁed, keratinized and corniﬁed epithelia. J. Anat. 2009, 214, 516–559. [CrossRef] [PubMed] g , ; o e ge , G S c e c o s o e p o e s s p e, s e , e e co e epithelia. J. Anat. 2009, 214, 516–559. [CrossRef] [PubMed] 2. Schneeberger, E.E.; Lynch, R.D. The tight junction: A multifunctional complex. Am. J. Physiol. Cell Physiol. 2004, 286, C1213–C1228. [CrossRef] [PubMed] p J 2. 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https://openalex.org/W4281606589	https://bmcoralhealth.biomedcentral.com/counter/pdf/10.1186/s12903-022-02262-7	English	null	Retention of bar clip attachment for mandibular implant overdenture	BMC oral health	2,022	cc-by	6,309	Abstract Objectives: The aim of the present study was to evaluate the retention and loss of retention after fatigue testing at different time intervals between two types of bar clip materials (digitally designed PEEK bar clip and regular Nylon bar clip). Materials and methods: An epoxy model was constructed for a completely edentulous mandible. Two implants were placed according to prosthetically driven implant placement by a computer-guided surgical stent. Bar clips were digitally designed, 3D printed, and pressed into Poly Ether Ether Ketone (PEEK). Pick up of PEEK and nylon clips was performed on the dentures fitting surface using self-cured acrylic resin. Each study group was subjected to an inser- tion and removal fatigue test simulating 3 years of patient usage. Retention values were recorded using the universal testing machine at initial retention and after 1, 2, and 3 years of simulated usage. For proper sample sizing, 24 models and dentures (12 for each group) were used. An independent sample t-test and repeated measures analysis of vari- ance were used to compare the data. Results: There were statistically significant differences in retention between the PEEK and nylon bar clips at the beginning of the experiment (p = 0.000). But after 3 years of simulated use, there was no significant difference in retention between the test groups (p = 0.055, NS). After 3 years of simulated use, the retention of PEEK clips decreased by − 58.66% recording 17.37 ± 1.07 N, while the retention of nylon clip increased by + 2.99% recording 16.56 ± 0.88 N. Conclusion: The digitally designed PEEK clip showed comparable retention results to the nylon clip after 3 years of g p (p , ) y , p by − 58.66% recording 17.37 ± 1.07 N, while the retention of nylon clip increased by + 2.99% recording 16.56 ± 0.88 N. Conclusion: The digitally designed PEEK clip showed comparable retention results to the nylon clip after 3 years of simulated use. Clinical relevance: Maintenance of bar attachment with PEEK clip offers a clinical solution after the wear of normal plastic clips, which is a cheap solution that is easily fabricated and picked up into the denture. Digital fabricated PEEK bar retentive inserts can be used in cases of bar attachment wear. Keywords: Dental materials, Denture precision attachment, Dental implantation, Denture retention, Computer-aided design © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hossam I. Nassar and Medhat Sameh Abdelaziz Hossam I. Nassar and Medhat Sameh Abdelaziz* Introduction Oral rehabilitation of edentulous and partially edentu- lous patients has been improved by the development of implants and their different prosthetic options [1]. Sev- eral clinical trials have proved that placement of implants in mandibular retained and/or supported overdentures results in a better quality of life compared to conven- tional complete dentures [1–4]. Correspondence: 20184574@fue.edu.eg; medhat.abdelaziz@fue.edu.eg; dr.medhatsameh@gmail.com Department of Prosthodontics, Faculty of Oral and Dental Medicine, Future University in Egypt, Fifth Settlement, End of 90 Street, Cairo, New Cairo City, Department of Prosthodontics, Faculty of Oral and Dental Medicine, Future University in Egypt, Fifth Settlement, End of 90 Street, Cairo, New Cairo City, Egypt © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Nassar and Abdelaziz BMC Oral Health (2022) 22:227 https://doi.org/10.1186/s12903-022-02262-7 Nassar and Abdelaziz BMC Oral Health (2022) 22:227 https://doi.org/10.1186/s12903-022-02262-7 Materials and methods A control model standard was fabricated from a cast obtained from a completely edentulous mandible. Any existing undercuts were blocked. The duplication of the stone model was carried out using laboratory addition silicone material (REPLISIL 22N, dent-e-con, Germany) to obtain an epoxy resin model (Swiss Chem; construc- tion chemicals, Egypt). PEEK was first developed in 1978 as a thermoplastic, polycyclic, semi-crystalline polymer obtained by binding ketone and ether functional groups with aryl rings [16]. It has superior mechanical properties with resistance to hydrolysis, chemical wear, and high temperatures [17]. It is a biologically inert material with no evidence of cyto- toxicity or immunogenicity. It also offers corrosion resist- ance, low plaque affinity, and minimal creep [14]. For surgical guide construction, Cone Beam Com- puted Tomography (CBCT) (parameters 85 KVP, 5 MA) was recorded for the model to create a DICOM file. The standard tessellation language file (STL file) of the model was also obtained using an intraoral scanner (MEDIT i700; MEDIT Corp). The STL file was superimposed on the DICOM file using the best-fit algorithm. fi In a study by Savabi et al. [18] it was reported that the retention forces for the bar attachments have decreased to (44%) after 5 years of follow-up. Regular bar mainte- nance depends on the activation of bar clips and even changing the clips [5, 11, 18].hi ii Using computer-aided design software (Exocad GMBH Dental CAD), a virtual lower denture was designed. A prosthetically driven implant placement concept was clear in mind, therefore a surgical guide using the virtual designed lower denture was constructed by an implant planning software (real guide; 3diemme, Italy). The implants were placed bilaterally between the lateral inci- sor and canine. The surgical guide was printed using clear surgical guide resin (EPAX Clear Resin; EPAX 3D). The resultant surgical guide was finished and cleaned with alcohol to remove excess monomer. The retention is the first factor responsible for patient satisfaction with the prosthesis, and it is defined as that quality inherent in the dental prosthesis acting to resist the forces of dislodgment along the path of placement [19, 20]. (33%) of prosthodontic complications are related to loss of retention [8]. The rate of attachment wear is related to its material of construction, which should be wear-resistant to maintain a stable retention force over- time. Open Access T Page 2 of 8 Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Implant overdenture can either use splinted implants by bar attachments or un splinted implants by stud- type attachments [5, 6]. Many factors affect appropriate attachment selection, such as jaw morphology, inter arch distance, the desired retention, prosthesis type, inclina- tion and number of implants, patient manual dexterity, financial options, and the availability for maintenance recall visits [7]. The bar overdenture with PEEK clip has low plaque accumulation with no gingival inflammation with high patient satisfaction in cleaning and maintenance com- pared to fixed full arch restorations [13]. The PEEK clip represents an alternative to metal ones with favourable prosthetic and clinical outcomes. It has high wear resist- ance which in turn decreases the number of maintenance visits and the need for changing the clip [14]. Bar attachment is used to splint implants with the low- est complications in the prosthetic superstructure and maximum patient satisfaction [8]. It offers stress-break- ing action and cross-arch involvement, which allows occlusal forces to be shared between the abutments [9]. The ideal length of a single bar should range from 20 to 22 mm to accommodate two clips [10]. It also requires an inter-arch distance of a minimum of 15 mm [11].h Aim of the study Th b f The objective of the present investigation was to compare digitally designed PEEK bar clips with the well-known nylon clip in their initial retention force and after a simu- lated 3 years of bar attachment usage. The null hypothesis is that the bar attachment clip fabricated from different materials offers similar retention values in retaining man- dibular overdenture. The bar can be fabricated from metal or milled from a non-metal material such as zirconia and PEEK (Poly- ether-ether-ketone), while the bar clip can be fabricated from PEEK or Poly Oxy Methylene (POM) [12–14]. Polyvinylsiloxane (PVS) has also been introduced and employed as an attachment matrix, which is similar to elastic impression materials, offering a chairside quick solution [15].i Materials and methods [12] Two dental implants (Internal Tapered; BIOHORI- ZONS) of 3.8 mm in diameter and 10.5 mm in length were loaded into the model. Two castable plastic abut- ments were tightened using a torque wrench at 25 N over the implants. With the aid of a dental surveyor, the plastic bar with a round cross-section was attached to the two plastic abutments using self-cure acrylic resin, creating a 2 mm clearance space between the bar and the model. The assembly was then unscrewed, cast in Ni–Cr alloy, Burns et al. [39] concluded that the least accepted retention force gained by different attachment systems in implant‑retained overdenture was between 5 and 8 N in the long‑term function [21, 22]. Therefore, studies on the retention of attachments are very important to determine the selection of specific retention systems for the patient [23]. Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Nassar and Abdelaziz BMC Oral Health Page 3 of 8 and finished and polished. The finished bar was checked Fig. 1 Bar fabricated over the model Fig. 2 Outlining the PEEK clip Fig. 3 The final for PEEK clip design with an outer surface undercut to provide mechanical retention with the denture Fig. 4 Pressed PEEK clip Fig. 3 The final for PEEK clip design with an outer surface undercut to provide mechanical retention with the denture Fig. 3 The final for PEEK clip design with an outer surface undercut to provide mechanical retention with the denture Fig. 1 Bar fabricated over the model Fig. 1 Bar fabricated over the model Fig. 2 Outlining the PEEK clip Fig. 4 Pressed PEEK clip Fig. 4 Pressed PEEK clip and finished and polished. The finished bar was checked for passivity and then finally screwed to the implants (Fig. 1).h Equipment Co., Ltd.) were fabricated. Mandibular trial dentures were flasked and packed with heat-cured resin (Denture Base Material; Vertex-Dental B.V.), then fin- ished and polished with a hock attached to the denture geometric center. The model with the bar screwed on was scanned using a desktop scanner (Medit T500) after the application of scan spray powder (Alldent, Germany) to get the STL file of the model and bar. The STL file of the bar and model was imported to the Meshmixer software (MESHMIXER 3.5 software, Autodesk). The tested groups were classified as follows: Group A Bar with a plastic (POM) clip attachment (control group) (Fig. 5). Materials and methods Group A Bar with a plastic (POM) clip attachment (control group) (Fig. 5). Group A Bar with a plastic (POM) clip attachment (control group) (Fig. 5). First, the PEEK clip design was drawn on the model by outlining the lingual, buccal, mesial, and distal extents (Fig. 2). The boundaries were smoothened. Undercuts were created on the buccal and lingual aspects of the bar clips by using an attract brush tool to ensure mechanical retention between the clip and the denture fitting surface in the pickup step [24] (Fig. 3). Group B A bar with a PEEK clip attachment (Fig. 6). A light body rubber base was loaded into the denture, and the denture was tried on the model with a bar and clips loaded on it. Any pressure areas preventing the den- ture from complete seating or any areas responsible for denture frictional retention were removed. The retromo- lar pads were used as a reference for the complete seating of the denture base on the model [18]. The designed clip was printed using (EPAX Dental Castable Resin; EPAX 3D). The clip wax pattern was pressed by the lost wax technique into PEEK (Fig. 4).h The epoxy model was duplicated into the stone cast on which 24 mandibular trial denture bases with waxed- up acrylic resin teeth (Zhengzhou Linker Medical Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Page 4 of 8 Fig. 5 Two nylon clips over the bar for pick up Fig. 8 Pick up of the PEEK clip in the denture Fig. 8 Pick up of the PEEK clip in the denture Fig. 8 Pick up of the PEEK clip in the denture of the universal testing machine via a screw hook. The direction of the pull forces was performed vertically.h Fig. 5 Two nylon clips over the bar for pick up The achieved maximum values of retention force were recorded at the beginning of the study (initial retention) and after 1, 2, and 3 years with an average of 1000 cycles per year based upon patients’ average of 3 insertions and removals per day [22, 25]. Twenty-four epoxy models and dentures were used (12 for each group) for proper statis- tical sample sizing.h Fig. 6 Two PEEK clips over the bar for pick up The sample size was calculated using G Power version 3.1.9.2. and according to previous studies [8, 25, 26]. Statistical methodology Th d ll d The data was collected and entered into the computer using the SPSS (Statistical Package for Social Science) program (version 21). The data was normally distributed by the Kolmogorov–Smirnov test of normality, so the parametric statistics were adopted. The mean, standard deviation, and 95% CI of the mean were used to describe the data. Fig. 6 Two PEEK clips over the bar for pick up Fig. 7 Pick up of the nylon clip in the denture Two studied independent, normally distributed varia- bles were compared using an independent sample T-test. Repeated measures analysis of variance was used. Model assumptions were tested and found to be satisfactory except for Mauchly’s test of sphericity. Results 9 Bar chart of mean retention loss in (Newton) between the two studied groups at a different time of measurement primary retention versus one, two, and three years of use Table 1 Retention in (Newton) between the two studied groups at various measurement times T0, at time of overdenture insertion; T1, after 1 year of use; T2, after 2 years of use; T3, after 3 years of use; NS, Statistically not significant (p ≥ 0.05) PEEK clip (M ± SD) Nylon clip (M ± SD) P value T0 42.08 ± 1.52 16.08 ± 0.68 0.000 T1 19.26 ± 1.15 15.78 ± 0.93 0.000* T2 19.90 ± 0.73 15.22 ± 0.53 0.000* T3 17.37 ± 1.07 16.56 ± 0.88 0.055 NS Table 1 Retention in (Newton) between the two studied groups at various measurement times Table 2 Repeated measure analysis of variance, comparing retention loss in (Newton) between different time periods of measurement (Primary retention vs one, two, and three years of use) in each studied group Table 1 Retention in (Newton) between the two studied groups at various measurement times T0, at time of overdenture insertion; T1, after 1 year of use; T2, after 2 years of use; T3, after 3 years of use; NS, Statistically not significant (p ≥ 0.05) Statistically significant (p < 0.05) PEEK clip p value Nylon clip P value T0–T1 0.000 1.000 NS T0–T2 0.000* 0.002* T0–T3 0.000* 0.195 NS T1–T2 1.000 NS 0.420 NS T1–T3 0.000* 0.006* T2–T3 0.001* 0.000* between 2 years and primary retention, 3rd, 1st year and 3rd and 2nd year was statistically significant at (p = 0.002), (p = 0.006), and (p = 0.000) respectively (Table 2). Statistically significant (p < 0.05) An increase in the percentage of retention for the Nylon clip attachment group after 3 years of use was noticed by + 2.99% compared to primary retention and by + 8.76% compared to 2 years of use. While the PEEK clip attach- ment group showed an increase in retention after 2 years of use by + 3.72% compared to 1 year of use (Table 3). Results Fig. 7 Pick up of the nylon clip in the denture Fig. 7 Pick up of the nylon clip in the denture Comparisons in retention between two studied groups show a statistically significant difference in mean reten- tion at the initial retention test and after different time intervals. (p = 0.000). But after 3 years of stimulated use, there was no significant difference in retention values (p = 0.055 NS) (Fig. 9) (Table 1).h Teflon and wax material were used to block any undercuts beneath the bar. Escape holes were made on the denture to act as an exit for the extra pickup mate- rial. The pickup was done by self-cured acrylic resin with the denture seated completely over the model. (Figs. 7 and 8).h The repeated measure analysis test revealed a statisti- cally significant loss of the mean of retention of the PEEK clip attachment group at different years of use (p = 0.000), with the exception of no statistically significant retention loss between the 2nd and 1st year of testing (p = 1.000). For the nylon clip attachment group, the mean of retention The specimen’s retention forces were measured using the Instron universal testing machine (model 3345; England). The denture was attached to the dynamic part Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Page 5 of 8 Fig. 9 Bar chart of mean retention loss in (Newton) between the two studied groups at a different time of measurement primary retention versus one, two, and three years of use Fig. Discussion In completely edentulous patients that need full arch rehabilitation, the presence of some anatomical and sur- gical limitations can affect the implant placement posi- tions and the number of implants, which necessitates the search for prosthetic solutions with perfect function and aesthetics and load distribution of implants [27]. The bar retained over denture offers a standard of care prosthetic solution by placing two implants in the canine area. Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Page 6 of 8 Table 3 Percentage of retention loss in (Newton) between the two studied groups at various times of measurement Primary retention vs one, two, and three years of use alternative measurement of overdenture retention and differs with the number of insertions/removal cycles. These tests could enable the clinicians to choose the most efficient attachment system and proper material for each patient. The conventional Instron (IS) test- ing machine has been well recognized as a reliable and acceptable instrument to test retention forces in vitro [8, 33, 34]. T0, at time of overdenture insertion; T1, after 1 year of use; T2, after 2 years of use; T3, after 3 years of use; NS, Statistically not significant (p ≥ 0.05) Statistically significant (p < 0.05) PEEK clip (M ± SD) (%) Nylon clip (M ± SD) (%) p value Percentage change T1 versus T0 (%) − 54.13 − 1.80 0.000* T2 versus T0 (%) − 52.63 − 5.24 0.000* T2 versus T1 (%) + 3.72 − 3.28 0.018* T3 versus T0 (%) − 58.66 + 2.99 0.000* T3 versus T2 (%) − 12.53 + 8.76 0.000* Previous in vitro studies tested the changes in reten- tion force between plastic clips and metal matrices. Plas- tic clips of poly-oxy-methylene (POM) reported fewer changes in retention compared to metallic ones. This may be attributed to their modulus of elasticity with superior resiliency. Consequently, the plastic clips turned out to be more prevalent and commonly used [33, 35].i *Statistically significant (p < 0.05) Carbon fibers reinforcement is considered one of the recent innovations in the prosthodontics field. It has many applications, such as crowns, bridges, and full arch hybrid restorations. The reinforcement of PEEK with carbon fibers has a great impact on load absorp- tion, resiliency, wear resistance, and patient comfort [36]. Recently, PEEK was introduced as an attachment tool due to its high mechanical properties such as high reten- tion and wear resistance. Discussion Abdelrehim et al. concluded that BioHPP (PEEK) bar seems to be a solid candidate for bar fabrication with minimal loss of retention and better wear resistance of the clip [37]. Complete denture digitalization used for implant sur- gical guide fabrication standardizes clinical results and research work and guarantees implant position accord- ing to prosthetically driven implant placement, leading to better load distribution between implants [28, 29]. A round cross-section bar (OT bar multisystem, Rhein83) design was selected in the present study to permit movement of the retained overdenture and allow better occlusal load distribution between implants and residual ridge [13]. The fabrication of the PEEK clip requires optical scanning of the bar attachment, which is more comfort- able for patients with less nausea and anxiety compared to conventional impression [30, 31]. With the develop- ment of digital dentistry and computer-aided design and computer-aided manufacturing (CAD-CAM) tech- nology, the design of dental attachments and reten- tive inserts has become easier with perfect expectable results [24, 30].h In a clinical 1 year trial, Abdraboh et al. [14] reported that PEEK housing could be an effective alternative to metal housing for a milled bar over inclined implants in the mandible with favourable prosthetic and clinical out- comes. The PEEK housing showed higher satisfaction with retention, stability, speech, and esthetics and a lower incidence of female clip wear and renewal rate [14]. The results of the present study showed a significant difference in the values of initial retention forces where the PEEK clip documented higher retention forces in comparison to the nylon clip. However, an insignificant difference was recorded by the end of the 3 years study period. This result is in accordance with several clinical and in-vitro studies. In their study, Emera and Alton- bary reported a significant difference in initial retention forces for the PEEK clip group over the POM clip group, although both clip materials showed no significant differ- ence in retention loss after 1 year of mandibular overden- ture clinical use over zirconia bar [13]. In a split-mouth clinical study, Bayer et al. [12] registered significant retention loss with PEEK clips in the first 3 months with a round cross-section metal bar. However, after 6 months, a stabilized retention loss with no statistically significant difference in the clinical performance of PEEK or POM clips was recorded [12]. Acknowledgements 12. Bayer S, Komor N, Kramer A, Albrecht D, Mericske-Stern REN. Retention force of plastic clips on implant bars: a randomized controlled trial. Oral Impl Res Clin. 2012;23:1377–84. 12. Bayer S, Komor N, Kramer A, Albrecht D, Mericske-Stern REN. Retention force of plastic clips on implant bars: a randomized controlled trial. Oral Impl Res Clin. 2012;23:1377–84. The authors thank professor Hussien Elcharkawi (head of the prosthodontics department) 13. Emera RMK, Altonbary GY. Retention force of zirconia bar retained implant overdenture: clinical comparative study between PEEK and plastic clips. Int Dent Res. 2019;9:92–8. 13. Emera RMK, Altonbary GY. Retention force of zirconia bar retained implant overdenture: clinical comparative study between PEEK and plastic clips. Int Dent Res. 2019;9:92–8. References Influence of attachment wear on retention of mandibular overdenture. J Oral Rehabil. 2007;34:41–51. 8. Rutkunas V, Mizutani H, Takahashi H. Influence of attachment wear on retention of mandibular overdenture. J Oral Rehabil. 2007;34:41–51. 9. Samra R, Bhide S, Goyal C, Kaur T. Tooth supported overdenture: a con- cept overshadowed but not yet forgotten! J Oral Res Rev. 2015;7:16. 10. Prasad DK, Prasad DA, Buch M. Selection of attachment systems in fabri- cating an implant supported overdenture. J Dent Implant. 2014;4:176–81 10. Prasad DK, Prasad DA, Buch M. Selection of attachment systems in fabri- cating an implant supported overdenture. J Dent Implant. 2014;4:176–81 11. Gonuldas F, Tokar E, Ozturk C. Evaluation of the retention characteristics of various stud attachment systems for implant retained overdenture. Acta Bioeng Biomech. 2018;20:135–41. 11. Gonuldas F, Tokar E, Ozturk C. Evaluation of the retention characteristics of various stud attachment systems for implant retained overdenture. Acta Bioeng Biomech. 2018;20:135–41. Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests h h d l h Co pet g te ests The authors declare that they have no conflict of interest. The authors declare that they have no conflict of interest. Received: 5 May 2022 Accepted: 1 June 2022 Received: 5 May 2022 Accepted: 1 June 2022 Discussion The designed PEEK clip had an undercut in its pol- ished surface to guarantee mechanical interlocking during pick- up on the intaglio surface of the denture [24].h The wear of retentive clips over bar attachments has been documented to directly influence the retention of overdentures, and attachment wear occurs as a result of friction between retentive attachment surfaces at insertion and removal or during masticatory cycles [20]. Williams et al. [32] reported that the plastic reten- tive clips, not the round bars, were responsible for the retention loss. For this reason, there is a need to evalu- ate the retention force of different bar clips if different materials. The maximum dislodging force was identified as the highest force utilized before the complete separa- tion of attachment components; it could be used as an Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Page 7 of 8 manuscript-concept-design- interpretation—statistics-data collection-soft- wares. All authors read and approved the final manuscript. Hammas et al. [38] concluded that PEEK clips showed more wear resistance than POM clips with metal or PEEK bars, and both materials showed in vitro compara- ble results concerning retention force [38].hf manuscript-concept-design- interpretation—statistics-data collection-soft- wares. All authors read and approved the final manuscript. Conclusions With the limitations of the present study, it could be con- cluded that: Funding g Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The least reported acceptable retention force of differ- ent attachment systems for implant‑retained overden- ture ranged between 5 and 8 N throughout the long‑term function. [39] Both studied groups reported higher val- ues by the end of the study period of 3 years. Although results of in-vitro studies that evaluated retention forces of different attachment systems cannot completely mimic all clinical conditions such as exact saliva composition, oral environment, temperature, and patient parafunc- tional habits that may influence the results, they can point out the performance of the new attachment materi- als and their gradual retention loss to be used as a substi- tute for traditional ones. Consent to publication Not Applicable. Consent to publication Not Applicable. Ethics approval and consent to participants Not Applicable. Ethics approval and consent to participants Not Applicable. References 1- Virtually designed and fabricated PEEK clips demon- strated no statistically significant difference in final retention values from nylon clips after stimulated 3 years of use. 1. Stoumpis C, Kohal RJ. To splint or not to splint oral implants in the implant-supported overdenture therapy? A systematic literature review. J Oral Rehabil. 2011;38:857–69. 2. Thomason JM. The McGill Consensus statement on overdentures. Mandibular 2-implant overdentures as first choice standard of care for edentulous patients. Eu J Prosthodont Restor Dent. 2002; 95–6. y 2- Application of digital designing of custom-made attachment clips provides ease for overdenture main- tenance. 3. Doukas D, Michelinakis G, Smith PW, Barclay CW. The influence of inter- implant distance and attachment type on the retention characteristics of mandibular overdentures on 2 implants: 6-month fatigue retention values. Int J Prosthodont. 2006;21:152–4. 3- PEEK clips could be used as an alternative to nylon and metal bar clips with comparable retention values with resistance to wear and surface alteration.h 4. Kawai Y, Murakami H, Shariati B, Klemetti E, Blomfield JV, Billette L, et al. Do traditional techniques produce better conventional complete den- tures than simplified techniques? J Dent. 2005;33:659–68. i 5. Salehi R, Shayegh SS, Johnston WM, Hakimaneh SMR. Effects of interim- plant distance and cyclic dislodgement on retention of LOCATOR and ball attachments: an in vitro study. J Prosthet Dent. 2019;122:550–6. 4- This is an in-vitro study which cannot simulate oral cavity temperature, patient para functional habits, and the effect of different foods and beverages with either acidic or alkaline composition on the wear of different clip materials. 6. Yilmaz B, Ozkir E, Johnston WM, McGlumphy E. Dislodgement force analysis of an overdenture attachment system. J Prosthet Dent. 2020;123:291–8. 7. Mizumoto RM, Yilmaz B, McGlumphy EA Jr, Seidt JJ, Johnston WM. Accuracy of different digital scanning techniques and scan bodies for complete-arch implant-supported prostheses. J Prosthet Dent. 2020;123:96–104. 7. Mizumoto RM, Yilmaz B, McGlumphy EA Jr, Seidt JJ, Johnston WM. Accuracy of different digital scanning techniques and scan bodies for complete-arch implant-supported prostheses. J Prosthet Dent. 2020;123:96–104. f 5- It is recommended to perform clinical ling term in vivo study for custom made PEEK clip attach- ments. It is also recommended to test the attachment performance with different denture cleansing solu- tions and to test the PEEK clip with different percent- ages of glass fiber reinforcement to improve its wear resistance. 8. Rutkunas V, Mizutani H, Takahashi H. 12. Bayer S, Komor N, Kramer A, Albrecht D, Mericske-Stern REN. Retention force of plastic clips on implant bars: a randomized controlled trial. Oral Impl Res Clin. 2012;23:1377–84. 11. Gonuldas F, Tokar E, Ozturk C. Evaluation of the retention characteristics of various stud attachment systems for implant retained overdenture. Acta Bioeng Biomech. 2018;20:135–41. Publisher’s Note S i N i Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. 18. Savabi O, Nejatidanesh F, Yordshahian F. Retention of implant-supported overdenture with bar/clip and stud attachment designs. J Oral Implantol. 2013;39:140–7. 19. Driscoll CF, Freilich MA, Guckes AD, Knoernschild KL, Mcgarry TJ, Goldstein G, et al. The glossary of prosthodontic terms: ninth edition. J Prosthet Dent. 2017;117:125–105. 20. Choi J-W, Yun B-H, Jeong C-M, Huh J-B. Retentive Properties of Two stud attachments with polyetherketoneketone or nylon insert in mandibular implant overdentures. Int J Oral Maxillofac Implants. 2018;33:1079–88. 21. Botega DM, Mesquita MF, Henriques GEP, Vaz LG. Retention force and fatigue strength of overdenture attachment systems. J Oral Rehabil. 2004;31:884–9. 22. Kamal Emera R, Elgamal M, Altonbary G. Retention force of all-zirconia, all-polyetheretherketone, and zirconia-polyetheretherketone telescopic attachments for implant-retained overdentures: in vitro comparative study. J Dent Implant. 2020;10:78. 23. Taha NEKS, Dias DR, Oliveira TMC, Souza JAC, Leles CR. Patient satisfaction with ball and Equator attachments for single-implant mandibular over- dentures: a short-term randomised crossover clinical trial. J Oral Rehabil. 2020;47:361–9. 24. Abdelaziz MS, El Abd EA, Tella M. Digital fabrication of polyetheretherk- etone retentive bar attachment inserts as overdenture maintenance: a dental technique. J Prosthet Dent. 2022. https://doi.org/10.1016/j.prosd ent.2022.04.019. 25. Marin DOM, Leite ARP, de Oliveira Junior NM, Paleari AG, Pero AC, Com- pagnoni MA. Retention force and wear characteristics of three attach- ment systems after dislodging cycles. Braz Dent J. 2018;29:576–82. 26. Abdelaziz MS, Fawzy AM, Nassar GRM, HI,. Retention of different attach- ment systems for digitally designed mandibular implant overdenture. J Prosthodont. 2022. https://doi.org/10.1111/jopr.13516. 27. Scrascia R, Cicciù M, Manco C, Miccoli A, Cervino G. Angled screwdriver solutions and low-profile attachments in full arch rehabilitation with divergent implants. Appl Sci. 2021;11:1–15. 28. Tasaka A, Matsunaga S, Odaka K, Ishizaki K, Ueda T, Abe S, et al. Accuracy and retention of denture base fabricated by heat curing and additive manufacturing. J Prosthodont Res. 2019;63:85–9. 29. Lo Russo L, Salamini A, Troiano G, Guida L. Digital dentures: a protocol based on intraoral scans. J Prosthet Dent. 2021;125:597–602. 30. Cicciù M, Fiorillo L, D’Amico C, Gambino D, Amantia EM, Laino L, et al. 3D digital impression systems compared with traditional techniques in dentistry: a recent data systematic review. Materials. 2020;13:1–18. 31. Beretta M, Manfredini M, Poli PP, Tansella S, Maiorana C. Author contributions HIN: article approval, operator in all the practical work, manuscript writing- interpretation-Concept—design—critical revision of the article. MSAEA: corresponding author, operator in all the practical work, writing of the 14. Abdraboh A, Elsyad M, Mourad S, Alameldeen H. Milled bar with PEEK and metal housings for inclined implants supporting mandibular 14. Abdraboh A, Elsyad M, Mourad S, Alameldeen H. Milled bar with PEEK and metal housings for inclined implants supporting mandibular Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Nassar and Abdelaziz BMC Oral Health (2022) 22:227 Page 8 of 8 Page 8 of 8 overdentures: 1-year clinical, prosthetic, and patient-based outcomes. Int J Oral Maxillofac Implants. 2020;35:982–9. 37. Abdelrehim A, Abdelhakim A ES. Influence of different materials on reten- tion behavior of CAD-CAM fabricated bar attachments. J Prosthet Dent. overdentures: 1-year clinical, prosthetic, and patient-based outcomes. Int J Oral Maxillofac Implants. 2020;35:982–9. 38. Hammas M, El-Saadawy ME-AA. Effect of different bar attachment and clip materials on retention force for mandibular implant supported overdentures (an invitro study). ADJ-for Girls. 2018;5(2):195–204. 15. Osman R, Abdel Aal M. Comparative assessment of retentive characteris- tics of nylon cap versus retention. Sil in ball-retained mandibular implant overdentures. A randomized clinical trial. Egypt Dent J. 2019;65:1787–94. 38. Hammas M, El-Saadawy ME-AA. Effect of different bar attachment and clip materials on retention force for mandibular implant supported overdentures (an invitro study). ADJ-for Girls. 2018;5(2):195–204. y 39. Burns DR, Unger JW, Elswick RK, Beck DA. Prospective clinical evaluation of mandibular implant overdentures: part I-retention, stability, and tissue response. J Prosthet Dent. 1995;73:354–63. 39. Burns DR, Unger JW, Elswick RK, Beck DA. Prospective clinical evaluation of mandibular implant overdentures: part I-retention, stability, and tissue response. J Prosthet Dent. 1995;73:354–63. 16. Heimer S, Schmidlin PR, Roos MSB. Surface properties of polyethere- therketone after different laboratory and chairside polishing protocols. J Prosthet Dent. 2017;117(3):419–25. 17. Najeeb S, Zafar MS, Khurshid Z, Najeeb S, Zafar MS, Khurshid Z, Siddiqui F. Applications of polyetheretherketone (PEEK) in oral implantology and prosthodontics. J Prosthodont Res. 2016;60(1):12–9. Publisher’s Note S i N i Full digital model- free maxillary prosthetic rehabilitation by means of one-piece implants : a proof of concept clinical report with three-years follow up. Prosthesis. 2022;4:202–12. 32. Williams BH, Ochiai KT, Baba T, Caputo AA. Retention and load transfer characteristics of implant-retained auricular prostheses. Int J Oral Maxil- lofac Implants. 2007;22:366–72. • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: 33. Bayer S, Gruner M, Keilig L, Hultenschmidt R, Nicolay C, Bourauel CUK. Investigation of the wear of prefabricated attachments: an in vitro study of retention forces and fitting tolerances. Quintessence Int. 2007;38:229–37. 34. Petropoulos VCSW. Maximum dislodging forces of implant overdenture stud attachments. Int J Oral Maxillofac Implant. 2002;17:526–35. 35. Fromentin O, Lassauzay C, Abi Nader S, Feine J, De Albuquerque Junior RF. Testing the retention of attachments for implant overdentures: validation of an original force measurement system. J Oral Rehabil. 2010;37:54–62. 36. • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: Publisher’s Note S i N i Fiorillo L, D’Amico C, Turkina AY, Nicita F, Amoroso G, Risitano G. Endo and exoskeleton: new technologies on composite materials. Prosthesis. 2020;2:1–9.
https://openalex.org/W2782786366	https://cyberleninka.ru/article/n/pokorenie-gortsev-v-pervoy-polovine-xix-v-kak-odin-iz-etapov-prisoedineniya-osetii-k-rossii/pdf	Russian	null	Покорение горцев в первой половине XIX в. как один из этапов присоединения Осетии к России	Obŝestvo: filosofiâ, istoriâ, kulʹtura	2,018	cc-by	2,332	Summary: y The paper deals with the processes of state administra- tion of national regions and administrative and territo- rial transformations in this regard. The study is to clar- ify a set of issues describing the most eventful and de- cision-making period in the history of the Russian state. A retrospective scientific analysis of the state policy on the creation of a centralized control system at turning points is presented. The study describes the in- tegration of mountain peoples into the all-Russian so- ciety and the nature of interethnic relations in the re- gions as well as identifies interethnic problems and contradictions among the highlanders. A comparative analysis of the control system and institutional trans- formations in various areas of the region determines the specific characteristics of social processes and em- phasizes the historical features of individual territories in the regional environment that have affected the na- ture of power and their institutional arrangements. В работе рассматриваются процессы в области государственного управления национальными ре- гионами и связанные с ними административно- территориальные преобразования. Статья наце- лена на внесение ясности в рассмотрение ком- плекса вопросов, характеризующих, пожалуй, са- мый насыщенный судьбоносными событиями и решениями период в истории российского госу- дарства. Представлен ретроспективный науч- ный анализ государственной политики в области построения централизованной системы управле- ния на переломных этапах. Описаны особенности процесса интеграции горских народов в общерос- сийский социум и межэтнического взаимодей- ствия в регионах, выделяются проблемы и про- тиворечия межнационального характера в гор- ской среде. Сравнительный анализ системы управления и институциональных преобразова- ний в различных областях региона, который опре- деляет специфику происходящих в нем социаль- ных процессов, подчеркивает исторические осо- бенности отдельных территорий в региональ- ном пространстве, повлиявших на характер вла- сти и институциональной организации в них. Ключевые слова: покорение горцев, присоединение Осетии к Рос- сии, интеграция, реформирование власти, прави- тельство, карательные операции. В последней четверти XVIII в. происходило расширение территорий российского государ- ства на юго-восток. Если рассматривать данное расширение с политической точки зрения, то важно отметить, что российское присутствие на Кавказе было продиктовано соображениями без- опасности. В борьбе за этот регион участвовали Турция, Иран и Россия. В процессе ряда успеш- ных военных операций, таких как Русско-турецкая война 1768–1774 гг. и заключение после ее окончания выгодного для Российской империи Кючук-Кайнарджийского мира, России удалось от- стоять свои внешнеполитические интересы на Кавказе. Также следует обратить внимание на причины экономического характера. Царское прави- тельство нуждалось в плодородных землях для раздачи их дворянству. Keywords: conquest of the highlanders, Ossetia’s accession to Russia, integration, reforms of the power sector, gov- ernment, punitive operations. УДК 94:341.223(470.65+479.225)“180/185” Shavlokhova Elena Sergeevna Шавлохова Елена Сергеевна D.Phil. in History, Professor, Service Technologies and Business Communication Department, Vice-Rector for Research, Academy of Marketing and Social Information Technologies CONQUEST OF THE HIGHLANDERS IN THE FIRST HALF OF THE 19TH CENTURY AS ONE OF THE STAGES OF OSSETIA’S ACCESSION TO RUSSIA [1] D.Phil. in History, Professor, Service Technologies and Business Communication Department, Vice-Rector for Research, Academy of Marketing and Social Information Technologies доктор исторических наук, профессор кафедры технологий сервиса и деловых коммуникаций, проректор по научной работе Академии маркетинга и социально-информационных технологий – ИМСИТ ПОКОРЕНИЕ ГОРЦЕВ В ПЕРВОЙ ПОЛОВИНЕ XIX В. КАК ОДИН ИЗ ЭТАПОВ ПРИСОЕДИНЕНИЯ ОСЕТИИ К РОССИИ [1] D.Phil. in History, Professor, Service Technologies and Business Communication Department, Vice-Rector for Research, Academy of Marketing and Social Information Technologies CONQUEST OF THE HIGHLANDERS IN THE FIRST HALF OF THE 19TH CENTURY AS ONE OF THE STAGES OF OSSETIA’S ACCESSION TO RUSSIA [1] D.Phil. in History, Professor, Service Technologies and Business Communication Department, Vice-Rector for Research, Academy of Marketing and Social Information Technologies CONQUEST OF THE HIGHLANDERS IN THE FIRST HALF OF THE 19TH CENTURY AS ONE OF THE STAGES OF OSSETIA’S ACCESSION TO RUSSIA [1] доктор исторических наук, профессор кафедры технологий сервиса и деловых коммуникаций, проректор по научной работе Академии маркетинга и социально-информационных технологий – ИМСИТ ПОКОРЕНИЕ ГОРЦЕВ В ПЕРВОЙ ПОЛОВИНЕ XIX В. КАК ОДИН ИЗ ЭТАПОВ ПРИСОЕДИНЕНИЯ ОСЕТИИ К РОССИИ [1] доктор исторических наук, профессор кафедры технологий сервиса и деловых коммуникаций, проректор по научной работе Академии маркетинга и социально-информационных технологий – ИМСИТ https://doi.org/10.24158/fik.2018.1.7 https://doi.org/10.24158/fik.2018.1.7 УДК 94:341.223(470.65+479.225)“180/185” Summary: Степное Предкавказье и Северный Кавказ в целом казались идеальной территорией для этих целей. Также следует обратить внимание на причины экономического характера. Царское прави- тельство нуждалось в плодородных землях для раздачи их дворянству. Степное Предкавказье и Северный Кавказ в целом казались идеальной территорией для этих целей. Некоторые авторы считают, что в силу причин геополитического и экономического харак- тера Россия стремилась подчинить Кавказский регион своему влиянию, а затем и включить его в состав империи. Проводниками политической воли на местах должны были стать администра- Н й В С Т й Д у д д р д д р д д р у р д Северный Кавказ в целом казались идеальной территорией для этих целей. Некоторые авторы считают, что в силу причин геополитического и экономического харак- тера Россия стремилась подчинить Кавказский регион своему влиянию, а затем и включить его в состав империи. Проводниками политической воли на местах должны были стать администра- тивные органы. Но есть и другой взгляд на этот вопрос. В.С. Толстой пишет: «До занятия рус- скими Кавказа осетины находились под совершенным игом кабардинцев…», «Благоденствие осетин началось с низложения надменного коварного владычества кабардинцев. Генерал Ермо- лов усмирил Кабарду, и вся Терекская долина от Ларса до Екатеринограда приобретена ценою дорогой русской крови» [2, с. 43–45]. Горские народы Северного Кавказа и Закавказья имеют длительную и богатую историю взаимоотношений с Россией, в течение которой происходил процесс их постепенной интеграции в систему российской государственности и управления. Проблема взаимоотношений власти с малыми народами, управления их территориями, яв- ляясь одним из факторов развития российской государственности, сохраняет свою актуальность и требует новых интерпретаций. Только с помощью опоры на исторический опыт можно дать адек- ватную оценку современным реформам, протекающим на фоне такого социально-политического явления, как кардинальная ломка системных установок и ценностей, а также ее последствий. Общественно-политическая жизнь страны в середине XIX в. полна драматизма. Особенно характерными в этом отношении являются многочисленные попытки реформирования власти. Эпоха реформ, действительно, насыщена поиском оптимальных вариантов построения взаимо- отношений между властью и обществом различных регионов. Ее изучение помогает понять сущ- ность происходившего, определить содержание внутренней политики, а заодно и характер госу- дарственной власти. В середине XIX в. военно-административную и политическую деятельность на Кавказе проводил Е.А. Головин, который в своем рапорте военному министру от 22 июля 1838 г. писал: «Осетия, несмотря на близость управления здешним краем, распространилась по хребту и ущельям Кавказа, до сих пор не вся еще нам подвластна» [3]. В Осетии начала XIX в. происходили изменения в связи с присоединением Картли-Кахетии и Имеретии к России. Summary: Произошло образование Тифлисской и Кутаисской губерний, что видоиз- менило политическую карту Кавказа. Российское правительство не желало напрямую включаться во внутренние вопросы, которые касались управления Осетией. Изменения в управлении Кавка- зом касались этнической целостности народов. Разделяя Осетию, российские управленцы ее южные общества отнесли к Тифлисской и Кутаисской губерниям, северо-восточную равнинную часть передали в ведение Владикавказского коменданта, а Дигорское общество – военного начальника в Кабарде. В результате данной административно-территориальной деятельности появились две Осетии – Южная и Северная. Процесс присоединения Осетии к России проходил в различных частях по-разному. В Се- верной Осетии он осуществлялся более спокойно и при лояльном отношении к российскому управлению, но в некоторых случаях важно показать как позитивное, так и негативное отношение к «подданству всемилостивейшего государя императора» [4]. Как описывал И.Ф. Паскевич, отно- шение северных осетин к внедрению военных чиновников и назначению их правительством было вполне положительным, но в процессе движения отряда генерала И.Н. Абхазова в Северную Осетию его встретили с упорным сопротивлением жители Тагаурии, Куртатии, Алагирии. И, как мы можем заметить, отношение к российскому вторжению было не столь однозначным. В конеч- ном счете были определены уступки местным феодалам. Вместе с тем в 1826 г. завершалась работа по составлению плана, согласно которому во всех районах Северного Кавказа должен был установиться российский административный режим. у р р р В Южной Осетии происходили более сложные процессы. Проводились множественные ка- рательные операции для усмирения местного населения: операция главнокомандующего П.Д. Ци- цианова 1804 г.; генерала А.П. Тормасова 1812 г.; генерала А.П. Ермолова 1817 г., которая оказа- лась неудачной, так как ее участники, попавшие в снежную бурю, погибли; майора Титова, который возглавлял в 1821 г. по приказу А.П. Ермолова экспедицию в село Кроз, сжег его дотла и еще 21 село разорил; операции 1822 и 1824 гг. В данный период происходившие в Южной Осетии со- бытия вызывали тревогу в северных обществах, так как карательные экспедиции становились по- стоянными. В феврале 1830 г. была предпринята карательная экспедиция главнокомандующего И.Ф. Паскевича, 19 июня 1830 г. – генерала К.П. Ренненкампфа, в которой он занимал одно село за другим, но сталкивался с невероятным сопротивлением, в котором участвовали не только муж- чины, но и женщины. В.А. Потто, описывая бои у горы Зикара, отмечал: «Однажды, когда казаки взбирались на голый утес, из-за камней вдруг выскочила молодая осетинка и, как разъяренная тигрица, обхватила первого попавшегося ей казака, напрягла все силы, чтоб вместе с ним упасть в пропасть… Но силы ее истощились и она одна полетела в бездонную пропасть» [5, с. 205–218]. Summary: Карательная экспедиция генерала И.Н. Абхазова летом 1830 г., несмотря на то, что Николай I был доволен и наградил командира орденом Анны I степени, не добилась определенных результатов. Ему не удалось настроить население на гражданское повиновение. Население Осетии не призна- вало новой администрации, хотя открытого сопротивления уже не оказывало [6, с. 257–282]. Это следствие военно-административной и политической деятельности России в 30–40-х гг. XIX в. Помимо карательных экспедиций применялись и другие методы для усмирения населения та Помимо карательных экспедиций применялись и другие методы для усмирения населения, та- кие как введение в Осетии налоговой системы. На первоначальном этапе российская администрация лишь иногда облагала крестьян налогами. Впоследствии осетинских крестьян обязывали доставлять различные строительные материалы и нести подводную, дорожную и почтовую повинности. Общественный порядок нарушался в Южной Осетии, по мнению Е.А. Головина, в связи с набегами, которые устраивали жители отдельных ущелий, «нарушив в глубине гор безопасность мирных соплеменников своими разбоями и грабежами, вынуждали их не только к защите себя, но и к кровомщению» [7]. Е.А. Головин также санкционировал карательную операцию в 1841 г. в Южную Осетию. Впоследствии описывая свои действия, ссылался на приставов, которые нахо- дились под влиянием грузинских властей и ввели его в заблуждение, сообщив о готовившемся вооруженном восстании. Естественно, большинство отряда составляли грузины, знающие только грузинский язык, и возглавлял отряд грузинский князь полковник И.М. Андроников. По мнению М.М. Блиева, «это было не столько карательной экспедицией, обычно направляемой для наве- дения “порядка” среди местного населения, сколько организованным официальными властями нашествием в Южную Осетию грузинских вооруженных сил во главе с тавадами» [8, с. 67]. Процессы включения Осетии в административно-правовую систему можно было проводить мирным путем, но этому помешало убеждение в кругах российской столицы, что именно такой способ покорения горцев придаст прочность имперским позициям. Итогом карательных мер в Северной Осетии являлось военно-политическое покорение Осе- тии, которое было достигнуто в процессе совместной деятельности генерала И.Н. Абхазова и И.Ф. Паскевича в 1830 г. Позже, в 1831 г., карательная экспедиция в Дигорское общество была пред- принята генералом А.З. Горихвостовым. Экспедиция в Дигорское общество завершилась военно- политическим покорением Осетии. Был установлен политико-административный режим, который в полной мере отвечал принципам природы российского самодержавия. Как отмечал К. Хетагуров, такой режим «с первых шагов пошел вразрез с духовно-социальным строем туземцев» [9, с. 205]. В этот период кавказские горские народы переживают очередную трансформацию, посте- пенно втягиваясь в общероссийское социально-экономическое и культурное пространство со всеми его негативными и позитивными процессами. Summary: С внешним воздействием российской админи- стративной системы на региональный социум были связаны распространение правовых институ- тов административного управления горскими сообществами, постепенное разрушение прежней, традиционной управленческой структуры, принятой у горских народов. Значительную роль в этом играли те административные и правовые реформы в крае, которые были осуществлены в конце XIX – начале XX в. Несмотря на резкие высказывания некоторых авторов, изменения в правовой сфере горских сообществ и системе управления горскими народами происходили постепенно с учетом местных особенностей и традиций. По существу, Северный Кавказ повторял тот путь адми- нистративного и правового развития, который уже давно прошли другие российские регионы. Вме- сте с тем нельзя не учитывать, что слой носителей «общеимперского начала» в них был чрезвы- чайно тонок, часто едва заметен на фоне традиционных социальных структур и правовой культуры, имеющей традиционный самодовлеющий и глубоко укорененный характер. Так как внедрение рос- сийского администрирования происходило с учетом народных обычаев, можно говорить о низком уровне правовой культуры среди населения региона. Тем не менее те преобразования, которые проходили в российском социуме на рубеже веков, постепенно захватывали и регион Северного Кавказа. Росло влияние общеимперских правовых норм и учреждений, развивалась система управ- ления в крае, усложнялась социальная структура регионального социума. 8. Блиев М.М. Южная Осетия в коллизиях российско-грузинских отношений. 2-е изд. М., 2006. С. 67. 9. Хетагуров К. Избранное. Орджоникидзе, 1989. С. 205. На осет. яз. 1. Издание статьи осуществлено при финансовой поддержке РФФИ в рамках проекта проведения научных исследова- ний «Присоединение Осетии к России как процесс интеграции народов Северного Кавказа в административно-пра- вовую систему России» (конец XVIII – начало XIX в.), проект № 16-11-23014. 6. Блиев М.М., Бзаров Р.С. История Осетии с древнейших времен и до конца XIX в. Владикавказ, 2000. С. 257–282. 7. РГИА. Ф. 1268. Оп. 1. Д. 84. Л. 3 об. 8. Блиев М.М. Южная Осетия в коллизиях российско-грузинских отношений. 2 9. Хетагуров К. Избранное. Орджоникидзе, 1989. С. 205. На осет. яз. Ссылки и примечания: 1. Издание статьи осуществлено при финансовой поддержке РФФИ в рамках проекта проведения научных исследова- ний «Присоединение Осетии к России как процесс интеграции народов Северного Кавказа в административно-пра- вовую систему России» (конец XVIII – начало XIX в.), проект № 16-11-23014. 2 Т й В С С С й О В 1997 С 43 45 1. Издание статьи осуществлено при финансовой поддержке РФФИ в рамках проекта проведения научных исследова- ний «Присоединение Осетии к России как процесс интеграции народов Северного Кавказа в административно-пра- вовую систему России» (конец XVIII – начало XIX в.), проект № 16-11-23014. у у ( ц ), р 2. Толстой В.С. Сказание о Северной Осетии. Владикавказ, 1997. С. 43–45. р 3. РГИА (Рос. гос. ист. арх.). Ф. 1268. Оп. 1. Д. 84. Л. 1 об. 4. РГВИА (Рос. гос. воен.-ист. арх.). Ф. ВУА. Д. 6245. Л. 2–5. 5. Потто В.А. Русские на Кавказе. XIX век. М., 2017. С. 205–218. ( р ) Д 5. Потто В.А. Русские на Кавказе. XIX век. М., 2017. С. 205–218.
https://openalex.org/W4220981208	https://research.chalmers.se/publication/529305/file/529305_Fulltext.pdf	English	null	Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation	Acta pædiatrica	2,022	cc-by	6,889	Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation Downloaded from: https://research.chalmers.se, 2024-10-24 04:42 UTC Citation for the original published paper (version of record): Morsing, E., Lundgren, P., Hård, A. et al (2022). Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation. Acta Paediatrica, International Journal of Paediatrics, 111(6): 1167-1175. http://dx.doi.org/10.1111/apa.16316 N.B. When citing this work, cite the original published paper. research.chalmers.se offers the possibility of retrieving research publications produced at Chalmers University of Technology. It covers all kind of research output: articles, dissertations, conference papers, reports etc. since 2004. research.chalmers.se is administrated and maintained by Chalmers Library research.chalmers.se offers the possibility of retrieving research publications produced at Chalmers University of Technology. It covers all kind of research output: articles, dissertations, conference papers, reports etc. since 2004. research.chalmers.se is administrated and maintained by Chalmers Library Abstract Ann Hellström, Department of Pediatric Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden. Aim: This study investigated childhood diagnoses in children born extremely preterm before 24 weeks of gestation. Aim: This study investigated childhood diagnoses in children born extremely preterm before 24 weeks of gestation. Methods: Diagnoses of neurodevelopmental disorders and selected somatic diagno- ses were retrospectively retrieved from national Swedish registries for children born before 24 weeks from 2007 to 2018. Their individual medical files were also examined. Results: We studied 383 children born at a median of 23.3 (range 21.9–23.9) weeks, with a median birthweight of 565 (range 340–874) grams. Three-quarters (75%) had neurodevelopmental disorders, including speech disorders (52%), intellectual disabili- ties (40%), attention deficit hyperactivity disorder (30%), autism spectrum disorders (24%), visual impairment (22%), cerebral palsy (17%), epilepsy (10%) and hearing im- pairment (5%). More boys than girls born at 23 weeks had intellectual disabilities (45% vs. 27%, p < 0.01) and visual impairment (25% vs. 14%, p < 0.01). Just over half of the cohort (55%) received habilitation care. The majority (88%) had somatic diagnoses, including asthma (63%) and failure to thrive/short stature (39%). Email: ann.hellstrom@medfak.gu.se Eva Morsing1 \| Pia Lundgren2 \| Anna-Lena Hård2 \| Alexander Rakow3 \| Lena Hellström-Westas4 \| Lena Jacobson2,5 \| Mats Johnson6 \| Staffan Nilsson7,8 \| Lois E.H. Smith9 \| Karin Sävman10,11 \| Ann Hellström2 Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden 2The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgren Academy, University of Gothenburg, Gothenburg, Sweden 3Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden 4Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden 5Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden 6Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 7Department of Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden 8Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 9Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA 10Region Västra Götaland, Department of Neonatology, The Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden 11Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 2The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neurosc Academy, University of Gothenburg, Gothenburg, Sweden Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden O R I G I N A L A R T I C L E O R I G I N A L A R T I C L E Abbreviations: ADHD, attention deficit hyperactivity disorder; ASD, autism spectrum disorders; EPT, extremely preterm; EXPRESS, Extremely Preterm in Sweden Study; ICD-10, International Classification of Diseases, Tenth Revision; IQ, intelligence quotient; NDI, neurodevelopmental impairment; SD, standard deviation; SWEDROP, Swedish National Register for Retinopathy of Prematurity. Acta Paediatrica. 2022;00:1–9. Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation Eva Morsing1 \| Pia Lundgren2 \| Anna-Lena Hård2 \| Alexander Rakow3 \| Lena Hellström-Westas4 \| Lena Jacobson2,5 \| Mats Johnson6 \| Staffan Nilsson7,8 \| Lois E.H. Smith9 \| Karin Sävman10,11 \| Ann Hellström2 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. order; ASD, autism spectrum disorders; EPT, extremely preterm; EXPRESS, Extremely Preterm in Sweden Study; ICD-10, (article starts on next page) Received: 16 December 2021 \| Revised: 11 February 2022 \| Accepted: 24 February 2022 Received: 16 December 2021 \| Revised: 11 February 2022 \| Accepted: 24 February 2022 DOI: 10.1111/apa.16316 DOI: 10.1111/apa.16316 O R I G I N A L A R T I C L E Key Notes During the last two decades, the survival of extremely preterm (EPT) infants, born before 28 completed weeks of gestation, has increased. This has partly been due to the more proactive care of infants born before they have completed 24 weeks.1 Initiating in- tensive care for the most immature infants is a matter of debate, due to their high mortality, the heavy burden of neonatal morbidi- ties and later sequelae. In Sweden, the one-year survival rates for infants born alive 2014–2016 with gestational age 22 and 23 weeks were 30% and 61%, respectively.1 Neurodevelopmental disorders following EPT birth have been investigated by a number of studies with large cohorts. These disorders have included intellectual dis- abilities, cerebral palsy and visual and hearing impairment.2 In ad- dition, speech disorders,3 attention deficit hyperactivity disorders (ADHD),4–6 autism spectrum disorders (ASD),7,8 psychological prob- lems,9 epilepsy10 and sleep disturbances11 have been reported after preterm birth but have not been included in the large cohort studies on neurodevelopmental outcome after EPT birth. The long-term se- quelae of EPT birth also include dysfunction of other organ systems that manifest as respiratory dysfunction,12 poor growth13 and kid- ney dysfunction.14 Outcome data for children born before 24 weeks are scarce. This is mainly due to the limited number of survivors and the fact that studies have not covered the broad range of follow-up diagnoses that these infants receive. • This large registry-based study showed that 75% of Swedish children born before 24 weeks of gestation had neurodevelopmental disorders, including intellectual disabilities (40%), autism (24%) and 55% required habili- tation services. • Somatic disorders were diagnosed in 88% of the cohort: 63% had asthma and 39% failed to thrive and/or had a short stature. • Boys were more likely to have intellectual disabilities and visual impairment than girls if they were born at 23 weeks. K E Y W O R D S K E Y W O R D S extremely preterm birth, habilitation care, long-term support, neurodevelopmental disorders, somatic disorders K E Y W O R D S extremely preterm birth, habilitation care, long-term support, neurodevelopmental disorders, somatic disorders 2.1 \| Study population The study comprised a Swedish national cohort of 399 children born before 24 weeks of gestation from January 2007 to December 2018. They had all survived until 40 weeks of postmenstrual age, and their details were registered in the Swedish National Register for Retinopathy of Prematurity (SWEDROP). In Sweden, all infants born before 30 weeks are included in an ROP screening schedule and the results are reported to SWEDROP, which has been estimated to cover 98% of cases.15 The wide range of neurodevelopmental disorders that have been reported in EPT infants indicates the need for long-term support. Sweden has habilitation centres, where multi-professional teams of neurologists, physiotherapists and psychologists look after patients that have neurodevelopmental disorders with functional impair- ments. The number of children born EPT that are referred to habili- tation centres may reflect the need for special support in this group. Habilitation centres offer treatment, training and medical aids for the children and support for the parents. Low vision clinics offer cor- responding services to habilitate visually impaired children. The children's diagnoses were retrieved from the National Board of Health and Welfare's National Patient Register and from the National Register of Patients with Cerebral Palsy. In addition, the individual medical charts of the children were examined to validate and complete the diagnoses received from the registries. The Swedish Ethics Review Authority approved the study (D. nr 2019-05265). The primary aim of this large, retrospective, national study was to report clinical diagnoses registered after children born before 24 weeks were discharged from neonatal care. We selected and doc- umented the diagnoses that were likely to have a significant impact on the children's lives. In addition, we wanted to investigate the need that this patient group would have for medical care and habilitation services during childhood. 2 \| Conclusion: Most children born before 24 weeks had neurodevelopmental disorders and/or additional somatic diagnoses in childhood and were referred to habilitation services. Clinicians should be aware of the multiple health and developmental prob- lems affecting these children. Resources are needed to identify their long-term sup- port needs at an early stage. Funding information This study was supported by the Swedish Medical Research Council (#2016- 01131), The Gothenburg Medical Society and Government grants under the ALF agreement (ALFGBG-717971), De Blindas Vänner, Knut and Alice Wallenberg Clinical Scholars. None of the funders played any role in any aspect of the study or paper y , p g p p y p p © 2022 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica. \| 1 wileyonlinelibrary.com/journal/apa 2 \| 2 \| 2 \| 2 \| MORSING et al. 3.2 Table 1 summarises the diagnoses of neurodevelopmental disorders after discharge. This showed that 75% of the children had any neu- rodevelopmental disorder. These comprised speech disorders (52%), intellectual disabilities (40%), ADHD (30%), ASD (24%), visual impair- ment (22%), cerebral palsy (17%), epilepsy (10%) and hearing impair- ment (5%). A larger proportion of children born at 21 and 22 weeks compared to those born at 23 weeks had intellectual disabilities (49% vs. 36%, p < 0.05), and a larger proportion were referred for habilitation care (64% vs. 52%, p < 0.05 (Figure 1A). More boys than girls were diagnosed with intellectual disabilities (46% vs. 36%, p < 0.01), and this difference was more pronounced in those born at 23 weeks (45% vs. 27%, p < 0.01) (Figure 1B). When we looked at the 23-week group, more boys than girls were visually impaired (25% vs. 14%, p < 0.01) and/or referred for habilitation (60% vs. 43%, p < 0.01) (Figure 1B). 3.1 \| Birth characteristics The 383 infants were born at a median of 23.3 (range 21.9–23.9) weeks of gestation. The median birth weight was 565 (range 340– 874) grams, and the median birth weight SD was −0.40 (range minus 3.63–3.17). Two infants, a boy and a girl, were born at 21 weeks, 91 infants were born at 22 weeks (54% boys), and 290 infants were born at 23 weeks (51% boys). The two infants born at 21 weeks were added to the 22-week group. 3.3 \| Somatic diagnoses Table 2 summarises the somatic diagnoses after discharge. Failure to thrive/short stature was diagnosed in 39% of the children, and it was more frequent in those born at 21 and 22 weeks than those born at 23 weeks (49% vs. 36%, p < 0.05). Severe constipation was found in 29% of the total cohort, and 18% had a gastrostomy. 2.3 \| Childhood diagnoses Diagnoses related to prematurity were divided into neurodevelop- mental disorders and other somatic diagnoses. 2.4 \| Neurodevelopmental disorders We found that 16 of the 399 infants identified through the SWEDROP died before they could be followed up, and this meant that 383 infants were included in the study. The children's ages at the time of the last visit ranged from 2 to 13 years. Cerebral palsy (any) was recorded as a neurodevelopmental disorder in children with a Gross Motor Function Classification System level ≥1 and an International Classification of Diseases, Tenth Revision (ICD-10) code of G80.0-G80.9. The diagnoses were double-checked with the National Board of Health and Welfare's Patient Register and the register for patients with cerebral palsy. A diagnosis of intel- lectual disability was based on developmental tests and estimated adaptive skills and classified using the intelligence quotient (IQ) scores and the ICD-10 codes in brackets. Mild (IQ 50–69), moder- ate/severe (IQ < 50) and any intellectual disability (F70.0-72.9) as well as epilepsy (G40.1-40.9) were recorded. Hearing impairment was defined as dependence on hearing aids or worse. Visual impair- ment was defined as being referred to a low vision clinic at any age or having a best-corrected visual acuity of <0.33 (20/60) in the best eye or with both eyes together at 3.5 years or older. In addition, we recorded the neurobehavioral disorders ASD (F84.0) and ADHD (F90.0-90.9) and impressive and/or expressive speech disorders (F80.1-80.9). 2.5 \| Other somatic diagnoses Other somatic diagnoses included diagnoses related to growth, nutrition and gastrointestinal functions, such as failure to thrive (R62.8), short stature due to endocrine disorder (E34.3), obstipa- tion (K59.0), surgically treated inguinal hernia and gastrostomy (K40.9A-B, JDB 10 and Z931). The kidney diseases nephrocalci- nosis and nephritis (N20.0, N10.9 and N12.9) were also recorded, as were the respiratory diagnoses of asthma and childhood bron- chopulmonary dysplasia (J45.0-J45.9, P27.1), persistent pulmonary hypertension (I27.2) and vocal cord paresis (J38.0). Severe respira- tory impairment was defined as a need for oxygen supplementation up to at least 2 years of age or more and/or tracheostomy and/or a home ventilator during childhood. Referrals to habilitation centres were also recorded. \| 3 birth weight and sex. The birth weight standard deviation (SD) was calculated.16 Numbers and percentages are provided for categorical vari- ables, with medians and ranges for continuous variables. We used Pearson's chi-square test and Fisher's exact test for dichotomous variables. Logistic regression was used to evaluate the relationships between age and diagnosis. The level of significance was set as a p value of <0.05. 2.2 Birth characteristics were recorded, including gestational age, which was determined by routine ultrasound assessments at 17–18 weeks, MORSING et al. \| 3 3 \| 3.4 \| Summary The majority (96%) of the children had one or more of the diag- noses selected for this study. There were 15 children without any diagnoses, 10 girls and 5 boys, and they included one boy and one girl born at 22 weeks. The medical records clearly stated that 5 of the 15 children were healthy. The data were sporadic for 2 of the children, as they did not attend the planned follow-up visits after the neonatal period. There were medical file indications of disorders in the remaining 8 children, such as lung problems, al- lergies and neurobehavioral problems, but no ICD diagnoses had been recorded. In general, Sweden has a proactive approach to neonatal care. The current Swedish guidelines, which were introduced in 2016, state that resuscitation should be considered for infants born at 22 weeks and is recommended for those born at 23 weeks.17 Survival to discharge increased over time, and further unpublished data from our cohort show that this was particularly pronounced for infants born alive at 22 weeks. Their survival rates rose from 20% in 2013–2015 to 38% in 2016–2018. The increased survival of EPT infants during the last decades has been accompanied by increasing data on neurodevelopmental impairment (NDI), in terms of cognition, motor function, hearing and vision. Most large cohort studies have not addressed neu- robehavioral issues.18–22 Previous studies have also been limited by the low number of infants born before 24 weeks. Most stud- ies have focussed on children below 3 years of age, and it may have been difficult to diagnose neuropsychiatric problems at this early age. In addition, varying definitions of impairment have complicated comparisons. For example, many studies have used definitions of cognitive deficits that differ from the definitions in ICD-10. Many studies have used an IQ of 70–85 to indicate mild cognitive deficits, but ICD-10 refers to mild intellectual disability as an IQ of 50–69. Figure 2 reports all the diagnoses stratified by the children's ages at the follow-up visits: 2–5, 6–9 and 10–13 years. There was a sig- nificant trend for neurodevelopmental disorders to become more frequent with age, with an odds risk of 1.090 per year and a 95% confidence interval of 1.015–1.169 (p < 0.05). However, there were no age-dependent differences for the other diagnoses. 4 \| DISCUSSION Asthma and childhood bronchopulmonary dysplasia, pulmonary hypertension and vocal cord paresis were diagnosed in 63%, 12%, 13%, respectively, and 12% had severe respiratory impairment. There were no significant differences between boys and girls (data not shown). This was a retrospective national file review registry-based study of children born before 24 weeks of gestation, who were followed up until 2 to 13 years of age. We found that 75% had neurode- velopmental disorders at 2–13 years of age and more than half of the children (55%) required assistance from habilitation services. Boys were more likely to be affected by intellectual and visual im- pairment than girls. The vast majority of the cohort (96%) had a combination of neurodevelopmental disorders and other somatic diagnoses. 2.6 \| Statistical analysis The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 25.0. (IBM Corp). MORSING et al. 4 noses of neurodevelopmental disorders in children born before 24 weeks of gestation in Sweden 2007–2018 B LE 1 Diagnoses of neurodevelopmental disorders in children born before 24 weeks of gestation in Swede 22 weeks GA (n = 93)a 23 weeks GA (n = 290) Total (n = 383) Missing value (n) Cerebral palsy 18/87 (21%) 43/265 (16%) 61/352 (17%) 31/383 (8%) Epilepsy 8/89 (9%) 30/282 (11%) 38/371 (10%) 12/383 (3%) Intellectual disability 42/85 (49%)* 93/257 (36%)* 135/342 (40%) 41/383 (11%) Autism spectrum disorder 22/80 (28%) 59/254 (23%) 81/334 (24%) 49/383 (13%) ADHD after 6 years of age 8/32 (25%) 43/136 (32%) 51/168 (30%) 54/222 (24%) Hearing impairment 5/90 (6%) 13/280 (5%) 18/370 (5%) 13/383 (3%) Visual impairment 25/85 (29%) 48/248 (19%) 73/333 (22%) 50/383 (13%) Speech disorders 46/82 (56%) 134/261 (51%) 180/343 (52%) 40/383 (10%) Referred to habilitation services 56/87 (64%)* 138/266 (52%)* 194/353 (55%) 30/383 (8%) Any neurodevelopmental disorder at follow-up 73/93 (78%) 214/288 (74%) 287/381 (75%) 2/383 (0.5%) Note: Data expressed as n and (%). Any neurodevelopmental disorder diagnosis is defined as one or more of the above-defined diagnoses and disorders. Abbreviations: ADHD, Attention deficit hyperactivity disorder; GA, gestational age. aThe two infants born at 21 weeks GA are included. p < 0 05 difference between children born at GA 22 and 23 weeks p < 0.05 difference between children born at GA 22 and 23 weeks. 3.4 \| Summary We found that 193 (50%) of the children had further episodes of inpatient care after they were discharged from the neonatal in- tensive care unit and the median number was 2 (range 0–18). The median number of days in inpatient care was 8 (range 0–276 days), as shown in Figure S1A,B. No inpatient care was needed for the other 190 children. There were no significant differences in the number of episodes or length of care, when gestational age was taken into account. \| 5 MORSING et al. FI G U R E 1 (A) Percentage of children diagnosed with neurodevelopmental disorders by gestational age. Significant differences are presented as p < 0.05. (B) Percentage of children diagnosed with neurodevelopmental disorders and significant associations with sex. Significant differences are presented as p < 0.05 and *p < 0.01 (A) (B) \| 5 5 MORSING et al. \| 5 \| (A) (A) Percentage of children diagnosed with neurodevelopmental disorders by gestational age. Significant differences are < 0.05. (B) Percentage of children diagnosed with neurodevelopmental disorders and significant associations with sex. (B) (B) FI G U R E 1 (A) Percentage of children diagnosed with neurodevelopmental disorders by gestational age. Significant differences are presented as p < 0.05. (B) Percentage of children diagnosed with neurodevelopmental disorders and significant associations with sex. Significant differences are presented as p < 0.05 and p < 0.01 This study found that diagnoses such as ASD and intellectual disability were more frequent in the older age groups. It is likely that the younger children may have cognitive or neuropsychiatric disorders that will be discovered later. In addition, studies have reported increases in neurodevelopmental dysfunction between 2.5 and 6.5 years of age.20,23 Another study found that health- related quality of life declined from 11 to 19 years of age, ac- cording to reports from adolescents born extremely preterm and their parents.24 The population-based EPICure study from the UK found that the prevalence of intellectual impairment increased significantly from 11 to 19 years of age and that there was impair- ment in multiple neuropsychological domains.25 This may have an impact on social skills later in life.26 In general, studies of childhood ASD and ADHD have found that these diagnoses had a profound impact on later life, with adults showing decreased independence and need for support.27,28 The national Extremely Preterm in Sweden Study (EXPRESS), of infants born from 2004 to 2007, stated that the number of children born at 22 weeks was too small to analyse outcomes at 6.5 years of age.20 However, the mean (SD) Full-Scale Intelligence MORSING et al. \| 5 6 E 2 Other somatic diagnoses in children born before 24 weeks of gestation in Sweden 2007–2018 22 weeks GA (n = 93)a 23 weeks GA (n = 290) Total (n = 383) Missing value (n) Failure to thrive/short-stature 41/84 (49%) 98/272 (36%)* 139/356 (39%) 27/383 (7%) Obstipation 28/89 (32%) 78/278 (28%) 106/367 (29%) 16/383 (4%) Gastrostomy 15/90 (17%) 53/282 (19%) 68/372 (18%) 11/383 (3%) Kidney disorder 8/89 (9%) 18/281 (6%) 26/370 (7%) 13/383 (3%) Inguinal hernia (boys) 15/48 (31%) 53/147 (36%) 68/195 (35%) 4/199 (2%) Asthma 52/90 (58%) 182/281 (65%) 234/371 (63%) 12/383 (3%) Pulmonary hypertension 12/89 (14%) 31/281 (11%) 43/370 (12%) 13/383 (3%) Uni- or bilateral vocal cord paresis 13/90 (14%) 35/281 (12%) 48/371 (13%) 12/383 (3%) Severe respiratory impairment 12/92 (13%) 33/288 (12%) 45/380 (12%) 3/383 (1%) Any of the other somatic diagnoses at follow-up 81/93 (87%) 256/289 (89%) 337/382 (88%) 1/383 (0.3%) Note: Data expressed as n and (%). Severe respiratory impairment is defined as requiring a home-ventilator and/or tracheostomy and/or having a need for oxygen supplementation up to at least two years of age or more. Any other somatic diagnosis is defined as one or more of the above-defined diagnoses and disorders. Note: Data expressed as n and (%). Severe respiratory impairment is defined as requiring a home-ventilator and/or tracheostomy and/or having a need for oxygen supplementation up to at least two years of age or more. Any other somatic diagnosis is defined as one or more of the above-defined diagnoses and disorders. Note: Data expressed as n and (%). Severe respiratory impairment is defined as requiring a home-ventilator and/or tracheostomy and/or having a need for oxygen supplementation up to at least two years of age or more. Any other somatic diagnosis is defined as one or more of the above-defined diagnoses and disorders. FI G U R E 2 Percentage of children with neurodevelopmental disorders, somatic diagnoses and/or a combination of the 2, as defined in Tables 1 and 2, in different age groups. Significant differences over time are presented as p < 0.05 FI G U R E 2 Percentage of children with neurodevelopmental disorders, somatic diagnoses and/or a combination of the 2, as defined in Tables 1 and 2, in different age groups. born at 22 weeks and 155/303 (51%) born at 23 weeks. There was no change in outcomes among the infants born at 22 weeks between 2002–2003 and 2008–2011 and survival without NDI increased with time in those born at 23 weeks.21 ADHD are most likely to be affected by the inattentive subtype and associated intellectual disabilities.5,6,37 More than half of all children (52%) in our study had been di- agnosed with speech disorders, including impaired articulation and language development, and 13% had vocal cord paresis, which may impact both their voice and their respiration.38 It has been suggested that more active treatment and increased survival may lead to fewer children affected by morbidities and/ or less severe diseases29 but this has been questioned by others.30 Changes in survival rates over the years, and differences between hospitals and countries, can be explained by a number of factors. These include rates of initiating active life-supporting care and the quality of neonatal care for very immature infants.31–33 The trend analyses carried out by our study found that the rates for cerebral palsy did not alter over time (data not shown), which means that initiating active care at younger gestational ages did not result in a lower incidence of cerebral palsy in this Swedish cohort. Trend analyses for other diagnoses were complicated, because they were age-dependent. Analyses between sites were not performed in our study, as the wide age ranges at follow-up, and variations in local routines, could have influenced the results. Our findings agree with the EPICure 2 study, which reported no changes in neurodevelop- mental impairment at 11 years of age in children born between 1995 and 2006.34 It is challenging to achieve optimal growth in those born EPT during the neonatal period and childhood. One study reported that children who were born EPT demonstrated catch-up growth in weight and length during childhood, but not head circumference.13 Poor growth and gastrointestinal problems were common in our study, and 29% had severe constipation. We found that 7% of the cohort were diagnosed with nephro- calcinosis or nephritis. Nephrocalcinosis is common after EPT birth, but usually resolves during childhood.39 However, children born EPT are three times as likely to have chronic kidney disease as those born at term.40 The majority (63%) of the children in our study had been diag- nosed with asthma and/or childhood bronchopulmonary dysplasia, but these diagnoses are often difficult to distinguish from each other and are not consistently applied in different regions. In comparison, another study reported asthma-like disease in 40% of children born EPT and in 15% of controls born at term.41 Functional difficulties, such as asthma and cerebral palsy, have been linked to anxiety and depression, which are commonly found in children born EPT.9 A Japanese multicentre study with comparatively high survival rates found that 12/23 (52%) children born at 22 weeks had NDIs and 30% had profound NDIs at 36–42 months of age. The respective figures for those born at 23 weeks were 65/114 (57%) and 45/114 (40%).18 A centre in the United States, with an active perinatal ap- proach to births at 22 and 23 weeks in 2006–2015, reported the prevalence of moderate-to-severe NDIs at 18–22 months. These af- fected 5/11 (45%) children born at 22 weeks and 11/34 (32%) born at 23 weeks.22 A Swedish centre that adopted a uniform active ap- proach to the most immature infants retrospectively reported that 50% of children born at 22 weeks and 62% born at 23 weeks did not have NDIs at 2.5 years.35 These results differ from our findings and may be partly explained by the young age at follow-up examina- tions and the limited number of diagnoses reported in those stud- ies. In comparison, a German study of children born from 1999 to 2003, who received proactive care, reported that 1/6 (17%) born at 22 weeks and 8/35 (23%) born at 23 weeks were considered unim- paired at 7–10 years of age.36 Genetic factors, including sex, influence the development of EPT.42 It is well known that boys are more vulnerable to oxidative stress-related complications of prematurity than girls.43 We found no differences in the diagnosis rates between boys and girls, with one exception. Boys born at 23 weeks were more frequently diagnosed with an intellectual disability than girls born at the same age, and they also had higher risks of visual impairment and habilitation referrals. Perinatal management is challenging when infants are born EPT.44 There are debates about whether it is right to initiate in- tensive care for the most immature infants and whether clinicians should withdraw or withhold life-saving actions in certain cases, es- pecially if infants have a severe brain injury.45 \| 5 Significant differences over time are presented as p < 0.05 Quotient scores on the Wechsler Intelligence Scale for Children, Fourth Edition, were 76 (5.4) for four children born at 22 weeks and 75 (13.8) for 37 children born at 23 weeks. When children born at 23 weeks were assessed at 6.5 years of age, 22% had se- vere functional impairment and 35% had moderate impairment. The other 44% had no or mild impairment.20 Our study found that 17% of children born before 24 weeks had cerebral palsy. In com- parison, the Extremely Preterm in Sweden Study reported cere- bral palsy in 10% of infants born before 27 weeks and none infant born at term.20 Our study found that the rates for hearing and visual impairments were 5% and 22%, respectively. These were compared to 2% and 5%, respectively, in children born before 27 weeks in the EXPRESS study and 0.5% and 0.6%, respectively, in term-born children.20 EPICure 2 found that it was uncommon for children born at 22 weeks to survive to 3 years of age and that two of three sur- viving children (67%) had moderate or severe NDI. Of those born at 23 weeks, 31/63 (49%) had moderate-to-severe NDI at that age.19 These outcomes were similar to the findings of a US National Institute of Child Health and Human Development Neonatal Research Network study, which studied neurodevelopmental impair- ment at 18–22 months of age. This affected 18/27 (67%) of infants MORSING et al. 7 ORCID Pia Lundgren https://orcid.org/0000-0002-7731-1988 Anna-Lena Hård https://orcid.org/0000-0002-2440-2851 Lena Jacobson https://orcid.org/0000-0001-8563-2127 Ann Hellström https://orcid.org/0000-0002-9259-1244 16. Marsál K, Persson PH, Larsen T, Lilja H, Selbing A, Sultan B. Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatr. 1996;85(7):843-848. doi:10.1111/ j.1651-2227.1996.tb14164.x 17. Domellöf M, Jonsson B. The Swedish approach to management of extreme prematurity at the borderline of viability: a historical and ethical perspective. Pediatrics. 2018;142(Suppl 1):S533-S538. doi:10.1542/peds.2018-0478C 8 \| MORSING et al. 6. Montagna A, Karolis V, Batalle D, et al. ADHD symptoms and their neurodevelopmental correlates in children born very preterm. PLoS One. 2020;15(3):e0224343. doi:10.1371/journal.pone.0224343 latest follow-up visit, which ranged from 2 to 13 years, as some diag- noses only become apparent later in childhood.23 A further weakness was the variations in regional policies regarding follow-up assess- ments, as this might have affected referrals and the age at diagnosis. 7. Joseph RM, O'Shea TM, Allred EN, et al. Prevalence and associated features of autism spectrum disorder in extremely low gestational age newborns at age 10 years. Autism Res. 2017;10(2):224-232. doi:10.1002/aur.1644 8. Padilla N, Fransson P, Donaire A, et al. Intrinsic functional connec- tivity in preterm infants with fetal growth restriction evaluated at 12 months corrected age. Cereb Cortex. 2017;27(10):4750-4758. doi:10.1093/cercor/bhw269 5 \| CONCLUSION Our study showed that 75% of infants born EPT, before 24 weeks of gestation, were affected by neurodevelopmental disorders dur- ing childhood and 88% had somatic disorders. The most common issues included asthma and childhood bronchopulmonary dysplasia, speech disorders, intellectual disabilities, failure to thrive, ADHD and ASD. Boys were more likely to have intellectual disabilities than girls. Further studies are needed to understand functional domains and social skills as these children grow up, so that relevant support can be provided. In addition, neonatal clinical practice needs to adopt a long-term perspective and clinicians treating children and adults should be aware of the complicated health problems of chil- dren born before 24 weeks. 9. Moore PS, Mokrova I, Frazier JA, et al. Anxiety and depression correlates at age 10 in children born extremely preterm. J Pediatr Psychol. 2021;46(4):422-432. doi:10.1093/jpepsy/jsaa118 10. Hirschberger RG, Kuban KCK, O'Shea TM, et al. Co-occurrence and severity of neurodevelopmental burden (cognitive impair- ment, cerebral palsy, autism spectrum disorder, and epilepsy) at age ten years in children born extremely preterm. Pediatr Neurol. 2018;79:45-52. doi:10.1016/j.pediatrneurol.2017.11.002 11. Durankus F, Aladag Ciftdemir N, Vatansever Ozbek U, Duran R, Acunas B. Comparison of sleep problems between term and preterm born preschool children. Sleep Med. 2020;75:484-490. doi:10.1016/j.sleep.2020.09.013 12. Hurst JR, Beckmann J, Ni Y, et al. Respiratory and cardiovascu- lar outcomes in survivors of extremely preterm birth at 19 years. Am J Respir Crit Care Med. 2020;202(3):422-432. doi:10.1164/ rccm.202001-0016OC ACKNOWLEDGEMENT 13. Ni Y, Lancaster R, Suonpera E, et al. Growth in extremely preterm children born in England in 1995 and 2006: the EPICure stud- ies. Arch Dis Child Fetal Neonatal Ed. 2022;107(2):193-200. doi:10.1136/archdischild-2020-321107 We thank research nurse Carola Pfeiffer-Mosesson for helping to collect the medical files from the Swedish hospitals and habilitation centres and the hospital staff who supplied them. 14. Sanderson KR, Chang E, Bjornstad E, et al. Albuminuria, hyper- tension, and reduced kidney volumes in adolescents born ex- tremely premature. Front Pediatr. 2020;8:230. doi:10.3389/ fped.2020.00230 The authors have no conflicts of interest to declare. 15. Holmström GE, Hellström A, Jakobsson PG, Lundgren P, Tornqvist K, Wallin A. Swedish national register for retinopathy of prematu- rity (SWEDROP) and the evaluation of screening in Sweden. Arch Ophthalmol. 2012;130(11):1418-1424. doi:10.1001/archophtha lmol.2012.2357 4.1 \| Strengths and weaknesses The risk for the neuropsychiatric disorders ASD and ADHD is dramatically increased after extremely preterm birth and has been reported to be inversely related to GA at birth.4,7 In one study, 15% of children born at 23–24 weeks were diagnosed with ASD,4 com- pared to 24% of the children in our study. Since autism can be under- recognised at an early age, it cannot be ruled out that additional children might be affected. The proportion of children affected by ASD in our study was significantly higher than in previous reports, and this warrants further investigation in a controlled setting. In ad- dition, almost a third (30%) of the children over 6 years of age in our study were diagnosed with ADHD. Because this was a retrospective study, we did not have access to the children's ADHD phenotype. However, other studies have reported that EPT born children with One strength of this study is that we were able to use SWEDROP, which has 98% national coverage, to identify infants born before 24 weeks.15 In addition, this study comprised validated data from 2007-2020 including 2-13 years of follow-up for a large number of infants in a rare patient group. The diagnoses were initially retrieved from national registries, but we also examined the individual medi- cal charts of all the children to validate and complete diagnoses. Furthermore, the Swedish personal identification numbers issued to all citizens enabled us to track the infants and children who were transferred to other hospitals or moved to other addresses. This retrospective file review of national Sweden data did have some limitations. A major drawback was the large age range at the CONFLICTS OF INTEREST The authors have no conflicts of interest to declare. The authors have no conflicts of interest to declare. 23. Kaul YF, Naseh N, Strand Brodd K, Böhm B, Holmström G, Hellström-Westas L. Average 2.5-year neurodevelopmental test results in children born very preterm did not rule out cognitive deficits at 6.5 years of age. Acta Paediatr. 2021;110(3):846-854. doi:10.1111/apa.15586 36. Herber-Jonat S, Streiftau S, Knauss E, et al. Long-term outcome at age 7–10 years after extreme prematurity – a prospective, two centre cohort study of children born before 25 completed weeks of gestation (1999–2003). J Matern Fetal Neonatal Med. 2014;27(16):1620-1626. doi:10.3109/14767058.2013.871699 24. Ni Y, O'Reilly H, Johnson S, Marlow N, Wolke D. Health-related quality of life from adolescence to adulthood following extremely preterm birth. J Pediatr. 2021;237:227-236.e5. doi:10.1016/j. jpeds.2021.04.005 37. Johnson S, Hollis C, Kochhar P, Hennessy E, Wolke D, Marlow N. Psychiatric disorders in extremely preterm children: longitudi- nal finding at age 11 years in the EPICure study. J Am Acad Child Adolesc Psychiatry. 2010;49(5):453-63.e1. 25. O'Reilly H, Johnson S, Ni Y, Wolke D, Marlow N. Neuropsychological outcomes at 19 years of age following extremely preterm birth. Pediatrics. 2020;145(2):e20192087. doi:10.1542/peds.2019-2087 38. Engeseth MS, Engan M, Clemm H, et al. Voice and exercise related respiratory symptoms in extremely preterm born children after neonatal patent ductus arteriosus. Front Pediatr. 2020;8:150. doi:10.3389/fped.2020.00150 26. Ritchie K, Bora S, Woodward LJ. Social development of children born very preterm: a systematic review. Dev Med Child Neurol. 2015;57(10):899-918. doi:10.1111/dmcn.12783 39. Porter E, McKie A, Beattie TJ, et al. Neonatal nephrocalcinosis: long term follow up. Arch Dis Child Fetal Neonatal Ed. 2006;91(5):F333 -F336. doi:10.1136/adc.2006.094755 27. Halmøy A, Fasmer OB, Gillberg C, Haavik J. Occupational outcome in adult ADHD: impact of symptom profile, comorbid psychiatric problems, and treatment: a cross-sectional study of 414 clinically diagnosed adult ADHD patients. J Atten Disord. 2009;13(2):175- 187. doi:10.1177/1087054708329777 40. Crump C, Sundquist J, Winkleby MA, Sundquist K. Preterm birth and risk of chronic kidney disease from childhood into mid-adulthood: national cohort study. BMJ. 2019;365:l1346. doi:10.1136/bmj. l1346 41. Thunqvist P, Tufvesson E, Bjermer L, et al. Lung function after ex- tremely preterm birth-A population-based cohort study (EXPRESS). Pediatr Pulmonol. 2018;53(1):64-72. doi:10.1002/ppul.23919 28. Billstedt E, Gillberg IC, Gillberg C. Autism after adolescence: population-based 13- to 22-year follow-up study of 120 individ- uals with autism diagnosed in childhood. J Autism Dev Disord. 2005;35(3):351-360. doi:10.1007/s10803-005-3302-5 42. Hintz S, Kendrick D, Vohr B, Kenneth Poole W, Higgins R. Gender differences in neurodevelopmental outcomes among extremely preterm, extremely-low-birthweight infants. Acta Paediatr. 2006;95(10):1239-1248. doi:10.1080/08035250600599727 29. Håkansson S, Farooqi A, Holmgren PA, Serenius F, Högberg U. Proactive management promotes outcome in extremely preterm infants: a population-based comparison of two perinatal man- agement strategies. Pediatrics. 2004;114(1):58-64. doi:10.1542/ peds.114.1.58 43. van Westering-Kroon E, Huizing MJ, Villamor-Martínez E, Villamor E. Male disadvantage in oxidative stress-associated complications of prematurity: a systematic review, meta-analysis and meta- regression. Antioxidants. 2021;10(9):1490. doi:10.3390/antio x10091490 30. Cheong JL, Spittle AJ, Burnett AC, Anderson PJ, Doyle LW. Have outcomes following extremely preterm birth improved over time? Semin Fetal Neonatal Med. 2020;25(3):101114. doi:10.1016/j. siny.2020.101114 44. Brunkhorst J, Weiner J, Lantos J. Infants of borderline viabil- ity: the ethics of delivery room care. Semin Fetal Neonatal Med. 2014;19(5):290-295. doi:10.1016/j.siny.2014.08.001 31. Rysavy MA, Li L, Bell EF, et al. Between-hospital variation in treat- ment and outcomes in extremely preterm infants. N Engl J Med. 2015;372(19):1801-1811. doi:10.1056/NEJMoa1410689 45. Lagercrantz H. The emergence of consciousness: science and eth- ics. Semin Fetal Neonatal Med. 2014;19(5):300-305. doi:10.1016/j. siny.2014.08.003 32. Janvier A, Baardsnes J, Hebert M, Newell S, Marlow N. Variation of practice and poor outcomes for extremely low gestation births: ordained before birth? Arch Dis Child Fetal Neonatal Ed. 2017;102(6):F470-f471. doi:10.1136/archdischild-2017-313332 33. Morgan AS, Zeitlin J, Källén K, et al. Birth outcomes between 22 and 26 weeks’ gestation in national population-based cohorts from Sweden, England and France. Acta Paediatr. 2022;111(1):59-75. doi:10.1111/apa.16084 REFERENCES 1. 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Watkins PL, Dagle JM, Bell EF, Colaizy TT. Outcomes at 18 to 22 months of corrected age for infants born at 22 to 25 weeks of gestation in a center practicing active management. J Pediatr. 2020;217:52-58.e1. doi:10.1016/j.jpeds.2019.08.028 5. Johnson S, Kochhar P, Hennessy E, Marlow N, Wolke D, Hollis C. Antecedents of attention-deficit/hyperactivity disorder symp- toms in children born extremely preterm. J Dev Behav Pediatr. 2016;37(4):285-297. doi:10.1097/dbp.0000000000000298 MORSING et al. 9 SUPPORTING INFORMATION Additional supporting information may be found in the online version of the article at the publisher’s website. 34. Marlow N, Ni Y, Lancaster R, et al. No change in neurodevelop- ment at 11 years after extremely preterm birth. Arch Dis Child Fetal Neonatal Ed. 2021;106(4):418-424. doi:10.1136/archdischi ld-2020-320650 How to cite this article: Morsing E, Lundgren P, Hård A-L, et al. Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation. Acta Paediatr. 2022;00:1–9. doi:10.1111/apa.16316 How to cite this article: Morsing E, Lundgren P, Hård A-L, et al. Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation. Acta Paediatr. 2022;00:1–9. doi:10.1111/apa.16316 35. Söderström F, Normann E, Jonsson M, Ågren J. Outcomes of a uniformly active approach to infants born at 22–24 weeks of ges- tation. Arch Dis Child Fetal Neonatal Ed. 2021;106(4):413-417. doi:10.1136/archdischild-2020-320486
https://openalex.org/W4365934681	http://bohemica.upol.cz/doi/10.5507/bo.2021.027.pdf	Czech	null	NONVERBAL COMMUNICATION OF A CHILD WITH DOWN SYNDROME IN THE EARLY AGE	Bohemica Olomucensia	2,021	cc-by-sa	5,681	NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU KAMILA HOMOLKOVÁ IN THE EARLY AGE This article examines the significant role of nonverbal communication in typically deve- loping children and children with Down syndrome as well. The speech development in this part of population is delayed and because of that it is powerful to use the methods of augmentative or alternative communication with them, e.g. the sign systems. Thanks to this the children are able to achieve the communication success earlier, moreover motor skills and cognitive functions are positively developed. One part of this article is a case study of a nonverbal communication of a boy with Down syndrome and his specific means of communication are introduced. Keywords: alternative and augmentative communication, Down syndrome, intellectual disability, nonverbal communication Mezilidská komunikace je zpravidla založena na kombinaci různorodých sé- miotických systémů (např. jazyka a gestiky, psaného jazyka a piktogramů apod.), a značná část mezilidské komunikace je tedy multimodální. To sou- visí s multimodální percepcí (vnímáním reality několika smysly zároveň) a také s multimodální kognicí (poznávací činností konstituující se pod vlivem jazyka, obraznosti a tělesné zkušenosti; Kaderka 2017). Tato multimodalita je jasně vidět také při osvojování jazyka dětmi: Kapalková (2008) například uvádí, že se gesta ve vývoji dětské komunikace objevují velmi brzy a jsou prvním signálem, jenž dokazuje, že chování dítěte se stává záměrným. Děti s typickým vývojem užívají gesta k označení či vyžádání předmětu předtím, 166 NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU než jsou toho schopny verbálně, a tato raná gesta naznačují obsah i šíři jejich tvořícího se slovníku (Özçalışkan 2017). Až zhruba do dvou let komunikuje dítě na úrovni dvou rovnocenných modalit – na úrovni gest a slov. Po tomto věku se dítě v komunikaci orientuje na slovo. V komunikačním projevu gesto předchází slovu a zároveň v raném věku často vystupuje jako jediný a samostatný projev dítěte, je plnohodnotnou sémiotickou komunikační jednotkou v raném projevu dítěte (Kapalková 2008).(1) Každodenní jazyková interakce je tedy skutečně multimodální jev. Lehečková – Jedlička (2018) uvádějí, že samotná verbální složka představuje při spontánní dialogické interakci sice nutnou, ne však dostačující podmín- ku úspěšné komunikace: do mezilidské interakce vstupuje množství dalších sémiotických kódů, modů či modalit, které zásadním způsobem dotvářejí intersubjektivně sdílený význam. Podle tohoto pohledu je navíc vyvráceno zakotvené tvrzení, že gesta jsou doprovodným jevem komunikačního proje- vu; opět se potvrzuje, že gesta představují jeho autonomní složku. 1 Kapalková operuje v rámci sémiotiky s pojmem znak. Jelikož v tomto příspěvku nabývá znak ještě jiného, konkrétního významu (uměle naučeného gesta zastupujícího slovo), používáme slovo jednotka. 2 Downův syndrom je genetická odchylka, která je způsobena trojí přítomností chromozomu č. 21 v buňkách těla. Důsledkem je mimo jiné snížení intelektu. 2 Downův syndrom je genetická odchylka, která je způsobena trojí přítomností chromozomu v buňkách těla. Důsledkem je mimo jiné snížení intelektu. IN THE EARLY AGE Podobné rysy spatřujeme i u dětí s Downovým syndromem.(2) V klinic- kém obraze lidí s tímto syndromem se objevuje narušená komunikační schopnost (narušená schopnost vyjadřovat se řečí v porovnání s vrstevní- ky nebo rozumět mluvené řeči; Lechta 2008), zejména opožděný vývoj řeči (tzn. že dítě dosahuje řečových milníků opožděně oproti svým vrstevní- kům s typickým vývojem), ale právě proto se více a delší dobu spoléhají na svůj neverbální projev, díky němuž mohou dříve dosáhnout v komunikaci s partnerem vzájemného porozumění. Tento příspěvek se zaměří na neverbální komunikaci u dítěte s Downo- vým syndromem, jehož komunikační chování bylo pozorováno od 24 do 48 měsíců věku. Představena budou zaznamenaná gesta přirozená, ale také gesta-znaky z podpůrného znakového systému a jejich role v chlapcově komunikačním projevu. 167 KAMILA HOMOLKOVÁ 3 Tedy gesta záměrná, která směřují k určitému cíli, jehož má být těmito prostředky dosaženo (srov. Mukařovský 2000). 4 Tento postřeh není samozřejmý pro všechny typy intelektového postižení – například děti s některým z postižení autistického spektra (PAS) užívají gesta v mnohem menší míře i frekvenci (Özçalışkan 2017). 5 V současné době je možné využívat různé metody alternativní a augmentativní komunikace (AAK), u dětí s Downovým syndromem (dle míry postižení) zejména znakové systémy, komunikaci usnadněnou piktogramy či fotografiemi, technické pomůcky (např. tablety) apod. 1 NEVERBÁLNÍ KOMUNIKACE V RANÉM KOMUNIKAČNÍM VÝVOJI DÍTĚTE Neverbální prostředky, včetně pohybu, jsou přirozenou součástí každé ko- munikace a jsou její neoddělitelnou složkou. Záměrné pohyby (komunikační gesta)(3) jsou nositelem pragmatického významu (funkce) i významu séman- tického (obsahu) a jsou formálně ukotvené ve výpovědi jako její plnohod- notný prvek (Kapalková 2008). Zejména u malých dětí není komunikačními gesty míněn jen pohyb rukou (ten převládá především u dalších věkových skupin), ale i pohyb celého těla, mimika i posturika. V tomto příspěvku ope- rujeme se dvěma základními pojmy neverbální komunikace, a to gestem a znakem. Za gesto je zde považován projev záměrného komunikačního cho- vání (za účelem ovlivnění pozornosti komunikačního partnera), v němž se o své myšlenky, potřeby a pocity účastník komunikace se svým partnerem dělí prostřednictvím pohybů rukou, nohou, hlavy, prstů, celého těla, ale také mimiky a očního kontaktu (srov. Kapalková 2017). Tento pohyb nese prag- matickou a sémantickou informaci, kterou komunikační partner dekóduje. Existují ale také pohyby, které vychází z vnitra a tuto prvotní motivaci ovliv- nit nebo změnit chování komunikačního partnera postrádají (např. tření očí, zívání aj.). Oproti tomu znak se dítě musí naučit z podpůrného znakového systému (viz kap. 2), jedná se o naučené gesto zastupující slovo. Pokud tedy dítě znakuje, užívá pro potřebné slovo tuto zástupnou neverbální alterna- tivu. Většinou je ve větě znakováno (dítětem i dospělým) klíčové slovo a ve chvíli, kdy dítě toto slovo produkuje, znak pro ně automaticky vypouští. Dle neverbálních prostředků, které dítě užívá, lze usuzovat, na jaké ko- munikační úrovni se může nacházet, popř. jaké úrovni se blíží. Kapalková (2017) popisuje, že první gesta, objevující se u typicky se vyvíjejících dětí obvykle kolem sedmého a osmého měsíce, jsou zpočátku izolovaná a často bývají doprovázena očním kontaktem s komunikačním partnerem jako po- tvrzením, že dítě získalo jeho pozornosti. Později bývají gesta často dopro- 168 NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU 4 Tento postřeh není samozřejmý pro všechny typy intelektového postižení – například děti s některým z postižení autistického spektra (PAS) užívají gesta v mnohem menší míře i frekvenci (Özçalışkan 2017). 5 V současné době je možné využívat různé metody alternativní a augmentativní komunikace (AAK), u dětí s Downovým syndromem (dle míry postižení) zejména znakové systémy, komunikaci usnadněnou piktogramy či fotografiemi, technické pomůcky (např. tablety) apod. NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU vázena rozmanitými zvuky, následně ještě slovy. Zhruba 2–3 měsíce před prvními dvojslovnými výpověďmi se v komunikačním projevu dětí obje- vují spojení gesto + gesto, příp. gesto + slovo (např. Özçalişkan – Goldin- -Meadow 2005). Kombinace slova a gesta v jedné výpovědi se ale mohou kvalitativně lišit (Kapalková 2008); pokud dítě slovem i znakem označuje jednu a tu samou věc (mají totožný obsah), jedná se o spojení komple- mentární (např. dítě ukazuje na knihu a říká to). Kognitivně náročnější je spojení suplementární, které spojuje slovo a gesto s rozdílným obsahem (např. dítě ukazuje na knihu a říká tí, ve významu číst). V tomto příspěvku se zaměřujeme na tzv. empty-handed gesta – ges- ta, která nevyužívají zacházení s předměty (s výjimkou ukazování a po- dávání předmětu). Aby byl pohyb nazván gestem, musel plnit alespoň jednu ze dvou podmínek: 1) pohyb je jednoznačný, většinou doprovázený výměnou pohledu s komunikačním partnerem; 2) komentář zúčastněné osoby, která bezprostředně zverbalizuje komunikační záměr dítěte (in- spirace viz Kapalková 2017). Neverbální komunikace je u dětí s Downovým syndromem ještě nápad- nější než u dětí s typickým vývojem, a to jak z hlediska frekvence, s jakou gesta užívají, tak z hlediska velikosti repertoáru užívaných typů gest,(4) z důvodu opožděného řečového vývoje a narušené komunikační schopnos- ti, která má charakter symptomatické poruchy řeči, tvoří většinovou část jejich komunikačního projevu. Jelikož se delší dobu nemohou vyjádřit řečí, kompenzují tento nedostatek právě prostředky neverbální komunikace a (ne)vokalickými zvuky.(5) V komunikaci populace s typickým vývojem vystupují prostředky verbální a neverbální komunikace ve velké míře společně, zejména jedná-li se o vyjá- dření spojená se spontánními gesty (viz například vyjádření pragmatických funkcí; Kapalková 2008). U populace s Downovým syndromem situace není 169 KAMILA HOMOLKOVÁ jiná. Změna se objevuje až například při tvoření prvních vět, kdy – v případě, že dítě znakuje – častěji dochází ke spojování slov a naučených znaků v jedné výpovědi. Na druhou stranu kombinace plnovýznamového slova a gesta (například deiktického), stejně jako gesta a gesta, jsou obvykle přítomné vel- mi brzy po výskytu prvních slov nejen u dětí s takovýmto odlišným vývojem, ale i s vývojem typickým (Kapalková 2008; jak bylo naznačeno výše, tato spojení se objevují dříve než první dvouslovné věty). Zatímco ale u typicky se vyvíjejících dětí zhruba v šestnácti měsících života obvykle nastoupí období dvouslovných výpovědí (Slančová 2008), u dětí s Downovým syndromem trvá období spojování gest mnohem déle. NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU Délka tohoto mezistupně je u kaž- dého jedince individuální a může trvat i několik let (Selikowitz 2011). 2 ALTERNATIVNÍ A AUGMENTATIVNÍ KOMUNIKACE Neubauerová a Neubauer (2018) popisují, že alternativní a augmentativní komunikace (dále AAK) je víceoborovou oblastí (zahrnuje lingvistiku, pe- dagogiku, psychologii či rehabilitaci) věnující se rozvoji přístupu ke komu- nikaci osob, které nemohou efektivně využívat běžné formy mezilidské komunikace – především řeč, její psanou formu a běžné formy neverbál- ních komunikačních modalit (gesta, intonační a zvuková dynamika apod.). AAK je využívána osobami s obtížemi vývojového charakteru (např. s men- tálním deficitem – zahrnující také lidi s Downovým syndromem, dětskou mozkovou obrnu, senzorický handicap, pervazivní vývojové poruchy – především autismus aj.), ale také osobami s obtížemi získanými (afázie, dysartrie, nádory mozku, úrazy aj.). Pojem alternativní komunikace je za- střešující pojem pro komunikační systémy, které zcela nahrazují mluvenou řeč. Augmentativní komunikace je komunikace doplňková (rozšiřující), která podporuje již existující, ale pro běžné dorozumívání nedostačující komunikační schopnosti. Hlavním cílem AAK je minimalizovat možnost vzniku komunikačního deficitu osob s tělesným či vícečetným postižením (v kombinaci s narušenou komunikační schopností), a umožnit jim tak stát se rovnocennými komunikačními partnery na základě vytvoření podpůr- ného nebo náhradního komunikačního systému (Bendová 2013). Do pově- 170 NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU domí se AAK v České republice dostala především až po roce 1989, v roce 1994 bylo založeno Sdružení pro AAK (SAAK). V následujících letech se začala zřizovat speciálně pedagogická centra pro děti a mládež s vadami řeči – se zaměřením na AAK (např. v roce 1998 SPC pro děti s vadami řeči, dostupné na www.alternativnikomunikace.cz). domí se AAK v České republice dostala především až po roce 1989, v roce 1994 bylo založeno Sdružení pro AAK (SAAK). V následujících letech se začala zřizovat speciálně pedagogická centra pro děti a mládež s vadami řeči – se zaměřením na AAK (např. v roce 1998 SPC pro děti s vadami řeči, dostupné na www.alternativnikomunikace.cz). Obrázek 1. Schéma systémů alternativní a augmentativní komunikace Systémy AAK S pomůckami Bez pomůcek: orální řeč, znakové sys- témy, prstová abeceda, gestika, haptika aj. Technické: elektronické pomůcky a počítače Netechnické: komunikační tabulky, piktogramy, knihy aj. Bez pomůcek: orální řeč, znakové sys- témy, prstová abeceda, gestika, haptika aj. Technické: elektronické pomůcky a počítače Systémy AAK S pomůckami Netechnické: komunikační tabulky, piktogramy, knihy aj. Obrázek 1. Schéma systémů alternativní a augmentativní komunikace Volba vhodného komunikačního systému či pomůcky závisí čistě na individuálních potřebách uživatele. Při výběru nezáleží pouze na výsled- cích diagnostiky komunikační kompetence, ale i na dalších faktorech – např. 6 Prstová abeceda je systém znaků tvořený různou polohou prstů a dlaní jedné nebo obou rukou, jež v prostoru zobrazují jednotlivé grafémy (Maštalíř – Pastieriková 2018). 7 Lormova abeceda je nejčastěji využívána ke komunikaci osob s praktickou či totální hluchosle- potou. Je založena na faktu, že každému písmenu v abecedě odpovídá bod či skupina bodů na dlani (Maštalíř – Pastieriková 2018). 6 Prstová abeceda je systém znaků tvořený různou polohou prstů a dlaní jedné nebo obou rukou, jež v prostoru zobrazují jednotlivé grafémy (Maštalíř – Pastieriková 2018). 7 Lormova abeceda je nejčastěji využívána ke komunikaci osob s praktickou či totální hluchosle- potou. Je založena na faktu, že každému písmenu v abecedě odpovídá bod či skupina bodů na dlani (Maštalíř – Pastieriková 2018). 2 ALTERNATIVNÍ A AUGMENTATIVNÍ KOMUNIKACE úrovni jemné a hrubé motoriky, úrovni porozumění mluvené řeči i signálům neverbální komunikace, stupni čtenářských dovedností, emoč- ních projevech aj. (více např. Maštalíř – Pastieriková 2018). AAK využívá systémů bez pomůcek (např. znakové systémy, prstová abe- ceda,(6) Lormova abeceda,(7) gestika, haptika, proxemika, oční kontakt aj.) i s pomůckami. Ty mohou využívat techniku (např. počítače s hlasovými 171 KAMILA HOMOLKOVÁ výstupy), či nikoli (komunikační tabulky, obrázkové karty ad.). Námi po- zorovaný chlapec ze systémů AAK využívá znakový systém (tzn. systém bez pomůcek), proto zde budou představeny pouze právě znakové systémy. 8 Naopak mezi tzv. statické systémy patří např. dvou- nebo trojrozměrné obrázky – piktogramy, VOKS ad. (Maštalíř – Pastieriková 2018). NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU Znak do řeči je systém vyvinutý v Dánsku a jeho slovní zásobu tvoří cca 400 znaků. Jde však o otevřený komunikační systém znaků, které lze upravovat a doplňovat dle individuálních potřeb uživatele (Bendová 2013). Metoda kombinuje především gesta a mimiku a respektuje individuálně sníženou úroveň motorických, vizuálních i kognitivních funkcí jejích uži- vatelů (Maštalíř – Pastieriková 2018). Znakování se stále častěji nepoužívá jen u dětí s řečovým handicapem, ale také u nejmenších dětí, které ještě nemluví. Díky znakům totiž dítě dovede vyjádřit své potřeby. Šarounová (2014) představuje i jejich další výhody; dítě (s řečovým handicapem) při nich využívá potenciál dobrého zrakového vnímání (toto tvrzení platí rozhodně u dětí s Downovým syn- dromem, které mají alespoň v raném věku vizuální vnímání podstatně sil- nější než vnímání auditivní), dochází při nich k propojení smyslů (zraku, sluchu i hmatu), mají nižší motorickou náročnost než slova, bývají také srozumitelnější (protože se soustředí na to podstatné a obsah je dětem i ostatním uživatelům snadněji přístupný), jsou ilustrativní (a konkrétní – jeden znak většinou zastupuje jedno slovo). A co je nejdůležitější, dítě pomocí znakování zažívá komunikační úspěch mnohem dříve, než by se mu ho dostalo jen díky verbální produkci. 2.1 ZNAKOVÉ SYSTÉMY Znakové systémy patří k tzv. dynamickým systémům (společně s gesty).(8) Jedná se o souhrn vizuálně-pohybových signálů, které jsou tvořeny defini- tivními konfiguracemi pohybů jedné nebo obou rukou (Maštalíř – Pastie- riková 2018). Důležité je, že se jedná o znakování klíčového slova ve větě, a ne celé výpovědi; tím dochází ke smyslovému propojení s mluveným slovem a jeho podpoře. Jakmile se dítě naučí znakované slovo vyslovit, znak (okamžitě či postupně) vypouští. Užívání znaků nebrání vývoji verbální řeči, naopak ho podporuje (např. Acredolo – Goodwyn 2002); jak bylo naznačeno výše, neverbální komunikace je nedílnou součástí osvojo- vání jazyka, díky níž je dítě schopno komunikovat s okolím již od narození, ilustrativní znaky tedy komunikaci dítěti přibližují a usnadňují. Znakový jazyk, tj. národní znakový jazyk, do systému AAK nespadá, neboť jde o ja- zyk přirozený a plnohodnotný (Maštalíř – Pastieriková 2018). V České republice je využíváno několik systémů, například Makaton a Znak do řeči. Makaton byl vyvinut ve Velké Británii a jeho základem je 350 znaků a symbolů. Jednotlivé znaky jsou podle vzrůstající abstrakce je- jich významu a náročnosti na pohybovou koordinaci při jejich provedení uspořádány do osmi základních etap, devátou etapu slovníku tvoří indivi- duální slovník obsahující cca 40 slov vycházejících z individuálních potřeb člověka (Janovcová 2003). U malých dětí se často znaky kombinují ještě s posílením vizualizace – např. užitím fotografií či piktogramů (například i u dětí s Downovým syndromem, které mají vizuální stránku dominantní). V praxi je Makaton spojen mimo znakování klíčových slov také s dalšími doprovodnými akcemi, například rytmizovanou řečí, mimickými prvky, modulací řeči a demonstrací symbolů (Kubová 1996). 172 9 Tato kapitola čerpá z webových stránek Deutsches Down-Syndrom Infocenter, dostupných na www.ds-infocenter.de/html/guk. 10 Obrázky dostupné na https://www.ds-infocenter.de/html/guk.html. 11 Obrázky dostupné na https://www.ds-infocenter.de/html/guk.html. 12 První otázky typu Co to je? začal pokládat ve věku 50 měsíců (typicky se vyvíjející dítě cca ve věku 24–36 měsíců). S DOWNOVÝM SYNDROMEM V RANÉM VĚKU Obrázek 3. Ukázka z knihy Und nun? představující komunikaci znaky ve všedních situacích(11) Obrázek 3. Ukázka z knihy Und nun? představující komunikaci znaky ve všedních situacích(11) 11 Obrázky dostupné na https://www.ds-infocenter.de/html/guk.html. První otázky typu Co to je? začal pokládat ve věku 50 měsíců (typicky se vyvíjející dítě cca ve ku 24–36 měsíců). 2.1.1 ZNAKOVÝ SYSTÉM GUK(9) Chlapec pracoval s německým podpůrným systémem GuK, celým názvem Gebärden-unterstützte Kommunikation, tedy komunikace podporova- ná znaky. Ten patří k nejužívanějším podpůrným znakovým systémům v Německu. Jeho podstatou je, stejně jako u jiných znakových systémů, že usnadňuje dětem přechod od vyjadřování symbolického k verbálnímu; napomáhá dětem, které dosud nemluví, komunikovat prostřednictvím do- provodných gest. Zakladatelkou metody GuK je speciální pedagožka, logo- pedka a emeritní profesorka na Leibniz Universität Hannover Etta Wilken (*1943). Jelikož je znakování v určitých ohledech jednodušší než mluvení 173 KAMILA HOMOLKOVÁ (např. v ilustrativnosti znaku a tím pochopení významu slova, delším trvá- ní v čase než slovo apod.), podílí se také na rozvoji porozumění dítěte, a tím postupně i na osvojování jazyka a verbální komunikace. i Metoda GuK nemusí být využívána pouze dětmi se specifickými vzdělá- vacími potřebami (dále SVP), ale například i při individuální hře s dítětem či v mateřské škole, jelikož znaky podporují koordinaci rukou, očí a paměti (kombinuje vnímání taktilní, vizuální i auditivní). Může tak zároveň napří- klad sloužit jako podpůrný prostředek pro začlenění dítěte s SVP do běžné komunity. Toto tvrzení lze vztáhnout i na ostatní znakové systémy. Základní materiál tvoří karty GuK 1 (se základní slovní zásobou), GuK 2 (pokročilá slovní zásoba) a dále čtyři CD. Každá karetní sada obsahuje cel- kem 300 karet se třemi typy obsahů: znakem, obrázkem a slovním pojmeno- váním v němčině. Součástí je také manuál pro práci se sadou a abecední se- znam gest. Tři CD obsahují stejný materiál jako karetní sady, jsou ale pouze doplňkovým materiálem a nenahrazují práci s kartami. Čtvrté CD (GuK plus) obsahuje 37 doplňkových gest pro předškolní a školská zařízení. Obrázek 2. Ukázka karet (znak, obrázek, pojmenování) a CD znakového systému GuK(10) Obrázek 2. Ukázka karet (znak, obrázek, pojmenování) a CD znakového systému GuK(10) Etta Wilken vytvořila i doplňkové materiály, jsou jimi např. GuK mal!, kniha tradičních i autorčiných veršů a písniček, které mohou být doprová- zeny gesty, či obrázková kniha Und nun?, přinášející krátké příběhy dvou dětí, jež představují komunikaci znaky v každodenním životě. 174 NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE Ý É Ě 3.1 CHARAKTERISTIKA SITUACE A METODOLOGIE Pozorovaný chlapec se narodil v červnu 2014 v Německu českým rodičům. Oba rodiče jsou vysokoškolsky vzdělaní, bez obtíží v řeči, jazyce, komunika- ci. Rodina žije v německém pohraničí, ale každých čtrnáct dní jezdí za svý- mi příbuznými do České republiky. V místě bydliště se stýkají s německou i silnou českou komunitou. Chlapec jedenkrát týdně dochází na logopedii v německém jazyce, logopedie v českém jazyce je kvůli vzdálenosti méně frekventovaná (zhruba jednou za dva měsíce, v online prostředí častěji, pravidelně ji ale matka provádí s dítětem v domácím prostředí). Jednou týdně chlapec také dochází na fyzioterapii a ergoterapii, v nepravidelných intervalech ještě na hipoterapii. Chlapec, jehož komunikační projevy jsme pozorovali po dobu dvou let (od 24 do 48 měsíců), je aktivním komunikačním partnerem. Je u něho patrná snaha o udržení rozhovoru, přestože v pozorovaném období sám nepokládal otázky.(12) Jeho výpovědi jsou melodické, s přirozenou prozodií, jejich základ 175 KAMILA HOMOLKOVÁ tvoří jedno, případně více smysluplných slov a dále zvuky vokalického i ne- vokalického charakteru. V projevu je patrná také výrazná gestikulace a do cca 45 měsíců věku komunikoval také pomocí znaků z německého podpůr- ného znakového systému GuK (nově např. Wilken 2018, viz kap. 2.1.1.). Chla- pec do věku 48 měsíců velmi zřídka užíval gramatické konstrukce, v rámci jazykových rovin u něj byla nejvýraznější rovina lexikální. Chlapec vyrůstá v simultánním bilingvismu, přičemž dominantní jazyk (čeština) je vázán na pečující osoby (oba rodiče). S německým jazykem se odmalička setkává při terapiích různého druhu, v mateřské škole, kam dochází od září 2017, a na zájmových aktivitách. Výzkum neverbální komunikace u chlapce s Downovým syndromem je součástí longitudinálního výzkumu osvojování jazyka dítětem s Dow- novým syndromem. Základními metodami zde bylo videonahrávání je- denkrát měsíčně (ideálně kolem dne chlapcových narozenin, v délce cca 20 minut) po dobu dvou let, pozorování komunikačního chování chlap- ce při běžných aktivitách a rodičovské deníky, do nichž rodiče zaznamená- vali důležité milníky v chlapcově motorickém i řečovém vývoji. Nahrávky nebo jejich adekvátní části byly přepisovány v transkripci CHAT databáze CHILDES;(13) pravidla pro přepis byla pro potřeby výzkumu doplněna o za- znamenávání komunikace gesty a znaky a komunikace bilingvní. 13 Dostupné na: https://talkbank.org/manuals/CHAT.pdf. 14 Svetlana Kapalková vycházela z první verze taxonomie pragmatických funkcí popsaných v cito- vané studii Kesselové – Slančové (2006). 3.2 PŘIROZENÁ NEVERBÁLNÍ KOMUNIKACE Jako jedny z prvních si dítě v raném věku obvykle osvojuje gesta s pragma- tickou funkcí. Tou je zamýšleno zaměření mluvčího v určitém úseku komu- nikační události na realizaci určitého komunikačního záměru (Kesselová – Slančová 2006). Jinak řečeno, tato funkce osvětluje skutečnost, proč dítě ko- munikuje (Kapalková 2008). Mimo gesta s pragmatickou funkcí je zároveň do této kapitoly zahrnuto několik gest konvenčních, společensky vžitých. Následující tabulka (tab. 1) zaznamenává vyjadřované funkce, nikoli podo- bu gest. Vychází z taxonomie pragmatických funkcí popsaných Kapalkovou 176 NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU (2008)(14) a obsahuje gesta s pragmatickou funkcí, která se u chlapce obje- vila do 24 měsíců věku. Zdrojem informací jsou rodičovské deníky, a jelikož do této doby neprobíhalo pozorování, není možné ověřit, zda je seznam úplný. Podobně jako ve zjištění Kapalkové (2008) u typicky se vyvíjejících dětí se jako jedny z prvních objevila gesta referenční biologická (spát, nataho- vání se / naklonění) a dále pohyby s operativní funkcí (podávání, ukazová- ní, chycení za ruku). Gesta s diskurzivní funkcí (jimiž probíhá komunikač- ní výměna s partnerem) se objevila nejpozději. Gesta s pragmatickou funkcí osvojená do 24 měsíců Referenční (vyjadřující informaci relativně samostatně) Operativní (regulující chování kom. partnera) Diskurzivní (týkající se verbální činnosti a gest) biologická: spát natahování se naklonění postojová: souhlas s činností nesouhlas s činností protest údiv expresivní: emoce (pozitivní a negativní) pohlazení polibek (příp. poslání polibku) rutiny: tanec podávání ukazování chycení za ruku odpověď: dej mi – podej mi pápá potřeba informace: ukázání předmětu (ve smyslu: To?) postoj k verbální činnosti partnera: souhlas, potvrzení nesouhlas protest ocenění – tleskání imitace gesta partnera Tabulka 1 Gesta s pragmatickou funkcí osvojená chlapcem do věku 24 měsíců Gesta s pragmatickou funkcí osvojená do 24 měsíců Referenční (vyjadřující informaci relativně samostatně) Operativní (regulující chování kom. partnera) Diskurzivní (týkající se verbální činnosti a gest) biologická: spát natahování se naklonění postojová: souhlas s činností nesouhlas s činností protest údiv expresivní: emoce (pozitivní a negativní) pohlazení polibek (příp. poslání polibku) rutiny: tanec podávání ukazování chycení za ruku odpověď: dej mi – podej mi pápá potřeba informace: ukázání předmětu (ve smyslu: To?) postoj k verbální činnosti partnera: souhlas, potvrzení nesouhlas protest ocenění – tleskání imitace gesta partnera Tabulka 1 Gesta s pragmatickou funkcí osvojená chlapcem do věku 24 měsíců Tabulka 1. 3.2 PŘIROZENÁ NEVERBÁLNÍ KOMUNIKACE Gesta s pragmatickou funkcí osvojená chlapcem do věku 24 měsíců 14 Svetlana Kapalková vycházela z první verze taxonomie pragmatických funkcí popsaných v cito- vané studii Kesselové – Slančové (2006). 177 KAMILA HOMOLKOVÁ Některá gesta, která chlapec užíval – intuitivní nebo ta, jež jsou běžně součástí společenské rutiny (například kývání hlavou na znamení souhlasu, mávání apod.), – byla totožná se znaky ze znakového systému GuK. Podob- ná gesta v tomto příspěvku pokládáme za znaky. U většiny gest, která jsme během pozorovaného období zaznamenali, jsme si nemohli být jisti, zda se jedná o jejich první výskyt, či nikoli. Do věku 24 měsíců již totiž děti mívají mnohá komunikační gesta osvojena a taktéž neverbální komunikace našeho chlapce byla velmi bohatá. Zároveň není možné odhadnout, zda zachycená gesta představují úplný rejstřík užívaných gest, nicméně i v této podobě nám umožňují orientovat se v okruzích, pro něž byla stěžejní. Z těchto důvodů není níže uvedená Tab. 2 obsahující ko- munikační gesta řazena dle chronologického věku osvojení, ale dle typu gest: Kategorie Typ gesta Popis formy Referenční gesta spát zívání, pokládání hlavy na podložku natahování sledování objektu, natahování k němu jedné ruky, příp. obou souhlas (s činností) úsměv, později pokývání hlavou nesouhlas (s činností) kopání nohama, máchání rukama, později kroucení hlavou protest odvrácení těla od komunikačního partnera, máchání rukama údiv široce otevřené oči, úsměv Operativní gesta podávání podání předmětu komunikačnímu partnerovi ukazování ukazování celou dlaní, později ukazo- váčkem chycení za ruku dlaň spojená s dlaní komunikačním partnerem Konvenční gesta bubu – kuk oči zakryté dlaněmi – odkrytí očí posílání polibku přiložení našpulených úst k nastavené dlani Jak jsi veliký? odpovědí jsou ruce zvednuté nad hlavu 178 178 Diskurzivní gesta dej mi – podej mi ruka před tělem ve směru požadova- ného předmětu pápá kývání celou paží, příp. zápěstím a prsty ukázání předmětu držení předmětu v dohledu komunikač- ního partnera; ve smyslu otázky: To? imitace činnosti partnera napodobení činnosti, bez předmětu (např. 3.2 PŘIROZENÁ NEVERBÁLNÍ KOMUNIKACE míchání) imitace gesta partnera napodobení gesta komunikačního partnera Rutiny a hry tanec reakce na hudbu horní polovinou těla, po postavení na nohy celým tělem četba textu přejíždění ukazováčkem po stránkách knihy četba grafémů přejíždění ukazováčkem po jednotli- vých písmenech a jejich čtení napodobování postav napodobování postoje postavy knižní ilustrace Vařila myška kašičku dětská říkanka – kroužení na dlani dítěte Expresivní gesta přitulení obejmutí člověka či předmětu smrdí/fuj nakrčení nosu tleskání opakované dotýkání se oběma dla- němi dupání (nesouhlas/důraz) střídavé dupání nohama úsměv pozvednutí koutků úst; především při výsměchu poodhalení zubů a dopro- vázeno zvukem pohlazení pohlazení partnera, nejčastěji po vlasech nebo ruce Otázka Co se děje? široce otevřené oči, tělo bez pohnutí Vyjádření způsobu rychle opakované mávání jednou rukou za hlavu a vpřed Variabilní gesta samomluva výrazné pohyby rukou i celého těla vyjádření minulosti výrazné pohyby rukou i celého těla Tabulka 2. Zaznamenaná gesta, jež chlapec v pozorovaném období používal Tabulka 2. Zaznamenaná gesta, jež chlapec v pozorovaném období používal 179 KAMILA HOMOLKOVÁ Zvláštní kategorií byla gesta, jež byla v tabulce označena jako „variabilní“. Tato gesta byla spojena se samomluvou a individuální hrou chlapce. Vyjád- ření minulosti je pro něj vždy velmi živé, poněvadž je zdrojem již uskuteč- něného poznání, z nějž může stále čerpat (na rozdíl např. od budoucnosti, kterou si představit do takové míry nedovede). Tento typ gestikulace byl a je vždy velmi výrazný, živelný, využívající pohyby rukou i celého těla. Často bývá doprovázen opakujícími se vokalickými zvuky, chlapec při něm málo- kdy produkuje smysluplná slova. Tato gestikulace se stala zřetelnější v době, kdy chlapec začal chodit (po druhém roce věku) a získal jistotu v prostoru. Nutno podotknout, že specifikem komunikace lidí s Downovým syndromem je právě také samomluva, s níž je tento typ gest spojený. 3.3 KOMUNIKACE PROSTŘEDNICTVÍM ZNAKOVÉHO SYSTÉMU GUK Chlapec se s německým znakovým systémem GuK začal seznamovat v 18 měsících věku, aktivněji ho užíval o tři měsíce později. Do konce po- zorovaného období si z něj osvojil 118 znaků. Znaky se z důvodu možnosti komunikace s chlapcem učili kromě rodičů také blízcí příbuzní a asistentka pedagoga v mateřské škole. K učení znaků chlapec využíval k tomu určené karty, z nichž mu matka vyráběla přehledné fotoalbum. Rodina vidí v užívání znaků značný přínos. Chlapec znaky užíval samostatně, ale později také ve spojení se slovy. 3.2 PŘIROZENÁ NEVERBÁLNÍ KOMUNIKACE Pomocí znaků a případně v kombinaci se slovy byl schopný tvořit výpovědi na úrovni slovních spojení, jednoduchých vět a později i sou- větí. Podoba znaku uváděná v materiálech znakového systému GuK nebyla vždy perfektně dodržena – vycházela z chlapcových motorických schopností. V této upravené podobě se chlapci přizpůsobovalo také znakující okolí. Po- tvrzovalo se, že když se chlapec naučil slovo vyslovit, znak pro něj postupně (či ihned) přestal používat a upřednostňoval verbální vyjádření. Ke konci pozorovaného období v dialozích mluvené slovo a přirozená gesta upřed- nostňoval téměř výhradně, přestože mu okolí ještě ne vždy rozumělo. Zatímco z verbální slovní zásoby si chlapec v pozorovaném období osvo- jil především substantiva, u znaků se jednalo hlavně o činnosti (verba). Díky znakům tak byl schopný tvořit fungující výpovědi obsahující jméno ve funkci subjektu nebo objektu a predikát. Dalšími nejpočetněji zastoupený- 180 NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU mi kategoriemi byly oblasti jeho zájmu a potřeb – zvířata, jídlo a pití, pří- davná jména (označující vlastnosti – v chlapcově slovní zásobě především substantiv) a společenská rutina (znaky vyjadřující pragmatickou funkci – např. poděkování, žádost apod.). Nejméně zastoupenými oblastmi byly především synsémantické slovní druhy a zájmena (zde pouze osobní zá- jmeno já a posesivum moje). Graf 1. Klasifikace znaků užívaných chlapcem s Downovým syndromem do 48 měsíců věku Graf 1. Klasifikace znaků užívaných chlapcem s Downovým syndromem do 48 měsíců věku 15 Během pozorovaného období byl také rodičům dětí s Downovým syndromem prostřednictvím sociální sítě rozeslán rodičovský dotazník zabývající se znakováním u jejich dětí. Stěžejní zde byla otázka, zda se v rodině vůbec užívá, či neužívá znakování: metodu využívalo 50 % dotázaných (36 rodin), nejčastěji se jednalo o vybrané znaky ze systému Makaton nebo Znak do řeči. ZÁVĚREM Mezilidská komunikace je multimodální jev a využívá různých sémiotic- kých systémů – verbálního slova, gestiky, v našem příspěvku ještě užívání podpůrných znaků. Přirozená gesta jsou součástí komunikačního projevu typicky se vyvíjejících dětí i dětí s Downovým syndromem a právě díky nim se komunikace stává záměrnou. U dětí s Downovým syndromem se vždy objevuje nějaký druh narušené komunikační schopnosti a vývoj jejich řeči je opožděný. Jelikož se delší dobu nemohou spoléhat na svůj verbální projev, využívají ke komunikaci řeč celého těla, výraznou gestikulaci a ně- kdy také metody AAK, například podpůrné znakové systémy. Přestože je ověřeno, že komunikace znaky (opakujeme, že jde o podpůr- nou metodu, která nenahrazuje komunikaci verbální) přináší do dialogu 181 KAMILA HOMOLKOVÁ pozitiva a jedná se o metodu úspěšnou a bezpečnou, která nebrzdí verbál- ní vývoj, ji podle naší zkušenosti mnoho rodin zatím nevyužívá;(15) udáva- jí, že jim nebyla doporučena logopedem nebo jiným odborníkem. Znaky se na výstavbě výpovědi mohou podílet různou měrou. Jsou užívány buď 1) separovaně, 2) jako plnohodnotné jednotky projevu, který obsahuje zna- ky i slova, nebo jako 3) přidaná hodnota k verbálnímu projevu. Pokud se dítě naučí slovo vyslovit, znak opouští (ihned, nebo postupně). Přestože verbální projev námi pozorovaného chlapce ještě nebyl na ta- kové úrovni, aby se vždy dorozuměl s okolím, znaky začal před čtvrtým rokem věku sám opouštět. V současné době (5,5 let) znaky neužívá vůbec, jeho slovní zásoba i hláskový repertoár se rozrůstají, chlapec tvoří jedno- duché věty i souvětí a užívá gramatické konstrukce, přetrvává ale narušená artikulace. Přesto komunikace znaky byla důležitá etapa chlapcova raného komunikačního vývoje, díky níž byl schopen dříve zažívat komunikační úspěch a vyjadřovat své potřeby. Neverbální komunikace je nedílnou složkou komunikace, často souvisí s vyjádřením emocí (lidé s Downovým syndromem mívají velmi vyvinuté so- ciální cítění a jsou empatičtí). Komunikace znaky potom u dětí s Downovým syndromem využívá ještě dobrého vizuálního vnímání a vizuální paměti, díky nimž si dítě význam slova zažije, zvnitřní. Je pro nás tedy důležité, aby se povědomí o přínosu podpůrných znakových systémů dostalo i k rodičům a širší veřejnosti, aby bylo možno naplno využívat potenciálu dětí. Mgr. Kamila Homolková, Ph.D. Ústav jazyků a komunikace neslyšících Filozofická fakulta Univerzity Karlovy nám. Jana Palacha 2 116 38 Praha 1 kamila.homolkova@ff.cuni.cz nám. Jana Palacha 2 116 38 Praha 1 kamila.homolkova@ff.cuni.cz 15 Během pozorovaného období byl také rodičům dětí s Downovým syndromem prostřednictvím sociální sítě rozeslán rodičovský dotazník zabývající se znakováním u jejich dětí. KAMILA HOMOLKOVÁ KAMILA HOMOLKOVÁ MAŠTALÍŘ, Jaromír – PASTIERIKOVÁ, Lucia 2018 Alternativní a augmentativní komunikace (Olomouc: Univerzita Palacké- ho v Olomouci) MUKAŘOVSKÝ, Jan 2000 „Záměrnost a nezáměrnost v umění“; in týž, Studie 1 (Brno: Host), s. 355–388 ÖZÇALIŞKAN, Seyda – GOLDIN-MEADOW 2005 „Gesture is at the cutting edgeof early language development“; Cogniti- on, 96, B101–B113 ÖZÇALIŞKAN, Seyda 2017 „Early gesture provides a helping hand to spoken vocabulary develop- ment for children with autism, Down syndrome and typical development“; Journal of Cognition and Development 18, č. 3, s. 325–337 SELIKOWITZ, Mark 2011 Downův syndrom (Praha: Portál) SLANČOVÁ, Daniela 2008 „Pragmatické funkcie vo vývine rečovej činnosti“; in táž, Štúdie o dets- kej reči (Prešov: Filozofická fakulta Prešovskej univerzity), s. 67–120 WILKEN, Etta 2018 Unterstützte Kommunikation (Stuttgart: Kohlhammer Verlag) ZÁVĚREM Stěžejní zde byla otázka, zda se v rodině vůbec užívá, či neužívá znakování: metodu využívalo 50 % dotázaných (36 rodin), nejčastěji se jednalo o vybrané znaky ze systému Makaton nebo Znak do řeči. 182 NEVERBÁLNÍ KOMUNIKACE U DÍTĚTE S DOWNOVÝM SYNDROMEM V RANÉM VĚKU LITERATURA ACREDOLO, Linda – GOODWYN, Susan 2002 How to talk with your baby before your baby can talk (New York: McGraw-Hill Education) BENDOVÁ, Petra 2013 Alternativní a augmentativní komunikace 1 (Olomouc: Univerzita Palackého) JANOVCOVÁ, Zora 2003 Alternativní a augmentativní komunikace (Brno: PdF MU) KADERKA, Petr 2017 „Multimodální komunikace“; in Petr Karlík, Marek Nekula, Jana Ples- kalová (eds.), CzechEncy – Nový encyklopedický slovník češtiny [on-line]; https://www.czechency.org/slovnik/MULTIMODÁLNÍ KOMUNIKACE KAPALKOVÁ S tl KADERKA, Petr 2017 „Multimodální komunikace“; in Petr Karlík, Marek Nekula, Jana Ples- kalová (eds.), CzechEncy – Nový encyklopedický slovník češtiny [on-line]; https://www.czechency.org/slovnik/MULTIMODÁLNÍ KOMUNIKACE KAPALKOVÁ, Svetlana 2008 „Gestá v kontexte raného vývinu detí“; in Daniela Slančová (ed.), Štúdie o detskej reči (Prešov: Filozofická fakulta Prešovskej univerzity), s. 169–211 2017 Gestá v detskom jazyku [habilitačná práca] (Prešov: Prešovská univerzi- ta v Prešově, Filozofická fakulta, Katedra slovenského jazyka) KESSELOVÁ, Jana – SLANČOVÁ, Daniela 2006 „K vzťahu sémantických kategórií, pragmatických funkcií a priemernej dĺžky výpovede v ranej ontogenéze reči dieťaťa“; Studia Slovaca. Zborník ve- deckých prác členov Katedry slovenského jazyka a literatúry (Banská Bystri- ca: Univerzita Mateja Bela v Banskej Bystrici Pedagogická fakulta), s. 26–33 KUBOVÁ, Libuše 1996 Alternativní komunikace, cesta ke vzdělávání těžce zdravotně postiže- ných dětí (Praha: TECH-MARKET) LEHEČKOVÁ, Eva – JEHLIČKA, Jakub 2018 „Multimodální konstrukce: jazyk a gestikulace jako vtělená kognice“; Studie z aplikované lingvistiky 9, č. 2, s. 89–103 LECHTA, Viktor 2008 Symptomatické poruchy řeči u dětí (Praha: Portál) 183 INTERNETOVÉ ODKAZY INTERNETOVÉ ODKAZY The CHAT Transcription format; talkbank.org, https://talkbank.org/manu- als/CHAT.pdf [přístup 5. 12. 2021] Deutsches Down-Syndrom Infocenter; ds-infocenter.de, https://www.ds-info- center.de/html/guk.html [přístup 5. 12. 2021] SPC pro děti s vadami řeči; alternativnikomunikace.cz, www.alternativniko- munikace.cz [přístup 5. 12. 2021] INTERNETOVÉ ODKAZY The CHAT Transcription format; talkbank.org, https://talkbank.org/manu- als/CHAT.pdf [přístup 5. 12. 2021] Deutsches Down-Syndrom Infocenter; ds-infocenter.de, https://www.ds-info- center.de/html/guk.html [přístup 5. 12. 2021] SPC pro děti s vadami řeči; alternativnikomunikace.cz, www.alternativniko- munikace.cz [přístup 5. 12. 2021] SPC pro děti s vadami řeči; alternativnikomunikace.cz, www.alternativniko- munikace.cz [přístup 5. 12. 2021] SPC pro děti s vadami řeči; alternativnikomunikace.cz, www.alternativniko- munikace.cz [přístup 5. 12. 2021] 184
https://openalex.org/W2058893345	https://www.scielo.br/j/rlae/a/qsBVM8KmP53WdT4VhsfVvKM/?lang=pt&format=pdf	Portuguese	null	Atenção à mulher mastectomizada: discutindo os aspectos ônticos e a dimensão ontológica da atuação da enfermeira no Hospital do Câncer III	Revista latino-americana de enfermagem	2,003	cc-by	6,491	CARE CARE CARE CARE CARE TTTTTO MASTECT O MASTECT O MASTECT O MASTECT O MASTECTOMIZED OMIZED OMIZED OMIZED OMIZED W W W W WOMAN: OMAN: OMAN: OMAN: OMAN: DISCUSSING ONTIC DISCUSSING ONTIC DISCUSSING ONTIC DISCUSSING ONTIC DISCUSSING ONTIC ASPECTS ASPECTS ASPECTS ASPECTS ASPECTS AND AND AND AND AND THE ONT THE ONT THE ONT THE ONT THE ONTOL OL OL OL OLOGICAL DIMENSION IN NURSES PERFORMANCE OGICAL DIMENSION IN NURSES PERFORMANCE OGICAL DIMENSION IN NURSES PERFORMANCE OGICAL DIMENSION IN NURSES PERFORMANCE OGICAL DIMENSION IN NURSES PERFORMANCE A AA AAT T T T T A CANCER HOSPIT A CANCER HOSPIT A CANCER HOSPIT A CANCER HOSPIT A CANCER HOSPITAL AL AL AL AL This reflection approaches aspects related to the ontic and ontological dimensions that constitute and, therefore, permeate nursing care delivered to the client with breast cancer submitted to mastectomy. This reflexive analysis was developed considering the author’s professional experience as a clinical nurse at the Cancer Hospital III and at the National Cancer Institute (INCA) as well as using the theoretical frameworks studied during her master and doctoral courses. Through a comprehensive attitude and using phenomenological interpretation, this study aimed at reflecting about nurse’s clinical actions in the routine of an institution, pointing out possibilities for a care based on the existential dimension of the involved persons. Therefore, the author emphasizes nurse’s performance with the client that is not only translated in the application of scientific techniques, orientations and information but also considering the perception, understanding and care provided by a human being in his/her singularity. DESCRIPTORS: breast cancer; nursing care; oncology nursing Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf 614 Artigo Original A AA AATENÇÃO À MULHER MASTECT TENÇÃO À MULHER MASTECT TENÇÃO À MULHER MASTECT TENÇÃO À MULHER MASTECT TENÇÃO À MULHER MASTECTOMIZAD OMIZAD OMIZAD OMIZAD OMIZADA: A: A: A: A: DISCUTINDO OS DISCUTINDO OS DISCUTINDO OS DISCUTINDO OS DISCUTINDO OS ASPECT ASPECT ASPECT ASPECT ASPECTOS OS OS OS OS ÔNTICOS E ÔNTICOS E ÔNTICOS E ÔNTICOS E ÔNTICOS E A DIMENSÃO ONT A DIMENSÃO ONT A DIMENSÃO ONT A DIMENSÃO ONT A DIMENSÃO ONTOLÓGICA D OLÓGICA D OLÓGICA D OLÓGICA D OLÓGICA DA A A A A A AA AATU TU TU TU TUAÇÃO D AÇÃO D AÇÃO D AÇÃO D AÇÃO DA AA AA ENFERMEIRA NO HOSPIT ENFERMEIRA NO HOSPIT ENFERMEIRA NO HOSPIT ENFERMEIRA NO HOSPIT ENFERMEIRA NO HOSPITAL DO CÂNCER III AL DO CÂNCER III AL DO CÂNCER III AL DO CÂNCER III AL DO CÂNCER III11111 Teresa Caldas Camargo2 Ivis Emília de Oliveira Souza3 Camargo TC, Souza IEO. Atenção à mulher mastectomizada: discutindo os aspectos ônticos e a dimensão ontológica da atuação da enfermeira no hospital do câncer III. Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21. Esta reflexão aborda os aspectos relativos às dimensões ôntica e ontológica, que constituem e, portanto, permeiam o cenário da atuação da enfermeira junto à cliente com câncer de mama, submetida à mastectomia. A análise reflexiva foi desenvolvida considerando tanto a experiência profissional como enfermeira assistencial do Hospital do Câncer III (HC III) do Instituto Nacional de Câncer (INCA), como pelo apoio de um referencial teórico filosófico obtido ao cursar o mestrado e o doutorado em Enfermagem. Numa atitude compreensiva e de interpretação fenomenológica, pretende-se refletir sobre as ações assistenciais da enfermeira na rotina do espaço institucional e apontar possibilidades da ação assistencial a partir da dimensão existencial das pessoas envolvidas. Nesse sentido, ênfase é dada à atuação da enfermeira junto à cliente, que não se traduz apenas na aplicação de técnicas científicas, orientações e informações, mas também percebe, compreende e cuida da mulher cidadã em sua singularidade. DESCRITORES: neoplasias mamárias; cuidados de enfermagem; enfermagem oncológica A AA AATENCIÓN TENCIÓN TENCIÓN TENCIÓN TENCIÓN A LA MUJER MASTECT A LA MUJER MASTECT A LA MUJER MASTECT A LA MUJER MASTECT A LA MUJER MASTECTOMIZAD OMIZAD OMIZAD OMIZAD OMIZADA: A: A: A: A: DISCUTIENDO L DISCUTIENDO L DISCUTIENDO L DISCUTIENDO L DISCUTIENDO LOS OS OS OS OS ASPECT ASPECT ASPECT ASPECT ASPECTOS ÓNTICOS OS ÓNTICOS OS ÓNTICOS OS ÓNTICOS OS ÓNTICOS Y LA DIMENSIÓN ONT Y LA DIMENSIÓN ONT Y LA DIMENSIÓN ONT Y LA DIMENSIÓN ONT Y LA DIMENSIÓN ONTOLÓGICA DE LA OLÓGICA DE LA OLÓGICA DE LA OLÓGICA DE LA OLÓGICA DE LA A AA AACTU CTU CTU CTU CTUA AA AACIÓN CIÓN CIÓN CIÓN CIÓN DE LA ENFERMERA EN EL HOSPIT DE LA ENFERMERA EN EL HOSPIT DE LA ENFERMERA EN EL HOSPIT DE LA ENFERMERA EN EL HOSPIT DE LA ENFERMERA EN EL HOSPITAL DEL CÁNCER III AL DEL CÁNCER III AL DEL CÁNCER III AL DEL CÁNCER III AL DEL CÁNCER III Esta reflexión discute los aspectos relacionados con las dimensiones óntica y ontológica, que constituyen y por lo tanto forman el escenario de la actuación de la enfermera con la mujer sometida a la mastectomía. El análisis reflexivo fue desarrollado teniendo en cuenta tanto la experiencia profesional como enfermera asistencial del Hospital del Câncer III (HC III), del Instituto Nacional de Cáncer (INCA), como por el apoyo de un referencial teórico filosófico obtenido durante la maestría y el doctorado en enfermería. Con una actitud comprensiva y de interpretación fenomenológica, se intenta reflejar las acciones asistenciales de la enfermera en el espacio institucional y apuntar las posibilidades de la acción asistencial partiendo de la dimensión existencial de las personas comprometidas. Desde este punto de vista, el énfasis está en la actuación de la enfermera con la mujer mastectomizada, la que no se traduce tan solo en la aplicación de técnicas científicas, orientaciones e informaciones, sino también, percibe, comprende y cuida de la mujer ciudadana en su singularidad. DESCRIPTORES: neoplasmas de la mama; atención de enfermería; enfermería oncológica INTRODUZINDO A TEMÁTICA CÂNCER DE MAMA Assim, o impacto psicossocial do câncer de mama pode ser delineado em três áreas: desconforto psicológico, que causa ansiedade, depressão e raiva; mudanças no estilo de vida, conseqüente ao desconforto físico, disfunção sexual, e alteração do nível de atividade; medo e preocupações com a possibilidade ou a ocorrência da mastectomia, o reaparecimento da doença e a morte(3). A mastectomia traz para a mulher a realidade da mutilação e com ela um turbilhão de sentimentos. A retirada da mama causa perturbações variadas no cotidiano de muitas mulheres que com ela passam a apresentar nervosismo, agressividade e insegurança. Esses sentimentos parecem permeados de significados como o desespero, medo, aceitação, segurança, impacto, readaptação, intercorrências e ainda a necessidade de autocuidado(7). O câncer de mama é uma experiência amedrontadora para a mulher e, para maioria delas, o diagnóstico da doença evoca sentimentos de pesar, raiva e intenso medo. Além disso, a doença em sua trajetória, pode levar a mulher a passar por situações que ameaçam sua integridade psicossocial, que provocam incertezas quanto ao sucesso do tratamento e que a levam a se defrontar com a possibilidade de recorrência da doença e a morte(4). Porém, a maioria das mulheres enfrenta a crise e a contorna sem desenvolver desordens psiquiátricas e sexuais severas(2). O câncer de mama é uma experiência amedrontadora para a mulher e, para maioria delas, o diagnóstico da doença evoca sentimentos de pesar, raiva e intenso medo. Além disso, a doença em sua trajetória, pode levar a mulher a passar por situações que ameaçam sua integridade psicossocial, que provocam incertezas quanto ao sucesso do tratamento e que a levam a se defrontar com a possibilidade de recorrência da doença e a morte(4). Porém, a maioria das mulheres enfrenta a crise e a contorna sem desenvolver desordens psiquiátricas e sexuais severas(2). O desejo de participação no autocuidado após a cirurgia, em estudo dedicado a analisar as oportunidades e as vontades de mulheres no pós-operatório de câncer de mama, mostrou que, apesar de sua determinação de tomarem parte no autocuidado, infelizmente há pouca informação e suporte profissional para que isso ocorra, o que leva a crer que o sistema de saúde apóia, insuficientemente, a recuperação da paciente. O que as mulheres esperavam após a hospitalização era receber encorajamento, reabilitação mental, ajuda para desenvolver uma atitude positiva em relação à doença e seu tratamento, e apoio dos profissionais de saúde, parentes e amigos(5). INTRODUZINDO A TEMÁTICA CÂNCER DE MAMA INTRODUZINDO A TEMÁTICA CÂNCER DE MAMA conservadora, muitos casos ainda exigem a mastectomia, e é nessa época que a mulher é confrontada definitivamente com a perda da mama e o medo da cirurgia, da mutilação e da morte(6). O câncer de mama ocupa o segundo lugar no tipo de câncer de maior incidência, estimado para 2001, na população brasileira. A estimativa de casos novos e de óbitos por câncer de mama no Estado do Rio de Janeiro, para 2001, é de 6120 e 1500 casos, respectivamente(1). O período pós-operatório é marcado pela ambivalência. Ocorre o alívio de ter sobrevivido à cirurgia e a esperança de estar curada. Mas também há o medo do retorno da doença, o medo de enfrentar a dor e os curativos, o medo de enfrentar a possibilidade permanente de um corpo mutilado e, ainda, preocupações com a feminilidade e com as reações do companheiro frente à mastectomia, podendo esse período levar de um a dois meses após a alta hospitalar. Segue-se, então, o período pós-operatório de dois a seis meses, durante o qual ocorre a depressão, a ansiedade e a diminuição da auto-estima, coexistentes com sentimentos de fortalecimento pessoal e esperança(6). O câncer de mama permanece sendo o tipo de tumor mais comum entre as mulheres e tem um típico e, às vezes, complexo impacto psicológico. A utilização, cada vez maior, da cirurgia conservadora (onde não há extirpação completa da mama) tem reduzido o efeito negativo na auto- imagem e imagem corporal das mulheres afetadas pela doença(2). Muitas mulheres hoje, diagnosticadas com câncer de mama, podem ficar curadas ou viver longos períodos com a doença. Entretanto, ao contrário de outros tratamentos para doenças crônicas, aqueles tratamentos contra o câncer são mais tóxicos e intensos, resultando num aumento tanto da demanda das reservas físicas como, também, de seus recursos sociais e psicológicos para sobreviver e enfrentar a doença. Assim, é que o desenvolvimento específico dos cuidados prestados às portadoras de câncer de mama chamou a atenção para o papel chave dos fatores psicossociais na prevenção, no tratamento e nos resultados finais obtidos(3). DESCRIPTORES: neoplasmas de la mama; atención de enfermería; enfermería oncológica 1 Recorte do trabalho apresentado na mesa técnica “Atenção à mulher mastectomizada” a convite da Sub-Comissão de Temas do 53º CBEn, que condensa as considerações finais da Dissertação de Mestrado e Tese de Doutorado; 2 Doutor em Enfermagem, Enfermeira da Educação Continuada e Pesquisa de Enfermagem do Hospital do Câncer III (HC III) do Instituto Nacional do Câncer (INCA), Membro da Comissão Científica da Sociedade Brasileira de Enfermagem Oncológica (SBEO), e-mail: tcamargo@inca.gov.br; 3 Doutor em Enfermagem, Docente da Escola de Enfermagem Anna Nery da Universidade Federal do Rio de Janeiro, Orientadora da Dissertação de Mestrado e da Tese de Doutorado Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf Atenção à mulher mastectomizada... Camargo TC, Souza IEO. Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf 615 O ESPAÇO INSTITUCIONAL - A DIMENSÃO ÔNTICA DO ASSISTIR O cenário institucional onde atuo, há mais de quinze anos, é o Hospital do Câncer III (HCIII) do Instituto Nacional de Câncer (INCA) que atende, diariamente, uma clientela predominantemente feminina, diagnosticando e tratando pessoas portadoras de câncer de mama e encaminhando, para os locais de atendimento de patologias da mama do município (pólos de mama) as portadoras de doença benigna da mama. Inicialmente, as enfermeiras oncológicas desempenhavam papéis importantes no cuidado de cabeceira, através de medidas de conforto para os pacientes cirúrgicos e/ou em tratamento paliativo, no caso dos pacientes terminais. Porém, a atuação da enfermeira em oncologia cresceu com o advento dos ensaios clínicos conduzidos com novos agentes terapêuticos quimioterápicos. Esses ensaios clínicos trouxeram a necessidade de um trabalho conjunto da equipe multidisciplinar, voltada para o cuidado do paciente de câncer e para a pesquisa(9). A clientela do hospital vem crescendo dia-a-dia e, com ela, o quantitativo de cirurgias de mama de grande porte (mastectomias e segmentectomias com linfadenectomia axilar), bem como o número de encaminhamentos para o tratamento oncológico, quer seja ele hormonal, quimioterápico e/ou radioterápico. A porta de entrada para o HC III é a consulta na Triagem, que ocorre diariamente de segunda a sexta-feira. Se nessa consulta for diagnosticada doença benigna da mama, a cliente é encaminhada para os pólos de mama, vinculados à Secretaria Municipal de Saúde; se há suspeita de malignidade ela é matriculada na Instituição, encaminhada para exames complementares que são realizados no mesmo dia da triagem e, na confirmação de malignidade, é encaminhada para o agendamento de primeira vez na deliberação cirúrgica (no caso de tumores operáveis) ou na oncologia clínica (no caso de tumores inoperáveis). A assistência de enfermagem em oncologia, então, abrange os vários estágios do continuum saúde- doença, já que, o assistir ao outro que tem câncer, possibilita a intervenção de enfermagem em diversos níveis: na prevenção primária e na prevenção secundária, no tratamento do câncer, na reabilitação e na doença avançada. Portanto, a prática da enfermeira em oncologia evoluiu para a assistência ao cliente e sua família através da educação, provendo suporte psicossocial, administrando a terapia recomendada, selecionando e administrando intervenções que diminuam os efeitos colaterais da terapia proposta, participando da reabilitação e provendo conforto e cuidado(10). A partir da matrícula no HC III, a cliente passa a fazer parte de um fluxo no qual inúmeras vezes terá contato com a enfermeira. INTRODUZINDO A TEMÁTICA CÂNCER DE MAMA A negação e a depressão são as defesas psicológicas geralmente mais utilizadas no caso de acometimento por uma doença como, por exemplo, o câncer de mama. Torna-se, pois, importante a informação adequada sobre a doença e suas conseqüências, pois dá à mulher a possibilidade de enfrentamento e de se adaptar à sua nova condição(5). No contato diário com clientes portadoras de câncer de mama, foi observado que as mesmas desejam compartilhar com a enfermeira suas dúvidas, suas O período cirúrgico é o mais estressante. Apesar da tendência atual para a realização da cirurgia Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf Atenção à mulher mastectomizada... Camargo TC, Souza IEO. 616 tristezas, sua desesperança e também suas angústias. E, nesse compartilhar, esperam receber o suporte necessário para enfrentar a doença e o seu tratamento(8). institucional e apontar possibilidades da ação assistencial a partir da dimensão existencial das pessoas envolvidas. A assistência de enfermagem em oncologia evoluiu muito desde seu aparecimento como especialidade, e a literatura existente aponta e preconiza importante papel da enfermeira no apoio ao cliente oncológico nas várias fases de sua doença. Pensar hoje em oncologia é pensar em sobrevida com qualidade e não se fixar na cura da doença. O ESPAÇO INSTITUCIONAL - A DIMENSÃO ÔNTICA DO ASSISTIR Assim, estará com a enfermeira no Grupo de orientação pré-operatória; na consulta de enfermagem na internação; no Grupo de orientação da internação cirúrgica; no Grupo de orientação na alta; no grupo Pro-Mama; na consulta de enfermagem na sala de curativos; na consulta de enfermagem de primeira vez na quimioterapia; na consulta de enfermagem na pesquisa clínica; e na consulta de enfermagem pré-radioterapia (que está em fase de formulação). Esta reflexão aborda os aspectos relativos às dimensões ôntica e ontológica, que constituem e, portanto, permeiam o cenário da atuação da enfermeira junto à cliente com câncer de mama submetida à mastectomia. A análise reflexiva foi desenvolvida considerando tanto a experiência profissional como enfermeira assistencial do Hospital do Câncer III (HC III) do Instituto Nacional de Câncer (INCA), como pelo apoio a um referencial teórico filosófico obtido ao cursar o mestrado e o doutorado em Enfermagem. Numa atitude compreensiva e de interpretação fenomenológica, pretende-se refletir sobre as ações assistenciais da enfermeira na rotina do espaço Dentre as diversas atribuições da enfermeira no HC III, portanto, destacam-se a atividade de consulta de enfermagem e de orientação à clientela e seus familiares. Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf Atenção à mulher mastectomizada... Camargo TC, Souza IEO. 617 Essas orientações são feitas através da consulta de enfermagem, de palestras com recursos audiovisuais, de folders, algumas vezes, em conjunto com a equipe multiprofissional, e são direcionadas à vivência dos diversos tipos de modalidades terapêuticas para o câncer de mama. e intervir nos aspectos que poderão prejudicar o tratamento e a recuperação física e moral; auxiliar a cliente e seus familiares a identificar e mobilizar fontes de ajuda para resolução de problemas; facilitar o acesso aos demais profissionais da equipe multidisciplinar; esclarecer sobre a conduta cirúrgica, certificando-se da compreensão e aceitação da mesma pela cliente; permitir que a cliente e seus familiares tomem decisões sobre o tratamento proposto; discutir sobre o retorno às atividades e convívio social, sexualidade, métodos anticoncepcionais e auto- exame das mamas e do plastrão; explicar e discutir as alterações decorrentes do ato cirúrgico (mutilação, limitação dos movimentos do membro superior, sintomatologia no pós-operatório, curativos e punção de seroma); orientar e enfatizar os cuidados necessários pós- linfadenectomia; identificar e intervir nas possíveis alterações presentes na auto-imagem e na auto-estima (aceitação, negação, rejeição); enfatizar a importância do seguimento; abordar a possibilidade de reconstrução mamária. O ESPAÇO INSTITUCIONAL - A DIMENSÃO ÔNTICA DO ASSISTIR Essas orientações são feitas através da consulta de enfermagem, de palestras com recursos audiovisuais, de folders, algumas vezes, em conjunto com a equipe multiprofissional, e são direcionadas à vivência dos diversos tipos de modalidades terapêuticas para o câncer de mama. Cabe ressaltar que, apesar do direcionamento técnico e científico da consulta de enfermagem e das orientações, há também a possibilidade de se olhar essa cliente sob o ponto de vista que considera o ser do humano. Então, ao analisar compreensivamente a prática da enfermagem nos diversos momentos pelos quais a cliente passa durante o seu tratamento, foi possível apreender que os objetivos tanto da consulta de enfermagem como das orientações foram direcionados para uma prática técnica, científica e humana, com o intuito de alcançar o que se mostrou como possibilidade de ser- com* e junto-à cliente durante seu tratamento e seguimento. Entendo, portanto, que devemos olhar a cliente, a pessoa, não apenas como objeto do assistir, mas como sujeito do nosso cuidado que, sendo, merece um olhar de natureza compreensiva e a oportunidade de recorrer à enfermeira, não para agir ou pensar por ela, mas para auxiliá-la em suas dificuldades, dúvidas, medos e ansiedades, deixando sempre claro que ela tem a responsabilidade final sobre si mesma. Desse modo a enfermeira estará ajudando a cliente a de-cidir-se e assumir seu próprio destino(11). * No pensar de Heidegger, o ser-com é uma característica existencial e deve se exprimir na convivência através de um preocupar-se com o outro e um ocupar-se das coisas er-com é uma característica existencial e deve se exprimir na convivência através de um preocupar-se com o outro O ESPAÇO ASSISTENCIAL - A DIMENSÃO ONTOLÓGICA DO CUIDADO Essas orientações visam esclarecer e apoiar a mulher e sua família para que possam, efetivamente, tomar parte na reabilitação psicossocial e, também, procuram habilitar a cliente ao autocuidado. Pretendem, também, dar estímulo para que readquiram a autoconfiança e mantenham o moral elevado. Durante quinze anos de convívio com a cliente portadora de câncer de mama e, portanto, com muitas mastectomizadas, pude conhecer e reconhecer vários sinais e sintomas decorrentes do medo nas diversas fases do diagnóstico, tratamento e reabilitação pós-cirúrgica. As mulheres e seus familiares consideram essas atuações da enfermeira como muito úteis e eficientes, pois, segundo eles, aliviam a tensão, esclarecem as dúvidas e ajudam o fortalecimento psicológico, permitindo que as mulheres enfrentem mais positivamente as adversidades surgidas com o diagnóstico da doença e seu tratamento. O medo é sempre latente nessa clientela, durante toda a história e a trajetória de sua doença e luta pela vida. Medo de ouvir que tem câncer, medo de enfrentar os comentários da família e dos amigos, medo da cirurgia, medo de se ver e se mostrar mutilada, medo das seqüelas da cirurgia, medo de não saber se cuidar e se tornar dependente, medo de fazer o tratamento complementar, medo da doença voltar, medo de não agüentar e morrer. Nesse contexto, a Fenomenologia surge como um caminho que permite a compreensão do outro, no caso a cliente, que teve seu cuidado confiado à enfermeira(12). No entanto, ao longo de sua trajetória, a cliente mostra-se buscando vencer os obstáculos e é nesse momento que a enfermeira tem papel fundamental. Dar voz e possibilitar ao outro que expresse o sentido de enfrentar a mastectomia e o câncer de mama em suas várias etapas e sobre como gostaria de ser ajudado, é imprescindível para o sucesso da reabilitação da cliente. O pensar e o agir fundado em base fenomenológica conduz à reflexão sobre o ser-aí, permitido um encontro de natureza existencial com o nosso semelhante, aquele de quem cuidamos e que passa um período difícil de sua vida, quando acometido, por exemplo, pelo câncer de mama. Ao nos conduzir a esse estado reflexivo, abre o caminho para repensar a atividade assistencial ainda hoje sustentada no modelo biologicista/biomédico e que, em conseqüência, se mostra tão afastada da clientela, do ser do humano. O ESPAÇO ASSISTENCIAL - A DIMENSÃO ONTOLÓGICA DO CUIDADO O cuidado de enfermagem tem como objetivo, em sua essência, assistir o ser humano em sua totalidade e, portanto, o cliente deve ser visto como um todo, observando-se a relação mente e corpo. Dessa forma, pode- se perceber que cada indivíduo é singular e tem necessidades e valores próprios. Nesse processo, a enfermeira, então, está oportunizando a essa cliente a possibilidade de cuidar de si, de reivindicar da Instituição que receba atenção e tratamento que minimize o máximo possível seu sofrimento. E, está, assim, abrindo o caminho para a cliente exercer a sua cidadania, pois, direcionar alguém para o autocuidado, implica em esse alguém conhecer os seus direitos de cidadão e, portanto, de requerer assistência à saúde digna e merecida por qualquer pessoa. A atuação da enfermeira no cotidiano do cuidar, portanto, deve se refletir numa assistência de enfermagem de qualidade que direciona para o autocuidado, objetiva a melhoria da qualidade de vida da cliente e, ainda, permite o reconhecimento e a valorização do profissional ao estabelecer relação positiva e empática enfermeira- cliente(8). Assim, os objetivos assistenciais visam: informar sobre rotinas hospitalares e procedimentos a serem realizados, diminuindo o stress das clientes gerado pela desinformação; facilitar e/ou possibilitar a recuperação física, emocional e social da cliente, preparando-a para o autocuidado (realização de curativo, cuidados com o dreno, exercícios); dar voz à cliente, permitindo que exponha seus medos, anseios, dúvidas e expectativas; procurar identificar Ao assistir a mulher que tem um câncer de mama e, em conseqüência, se submete ao tratamento cirúrgico e/ou clínico, pude compreender como no dia a dia criamos laços e compromissos com essa clientela. A partir do momento em que iniciamos qualquer aproximação com a cliente, mesmo que de caráter puramente informativo, nos tornamos responsáveis por * No pensar de Heidegger, o ser-com é uma característica existencial e deve se exprimir na convivência através de um preocupar-se com o outro e um ocupar-se das coisas Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf Atenção à mulher mastectomizada... Camargo TC, Souza IEO. 618 aquele de quem cuidamos. E não apenas responsáveis por conhecer e aplicar, na assistência à pessoa, os princípios técnicos e científicos mais atuais, visando a recuperação da saúde da cliente, mas, também, devemos estar atentos e disponíveis para auxiliar no enfrentamento da doença e suas conseqüências. consultas de enfermagem na sala de curativos, quimioterapia, pesquisa clínica e, muito em breve, pré- radioterapia. * Heidegger usou essa palavra para designar a existência própria do homem O ESPAÇO ASSISTENCIAL - A DIMENSÃO ONTOLÓGICA DO CUIDADO Privilegiando o outro sim, como pessoa, cidadã e objeto de nosso cuidado enquanto enfermeiras, sem nos determos somente no problema físico que, de imediato, o aflige, ou seja, valorizando o exercício da empatia e da cidadania como forma de convivência e assistência diária ao outro(13). A partir de minha vivência e experiência profissional, e por entender a enfermagem como uma assistência que se dá ao outro, numa relação entre pessoas, penso a fenomenologia como método adequado para a assistência, a pesquisa e o ensino na enfermagem já que busca a compreensão do humano em seu cotidiano. A investigação fenomenológica possibilita compreender o ser-aí no seu em si mesmo, propiciando, assim, melhor compreensão daquele de quem se cuida e, conseqüentemente, a possibilidade de um assistir mais humanizado e holístico porque se realiza a partir do outro, daquela que recebe o cuidado. A partir de minha vivência e experiência profissional, e por entender a enfermagem como uma assistência que se dá ao outro, numa relação entre pessoas, penso a fenomenologia como método adequado para a assistência, a pesquisa e o ensino na enfermagem já que busca a compreensão do humano em seu cotidiano. Percebi, então, a possibilidade de olhar o ser humano como ser-aí no meu cotidiano de assistir o outro, ou seja, não olhá-lo apenas a partir da dimensão da experiência, mas, também, da existência. Compreendo que o modelo biomédico, ao qual nossa formação enquanto enfermeiras está amplamente relacionada, entifica o humano pela patologia, tratando mais do que cuidando. Porém, a assistência de enfermagem pode-ser de natureza não apenas científica/explicativa, mas, também, de natureza compreensiva. A investigação fenomenológica possibilita compreender o ser-aí no seu em si mesmo, propiciando, assim, melhor compreensão daquele de quem se cuida e, conseqüentemente, a possibilidade de um assistir mais humanizado e holístico porque se realiza a partir do outro, daquela que recebe o cuidado. Compreendi, em todos esses anos de trabalho na assistência à mulher com câncer de mama, como o apoio, a disponibilidade e a orientação fornecida pela enfermeira à cliente, sobre sua doença, sobre o que esperar após o diagnóstico do câncer, sobre como se dá o tratamento e suas conseqüências e, ainda, a reabilitação são importantes para auxiliar a mulher na superação desses momentos difíceis de sua existência. O ESPAÇO ASSISTENCIAL - A DIMENSÃO ONTOLÓGICA DO CUIDADO Esse apoio parece auxiliar na recuperação do equilíbrio necessário ao ser-aí* para continuar a ser o que ele é em si e descobrir suas possibilidades mais próprias. E compreendendo-se como ser possível, o ser-aí pode então de-cidir com liberdade seu próprio modo de ser e ex-sistir frente à doença, ao tratamento, seus efeitos colaterais e sua reablitação(11). Essa atividade vem sendo centrada nos aspectos biomédicos, na separação do homem em órgãos independentes, nas técnicas, nos custos, na produtividade, nos lucros hospitalares. Assim, parece passar ao largo do doente como pessoa e de suas questões existenciais, levando os profissionais de enfermagem a se afastarem do ser do cliente, privilegiando o quantitativo de atendimentos que elevam os lucros e a produtividade individual. A tais fatos somam-se ainda o cumprimento da carga horária semanal e das escalas de serviço em detrimento da pessoa doente(11). O intuito, portanto, da atuação da enfermeira, é o de poder oferecer assistência que todo ser do humano merece, assistência técnica e científica, humana e singular e que se possa ver o outro como um Ser que possui sentimentos, que pensa, que tem a possibilidade de escolher e de-cidir e não como um organismo doente e dependente. Então, no meu caminhar, apoiada na Fenomenologia e no pensamento de Martin Heidegger, importou o meu cotidiano assistencial onde apareceram as inquietações iniciais e o olhar atentivo questionador dos fatos técnico-científicos, que não respondiam todas as questões surgidas no meu dia-a-dia profissional. Ao Portanto, é pensando na reabilitação da mulher que se submeteu à mastectomia ou segmentectomia, que há a realização da orientação individual para o autocuidado, feita pela enfermeira desde que a cliente é internada; do grupo de orientação à mulher e sua família no pré-operatório e quando da alta hospitalar; do grupo Pro-Mama; e das Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf Atenção à mulher mastectomizada... Camargo TC, Souza IEO. 619 interrogar o ente mulher com diagnóstico de câncer de mama e submetida à mastectomia emergiu a questão do ser (ser-aí, dasein, presença) e a possibilidade de compreensão e de desvelamento do sentido desse ser do humano, a quem presto assistência de enfermagem. e não apenas com a sua doença e/ou tratamento. O ESPAÇO ASSISTENCIAL - A DIMENSÃO ONTOLÓGICA DO CUIDADO Nesse sentido, penso que as enfermeiras devem estar mais atentas à sua atuação no dia-a-dia da labuta, pois parece que muitas vezes não percebem que, ao desenvolver ações educativas em grupo e/ou na consulta de enfermagem, privilegiando a singularidade, estão assumindo o modo de ser sendo-aí-com a cliente e, dessa forma, contribuindo para fortalecer os laços sociais e humanos com a sua clientela no sentido de possibilitá-la a ser o que é em si mesma e tem direito de ser, criando, assim, a possibilidade de uma qualidade de vida melhor. Pude ainda perceber como a disponibilidade, as orientações e o apoio às necessidades de cada pessoa na forma de grupo explicativo são, em alguns momentos, ainda não suficientes e não ajustados aos aspectos individuais que envolvem, por exemplo, a observação pela enfermeira dos gestos, das expressões, do olhar, enfim das emoções transmitidas pela cliente já que no coletivo, relevantes são os fatos, aquilo que já sabemos e conhecemos, e que é relativo ao que se observa e se comprova, na maioria das vezes e quase sempre, no acompanhamento terapêutico em oncologia(11-13). Assim, notei como a consulta de enfermagem é importante pois possibilita, em sua relação eu e tu, a singularidade de cada pessoa emergir e, portanto, deve estar permeando a atuação da enfermeira no seu cotidiano assistencial. Cuidar é a essência da enfermagem e implica envolvimento, zelo, amor, compaixão, ética. Cuidar não é tratar apenas de uma doença, mas é também vê-la como possibilidade do ser de quem cuidamos. Portanto, ouvir, tocar, estar disponível é uma forma de humanizar a assistência e resgatar o cuidado que, em nossa cultura científica, foi relegado e colocado em suspeição por ser de natureza subjetiva. Ainda sobre o cuidado diz-se: “Pelo cuidado não vemos a natureza e tudo que nela existe como objetos. A relação não é sujeito-objeto, mas sujeito-sujeito”(14). Sob essa ótica, a cliente pode-ser ouvida e assistida mediante um cuidado que não se basta no conhecimento científico e que, portanto, na dimensão ontológica, abre o ser-aí para o seu ser originário que é a cura. Vislumbro a assistência de enfermagem pela ótica da compreensão como possibilidade do agir profissional. CONSIDERAÇÕES FINAIS – O CUIDADO DE ENFERMAGEM COMO POSSIBILIDADE cumprir para ajudar no tratamento. cumprir para ajudar no tratamento. No entanto, a cliente deve ser vista como uma pessoa com questões e preocupações singulares. Portanto, a atuação da enfermeira não se reduz a orientações e informações sobre sua doença e seus direitos à saúde, mas envolve também atuação em nível existencial. Dessa forma, a enfermeira sendo-com a equipe de enfermagem, sendo-com a equipe de saúde, sendo- sujeito de suas ações em ambas e não apenas uma peça da engrenagem assistencial, é possível desenvolver o cuidado holístico e o autocuidado eficiente, já que estará centrado na singularidade de cada um, na sua história de vida e nos seus anseios de futuro. Este artigo buscou refletir sobre a prática assistencial da enfermeira no cotidiano de cuidar de mulheres com câncer de mama, submetidas à mastectomia. Abordou a problemática do câncer de mama a partir de sua incidência e o impacto causado pelo diagnóstico e tratamento cirúrgico dessa patologia, para a mulher. Numa atitude compreensiva, discutiu os aspectos ônticos e ontológicos relativos ao cuidado de enfermagem prestado a essa mulher, num hospital especializado em mastologia oncológica, considerando que esses aspectos permeiam a prática assistencial, e valorizando a dimensão existencial das pessoas envolvidas. Encontrou na Fenomenologia um caminho para o cuidado que é cura, que é singular, que é humanizado e também é direcionado ao resgate do ser-si-mesmo, cuidando de si com responsabilidade. Esta análise permite apreender que, ao olhar a mulher mastectomizada compreensivamente em sua singularidade, nas consultas de enfermagem, a enfermeira está dando a ela voz para expressar o sentido, ou seja, expressar a compreensão singular que ela tem dessa sua vivência. E é assim que se completa o ciclo que leva ao autocuidado eficiente. Finalmente, ancorada na interpretação fenomenológica, é possível tecer considerações sobre as possibilidades do cuidado prestado a essa clientela, propondo que tal cuidado deva ser realizado considerando- se a mulher como ser singular, como cidadã, como pessoa responsável por sua saúde e seu autocuidado, como um todo de carne e espírito, mente e corpo, ao qual se deve prestar assistência que congregue técnica, ciência e humanização. 4. Almeida AM, Mamede MV, Panobianco MS, Prado MAS, Clapis MJ . Construindo o significado da recorrência da doença: a experiência de mulheres com câncer de mama. Rev Latino-am Enfermagem 2001; 9(5):63-9. 5. Suominen T. Breast cancer patients opportunities to participate in their care. Cancer Nurs 1992; 15(1):68-72. 6. Turns DM. Psychosocial Factors In: Donegan WL, Spratt JS, organizadores. Cancer of the Breast. Philadelphia (PEN): W. B. Saunder; 1988. p. 728-38. 7. Silva RM, Mamede MV. Conviver com a Mastectomia. Fortaleza (CE): Universidade Federal do Ceará; 1998. 8. Amorim MH. C. A Enfermagem e a Psiconeuroimunologia no câncer de mama. [tese]. Rio de Janeiro (RJ): Escola de Enfermagem Anna Nery/UFRJ; 1999. O ESPAÇO ASSISTENCIAL - A DIMENSÃO ONTOLÓGICA DO CUIDADO Compreensão essa que não tem apenas o significado de entender, notar ou explicar as necessidades fisiológicas emergentes da patologia e do tratamento da cliente, mas que nos permite, enquanto profissionais da saúde que somos, estar com o outro como pessoa em sua totalidade, Cura que não significa a resolução de uma patologia, mas, sim, cuidar ou zelar, ou, ainda, relacionar- se com algo, e que é considerada por Heidegger, como estrutura fundamental do ser-aí(15). Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf Atenção à mulher mastectomizada... Camargo TC, Souza IEO. 620 CONSIDERAÇÕES FINAIS – O CUIDADO DE ENFERMAGEM COMO POSSIBILIDADE Portanto, a ação assistencial da enfermeira a partir da dimensão existencial da mulher mastectomizada tem a possibilidade de ocorrer num poder-ser, num entrelaçamento de ações e intervenções científicas, sociais e de natureza compreensiva, envolvendo o cliente, a família e as enfermeiras em suas relações de trabalho, despertando, ainda, suas consciências de cidadania e de ser-sujeito de suas ações. Portanto, a atenção à mulher mastectomizada tem como objetivo final capacitá-la para o autocuidado. Usualmente, em nosso sistema de saúde, que segue o modelo biomédico, envolver a cliente no autocuidado é compreendido apenas como o ato de dar-lhe informações e orientações sobre sua patologia e seu tratamento. Sobre aquilo que a equipe de saúde considera que ela deve Abre-se, então, a possibilidade da concretude social da enfermagem a partir da enfermeira que se mostra enquanto ser-aí no seu modo próprio de ser, sendo-com a cliente sem dominá-la, preocupando-se com ela e não apenas dela se ocupando. Prestando cuidado denominado por Heidegger de “anteposição liberadora”, pois devolve ao Ser a capacidade de cuidar de si. REFERÊNCIAS BIBLIOGRÁFICAS 3. Rowland JH, Massie MJ. Psychologic Reactions to Breast Cancer Diagnosis, Treatment and Survival. In: Harris JR, Lippman ME, Morrow M, Hellman S, organizadores. Diseases of the Breast. Philadelphia (PEN): Lippincott-Raven Publishers; 1996. p. 919-38. 1. Ministério da Saúde (BR). Instituto Nacional de Câncer. Estimativa da incidência e mortalidade por câncer no Brasil. Rio de Janeiro (RJ): Instituto Nacional de Câncer; 2001. 2. Carlsson M, Hamrin E. Psychological and psychosocial aspects of breast cancer and breast cancer treatment. Cancer Nurs 1994; 17(5):418-28. 1. Ministério da Saúde (BR). Instituto Nacional de Câncer. Estimativa da incidência e mortalidade por câncer no Brasil. Rio de Janeiro (RJ): Instituto Nacional de Câncer; 2001. 2. Carlsson M, Hamrin E. Psychological and psychosocial aspects of breast cancer and breast cancer treatment. Cancer Nurs 1994; 17(5):418-28. 3. Rowland JH, Massie MJ. Psychologic Reactions to Breast Cancer Diagnosis, Treatment and Survival. In: Harris JR, Lippman ME, Morrow M, Hellman S, organizadores. Diseases of the Breast. Philadelphia (PEN): Lippincott-Raven Publishers; 1996. p. 919-38. Recebido em: 16.4.2002 Aprovado em: 16.6.2003 REFERÊNCIAS BIBLIOGRÁFICAS 1. Ministério da Saúde (BR). Instituto Nacional de Câncer. Estimativa da incidência e mortalidade por câncer no Brasil. Rio de Janeiro (RJ): Instituto Nacional de Câncer; 2001. 2. Carlsson M, Hamrin E. Psychological and psychosocial aspects of breast cancer and breast cancer treatment. Cancer Nurs 1994; 17(5):418-28. Atenção à mulher mastectomizada... Camargo TC, Souza IEO. Rev Latino-am Enfermagem 2003 setembro-outubro; 11(5):614-21 www.eerp.usp.br/rlaenf 621 9. Yabro CH. The Oncology Nurse. In: De Vita VT Jr, Hellman NS, Rosenberg AS, organizadores. Principles and Practice of Oncology. Philadelphia (PEN): J.B. Lippincott; 1997. p. 2917- 23. 10. Ades T, Greene P. Principles of Oncology Nursing. In: Holleb AI Fink DJ Murphy GP organizadores American Cancer 10. Ades T, Greene P. Principles of Oncology Nursing. In: Holleb AI, Fink DJ, Murphy GP, organizadores. American Cancer Society Textbook of Clinical Oncology. Atlanta (GEO): American Cancer Society; 1991. p. 587-93. p y g Society Textbook of Clinical Oncology. Atlanta (GEO): American Cancer Society; 1991. p. 587-93. Cancer Society; 1991. p. 587-93. 11. Camargo TC. O ex-sistir feminino enfrentando a quimioterapia para o câncer de mama: um estudo de enfermagem na ótica de Martin Heideqger. [tese]. Rio de Janeiro (RJ): Escola de Enfermagem Anna Nery/UFRJ; 2000. 12. Lopes RLM, Souza IEO. A fenomenologia como abordagem metodológica: compartilhando a experiência de mulheres que buscam a prevenção do câncer cérvico-uterino. Rev Latino-am Enfermagem 1997; 5(3):5-11. 13. Camargo TC, Souza IEO. Enfermagem à mulher em tratamento quimioterápico: uma análise compreensiva do assistir. Rev Bras Enfermagem 1998 julho/setembro; 51(3):357-68. 14. Boff L. Saber Cuidar: ética do humano/compaixão pela terra. 3ª ed. Petrópolis (RJ): Vozes; 1999. 15. Heidegger M. Todos nós...ninguém. São Paulo (SP): Editora Moraes; 1981. 11. Camargo TC. O ex-sistir feminino enfrentando a quimioterapia para o câncer de mama: um estudo de enfermagem na ótica de Martin Heideqger. [tese]. Rio de Janeiro (RJ): Escola de Enfermagem Anna Nery/UFRJ; 2000. 12. Lopes RLM, Souza IEO. A fenomenologia como abordagem metodológica: compartilhando a experiência de mulheres que buscam a prevenção do câncer cérvico-uterino 11. Camargo TC. O ex-sistir feminino enfrentando a quimioterapia para o câncer de mama: um estudo de enfermagem na ótica de Martin Heideqger. [tese]. Rio de J i (RJ) E l d E f A N /UFRJ 2000 11. Camargo TC. O ex-sistir feminino enfrentando a quimioterapia para o câncer de mama: um estudo de enfermagem na ótica de Martin Heideqger. [tese]. REFERÊNCIAS BIBLIOGRÁFICAS Rio de Janeiro (RJ): Escola de Enfermagem Anna Nery/UFRJ; 2000. 12 Lopes RLM Souza IEO A fenomenologia como ( ) g y 12. Lopes RLM, Souza IEO. A fenomenologia como abordagem metodológica: compartilhando a experiência de mulheres que buscam a prevenção do câncer cérvico-uterino. Rev Latino-am Enfermagem 1997; 5(3):5-11. g ( ) 13. Camargo TC, Souza IEO. Enfermagem à mulher em tratamento quimioterápico: uma análise compreensiva do assistir. Rev Bras Enfermagem 1998 julho/setembro; 51(3):357-68. ( ) 14. Boff L. Saber Cuidar: ética do humano/compaixão pela terra. 3ª ed. Petrópolis (RJ): Vozes; 1999. 15. Heidegger M. Todos nós...ninguém. São Paulo (SP): Editora Moraes; 1981. ( ) 14. Boff L. Saber Cuidar: ética do humano/compaixão pela terra. 3ª ed. Petrópolis (RJ): Vozes; 1999. 15. Heidegger M. Todos nós...ninguém. São Paulo (SP): Editora Moraes; 1981.
https://openalex.org/W2087351664	https://www.aanda.org/10.1051/0004-6361:20078535/pdf	English	null	Faint super-soft X-ray sources in XMM-Newton Large Magellanic Cloud fields	Astronomy & astrophysics	2,008	public-domain	8,192	1. Introduction XMMU J052016.0-692505, which is a likely WD Be/X-ray bi- nary in the LMC was reported by Kahabka et al. (2006). Three ROSAT-discovered, super-soft sources in the ﬁeld of the Small Magellanic Cloud (SMC) were observed with XMM-Newton (Kahabka & Haberl 2006). One of them is identiﬁed with the symbiotic LIN 358, a second source can be a Galactic CV, quiescent low-mass X-ray binary, or isolated cooling NS. A third source could not be detected with XMM-Newton. Here we report about three new super-soft sources discovered in archival XMM-Newton observations of the LMC ﬁeld. In addi- tion, we investigate XMM-Newton observations of the ROSAT- discovered, super-soft source RX J0537.7−7034 and the candi- date RX J0507.1−6743 in the LMC. Super-soft X-ray sources are luminous, ∼1036−1038 erg s−1, and have soft, kT ∼ 20–80 eV, spectra (e.g. Kahabka & van den Heuvel 1997). They have been discovered in the direc- tion of more than 10 external galaxies (Kahabka 2006; Pietsch et al. 2005; DiStefano et al. 2006). Eight super-soft sources that were optically identiﬁed and for which an orbital period was de- termined are known in the Magellanic Clouds. Single-star super- soft sources like nuclei of planetary nebulae and post-AGB stars (PG1159 stars) are also known (see discussion in Kahabka & van den Heuvel 1997). Cooling neutron stars (NSs) can have very soft spectra but with much lower luminosities. Also, mag- netic cataclysmic variables (CVs, polars) have a super-soft spec- tral component. These low-luminosity sources can only be de- tected if they are nearby (Galactic) (see discussion in Kahabka & Haberl 2006). Binary super-soft sources with luminosities of ∼1036–1038 erg s−1 can be explained by steady or stable nuclear burning white dwarfs (WDs) accreting H-rich matter from a (slightly evolved) main-sequence star, subgiant, or giant (van den Heuvel et al. 1992). The number of such systems in the Galaxy can be predicted from population synthesis calculations, but they are diﬃcult to detect due to absorption by gas in the Galactic plane (Rappaport et al. 1994). The Magellanic Clouds are better suited to detect and study super-soft sources due to lower metallicities and lower mean absorbing columns. ABSTRACT Aims. We report the discovery of three faint, super-soft X-ray sources in LMC ﬁelds observed with XMM-Newton. Methods. We analyse the three new sources together with RX J0537.7−7034 and RX J0507.1−6743, both known since ROSAT. Results. We identify XMMU J050803.1−684017 with the LMC planetary nebula LHA 120-N 102 = LMC SMP 29. The EPIC-pn spectrum of XMMU J050803.1−684017 can be ﬁtted with a blackbody spectrum with an eﬀective temperature of ∼(26–51) eV and a bolometric luminosity of (0.1−30) × 1036 erg s−1, depending on the assumed absorption. The source is consistent with the nucleus of a planetary nebula. The EPIC-pn spectrum of XMMU J052530.5−671501 is characterized by a blackbody temperature of ∼(38–120) eV, a best-ﬁt bolometric luminosity of ∼3 × 1037 erg s−1 and absorbing LMC column of ∼8+2 −8 × 1021 cm−2. This most likely highly- absorbed super-soft source resembles the LMC super-soft source CAL 87. The EPIC-pn spectrum of XMMU J052215.0−701658 yields a blackbody temperature of ∼(24–83) eV, but there are only about 40 source counts and the spectral parameters of the source are not well constrained. We observe RX J0537.7−7034 with EPIC-pn to be about a factor of 15 fainter compared to the ROSAT observation 11 years earlier. RX J0507.1−6743 is observed as an absorbed super-soft source by XMM-Newton and the improved X-ray position coincides with a MACHO star which is consistent with a symbiotic star. Key words. galaxies: Magellanic Clouds – X-rays: stars – stars: binaries: close – stars – binaries: general – stars: general P. Kahabka1, F. Haberl1, M. Pakull2, W. C. Millar3, G. L. White3, M. D. Filipovi´c4, and J. L. Payne3 1 Max-Planck-Institut für extraterrestrische Physik, Giessenbachstrasse, 85741 Garching, Germany e-mail: [pkahabka;fwh]@mpe.mpg.de 2 Observatoire de Strasbourg, 11 rue de l’Université, 67000 Strasbourg, France e-mail: pakull@astro.u-strasbg.fr 2 Observatoire de Strasbourg, 11 rue de l’Université, 67000 Strasbourg, France e-mail: pakull@astro.u-strasbg.fr 3 Centre for Astronomy, James Cook University, Townsville, Queensland 4811, Australia 4 University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia 3 Centre for Astronomy, James Cook University, Townsville, Queensland 4811, Australia 4 University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia Received 23 August 2007 / Accepted 16 December 2007 Received 23 August 2007 / Accepted 16 December 2007 Astronomy & Astrophysics Astronomy & Astrophysics Astronomy & Astrophysics A&A 482, 237–245 (2008) DOI: 10.1051/0004-6361:20078535 c⃝ESO 2008 P. Kahabka1, F. Haberl1, M. Pakull2, W. C. Millar3, G. L. White3, M. D. Filipovi´c4, and J. L. Payne3 P. Kahabka1, F. Haberl1, M. Pakull2, W. C. Millar3, G. L. White3, M. D. Filipovi´c4, an 2. Search for super-soft sources in archival XMM-Newton LMC ﬁelds The results1 are summarized in Table 3, which in- cludes absorbing column density due to LMC gas NLMC H , black- body temperature kTbb, observed and absorption corrected ﬂux, and intrinsic source luminosity for a distance of 50 kpc in the 0.1–2.4 keV energy band. Errors denote 90% conﬁdence limits. The C-statistic (C-stat) and the number of spectral bins (Nbin) are listed in the ﬁnal columns. Also given are the absorption col- umn densities due to Galactic gas (ﬁxed in the ﬁt) and the total LMC gas as determined from 21-cm measurements in the direc- tion of the source (Brüns et al. 2005), for comparison with the value derived from the ﬁt. In total, we discovered four new super-soft sources that we further investigated by cross-correlating with optical catalogs (using Vizier). Three of the super-soft sources are presented and discussed here, the fourth super-soft source is described in Kahabka et al. (2006). We could not conﬁrm the super-soft source XMMU J053056.2−6548009 (Haberl et al. 2003), which turns out to be a detector artifact. We also include in our sam- ple the ROSAT detected super-soft sources RX J0537.7−7034 and RX J0507.1−6743, located in the ﬁelds of XMM-Newton observations. RX J0507.1−6743 is observed with HR1 > 0.0, in agreement with an absorbed super-soft source. If a suﬃcient number of source counts ≳50 were collected then an X-ray spec- tral ﬁt (using an absorbed blackbody model) was applied to the data and the spectral parameters were derived. The observations, which include the sources discussed here, are summarized in Table 1. During all seven observations, EPIC-pn was operated in full-frame read-out mode with 73 ms frame time. For J050803, we extracted the source counts in a circle with radius 15′′ and the background counts from a nearby circle with radius 15′′ and collected ∼122 source counts for X-ray spectral ﬁtting. In the case of J052530, we extracted the source counts in a circle with radius 35′′ and the background counts from a nearby circle with radius 35′′ and collected 60 source counts for X-ray spectral ﬁtting. J052215 was discovered in an archival ob- servation of the LMC classical nova N LMC 2000 performed on 25 July 2000. The source was also in the ﬁeld of view of a second observation of N LMC 2000 performed on 28 Aug. 2000. It was only marginally detected during the second obser- vation (cf. 2. Search for super-soft sources in archival XMM-Newton LMC ﬁelds We investigated the EPIC-pn observations from the public XMM-Newton archive in the direction toward the LMC, which were performed in large-window, full-frame, or extended full- frame imaging mode (a total of more than 50 observations). We applied a maximum likelihood source detection analysis to the data in the four energy bands 0.2–0.5 keV (with count rate S in this band), 0.5–1.0 keV (H), 1.0–2.0 keV (H1), and 2.0–4.5 keV (H2) and investigated the detected sources in the hardness ratio HR1 −HR2 plane (with HR1 = (H −S)/(H + S)) and HR2 = (H1 - H))/(H1 + H)). A source that fulﬁlled the hardness ra- tio criterion –1.0 ≤HR1 ≤0.0 and –1.0 ≤HR2 ≤−0.5 was checked on a displayed image. If conﬁrmed as a real source and We used XMM-Newton archival observations to search for new super-soft sources in Magellanic Cloud ﬁelds. The X-ray and optical investigation of one new super-soft source, Article published by EDP Sciences P. Kahabka et al.: Faint super-soft sources in XMM-Newton LMC ﬁelds 238 Table 1. Summary of XMM-Newton observations. y Target EPIC-pn Sat. Revol. / Obs.-ID Observation Exp. Filter Start End [ks] N103B Medium 106 / 0113000301 July 07 2000, 08:01 July 07 2000, 11:18 10.6 N51D Thin 347 / 0071940101 Oct. 31 2001, 20:50 Nov. 01 2001, 04:38 24.6 N LMC 2000 (a) Thin 115 / 0127720201 July 25 2000, 22:48 July 26 2000, 03:23 14.6 N LMC 2000 (b) Thin 132 / 0127720301 Aug. 28 2000, 13:53 Aug. 28 2000, 16:43 10.2 RX J0537.7−7034 Thin 673 / 0148870501 Aug. 12 2003, 08:36 Aug. 12 2003, 23:02 37.8 DEM L71 (a) Medium 241 / 0109990201 Apr. 02 2001, 12:32 Apr. 03 2001, 00:30 25.7 DEM L71 (b) Medium 735 / 0201840101 Dec. 13 2003, 20:39 Dec. 14 2003, 13:25 52.9 not as an artifact (e.g. a spurious detection in the halo of a bright source) then an image was binned in detector coordinates. If the source counts were recorded in one single pixel or in a 4 × 4 ma- trix or a similar matrix then we rejected the source as a hot pixel or as caused by a particle event. models) modiﬁed by Galactic absorption with the solar elemen- tal abundances of Anders & Grevesse (1989) and absorption due to LMC gas. 1 Hereafter, we abbreviate: XMMU J050803.1–684017 = J050803, XMMU J052530.5–671501 = J052530, XMMU J052215.0–701658 = J052215, RX J0537.7–7034 = J0537 and RX J0507.1–6743 = J0507. 2. Search for super-soft sources in archival XMM-Newton LMC ﬁelds Table 2), but the vignetting corrected count rates of both observations are consistent within 68% conﬁdence. We ex- tracted the source counts in a circle with radius 15′′ and the back- ground counts from a nearby circle with radius 15′′ and collected 32 counts for X-ray spectral ﬁtting. In the analysis of J0537, we obtain ∼64 and for J0507, ∼138 source counts for X-ray spectral ﬁtting. In Table 2, we give the source existence likelihood ra- tio (ML) for the soft (0.2–0.5 keV) and the hard (0.5–1.0 keV) spectral band, the equatorial source coordinates (RA and Dec) with 68% conﬁdence error radius, vignetting corrected source count rates in the soft and hard band, and hardness ra- tios HR1 and HR2, when available. We observed XMMU J052215.0−701658 and RX J0507.1−6743 twice, marked as (a) and (b) in Table 1. In Fig. 1, we present the EPIC-pn spectra of the investigated sources together with their best-ﬁt models. Figure 2 shows the conﬁdence contours for the spectral parameters NLMC H and kTbb. In Fig. 1, we present the EPIC-pn spectra of the investigated sources together with their best-ﬁt models. Figure 2 shows the conﬁdence contours for the spectral parameters NLMC H and kTbb. The sources J050803, J0537 and J0507 are also contained in the ﬁeld of view of the EPIC-MOS detectors. All three super- soft sources were detected with the MOS detectors. J052530 and J052215 were observed far oﬀ-axis and, unfortunately, were not in the ﬁeld of view of the EPIC-MOS detectors. The lower eﬃ- ciency of the MOS, in particular at low energies, does not yield a suﬃcient number of counts for a spectral analysis. 2.1. EPIC data We used data collected with the European Photon Imaging Cameras (EPIC) with the pn and two MOS CCD detectors (Strüder et al. 2001; Turner et al. 2001) located behind the X-ray telescopes (Aschenbach et al. 2000). Spectral analysis was per- formed from EPIC-pn data only. H The sources J050803, J0537 and J0507 are also contained in the ﬁeld of view of the EPIC-MOS detectors. All three super- soft sources were detected with the MOS detectors. J052530 and J052215 were observed far oﬀ-axis and, unfortunately, were not in the ﬁeld of view of the EPIC-MOS detectors. The lower eﬃ- ciency of the MOS, in particular at low energies, does not yield a suﬃcient number of counts for a spectral analysis. We created EPIC-pn event ﬁles with the tool “epchain” from the XMM-Newton analysis package (SAS 7.0) using the parame- ter setting screenlowthresh=0. In the extraction of the spectrum, we used single and double pixel events. For spectral ﬁtting, we calculated eﬀective areas and redistribution matrices for EPIC- pn using “arfgen” and “rmfgen”. We accumulated source spectra with a minimum of 20, 35, 15, 30, and 50 counts per spectral bin for each of the ﬁve sources listed in Table 3. We generated the EPIC-pn light curves of the ﬁve super-soft X-ray sources using a binsize of 3600 s (1 h) in a “soft” (0.12– 0.4 keV) or (0.17–0.4 keV) and “hard” (0.4–0.7 keV) band to- gether with the hardness ratio as a function of time. Due to the small number of counts detected from these sources, we could We performed spectral ﬁts using XSPEC v11.3.2 based on C-statistics (Cash 1979) since there were generally less than 10 background subtracted source counts per spectral bin. We used a simple blackbody model (the spectral resolution of the in- strument at lowest energies is insuﬃcient for more sophisticated 239 P. Kahabka et al.: Faint super-soft sources in XMM-Newton LMC ﬁelds Table 2. Maximum likelihood source detection results for the investigated super-soft sources. Table 2. Maximum likelihood source detection results for the investigated super-soft sources. 3.1. RX J0507.1−6743 J052530 has the MACHO star 60.7345.253 as an optical coun- terpart at a distance of 1.′′9. In Fig. 6, we show the B- and R-band light curve and the B −R color. The X-ray position of J0507 is 1.′′9 from a Denis star with B = 17.3, R = 16.4, I = 14.9, and J = 13.3 which is at a distance of 0.′′5 from the MACHO2 star 20.4313.548. We retrieved the MACHO light curve with the interactive light curve browser3. In Fig. 3, we show the B- and R-band light curves together with the B −R color. From the FFT analysis of the MACHO R- and B-band data with a magnitude error <0.05 mag, we found no signiﬁcant power for any period. For comparison, the FFT of the B-band data is shown in Fig. 7. Also, no signiﬁcant period close to one year is found. This would be consistent with a close-binary super-soft source if the orbital period is less than ∼1 day. An FFT analysis was applied to the MACHO R- and B-band data with a magnitude error <0.05 mag (Lomb 1976; Scargle 1982). We found high power (∼55) for a period of 374+10 −9 days (68% conﬁdence) in the B-band data (Fig. 4, see Fig. 5 for the folded light curve), but no signiﬁcant period is found in the R- band data. The ephemeris for the blue optical minimum is: a period of 362 ± 9 days, which is consistent with the one-year period. not detect signiﬁcant count rate or hardness ratio variations for any of the sources. not detect signiﬁcant count rate or hardness ratio variations for any of the sources. 2 The “Massive Compact Halo Object” project. 3 www.macho.mcmaster.ca/Data/MachoData.html 3 www.macho.mcmaster.ca/Data/MachoData.html 2 The “Massive Compact Halo Object” project. 2.1. EPIC data Source ML Position Count rate Hardness ratio soft RA Dec Err soft HR1 hard (J2000) hard HR2 (10−3 s−1) XMMU J050803.1−684017 71 05h08m03.s1 –68◦40′ 17.′′7 1.′′1 9.41 ± 1.40 −1.00 ± 0.11 – – XMMU J052530.5−671501 63 05h25m30.5s –67◦15′ 01.′′0 1.′′4 7.46 ± 1.22 −0.06 ± 0.12 51 6.63 ± 1.16 XMMU J052215.0−701658 (a) 47 05h22h15.0s –70◦16′ 58.′′5 1.′′7 9.17 ± 1.53 −0.60 ± 0.16 3 2.30 ± 1.08 XMMU J052215.0−701658 (b) 8 05h22h15.6s –70◦16′ 57.′′5 2.′′8 5.85 ± 1.82 −0.31 ± 0.30 2 3.08 ± 1.82 RX J0537.7−7034 16 05h37m45.0s –70◦33′ 46.′′4 1.′′9 0.96 ± 0.23 −0.51 ± 0.26 1 0.31 ± 0.20 RX J0507.1−6743 (a) 0 05h07m10.9s –67◦43′ 19.′′0 4.′′6 – – 2 1.99 ± 1.04 −1.00 ± 0.35 RX J0507.1−6743 (b) 23 05h07m10.7s –67◦43′ 17.′′0 0.′′9 1.75 ± 0.41 0.54 ± 0.09 98 5.79 ± 0.66 −0.68 ± 0.08 Table 3. Spectral analysis of EPIC-pn data using a blackbody model. Table 3. Spectral analysis of EPIC-pn data using a blackbody model. Source Ngal H,21 cm NLMC H,21 cm NLMC H kTbb ﬂuxabs ﬂuxunabs Lunabs C-stat Nbin (1020 cm−2) (1020 cm−2) (1020 cm−2) (eV) (10−13 erg cm−2 s−1) (1036 erg s−1) J050803 5.2 14 2+10 −2 41+10 −15 0.27 6.7 0.20 8.6 9 J052530 4.3 71 81+20 −78 46+74 −8 0.10 1050 31 7.4 7 J052215 (a) 5.0 7.2 ≤43 58+25 −34 0.13 0.75 0.022 2.8 3 J052215 (b) 0.10 0.58 0.017 J0537 4.7 29 15+30 −15 29+28 −11 0.019 400 12 3.4 6 J0507 (b) 4.4 11 180+70 −180 66+224 −6 0.091 1090 32 20.4 11 a period of 362 ± 9 days, which is consistent with the one-year period. 4. Optical identiﬁcation and spectroscopy of RX J0507.1−6743 For the nuclei of six LMC planetary nebulae, including: LMC SMP 7 = LHA 120-N 77F, LMC SMP 29 = LHA 120-N 102, LMC SMP 32 = LHA 120- N 192, LMC SMP 37 = LHA 120-N 28, LMC SMP 83 = IRAS 05363−6720 and LMC SMP 101, eﬀective tempera- tures of (1.6 −2.3) × 105 K and luminosities of (1.0 −1.3) × 1037 erg s−1 were derived from optical and UV data. These planetary nebulae therefore are candidates for super-soft X-ray sources that should be detectable with XMM-Newton EPIC-pn. As the XMM-Newton observations covered only a few percent of the LMC so far, the chance to serendipitously cover one of these J050803 is found at a distance of 2.′′7 from the position of the planetary nebula LHA 120–N 102 given in Leisy et al. (1997). Although such a distance is slightly larger than the general XMM-Newton position uncertainty of ∼2′′, the X-ray source is likely related to the planetary nebula. For the nuclei of six LMC planetary nebulae, including: LMC SMP 7 = LHA 120-N 77F, LMC SMP 29 = LHA 120-N 102, LMC SMP 32 = LHA 120- N 192, LMC SMP 37 = LHA 120-N 28, LMC SMP 83 = IRAS 05363−6720 and LMC SMP 101, eﬀective tempera- tures of (1.6 −2.3) × 105 K and luminosities of (1.0 −1.3) × 1037 erg s−1 were derived from optical and UV data. These planetary nebulae therefore are candidates for super-soft X-ray sources that should be detectable with XMM-Newton EPIC-pn. As the XMM-Newton observations covered only a few percent of the LMC so far, the chance to serendipitously cover one of these 4. Optical identiﬁcation and spectroscopy of RX J0507.1−6743 We obtained the optical spectrum of J0507 on 24 November 2006, using the Grating Spectrograph with SITe CCD on the 1.9 m (74 inch) Radcliﬀtelescope at the South African Astronomical Observatory (SAAO) in Sutherland. The CCD is eﬀectively 266 × 1798 pixels in size, with a pixel size of 15 µ. Using grating #7 (300 lines mm−1) set at an angle of 15◦, two spectral images between 4500 Å and 7000 Å with a spectral res- olution of 5 Å were taken. JD0 = 24450154 + (374+10 −9 × E). (1) JD0 = 24450154 + (374+10 −9 × E). (1) Folding the R-band data with the same period shows a weak modulation, but with a phase shift of ∼0.5 (Fig. 5). As this period is close to one year, we used a control star (B ∼18.5) 3′′ distant from the MACHO star and generated the FFT for this control star. We found in the B-band data a peak of low power (∼10) at We reduced and calibrated the spectra using NOAO IRAF software, with the instrument’s Cu/Ar arc standard and the star, P. Kahabka et al.: Faint super-soft sources in XMM-Newton LMC ﬁelds 240 40 P. Kahabka et al.: Faint super soft sources in XMM Newton LMC ﬁelds g. 1. EPIC-pn spectra of faint SSS with best-ﬁt blackbody model as histogram. Fig. 1. EPIC-pn spectra of faint SSS with best-ﬁt blackbody model as histogram. 5.1. The planetary nebula LMC SMP 29 Feige 110 (α = 23h19m58.4s, δ = −34◦42′51′′) as the ﬂux stan- dard. The calibrated spectrum is shown in Fig. 8. 5.1. The planetary nebula LMC SMP 29 Feige 110 (α = 23h19m58.4s, δ = −34◦42′51′′) as the ﬂux stan- dard. The calibrated spectrum is shown in Fig. 8. J050803 is found at a distance of 2.′′7 from the position of the planetary nebula LHA 120–N 102 given in Leisy et al. (1997). Although such a distance is slightly larger than the general XMM-Newton position uncertainty of ∼2′′, the X-ray source is likely related to the planetary nebula. 5. Discussion From the X-ray spectral ﬁt it is found that the source is probably heavily absorbed with NH = 8+2 −8 × 1021 cm−2. The color index B −R of the likely optical counterpart also sug- gests considerable reddening which is consistent with the ab- sorbing column inferred from the X-ray spectrum. For compar- ison, the color index B −R is 3.3 for the galactic super-soft source RX J0925.7−4758 (Šimon 2003), which is consistent with a large absorbing column of ∼1022 cm−2. The LMC absorb- ing column, inferred from the spectral ﬁt (although quite uncer- tain) is consistent with the total LMC column in the direction of the source (7.1 × 1021 cm−2) inferred from 21-cm. The unab- sorbed luminosity (0.1–2.4 keV) of ∼3×1037 erg s−1 is consistent with the luminosity of a super-soft X-ray source. This source re- sembles the super-soft sources CAL 87 and RX J0925.7−4758, planetary nebulae is not very large. This is consistent with ﬁnd- ing one of these LMC planetary nebulae, LMC SMP 29, as a super-soft X-ray source with XMM-Newton. The temperature and luminosity inferred from the blackbody spectral ﬁt to the X-ray data (cf. Table 3) can be compared with the values deter- mined from the optical and UV data. We ﬁnd that the temper- ature inferred from the X-ray data, assuming a blackbody de- scription of the continuum, is somewhat higher than the value inferred from the UV data. 5. Discussion Kahabka et al.: Faint super-soft sources in XMM-Newton LMC ﬁelds 241 0 1 2 3 4 5 6 7 8 9 10 11 12 NH (1021 cm-2) 0 50 100 150 kT (eV) 68% 68% 68% 90% 90% 90% 90% 99% 99% 99% 99% 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 XMMU J052530.5-671501 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 NH (1021 cm-2) 10 20 30 40 50 60 kT (eV) 68% 90% 90% 99% 99% 99% 99% 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 XMMU J050803.1-684017 kT (eV) 0 1 2 3 4 5 NH (1021 cm-2) 0 10 20 30 40 50 60 70 80 kT (eV) 68% 68% 68% 68% 90% 90% 90% 90% 99% 99% 99% 99% 99% 4 1033 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 RX J0537.7-7034 0 1 2 3 4 5 6 7 NH (1021 cm-2) 0 20 40 60 80 100 120 kT (eV) 68% 90% 90% 90% 90% 99% 99% 99% 99% 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 XMMU J052215.0-701656 (a) 100 kT (eV) kT (eV) 0 10 20 30 NH (1021 cm-2) 0 100 200 300 kT (eV) 68% 68% 68% 68% 90% 90% 90% 90% 99% 99% 99% 99% 99% 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 RX J0507.1-6743 g. 2. NLMC H – kT ﬁt parameter plane with conﬁdence contours. The formally best-ﬁt results are marked with a cross and dotted lines indicate l f L (i 1) 0 10 20 30 NH (1021 cm-2) 0 100 200 300 kT (eV) 68% 68% 68% 68% 90% 90% 90% 90% 99% 99% 99% 99% 99% 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 RX J0507.1-6743 Fig. 2. NLMC H – kT ﬁt parameter plane with conﬁdence contours. The formally best-ﬁt results are marked with a cross and dotted lines indicate levels of constant Lbol (in erg s−1). B −R ∼1.2. 5. Discussion We report the discovery of three new faint super-soft X-ray sources in the LMC ﬁeld. They have XMM-Newton EPIC-pn count rates of ∼(1–14) × 10−3 s−1. None of them were detected with ROSAT. Assuming a blackbody spectral ﬂux distribution, the bolometric luminosity of the three sources cannot be well constrained due to the small number of observed counts. From the conﬁdence contours of the spectral parameters (Fig. 2), it fol- lows that the bolometric luminosity of all new sources is at least ∼1034 erg s−1 if they are located in the LMC. P. Kahabka et al.: Faint super-soft sources in XMM-Newton LMC ﬁelds 241 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 NH (1021 cm-2) 10 20 30 40 50 60 kT (eV) 68% 90% 90% 99% 99% 99% 99% 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 XMMU J050803.1-684017 0 1 2 3 4 5 6 7 8 9 10 11 12 NH (1021 cm-2) 0 50 100 150 kT (eV) 68% 68% 68% 90% 90% 90% 90% 99% 99% 99% 99% 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 XMMU J052530.5-671501 0 1 2 3 4 5 6 7 NH (1021 cm-2) 0 20 40 60 80 100 120 kT (eV) 68% 90% 90% 90% 90% 99% 99% 99% 99% 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 XMMU J052215.0-701656 (a) 0 1 2 3 4 5 NH (1021 cm-2) 0 10 20 30 40 50 60 70 80 kT (eV) 68% 68% 68% 68% 90% 90% 90% 90% 99% 99% 99% 99% 99% 4 1033 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 RX J0537.7-7034 0 10 20 30 NH (1021 cm-2) 0 100 200 300 kT (eV) 68% 68% 68% 68% 90% 90% 90% 90% 99% 99% 99% 99% 99% 1 1034 3 1034 1 1035 3 1035 1 1036 3 1036 1 1037 3 1037 1 1038 RX J0507.1-6743 g. 2. NLMC H – kT ﬁt parameter plane with conﬁdence contours. The formally best-ﬁt results are marked with a cross and dotted lines indicate vels of constant Lbol (in erg s−1). P. 5.2. A highly absorbed super-soft source? The up and down arrows mark the phase of the XMM-Newton observations of RX J0507.1−6743 when the source was bright and faint, and the triangle and “-” the phase of the ROSAT PSPC observation when the source was bright and faint, respectively. Fig. 3. MACHO B- and R-band light curves of RX J0507.1−6743 to- gether with the B −R color (only for data points with magnitude error <0.05 mag). Uncalibrated light curves shifted in B and R to give a mean B = 17.7 and R = 16.5. Fig. 5. Folded B (upper panel) and R-band (lower panel) MACHO light curve of RX J0507.1−6743 for a period of 374 days and ephemeris JD0 = 24 450 154. The up and down arrows mark the phase of the XMM-Newton observations of RX J0507.1−6743 when the source was bright and faint, and the triangle and “-” the phase of the ROSAT PSPC observation when the source was bright and faint, respectively. Fig. 4. FFT of the blue MACHO light curve of RX J0507.1−6743. neutral hydrogen), then the bolometric luminosity of the source would be <∼3 × 1035 erg s−1 given the distance to the LMC. But we cannot exclude a Galactic nature for the source with an even lower luminosity. The source was observed during two obser- vations separated by one month. The count rate was consistent during both observations. 5.4. RX J0537.7−7034, a ROSAT-discovered super-soft source Fig. 4. FFT of the blue MACHO light curve of RX J0507.1−6743. The XMM-Newton position of J0537 is only 0.′′7 distant from the optical position (Orio et al. 1997). The temperature of 29+28 −11 eV inferred with EPIC-pn is consistent with the minimum tempera- ture of 18 eV and the maximum temperature of 42 eV given by Orio et al. (1997) from the ROSAT observations. The best-ﬁt lu- minosity (0.1–2.4 keV) of ∼1.2 × 1037 erg s−1 is consistent with stable nuclear burning on the surface of a WD. The observation of J0537 as a super-soft X-ray source for more than 10 years argues for a sub-class of super-soft sources with small orbital periods ∼(3.5−4) hours similar to classical novae, but with con- siderably longer stable nuclear burning times (>10 years). This argues for lower mass (∼0.6 M⊙) WDs in these systems (Greiner et al. 1994). 5.2. A highly absorbed super-soft source? The optical counterpart of J052530 may be an USN0–B1.0 star located 1.′′8 away from the X-ray position with B ∼20.0 and P. Kahabka et al.: Faint super-soft sources in XMM-Newton LMC ﬁelds 242 Fig. 3. MACHO B- and R-band light curves of RX J0507.1−6743 to- gether with the B −R color (only for data points with magnitude error <0.05 mag). Uncalibrated light curves shifted in B and R to give a mean B = 17.7 and R = 16.5. Fig. 5. Folded B (upper panel) and R-band (lower panel) MACHO light curve of RX J0507.1−6743 for a period of 374 days and ephemeris JD0 = 24 450 154. The up and down arrows mark the phase of the XMM-Newton observations of RX J0507.1−6743 when the source was Fig. 3. MACHO B- and R-band light curves of RX J0507.1−6743 to- gether with the B −R color (only for data points with magnitude error <0.05 mag). Uncalibrated light curves shifted in B and R to give a mean B = 17.7 and R = 16.5. Fig. 5. Folded B (upper panel) and R-band (lower panel) MACHO light curve of RX J0507.1−6743 for a period of 374 days and ephemeris JD0 = 24 450 154. The up and down arrows mark the phase of the XMM-Newton observations of RX J0507.1−6743 when the source was bright and faint, and the triangle and “-” the phase of the ROSAT PSPC observation when the source was bright and faint, respectively. neutral hydrogen), then the bolometric luminosity of the source would be <∼3 × 1035 erg s−1 given the distance to the LMC. But we cannot exclude a Galactic nature for the source with an even lower luminosity. The source was observed during two obser- vations separated by one month. The count rate was consistent during both observations. 5 4 RX J0537 7 7034 a ROSAT discovered super soft Fig. 3. MACHO B- and R-band light curves of RX J0507.1−6743 to- gether with the B −R color (only for data points with magnitude error <0.05 mag). Uncalibrated light curves shifted in B and R to give a mean B = 17.7 and R = 16.5. F c J X Fig. 5. Folded B (upper panel) and R-band (lower panel) MACHO light curve of RX J0507.1−6743 for a period of 374 days and ephemeris JD0 = 24 450 154. 5.2. A highly absorbed super-soft source? The expected ROSAT PSPC count rate based on the EPIC-pn spectrum is a factor of 15 smaller than the PSPC count rate observed ∼11 years earlier. This could indicate a decrease in luminosity and/or temperature, consistent with a lower mass WD. for which a high absorbing column has also been inferred from X-ray spectra. for which a high absorbing column has also been inferred from X-ray spectra. 5.3. A southern super-soft source No optical counterpart is found within 3′′ of the position of J052215 (from observation a) using the catalogues from Vizier. This may indicate that the optical counterpart of J052215 is op- tically faint. The position of the source derived from observation b deviates by 3′′ from the position of observation a, which is consistent with a 2′′ position uncertainty of the ﬁrst and a 3′′ position uncertainty of the second observation. The blackbody temperature of 24–83 eV (90% conﬁdence) is consistent with a super-soft X-ray source. If one constrains the absorbing column to this source to <∼7×1020 cm−2 (the LMC column inferred from P. Kahabka et al.: Faint super-soft sources in XMM-Newton LMC ﬁelds 243 Fig. 8. Optical spectrum of RX J0507.1−6743. Fig. 8. Optical spectrum of RX J0507.1−6743. Fig. 6. MACHO B and R band light curve of XMMU J052530.5−671501 together with the B −R color (only for data points with magnitude error <0.05 mag). Uncalibrated light curves shifted in B and R to give a mean B = 19.2 and R = 18.5. Fig. 8. Optical spectrum of RX J0507.1−6743. count rate inferred from the ﬁrst observation was a factor of 4±1 lower. The hardness ratios HR1 and HR2 together with a black- body spectral ﬁt indicate a very soft source (kT ∼20–100 eV) with an absorption due to LMC gas and intrinsic to the source, which is considerable (NLMC H ≈a few 1021 cm−2). A galactic foreground CV cannot be excluded from the X-ray data alone. We ﬁnd an optical star at a distance of 1.′′9 from the X-ray position, which is most likely the optical counterpart. The opti- cal spectrum taken at SAAO resembles the spectrum of a cool (≲3500 K) stellar atmosphere that is heavily absorbed (Lejeune et al. 1997). This is consistent with the high absorption indicated by the X-ray spectrum, which would then be caused by the stel- lar wind of the late type star. The expected brightness of the star is limited by the size of the Roche lobe and would be compati- ble with the observed brightness (R ∼16.5) for a giant star in a ∼370 day orbit around a one solar mass white dwarf. Thus, the likely optical counterpart of J0507 is consistent with a M-type giant star at LMC distance, and J0507 is likely a symbiotic sys- tem in the LMC. 5.3. A southern super-soft source The optical spectrum shows no strong emission lines, which could imply that the contribution of an accretion disk is minor or that the optical spectrum was taken when the (variable) X-ray source was at a lower X-ray luminosity level. Fig. 6. MACHO B and R band light curve of XMMU J052530.5−671501 together with the B −R color (only for data points with magnitude error <0.05 mag). Uncalibrated light curves shifted in B and R to give a mean B = 19.2 and R = 18.5. Fig. 7. FFT of the blue MACHO light curve of XMMU J052530.5−671501. The scale is the same as in Fig. 4. A possible periodicity of ∼374 days was found in the B band MACHO data of the probable optical counterpart of J0507. Although the period is close to one year, the non-detection in R and the (weak) detection of a somewhat shorter period from a control star suggests that the ∼374 day period is intrinsic to the source. In this case, the detection of periodicity in the blue and not in the red band data would argue against stellar pulsations of a giant star, and would favor orbital modulation, i.e. variable obscuration of the hot star due to a stellar wind from the cool star. Fig. 7. FFT of the blue MACHO light curve of XMMU J052530.5−671501. The scale is the same as in Fig. 4. A high extinction is consistent with the B −R color. The small optical amplitude of the modulation argues against a ther- monuclear outburst cycle. The XMM-Newton observations of the X-ray bright and faint state of J0507 coincide with the blue op- tical maximum and minimum respectively (Fig. 5). Also, the times of the reported bright and faint X-ray states observed with ROSAT PSPC (Haberl & Pietsch 1999b) fall in corresponding phase intervals of the optical light curve. This is consistent with viewing an optically bright accretion disk in front of and behind the optical (giant) star. Thus, it is likely that the ∼374 day period is the orbital period of the J0507 binary system. 5.5. RX J0507.1−6743, a variable and absorbed symbiotic? 5.5. RX J0507.1−6743, a variable and absorbed symbiotic? J0507 was covered twice by ROSAT PSPC observations sepa- rated by about one year. The source was only detected signif- icantly during the ﬁrst observation and the spectrum was very soft with counts detected below 0.4 keV. 5.6. Upper limit count rate for XMMU J052016.0−692505 We note that the white dwarf Be/X-ray binary candidate XMMU J052016.0−692505 (see Kahabka et al. 2006 for results from a XMM-Newton observation in January 2004) was in the ﬁeld of view of another XMM-Newton observation (rev. 1210, Obs. ID = 0311591201) performed on 2006 July 18, from 14:13 to 19:15. The source was at a large oﬀ-axis angle of ∼10′ and had a low exposure of ∼5 ksec. It was not detected and we de- rive a 3σ upper limit count rate (0.2–1.0 keV) from the observed counts in the source circle of ∼7 × 10−3 s−1. This upper limit count rate is consistent with the count rate of 2.4 ±0.6 ×10−3 s−1 observed during an XMM-Newton observation in 2004 January (Kahabka et al. 2006). variable star in the B-band with a period of ∼374 days, which is most likely the orbital period of a symbiotic system. Thus, J0507 may be a wide-binary, super-soft source. The performed and available XMM-Newton observations of the LMC ﬁeld cover only a fraction of the LMC ﬁeld. All newly-discovered, super- soft X-ray sources are found in the LMC bar region. 6. Comparison with the previously-known sample With the discovery of four new super-soft sources with XMM- Newton in the ﬁeld of the LMC we increase the number of known super-soft sources (including candidates) to 18. The sam- ple known so far comprises ﬁve close-binary, super-soft sources, one classical post-nova, a likely WD Be/X-ray binary, a wide- binary (symbiotic) system, one planetary nebula, one PG1159 star, and seven transient and/or faint super-soft sources that have so far not been optically identiﬁed (cf. Table 4). Acknowledgements. The XMM-Newton project is supported by the Bundesministerium für Wirtschaft und Technologie/Deutsches Zentrum für Luft- und Raumfahrt (BMWI/DLR, FKZ 50 OX 0001) and the Max-Planck Society. This research has made use of the VizieR catalog access tool, CDS, Strasbourg, France. This paper utilizes public domain data originally obtained by the MACHO Project, whose work was performed under the joint auspices of the US Department of Energy, National Nuclear Security Administration by the University of California, Lawrence Livermore National Laboratory under contract No. W-7405-Eng-48, the National Science Foundation through the Center for Particle Astrophysics of the University of California under cooperative agreement AST-8809616, and the Mount Stromlo and Siding Spring Observatory, part of the Australian National University. We used the NOAO (National Optical Astronomical Observatory) IRAF (Image Reduction and Analysis Facility) software package, with Brent Miszalski’s extractor task for IRAF, in conjunction with the MSSSO Karma software package and the Figaro software package from the Starlink Project. We also were granted observation time at the South African Astronomical Observatory (SAAO) and wish to thank them for their kind help and accommodations. Travel to the SAAO was funded by Australian Government Education Science and Training (DEST) – Access to Major Research Facilities Programme – No. 06/07-0-10. Although there is a diversity of systems, all optically- identiﬁed systems are consistent with a hot WD condition. Two of the systems correlate with a planetary nebula or PG1159 star, the remaining with steady or stable nuclear burning WDs. 7. Conclusions We analysed archival XMM-Newton observations in the direction of the LMC and discovered four new faint super-soft sources with EPIC-pn count rates (corrected for vignetting) of ∼(1– 14) × 10−3 s−1. Kahabka et al. (2006) discussed one source as a likely WD/Be X-ray binary. The likely identiﬁcation of one of the new super-soft sources, J050803, with the planetary nebula LMC SMP 29 in the LMC adds one super-soft planetary neb- ula to the LMC sample. A second source, J052530, may be faint due to a high LMC absorbing column. It could be a close-binary, super-soft LMC source. A third source, J052215, is less strongly absorbed and may be either less luminous (if it is located in the LMC) or a Galactic foreground source. We also detected the ROSAT super-soft source J0537 with XMM-Newton. We detected the ROSAT super-soft source J0507 with XMM-Newton as an ab- sorbed super-soft source. It is optically identiﬁed with a MACHO 5.3. A southern super-soft source Name Typea Refb RX J0439.8−6809 PG1159 star 4 RX J0454.0−6900 no ID 7 RX J0507.1−6743 B ∼17.7 7,3 XMMU J050803.1−684017 PN ? 3 RX J0513.9−6951 CBSS 1 XMMU J052016.0−692505 WD Be/XRB 2 XMMU J052215.0−701656 no ID 3 XMMU J052530.5−671501 B ∼19.2 3 N LMC 1995 CV-N 1 RX J0527.8−6954 CBSS 1 RX J0529.4−6713 no ID 6 RX J0531.9−7038 no ID, cand. 7 RX J0535.5−7026 no ID, cand. 7 RX J0537.7−7034 CBSS 1,3 CAL 83 CBSS 1 CAL 87 CBSS 1 RX J0549.7−7000 no ID, cand. 7 RX J0550.9−7151 no ID 5 a Close-binary super-soft source (CBSS), classical post-nova (CV-N), WD Be/X-ray binary (WD Be/XRB), planetary nebula (PN), no optical identiﬁcation (no ID). b 1) Kahabka & van den Heuvel (2006) and references therein, 2) Kahabka et al. (2006), 3) this paper, 4) Greiner et al. (1994), 5) Reinsch et al. (1999), 6) Kahabka (2002), 7) Haberl & Pietsch (1999a). Name Typea Refb RX J0439.8−6809 PG1159 star 4 RX J0454.0−6900 no ID 7 RX J0507.1−6743 B ∼17.7 7,3 XMMU J050803.1−684017 PN ? 3 RX J0513.9−6951 CBSS 1 XMMU J052016.0−692505 WD Be/XRB 2 XMMU J052215.0−701656 no ID 3 XMMU J052530.5−671501 B ∼19.2 3 N LMC 1995 CV-N 1 RX J0527.8−6954 CBSS 1 RX J0529.4−6713 no ID 6 RX J0531.9−7038 no ID, cand. 7 RX J0535.5−7026 no ID, cand. 7 RX J0537.7−7034 CBSS 1,3 CAL 83 CBSS 1 CAL 87 CBSS 1 RX J0549.7−7000 no ID, cand. 7 RX J0550.9−7151 no ID 5 5.3. A southern super-soft source The source was also detected during a ROSAT HRI observation (Sasaki et al. 2000). Assuming the spectral model obtained from the PSPC observa- tion, Haberl & Pietsch (1999b) inferred a variability factor of ∼10–40 and classiﬁed the source as a super-soft source in the LMC or a soft foreground CV. J0507 was covered twice by ROSAT PSPC observations sepa- rated by about one year. The source was only detected signif- icantly during the ﬁrst observation and the spectrum was very soft with counts detected below 0.4 keV. The source was also detected during a ROSAT HRI observation (Sasaki et al. 2000). Assuming the spectral model obtained from the PSPC observa- tion, Haberl & Pietsch (1999b) inferred a variability factor of ∼10–40 and classiﬁed the source as a super-soft source in the LMC or a soft foreground CV. Such a large orbital period is consistent with a symbiotic sys- tem and a giant as the cool component. We note that the orbital period of the symbiotic nova RR Tel is 387 days; J0507 may J0507 was observed twice with XMM-Newton, but we de- tected it signiﬁcantly only during the second observation. The P. Kahabka et al.: Faint super-soft sources in XMM-Newton LMC ﬁelds 244 diﬀer from RR Tel as it is not a (recurrent) nova, but rather a persistent super-soft source (at least for the ∼10 years since it was observed with ROSAT). This is consistent with the optical and infrared magnitudes that require a late K- to early M-type giant that ﬁlls the Roche lobe for such an orbital period. The optical spectrum we obtained from J0507 (Fig. 8) is consistent with such a spectral classiﬁcation. Such a symbiotic system falls well into the distribution of orbital periods and Roche lobe ﬁll- ing of symbiotic stars predicted by the population synthesis cal- culations of Lü et al. (2006; see also Yungelson et al. 1995). For a system with such an orbital period, a WD with a mass of ∼0.5–0.8 M⊙is predicted from the calculations of Yungelson et al. (1995). The steady nuclear burning rate of such a lower mass WD is ∼1037 erg s−1 and consistent with the X-ray lumi- nosity constrained from the EPIC-pn data. Thus, J0507 would be a canonical wide-binary super-soft source. Table 4. Known super-soft sources in the LMC ﬁeld (including candi- dates). Table 4. Known super-soft sources in the LMC ﬁeld (including candi- dates). Anders, E., & Grevesse, N. 1989, GeCoA, 53, 197 Aschenbach, B., Briel, U. G., Haberl, F., et al. 2000, in X-ray Optics, Instruments, and Mirrors III, ed. J. E. Trümper, & B. Aschenbach, Proc. SPIE, 4012, 731 Anders, E., & Grevesse, N. 1989, GeCoA, 53, 197 Aschenbach, B., Briel, U. G., Haberl, F., et al. 2000, in X-ray Optics, Instruments, and Mirrors III, ed. J. E. Trümper, & B. Aschenbach, Proc. SPIE, 4012, 731 Brüns, C., Kerp, J., Staveley-Smith, L., et al. 2005, A&A, 432, 937 Cash, W. 1979, ApJ, 228, 939 DiStefano, R., Kong, A., & Primini, F. A. 2006, [arXiv:astro-ph/0606364] Greiner, J., Hasinger, G., & Thomas, H.-C. 1994, A&A, 281, L61 Greiner, J., Orio, M., & Schwarz, R. 2000, A&A, 355, 1041 Brüns, C., Kerp, J., Staveley-Smith, L., et al. 2005, A&A, 432, 937 Cash, W. 1979, ApJ, 228, 939 DiStefano, R., Kong, A., & Primini, F. 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https://openalex.org/W2017249430	https://retrovirology.biomedcentral.com/counter/pdf/10.1186/1742-4690-7-S1-P119	English	null	Human immunodeficiency virus viral markers seroperevalence in first-time healthy blood donors refered to transfusion centers of bushehr province, South of Iran (April 2004 to March 2008)	Retrovirology	2,010	cc-by	511	POSTER PRESENTATION Open Access Maneshi et al. Retrovirology 2010, 7(Suppl 1):P119 http://www.retrovirology.com/content/7/S1/P119 Discussion HIV-contaminated bloods make a few percentage of all donated bloods. These contaminated bloods mostly belong to undergraduate young men whom don’t belong to high social levels. At the same time, due to awareness of their high-risk behavior they don’t want their blood to be injected to others. According to this fact that most of infected persons were young and undergraduate mar- ried men, this segment of society should be more considered. Author details 1 1Bushehr University of Medical Sciences - Student’s Research Committee, Bushehr, Iran, Islamic Republic of. 2Bushehr Blood transfusion organization, Bushehr, Iran, Islamic Republic of. Background AIDS is one of blood-transmitted diseases so that WHO recommends carrying out the HIV screening test on all donated blood samples. In this study we analyzed sero- prevalence, demographic and epidemiologic characteris- tics of positive HIV cases in first time blood donors of Bushehr province. Human immunodeficiency virus viral markers seroperevalence in first-time healthy blood donors refered to transfusion centers of bushehr province, South of Iran (April 2004 to March 2008) Hesam oddin Maneshi1, Mojtaba Karimi2, Shahab Zare1, Gholam Reza Hajiani2 From 16th International Symposium on HIV and Emerging Infectious Diseases Marseille, France. 24-26 March 2010 secretly and confirmatory test were also positive for these 5 individuals. (Self reject = 83.33%). Methods In this cross-sectional study, 66873 first time donors who were referred for blood donation, during 5 years (April2004 to March2008), according to the records registered in Bushehr province’s blood transfusion orga- nization were studied. Donors had been passed the initial screening (ELISA) and confirmatory test (Western Blot) for HIV Ags. Correspondence: h_maneshi@yahoo.com 1Bushehr University of Medical Sciences - Student’s Research Committee, Bushehr, Iran, Islamic Republic of © 2010 Maneshi et al; licensee BioMed Central Ltd. Results A total of 51884 people out of 66873 volunteers were able to blood sampled. 24 of them were HIV positive with respect to initial screening test. The results verified in confirmatory test for 6 donors (Prevalence = 0.011%). All of them were undergraduate men, below diploma, 4 married and 2 singles and all younger than 35 years old except one. It is notable that 5 people out of 24 people who were HIV positive with respect to initial screening test, were self-rejected their bloods out of the cycle Published: 11 May 2010 doi:10.1186/1742-4690-7-S1-P119 Cite this article as: Maneshi et al.: Human immunodeficiency virus viral markers seroperevalence in first-time healthy blood donors refered to transfusion centers of bushehr province, South of Iran (April 2004 to March 2008). Retrovirology 2010 7(Suppl 1):P119. doi:10.1186/1742-4690-7-S1-P119 Cite this article as: Maneshi et al.: Human immunodeficiency virus viral markers seroperevalence in first-time healthy blood donors refered to transfusion centers of bushehr province, South of Iran (April 2004 to March 2008). Retrovirology 2010 7(Suppl 1):P119. * Correspondence: h_maneshi@yahoo.com 1Bushehr University of Medical Sciences - Student’s Research Committee, Bushehr, Iran, Islamic Republic of * Correspondence: h_maneshi@yahoo.com 1Bushehr University of Medical Sciences - Student’s Research Committee, Bushehr, Iran, Islamic Republic of © 2010 Maneshi et al; licensee BioMed Central Ltd.
https://openalex.org/W2903532635	http://old.scielo.br/pdf/acb/v33n10/1678-2674-acb-33-10-00904.pdf	English	null	Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis	Acta Cirúrgica Brasileira	2,018	cc-by	4,776	5-Experimental Surgery Eduardo Pereira de MirandaI, Fernando LorenziniII, Bruno Vinicius Duarte NevesIII, Eduardo Felippe MelchiorettoIII, Thiago HotaIII, Rogerio De FragaIV Eduardo Pereira de MirandaI, Fernando LorenziniII, Bruno Vinicius Duarte NevesIII, Eduardo Felippe MelchiorettoIII, Thiago HotaIII, Rogerio De FragaIV IFellow Master degree, Postgraduate Program in Surgical Clinic, Department of Urology, Universidade Federal do Paraná (UFPR), Curitiba-PR, Brazil. Scientific, intellectual, conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; histopathological examinations; statistical analysis; manuscript preparation; critical revision. i IIPhD, Department of Urology, School of Medicine, UFPR, Curitiba-PR, Brazil. Scientific, intellectual, conception and design of the study; critical revision.ii IIIMD, Department of Urology, UFPR, Curitiba-PR, Brazil. Acquisition of data, technical procedures, histopathological examinations, critical revision. iii ii IVPhD, Associate Professor, Department of Urology, School of Medicine, UFPR, Curitiba-PR, Brazil. Scientific, intellectual, conception and design of the study; analysis and interpretation of data; statistical analysis; critical revision. Introduction The human population has experienced a sustained increase in life span, especially in recent decades; this increase occurred first in developed countries and, subsequently, in developing countries. Professional and cultural factors and the use of modern contraceptive methods have also led to an increase in the age of paternity. Moreover, the use of assisted reproduction techniques has increased, and changes due to aging have become more evident and important as one of the factors for determining the fertility of couples in such cases1. Abstract Purpose: To quantify, through stereological and morphometric analysis, spermatogenesis in rats undergoing the natural aging process. Methods: Seventy-two male Wistar rats were divided into 6 equal groups according to age at the time of killing: 3, 6, 9, 12, 18, and 24 months. All the rats were subjected orchiectomy and collection of testicular parenchymal fragments for histological and morphometric analysis. The numerical density of spermatids was calculated using a stereological study, and morphometric analysis was conducted to measure the height of the germinal epithelium and the area of the seminiferous tubules. Results: We found that the 18 and 24 months groups showed a significant reduction in the number of round spermatids. However, the height of the germinal epithelium was not significantly different between the groups. The area of seminiferous tubules was also significantly reduced in the elderly rats compared to that in the young ones. iii Conclusion: Aging of rats showed a significant reduction in the number of round spermatids and the area of the seminiferous tubules, more pronounced in the rats at 18 and 24 months of life. Key words: Aging. Spermatogenesis. Infertility. Testis. Spermatids. Rats. Acta Cir. Bras. 2018;33(10):904-913 DOI: http://dx.doi.org/10.1590/s0102-865020180100000005 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. Stereology is the quantitative assessment of the three-dimensional structure and spatial arrangement of thin two- dimensional sections of biological specimens9. This technique has been used in previous studies to evaluate parameters of the seminiferous tubule and germ cells9–11. In the present study, we conducted stereological analysis to precisely determine the stage of life when a greater deterioration in the morphological, cellular, and structural elements of spermatogenesis occurs with aging in rats. ■ ■ Methods The study was approved by the Ethics Committee in Animal Experimentation (CEEA), Department of Biological Sciences, Universidade Federal do Paraná. All animal experiments were conducted in accordance with the ethical principles established by the Brazilian College of Animal Experimentation (COBEA) and the requirements laid down in the “Guide for the Care and Use of Experimental Animals”. Aging is a natural ongoing process characterized by morphological and structural degeneration, and like other organs, the gonads also deteriorate due to this process; however, unlike women, who present clinical signs of ovarian failure, men do not show accurate visibly signs of testicular failure2. Although spermatogenesis continues throughout life, the quantity and quality of this process in elderly men is lower than that in young men2–4; however, it is difficult to determine the exact moment when this decline becomes more pronounced. Seventy-two 3-months-old male albino Wistar rats (Rattus novergicus albinus, Rodentia, Mammalia) were used in this study. The rats were housed under a controlled temperature of 22°C with a light/dark cycle of 12 h and with controlled air moisture in an environment free from external noises. Filtered water and species-specific rations were supplied ad libitum throughout the experiment. Besides spermatogenesis, another important role played by the testes is in the production of the male hormone, testosterone. Since all testicular functions are related to each other, infertile men have an increased risk of hypogonadism5. Aging affects both these testicular functions6. The aged male gonad presents structural and morphological changes such as decreased volume and reduced number of germ cells4, which are associated with a decrease in the quality of sperm and fertility7. The decrease in semen quality in elderly men may result, in addition to infertility, in an increase in the possibility of complications during pregnancy and certain diseases such as autism, schizophrenia, bipolarity, and achondroplasia8. The animals were divided into six groups (n = 12 in each group) and killed at different ages: 3 months, 6 months, 9 months, 12 months, 18 months, and 24 months. i The animals were anesthetized with ketamine (57.67 mg/kg) and xylazine hydrochloride (10mg/kg) via intraperitoneal injection under aseptic conditions. The procedures consisted of laparotomy and median thoracotomy for removal of organs 905 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. Morphometric and stereological analysis Subsequently, the histological slides were mounted with 3 sections of each sampling with hematoxylin & eosin (HE) staining. A single 2-mm (breadth and depth) incision was made in the upper, middle, and lower thirds of the right testes for better penetration of the fixative, and the testes were then submerged in ALFAC (alcohol 80%, formaldehyde, and acetic acid) for 16 h. The testes were then transferred into 70% alcohol, followed by dehydration in a series of decreasing concentrations of xylene and alcohol for subsequent embedding in paraffin blocks. The assessment of the height of the germinal epithelium and calculation of the area of the seminiferous tubule was performed with the aid of an appropriate software (TsVieW).i Ten microscopic fields were chosen in each of the three histological sections to perform the analysis, which yielded a total of 360 fields in each group of rats. The numerical density of the round spermatids (Nv[spermatids]), expressed as number of round spermatids per µm3 of testicular parenchyma, was calculated using the following formula: The testes were then cut into 5-µm- thick sections using a microtome (American Optical, Spencer AO 820). To obtain random and (µm3) ■ ■ Methods uniformly isotropic sections, the Orientatior12 method was used, and the Physical Disector13 method was used to calculate the numerical density of the spermatids. The sampling of testicular tissue was performed with two consecutive sections excluding, among them, three 5-µm sections, representing a thickness of 25 µm between the planes for the determination of tri-dimensional quantitative parameters of spermatids from two-dimensional sections. (for use in other studies), cardiac incision with induction of cardiac arrest by exsanguination, and bilateral orchiectomy by a median scrotal incision, isolation, ligature, and sectioning of the spermatic cord, and resection of both testes. The left testes were immediately frozen at -80°C (for use in another study), and the right testes of all the animals were weighed and measured (length, width, and thickness) and used in the present study. Results Statistical analysis was performed by analysis of variance (ANOVA) and by using post- hoc Tukey’s honest significant difference (HSD). Parameters for each group were compared using a statistical significance threshold of less than 5% (P<0.05). Pearson (parametric) and Spearman (nonparametric) correlations were used to correlate numerical variables. None of the animals in the study died before they were killed, and the animals in older-age groups presented characteristics of aging, such as thinning of hair and hypoactivity. Stereological analysis The numerical density of round 906 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. spermatids was slightly lower in the 6 months group than in the 3 months group. The 9 and 12 months groups showed slightly higher numerical density of round spermatids than the 3 and 6 months groups. In the 18 and 24 months groups, the numerical density of round spermatids was significantly reduced (P<0.0001; Figure 1, and Tables 1 and 2). Figure 2 shows a sample of the photodocumentation of the testicular parenchyma. Figure 1 - Means of the numerical densities of round spermatids (number of spermatids/μm3). Figure 1 - Means of the numerical densities of round spermatids (number of spermatids/μm3). Table 1 – Average of the numerical densities of round spermatids in the different groups. Groups N Mean SD 95% CI 3 months 360 75.74 15.96 74.08–77.39 6 months 360 71.75 17.77 69.91–73.59 9 months 360 72.13 17.63 70.30–73.95 12 months 360 72.60 17.37 70.79–74.39 18 months 360 28.64* 1.67 28.46–28.81 24 months 360 27.89* 6.17 27.24–28.52 P<0.001 (ANOVA) N t b f i i fi ld l d M f th i l d iti f d tid ( b f d Table 1 – Average of the numerical densities of round spermatids in the different ( ) Note: n = number of microscopic fields analyzed; Mean = mean of the numerical densities of round spermatids (number of round spermatids; SD = standard deviation; CI = confidence interval). Note: n = number of microscopic fields analyzed; Mean = mean of the numerical densities of round spermatids (number of round spermatids; SD = standard deviation; CI = confidence interval). Table 2 – Comparison between the mean numerical densities of round spermatids of rats in different Table 2 – Comparison between the mean numerical densities of round spermatids of rats in different groups. P 0.05 (ANOVA Tukey post hoc) Note: the difference between the mean = difference between the mean numerical densities of round spermatids (number of round spermatids/μm3) in different groups of rats; CI = confidence interval. Note: the difference between the mean = difference between the mean numerical densities of round sperm spermatids/μm3) in different groups of rats; CI = confidence interval. P<0.05 (ANOVA - Tukey post hoc)f Stereological analysis Comparison Difference between mean numerical densities of round spermatids P value 95% CI Group Groups 3 months 6 months 3.98 0.003* 0.94–7.01 9 months 3.60 0.009* 0.57–6.64 12 months 3.13 0.038* 0.10–6.17 18 months 47.09 0.000* 44.05–50.13 24 months 47.88 0.000* 44.81–50.88 6 months 9 months - 0.37 0.999 -3.40–2.66 12 months - 0.84 0.964 -3.87–2.19 18 months 43.11 0.000* 40.07–46.15 24 months 43.86 0.000* 40.83–46.90 9 months 12 months -0.46 0.998 -3.50–2.56 18 months 43.48 0.000* 40.45–46.52 24 months 44.24 0.000* 41.20–47.27 12 months 18 months 43.95 0.000* 40.92–46.99 24 months 44.70 0.000* 41.67–47.74 18 months 24 months 0.75 0.981 -2.28–3.78 P<0.05 (ANOVA - Tukey post hoc) Note: the difference between the mean = difference between the mean numerical densities of round spermatids (number of round spermatids/μm3) in different groups of rats; CI = confidence interval 907 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. Figure 2 – Microscopic sample of testicular parenchyma of a rat from the (A) 3-months-old group, (B) 6-months-old group, (C) 9-months-old group, (D) 12-months-group, (E) 18-months-old group, (F) 24-months- old group. Showing a decrease in the number of spermatids (black arrows: round espermatids). Figure 2 – Microscopic sample of testicular parenchyma of a rat from the (A) 3-months-old group, (B) 6-months-old group, (C) 9-months-old group, (D) 12-months-group, (E) 18-months-old group, (F) 24-months- old group. Showing a decrease in the number of spermatids (black arrows: round espermatids). Morphometric analysis a similar value to that observed in the groups with younger rats (Figure 3, and Tables 3 and 4). a similar value to that observed in the groups with younger rats (Figure 3, and Tables 3 and 4). a similar value to that observed in the groups with younger rats (Figure 3, and Tables 3 and 4). Figure 3 - Mean height of the germinal epithelium (μm). The results of the macroscopic morphometric analysis (weight, dimensions, and volume) were not significantly different between the groups. The height of the germinal epithelium, as assessed by microscopic analysis, was significantly reduced in the 18 months group (mean=100.06 μm) compared to that in the other groups. However, the 24 months group showed a significant increase (mean=108.21 μm) compared to the 18 months group, with Figure 3 - Mean height of the germinal epithelium (μm). Table 3 – Mean height of the germinal epithelium of rats in the different groups. Groups n Mean height of the germinal epithelium (μm) SD 95% CI 3 months 360 111.23 20.66 109.09–113.37 6 months 360 108.82 20.99 106.64–110.99 9 months 360 109.12 20.79 106.96–111.27 12 months 360 109.26 22.13 106.97–111.56 18 months 360 100.06 16.03 98.27–101.86 24 months 360 108.21 12.92 106.87–109.55 P<0.005 (ANOVA) Note: n = number of microscopic fields analyzed; Mean = mean height of the germinal epithelium; SD = standard deviation; CI = confidence interval. Table 3 – Mean height of the germinal epithelium of rats in the different groups. height of the germinal epithelium of rats in the different groups. 908 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. Table 4 – Comparison between the mean heights of the germinal epithelium between the different groups. Note: n = number of microscopic fields analyzed; Mean = mean tubular area in the different groups of rats; SD = standard deviation; CI = a confidence interval. Morphometric analysis Comparison Difference between the mean heights of the germinal epithelium (μm) P value 95% CI Group Groups 3 months 6 months 2.41 0.545 -1.68–6.51 9 months 2.11 0.682 -1.98–6.21 12 months 1.97 0.744 -2.12–6.07 18 months 11.16 0.000 6.90–15.43 24 months 3.02 0.285 -1.07–7.12 6 months 9 months -0.29 1.000 -4.39–3.80 12 months -0.44 1.000 -4.54–3.65 18 months 8.75 0.000* 4.48–13.01 24 months 0.60 0.998 -3.48–4.70 9 months 12 months -0.14 1.000 -4.24–3.95 18 months 9.05 0.000* 4.78–13.31 24 months 0.90 0.998 -3.19–5.00 12 months 18 months 9.19 0.000* 4.93–13.46 24 months 1.05 0.978 -3.04–5.15 18 months 24 months -8.14 0.000* -12.40–-3.87 P<0.05 (ANOVA - Tukey post hoc) Note: Difference between the means = difference between the mean heights of the germinal epithelium in the different groups of rats; CI = confidence interval. Table 4 – Comparison between the mean heights of the germinal epithelium between the different groups – Comparison between the mean heights of the germinal epithelium between the P<0.05 (ANOVA Tukey post hoc) Note: Difference between the means = difference between the mean heights of the germinal epithelium in the different groups of rats; CI = confidence interval. post hoc) en the means = difference between the mean heights of the germinal epithelium in the different groups of erval With regard to the tubular area, the results were similar to those found in the stereological analysis of the numerical density of spermatids. The 18 and 24 months groups showed a significant decrease in tubular area (6726.21 μm2 and 7395.75 μm2, respectively) compared to the other groups. However, unlike in the spermatids, the variation in the tubular area between the young and old rats was very slight (Figure 4, and Tables 5 and 6). Figure 4 - Mean area of the seminiferous tubules (μm2). Figure 4 - Mean area of the seminiferous tubules (μm2). Table 5 – Mean tubular area in the different groups. Groups n Mean (μm2) SD 95% CI 3 months 360 8540.59 723.42 8465.60–8615.57 6 months 360 8475.71 711.42 8401.97–8549.45 9 months 360 8533.54 688.97 8462.13–8604.95 12 months 360 8457.50 731.20 8381.71–8533.29 18 months 360 6726.21 825.90 6640.61–6811.82 24 months 360 7395.75* 707.39 7322.43–7469.07 P<0.005 Note: n = number of microscopic fields analyzed; Mean = mean tubular area in the different groups of rats; SD = standard deviation; CI = a confidence interval. Table 5 – Mean tubular area in the different groups. Morphometric analysis 909 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. Table 6 – Comparison of the mean tubular areas between the different groups of rats. Comparison Difference between mean tubular areas (µm2) P value 95% CI Group Groups 3 months 6 months 64.87 0.843 -90.89–220.65 9 months 7.04 1.000 -148.72–162.82 12 months 83.08 0.650 -72.68–238.86 18 months 1814.37 0.000 1658.59–1970.14 24 months 1144.83 0.000* 989.06–1300.61 6 months 9 months -57.82 0.898 -213.60–97.94 12 months 18.20 0.999 -137.56–173.98 18 months 1749.49 0.000* 1593.72–1905.27 24 months 1079.96 0.000* 924.18–1235.73 9 months 12 months 76.03 0.732 -79.73–231.81 18 months 1807.32 0.000* 1651.54–1963.09 24 months 1137.78 0.000* 982.01–1293.56 12 months 18 months 1731.28 0.000* 1575.51–1887.06 24 months 1061.75 0.000* 905.97–1217.52 18 months 24 months -669.53 0.000* -825.30–-513.75 P<0.05 (ANOVA - Tukey post hoc) Note: Difference between the mean = difference in the mean tubular areas between different groups of rats; CI = confidence interval. mparison of the mean tubular areas between the different groups of rats. P<0.05 (ANOVA - Tukey post hoc) Note: Difference between the mean = difference in the mean tubular areas between different groups of rats; CI = confidence interval. st hoc) he mean = difference in the mean tubular areas between different groups of rats; CI = confidence interval. P<0.05 (ANOVA - Tukey post hoc) Note: Difference between the mean = difference in the mean tubular areas between different groups of rats; ■ ■ Discussion review article, Kovac et al. previously showed that, in addition to low seminal quality and histological changes, paternal aging also leads to an increased risk of miscarriages, genetic abnormalities, cancer, autism, and other psychiatric disorders in the offspring1. Serre et al.15 also found similar results in an animal study, which indicated an increase in the pre- implantation loss of the embryo, decrease in fetal weight, and increase in neonatal death in offspring generated by elderly animals. i To better understanding the aging process and its characteristics, it is necessary to conduct studies with long follow-up times and using subjects at different stages of life, which requires experimental animal. Since rats have a short biological cycle, their entire life cycle can be controlled and the changes in spermatogenesis with the passage of time can be compared. The design of the groups in the present study allowed us to examine the animals at critical moments such as young adult (3 months of age) and at old age (24 months of age)14. Spermatogenesis and male fertility have been extensively studied, and the factors that alter them, such as varicocele, torsion of the testis, and cryptorchidism, have already been the targets of numerous studies16–18. As a variable that affects all beings, aging has been the focus of various studies, which have indicated testicular changes and change in seminal quality with increasing age4,11,19. However, most of these studies have only analyzed what occurs in older men or With an increase in the average life span and with couples tending to postpone conception, knowledge of the events occurring during spermatogenesis in aged populations and the consequences of aging on spermatogenesis has become important for both treatment and counseling. In a 910 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. stem cells (spermatogonial stem cells), which continually renew and produce other germ cells and, a priori, maintain their quality and quantity throughout life24. In this study, we showed that a decrease in the number of spermatids occurs with aging. ■ ■ Discussion In a study involving the transplantation of stem cells from elderly rats into young mouse testes, Ryu et al.25 found that cells from the elderly rats in a young environment maintained spermatogenesis for another 3 years and concluded that the deterioration of spermatogenesis in elderly men is related to a deterioration of the testicular microenvironment. compared it to observations in young men without establishing a time point for when these changes occur. In the present study, we identified stability of the analyzed variables in the first four groups and a significant decrease in the same variables in the last two groups, which indicated that deterioration in spermatogenesis does not occur uniformly. The results of the present study are also consistent with those of previous studies, which also revealed a regression in the quality of spermatogenesis and decrease in the number of germinal cells with age4,20. Our study showed that the histology with regard to spermatogenesis remains unchanged in the period between puberty and the initial two-thirds of life and that there is a marked decline in the last one-third stage of life, which indicates that fertility in a 3-months-old rat and a 12-months-old rat is probably the same. In men, it can be inferred that this decline occurs between the fourth and sixth decade of life14. i Our results also indicate that, unlike spermatid counts, when the tubular area and height of the germinal epithelium were analyzed, there was either no difference or only a slight difference between the elderly rats and the young ones. In a previous study, Xia et al.11 analyzed the histopathology of the testes of men with advanced prostate cancer subjected to orchiectomy and compared them with the histopathologies of testicular biopsies of young men and found similar results; they therefore hypothesized connective tissue hyperplasia and interstitial laxity as an explanation for this finding. i Cellular apoptosis is a component of normal spermatogenesis, and it maintains an appropriate number of germ cells and eliminates defective cells. An increase in apoptosis associated with a decrease in cell proliferation in aged testes leads to an imbalance and a consequent decrease in the number of germ cells21. ■ ■ Discussion The results of the present study show a reduction in the number of spermatids in aged testes, which is in agreement with previous literature that showed a decrease in the number of spermatids while the number of spermatogonia and spermatocytes remained stable when compared to that in young testes4,22. Furthermore, previously, Tomomasa et al.23 analyzed the spermatogenesis of cryptorchid rats and found an increase in spermatocyte apoptosis as a cause of germinal cell reduction. Thus, the increase in spermatocyte apoptosis probably explains the results obtained in the present study. i One limitation of the present study is that we did not conduct seminal analysis. Nevertheless, we established, with follow-up time and stereological (three-dimensional) analysis, that the decrease in the number of spermatids and, consequently, the deterioration of spermatogenesis occurs in rats at 18 months of age. Further studies with more specific analyses aimed at determining the causes and consequences of this deterioration need to be conducted in the future. ■ ■ References 1. Kovac JR, Addai J, Smith RP, Coward RM, Lamb DJ, Lipshultz LI. The effects of advanced paternal age on fertility. Asian J Androl. 2013 Nov;15(6):723–8. doi: 10.1038/aja.2013.92. 12. Mattfeldt T, Mobius HJ, Mall G. Orthogonal triplet probes: an efficient method for unbiased estimation of length and surface of objects with unknown orientation in space. J Microsc. 1985 Sep;139(3):279–89. PMID: 3908688. ii 2. Eskenazi B, Wyrobek AJ, Sloter E, Kidd SA, Moore L, Young S, Moore D. The association of age and semen quality in healthy men. Hum Reprod. 2003 Feb;18(2):447–54. PMID: 12571189. l 13. Sterio DC. The unbiased estimation of number and sizes of arbitrary particles using the disector. J Microsc. 1984 May;134(2):127–36. PMID: 6737468. 3. Plas E, Berger P, Hermann M, Pflüger H. Effects of aging on male fertility? Exp Gerontol. 2000 Aug;35(5):543–51. PMID: 10978677. 14. Quinn R. Comparing rat’s to human’s age: how old is my rat in people years? Nutrition. 2005 Jun;21(6):775–7. doi: 10.1016/j. nut.2005.04.002.f 4. Jiang H, Zhu WJ, Li J, Chen QJ, Liang WB, Gu YQ. Quantitative histological analysis and ultrastructure of the aging human testis. Int Urol Nephrol. 2014 May;46(5):879–85. doi: 10.1007/s11255-013-0610-0. 15. Serre V, Robaire B. Paternal age affects fertility and progeny outcome in the Brown Norway rat. Fertil Steril. 1998 Oct;70(4):625– 31. PMID: 9797088. 5. O’Brien JH, Lazarou S, Deane L, Jarvi K, Zini A. Erectile dysfunction and andropause symptoms in infertile men. J Urol. 2005 Nov;174(5):1932–4. doi: 10.1097/01. ju.0000177453.14334.a2.ti 16. Al Bakri A, Lo K, Grober E, Cassidy D, Cardoso JP, Jarvi K. Time for improvement in semen parameters after varicocelectomy. J Urol. 2012 Jan;187(1):227–31. doi: 10.1016/j. juro.2011.09.041. 6. Beattie MC, Adekola L, Papadopoulos V, Chen H, Zirkin BR. Leydig cell aging and hypogonadism. Exp Gerontol. 2015 Aug;68:87–91. doi: 10.1016/j. exger.2015.02.014. j 17. Lorenzini F, Tambara Filho R, Gomes RP, Martino-Andrade AJ, Erdmann TR, Matias JE. Long-term effects of the testicular torsion on the spermatogenesis of the contralateral testis and the preventive value of the twisted testis orchiepididymectomy. Acta Cir Bras. 2012 Jun;27(6):388–95. PMID: 22666756. 7. Hellstrom WJ, Overstreet JW, Sikka SC, Denne J, Ahuja S, Hoover AM, Sides GD, Cordell WH, Harrison LM, Whitaker JS. Semen and sperm reference ranges for men 45 years of age and older. J Androl. 2006 May-Jun;27(3):421–8. doi: 10.2164/ jandrol.05156. 18. Penson DF, Lugg JA, Coyne C, Sadeghi F, Freedman AL, Gonzalez-Cadavid NF, Rajfer J. ■ ■ Conclusions The aging of the rats led to a deterioration of histological parameters of the spermatogenesis by a significant decrease in the Spermatogenesis is a self-renewing productive system that is maintained by 911 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. number of round spermatids and a decrease in the area of the seminiferous tubules. Although, at the stage of life where there is the greater histological loss of the spermatogenesis there are no obvious clinical signs, this study showed that it occurs mainly at 18 months of age 10. Bechara GR, de Souza DB, Simoes M, Felix- Patrício B, Medeiros JL Jr, Costa WS, Sampaio FJ. Testicular morphology and spermatozoid parameters in spontaneously hypertensive rats treated with enalapril. J Urol. 2015 Nov;194(5):1498–503. doi: 10.1016/j. juro.2015.06.073. 11. Xia Y, Zhu WJ, Hao SF, Liang WB, Li J. Stereological analysis of age-related changes of testicular peritubular cells in men. Arch Gerontol Geriatr. 2012 Jul-Aug;55(1):116–9. doi: 10.1016/j.archger.2011.05.005.tf ■ ■ References Effect of cryptorchidism on testicular histology in a naturally cryptorchid animal model. J Urol. 1997 Nov;158(5):1978–82. PMID: 9334653. 8. Lawson G, Fletcher R. Delayed fatherhood. J Fam Plann Reprod Health Care. 2014 Oct;40(4):283–8. doi: 10.1136/ jfprhc-2013-100866. 19. Well D, Yang H, Houseni M, Iruvuri S, Alzeair S, Sansovini M, Wintering N, Alavi A, Torigian DA. Age-related structural and metabolic changes in the pelvic 9. Liu Z, Chang Q, Xu ZL, Zhang ZG. Stereological measurement of rat’s seminiferous tubule. Chin Med J (Engl). 2009 Nov;122(21):2643– 6. PMID: 19951585. 912 Acta Cir Bras. 2018;33(10):904-913 Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis Miranda EP et al. related to spermatogenesis in aged men. J Androl. 2003 Mar-Apr;24(2):185–91. PMID: 12634304. reproductive end organs. Semin Nucl Med. 2007 May;37(3):173–84. doi: 10.1053/j. semnuclmed.2007.01.004. 20. Levy S, Serre V, Hermo L, Robaire B. The effects of aging on the seminiferous epithelium and the blood-testis barrier of the Brown Norway rat. J Androl. 1999 May- Jun;20(3):356–65. PMID: 10386815. i 23. Tomomasa H, Adachi Y, Oshio S, Umeda T, Irie H, Ishikawa H. Germ cell apoptosis in undescended testis: the origin of its impaired spermatogenesis in the TS inbred rat. J Urol. 2002 Jul;168(1):343–7. PMID: 12050567. 21. Pastor LM, Zuasti A, Ferrer C, Bernal- Mañas CM, Morales E, Beltrán-Frutos E, Seco-Rovira V. Proliferation and apoptosis in aged and photoregressed mammalian seminiferous epithelium, with particular attention to rodents and humans. Reprod Domest Anim. 2011 Feb;46(1):155–64. doi: 10.1111/j.1439-0531.2009.01573.x. 24. Brinster RL. Germline stem cell transplantation and transgenesis. Science. 2002 Jun;296(5576):2174–6. doi: 10.1126/ science.1071607. 25. Ryu BY, Orwig KE, Oatley JM, Avarbock MR, Brinster RL. Effects of aging and niche microenvironment on spermatogonial stem cell self-renewal. Stem Cells. 2006 Jun;24(6):1505–11. doi: 10.1634/ stemcells.2005-0580. j 22. Kimura M, Itoh N, Takagi S, Sasao T, Takahashi A, Masumori N, Tsukamoto T. Balance of apoptosis and proliferation of germ cells Conflict of interest: none Financial source: none Conflict of interest: none Financial source: none Correspondence: Eduardo Pereira de Miranda Rua Juci Cidade, 121/501 88701-425 Tubarão – SC Brasil Tel.: (55 48)99101-0656 eduardo.miranda1982@gmail.com 1Research performed at Laboratory of Anatomy and Experimental Surgery, Division of Urology, Department of Surgery, Universidade Federal do Paraná (UFPR), Curitiba-PR, Brazil. Part of Master degree thesis, Postgraduate Program in Surgical Clinic. Tutors: Rogério de Fraga and Fernando Lorenzini. Received: June 09, 2018 Review: Aug 10, 2018 Accepted: Sept 12, 2018 913
https://openalex.org/W2592227277	https://eprints.soton.ac.uk/406210/1/Systematic_review_of_the_health_related_quality_of_life_issues.pdf	English	null	Systematic review of the health-related quality of life issues facing adolescents and young adults with cancer	Quality of life research	2,017	cc-by	11,757	Introduction * Samantha C. Sodergren S.C.Sodergren@soton.ac.uk 1 Faculty of Health Sciences, University of Southampton, Southampton, UK 2 Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands 3 Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway 4 Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland 5 Marie Curie Palliative Care Research Department and Division of Psychiatry, University College London, London, UK 6 Torbay Hospital, Torquay, UK 7 Department of Clinical Research, Sorlandet Hospital, Kristiansand, Norway Abstract Purpose For adolescents and young adults (AYAs), the impact of a cancer diagnosis and subsequent treatment is likely to be distinct from other age groups given the unique and complex psychosocial challenges of this developmen- tal phase. In this review of the literature, we report the health-related quality of life (HRQoL) issues experienced by AYAs diagnosed with cancer and undergoing treatment. Methods MEDLINE, EMBASE, CINAHL, PsychINFO and the Cochrane Library Databases were searched for publications reporting HRQoL of AYAs. Issues generated from interviews with AYAs or from responses to patient reported outcome measures (PROMs) were extracted. Conclusion The HRQoL issues presented within this review are likely to be informative to health care profes- sionals and AYAs. The extensive list of issues suggests that the impact of a cancer diagnosis and treatment during ado- lescence and young adulthood is widespread and reflects the complexities of this developmental phase. Keywords Adolescents and young adults (AYAs) · Health-related quality of life (HRQoL) · Cancer · Patient reported outcome measures (PROMs) Keywords Adolescents and young adults (AYAs) · Health-related quality of life (HRQoL) · Cancer · Patient reported outcome measures (PROMs) Results 166 papers were reviewed in full and comprised 72 papers covering 69 primary studies, 49 measurement development or evaluation papers and 45 reviews. Of the 69 studies reviewed, 11 (16%) used interviews to elicit AYAs’ Samantha C. Sodergren1 · Olga Husson2 · Jessica Robinson1 · Gudrun E. Rohde3,7 · Iwona M. Tomaszewska4 · Bella Vivat5 · Rebecca Dyar6 · Anne‑Sophie Darlington1 · On behalf of the EORTC Quality of Life Group Samantha C. Sodergren1 · Olga Husson2 · Jessica Robinson1 · Gudrun E. Rohde3,7 · Iwona M. Tomaszewska4 · Bella Vivat5 · Rebecca Dyar6 · Anne‑Sophie Darlington1 · On behalf of the EORTC Quality of Life Group Accepted: 2 February 2017 © The Author(s) 2017. This article is published with open access at Springerlink.com descriptions of HRQoL issues. The majority of the PROMs used in the studies represent adaptations of paediatric or adult measures. HRQoL issues were organised into the fol- lowing categories: physical, cognitive, restricted activities, relationships with others, fertility, emotions, body image and spirituality/outlook on life. Conclusion The HRQoL issues presented within this review are likely to be informative to health care profes- sionals and AYAs. The extensive list of issues suggests that the impact of a cancer diagnosis and treatment during ado- lescence and young adulthood is widespread and reflects the complexities of this developmental phase. descriptions of HRQoL issues. The majority of the PROMs used in the studies represent adaptations of paediatric or adult measures. HRQoL issues were organised into the fol- lowing categories: physical, cognitive, restricted activities, relationships with others, fertility, emotions, body image and spirituality/outlook on life. descriptions of HRQoL issues. The majority of the PROMs used in the studies represent adaptations of paediatric or adult measures. HRQoL issues were organised into the fol- lowing categories: physical, cognitive, restricted activities, relationships with others, fertility, emotions, body image and spirituality/outlook on life. * Samantha C. Sodergren S.C.Sodergren@soton.ac.uk * Samantha C. Sodergren S.C.Sodergren@soton.ac.uk 1 Faculty of Health Sciences, University of Southampton, Southampton, UK 2 Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands 3 Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway 4 Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland 5 Marie Curie Palliative Care Research Department and Division of Psychiatry, University College London, London, UK 6 Torbay Hospital, Torquay, UK 7 Department of Clinical Research, Sorlandet Hospital, Kristiansand, Norway Qual Life Res DOI 10.1007/s11136-017-1520-x REVIEW REVIEW Objectives This review focuses on HRQoL issues experienced by AYAs during their diagnosis and treatment for cancer and refers to descriptive accounts provided during interviews with AYAs with cancer and the content of AYA-specific or adapted PROMs. This review will also pave the way for a discussion on how these HRQoL issues might be distinct from those important to children and older adults. To the best of our knowledge, this review is the first of its kind in terms of systematically reviewing the literature for HRQoL issues faced by AYAs with the specific focus on the diag- nosis and treatment period rather than the post-treatment or survivorship phase which presents its own challenges, such as living with long lasting effects of treatment, anxiety over leaving the hospital system, readjusting to life after treat- ment and fear of recurrence [17]. There are several issues that warrant the classifi- cation of AYAs as different from paediatrics or older adults with cancer. Firstly, the epidemiology of cancer in AYAs differs from other age groups. While cancer in AYAs is relatively rare, its incidence is increasing and is higher than that in children [7–11]. In the UK, 2000 AYAs (aged between 15 and 24 years) are diagnosed with cancer each year which is the second cause of death in this age group [12]. Cancer types in this group are less prevalent in other age groups and there is evi- dence to suggest that survival outcomes for some can- cers in this group have not improved in line with figures achieved for paediatric or older adult groups [13–15]. Ten per cent of tumours seen in AYAs are predominantly childhood tumours, while 30% of tumours have a peak in adolescence and include Hodgkin lymphoma, Ewing’s sarcoma, osteosarcoma, germ-cell tumours and rare soft- tissue sarcomas. A final 60% are early-onset adult can- cers [14, 15]. Methods The protocol for this systematic review was informed by the Centre for Reviews and Dissemination guidance for undertaking reviews in health care [18] and the reporting follows the preferred reporting items of systematic reviews and meta-analyses (PRISMA) guidelines [19]. The protocol is available from the first author. Background 1 Faculty of Health Sciences, University of Southampton, Southampton, UK In recent years, there has been increased emphasis in health care on the development and use of measures which give patients the opportunity to rate the physical and psycho- social impact of illness and treatment [1]. These patient reported outcome measures (PROMs) are informative for both patient and clinician and contribute valuable informa- tion for clinical trials and medical decision making [2]. 2 Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands 3 Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway 4 Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland For one group of patients, adolescents and young adults (AYA) with cancer, health-related quality of life (HRQoL) assessment is especially relevant as, compared with children and older adults, this group is regarded as particularly vulnerable [3, 4]. Adolescence marks the transitional stage linking childhood and adulthood in 5 Marie Curie Palliative Care Research Department and Division of Psychiatry, University College London, London, UK 6 Torbay Hospital, Torquay, UK 6 Torbay Hospital, Torquay, UK 7 Department of Clinical Research, Sorlandet Hospital, Kristiansand, Norway (0121 3456789) 3 Qual Life Res which puberty occurs. The World Health Organization [5] defines adolescents as 10–19 year olds although it is recognised that this age definition is not fixed and var- ies according to gender, biological, cultural and socio- economic factors. There is also fluidity in what defines a young adult and while the World Health Organiza- tion’s definition of young people includes 10–24 year olds, the age range used by other organisations, such the Adolescent and Young Adult Oncology Progress Review Group, extends to 39 year olds [6].i Search strategies and criteria for considering studies Adolescence and early adulthood is a unique and com- plex developmental phase characterised not only by sig- nificant physical and cognitive changes but also critical psychosocial challenges, relating to self-identity, peer relationships, development of autonomy, and sexuality. This also represents an important life stage with regard to education and future goal setting. Given the unique life circumstances and challenges of this group, it could be argued that the experience and impact of cancer on AYAs’ HRQoL will be distinct from other age groups. An initial scoping of the literature using MEDLINE with the following search terms and their synonyms “cancer”, “adolescent”, “young adult” and “health-related quality of life” generated 8635 records. A revised, more focused strategy was adopted and verified by two medical librar- ians. This strategy used exact major headings (MM) as well as medical subject headings (MeSH terms) and applied the focus/major concept options with Boolean logic rules (Table 1). MEDLINE, EMBASE, CINAHL, PsychINFO and the Cochrane Library Databases were searched for publications up until May 2015 with no defined start date.i According to the World Health Organization Quality of Life Group, HRQoL can be defined as a multi-dimen- sional construct shaped by physical health, psychologi- cal state, level of independence, social relationships, personal beliefs and their relationship to important envi- ronmental features with HRQoL appraisals shaped by coping strategies, goals and expectations [16]. Thus, it follows that HRQoL measures for this age group should be tailored to AYA-specific issues. HRQoL measures developed for paediatric practice often incorporate the adolescent years as their recommended upper age limit for use. In addition, adolescence and early adulthood are often included within the lower age limits of adult measures. i The first phase of the selection process involved three independent reviewers (S.S., O.H., J.R.) identifying eligible papers based on their titles and abstracts. S.S. screened all the papers while O.H. and J.R. independently reviewed half the records each. Papers selected by either reviewer were included in the second phase of the review process. The process was monitored by a further reviewer (A-S.D.). Eng- lish language publications were eligible for inclusion if they assessed HRQoL in AYAs with cancer from the perspec- tive of the AYA rather than proxy, although papers includ- ing parent assessments alongside AYAs self-reports were accepted. Papers describing trials or patient cohort studies 1 Literature search The selection process generated 2671 hits (Fig. 1). Screen- ing of titles and abstracts identified 587 (22%) papers for full review with agreement between reviewers for 1911 (72%) papers. The subsequent data extraction phase identi- fied 432 papers of the 587 papers as ineligible for review with 245 papers describing the experiences of AYAs post- treatment and 187 rejected on the basis of subject matter (not reporting HRQoL issues), patient group (non-AYA with cancer), language (non-English) or type of publica- tion (case study, conference report, proxy assessment). The additional 11 papers were identified through cross-refer- encing; thus, 166 papers were considered for review. There were 45 review papers, 49 papers describing the proper- ties of questionnaires used with AYAs with cancer and 72 reporting the results of studies (69 in total) using HRQoL as an outcome assessment. were included. Reviews and reports were also considered for descriptive and cross-referencing purposes but not for data extraction to avoid duplication. Papers describing the development of measures to assess HRQOL in AYAs with cancer were also eligible for inclusion for descriptive pur- poses. Given the variability of age definitions of AYAs in the literature, we did not set age cut-offs for inclusion; thus, a study was considered for inclusion if it reported including adolescents and/or young adults. The focus of the review is on issues facing AYAs at the time of diagnosis and treat- ment, thus papers solely describing the experiences of survivors were excluded. Prospective cohort studies cover- ing post-treatment and studies including patients both on and off treatment were however considered for inclusion; thus, some of the studies included in our review included AYAs off treatment. We note that definitions of survivors also vary in the literature and we used the working defini- tion adopted by the European Organisation of Research and Treatment for Cancer (EORTC) Survivorship Task Force of any person who has been diagnosed with cancer and is off treatment with curative-intent (with the exception of maintenance treatment) and disease free (has no evidence of active cancer) [20]. Individual case reports and abstracts from conference proceedings were also excluded. Duplicate records were removed. Description of studies Out of the 69 studies reviewed, 3 included only AYAs in their sample using the authors’ definition of AYAs [21–24] with an upper age of 39 years used as an inclusion criteria in the Adolescent and Young Adult Health Outcomes and Patient Experience (AYA HOPE) Study [23, 24]. Young adults were the focus of 6 studies [25–30] and again these were heterogeneous in terms of age range of inclusion with the lowest age of 20 used for 3 studies [26, 29, 30] and 47 years representing the oldest age [28]. Adolescents were described as the focus of 14 studies [31–44] with the age for inclusion ranging between 10 years [39, 40, 43] and 23 years [36]. The remaining studies reviewed included ado- lescents as part of a larger sample which also included chil- dren and 9 of these [45–53] treated adolescents (12/13 year olds) as a separate group. 3 3 3 Qual Life Res Table 1 Revised strategy a Terms not identified in PsychINFO, EMBASE or CINAHL b Exact major subheading search c Medical subheading Step Search term 1 MMb Health status indicators (MeSHc, Major Concept) 2 MM Patient outcome assessment (MeSH, Major Concept)a 3 MM Outcome assessment (Health care) (MeSH, Major Concept)a 4 MM Quality of life (MeSH, Major Concept) 5 1 or 2 or 3 or 4 6 Young adult (MeSH) 7 Adolescent 8 6 or 7 9 MM Neoplasms+ (MeSH, Major Concept, Exploded) 10 5 and 8 and 9 Table 1 Revised strategy a Terms not identified in PsychINFO, EMBASE or CINAHL b Exact major subheading search c Medical subheading Step Search term 1 MMb Health status indicators (MeSHc, Major Concept) 2 MM Patient outcome assessment (MeSH, Major Concept)a 3 MM Outcome assessment (Health care) (MeSH, Major Concept)a 4 MM Quality of life (MeSH, Major Concept) 5 1 or 2 or 3 or 4 6 Young adult (MeSH) 7 Adolescent 8 6 or 7 9 MM Neoplasms+ (MeSH, Major Concept, Exploded) 10 5 and 8 and 9 of the data was used because of the heterogeneity of stud- ies in terms of research focus and methods of recording HRQoL outcomes. The data extraction sheet identifies the age range of participants, research objective, methodol- ogy used, and HRQoL issues assessed or described using formal measurement tools or captured using interviews. A separate data recording sheet was used for papers focusing on AYA measures with the intention to capture the HRQoL issues assessed by the measures. Fig. 1 Flow chart of the paper selection process Evaluation and data extraction HRQoL issues were extracted from primary sources and recorded using a data extraction form. This task was car- ried out for all eligible papers and shared between the reviewers (S.S., O.H., J.R., R.D.). The extraction forms were verified by A-S.D. who also addressed additional que- ries regarding eligibility of papers. A descriptive synthesis Leukaemia, lymphoma, cancer of the central nerv- ous system and sarcoma were amongst the most common disease groups. Several studies provided a comparison of HRQOL issues according to disease type (solid versus 1 3 Qual Life Res . 1 Flow chart of the paper ection process Records identified through database search n=2671 (1042 duplicates) Articles subsequently excluded n=432 245 reports of survivors 71 type of publication (case study, letter, short report) 55 did not assess HRQoL outcomes (or were intervention studies) 24 no patient-self-report 14 studies did not include AYAs 14 non - English language 7 studies did not include cancer patients 2 duplicates Full text articles eligible for review n=587 Measures n=49 Articles rejected that did not meet the inclusion criteria n=2084 Primary data n=72 (69 studies) Reviews n=45 Papers accepted for review n=155 Additional papers identified through cross-referencing n=11 Papers reviewed n=166 Records identified through database search n=2671 (1042 duplicates) (69 studies) to evaluate the experiences of AYAs and capture HRQoL issues. Five studies [25, 34, 50, 59, 61] used open-ended, semi-structured interviews and 6 were more structured with a particular domain of interest including pain [32], fatigue [39, 49], body image [28], romantic relation- ships and fertility [42]. Three studies [32, 39, 60] used interviews to complement the completion of measures. The remaining 58 studies reviewed relied solely on the use of questionnaires which were either generic in their focus (PedsQL) [62] or measured a specific HRQoL con- cern (Reproductive Concerns Instrument) [38]. PROMS selected also varied according to their intended age group. Some studies asked AYAs with cancer to complete measures designed for adult respondents, for example, the EORTC core generic cancer quality of life question- naire (EORTC-QLQ-C30) [63] was used in four of the studies reviewed [22, 26, 45, 55]. Indeed, Trevino et al. to evaluate the experiences of AYAs and capture HRQoL issues. Five studies [25, 34, 50, 59, 61] used open-ended, semi-structured interviews and 6 were more structured with a particular domain of interest including pain [32], fatigue [39, 49], body image [28], romantic relation- ships and fertility [42]. Evaluation and data extraction Three studies [32, 39, 60] used interviews to complement the completion of measures. The remaining 58 studies reviewed relied solely on the use of questionnaires which were either generic in their focus (PedsQL) [62] or measured a specific HRQoL con- cern (Reproductive Concerns Instrument) [38]. PROMS selected also varied according to their intended age group. Some studies asked AYAs with cancer to complete measures designed for adult respondents, for example, the EORTC core generic cancer quality of life question- naire (EORTC-QLQ-C30) [63] was used in four of the studies reviewed [22, 26, 45, 55]. Indeed, Trevino et al. haematological cancers) [54] or subtype [acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL)] [55], disease risk (Hodgkin lymphoma ‘high risk’ vs leuke- mia ‘low risk’) [56] and treatment status [57]. Some stud- ies captured HRQoL across the disease/treatment trajectory looking at change over time [29]. Comparisons have been made with healthy individuals either in terms of reference to population norms [24, 57] or the inclusion of a separate sample of healthy participants [58]. Patients have also been compared according to age group (children versus adoles- cents) [45, 53, 55]. Finally, patients’ self-reports have been compared with proxy assessments in order to identify con- sistency in reporting of HRQoL issues [38]. The studies reviewed asked AYAs to describe or rate their HRQoL using interview questions or self-completed questionnaire assessments. Of the 69 studies reviewed, 11 [25, 28, 32, 34, 39, 42, 49, 50, 59–61] used interviews 1 3 Qual Life Res Adapted existing measures [30] noted that as psychological well-being and distress scales have not been validated with young adults, they had to look for measures validated in other populations (i.e. adults). The majority of studies we reviewed used measures which had been either specifically developed for AYAs, adolescents or young adults, or which had been adapted from paediatric or adult measures to cap- ture the needs and concerns of AYAs. The majority of questionnaires captured in this review rep- resent adaptations of paediatric or adult measures and thus include different age versions. The PedsQL [62] was the most common measurement scale of choice amongst the studies reviewed and used in 27 of the 69 studies The Ped- sQL measurement model captures both generic (core meas- ure) and disease-specific aspects of measurement with the core instrument supplemented by disease-specific (e.g. can- cer), tumour-specific (e.g. brain) or symptom-specific (e.g. fatigue) modules. Evaluation and data extraction In terms of age versions, the PedsQL offers an adolescent form for 13–18 years and was adapted by Ewing et al. [80] to create an AYA form appropriate for 16–24 years. The Pediatric Cancer Quality of Life Inven- tory (PCQL-32) [81] and the Quality of Life for Children with Cancer (QOLCC) [82] also have adolescent versions for 13–18 year olds. The Pediatric Advanced Care Qual- ity of Life Scale (PAC-QoL) [83] has an adolescent ver- sion for 13–19 year olds. The KINDL measure of quality of life in chronically ill children has an oncology-specific as well as adolescent version (KINDL Kiddo) for children 13–16 years [84]. The Child Health and Illness Profile also has an adolescent edition (CHIP-AE) for 11–17 year olds [85]. There are also several measures developed with adults that have been adapted for use with younger respondents. The Health-related Hindrance Inventory (HRHI) [86] was adapted for use with adolescents and the Reproductive Con- cerns Instrument [87] was adapted for use with 12–18 year old females with cancer [38]. The Memorial Symptom Assessment Scale (MSAS 10–18) was also adapted for children and adolescents (aged 10–18 years) [88]. The Min- neapolis–Manchester Quality of Life (MMQL) Question- naire has an adolescent form (13–20 years) [89] and the Behavioural Affective and Somatic Experiences Scale has a child-form (BASES-C) [90] covering AYAs (up to 20 years). Finally, the 16-Dimensional Health-related Measure (16D) [91] represents an adaptation of the adult 15D meas- ure and is suitable for 12–15 years. HRQoL issues HRQoL issues extracted from interviews with AYAs or measurement concepts of instruments used in the studies reviewed are presented in Table 2. Adolescent and/or young adult‑specific measures Our review captured one measure which was specifically designed for both adolescents and young adults with can- cer: The Cancer Needs Questionnaire-Young People (CNQ- YP) [64] which includes items relevant to young people aged 14–25 years. In addition, two other measures, one tumour-specific, the Dutch DUX questionnaire for lower extremity bone tumour patients (Bt-DUX) [65] and one generic, the Perceived Illness Experience (PIES) Scale [66], were developed using children as well as AYAs (up to 25 and 24 years respectively). We identified two ado- lescent measures which are generic in terms of their dis- ease focus: The Adolescent Quality of Life Instrument [67] was piloted with 9–20 year olds and the Hopefulness Scale for Adolescents (HSA) [68]. One measure reviewed was designed for young adults with testicular cancer (aged 18–29 years): The Cancer Assessment for Young Adults— Testicular (CAYA-T) [69]. In addition, there was one meas- ure designed for children and adolescents (8–18 year olds): The Quality of Life in Children and Adolescents with Can- cer Scale (PEDQOL) [70]. The studies reviewed also used several generic measures developed for use with age groups covering adolescence, for example the Child Health Ques- tionnaire (CHQ) [71] is relevant for children aged 10–15 years and the Behavioural Assessment System for Children (BASC) [72] is designed to be used with children aged 4–18 years. The DISAKIDS measure (DCGM-37) [73] is used with school aged children including adolescents [74]. The Activities Scale for Kids Performance Version (ASKp) [75] was designed for children aged 10–15 years and has since been used to assess physical function in adolescents with bone tumours aged 10–18.9 years [76] and the Pedi- atrics Outcomes Data Collection Instrument (PODCI) [77] provides an assessment of functional status in children and adolescents. The Pediatric Functional Assessment of Ano- rexia and Cachexia Therapy (peds-FAACT) [78] is specific to 7–17 years and includes additional peripheral items for 10–17 year olds. In addition, the PROMIS Pediatric Meas- ures selected for use by Hinds et al. [79] were suitable for completion by 8–17 year olds. Physical AYAs talked about their symptoms such as fatigue, loss of strength, pain, cognitive difficulties, hair loss, impaired appetite and desire to eat [28, 32, 34, 39, 42, 49, 50, 59, 61]. Physical Symptoms were recognised as a major theme in Moody et al.’s exploratory study [61] and as a HRQoL 1 3 Qual Life Res Qual Life R 1 3 Table 2 HRQoL issues generated from PROMs or interviews with AYAs Measurement concept Source PROMa Interview Physical functioning General physical functioning/health status Adolescent Quality of Life Instrument, ASKp, Bt-DUX, CHIP-AE, CHQ, CAYA-T, MMQL, KINDL Kiddo, PCQL-32, PEDQoL, PedsQL meas- ures, PODCI, QOLCC, FACT-G, SF-36 [59] Symptoms Pain/discomfort/hurt Fatigue, energy, loss of strength, insomnia, nausea, vomiting, diarrhoea, constipation, skin changes, dizziness, oedema, hair loss, mouth sores, weight loss, anorexia, cachexia, appetite, desire to eat CHQ, CHIP-AE, CNQ-YP, HRHI, MSAS 10–18, PAC-QoL, PCQL-32, PedsFAACT, PedsQL measures, PODCI, PROMIS, QOLCC, 16-D, HUI, EORTC QLQ-C30, SCNS, PGWB [25, 28, 32, 34, 39, 42, 49, 50, 59, 61] Physical limitations CNQ-YP, DISAKIDS, PedsQL, PODCI, PROMIS, 16-D, EORTC QLQ- C30 Cognitive functioning Concentration, memory CAYA-T, MMQL, MSAS 10–18, PedsQL, PEDQOL, PCQL-32, QOLCC, HUI, EORTC QLQ-C30 [49] Activity limitation Self-care, education, work, sport/leisure/hobbies, social/family activities Adolescent Quality of Life Instrument, BASES-C, CAYA-T, CHQ, CNQ- YP, PedsQL, PIES, 16-D, HUI, EORTC QLQ-C30, SCNS [25, 34, 39, 49, 50, 59–61] Loss of “normal life” [50, 60, 61] Plans for the future CNQ-YP [49] Abilities/realisation of talents/difficulty competing CHIP-AE, CNQ-YP [49] Positive effects of restricted activities (education) [61] Relationships with others General social functioning BASES-C, Bt-DUX, CAYA-T, DISAKIDS, MMQL, PAC-QoL, PCQL-32, QOLCC, EORTC QLQ-C30, FACT-G, SF-36 [60] Friends Loss of friendships, disconnected, isolated from others, peer rejection, bullying CNQ-YP, DISAKIDS, KINDL Kiddo, PEDQOL, PedsQL, PIES, PROMIS, 16-D [25, 34, 50, 59, 61] Family Strained relationships Dependency on others/lack of autonomy Adolescent Quality of Life Instrument, CHQ CNQ-YP, DISAKIDS, KINDL Kiddo, PEDQOL [25, 34, 49, 50, 59] Communication/refusal to talk PedsQL, QOLCC, 16-D [34, 49] Romantic/sexual relationships CAYA-T, CNQ-YP, MMQL, SCNS, IOC [42] Prospects for future relationships [42] Impact on others Emotional, time impact, parental behaviour, over-protectiveness CHQ, CNQ-YP, PIES, SCNS [34, 61] Positive effects Greater value placed on friendships, appreciation of the support from oth- ers, strengthened family ties, opportunities for new friendships, positive attention from others [25, 34, 42, 50] Table 2 HRQoL issues generated from PROMs or interviews with AYAs Measurement concept Source PROMa Interview Physical functioning General physical functioning/health status Adolescent Quality of Life Instrument, ASKp, Bt-DUX, CHIP-AE, CHQ, CAYA-T, MMQL, KINDL Kiddo, PCQL-32, PEDQoL, PedsQL meas- ures, PODCI, QOLCC, FACT-G, SF-36 [59] Symptoms Pain/discomfort/hurt Fatigue, energy, loss of strength, insomnia, nausea, vomiting, diarrhoea, constipation, skin changes, dizziness, oedema, hair loss, mouth sores, weight loss, anorexia, cachexia, appetite, desire to eat CHQ, CHIP-AE, CNQ-YP, HRHI, MSAS 10–18, PAC-QoL, PCQL-32, PedsFAACT, PedsQL measures, PODCI, PROMIS, QOLCC, 16-D, HUI, EORTC QLQ-C30, SCNS, PGWB [25, 28, 32, 34, 39, 42, 49, 50, 59, 61] Physical limitations CNQ-YP, DISAKIDS, PedsQL, PODCI, PROMIS, 16-D, EORTC QLQ- C30 Cognitive functioning Concentration, memory CAYA-T, MMQL, MSAS 10–18, PedsQL, PEDQOL, PCQL-32, QOLCC, HUI, EORTC QLQ-C30 [49] Activity limitation Self-care, education, work, sport/leisure/hobbies, social/family activities Adolescent Quality of Life Instrument, BASES-C, CAYA-T, CHQ, CNQ- YP, PedsQL, PIES, 16-D, HUI, EORTC QLQ-C30, SCNS [25, 34, 39, 49, 50, 59–61] Loss of “normal life” [50, 60, 61] Plans for the future CNQ-YP [49] Abilities/realisation of talents/difficulty competing CHIP-AE, CNQ-YP [49] Positive effects of restricted activities (education) [61] Relationships with others General social functioning BASES-C, Bt-DUX, CAYA-T, DISAKIDS, MMQL, PAC-QoL, PCQL-32, QOLCC, EORTC QLQ-C30, FACT-G, SF-36 [60] Friends Loss of friendships, disconnected, isolated from others, peer rejection, bullying CNQ-YP, DISAKIDS, KINDL Kiddo, PEDQOL, PedsQL, PIES, PROMIS, 16-D [25, 34, 50, 59, 61] Family Strained relationships Dependency on others/lack of autonomy Adolescent Quality of Life Instrument, CHQ CNQ-YP, DISAKIDS, KINDL Kiddo, PEDQOL [25, 34, 49, 50, 59] Communication/refusal to talk PedsQL, QOLCC, 16-D [34, 49] Romantic/sexual relationships CAYA-T, CNQ-YP, MMQL, SCNS, IOC [42] Prospects for future relationships [42] Impact on others Emotional, time impact, parental behaviour, over-protectiveness CHQ, CNQ-YP, PIES, SCNS [34, 61] Positive effects Greater value placed on friendships, appreciation of the support from oth- ers, strengthened family ties, opportunities for new friendships, positive attention from others [25, 34, 42, 50] 1 Qual Life Res Table 2 (continued) Measurement concept Source PROMa Interview Emotional functioning Frustration, anger, upset, anxiety, depression, fear, vulnerability, preoc‑ cupation with illness, meaning of being ill, boredom Adolescent Quality of Life Questionnaire, BASC, BASES-C, Bt-DUX, CAYA-T, CHQ, CNQ-YP, DISAKIDS, KINDL Kiddo, MMQL, MSAS 10–18, PAC-QoL, PCQL-32, PEDQOL, PROMIS, PIES, QOLCC, 16-D, McGill Quality of Life Questionnaire, MASC, HUI, EORTC QLQ-C30, PGWB, HADS, Beck Depression Inventory, STAI-S, FACT-G, SF-36 [25, 34, 49, 50, 59–61] Loss of confidence/self-esteem CHQ, PODCI [34, 42, 49] Lack of motivation [49] Hope HSA [34] Improved self-appraisals (maturity, better person), self-esteem [34, 50] Fertility Reproductive Concerns Instrument, HUI [42] Body image CNQ-YP, Bt-DUX, MMQL, MSAS 10–18, PEDQOL, PedsQL, PIES, and 16-D [28, 34, 42] Spiritual wellbeing/outlook on life Spiritual CAYA-T, McGill Quality of Life Questionnaire [60] Outlook on life Positive attitude to life MMQL, PWBS [25, 50] Financial difficulties EORTC QLQ-C30, SCNS a PROMS used in the studies reviewed Adolescent and/or Young Adult PROMs: Cancer Needs Questionnaire-Young People (CNQ-YP) [64], Bt-DUX [65], Perceived Illness Experience (PIES) [66], Adolescent Quality of Life Instru- ment [67], Hopefulness Scale for Adolescents (HSA) [68], Cancer Assessment for Young Adults—Testicular (CAYA-T) [69], Quality of Life in children and adolescents with cancer PEDQOL [70], Child Health Questionnaire (CHQ) CF 871 [71], The Behavioral Assessment System for Children (BASC) [72], DISAKIDS (DCGM-37) [73], Activities Scale for Kids, performance ver- sion (ASKp) [75], Pediatrics Outcomes Data Collection Instrument (PODCI) [77], Pediatric Functional Assessment of Anorexia and Cachexia Therapy (peds-FAACT) [78], PROMIS Pediatric Measures [79], MASC Multidimensional Anxiety Scale for Children [99] Adapted existing measures: Paediatric Pediatric Quality of Life Inventory (PedsQL) Core [62, 80], Pediatric Cancer Quality of Life Inventory (PCQL-32) Varni et al. Restricted activities Symptoms such as fatigue, lack of strength and motivation as well as time spent undergoing medical treatment com- promised participants’ ability to engage in everyday activi- ties, partake in sports, attend school and interact with oth- ers [25, 34, 39, 49, 50, 59, 60]. When discussing the impact of illness and treatment, adolescents often made reference to milestones their peers had reached such as selecting colleges and learning to drive [60]. Parents’ over-protec- tiveness was also perceived by adolescents as a barrier to engaging in everyday activities [49]. For adolescents in Chiang et al.’s study [49], this lack of participation in activ- ities was expressed as impairing their self-performance and compromising the realisation of talents which also impacted on future life plans. Participants of Moody et al.’s [61] study described feeling trapped and bored by their lack of freedom and loss of a normal life. Poor attendance at school resulted in adolescents falling behind their peers [49, 61]. However, for participants of Momani et al.’s study [50], missing school was described as a positive effect of being ill. Social functioning is covered by most of the measures used in the studies reviewed (CNQ-YP, Bt-DUX, CAYA- T, PCQL-32, QOLCC, PedsQL, PIES, CHQ, DCGM, Adolescent Quality of Life Instrument, PROMIS Meas- ures, PAC-QoL, KINDL/KIDDO, BASES-C, MMQL and 16-D). The PEDQOL and KINDL Kiddo distin- guishes between relationships with family and friends. Social exclusion including peer rejection and bullying is assessed by the DCGM, PedsQL and PIES. In addition to measuring the impact on family relationships and inter- actions, some measures examine the perceived impact on family members, for example, emotional/time pressures on parents, limited family activities and family cohesion are assessed by the CHQ while parental behaviour repre- sents a domain of the PIES. Emotional reactions of others also formed part of Enskär et al.’s problem list [34] and concern over the feelings of family members was voiced in Moody et al.’s study [61]. Dyson et al. [21] used The Supportive Care Needs Survey (SCNS) [94] to assess AYAs’ concerns about worries of those close to them. PROMs also evaluate the impact of physical health sta- tus and cognitive functioning on the ability to carry out daily activities, most notably self-care, work, education and hobbies. (CNQ-YP, PIES, Adolescent Quality of Life Instrument, CAYA-T, CHQ, PedsQL, 16-D). Cognitive functioning Increased dependency on others came at a time when adolescents had recently gained independence and resulted in feelings of loss of control [25]. AYAs in Enskär’s et al.’s study [34] also talked about strained rela- tionships with family members. Difficulties thinking and concentrating were described by adolescents in Chiang et al.’s study [49] as impacting on their school attendance. Cognitive functioning in terms of attentiveness, memory and cognitive fatigue also forms part of the CAYA-T, PedsQL (within the school function- ing subscale and the PedsQL Fatigue measure). Opportunities for romantic relationships were also described as limited and took on a lower priority due to symptoms of fatigue and nausea as well as lowered self- esteem and prolonged hospital stays [42]. In addition, anxiety surrounding fertility was also reported [41] and led to concerns about prospects for future relationships. Stinson et al. [42] also explored the impact of cancer on adolescents’ sexual relationships and discovered that, in contrast to the assumptions held by parents, AYAs per- ceived little impact. Physical [81], Quality of Life for Children with Cancer (QOLCC) [82], The Pediatric Advanced Care Quality of Life Scale (PAC-QoL) [83], KINDL Kiddo [84], Child Health and Illness Profile (CHIP-AE) [85]. Adult Health-related Hindrance Inventory (HRHI) [86], Reproductive Concerns Instrument [87], Memorial Symptom Assessment Scale (MSAS 10–18) [88], Minneapolis-Manchester Quality of Life (MMQL) Questionnaire [89], Behavioural Affective and Somatic Experiences Scale (BASES-C) [90], 16-Dimensional Health-related Measure (16-D) [91] Non-AYA specific: EORTC QLQ-C30 [63], Supportive Care Needs Survey (SCNS) [94], Impact of Cancer Scale (IOC) [95]. Note Roper used two questions from the IOC social and relation- ship scale, Health Utilities Index (HUI) [96], Psychological Wellbeing Scale (PWBS) [98]. Monteiro et al. [26] used only the personal growth subscale of the PWBS, Psychological General Wellbeing Index (PGWB) [100], McGill Quality of Life Questionnaire [101] Trevino et al. [30] used only the psychological well-being and existential subscales, Beck Depression Inventory [102], State Trait Anxiety Scale (STAI) [103], Hospital Anxiety and Depression Scale (HADS) [104], Functional Assessment of Cancer Treatment (FACT-G) [105], The MOS 36-Item Short- Form Health Survey (SF-36) [106] 1 3 Qual Life Res Relationships with others domain by Hinds et al. [59]. Physical functioning of AYAs with cancer including health status, mobility and symp- toms (disease- and treatment-related) such as pain, fatigue, nausea, discomfort, difficulty sleeping, mobility, anorexia and cachexia, is assessed by a number of PROMs (Ped- sQL instruments, CHQ, CHIP-AE, Bt-DUX, Adolescent Quality of Life Instrument, CAYA-T, DCGM-37, ASKp, PODCI, PROMIS measures, PCQL-32, QOLCC, PAC- QOL, BASES-C, MMQI, HRHI, KIDDO and 16-D). The PedsQL also includes a fatigue-specific module. Five stud- ies recorded symptom prevalence and impact using symp- tom distress or checklist measures [27, 36, 92, 93]. Restricted social interactions were a recurring theme leaving AYAs feeling disconnected and isolated from their peers [25, 34, 50, 59, 61]. There were reports of friends “keeping their distance” [34] as well as an insight into “true friends” [34, 61]. In addition to losing friend- ships, there were accounts of opportunities to establish new friends amongst fellow patients [50]. Participants also described greater value placed on relationships with others with friendships taking on a new meaning and family ties strengthened and these were seen as an impor- tant source of comfort [25, 34, 50]. Restricted activities The PedsQL core measure assesses aspects of school functioning with the AYA form adapted to read study/work. In addition, the CHIP-AE provides an assessment of achievement (aca- demic and work). Intimate relationships are a domain of the MMQL and sexual functioning is assessed as part of the CAYA-T and formed part of the supportive needs assessment used by Dyson et al. [21]. Roper et al. [27] used the Impact 1 Financial difficulties Interviews with AYAs provided accounts of their emotional reactions to being ill. Mood was identified as a HRQoL domain by Hinds [59] and emotional reactions were a major theme reported by Moody et al. [61]. Participants described a greater tendency to become upset [50], as well as feelings of vulnerability [25], frustration [49], anger [61], and fear over mortality [61]. The impact of cancer on self-confidence [34] and self-esteem was also reported [34, 42] although improvements to self-appraisals were also described such as becoming a better, more positive and less selfish person [34, 50] as well as feelings of greater matu- rity [34]. Zareifar et al. [55] used the EORTC QLQ C30 [63] to pro- vide an evaluation of financial difficulties. Roper et al. [27] also measured the use of supportive care services and dis- covered that financial concerns were identified as a major reason for accessing such services. Discussion From our review of studies reporting the HRQoL impact of cancer on AYAs and our examination of the content of AYA-specific or adapted PROMs, we have generated a comprehensive list of HRQoL issues relevant to AYAs with cancer. Researchers interested in measuring the impact of cancer and its treatment on the HRQoL of AYAs have used a wide range of validated instruments. Measures developed with and for adults, such as the EORTC QLQ-C30 provide opportunities for the measurement of HRQoL concepts, in particular symptoms such as pain, fatigue, nausea and vom- iting that do not begin and end in the AYA years. Adult and paediatric measures have also been adapted to the specific issues relevant to AYAs and have AYA versions (PedsQL [62]) and finally there are measures which have been devel- oped with and designed specifically for AYAs (CNQ-YP) [64]. Choice of measurement tool is driven by the purpose of the study with the focus of some studies refined to a particular aspect of HRQoL. The types of HRQoL issues captured from these studies thus reflect the purpose of the study and measure used. Feelings are evaluated alongside relationships in the (CNQ-YP). Assessments of emotional or psychologi- cal functioning amongst AYAs with cancer include mood (Adolescent Quality of Life Questionnaire, BASES-C), anxiety (BASC, PROMIS, PedsQL), depression (BASC, PROMIS), sadness (PedsQL) preoccupation with cancer (PIES), concerns for the future (PedsQL, SCNS), fear of the unknown (PedsQL), lack of motivation, anger (PROMIS, PedsQL), irritability, vulnerability, hopefulness (HSA), confidence and self-esteem/self-worth (CHQ, PODCI). Fertility Concerns over fertility are the focus of one of the meas- ures reviewed (Reproductive Concerns Instrument, used by Quinn et al. [38]) and forms part of the Health Utilities Index [96] used by Yaris et al. [97]. Trevino et al. [30] dis- cussed loss of fertility in the context of causing significant unique cancer-related grief amongst young adults. 3 3 Qual Life Res Spirituality and outlook on life of Cancer scale [95] to assess intimate relationships in young adults. The impact of illness on spirituality was explored amongst children and adolescents of Kamper et al.’s study [60] and altered, often positive, perspectives on life were described by adolescents [50] and young adults [25]. The Adoles- cent Quality of Life Instrument evaluates the meaning of being ill. Spirituality is covered by the CAYA-T and is the focus of the Spiritual Quality of Life Questionnaire used in Kamper et al.’s interviews [60]. Personal growth amongst young adults with cancer was evaluated by Monteiro et al. [26] by using the Personal growth subscale of the Psycho- logical Well-Being Scale [98]. The MMQL assessment also provides an insight into outlook on life. Body image The heterogeneous nature of the stud- ies reviewed in terms of their focus, outcomes assessed and measures used resulted in data being presented in different formats; comparisons between studies were difficult and we were not in a position to present prevalence figures for indi- vidual HRQoL issues. While our review captured issues from measures used with AYAs in the studies reviewed, it is possible that we overlooked some adult measures with content relevant to AYAs. In addition, age definitions of adolescents and young adults varied across studies and the number of studies focusing exclusively on adolescents and young adults was limited, which meant we relied on findings from studies including AYAs as part of a sam- ple including children or older adults. Care was taken to report only issues relating to AYAs although this was com- promised in studies not providing a separate treatment of the responses of AYAs. Thus, the list of issues might not necessarily be specific to AYAs. In addition, it could be argued that we should not treat AYAs as one group [108]. However, our review was not designed to produce separate lists according to age and we did not attempt to draw age comparisons. Although we were interested in issues facing AYAs at diagnosis and treatment, our review included stud- ies with AYAs off treatment as part of their sample; thus, our list of issues might include those relevant to patients post-treatment. However, it was not the intention of this review, to make claims regarding issues which are likely to remain post-treatment and the experience of AYA cancer survivors. The studies and measures reviewed in the current paper highlight the wide spectrum of HRQoL issues facing AYAs and include physical, cognitive, emotional, social and spir- itual functioning which fit with the general, i.e. non-age specific definition of HRQoL offered by the World Health Organization. Within these HRQoL domains, there are issues which are particularly relevant to AYAs which may not be so familiar or relevant to children or older patients, for example, within the generic core PedsQL, social func- tioning includes relationships with peers, social exclusion and bullying with the AYA version including items relat- ing to study and work. Additional domains covered in this review include inability to engage in activities enjoyed by peers, body image, concerns over reproductive capacity and intimate relationships. Body image Emotions relating to appearance issues such as hair loss formed part of the problem list discussed by AYAs in Enskär et al.’s study [34] and was the focus of Snöbohm et al.’s study [28]. Adolescents in Stinson et al.’s study described feeling less attractive and desirable to others which in turn impacted on their self-esteem and confidence in engaging in romantic relationships [42]. Physical appear- ance or perceived body image is evaluated as part of the PIES, PEDQOL, Bt-DUX, MMQL, 16-D and PedsQL Cancer module which includes the item “I don’t look like myself”. Interviews, as an alternative or addition to the comple- tion of questionnaires, provide AYAs the opportunity to evaluate aspects of HRQoL which might not be covered in existing measures. In addition, interviews with AYAs have the potential of offering greater insight into the HRQoL issues as expressed by AYAs with issues captured often incidental to the main purpose of the research, for example, 1 3 Qual Life Res Kamper et al.’s [60] interviews on spiritual wellbeing also generated accounts of emotional and social functioning. small numbers of patients; thus, caution is required before making generalisations about the HRQoL concerns of this patient group. In addition, formal comparisons with other age groups and between genders fell beyond the scope of this review. There is widespread agreement within the literature that adolescence and early adulthood mark a period of great turmoil with accelerated physical, cognitive and emotional growth and with this comes challenges regarding sense of self and autonomy, interpersonal relationships (family, romantic and friends) and decision making regarding the future [107]. Indeed, it has been argued that adolescents and young adults are not a “homogeneous entity” [108] thus they might differ from each other in terms of HRQoL concerns—for adolescents, independence from parents, peer relationships and educational achievement might be more pertinent while young adults might be more con- cerned with career choices, financial independence and establishing intimate relationships in view of starting a family. The challenges presented during this period of sig- nificant developmental transition are exacerbated by a diag- nosis of cancer. Thus, HRQoL measurement during this developmental phase needs to be sensitive to these unique challenges. This review is also limited in terms of its descriptive synthesis of the data. Body image In addition, this review revealed that not all consequences of a cancer diagnosis and treat- ment are viewed by AYAs as negative with descriptions of greater maturity, becoming a better person, positive effects of missing school, increased family time and improved relationships with others reported (e.g. [34, 50]). Further avenues for research could include a more detailed analysis of the prevalence of the HRQoL issues amongst AYAs with cancer using a more conservative age definition such as 14–25 years. In addition, comparisons with the cancer experiences of other age groups would also merit further study in order to help identify and address the unique needs of AYAs. Conclusion One of the main limitations of this review is that the HRQoL concerns of AYAs presented in this paper are con- fined to the content of questions asked of patients. With a limited number of interview-based studies giving AYAs the opportunity to rate aspects of their cancer or treat- ment not covered by the questionnaires, it is likely that this review might have missed important issues. The studies reviewed were mostly cross-sectional and included only To the best of our knowledge, this review represents the first attempt to systematically review studies and the PROMS they have used to capture HRQoL issues as described by AYAs undergoing treatment for cancer. From this review, we have provided a comprehensive list of HRQoL issues for this age group which might be of value to clinicians in providing insight into the complexities of 1 3 3 Qual Life Res 1960–2002. 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https://openalex.org/W2334619618	https://zenodo.org/records/1717313/files/article.pdf	English	null	Zur römischen Datierung. By A. H. Salonius. Pp. 3 + 56. Suomalaisen Tiedeakatemian Toimituksia, Sarja B. Nid XV. N. 0 10 (Annales Academiae Scientiarum Fennicae, Ser. B. Tom. XV. N. 0 10). Helsingfors, 1922.	Classical review	1,922	public-domain	1,358	The Classical Review http://journals.cambridge.org/CAR The Classical Review http://journals.cambridge.org/CAR Additional services for The Classical Review: Additional services for The Classical Review: Email alerts: Click here Subscriptions: Click here Commercial reprints: Click here Terms of use : Click here Email alerts: Click here Subscriptions: Click here Commercial reprints: Click here Terms of use : Click here Zur römischen Datierung. By A. H. Salonius. Pp. 3 + 56. Suomalaisen Tiedeakatemian Toimituksia, Sarja B. Nid XV. N. 0 10 (Annales Academiae Scientiarum Fennicae, Ser. B. Tom. XV. N. 0 10). Helsingfors, 1922. J. K. Fotheringham The Classical Review / Volume 36 / Issue 7-8 / November 1922, pp 190 - 190 DOI: 10.1017/S0009840X00017364, Published online: 27 October 2009 Link to this article: http://journals.cambridge.org/abstract_S0009840X00017364 THE CLASSICAL REVIEW The slave in Homer might be a gentleman—here a Victorian phrase must be excused—as much as his master. Homer marshalls his contingents not as Hel- lenes and barbarians, but as Achaeans and Trojans. They live, indeed, in a world of inter- national conflict, which is far removed from the golden age of Hesiod, to which the later Hel- lenes look back with regret. Only when foreign worships promised happiness to come could the ideal of peace be formulated in Greece. The Hellenic spirit was cramped by nationalism. To the average man, mystical, that is, inter- national, religion alone offered release. It is the crowning distinction of Homer that without these consolations of religion he could pourtray man with an impartiality which is nearly divine. For him a tomb, even on Trojan soil, was of a mortal long since dead; a stone was a monu- ment set up in ihe times of former men. Aristotle protected himself against his own conclusions by saying that a man who could rise above nationalism was more than mortal, just as one who falls short of nationalism is less than human. Homer found his true successor in the Mace- donian monarch. But the intervening age was in the main incapable of their attitude towards international relations. I note that Dr. Krumbacher accepts the statement, for which our texts and not the MSS. of Quintilian (XI. 3. 55) are responsible, that the Greek term for a tremolo was ^payxps. Now the normal meaning of this word is 'hoarseness,' which has no connexion with a tremolo. Further, the best MSS. read ppa/xov. It would seem probable that the word con- cealed by this reading is /fyaoyioy, a term used in Greek medicine in the sense of' shivering,' and therefore readily applicable to the tremolo. able to the tremolo H. E. BUTLER. Zur rdmischtn Datierung. By A. H. SALONIUS. Pp- 3 + 56- Suomalaisen Tiedeakatemian Toimituksia, Sarja B. Nid XV. N. o 10 (Annales Academiae Scientiarum Fennicae, Ser. B. Tom. XV. N. o 10). Helsingfors, 1922. THIS is a valuable piece of work. The author confines himself to the actual phraseology by which days of the month were expressed in Latin, carefully collects and discriminates the different usages, and discusses their etymology and grammatical construction. It is for gram- marians to criticise Mr. THE CLASSICAL REVIEW THE CLASSICAL REVIEW i go calendar. Every future treatise on that subject ought to contain the substance of this paper. J. K. FOTHERINGHAM. summary of all that is known to us of the methods of voice-training employed by the ancient rhetoricians. It is little more than a summary, but the facts have been carefully cor- rected and clearly stated, and his work should be of real value to the small, but devoted, band of those who have dedicated themselves heroically to the exploration of the somewhat arid regions of Greek and Latin rhetoric. An index would have improved this excellent little handbook. summary of all that is known to us of the methods of voice-training employed by the ancient rhetoricians. It is little more than a summary, but the facts have been carefully cor- rected and clearly stated, and his work should be of real value to the small, but devoted, band of those who have dedicated themselves heroically to the exploration of the somewhat arid regions of Greek and Latin rhetoric. An index would have improved this excellent little handbook. Hellenic Conceptions of Peace. By WALLACE E. CALDWELL. One vol. Octavo. Pp. 140. New York: Longmans, Green and Co., 1919. 5s. 5s. DR. CALDWELL has rather collected the his- torical materials from which the Hellenic con- ceptions of peace might be deduced than carried out his announced programme. In successive chapters upon the epic age, the early period of the city-state, the Persian wars, the age of Pericles, the Peloponnesian war, the fourth century, he has enumerated the conditions which alternately made for peace and war, but no general concepts emerge. There are obvious causes which made such concepts exceedingly difficult. The distinctions between Hellenes and barbarians on the one hand, and Hellenes and slaves on the other, were so vividly felt that even Aristotle treated the distinction between freeman and slave as founded upon human nature. The furthest the Hellenic mind could reach towards peace was a war against the out- side world, in which internal disputes should be swallowed up. Alexander's attempt, there- fore, to bring in Egypt and Babylon on an equality with the Greeks was of more importance for the development of the idea of peace than all the details which Dr. Caldwell gathers together. If Alexander was not a Hellene, then Homer was one just as little. How to cite this article: How to cite this article: J. K. Fotheringham (1922). The Classical Review, 36, pp 190-190 doi:10.1017/ S0009840X00017364 J. K. Fotheringham (1922). The Classical Review, 36, pp 190-190 doi:10.1017/ S0009840X00017364 Request Permissions : Click here Request Permissions : Click here Downloaded from http://journals.cambridge.org/CAR, IP address: 134.176.129.147 on 17 Mar 2015 La Langue Gauloise. G. DOTTIN. Paris: Librairie C. Klincksieck, 1920. THIS work contains an account by a highly competent authority of practically all that is known of the Gaulish language. All the sur- THE CLASSICAL REVIEW Salonius, if they dare; but his conclusions should be of value to pro- fessed students of chronology, to students of epigraphy in dating and sometimes in restoring inscriptions, to editors of texts in which such dates occur, and to students of history in the few cases where there has been room for doubt in the interpretation of a Roman date. In the author's opinion kalendae is a verbal noun, to be compared as a feminine plural with feriae, nuptiae, nundifiae, and induiiae. He derives it from the obsolete verb calare, but believes that its form was influenced by calere. He does not profess to be able to give the etymology of idus. He treats ante diem tertium Kalendas as analogous to the adverbial phrase ante diem tertium, except that the preposition has acquired a double character. A most interesting part of this treatise is the discussion of the two methods of dating used by Cicero, a. d. V. Kal. Ian. and V. Kal. Ian., the latter being apparently declinable. Your reviewer, accustomed to the MSS. of another writer, marvels at the author's success in work- ing back through the MS. tradition to a clearly marked and statistically demonstrable change in practice, and still more at the author's suc- cess in distinguishing in several ancient writers the cases of numerals used in dates. But it cannot be denied that Mr. Salonius's treatment carries conviction. FRANK GRANGER. La Langue Gauloise. G. DOTTIN. Paris: Librairie C. Klincksieck, 1920. THIS work contains an account by a highly competent authority of practically all that is known of the Gaulish language. All the sur- La Langue Gauloise. G. DOTTIN. Paris: Librairie C. Klincksieck, 1920. THIS work contains an account by a highly competent authority of practically all that is known of the Gaulish language. All the sur- La Langue Gauloise. G. DOTTIN. Paris: Librairie C. Klincksieck, 1920. Librairie C. Klincksieck, 1920. THIS work contains an account by a highly competent authority of practically all that is known of the Gaulish language. All the sur- It is to be hoped that the fact that this work appeared in Finland will not lead to its being overlooked by future writers on the Roman
https://openalex.org/W2605700245	https://europepmc.org/articles/pmc5391114?pdf=render	English	null	Blindness enhances auditory obstacle circumvention: Assessing echolocation, sensory substitution, and visual-based navigation	PloS one	2,017	cc-by	14,003	Editor: Krish Sathian, Emory University, UNITED STATES Received: November 25, 2016 Accepted: March 30, 2017 Published: April 13, 2017 Received: November 25, 2016 Accepted: March 30, 2017 Published: April 13, 2017 Copyright: © 2017 Kolarik et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Copyright: © 2017 Kolarik et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: This research was supported by the Vision and Eye Research Unit, Postgraduate Medical Institute at Anglia Ruskin University (awarded to SP), and the Medical Research Council (awarded to BCJM, Grant number G0701870), http://www.anglia.ac.uk/postgraduate-medical- institute/groups/visionand-eyeresearch-unit; http:// www.mrc.ac.uk. The funders had no role in study Blindness enhances auditory obstacle circumvention: Assessing echolocation, sensory substitution, and visual-based navigation Andrew J. Kolarik1,2,3, Amy C. Scarfe1,4, Brian C. J. Moore2, Shahina Pardhan1 1 Vision and Eye Research Unit (VERU), Postgraduate Medical Institute, Anglia Ruskin University, Cambridge, United Kingdom, 2 Department of Psychology, University of Cambridge, Cambridge, United Kingdom, 3 Centre for the Study of the Senses, Institute of Philosophy, University of London, London, United Kingdom, 4 Department of Clinical Engineering, Medical Imaging and Medical Physics Directorate, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 ak771@cam.ac.uk * ak771@cam.ac.uk RESEARCH ARTICLE Abstract Performance for an obstacle circumvention task was assessed under conditions of visual, auditory only (using echolocation) and tactile (using a sensory substitution device, SSD) guidance. A Vicon motion capture system was used to measure human movement kinemat- ics objectively. Ten normally sighted participants, 8 blind non-echolocators, and 1 blind expert echolocator navigated around a 0.6 x 2 m obstacle that was varied in position across trials, at the midline of the participant or 25 cm to the right or left. Although visual guidance was the most effective, participants successfully circumvented the obstacle in the majority of trials under auditory or SSD guidance. Using audition, blind non-echolocators navigated more effectively than blindfolded sighted individuals with fewer collisions, lower movement times, fewer velocity corrections and greater obstacle detection ranges. The blind expert echolocator displayed performance similar to or better than that for the other groups using audition, but was comparable to that for the other groups using the SSD. The generally better performance of blind than of sighted participants is consistent with the perceptual enhancement hypothesis that individuals with severe visual deficits develop improved audi- tory abilities to compensate for visual loss, here shown by faster, more fluid, and more accu- rate navigation around obstacles using sound. Citation: Kolarik AJ, Scarfe AC, Moore BCJ, Pardhan S (2017) Blindness enhances auditory obstacle circumvention: Assessing echolocation, sensory substitution, and visual-based navigation. PLoS ONE 12(4): e0175750. https://doi.org/ 10.1371/journal.pone.0175750 Editor: Krish Sathian, Emory University, UNITED STATES Citation: Kolarik AJ, Scarfe AC, Moore BCJ, Pardhan S (2017) Blindness enhances auditory obstacle circumvention: Assessing echolocation, sensory substitution, and visual-based navigation. PLoS ONE 12(4): e0175750. https://doi.org/ 10.1371/journal.pone.0175750 Blindness enhances auditory obstacle circumvention [4–9]. In the current study, we used an obstacle circumvention task to assess and compare nav- igation by sighted participants under three experimental conditions: auditory guidance using echolocation; a tactile SSD; and full vision. We also tested obstacle circumvention with early- onset blind participants, using auditory or SSD guidance. design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. According to the perceptual deficiency hypothesis, without vision to aid in calibrating audi- tion, auditory spatial abilities may be worse for blind than for sighted individuals [10, 11]. Alternatively, blind individuals may have enhanced auditory spatial abilities as a result of extensive experience and reliance on auditory information [12], and because compensatory processes, such as cortical reorganization, may have enhanced auditory spatial performance in certain conditions [13]. Both views have received support in previous studies [3, 14–17], for a review, see [18] and one of the aims of the current work was to test whether blindness results in perceptual deficiency or enhancement when navigating around an obstacle using sound. Some blind people are able to use echolocation, by generating click-like sounds and listening to the returning echoes, which provide information about the spatial layout of the environ- ment [19, 20]. Sighted people can also be trained to echolocate [21–23], and self-generated sound can guide locomotion when vision is absent (see [24] for a review). Wallmeier and Wie- grebe [25] reported that sighted and blind individuals could echolocate to accurately adjust the orientation of the body, and move towards a chosen direction. Furthermore, expertise gained by blind echolocators can lead to excellent spatial abilities in order to guide locomotion. Tha- ler, et al. [26] tested two blind expert echolocators who used clicks to explore cities, and also for hiking, mountain biking and playing basketball. McCarty and Worchel [27] described a blind echolocator who used clicks to avoid obstacles when riding a bicycle. Fiehler, et al. [28] found that blind expert echolocators were better able than blind and sighted non-echolocators to use echolocation clicks, previously recorded when walking along a corridor, to identify whether the corridor’s direction was straight ahead, leftwards or rightwards. Teng, et al. Introduction For those who have lost their sight, information regarding the position of silent obstacles might be obtained using echoes from self-generated sounds, or using electronic sensory substi- tution device (SSD) travel aids, which provide information about the surrounding space by means of an intact modality, such as audition or touch [1]. Blind people are generally more sensitive to echoes than sighted people [2, 3], and often have improved echolocation abilities http://www.anglia.ac.uk/postgraduate-medical- institute/groups/visionand-eyeresearch-unit; http:// www.mrc.ac.uk. The funders had no role in study PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 1 / 25 PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 [19] found that blind expert echolocators achieved a relatively high degree of precision when deter- mining the location of objects, which was similar to that found in the visual periphery of sighted individuals. Overall, these results suggest superior echolocation acuity for blind echolocators, which may lead to superior navigation using sound. However, echolocation abilities within the blind population demonstrate substantial individual variability. While some studies show that good echoic auditory abilities are associated with blindness even without extensive training [2, 3, 6], other studies have suggested that it is echolocation expertise rather than blindness that drives performance, as blind non-echolocators performed similarly to sighted participants and per- formed more poorly than blind expert echolocators in various tasks including using sound echoes to determine 2-D shape [29], using echolocation to correctly identify physical size inde- pendently of distance (size constancy) [30], and in auditory spatial bisection tasks [31]. In the current study, obstacle circumvention performance for a group of blind non-echolocators was compared to performance for a normally sighted group, and a single blind expert echolocator. Previous work utilizing a classical obstacle approach and detection task has shown that sound can guide locomotion in both blind people [32–34] as well as blindfolded sighted people [32, 35–37]. In these studies, participants reported when they first detected a large obstacle (such as a wall) in their path. They then approached as close as they could while avoiding colli- sion, and stopped in front of the obstacle. Relatively few collisions were made, and blind par- ticipants generally performed better than blindfolded sighted participants. In general, blind participants detected obstacles at a similar or increased range compared to sighted controls and made fewer collisions [32]. Kolarik, et al. [24] assessed obstacle circumvention perfor- mance in blindfolded sighted people using self-generated clicks, and showed that participants could successfully navigate around the obstacle on 67% of the trials. However, movement PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 2 / 25 Blindness enhances auditory obstacle circumvention times, velocity corrections, and buffer space (clearance between the shoulder and the obstacle) were greater than when participants navigated using vision. In addition, under visual guidance participants passed the obstacle on the side affording most space, but they were not able to do this using echolocation. However, performance for blind participants performing a similar obstacle circumvention task has not yet been investigated. This was the main aim of the cur- rent study. Another form of locomotor guidance for use by participants without vision is offered by SSDs. Some, referred to in the current paper as “echoic SSDs,” use ultrasound echoes to detect objects and then provide a tactile or auditory cue regarding the distance of the object. Other “visual pattern SSDs” transform visual signals into sound or tactile information [38]. For early-onset blind participants, an echoic SSD improved judgements of obstacle direction and distance [39]. Blind and blindfolded sighted participants have also been shown to use a visual pattern SSD named the tongue display unit (TDU) to negotiate an obstacle course [40], and Kupers, et al. [41] showed that blind participants were more accurate than sighted participants in using the TDU in a virtual route recognition task. Hughes [42] showed that blindfolded nor- mally sighted participants were able to use an echoic SSD to judge the passability of narrow apertures, and Kolarik, et al. [43] found that blindfolded sighted participants navigating under echoic SSD guidance made appropriate shoulder rotations to allow them to pass through nar- row apertures safely. Kolarik, et al. [44] also investigated obstacle circumvention by blind- folded sighted participants using an echoic SSD, and showed that movement times, velocity corrections, and buffer space were greater than when participants navigated using full vision, and that participants generally passed the obstacle on the side affording most space. However, the effects of blindness on obstacle circumvention kinematics under SSD guidance have not previously been investigated, and were examined in the current study. Rosenblum, et al. [45] pointed out that relatively few studies have directly compared behav- iorally relevant performance across modalities, to determine if different senses can guide behavior in a comparable manner. Obstacle circumvention may be particularly behaviorally relevant, as detecting and walking around an obstacle in the path of travel is one of the most commonly encountered tasks of everyday locomotion [46, 47]. Furthermore, the task extends the classic obstacle approach and detection task described above, requiring sound or tactile input to be used not only to estimate the distance of an obstacle, but also to accurately perceive the location of the edges and navigate around the obstacle without collision. The current study is the first that we are aware of to formally assess kinematic indices for blind non-echolocators and a blind expert echolocator using echolocation or an SSD during obstacle circumvention. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 The kinematic indices measured included buffer space, movement times, and number of velocity corrections. Increased buffer space is indicative of increased caution by allowing a greater margin between the body and obstacle, at the cost of expending greater energy. Move- ment time provides practical information regarding how long is needed to determine the size and location of an obstacle. The number of velocity corrections provides information about how fluid the movement is under different forms of sensory guidance, as frequently stopping and starting would increase energy consumption and reduce efficiency. These measures pro- vide an indication of how practical sound echoes are compared to vision for navigation outside of the laboratory. As for previous studies [24, 44], locomotion with full vision in normally sighted participants provided a baseline for performance. Rosenblum, et al. [45] pointed out that relatively few studies have directly compared behav- iorally relevant performance across modalities, to determine if different senses can guide behavior in a comparable manner. Obstacle circumvention may be particularly behaviorally relevant, as detecting and walking around an obstacle in the path of travel is one of the most commonly encountered tasks of everyday locomotion [46, 47]. Furthermore, the task extends the classic obstacle approach and detection task described above, requiring sound or tactile input to be used not only to estimate the distance of an obstacle, but also to accurately perceive the location of the edges and navigate around the obstacle without collision. The current study is the first that we are aware of to formally assess kinematic indices for blind non-echolocators and a blind expert echolocator using echolocation or an SSD during obstacle circumvention. The current study extends previous work by Kolarik, et al., that investigated the kinematics of obstacle circumvention for blindfolded normally-sighted participants using echolocation [24] and SSD guidance [44], by using similar methods to investigate obstacle circumvention by blind non-echolocators and an expert blind echolocator. The findings are intended to increase our understanding of how blind individuals navigate in real-world environments, and PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 3 / 25 Blindness enhances auditory obstacle circumvention to objectively measure obstacle circumvention performance using auditory, tactile and visual guidance in sighted blindfolded participants, and using auditory and tactile guidance in blind non-echolocators, and a blind expert echolocator. In addition, a “no-click” auditory guidance control experiment was used to assess obstacle circumvention based on footfalls on the carpet or ambient sound, rather than self-generated clicks or SSD information, for sighted blind- folded participants, blind non-echolocators, and a blind expert echolocator [24]. The following hypotheses were tested: 1) If enhanced abilities to use sound echoes following blindness [2, 3] can be used to improve navigation, and blindness is the primary factor that drives the ability to use auditory cues for navigation, then blind non-echolocators should show better locomotion performance than the sighted group under auditory guidance. This should result in fewer velocity corrections, shorter movement times, smaller buffer space and fewer impacts, consistent with the perceptual enhancement hypothesis; 2) On the other hand, if echolocation expertise [29–31] is the primary factor driving the ability to use auditory cues for navigation, then only the blind expert echolocator should show better locomotion perfor- mance under auditory guidance, and the blind non-echolocators should perform similarly to or even more poorly than the other groups, consistent with the perceptual deficiency hypothe- sis; 3) Navigation performance should be better under visual guidance than under auditory or SSD guidance. Methods The apparatus, data acquisition, and procedure (described below) were the same as used by Kolarik, et al. [24] for evaluating the kinematics of obstacle circumvention for sighted partici- pants using auditory guidance and full vision, and for sighted participants using SSD guidance and full vision [44]. These methods are applicable to both normally sighted and visually impaired participants. https://doi.org/10.1371/journal.pone.0175750.t001 Participants There were 19 participants, comprising a normally sighted group (n = 10, 5 females, mean age 37 yrs, range 22–59 yrs), a blind non-echolocator group (n = 8, 5 females, mean age 41 yrs, range 25–54 yrs, B1-8 in Table 1), and a blind expert echolocator (female, aged 20 yrs, BE in Table 1). Data for a number of sighted participants tested in previous work, in our laboratory under identical conditions, under auditory guidance (n = 7, [24]) or SSD guidance (n = 9, [44]) were included in the data for the current normally sighted group, and additional sighted participants were included in order to age-match this group with the blind non-echolocating group. For the “no-click” control experiment, all blind participants and 8 sighted participants Table 1. Details of blind participants. B1-8 were non-echolocators. BE was an expert echolocator. Age, age of onset of vision loss (yrs) Gender Cause of vision loss Visual status, WHO category B1 54, 5 F Macular degeneration Light perception, 4 B2 48, 5 M Stickler’s Syndrome, retinal detachment No light perception, 5 B3 54, 1.5 F Glaucoma No light perception, 5 B4 41, 1 F Retinoblastoma No light perception, 5 B5 26, 2 F Norrie disease Light perception, 4 B6 25, 3 M Retinoblastoma No light perception, 5 B7 42, birth F Retinopathy of prematurity No light perception, 5 B8 39, 1 M Retinoblastoma Light perception, 4 BE 20, 2.5 F Retinoblastoma No light perception, 5 htt //d i /10 1371/j l 0175750 t001 Table 1. Details of blind participants. B1-8 were non-echolocators. BE was an expert echolocator. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 4 / 25 Blindness enhances auditory obstacle circumvention took part (3 females, mean age 37 yrs, range 29–52 yrs, 4 of whom took part in the main exper- iment). All blind participants were either totally blind or had some light perception only, and fell into categories 4–5 of the World Health Organization classification [48]. All were early- onset blind, defined here as having lost their sight between birth and 5 yrs of age (Table 1). The sighted participants all reported normal or corrected-to-normal vision. All participants had normal hearing. Their pure tone thresholds were less than or equal to 25 dB HL for all audiometric frequencies up to 8 kHz, measured with an Interacoustics AS608 audiometer using methods described by the British Society of Audiology [49]. Apparatus and data acquisition The experiments took place in a quiet room (ambient sound level of approximately 36 dBA) measuring 5.7 × 3.5 m, height 2.8 m. The room had a tiled ceiling and painted walls, and a car- pet covered the floor. The obstacles used for testing were rectangular, movable, flat, and made of wood. Smooth reflective aluminum foil was used to cover the obstacles to achieve high reflectivity, as used by Arnott, et al. [50]. However, the reflective foil also produced near-specu- lar sound reflections, which may have made the obstacle harder to accurately locate than would be the case for a wood surface. For static training, a practice small obstacle, width 0.5 m × height 0.34 m, with a thickness of 2 cm was utilized. For dynamic training and testing, a large obstacle mounted on castors was utilized, width 0.6 m × height 2 m, with a thickness of 0.6 cm, with a small plastic frame at the bottom on the side of the obstacle not facing the partic- ipant. The obstacle was placed near the middle of the room, to prevent SSD reflections from surfaces apart from the obstacle used in the experiment. Fig 1 shows the layout of the experi- mental set up. The SSD, the Miniguide [51], provided spatial information via a tactile signal, so that if an obstacle was present the aid transmitted vibrations to the hand that held the device. The SSD vibrated at a rate that was proportional to the distance between the obstacle and the SSD. The operable range of the device was set to 1 m, and participants held the device in their dominant hand perpendicular to the body with the device pointed straight ahead, while tucking their elbow against their side, as reported in Kolarik, et al. [43]. Trials in which the SSD or a part of the body of the participant collided with the obstacle were noted by the experimenter, and these were not used in the final analyses of the kinematic indices. The side (on the right or left of the obstacle) used by the participant to avoid the obsta- cle was also noted by the experimenter. As described in detail previously [24, 44], an 8-camera motion capture system (Vicon Bonita; Oxford Metrics) was used to collect three-dimensional kinematic data at a rate of 50-Hz. Participants None of the normally sighted or blind non-echolocators had received prior echolocation training to perceive objects or to navigate in their daily lives. The BE echolocator used echolocation in daily life, and had received training at a formal course teaching echolocation skills. None of the participants had any previous experience using tactile echoic SSDs. All participants were right handed except for BE and one sighted participant. All participants gave written informed consent following an explanation of the nature and any possible consequences of taking part in the experiments. The study was approved by the Anglia Ruskin University Ethics committee, and the experi- ments followed the tenets of the Declaration of Helsinki. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Apparatus and data acquisition Retro-reflective, spherical markers were placed bilaterally at the following locations on the participant’s body: the posterior aspect of the calcanei, the acro- mio-clavicular joint, the most distal, superior aspect of the 1st toe, the most distal, superior aspect of the 5th toe, and antero-lateral and postero-lateral aspects of the head. Single markers were attached on the sternum and the posterior aspect of the dominant hand. Three markers were attached to the front of the obstacle, to define the obstacle location and width in the coor- dinate system of the laboratory. Kinematic data were processed using Vicon Nexus (Oxford PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 5 / 25 Blindness enhances auditory obstacle circumvention Fig 1. Experimental layout. The obstacle was 0.6-m wide, located directly ahead of the participant on the midline (shaded bar), or ±25 cm leftwards or rightwards (bars marked by dashed lines). Two approach distances were used (1.5 and 2 m). https://doi.org/10.1371/journal.pone.0175750.g001 Fig 1. Experimental layout. The obstacle was 0.6-m wide, located directly ahead of the participant on the midline (shaded bar), or ±25 cm leftwards or rightwards (bars marked by dashed lines). Two approach distances were used (1.5 and 2 m). https://doi.org/10.1371/journal.pone.0175750.g001 https://doi.org/10.1371/journal.pone.0175750.g001 Metrics) and the cross-validatory quintic spline smoothing routine was used to filter the marker trajectory data. ‘Smoothing’ options were set at a predicted mean squared error value of 10. Custom written Visual Basic scripts were used to evaluate key variables involving obsta- cle circumvention, or the experimenter recorded these (see Table 2). When the participant accelerated or decelerated in the anterior/posterior direction, a velocity correction was Table 2. Dependent variables. These were also described in detail in previous studies of obstacle circum- vention [24, 44]. Variable Obstacle-present trials Buffer space The medio-lateral distance between the obstacle marker and the shoulder marker at the point of passing the obstacle marker (determined as the point where the shoulder marker passed the marker attached to the front aspect of the obstacle). Movement time Time to complete the movement, measured from when the obstacle marker was 1 m distant from the sternum marker in the anterior-posterior direction, until the obstacle marker was passed. Velocity corrections Number of changes in forward velocity (changes from acceleration to deceleration or vice versa), measured from when the obstacle marker was 1 m from the sternum marker until the point of passing the obstacle marker. For additional information, see main text. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Procedures All participants took part in the auditory guidance and SSD conditions (order randomized and counterbalanced across participants). For normally sighted participants, the visual guidance condition was performed last [24, 43], so that participants did not become familiar with the dif- ferent obstacle placements. Except in the visual guidance condition, all participants wore close- fitting blindfolds, for consistency across participants and to prevent use of residual light percep- tion by some of the blind non-echolocator group (BE had no residual light perception). Participants received static and dynamic training at the start of the auditory guidance con- dition. This has previously been shown to allow sighted participants to become sufficiently familiar with echolocation to navigate around an obstacle without collision in the majority of trials [24]. It allowed participants to practice producing mouth clicks and to listen to them dur- ing locomotion. For the static training, participants sat in the middle of the room with the small obstacle positioned on a table directly in front of them 25 cm away and at head height. Participants made mouth clicks to detect the presence of the obstacle, which was randomly present or absent. Feedback was provided. The duration of the static auditory training was at least 15 minutes. For the first 5 minutes the sighted participants were instructed to keep their eyes open, for the next 5 minutes they were instructed to attempt the task with eyes closed, and for the last 5 minutes they wore a blindfold. Blind participants were blindfolded for the last five minutes. For sighted participants, visual feedback was allowed in the first two stages, fol- lowing previous work [24] and pilot testing indicating that this group often showed initial dif- ficulties associating the echoes with the presence or absence of the obstacle, whereas blind participants did not report any difficulties. All participants reported that they felt that they were able to hear the changes in echoes sufficiently following static training to move onto the next phase of training. In the dynamic auditory training phase, participants practiced moving around the large obstacle, using mouth clicks to perceive its location. The approach distance was 1.75 m, and training lasted for at least 15 minutes. Apparatus and data acquisition Obstacle detections Auditory guidance trials when the participant raised their hand marker to indicate obstacle perception, recorded by the experimenter. Obstacle detection range The anterior-posterior distance between the obstacle marker and the participant’s sternum marker. This was measured at the time when the participant raised their hand marker, indicating perception of the obstacle. Collisions Trials where a collision occurred between any part of the participant’s body or the SSD and the obstacle, recorded by the experimenter. Side of obstacle avoidance The experimenter recorded the side of avoidance of the obstacle (passing the obstacle on the left or right). False perceptions on obstacle- absent trials The number of obstacle-absent auditory guidance trials in which the participant raised their hand marker, incorrectly indicating perception of the obstacle. htt //d i /10 1371/j l 0175750 t002 6 / 25 PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Blindness enhances auditory obstacle circumvention recorded. This was required to last for 50 frames (1 second) to avoid including very small velocity fluctuations. Slowing down and speeding up, and stopping and starting were all recorded as velocity corrections. To be counted as a velocity correction, a change in trajectory was required to involve a forward acceleration or deceleration. A side step without slowing down in the anterior/posterior direction was not counted. If participants stopped, side stepped and then moved forward, this was recorded as two velocity corrections (the first for decelerat- ing prior to side stepping, and the second for accelerating after side stepping). PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Blindness enhances auditory obstacle circumvention performance was 84% (SD = 12%) for the sighted group, 97% (SD = 6%) for the blind non- echolocators, and 100% for BE. All participants scored 70% or higher. In the auditory testing phase, participants were instructed that they would wear a blindfold, should walk straight forward while making mouth clicks, and should report if they perceived the large obstacle to be present. They were instructed to move in a straight line until first per- ceiving the obstacle, to indicate this by raising their dominant hand, as used for the obstacle approach and detection task in previous work [32, 37], and then to circumnavigate the obstacle without touching it. Participants were instructed not to use their hands to touch the obstacle, and they were told that the obstacle would be absent in some trials. When the participant had moved past the obstacle or if the participant touched or collided with the obstacle, the trial was terminated. The obstacle was positioned randomly either on the midline, or 25 cm rightwards or leftwards. The approach distance was either 1.5 or 2 m (randomized). The approach dis- tances were less than previously tested for visual obstacle circumvention e.g. 5 m [46, 47], but not for auditory [24] or SSD-guided [44] obstacle circumvention tasks. Pilot data indicated that participants generally stood stationary a short distance before the obstacle, and scanned it using audition (or the SSD in the SSD guidance condition), as was observed in a previous study for participants moving through apertures using an SSD [43]. Three trials were performed for each obstacle position. In total, 24 trials were completed, including six no-obstacle ‘catch’ trials [33, 34, 52]. Ear-defender headphones were used to occlude participants’ ears between each trial. The experimenter signaled the start of the trial by tapping on the participant’s shoulder. In the SSD condition, participants performed an SSD dynamic training phase followed by an SSD testing phase. The SSD training phase was similar to the auditory guidance training, except that practice with the small obstacle and static detection of the large obstacle were not included, as in this condition participants did not need to become familiar with producing sounds and the device always allowed them to detect the obstacle if it was present. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Procedures As for static training, for the first 5 minutes the sighted participants were allowed to keep their eyes open, followed by five minutes in which they were encouraged to close their eyes, and for the last five minutes they were blindfolded. Blind partici- pants wore a blindfold for the last five minutes. The obstacle center was placed on the midline directly straight ahead of the participant for the first 10 minutes. During the last 5 minutes of training, when the participants were blindfolded, the obstacle’s location was varied randomly relative to the participant: at the midline or 25 cm to the right or left. After training, all partici- pants reported that they were sufficiently familiar with hearing the changes in echoes to circum- vent an obstacle. To test whether participants were able to detect obstacles using echolocation prior to the auditory testing phase, blindfolded participants stood 25 cm from and facing the position where the large obstacle might be placed, made mouth clicks, and were asked to report whether they perceived the obstacle to be present or absent for twenty trials. For half of the trials the obstacle was present, and for the other half it was removed (randomized). Mean detection PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 7 / 25 Statistical analyses To compare the performance of the sighted and the blind non-echolocator groups, unless oth- erwise specified, repeated-measures analyses of variance (ANOVAs) were utilized to analyze how movement time, buffer space, side of obstacle avoidance (right or left), and number of velocity corrections were influenced by visual status (sighted or blind non-echolocators, a between-subjects factor), guidance condition (audition, SSD and vision), and repetition (one, two and three) (within-subjects factors). The significance level was p<0.05. Following prelimi- nary analyses showing that scores for all measures did not vary significantly (p>0.05) with obstacle lateral location or distance, the results for the three locations (with the exception of the side of obstacle avoidance analysis) and two distances were pooled. Prior to analysis, pro- portional data for side of avoidance were subjected to arcsine transformation [54]. Bonferroni correction was used for post hoc analyses. Data from trials where collisions with the obstacle occurred were not used in the final analy- ses of the kinematic indices. It is possible that a difference across groups in the numbers of tri- als with collisions might have affected the results for the other parameters. However we believe that any such effect is likely to be small, since there were 18 trials for each condition where col- lisions might have occurred and the obstacle was passed without collision in the majority of those trials for each group. Thus, it is likely that sufficient trials were included in the analyses to avoid potential biases. The performance of BE was compared to that of the sighted and the blind non-echolocator groups using t-tests as modified by Crawford et al. [55, 56], and as described by Vercillo, et al. [31]. The modified t-tests tested the hypothesis that scores for BE did not originate from scores from a comparison population. The null hypothesis was that the score for a given measure for BE came from a distribution that had the same mean and variance as for the comparison group [55, 56]. In this way, scores for the comparison sample were treated as statistics instead of popu- lation parameters. If the value of t obtained from the test was below the negative one-tailed 5% critical value, then the null hypothesis was rejected and it was concluded that BE’s score was not an observation from the population of scores for the comparison group. In previous experiments that assessed the use of an echoic SSD for aperture navigation, training with the device lasted approximately 5 minutes [42, 53]. To provide greater training with the SSD than provided in these experiments, participants practiced circumventing the large obstacle using the SSD from an approach distance of 1.75 m, for at least 15 minutes. Following dynamic SSD training, participants performed the SSD testing phase. This was similar to the auditory guid- ance testing phase, except that participants used the SSD for obstacle circumvention instead of producing mouth clicks and wore ear-defender headphones during the trials, as reported by Kolarik et al. [44], to avoid sound from footfalls on the carpet or ambient auditory information being audible. Normally sighted participants performed a visual guidance condition similar to that tested by Hackney, et al. [46]. The visual guidance condition was the same as the testing phase of the other conditions, except that the SSD was not used and mouth clicks were not produced. Ear- defender headphones were worn, and participants were blindfolded between trials only. At the start of each trial for the auditory and SSD dynamic training and testing phases, a removable plastic box was used so that participants could align their feet facing forward along the edge of the box. The experimenter always took participants back to the starting point at the end of each trial, and they placed themselves in the same place to the right of the starting point against the wall throughout the trial. Except when required to make mouth clicks, the experi- menter and participant were silent throughout testing. The participants did not receive feed- back during the testing phases. Data were obtained in a single session lasting approximately 2.5 hours (including breaks) for the blind participants, and 3 hours for the sighted participants (the duration was longer as they also performed the visual guidance condition). PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 8 / 25 Blindness enhances auditory obstacle circumvention For the “no-click” control experiment, participants did not produce mouth clicks, and com- pleted seven trials (one for each obstacle position and one with the obstacle absent). Otherwise the procedure was identical to that for the testing phase of the auditory-guidance condition of the main experiment. Data were collected in a single session lasting approximately 20 minutes. Statistical analyses One-tailed tests were used as it was hypothesized that BE would perform better than the other participant groups. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Blindness enhances auditory obstacle circumvention Table 3. Summary of obstacle detection, collision and false reports. The percentage of obstacle-present trials is reported in which the obstacle was detected, or for which collisions did not occur. The percentage of false reports of the obstacle being present for obstacle-absent trials is also reported. Perfor- mance under auditory guidance, SSD guidance, and for the “no-click” control experiment is reported. Under visual guidance, the obstacle was always detected, no collisions occurred, and there were no false reports. p Normally sighted (mean, SD) Blind non-echolocators (mean, SD) BE (mean) % of trials in which the obstacle was detected Auditory guidance 75 (18) 96 (4) 100 SSD 100 (0) 100 (0) 100 “no-click” control experiment 21 (31) 81 (21) 83 % of trials where collision did not occur Auditory guidance 58 (21) 88 (7) 94 SSD 93 (8) 90 (15) 83 “no-click” control experiment 11 (23) 69 (19) 50 % of false reports of obstacle being present Auditory guidance 17 (22) 27 (23) 0 SSD 0 (0) 0 (0) 0 “no-click” control experiment 0 (0) 25 (46) 0 https://doi.org/10.1371/journal.pone.0175750.t003 of trials for BE. Under SSD guidance when the obstacle was present there were no collisions of trials for BE. Under SSD guidance when the obstacle was present there were no collisions on 93% of trials for the normally sighted participants, 90% of trials for the blind non-echoloca- tors, and 83% of trials for BE. As expected, there were no collisions when navigating using full vision. In the auditory guidance condition, the percentage of false reports of the obstacle being present were 17% for the normally sighted group, 27% for the blind non-echolocators, and 0% for BE. Sighted participants collided with the obstacle significantly more than the blind non- echolocators under auditory guidance [χ2 (1) = 34.02, p = 0.001], but not under SSD guidance [χ2 (1) = 1.47, ns]. For the “no-click” control experiment, the percentages of trials on which the obstacle was detected were: sighted group, 21%; blind non-echolocators, 81%; BE, 83%. The percentages of trials on which the obstacle was circumvented without collision were: sighted group, 11%; blind non-echolocators, 69%; BE, 50%. False perceptions for obstacle-absent trials were: sighted, 0%; blind non-echolocators: 25%; BE: 0%. Obstacle detections and collisions For participant data, see S1 File. Under auditory guidance, five trials for the sighted group and three trials for the blind non-echolocators were discarded from the analyses, as the participants did not start the trial facing directly to the front. Table 3 summarizes the percentage of trials on which the obstacle was detected, trials where no collision occurred, and false reports, for auditory guidance, SSD guidance, and the “no- click” control experiment. In the main experiment, all groups detected the obstacle in the majority of trials. Under auditory guidance when the obstacle was present the obstacle was detected on 75% of trials for the normally sighted group, 96% of trials for the blind non-echo- locators, and 100% of trials for BE. Participants always detected the obstacle under SSD guid- ance. Under auditory guidance when the obstacle was present there were no collisions on 58% of trials for the normally sighted group, 88% of trials for the blind non-echolocators, and 94% PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 9 / 25 PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 These results show that although the blind participants were often able to detect and circumvent the obstacle without making mouth clicks, sighted par- ticipants often failed to detect the obstacle and almost always collided with it, and performance for all groups was lower than performance with mouth clicks. The results are consistent with the finding of Supa, et al. [32] that both blind and sighted participants showed lower perfor- mance on an obstacle approach and detection task when using sound from stockinged feet on a carpet runner than when using sound from shoes on a hardwood floor. Fig 2 shows trajectories for a representative participant from each group under auditory guidance (dotted line), SSD guidance (solid line) and visual guidance (dashed line). The obsta- cle’s lateral position was 25 cm to the left of the participant. For sighted participants (panel A) and blind non-echolocators (panel B), participants generally moved closer to the obstacle under auditory guidance than under SSD guidance before showing distinct deviations from moving straight ahead. However, the expert blind echolocator (panel C) generally moved closer to obstacle under SSD guidance than under auditory guidance before substantially deviating from the straight-ahead direction. This is consistent with the difference in operable range for detect- ing the obstacle across different guidance conditions, as participants only substantially deviated from the midline when the obstacle was within detectable range. The operating range of the SSD was set to 1 m, and participants under SSD guidance deviated substantially from straight ahead when the obstacle was within the operative range. Under auditory guidance, the mean PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 10 / 25 Blindness enhances auditory obstacle circumvention Fig 2. Representative participant trajectories under auditory guidance using echolocation (dotted line), SSD guidance (solid line) and visual guidance (dashed line) for a sighted participant (top left panel A), a blind non-echolocator (top right panel B), and the blind expert echolocator (BE, bottom left panel C). The obstacle is shown by the black rectangle. Data are shown for the left shoulder marker, for an approach distance of 1.5 m. The obstacle was placed 25 cm to the participant’s left. https://doi.org/10.1371/journal.pone.0175750.g002 Fig 2. Representative participant trajectories under auditory guidance using echolocation (dotted line), SSD guidance (solid line) and visual guidance (dashed line) for a sighted participant (top left panel A), a blind non-echolocator (top right panel B), and the blind expert echolocator (BE, bottom left panel C). The obstacle is shown by the black rectangle. Data are shown for the left shoulder marker, for an approach distance of 1.5 m. The obstacle was placed 25 cm to the participant’s left. https://doi.org/10.1371/journal.pone.0175750.g002 https://doi.org/10.1371/journal.pone.0175750.g002 echolocation detection range was less than 1 m for the sighted and blind non-echolocators, whereas the mean detection range of BE was greater than 1 m (see Echolocation detection range section below). Under visual guidance, participants deviated from straight ahead immediately when movement was initiated. In no-obstacle catch trials, participants moved approximately straight ahead in all conditions, showing that substantial deviation from the midline only occurred in the presence of an obstacle. Movement times Fig 3 shows the mean movement times required to circumvent the obstacle. Under auditory guidance, the times were shortest for BE, larger for the blind non-echolocating group, and largest for the sighted group. Under SSD guidance, the times were similar for all groups. As anticipated, movement times for the sighted group were shortest under visual guidance. For sighted partici- pants, the mean movement times were 23 s under auditory guidance, 9 s using the SSD, and 1.1 s using vision. For blind non-echolocators the corresponding times were 10 s under auditory guidance and 8 s under SSD guidance. For BE, the times were 4 s using auditory guidance, and 11 s under SSD guidance. The blind non-echolocators were significantly faster than the sighted PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 11 / 25 Blindness enhances auditory obstacle circumvention Fig 3. Mean movement time to circumvent the obstacle under auditory guidance (upper panel), SSD guidance (middle panel), or visual guidance (lower panel), for sighted participants (open bars), blind non-echolocators (grey bars), and BE (dashed bars). In this and subsequent figures, 0 indicates where there was no effect (e.g. zero collisions), N/A marks when the group did not participate, error bars represent ±1 standard error, and asterisks indicate significant differences, * <0.05, ** <0.01. The y axis is logarithmic. https://doi.org/10.1371/journal.pone.0175750.g003 Fig 3. Mean movement time to circumvent the obstacle under auditory guidance (upper panel), SSD guidance (middle panel), or visual guidance (lower panel), for sighted participants (open bars), blind non-echolocators (grey bars), and BE (dashed bars). In this and subsequent figures, 0 indicates where there was no effect (e.g. zero collisions), N/A marks when the group did not participate, error bars represent ±1 standard error, and asterisks indicate significant differences, * <0.05, ** <0.01. The y axis is logarithmic. https://doi.org/10.1371/journal.pone.0175750.g003 group under auditory guidance [F(1, 16) = 18.22, p = 0.001], but not SSD guidance [F(1, 16) = 0.20, ns]. There was no effect of repetition. Movement times for the sighted group under visual guidance were significantly faster than for the blind non-echolocators under auditory guidance [F(1, 16) = 38.56, p = 0.001] or SSD guidance [F(1, 16) = 41.03, p = 0.001]. Modified t-tests showed that under auditory guidance BE circumvented the obstacle in a significantly shorter time than the sighted participants (t = 2.21, p = 0.03) but not the blind non-echolocators (t = 1.23, ns). PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Movement times PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 12 / 25 Blindness enhances auditory obstacle circumvention PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Buffer space Fig 5 shows the mean buffer space for each condition and group. The buffer space was smallest under visual guidance. For sighted participants, mean buffer spaces were 41 cm using auditory guidance; 48 cm using the SSD; 22 cm for vision. For blind non-echolocators the mean buffer spaces were 41 cm using auditory guidance and 38 cm under SSD guidance. For BE, the mean buffer spaces were 43 cm under auditory guidance and 32 cm under SSD guidance. No signifi- cant differences were found for buffer space between blind non-echolocators and the sighted group under auditory guidance [F(1, 16) = 0.013, ns], or SSD guidance [F(1, 16) = 3.88, ns]. There was no effect of repetition. Buffer space for the sighted group under visual guidance was significantly smaller than for the blind non-echolocators under auditory guidance [F(1, 16) = 26.54, p = 0.001] or SSD guidance [F(1, 16) = 22.11, p = 0.001]. Modified t-tests showed that, on average under auditory guidance, buffer space was not significantly different for BE and the sighted participants (t = 0.16, ns) or the blind non-echolocators (t = 0.24, ns). Echolocation detection range Fig 6 shows that the echolocation obstacle detection range was greatest for BE and smallest for the sighted group, with performance for the blind non-echolocators falling between. Mean obstacle detection ranges were 45 cm for the sighted group; 85 cm for the blind non-echoloca- tors, and 122 cm for the BE echolocator. The detection range was significantly greater for the blind non-echolocators than for the sighted group [F(1, 16) = 14.4, p = 0.002]. There was a sig- nificant interaction between repetition and group [F(2, 32) = 8.93, p = 0.001]. However, post- hoc tests indicated that there were no significant differences across repetitions for either group. Modified t-tests showed that, on average, BE had a greater echolocation range than the sighted participants (t = 4.72, p = 0.001) but not the blind non-echolocators (t = 1.26, ns). Velocity corrections Fig 4 shows the mean number of velocity corrections for each group and condition. Under auditory guidance, the BE echolocator made the fewest velocity corrections and the sighted group made the most. Under SSD guidance, all groups made similar numbers of velocity cor- rections. Fewest velocity corrections were made under visual guidance. For sighted participants, Fig 4. Mean number of velocity corrections under auditory guidance (upper panel), SSD guidance (middle panel), and vision (lower panel), for sighted participants (open bars), blind non-echolocat (grey bars), and the BE echolocator (dashed bars). The y axis is logarithmic. https://doi.org/10.1371/journal.pone.0175750.g004 Fig 4. Mean number of velocity corrections under auditory guidance (upper panel), SSD guidance (middle panel), and vision (lower panel), for sighted participants (open bars), blind non-echolocators (grey bars), and the BE echolocator (dashed bars). The y axis is logarithmic. https://doi.org/10.1371/journal.pone.0175750.g004 PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 13 / 25 Blindness enhances auditory obstacle circumvention the mean velocity corrections were 50 using auditory guidance; 19 using the SSD; and 4 using vision. For blind non-echolocators, the mean velocity corrections were 26 using auditory guid- ance; and 25 under SSD guidance. For BE, the mean velocity corrections were 11 under audi- tory guidance and 27 under SSD guidance. The blind non-echolocators made significantly fewer velocity corrections than the sighted group under auditory guidance [F(1, 16) = 11.0, p = 0.004] but not SSD guidance [F(1, 16) = 0.93, ns]. There was no effect of repetition. Mean numbers of velocity corrections for the sighted group under visual guidance were significantly fewer than for the blind non-echolocators under auditory guidance [F(1, 16) = 34.7, p = 0.001] or SSD guidance [F(1, 16) = 13.7, p = 0.002]. Modified t-tests showed that, on average under auditory guidance, BE made significantly fewer velocity corrections than the sighted partici- pants (t = 2.10, p = 0.03) but not the blind non-echolocators (t = 1.20, ns). PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Side of avoidance of the obstacle Fig 7 shows the percentage of times the participant chose to move in a rightwards direction to pass the obstacle. When navigating using vision, sighted participants nearly always moved past the obstacle on the side that afforded the most space, i.e. they moved in a leftwards direction when the obstacle was positioned to the right and vice versa (Fig 7, bottom panel). There was a trend in the same direction under SSD guidance for all groups, but the effect was markedly reduced under auditory guidance (Fig 7 middle and upper panels, respectively). The blind non- echolocators did not always move past the obstacle on the side affording most space, either under auditory or SSD guidance, whereas the sighted group generally did move past the obstacle on the side affording most space under SSD guidance. An analysis of side of avoidance for the sighted group showed a main effect of obstacle location only [F(2, 18) = 35.59, p = 0.001] and a PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 14 / 25 Blindness enhances auditory obstacle circumvention Fig 5. Mean buffer space at the time of crossing under auditory guidance (upper panel), SSD guidance (middle panel), and visual guidance (lower panel), for sighted participants (open bars) blind non-echolocators (grey bars), and the BE echolocator (dashed bars). https://doi.org/10.1371/journal.pone.0175750.g005 y Fig 5. Mean buffer space at the time of crossing under auditory guidance (upper panel), SSD guidance (middle panel), and visual guidance (lower panel), for sighted participants (open bars), blind non-echolocators (grey bars), and the BE echolocator (dashed bars). Fig 5. Mean buffer space at the time of crossing under auditory guidance (upper panel), SSD guidance (middle panel), and visual guidance (lower panel), for sighted participants (open bars), blind non-echolocators (grey bars), and the BE echolocator (dashed bars). https://doi.org/10.1371/journal.pone.0175750.g005 https://doi.org/10.1371/journal.pone.0175750.g005 significant interaction between obstacle location and guidance condition [F(4,36) = 4.93, p = 0.003]. Sighted participants moved rightwards to pass the obstacle significantly more often in conditions when the obstacle was positioned on the left or on the midline than when it was positioned on the right, and when the obstacle was positioned on the midline compared to being positioned the right, under visual guidance (p < 0.001), and SSD guidance (p < 0.016), but not auditory guidance. For blind non-echolocators, an analysis of side of avoidance showed significant interaction between obstacle location and guidance condition [F(4,36) = 4.93, p = 0.003]. Side of avoidance of the obstacle Modified t-tests did not show any significant differences in side of avoidance between BE and the sighted group or blind non-echolocators (all p > 0.05). Side of avoidance of the obstacle Sighted participants moved rightwards to pass the obstacle significantly more often in conditions when the obstacle was positioned on the left or on the midline than when it was positioned on the right, and when the obstacle was positioned on the midline compared to being positioned the right, under visual guidance (p < 0.001), and SSD guidance (p < 0.016), but not auditory guidance. For blind non-echolocators, an analysis of side of avoidance showed significant interaction between obstacle location and guidance condition [F(4,36) = 4.93, p = 0.003]. Sighted participants moved rightwards to pass the obstacle significantly more often in conditions when the obstacle was positioned on the left or on the midline than when it was positioned on the right, and when the obstacle was positioned on the midline compared to being positioned the right, under visual guidance (p < 0.001), and SSD guidance (p < 0.016), but not auditory guidance. For blind non-echolocators, an analysis of side of avoidance showed PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 15 / 25 Blindness enhances auditory obstacle circumvention a main effect of obstacle location only [F(2, 14) = 5.12, p = 0.02]. Blind non-echolocators moved rightwards to pass the obstacle significantly more when the obstacle was positioned on the left, than when it was positioned on the right under SSD guidance only (p = 0.01). Modified t-tests did not show any significant differences in side of avoidance between BE and the sighted group or blind non-echolocators (all p > 0.05). Fig 6. Mean echolocation obstacle detection range when navigating using audition. https://doi.org/10.1371/journal.pone.0175750.g006 Fig 6. Mean echolocation obstacle detection range when navigating using audition. https://doi.org/10.1371/journal.pone.0175750.g006 a main effect of obstacle location only [F(2, 14) = 5.12, p = 0.02]. Blind non-echolocators moved rightwards to pass the obstacle significantly more when the obstacle was positioned on the left, than when it was positioned on the right under SSD guidance only (p = 0.01). Modified t-tests did not show any significant differences in side of avoidance between BE and the sighted group or blind non-echolocators (all p > 0.05). a main effect of obstacle location only [F(2, 14) = 5.12, p = 0.02]. Blind non-echolocators moved rightwards to pass the obstacle significantly more when the obstacle was positioned on the left, than when it was positioned on the right under SSD guidance only (p = 0.01). PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Discussion The main findings were: 1) Under auditory guidance, the blind non-echolocators were better able to use echolocation in an obstacle circumvention task than the normally sighted group, as indicated by fewer collisions, lower movement times, fewer velocity corrections, and greater range of obstacle detection. However, buffer space was similar for both the blind non-echolo- cators and the sighted groups, and blind non-echolocators did not use sound to pass the obsta- cle on the side affording most space. 2) Under SSD guidance, navigation performance was generally comparable between the blind non-echolocators and the sighted group, indicated by similar numbers of collisions, movement times, velocity corrections, and buffer space. The sighted group generally moved past the obstacle on the side affording most space under SSD guidance, which the blind non-echolocators did not always do. 3) For sighted participants, obstacle circumvention was generally better under SSD guidance than under auditory guid- ance, indicated by fewer collisions, faster movement times and fewer velocity corrections, although buffer space was similar. For the blind non-echolocators, obstacle circumvention per- formance was generally similar under SSD and auditory guidance conditions, with similar numbers of collisions, movement times, velocity corrections and buffer space. Navigation performance using auditory guidance was generally better for blind than for sighted participants, which is consistent with the perceptual enhancement hypothesis. In line with this, the blind non-echolocators were also better than the sighted group at detecting the obstacle using echolocation given comparable training, in the initial obstacle detection task PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 16 / 25 Blindness enhances auditory obstacle circumvention Fig 7. Percentage of times the participant chose to move in a rightwards direction to pass the obstacle under auditory guidance (upper panel), SSD guidance (middle panel), and visual guida (lower panel), for sighted participants (open bars), blind non-echolocators (grey bars), and BE (dashed bars) for each obstacle location. Under auditory guidance, the BE echolocator made 0% pas Fig 7. Percentage of times the participant chose to move in a rightwards direction to pass the obstacle under auditory guidance (upper panel), SSD guidance (middle panel), and visual guidance (lower panel), for sighted participants (open bars), blind non-echolocators (grey bars), and BE (dashed bars) for each obstacle location. Under auditory guidance, the BE echolocator made 0% passes on the right side of the obstacle when the obstacle was located on the right. https://doi.org/10.1371/journal.pone.0175750.g007 Fig 7. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Discussion Consistent with this, Milne, et al. [29] pre- sented evidence suggesting that self-generated sounds could be used to form perceptual repre- sentations of the shapes of objects. Serino, et al. [60] pointed out that sighted people experience their bodies as being positioned at a specific location in the world, with a single visuo-spatial perspective, obtained using perceptual information regarding the position and orientation of the body in relation to external space. The blind participants in the current study may have been more accurate than the sighted participants in their perception of the spatial extent and position of their own bodies, helping them to avoid collisions when navigating. The results from the current study are consistent with the idea that blind people can use sound to perceive their location relative to external space and to construct an internal representation of an obsta- cle in the environment. Consistent with this, several of the blind participants reported that the obstacle was perceived as being “out there”. The finding that blind and sighted individuals used spatial information from auditory and tactile inputs to guide navigation around an obstacle is consistent with the idea that the repre- sentation of space is amodal [44, 61, 62], and the concept of crossmodal functional parity (that sensory modalities sharing a task-based mechanism display a form of equivalence in percep- tual behavior [45]). Although navigation using auditory and tactile information was poorer than that using vision, our data show that the information needed to perform the obstacle cir- cumvention task was available in the auditory and tactile modalities as well as in the visual modality. Furthermore, information in the auditory modality was used more effectively by the blind than by the sighted participants, consistent with earlier studies [2, 3] and with the idea that prolonged reliance on sound leads to a more precise sound-evoked brain representation of the spatial environment. An alternative approach to sensory processing is information-based control [63–65]. According to this approach, on-going sensory information is used to guide locomotion around an obstacle, rendering path planning or internal representations unnecessary. Blind partici- pants may have been better able than sighted participants to adapt their movements “online” [65], because of their superior ability to utilize information from echoes. Our results do not rule out this alternative approach. Cross-modal plasticity can result in the recruitment of visual navigation areas following blindness. Kupers, et al. Discussion Percentage of times the participant chose to move in a rightwards direction to pass the obstacle under auditory guidance (upper panel), SSD guidance (middle panel), and visual guidance (lower panel), for sighted participants (open bars), blind non-echolocators (grey bars), and BE (dashed bars) for each obstacle location. Under auditory guidance, the BE echolocator made 0% passes on the right side of the obstacle when the obstacle was located on the right. https://doi.org/10.1371/journal.pone.0175750.g007 https://doi.org/10.1371/journal.pone.0175750.g007 prior to the auditory testing phase, and detecting the obstacle in the “no-click” control experi- ment. Navigation performance for BE using sound was slightly but non-significantly better than that for the blind non-echolocators, but it was significantly better than for the sighted group. The similar performance of BE and the non-expert blind participants suggests that expertise was not the primary factor driving obstacle circumvention using sound echoes. How- ever, we acknowledge that a larger sample of blind experts in future studies is needed to assess this conclusion more rigorously. Finally, as anticipated, navigation performance was much better under visual guidance than under auditory or SSD guidance. The exact way in which the blind participants differed from the sighted participants in their ability to use auditory cues for navigation remains unclear. Blind participants may have been better able to use cues such as the time delay of the echo produced by the obstacle, as well as ‘echoic tau’ [57] or ‘echoic time-to-contact’ [8]. The derivation of echoic tau involves the use PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 17 / 25 Blindness enhances auditory obstacle circumvention of the rate of change of acoustic cues, such as intensity differences between the self-generated click and the corresponding echo, the delay of the sound echo, the changing angle of incidence of the sound echo, and changes in spectrum. It has been shown that blindfolded sighted partic- ipants who were moving were more accurate than static participants when judging the position of a removable wall using echolocation [35], suggesting that movement provides benefits for blindfolded sighted people. Wallmeier and Wiegrebe [25] showed that self-motion benefitted echo-acoustic orientation by sighted echolocating participants. The benefits may be even greater for blind people, but this remains to be determined. Representation approaches to sensory processing (also known as model-based control) [58, 59] are based on the assumption that sensory information is used by individuals to form an internal representation of the local environment. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Blindness enhances auditory obstacle circumvention frontal cortex in each of the three groups. For sighted echolocation novices, additional activa- tion was found in the inferior parietal lobule and in the middle and superior frontal areas. These results raise the possibility that blind people may more spontaneously allocate direc- tional meaning to echoes during locomotion, whereas sighted echolocation novices may need to use high-level spatial processing at a more conscious level to allocate directional meaning to echoes. In the current study, application of more conscious, high-level spatial processing may have contributed to increased movement times, velocity corrections and number of collisions for the sighted group relative to the blind group when navigating under auditory guidance. Our results are consistent with the idea that blind individuals can utilize echoes to generate personal space, in a similar way to vision [46, 47]. Greater buffer space under auditory than under visual guidance suggests that even though blind participants were better able than sighted participants to use echoes for navigation, both blind and sighted participants generated a larger ‘protective envelope’ when walking using auditory guidance. Participants circumvent- ing the obstacle using full vision almost always passed the side of the obstacle that afforded the most space, supporting previous findings [46, 63]. This also occurred for sighted participants navigating under SSD guidance, but not auditory guidance. The blind non-echolocators dis- played a bias towards moving towards the right around the obstacle, for both auditory and SSD guidance and for all obstacle positions. The reason for this is unclear. However, all but one of these participants were right-handed. It is possible that blind non-echolocators, if not specifically instructed to pass on the side affording most space, prefer to move around the obstacle on their non-dominant side, so that they can react with their dominant arm should a collision occur. Further testing with a left-handed group would be needed to test this idea. A number of factors might influence the direction of travel around the obstacle, including the foot with which blind non-echolocators preferred to lead and the direction in which they chose to lean/orientate their head when they first explored the obstacle. Although not reaching performance levels comparable to those obtained with visual guid- ance, auditory performance by BE was generally high across kinematic measures, with almost no collisions, relatively fast movement times, and few velocity corrections. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Discussion [41] tested blind and blindfolded normally sighted participants using the TDU tactile SSD mentioned in the introduction, in a virtual route recognition task. They showed that in congenitally blind participants the posterior parahippocampus and posterior parietal and ventromedial occipito-temporal cortices were activated. These brain areas are involved in spatial navigation using vision, suggesting that following blindness cross-modal plasticity results in the recruitment of visual navigation areas. Fiehler, et al. [28] investigated the neural activity underlying echolocation-based processing of path direction by presenting binaural recordings of sounds produced during walking to blind echolocation experts and blind and sighted novices. They found activation in the superior parietal lobule and inferior PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 18 / 25 This participant often performed better than the other blind participants, although the differences failed to reach significance. The trend towards better performance by BE suggests that perceptual enhancement following blindness and the effects of training might combine rather than being mutually exclusive. It is likely that training enhances the ability to use perceptual information effectively, and that this effect adds to the effects of perceptual enhancement. However, the inclusion of a single blind expert echolocator, and differences between her and the blind non- echolocators, including age differences and being left-handed instead of right-handed, limit the generality of the findings. It would be informative to conduct further tests with a larger number of blind expert echolocators. Good echolocation may be beneficial when calibrating auditory space [9, 31, 66]. Vercillo, et al. [31] showed that the perception of auditory space was improved for blind expert echolocators relative to blind non-echolocators in a space bisection task, most likely through audio-motor feedback that aided in sensory calibration. Performance varied markedly across the blind non-echolocators under auditory guidance, with some showing performance similar to that of BE (BE, B1-2 and B4 made zero or only 1 collision across all trials), even though they had received no echolocation training. Similar individual differences have been reported previously for blind participants who had not received formal training when performing an echolocation task [6], and when performing other auditory spatial tasks, such as monaural sound localization [67, 68]. The reasons for the individual differences are not well understood. Possibly, some blind people implicitly learn to use information from echoes even when not trained to do so. Differences in age may also have contributed to the variability in performance across the blind non-echolocators. Increasing PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 19 / 25 Blindness enhances auditory obstacle circumvention age has previously been shown to be associated with a decline in performance when navigating [69]. Levy-Tzedek et al. [70] showed that older sighted participants took longer than younger sighted participants to navigate a virtual maze using auditory cues, and the former also made more pauses and collisions. Age may also have contributed to the differences between the blind non-echolocators and BE, who was younger. However, the blind non-echolocators who performed similarly to BE (B1-2 and B4) were among the older participants in this group. Also, there was no correlation between number of collisions and participant age (r = 0.01) for the blind non-echolocators. However, there was a weak correlation between number of colli- sions and age of onset of blindness (r = 0.45, p = 0.27). The current findings show similar performance for the blind non-echolocators and sighted participants when navigating using an SSD around a large obstacle, suggesting that blindness does not necessarily result in perceptual enhancement for tactile machine-produced echoloca- tion. This appears to be inconsistent with previous studies showing better performance for blind than for sighted participants when navigating using the TDU SSD [40, 41]. However, a study that tested navigation and obstacle avoidance using the more minimalistic EyeCane SSD, a device designed to have low complexity to make it simple and intuitive to use with min- imal training in common with the Miniguide used in the current study, showed similar perfor- mance for blind and sighted participants [71]. The difference across studies might reflect the limited amount of training given in our experiment, differences in obstacle size, or differences in the complexity of the devices and tasks used. Kupers et al. [41] reported that blind partici- pants were better at using the TDU for a virtual navigation task only at the end of extended training, and that performance on the first day of testing was similar for blind and sighted par- ticipants. Also, no difference in performance between groups was observed for route naviga- tion and recognition tasks. Chebat et al. [40] showed that blind participants were better than sighted participants at using TDU information to detect and avoid small obstacles. However, the two groups were equally good at detecting large obstacles. Further testing using the Mini- guide SSD would be informative in establishing whether differences in performance arise between blind and sighted participants following more extensive training and for obstacles of smaller sizes. This could lend support to the hypothesis that the effects of perceptual enhance- ment and training combine, as described above. The present experiments were conducted in a quiet environment with a single, static and highly reflective obstacle, and the walking speed was not restricted, making the task relatively easy. Increasing the task difficulty may lead to increased differences in performance between trained and untrained blind participants. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Further work is needed to investigate locomotion in more challenging everyday environments, such as noisy rooms with high reverberation, where multiple dynamic objects are present that have higher or lower acoustic reflectivity, or when participants are moving at different walking speeds. Ge´rin-Lajoie, et al. [47] reported that under visual guidance, the shape and size of personal space were maintained at different walk- ing speeds. However, as the spatial detail provided by sound and SSD devices is lower than for visual information, locomotor accuracy and efficiency based on sound or tactile information alone might be impaired when walking quickly. The current results show that early-onset blind participants were able to use auditory guid- ance for obstacle circumvention more effectively than blindfolded sighted participants. How- ever, further work is needed to establish whether people with late-onset blindness are able to use auditory guidance as effectively. Duration of visual loss has previously been shown to affect human movement performance [72] and echolocation acuity [19]. A study on the reaching and grasping performance of partially sighted individuals showed that the performance was better if the duration of visual impairment was longer [72]. For echolocation, Teng, et al. [19] reported a correlation between echolocation acuity and age of onset of blindness. If better PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 20 / 25 Blindness enhances auditory obstacle circumvention echolocation acuity is linked with improved locomotor precision, people with late-onset blind- ness may perform more poorly at obstacle circumvention using auditory guidance than people with early-onset blindness. This remains to be tested. A survey showed that blind people who used echolocation found it easier to move around in novel places than those who did not echo- locate, although echolocation benefits may have depended upon use of a long cane [73]. The results of the current study show that audition and echoic SSDs provide useful information for guiding navigation around obstacles. An investigation of the effectiveness of audition or an SSD when using a cane or walking with a guide dog would provide further information regard- ing the real-life practicality of these forms of guidance for blind people. Obstacle circumvention performance was generally similar under SSD and auditory guid- ance conditions for the blind non-echolocators. Acknowledgments We thank Silvia Cirstea for early discussions regarding the experiments and John Peters and George Oluwafemi for assistance in data collection. We also thank the participants, The Nor- folk & Norwich Association for the Blind, and Camsight. Supporting information S1 File. Participant data for number of collisions, side of obstacle avoidance, buffer space, overall movement times, the number of velocity corrections, and obstacle detection range for each guidance condition (audition, SSD and vision), for each obstacle location (left, midline and right). (XLSX) These findings have practical implications for blind people, as a common question in relation to SSDs is whether it is worth buying a device and investing time to train with it if one can train to an equivalent or better level using self- generated sounds. SSDs have drawbacks such as cost and limited battery life, and training pro- cedures for some SSDs are not well established [38]. Our findings suggest that even without training, using natural echolocation to circumvent obstacles leads to performance similar to that using an SSD. BE tended to move faster and more smoothly with fewer velocity correc- tions under auditory guidance than when using the SSD, but BE had much more experience of echolocation using self-generated sounds than using the SSD. One advantage of some SSDs is the adjustability of the detection range. This was set to 1 m for the current experiment, but the detection range for the Miniguide can be set as high as 8 m, which is greater than the detection range of the blind non-echolocators (approximately 0.9 m), and BE (approximately 1.2 m). Further investigation of the effects of training for both echolocation and SSD guidance, using different SSD ranges, would help to elucidate the advantages and disadvantages of the two modes of visionless navigation. The complexity of the task and environment are also factors that need to be explored to compare navigation under SSD guidance and echolocation. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Writing – review & editing: AJK ACS BCJM SP. Writing – review & editing: AJK ACS BCJM SP. Writing – review & editing: AJK ACS BCJM SP. References 1. Bach-y-Rita P, Collins CC, Saunders FA, White B, Scadden L. Vision substitution by tactile image pro- jection. Nature. 1969; 221:963–4. PMID: 5818337 2. Dufour A, Despre´s O, Candas V. Enhanced sensitivity to echo cues in blind subjects. Exp Brain Res. 2005; 165:515–9. https://doi.org/10.1007/s00221-005-2329-3 PMID: 15991030 3. Kolarik AJ, Cirstea S, Pardhan S. Evidence for enhanced discrimination of virtual auditory distance among blind listeners using level and direct-to-reverberant cues. Exp Brain Res. 2013; 224:623–33. https://doi.org/10.1007/s00221-012-3340-0 PMID: 23178908 4. Schenkman BN, Nilsson ME. Human echolocation: Blind and sighted persons’ ability to detect sounds recorded in the presence of a reflecting object. 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Auditory spatial representations of the world are com- pressed in blind humans. Exp Brain Res. 2017; 235:597–606. https://doi.org/10.1007/s00221-016- 4823-1 PMID: 27837259 16. Zwiers M, Van Opstal A, Cruysberg J. A spatial hearing deficit in early-blind humans. J Neurosci. 2001; 21:141–5. 17. Kolarik AJ, Cirstea S, Pardhan S, Moore BCJ. Project administration: AJK ACS BCJM SP. Resources: SP BCJM. Software: ACS. Visualization: AJK ACS BCJM SP. Writing – original draft: AJK. Writing – original draft: AJK. PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Conceptualization: AJK ACS BCJM SP. Conceptualization: AJK ACS BCJM SP. Data curation: AJK ACS. Formal analysis: AJK ACS. Funding acquisition: SP BCJM. Investigation: AJK ACS. 21 / 25 PLOS ONE \| https://doi.org/10.1371/journal.pone.0175750 April 13, 2017 Blindness enhances auditory obstacle circumvention Methodology: AJK ACS BCJM SP. Project administration: AJK ACS BCJM SP. Resources: SP BCJM. Software: ACS. 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https://openalex.org/W1010635630	https://www.annalsofgeophysics.eu/index.php/annals/article/download/5868/5801	Italian	null	STUDIO DELLA RADIOATTIVITA' DELLE LAVE DELL'ETNA COL METODO DELLE EMULSIONI NUCLEARI	Annals of geophysics	1,952	cc-by	2,039	S T U D I O D E L L A R A D I O A T T I V I T A ' D E L L E L A V E D E L - L ' E T N A C O L M E T O D O D E L L E E M U L S I O N I N U C L E A R I L. BARBERA - M. CURATOLO - M. M. INDOVINA ADDARIO - M. SANTANGELO 1. — In questi ultimi tempi sono state eseguite diverse ricerche sulla radioattività dei materiali costituenti la crosta terrestre. Questo studio lia importanza in quanto può dare informazioni sui processi fisici e fisico-chimici, che interessano i problemi connessi con la formazione e con l'evoluzione della crosta terrestre (differenziazione dei magmi, calore radioattivo...). Tra i materiali solidi le lave vulca- niche presentano interesse particolare; due sono i problemi principali che si incontrano nello studio della radioattività delle lave: a) deter- minazione del rapporto delle concentrazioni di Uranio e di Torio: b) investigazione sull'esistenza o meno dello stato di equilibrio radio- attivo dei componenti le due famiglie. Recentemente sono state effettuate sulle lave del Vesuvio delle misure ('), le quali confermano quanto era già stato affermato fin dal 1909 da Joly (2), cioè che dette lave hanno un contenuto radioattivo dipendente dalla data d'eruzione. E poiché è stato affermato che in lave di altri vulcani non è stata riscontrata fin'ora questa caratteri- stica, abbiamo ritenuto opportuno sottoporre ad esame quelle dell'Etna, per vedere se la loro attività dipendesse o no dalla data d'eruzione. Per eseguire queste misure abbiamo usato la tecnica delle emulsioni nucleari, tecnica già impiegata da molti autori per ricerche sulla ra- dioattività delle rocce (1), (3), (4), (5), (6), (7), (8), (»), (]0). 2. — Lastre Ilford C^, spesse 50 [i, sono state esposte per 51 giorni all'irraggiamento di sezioni levigate di lave, aventi uno spessore > lOOu, cioè uno spessore tale da potersi ritenere infinito rispetto al range massimo delle particelle a ; tali lave appartengono a un'eruzione prei- storica (lava I), a una del 1381 (lava II), a una del 1669 (lava III) e infine a una del 1928 (lava IV) ( n). Poiché l'attività delle lave in ge- nere risulta molto debole, si è stimato necessario prolungare il tempo L. BARBERA, M . CURATOLO, M . M . INDOVINA ADDARIO, M . SANTANF.ELO 604 di esposizione; per questo abbiamo pensato fosse opportuno prendere alcune precauzioni per rendere minimo il fading, per pèrdere il mi- nor numero possibile di particelle a e infine per diminuire il fondo. Non abbiamo usato balsamo del Canada per attaccare le sezioni ai vetrini, dato cbe questo prodotto può sviluppare perossido d'idrogeno, Fig. 1 - Mappa dell'attività della lava I. Fig. 1 - Mappa dell'attività della lava I. Fig. S T U D I O D E L L A R A D I O A T T I V I T A ' D E L L E L A V E D E L - L ' E T N A C O L M E T O D O D E L L E E M U L S I O N I N U C L E A R I 1 - Mappa dell'attività della lava I. composto quest'ultimo cbe favorisce il fading (12): abbiamo attaccato perciò le sezioni con una colla di cellulosa vergine all'acetone. Sempre per rendere minimo il fading abbiamo tenuto, durante tutto il periodo dell'esposizione, le lastre entro un essiccatore, conte- nente cloruro anidro di calcio, e in un ambiente mantenuto alla tem- S T U D I O DELLA RADIOATTIVITÀ DELLE LAVE DELL'ETNA 605 ji era tura costante di 0 "C ('-). Allo scopo di ridurre gli effetti di fondo è stata ricoperta di paraffina la superfìcie della lastra non occupata dalla sezione. Per mantenere le sezioni a contatto coll'emulsione fotografica e rendere minimo la strato d'aria tra sezione ed emulsione, abbiamo usato dei torchietti (12). Lo strato di gomma piuma è stato posto per rendere uniforme la pressione su tutta la superficie della lastra, in modo da evitare alterazioni. Fig. 2 - Mappa dell'attività della lava III. Fig. 2 - Mappa dell'attività della lava III. Nella costruzione dei torchietti abbiamo usato bachelite invece di un'altra sostanza, perché la bachelite ha un basso contenuto di im- purità radioattive. Le lastre sono state sviluppate, subito dopo l'esposizione, nel se- guente modo: 1) sviluppo: 1 g Amidol, 8 g Na2SO.v 340 cm 3 H20: tempo 25 min; temperatura 16 °C; nessuna agitazione; 1) sviluppo: 1 g Amidol, 8 g Na2SO.v 340 cm 3 H20: tempo 25 min; temperatura 16 °C; nessuna agitazione; 2) lavaggio in acqua per 5 min.; 3) bagno di frenaggio: acido acetico al 2 % ; tempo 15 min.: temperatura 16 °C: L. BARBERA, M . CURATOLO, M . M . INDOVINA ADDARIO, M . SANTANF.ELO 604 4) fissaggio: iposolfito al 40%; tempo circa 45 min.; tempe- ratura 20 °C; nessuna agitazione; 4) fissaggio: iposolfito al 40%; tempo circa 45 min.; tempe- ratura 20 °C; nessuna agitazione; 5) lavaggio in acqua corrente per 15 min. 5) lavaggio in acqua corrente per 15 min. L'esplorazione è stata eseguita con un ingrandimento di 460 dividendo la lastra in caselle di 330 X 330LI2; di ogni lastra è stata eseguita una mappa (fig. 1 e fig. 2), riportando le particelle trovate in una casella di 330 X 330 u2 in u n quadratino di 5 X 5 mm 2. Du- rante l'esplorazione sono state segnate solo le tracce di particelle o, aventi una proiezione orizzontale compresa tra 5 \|i e 50 3. SUMMARY The Authors give some preliminary results on the radioactivity of the « lave etnee ». They conclude that the total media activity of illese « lave » do not chanae ivith the date of the eruption and it is oo 5-6.10 4 a/crn" sec. RIASSUNTO Si espongono i primi risultati di uno studio sulla radioattività delle lave dell'Etna; si conclude che l'attività globale media di tali lave non varia con la data d'eruzione, essa ha un valore di <v> 5-6.10 4 particelle a per cni1 e per sec. S T U D I O D E L L A R A D I O A T T I V I T A ' D E L L E L A V E D E L - L ' E T N A C O L M E T O D O D E L L E E M U L S I O N I N U C L E A R I — I risultati ottenuti sono stati riportati nella Tabella I, dalla quale risulta cbe l'attività delle sezioni considerate è piuttosto bassa; essa è dell'ordine di grandezza di quella delle lave meno attive (più antiche) del Vesuvio. Dal confronto diretto dei risultati per i quattro campioni si può dire che l'attività delle lave dell'Etna, entro gli errori Fig. 3 - Lava I. Fig. 3 - Lava I. L. BARBERA, M . CURATOLO, M . M . INDOVINA ADDARIO, M . SANTANF.ELO 604 sperimentali, non varia col variare della data di eruzione. Invero l'at- tività della lava lì presenta uno scarto, leggermente fuori degli er- rori, rispetto ai valori delle altre, questo fatto però non ci sembra possa assumersi come indizio di una variazione dell'attività con il tempo, anche per il fatto cbe le lave I e IV, corrispondenti a date estreme d'eruzione, danno valori praticamente uguali. È stata fatta l'analisi statistica della distribuzione delle tracce nelle quattro mappe, dato che ad un primo esame risultano evidenti disuniformità, come si può vedere osservando la fig. 1; abbiamo cal- colato col metodo di Poisson la funzione di distribuzione del numero delle caselle rispetto al numero delle tracce in esse contenute e al valore medio di tracce per casella. Nelle figg. 3, 4, 5, 6 le curve sono calcolate con i dati della Tabella I, mentre i punti rappresentano i corrispondenti valori sperimentali. Dall'esame delle curve risulta che per le lave II e III la distri Fig. 6 - Lava IV. Fig. 6 - Lava IV. Fig. 6 - Lava IV. L. BARBERA, M . CURATOLO, M . M . INDOVINA ADDARIO, M. SANTANF.ELO 604 buzione sperimentale si adatta grosso modo a quella teorica di Pois- son; infatti la mappa della lava III (fig. 2) si presenta con pocliissime disuniformità. Invece la distribuzione sperimentale per le lave I e IV si allontana in modo più marcato da quella di Poisson: osservando la mappa della figura 1, si vede che si hanno zone di addensamento di particelle a e zone di rarefazione. 4. — Ci è gradito ringraziare il prof. Angelo Bellanca, direttore dell'Istituto di Mineralogia dell'Università di Palermo, per avere messo a nostra disposizione parte dell'attrezzatura necessaria alla ricerca; ringraziamo pure la laureanda Maria Giardina per la preparazione delle sezioni sottili. Palermo — Istituto di Fisica dell'Università — Luglio 1952. Palermo — Istituto di Fisica dell'Università — Luglio 1952. B I B L I O G R A F I A ( ] ) F . B A C H E L E T , M . F E R R E T T I S F O R Z I N I e F . I P P O L I T O , NUOVO Cimento. 8, 851 (1951). <-') J . J O L Y , Phil. Mag. 1 8 , 5 7 7 ( 1 9 0 9 ) . ( 3 ) I . C U R I E , Journ. Pliys. et Rad. 7 , 3 1 3 ( 1 9 4 6 ) . l ' I E . E . P I C C I O T T O , Bull. Soc. Heine Gèo. Paléont. el Hydrol. 5 8 , 7 5 ( 1 9 4 9 ) . ( 3 ) E . E . P I C C I O T T O , Bull. Soc. Belge Gèo. Paléont. et Hydrol. 5 9 , 1 7 0 ( 1 9 5 0 ) . S T U D I O DELLA RADIOATTIVITÀ DELLE LAVE DELL'ETNA 611 (°) J. H. J. P O O L E e J. W . B R E M M E R , Nature. 163, 130 (1919). ( 7) J. H. J. P O O L E e J. W . B R F . M M E R , Nature. 1 6 1 , 881 (1948). ( 8 ) I . H . FORD, Nature. 1 6 7 , 2 7 3 ( 1 9 3 1 ) . ( " ) S . M I L O N E , T A M B U R I N O e A . S T E L L A , NUOVO Cimento. 9 , 2 5 3 ( 1 9 5 2 ) . ( 1 0 ) H V B L T T L A R e F G H O U T E R M A N S Geochim et Cosmochim Ad ( " ) S . M I L O N E , T A M B U R I N O e A . S T E L L A , NUOVO Cimento. 9 , 2 5 3 ( 1 9 5 2 ) . ( 1 0 ) H . V. B L T T L A R e F . G. H O U T E R M A N S , Geochim. et Cosmochim. Ada, 2, ( 1 0 ) H . V. B L T T L A R e F . G. H O U T E R M A N S , Geochim. et Cosmochim. Ada, 2, (1951). ( 1 1) Ringraziamo il prof. G. Ponte per averci gentilmente fornito i suddetti ampioni di lava. ( 1 2) H. Y A C O D A , Radioactive Measurementes with Nuclear Emulsions. (New ork, 1949). ( 1 1) Ringraziamo il prof. G. Ponte per averci gentilmente fornito i suddetti ampioni di lava. ( 1 2) H. Y A C O D A , Radioactive Measurementes with Nuclear Emulsions. (New ork, 1949).
https://openalex.org/W3128541280	https://www.researchsquare.com/article/rs-33779/v2.pdf?c=1631873232000	English	null	The impact of age and receipt antihypertensives to systolic blood pressure and shock index at injury scene and in the emergency department to predict massive transfusion in trauma patients	Scandinavian journal of trauma, resuscitation and emergency medicine	2,021	cc-by	6,895	The Impact of Age and Receipt Antihypertensives to Systolic Blood Pressure and Shock Index at Injury Scene and in the Emergency Department to Predict Massive Transfusion in Trauma Patients The Impact of Age and Receipt Antihypertensives to Systolic Blood Pressure and Shock Index at Injury Scene and in the Emergency Department to Predict Massive Transfusion in Trauma Patients Se Jin Park Kyungpook National University School of Medicine https://orcid.org/0000-0003-3430-6449 Mi Jin Lee (  emmam@knu.ac.kr ) Kyungpook National University School of Medicine https://orcid.org/0000-0002-3773-8047 Changho Kim Kyungpook National University School of Medicine Haewon Jung Kyungpook National University School of Medicine Seong Hun Kim CHA University Wooyoung Nho CHA University Kang Suk Seo Kyungpook National University School of Medicine Jungbae Park Kyungpook National University School of Medicine Hyun Wook Ryoo Kyungpook National University School of Medicine Jae Yun Ahn Kyungpook National University School of Medicine Sungbae Moon Kyungpook National University School of Medicine Jae Wan Cho Kyungpook National University School of Medicine Shin-ah Son Kyungpook National University School of Medicine y Kang Suk Seo Kyungpook National University School of Medicine Jungbae Park Kyungpook National University School of Medicine Hyun Wook Ryoo Kyungpook National University School of Medicine Jae Yun Ahn Kyungpook National University School of Medicine Sungbae Moon Kyungpook National University School of Medicine Jae Wan Cho Kyungpook National University School of Medicine Shin-ah Son Kyungpook National University School of Medicine Kyungpook National University School of Medicine Original research Page 1/19 Keywords: Emergency Medical Services, Geriatrics, Antihypertensives, Massive Transfusion, Shock Index Systolic Blood Pressure Posted Date: October 26th, 2020 DOI: https://doi.org/10.21203/rs.3.rs-33779/v2 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Keywords: Emergency Medical Services, Geriatrics, Antihypertensives, Massive Transfusion, Shock Index, Systolic Blood Pressure Posted Date: October 26th, 2020 DOI: https://doi.org/10.21203/rs.3.rs-33779/v2 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Version of Record: A version of this preprint was published on January 30th, 2021. See the published version at https://doi.org/10.1186/s13049-021-00840-2. Page 2/19 Abstract Background: Systolic blood pressure (SBP) and shock index (SI) are accurate indicators of hemodynamic instability and the need for transfusion in trauma patients. We aimed to determine whether the utility and cutoff point for SBP and SI are affected by age and antihypertensives. Methods: This was a retrospective observational study of a level 1 trauma center between January 2017 and December 2018. We analyzed the utility and cutoff points of SBP and SI for predicting massive transfusion (MT) and 30-day mortality according to patients’ age and whether they were taking antihypertensives. A multivariable logistic regression analysis was conducted to estimate the association of age and antihypertensives on primary and secondary outcomes. Results: We analyzed 4681 trauma cases. There were 1949 patients aged 65 years or older (41.6%), and 1375 hypertensive patients (29.4%). MT was given to 137 patients (2.9%). The 30-day mortality rate was 6.3% (n = 294). In geriatric trauma patients taking antihypertensives, a prehospital SBP less than 110 mmHg was the cutoff value for predicting MT in multivariate logistic regression analyses; packed red blood cell transfusion volume decreased abruptly based on prehospital SBP of 110 mmHg. Emergency Department SI greater than 1.0 was the cutoff value for predicting MT in patients who were older than 65 years and were not taking antihypertensives. Conclusions: The triage of trauma patients is based on the identification of clinical features readily identifiable by first responders. However, age and medications may also affect the accurate evaluation. In initial trauma management, we must apply SBP and SI differently depending on age, whether a patient is taking antihypertensives, and the time at which the indicators are measured. Background Trauma is an important cause of death among geriatric patients [1]. Older age is associated with higher rates of morbidity and mortality after injury as aging and the presence of comorbidities reduce physiological reserves [2, 3]. Age itself is a significant risk factor and predictor of increased mortality in polytrauma patients. A very low Glasgow Coma Scale (GCS) score and systolic blood pressure (SBP) of less than 80 mmHg are potential clinical indicators of massive bleeding and traumatic brain injury [4]. However, the assessment of injury severity and hemodynamic instability in geriatric patients is often difficult because of their altered response to injury [1, 5]. The low physiological capacity in geriatric patients masks the clinical exacerbation of injury, which makes the management of these patients more difficult [6]. SBP and heart rate (HR) are routinely used for assessing trauma patients [7, 8]. The shock index (SI), which is the ratio of HR to SBP, can be easily calculated in the field or emergency department (ED) [9]. SI has been an accurate indicator of hemodynamic instability and the need for transfusion in trauma patients [10] and serves as a marker for significant injury in trauma patients with hypovolemic shock, who likely needs massive transfusion (MT) [11]. However, it has been questioned whether SBP and HR Page 3/19 Page 3/19 are reliable for assessing geriatric trauma patients [6]. Early recognition of the need for MT is important but still presents a challenge in trauma patients [12]. are reliable for assessing geriatric trauma patients [6]. Early recognition of the need for MT is important but still presents a challenge in trauma patients [12]. Although SBP and SI are practical and useful predictors of outcomes for trauma patients, the literature has shown that SBP and SI cutoff points vary depending on the cause of trauma and the patient’s illness [9, 10, 13-16]. Under-triage among older injured patients is more likely to occur, with different thresholds for SBP, which indicates traumatic shock (<90, <100 or <110 mmHg) [17]. Old age, hypertension, and β- or calcium channel blockers weaken the association between SI and 30-day mortality [13]. The role of SBP and SI as assessment tools in geriatric trauma patients or patients with antihypertensives is not well defined [18]. Study Design and Population This study was a retrospective, observational cross-sectional study. The data were obtained from the trauma database at Kyungpook National University Hospital, a regional level 1 trauma center in South Korea, from 1 January 2017 to 31 December 2018. We included patients who were admitted to the hospital after trauma who were 15 years old or older, and had a measurement of SBP and HR taken at the injury scene and in the ED. The exclusion criteria included patients who were transferred from other hospitals or using private vehicles, patients who had missing SBP or HR data, patients younger than 15 years old, patients who had incomplete registered data, and those who had burn injuries or trauma due to hanging (Fig. 1) [12,14]. Background This study aimed to assess the utility and cutoff of points for SBP and SI assessed at the injury scene and in the ED for predicting MT and 30-day mortality in geriatric trauma patients and trauma patients taking antihypertensives. Variables and Data Processing We retrieved the detailed patient information including age, sex, vital signs, and comorbidities, such as diabetes mellitus, hypertension, congestive heart failure, cerebral vascular accident, and chronic renal disease. We documented trauma scores (e.g., Abbreviated Injury Scale, Revised Trauma Score [RTS], and Injury Severity Score [ISS]), units of packed red blood cells (PRBC) transfused within four and 24 hours, and 30-day mortality. Elderly patients were defined as those who were 65 years old or older [19]. The prehospital and ED SIs were calculated as the ratio of HR to SBP in the field and ED as recorded by the emergency medical services personnel. ISS was classified into the following groups: 1 to 15, 16 to 24, and greater than 25 [20]. MT was defined as a requirement of 10 PRBCs or more in the first 24 hours or 4 PRBCs or more in the first 4 hours of hospital admission [21]. Outcome Measures Page 4/19 The primary outcome was MT and in-hospital mortality within 30 days. The secondary outcome was critical cutoff points of SBP (<90, 90–110, and ≥110 mmHg) and SI as a categorical variable (<0.7, 0.7– 1, and ≥1) at the injury scene and in the ED [13, 14]. The primary outcome was MT and in-hospital mortality within 30 days. The secondary outcome was critical cutoff points of SBP (<90, 90–110, and ≥110 mmHg) and SI as a categorical variable (<0.7, 0.7– 1, and ≥1) at the injury scene and in the ED [13, 14]. The primary outcome was MT and in-hospital mortality within 30 days. The secondary outcome was critical cutoff points of SBP (<90, 90–110, and ≥110 mmHg) and SI as a categorical variable (<0.7, 0.7– 1, and ≥1) at the injury scene and in the ED [13, 14]. Overall Characteristics of Study Patients Overall Characteristics of Study Patients Of the 6741 trauma cases, 4681 patients were enrolled in this study. There were 1949 patients aged 65 years old or older (41.6%), and 1375 patients with hypertension (29.4%) (Fig. 1 and Online Supplemental Content). 222 patients (4.7%) had received prehospital intravenous hydration. At the injury scene, the median SBP, HR, and SI were 130 mmHg, 84 beats per minute, and 0.7, respectively. On arrival at the ED, the median SBP, HR, and SI were 139 mmHg, 85 beats per minute, and 0.6, respectively. There were 914 (19.5%) transfused patients, and 137 (2.9%) had received MT. Other overall demographics are described in the Online Supplemental Content. Statistical Analysis The data were analyzed using IBM SPSS Statistics (version 25; IBM Corp., Armonk, NY, USA) and MedCalc (version 17; MedCalc Software, Mariakerke, Belgium). Categorical variables are presented as frequency and percent, whereas continuous variables are presented as mean ± standard deviation or as median and interquartile range (IQR, 25th–75th percentile). The Χ2 or Fisher’s exact tests were used to compare the categorical variables. The normality of the variables was determined using the Shapiro–Wilk test. Normally distributed data were expressed as mean and standard deviation, and median and IQRs were used for non-normally distributed data. A t- test or 1-way analysis of variance and the Mann– Whitney U- test were used to compare continuous variables. Multivariable logistic regression analysis was used to identify the independent associations of univariate predictive variables on the occurrence of MT for adult trauma patients. Multivariable logistic regression analysis was mainly used in the age>65 years (geriatric group), and was additionally performed in <65 years (young adult group). The odds ratio (OR) with 95% confidence interval (CI) of the associated conditions of the patients and the OR of a need for MT were based on vital signs at the injury scene and in the ED. A multivariable logistic regression analysis was conducted to estimate the association of age and antihypertensives on primary and secondary outcomes. Adjusted ORs were calculated after adjustment for sex, age, SBP and SI at the injury scene or at the initial time of ED admission, RTS, and ISS. P- values less than 0.05 were considered statistically significant. Predicting MT Stratified by Age and Antihypertensives We conducted multivariable logistic regression analyses of the associated factors that were significant in the univariate logistic regression analyses for MT prediction (Table 4). In the subgroup analysis for MT stratified by age and antihypertensives, only prehospital SBP was a significant predicting factor in elderly trauma patients taking antihypertensives (Fig. 3A). However, ED SI greater than 1.0 and RTS were statistically significant in the elderly patients not taking antihypertensives (Fig. 3B). Geriatric Trauma Patients According to Antihypertensives and MT Table 1 shows the general demographic information of the geriatric trauma population. Among 1949 elderly trauma patients, there were significant differences between antihypertensive and non- antihypertensive group in terms of age, sex, diabetes, SBP at the injury scene and in the ED, and SI on Page 5/19 Page 5/19 arrival in the ED. The median prehospital response time was the same in both groups (9 min) (Table 1). In the non-antihypertensive group, the total red blood cell transfusion volume gradually changed according to the prehospital SBP ranges. However, in the antihypertensive group, there was no difference between the SBP under 90 mmHg and SBP between 90 and 110 mmHg, and it decreased abruptly based on prehospital SBP 110 mmHg (Fig. 2). In geriatric trauma patients, there was no significant difference between the MT and non-MT groups in terms of age. The shock-related indices, GCS, and ISS were worse in the MT group (Table 2). Predicting Clinical Outcomes According to Antihypertensives Multivariable logistic regression analysis was conducted to compare the association between the shock- related index at the injury scene and in the ED and MT and 30-day mortality. In the univariate analysis for predicting MT, prehospital SBP of less than 110 mmHg, ED SI greater than 1.0, RTS, and ISS were the significant variables for elderly patients taking antihypertensives. However, prehospital SBP was the only strongly related factor among the aforementioned factors after multivariable analysis. In the elderly non- antihypertensive group, ED SI greater than 1.0 and RTS were statistically significant for predicting MT, but not prehospital SBP (Table 3A). As shown in Table 3B, ED SI greater than 1.0 significantly increased 30- day mortality only in the elderly non-antihypertensive group. But ISS significantly increased 30-day mortality in both groups. Discussion We aimed to examine the utility and cutoff of points for SBP and SI, as determined at the injury scene and in the ED, for predicting MT and 30-day mortality in geriatric trauma patients and patients taking antihypertensives. In geriatric trauma patients taking antihypertensives, a prehospital SBP lower than 110 mmHg was the cutoff value for the prediction of MT in multivariable logistic regression analyses. There was no significant value in multivariable logistic regression analyses of prehospital SI for predicting MT and 30-day mortality. ED SI greater than 1.0 was the cutoff value for predicting MT in patients who were older than 65 years and who were not taking antihypertensives. The European guideline on the management of major bleeding and coagulopathy after trauma recommends that physicians clinically assess the extent of traumatic hemorrhage using a combination of patient physiology, anatomical injury pattern, mechanism of injury, and patient response to initial Page 6/19 Page 6/19 resuscitation. Isolated vital signs, such as HR or SBP, are unreliable in the assessment of hypovolemic shock. HR alone does not predict the need for MT [11, 22]. In contrast, SI has been shown to better risk- stratify patients for critical bleeding, increased transfusion requirements and early mortality [11, 23]. SI is an effective tool that can be implemented in a prehospital setting for the triage of geriatric trauma patients and is superior to HR and SBP for predicting mortality in geriatric trauma patients. Geriatric trauma patients with an SI of 1 or greater should be transferred to a Level 1 trauma center [6]. Bruijns et al reported that the difference between ED and prehospital SBP, respiratory rate, and SI are good predictor of 48-hours mortality in trauma and may supplement decisions on trauma treatment [24]. Fligor et al reported that MT in geriatric trauma patients can be reliably and simply predicted by the arrival vital signs of SBP, pulse pressure, diastolic blood pressure, and SI [22]. Most studies have assessed predictive properties of SI for requiring at least 10 units of PRBC in the first 24 hours. It would be useful to conduct more studies evaluating the estimation and recording of the SI at earlier time-points, including the prehospital phase [25]. MT in older trauma patients should be considered based on anatomical factors, pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal [26]. Discussion Studies have suggested that advanced age and the presence of comorbidities such as hypertension, diabetes, use of anticoagulation medications can affect the prognosis of trauma patients based on SBP and SI, and therefore the cutoff value should be different. Kristensen et al reported that SI is independently associated with 30-day mortality in a broad population of ED patients, and an SI of 1 or more is associated with an adjusted OR of 10.5 (95% CI, 9.3–11.7) for 30-day mortality. However, age, hypertension, and β- or calcium channel blockers weaken the association between SI and mortality [13]. Additionally, Brown et al [27] noted that formally substituting an SBP of less than 110 mmHg for the current SBP of less than 90 mmHg is beneficial in geriatric patients and may be potentially valuable in all adult patients at field triage. Geriatric patients with SBP of 90 to 109 mmHg had odds of mortality similar to those of geriatric patients with SBP of less than 90 mmHg [27]. SBP of less than 110 might represent shock in patients older than 65 years [28]. Prehospital trauma triage ensures proper transport of patients at risk of severe injury to hospitals with an appropriate level of trauma care. Incorrect triage results in under-triage and over-triage [29]. According to the National Trauma Triage Protocol guideline [30], GCS, SBP and respiratory rate are involved in Step 1 of field triage. Next, the anatomy of injury is considered in Step 2; the mechanism of injury is considered in Step 3; and older age, anticoagulant use, and bleeding disorders are considered in Step 4. Studies of trauma patients have suggested an upward review of the SBP cutoff value to less than 90 mmHg in elderly patients older than 65 years [8, 16, 27]. The above are reflected in the National Trauma Triage Protocol guideline in Step 4, and the presence or absence of antihypertensive use is not considered. Based on this and other studies, it is advisable to include antihypertensive use as a consideration in field triage and to consider it at an earlier stage along with older age [27]. For example, we recommend that “SBP < 110 might represent shock after age 65 years” is eliminated on Step 4 and “SBP < 110 might represent shock after age 65 years taking antihypertensives” is added on Step 2. Discussion Page 7/19 Page 7/19 SBP, HR and SI, the main analysis variables we used, are continuous variables, and some results may be different depending on the interval classification method. When they were used as a continuous variable instead of an interval for MT prediction, SI at ED arrival [odds ratio 257 (95% CI 8.36–791) in elderly patients taking antihypertensives, odds ratio 20.9 (95% CI 4.04–108) in elderly patients not taking antihypertensives] was analyzed as a statistically significant factor along with ISS and RTS. However, in this case, the influence of SI unit, which is a variable smaller than SBP unit, increase in the unit and interval characteristics of the continuous variable seen in regression analysis. So unit correction is required. And we assumed that presenting the cut-off value is familiar to clinician and more useful for interpretation. We analyzed both the patients’ medical history and prehospital vital signs and indicators, which were not fully covered in previous studies, and performed multivariable logistic regression analysis including in- hospital mortality and MT. In addition, we were able to present a more accurate understanding of the underlying condition and flexible cutoff by stratifying the associations of vital signs and SI on clinical prognosis according to age and whether the patient was taking antihypertensives. In the group of patients who were younger than 65 years and not taking antihypertensives, RTS, ISS and ED SI were strongly associated with prediction of MT. Prehospital SBP was the only significant predicting factor in elderly trauma patients taking antihypertensives. However, SI measured at the time of ED admission and RTS were significant in the elderly patients who were not taking antihypertensives. These results could suggest that the uncritical application by cutoff values of SI and SBP in any aged trauma patients is inaccurate. Limitations Our study had several limitations. Because this was an observational study, there was a potential selection bias from excluding many patients who were missing or did not have SBP and HR measured in the emergency medical services setting (n = 898, Fig. 1). These were 684 patients not transported by EMS or direct visits (including patients under the age of 14), 269 patients under the age of 14, and 26 cases of refusal to measure vital sign because of self-harm, etc. Instead, their ED vital signs are all recorded (95% CI of ED SBP 120-156 mmHg, ED HR 74-98 bpm). Second, these contradictory results included a potential bias in that no transfusion was recorded if a patient died before receiving a transfusion, despite being a severe trauma patient requiring transfusion. Therefore, although MT is the main interest, we also studied the 30-day-mortality as a primary outcome. Finally, we did not exclude traumatic brain injury, which may confound the data due to the classic Cushing reflex whereby SBP increases and HR decreases. However, the predictive effect of SI and SBP was not changed in the primary outcome for the remaining 1853 patients excluding 96 severe traumatic brain injury (TBI) patients. Conclusion We need to apply the indicators differently depending on a patient’s age and the presence of hypertension in the initial trauma management. In trauma patients older than 65 years who are taking Page 8/19 Page 8/19 antihypertensives, MT can be predicted based on SBP of 110 mmHg measured in the field, whereas in patients older than 65 years and not using antihypertensives, MT can be predicted based on an ED SI of 1.0. Further research is needed to establish the vital signs and delta SI at the injury scene and ED discharge in elderly trauma patients. antihypertensives, MT can be predicted based on SBP of 110 mmHg measured in the field, whereas in patients older than 65 years and not using antihypertensives, MT can be predicted based on an ED SI of 1.0. Further research is needed to establish the vital signs and delta SI at the injury scene and ED discharge in elderly trauma patients. Ethics approval and consent to participate The study was approved by the institutional review board of KNUH University Hospital (KNUH 2020- 03035) with a waiver of informed consent. Consent for publication Not applicable Availability of data and material Page 9/19 Abbreviations CI Confidence interval ED Emergency department ISS Injury Severity Score KNUH KNUH University Hospital OR Odds ratio PRBC Packed red blood cells RTS Revised Trauma Score GCS Glasgow Coma Scale HR Heart rate MT Massive transfusion SBP Systolic blood pressure SI Shock index Acknowledgements Not applicable Not applicable Author contributions SKS, LMJ, and PSJ analyzed and interpreted the data. PSJ drafted the manuscript. SKS and LMJ conceived and coordinated the study. All authors completed critical revisions of the manuscript. SKS coordinated the study. All authors read and approved the final manuscript. Funding Not applicable References 1. Broos PLO, D’Hoore A, Vanderschot P, Rommens PM, Stappaerts KH. Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury. 1993;24:365-8. 1. Broos PLO, D’Hoore A, Vanderschot P, Rommens PM, Stappaerts KH. 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Resuscitation. 1992;23:227-34. 11. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ et al. The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma. 5th ed. Crit Care 23; vol 98; 2019. 12. Wu SC, Rau CS, Kuo SCH, Hsu SY, Hsieh HY, Hsieh CH. Shock index increase from the field to the emergency room is associated with higher odds of massive transfusion in trauma patients with stable blood pressure: A cross-sectional analysis. PLOS ONE. 2019;14:e0216153. 13. Kristensen AK, Holler JG, Hallas J, Lassen A, Shapiro NI. Is Shock Index a Valid Predictor of Mortality in Emergency Department Patients with hypertension, Diabetes, High Age, or Receipt of beta- or Calcium Channel Blockers? Ann Emerg Med. 2016;67:106-13. 13. Kristensen AK, Holler JG, Hallas J, Lassen A, Shapiro NI. Is Shock Index a Valid Predictor of Mortality in Emergency Department Patients with hypertension, Diabetes, High Age, or Receipt of beta- or Calcium Channel Blockers? Ann Emerg Med. 2016;67:106-13. 14. Lai WH, Rau CS, Hsu SY, Wu SC, Kuo PJ, Hsieh HY et al. Using the reverse shock index at the injury scene and in the Emergency Department to identify high-risk patients: A cross-sectional retrospective study. Int J Environ Res Public Health. 2016;13:357. 14. Lai WH, Rau CS, Hsu SY, Wu SC, Kuo PJ, Hsieh HY et al. Using the reverse shock index at the injury scene and in the Emergency Department to identify high-risk patients: A cross-sectional retrospective study. Int J Environ Res Public Health. 2016;13:357. 15. Cannon CM, Braxton CC, Kling-Smith M, Mahnken JD, Carlton E, Moncure M. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma. 2009;67:1426-30. 15. Cannon CM, Braxton CC, Kling-Smith M, Mahnken JD, Carlton E, Moncure M. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma. 2009;67:1426-30. 16. Martin JT, Alkhoury F, O’Connor JA, Kyriakides TC, Bonadies JA. References ‘Normal’ vital signs belie occult hypoperfusion in geriatric trauma patients. Am Surg. 2010;76:65-9. 16. Martin JT, Alkhoury F, O’Connor JA, Kyriakides TC, Bonadies JA. ‘Normal’ vital signs belie occult hypoperfusion in geriatric trauma patients. Am Surg. 2010;76:65-9. 17. Uribe-Leitz T, Jarman MP, Sturgeon DJ, Harlow AF, Lipsitz SR, Cooper Z et al. National study of triage and access to Trauma Centers for Older Adults. Ann Emerg Med. 2020;75:125-35. 17. Uribe-Leitz T, Jarman MP, Sturgeon DJ, Harlow AF, Lipsitz SR, Cooper Z et al. National study of triage and access to Trauma Centers for Older Adults. Ann Emerg Med. 2020;75:125-35. 18. Kim SY, Hong KJ, Shin SD, Ro YS, Ahn KO, Kim YJ et al. Validation of the shock index, modified shock index, and Age shock index for predicting mortality of geriatric trauma patients in emergency departments. J Korean Med Sci. 2016;31:2026-32. 18. Kim SY, Hong KJ, Shin SD, Ro YS, Ahn KO, Kim YJ et al. Validation of the shock index, modified shock index, and Age shock index for predicting mortality of geriatric trauma patients in emergency departments. J Korean Med Sci. 2016;31:2026-32. 19. Attanasio F, Carrer P, Zurlo A, Rossi A, Babuin L, Mion MM et al. Prognostic value of cardiac troponin I assay in hospitalized elderly patients. Aging Clin Exp Res. 2019;31:233-9. 19. Attanasio F, Carrer P, Zurlo A, Rossi A, Babuin L, Mion MM et al. Prognostic value of cardiac troponin I assay in hospitalized elderly patients. Aging Clin Exp Res. 2019;31:233-9. 20. Rau CS, Wu SC, Kuo SC, Pao-Jen K, Shiun-Yuan H, Chen YC et al. Prediction of massive transfusion in trauma patients with shock index, modified shock index, and Age shock index. Int J Environ Res Public Health. 2016;13. 21. Sihler KC, Napolitano LM. Massive transfusion: new insights. Chest. 2009;136:1654-67. 21. Sihler KC, Napolitano LM. Massive transfusion: new insights. Chest. 2009;136:1654-67. 22. Fligor SC, Hamill ME, Love KM, Collier BR, Lollar D, Bradburn EH. Vital Signs strongly predict massive transfusion need in geriatric trauma patients. Am Surg. 2016;82:632-6. Page 11/19 23. DeMuro JP, Simmons S, Jax J, Gianelli SM. Application of the Shock Index to the prediction of need for hemostasis intervention. Am J Emerg Med. 2013;31:1260-3. 24. Bruijns SR, Guly HR, Bouamra O, Lecky F, Wallis LA. The value of the difference between ED and prehospital vital signs in predicting outcome in trauma. EMJ. 2014;31:579-82. 25. Olaussen A, Blackburn T, Mitra B, Fitzgerald M. References Review article: shock index for prediction of critical bleeding post-trauma: a systematic review. Emerg Med Australas EMA. 2014;26:223-8. 26. Ohmori T, Kitamura T, Ishihara J, Onishi H, Nojima T, Yamamoto K et al. Early predictors for massive transfusion in older adult severe trauma patients. Injury. 2017;48:1006-12. 27. Brown JB, Gestring ML, Forsythe RM, Stassen NA, Billiar TR, Peitzman AB et al. Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90. J Trauma Acute Care Surg. 2015;78:352-9. 27. Brown JB, Gestring ML, Forsythe RM, Stassen NA, Billiar TR, Peitzman AB et al. Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90. J Trauma Acute Care Surg. 2015;78:352-9. 28. McCoy CE, Chakravarthy B, Lotfipour S. Guidelines for Field Triage of Injured Patients: in conjunction with the Morbidity and Mortality weekly Report published by the Center for Disease Control and Prevention. West J Emerg Med. 2013;14:69-76. 28. McCoy CE, Chakravarthy B, Lotfipour S. Guidelines for Field Triage of Injured Patients: in conjunction with the Morbidity and Mortality weekly Report published by the Center for Disease Control and Prevention. West J Emerg Med. 2013;14:69-76. 29. van Rein EAJ, Houwert RM, Gunning AC, Lichtveld RA, Leenen LPH, van Heijl M. Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review. J Trauma Acute Care Surg. 2017;83:328-39. 29. van Rein EAJ, Houwert RM, Gunning AC, Lichtveld RA, Leenen LPH, van Heijl M. Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review. J Trauma Acute Care Surg. 2017;83:328-39. 30. Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep Morb Mortal Wkly Rep Recomm Rep. 2012;2011:61:1-20. 30. Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep Morb Mortal Wkly Rep Recomm Rep. 2012;2011:61:1-20. Table 1. Baseline demographic characteristics of elderly trauma patients Tables Page 12/19 Overall elderly (n = 1949) Non-antihypertensive group (n = 951) Antihypertensive group (n = 998) P value Age (IQR), yr 76.0 (70.0–81.0) 75.0 (69.0–80.0) 77.0 (71.0–82.0) <0.001 Male sex, n (%) 1002 (51.4) 539 (56.7) 463 (46.4) <0.001 Comorbidities, n (%) Diabetes 529 (27.1) 167 (17.6) 362 (36.3) <0.001 Cerebrovascular accident 271 (13.9) 92 (9.7) 179 (17.9) <0.001 Congestive heart failure 68 (3.5) 29 (3.0) 39 (3.9) 0.575 Chronic renal disease 127 (6.5) 34 (3.6) 93 (9.3) <0.001 Traumatic brain injury, n (%) 96 (4.9) 57 (6.0) 39 (3.9) 0.033 Prehospital response time (IQR), min 9.0 (6.0–14.0) 9.0 (7.0–14.0) 9.0 (6.0–15.0) 0.912 Total prehospital time (IQR), min 24.0 (17.5–33.0) 25.0 (17.5–34.0) 23.0 (17.5–32.0) 0.498 Prehospital IV hydration, n (%) 57 (2.9) 38 (4.0) 19 (1.9) 0.014 Physiological parameters (IQR) At the injury scene SBP, mmHg 140.0 (121.0– 160.0) 130.0 (120.0–153.0) 140.0 (120.0– 160.0) 0.048 HR, beats per min 80.0 (72.0–90.0) 80.0 (72.0–90.0) 82.0 (72.0–93.5) 0.414 SI 0.59 (0.51–0.71) 0.60 (0.51–0.70) 0.59 (0.50–0.71) 0.571 At ED arrival SBP, mmHg 147.0 (124.0– 165.0) 134.0 (121.0–162.0) 149.0 (128.0–168.0) <0.001 HR, beats per min 82.0 (71.0–94.0) 82.0 (71.0–95.0) 82.0 (71.0–94.0) 0.603 SI 0.57 (0.47–0.69) 0.58 (0.49–0.72) 0.56 (0.47–0.68) 0.001 GCS 15.0 (14.0–15.0) 15.0 (15.0–15.0) 15.0 (14.0–15.0) 0.131 Mechanism of injury, n (%) 0.433 Blunt 1916 (98.3) 933 (98.1) 983 (98.5) Penetrating 33 (1.7) 18 (1.9) 15 (1.5) ISS (IQR) 9.0 (5.0–14.0) 9.0 (5.0–16.0) 9.0 (5.0–13.0) 0.195 RTS (IQR) 12.0 (11.0–12.0) 12.0 (12.0–12.0) 12.0 (11.0–12.0) 0.004 Clinical course and interventions Length of stay in ICU (IQR), day 0 (0–0.67) 0 (0–0.65) 0 (0–0.67) 0.932 Transfusion, n (%) 443 (22.7) 210 (22.1) 233 (23.3) 0.794 Massive transfusion, n (%) 56 (2.9) 37 (3.9) 19 (1.9) 0.009 30-day mortality, n (%) 149 (7.6) 89 (9.4) 60 (6.0) 0.005 IQR denotes interquartile range. ED d t t ICU i t i it IV i t HR h t t GCS l l IQR denotes interquartile range. IQR denotes interquartile range. IQR denotes interquartile range. ED, emergency department; ICU, intensive care unit; IV, intravenous; HR, heart rate; GCS, glasgow coma scale; ISS, injury severity score; RTS, revised trauma score; SBP, systolic blood pressure; SI, shock index ED, emergency department; ICU, intensive care unit; IV, intravenous; HR, heart rate; GCS, glasgow coma scale; ISS, injury severity score; RTS, revised trauma score; SBP, systolic blood pressure; SI, shock index Page 13/19 Page 13/19 Table 2. Shock-related index between patients with and without massive transfusion in elderly trauma patients x between patients with and without massive transfusion in elderly Table 2. Shock-related index between patients with and without massive transfusion in elderly trauma patients Overall elderly (n = 1949) Non–MT (n = 1893) MT (n = 56) P value Age (IQR), yr 76.0 (70.0–81.0) 76.0 (70.0–81.0) 76.0 (70.0–82.5) 0.766 Male sex, n (%) 1002 (51.4) 964 (50.9) 38 (67.9) 0.012 Taking antihypertensives, n(%) 998 (51.2) 979 (51.7) 19 (33.9) 0.009 Shock-related Index categories At injury scene (prehospital) SBP (IQR), mmHg 140.0 (121.0–160.0) 140.0 (120.0–160.0) 100.0 (100.0–120.0) <0.001 SI (IQR) 0.59 (0.51–0.71) 0.59 (0.51–0.69) 0.83 (0.65–0.90) 0.001 SBP category, n (%) <0.001 >110 mmHg 1768 (90.6) 1742 (92.0) 27 (47.4) 90–110 mmHg 149 (7.7) 125 (6.6) 24 (42.1) <90 mmHg 33 (1.6) 27 (1.4) 6 (10.5) SI category, n (%) <0.001 <0.7 1443 (73.9) 1422 (75.1) 21 (36.8) 0.7–1.0 420 (21.7) 394 (20.8) 27 (47.4) >1.0 86 (4.4) 78 (4.1) 9 (15.8) At ED arrival SBP (IQR), mmHg 147.0 (124.0–165.0) 151.0 (129.0–171.0) 88.0 (80.0–103.0) <0.001 SI (IQR) 0.57 (0.47–0.69) 0.55 (0.46–0.67) 0.94 (0.87–1.06) <0.001 SBP category, n (%) <0.001 >110 mmHg 1692 (86.8) 1670 (88.2) 22 (38.9) 90–110 mmHg 172 (8.8) 168 (8.9) 4 (7.4) <90 mmHg 85 (4.3) 55 (2.9) 30 (53.7) SI category, n (%) <0.001 <0.7 1468 (75.4) 1459 (77.1) 9 (16.7) 0.7–1.0 372 (19.1) 354 (18.7) 18 (31.5) >1.0 109 (5.5) 80 (4.2) 29 (51.9) GCS, n (%) <0.001 >12 1778 (91.3) 1750 (92.3) 28 (50.0) 9–12 68 (3.5) 62 (3.3) 6 (11.4) <9 103 (5.1) 81 (4.3) 22 (38.6) <0.001 Injury severity score, n (%) <0.001 <16 1482 (76.0) 1473 (77.8) 9 (16.1) 16–24 292 (15.0) 267 (14.1) 25 (44.6) >24 175 (9.0) 153 (8.1) 22 (39.3) 30-day mortality, n (%) 149 (7.6) 121 (6.4) 28 (50.0) <0.001 IQR denotes interquartile range. IQR denotes interquartile range. Page 14/19 ED, emergency department; GCS, glasgow coma scale; SBP, systolic blood pressure; SI, shock index j y g y p y p Aged >65 years taking antihypertensives Aged >65 years not taking antihypertensives Crude OR (95% CI) adjusted OR (95% CI) Crude OR (95% CI) adjusted OR (95% CI) A. Prediction of MT Male sex 1.60 (0.64–4.02) 2.51 (0.09-72.7) 2.12 (1.00–4.43) 0.68 (0.16–2.99) Age, yr 0.95 (0.88–1.02) 1.13 (0.91–1.40) 1.02 (0.96–1.07) 0.99 (0.88-1.11) Prehospital SBP <90 mmHg 95.7* (4.78–194) 94.0* (4.16–795) 6.38 (0.67–61.1) 1.02 (0.95–2.25) 90–110 mmHg 28.7* (2.49–133) 28.1* (1.75-52.0) 10.8* (3.17–32.0) 2.37 (0.48–11.7) >110 mmHg 1.00 1.00 1.00 1.00 SI > 1.0. ED 20.7* (7.48–57.2) 8.04 (0.17–83.8) 23.9* (11.6–49.1) 10.3* (2.27-46.3) RTS 0.52* (0.37–0.77) 0.35 (0.10–1.16) 0.33* (0.26–0.43) 0.49* (0.28-0.87) ISS 1.09* (1.05–1.14) 1.08 (0.96–1.22) 1.10* (1.06–1.14) 1.02 (0.93-1.12) B. 30-day mortality Male sex 1.01 (0.60–1.71) 0.29 (0.07-1.25) 2.09* (1.29–3.37) 1.00 (0.31-3.28) Age, yr 1.00 (0.96–1.03) 1.08 (0.98-1.19) 1.00 (0.97–1.03) 0.99 (0.92-1.08) Prehospital SBP <90 mmHg 5.00 (0.50–50.5) 1.00 (0.06–12.0) 4.56 (0.80–26.1) 1.01 (0.26–11.0) 90–110 mmHg 1.50 (0.33–6.93) 2.69 (0.44-16.6) 2.88* (1.06–7.85) 0.79 (0.17-3.72) >110 mmHg 1.00 1.00 1.00 1.00 SI > 1.0. ED 7.96* (3.61–17.5) 0.80 (0.04–17.1) 3.05* (1.51–6.17) 0.06* (0.01-0.56) RTS 0.30* (0.22–0.39) 0.45* (0.28–0.71) 0.28* (0.22–0.36) 0.33* (0.21-0.53) ISS 1.18* (1.14–1.22) 1.12* (1.05–1.20) 1.15* (1.21–1.18) 1.09* (1.02-1.16) Page 15/19 P value < 0.05 P value < 0.05 ED, emergency department; CI, confidence interval; ISS, Injury Severity Score; MT, massive transfusion; OR, odds ratio; RTS, Revised Trauma Score; SBP, systolic blood pressure; SI, shock index ED, emergency department; CI, confidence interval; ISS, Injury Severity Score; MT, massive transfusion; OR, odds ratio; RTS, Revised Trauma Score; SBP, systolic blood pressure; SI, shock index ED, emergency department; CI, confidence interval; ISS, Injury Severity Score; MT, massive transfusion; OR, odds ratio; RTS, Revised Trauma Score; SBP, systolic blood pressure; SI, shock index Table 4. aOR, adjusted odds ratio; CI, confidence interval; ED, emergency department; ISS, Injury Severity Score; RTS, Revised Trauma Score; SBP, systolic blood pressure; SI, shock index Adjusted for sex, age, prehospital SBP, SI measured at ED admission, RTS, and ISS P value < 0.05 IQR denotes interquartile range. Multivariable logistic regression for predicting massive transfusion stratified by age and antihypertensives Aged >65 years not taking antihypertensives Aged >65 years taking antihypertensives Aged <65 years not taking antihypertensives Aged <65 years taking antihypertensives P value aOR (95% CI) P value aOR (95% CI) P value aOR (95% CI) P value aOR (95% CI) Male sex 0.613 0.68 (0.16–2.99) 0.593 2.51 (0.09– 72.6) 0.997 1.00 (0.29– 3.38) 0.108 0.14 (0.01– 1.55) Age, yr 0.836 0.99 (0.88-1.11) 0.271 1.13 (0.91– 1.40) 0.039 1.04 (1.00- 1.07) 0.909 0.99 (0.86– 1.15) Prehospital SBP <90 mmHg 0.959 1.02 (0.95–2.25) 0.012 94.0* (4.16– 795) 0.237 2.12 (0.61– 7.23) 0.441 4.16 (0.11– 36.6) 90–110 mmHg 0.290 2.37 (0.48–11.7) 0.024 28.1* (1.75– 52.0) 0.447 1.58 (0.49– 5.12) 0.049 10.3* (1.01– 44.7) >110 mmHg (reference) – 1.00 – 1.00 – 1.00 – 1.00 SI > 1.0. ED initial 0.002 10.3* (2.27–46.3) 0.291 8.04 (0.17– 83.8) 0.044 3.87* (1.36– 11.0) 0.802 0.67 (0.03– 15.1) RTS 0.015 0.49* (0.28–0.87) 0.087 0.35 (0.11– 1.16) 0.001 0.59* (0.43– 0.81) 0.147 0.52 (0.22– 1.26) ISS 0.655 1.02 (0.93–1.12) 0.216 1.08 (0.96– 1.22) <0.001 1.10* (1.05– 1.14) 0.100 1.06 (0.99– 1.13) Adjusted for sex, age, prehospital SBP, SI measured at ED admission, RTS, and ISS istic regression for predicting massive transfusion stratified by age Table 4. Multivariable logistic regression for predicting massive transfusion stratified by age and antihypertensives Adjusted for sex, age, prehospital SBP, SI measured at ED admission, RTS, and ISS P value < 0.05 Page 16/19 Figures Figures Figure 1 Study flow diagram of trauma stratified by age and antihypertensive use Figure 1 Study flow diagram of trauma stratified by age and antihypertensive use Study flow diagram of trauma stratified by age and antihypertensive use Page 17/19 Page 17/19 Page 17/19 Page 17/19 Figure 2 Red blood cell transfusion amount during the initial 24 hours in subgroups of antihypertensives according to prehospital systolic blood pressure P values calculated by Kruskal–Wallis test with post- hoc analysis. The capped bars indicate 95% confidence intervals. Figure 2 Figure 3 Forest plot multivariable logistic regression analysis for massive transfusion prediction in trauma patients at the injury scene and at the time of emergency department admission in elderly trauma patients Forest plot multivariable logistic regression analysis for massive transfusion prediction in trauma patients at the injury scene and at the time of emergency department admission in elderly trauma patients Figure 2 Red blood cell transfusion amount during the initial 24 hours in subgroups of antihypertensives according to prehospital systolic blood pressure P values calculated by Kruskal–Wallis test with post- hoc analysis. The capped bars indicate 95% confidence intervals. Red blood cell transfusion amount during the initial 24 hours in subgroups of antihypertensives according to prehospital systolic blood pressure P values calculated by Kruskal–Wallis test with post- hoc analysis. The capped bars indicate 95% confidence intervals. Page 18/19 Fi 3 SI.docx Supplementary Files This is a list of supplementary files associated with this preprint. Click to download. Page 19/19
https://openalex.org/W4393164778	https://link.springer.com/content/pdf/10.1007/s11548-024-03094-2.pdf	English	null	PitSurgRT: real-time localization of critical anatomical structures in endoscopic pituitary surgery	International journal of computer assisted radiology and surgery	2,024	cc-by	5,877	Abstract Purpose Endoscopic pituitary surgery entails navigating through the nasal cavity and sphenoid sinus to access the sella using an endoscope. This procedure is intricate due to the proximity of crucial anatomical structures (e.g. carotid arteries and optic nerves) to pituitary tumours, and any unintended damage can lead to severe complications including blindness and death. Intraoperative guidance during this surgery could support improved localization of the critical structures leading to reducing the risk of complications. Methods A deep learning network PitSurgRT is proposed for real-time localization of critical structures in endoscopic pituitary surgery. The network uses high-resolution net (HRNet) as a backbone with a multi-head for jointly localizing critical anatomical structures while segmenting larger structures simultaneously. Moreover, the trained model is optimized and accelerated by using TensorRT. Finally, the model predictions are shown to neurosurgeons, to test their guidance capabilities. Results Compared with the state-of-the-art method, our model signiﬁcantly reduces the mean error in landmark detection of the critical structures from 138.76 to 54.40 pixels in a 1280 × 720-pixel image. Furthermore, the semantic segmentation of the most critical structure, sella, is improved by 4.39% IoU. The inference speed of the accelerated model achieves 298 frames per second with ﬂoating-point-16 precision. In the study of 15 neurosurgeons, 88.67% of predictions are considered accurate enough for real-time guidance. g g Conclusion The results from the quantitative evaluation, real-time acceleration, and neurosurgeon study demonstrate the proposed method is highly promising in providing real-time intraoperative guidance of the critical anatomical structures in endoscopic pituitary surgery. Keywords Surgical scene understanding · Segmentation · Landmark detection · Pituitary tumour International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 https://doi.org/10.1007/s11548-024-03094-2 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 https://doi.org/10.1007/s11548-024-03094-2 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 https://doi.org/10.1007/s11548-024-03094-2 ORIGINAL ARTICLE PitSurgRT: real-time localization of critical anatomical structures in endoscopic pituitary surgery Zhehua Mao1,2 · Adrito Das2 · Mobarakol Islam2,3 · Danyal Z. Khan2,4 · Simon C. Williams2,4 · John G. Hanrahan2,4 · Anouk Borg4 · Neil L. Dorward4 · Matthew J. Clarkson2,3 · Danail Stoyanov1,2 · Hani J. Marcus2,4 · Sophia Bano1,2 Zhehua Mao1,2 · Adrito Das2 · Mobarakol Islam2,3 · Danyal Z. Khan2,4 · Simon C. Williams2,4 · John G. Hanrahan2,4 · Anouk Borg4 · Neil L. Dorward4 · Matthew J. Clarkson2,3 · Danail Stoyanov1,2 · Hani J. Marcus2,4 · Sophia Bano1,2 Received: 19 January 2024 / Accepted: 28 February 2024 / Published online: 25 March 2024 © The Author(s) 2024 B Zhehua Mao z.mao@ucl.ac.uk 1 Department of Computer Science, University College London, London, UK B Zhehua Mao z.mao@ucl.ac.uk 1 Department of Computer Science, University College London, London, UK 2 Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK 3 Department of Medical Physics and Biomedical Engineering, University College London, London, UK 4 Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK Introduction Our contributions are as follows: (1) Based on the HRNet [19] which originally solved the segmentation task only, we proposed a multi-task net- work named PitSurgRT that can solve the anatomy segmentation and landmark detection simultaneously in the endoscopic pituitary surgery. Deep learning encoder–decoder architectures ﬁnd exten- sive application in tasks such as image segmentation and landmarkdetection[6].Convolutionneuralnetworks(CNNs) are often used in the encoder phase to extract features from images, progressively reducing the resolution of the feature maps. Subsequently, the decoding phase involves gradual image reconstruction through upsampling or deconvolution. In[7], apyramidsceneparsingnetwork(PSPNet) was trained to localize the safe and dangerous areas of dissection and anatomical landmarks during the laparoscopic cholecystec- tomy. In [8], an UNet model was trained to predict the positions of critical anatomical structures in the nasal phase of endoscopic pituitary surgery. In [9], a multi-task network (PAINet) was proposed to identify the areas of the sella and clival recess, and central points of eight other critical struc- tures during the sellar phase of endoscopic pituitary surgery. Based on a U-Net++ [10] architecture with an EfﬁcientNetB3 encoder [11], PAINet achieved state-of-the-art performance on the dataset. However, while PAINet managed to give tem- porally consistent segmentation performance, the detection of landmarks required extensive improvement. Deep learning encoder–decoder architectures ﬁnd exten- sive application in tasks such as image segmentation and landmarkdetection[6].Convolutionneuralnetworks(CNNs) are often used in the encoder phase to extract features from images, progressively reducing the resolution of the feature maps. Subsequently, the decoding phase involves gradual image reconstruction through upsampling or deconvolution. (2) An effective loss function that combines four losses is proposed in this paper to solve the issue of the highly imbalanced dataset for the training. In[7], apyramidsceneparsingnetwork(PSPNet) was trained to localize the safe and dangerous areas of dissection and anatomical landmarks during the laparoscopic cholecystec- tomy. In [8], an UNet model was trained to predict the positions of critical anatomical structures in the nasal phase of endoscopic pituitary surgery. In [9], a multi-task network (PAINet) was proposed to identify the areas of the sella and clival recess, and central points of eight other critical struc- tures during the sellar phase of endoscopic pituitary surgery. Based on a U-Net++ [10] architecture with an EfﬁcientNetB3 encoder [11], PAINet achieved state-of-the-art performance on the dataset. However, while PAINet managed to give tem- porally consistent segmentation performance, the detection of landmarks required extensive improvement. Introduction the brain close to critical nerves and vessels [1, 2]. Tumours formed on this gland may lead to symptoms such as vision loss and changes in bodily function [3]. Endoscopic pituitary surgery is the gold-standard method for removing pituitary tumours [3]. With the assistance of an endoscope to visu- alize the procedure, surgeons enter the sella through the nasal cavity, with the aim of maximizing tumour resection whilst minimizing collateral damage to critical surrounding anatomical structures [3]. Identifying these critical structures is challenging, as the structures are located behind the sphe- noid bone so their position can only be inferred from the their imprints on the bone (see Fig. 1) [1, 2]. Failure to distinguish the safe sella region, behind which the tumour is located, from the other structures may lead to adverse effects [2]. The pituitary gland secretes hormones essential for support- ing human life. It is a pea-sized gland found at the base of 2 Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK 3 Department of Medical Physics and Biomedical Engineering, University College London, London, UK 4 Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK 12 3 123 1054 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 During the surgery, the most common way to locate these anatomical landmarks involves using an optical tracking sys- tem [4]. This system registers the patient’s head to a 3D magnetic resonance image before the operation, and then a tracked pointer is used to identify the speciﬁc areas of the sella and landmarks of other critical structures on the sphe- noid bone [4]. However, if the surgeon’s view is obstructed by blood or if they remove and then replace the endoscope in the sphenoid sinus, they may need to re-identify these critical anatomical structures. Moreover, this process is time- consuming, disrupts surgical workﬂow, and can also bring in potential risks [2, 5]. tion in practice, which can reduce the dependence on the network structure design. Among these methods, open neu- ral network exchange (ONNX)1 and NVIDIA TensorRT2 are most widely used. ONNX is a standard for model inter- change, allowing models to be shared between different deep-learning frameworks. TensorRT, on the other hand, is focused on accelerating the inference of deep learning mod- els on NVIDIA GPUs. Improving on the downfalls of PAINet [9], PitSurgRT is proposed. Introduction (3) Through the ﬁvefold cross-validation based on the in- vivo dataset, the proposed PitSurgRT is demonstrated to signiﬁcantly improve the landmark detection and seman- tic segmentation of the critical anatomical structures in the sellar phase of endoscopic pituitary surgery com- pared with our previous work PAINet. (4) The proposed model is accelerated by using the Ten- sorRT technique to achieve real-time intraoperative guidance. The results are veriﬁed by 15 neurosurgeons. To the best of our knowledge, this is the ﬁrst work that can achieve real-time and simultaneous inference of anatomy segmentation and landmark detection in endoscopic pituitary surgery. Moreover, real-time inference is always needed for intra- operative guidance in clinical settings. In general, the pursuit of ever more accurate results frequently results in highly complex deep learning architectures that are computation- ally costly and slow [12]. One approach to this issue is to design more efﬁcient architectures by using techniques such as downsampling and upsampling [13], efﬁcient convolution [14], residual connection [15]. In [16], by holistically and efﬁciently aggregating spatiotemporal knowledge through the convolutional long short-term memory (LSTM) lay- ers, the method achieves real-time instrument segmentation. In [17], authors designed an encoder–decoder architecture featuring a residual block with a squeeze-and-excitation network, achieving real-time segmentation in colonoscopy with fewer parameters. Despite achieving real-time perfor- mance with well-designed architectures, these methods face constraints, especially when utilizing common backbone networks in deep learning models, where backbone architec- tures usually remain unchanged [12]. In these cases, using model acceleration techniques [18] is a more ﬂexible solu- 1 https://github.com/onnx/onnx. 2 https://developer.nvidia.com/tensorrt. 1 https://github.com/onnx/onnx. 2 https://developer.nvidia.com/tensorrt. Clinical motivation and validation The pituitary tumour is found behind the sella, highlighted in blue in Fig. 1, and is required to be opened during endoscopic pituitary surgery. The clival recess, highlighted in yellow in Fig. 1, is not as surgically important as the other structures. However, as it is a large, visually distinct, and common struc- ture, it provides additional visual information to help locate the other structures while training the model. Our problem is focused on landmark detection of four critical structures, namely the left and right carotid and the left and right optic protuberance, shown in Fig. 1. Since these 123 123 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 1055 Fig. 1 Critical anatomical structures as present during the sellar phase of endoscopic pituitary surgery. Sella (1) and Clival Recess (2) are rela- tively bigger structures and easy to identify. Carotids (3 left, 6 right) and Optic Protuberance (4 left, 5 right) are critical neurovascular structures to be avoided HRNet as the base model to maintain high-resolution repre- sentations. Compared with UNet++ structure used in PAINet, which maintains multi-resolution representation to improve spatial precision by continuously fusing low-resolution expression with high-resolution expression, HRNet not only maintains several resolutions in a parallel manner but also repeatedly fuses high and low resolutions between stages to boost high-resolution and low-resolution representations [19], which are beneﬁcial for both segmentation and land- mark detection tasks. Fig. 1 Critical anatomical structures as present during the sellar phase of endoscopic pituitary surgery. Sella (1) and Clival Recess (2) are rela- tively bigger structures and easy to identify. Carotids (3 left, 6 right) and Optic Protuberance (4 left, 5 right) are critical neurovascular structures to be avoided The proposed PitSurgRT architecture is shown in Fig.2. The input image ﬁrst passes through a stem, and the image resolution is reduced to 1/4 of the original through two 3×3 convolution operations with a step size of 2. Then, the output feature maps pass the main body of the HRNet consisting of four stages with four parallel convolution branches. The resolutions of feature maps in four branches are maintained as 1/4, 1/8, 1/16, and 1/32, respectively. The ﬁrst stage of the HRNet consists of four residual units and the width of the output feature maps are 48 and 96 for the two branches formedinstage2.Startingfromthesecondstage,eachbranch will maintain a ﬁxed feature map width. Multitask heads Following the output feature map, two heads are connected that are responsible for the (a) segmentation of sella and clival recessand(b)landmarkdetectionoftheotherfouranatomies, respectively. Thesegmentationheadcontainsa1×1convolutionallayer with stride 1, followed by batch normalization and ReLU activation, and ﬁnally outputs the segmentation results by using a 1 × 1 convolutional layer with stride 1, followed by argmax activation and upsampling to recover the original resolution for segmentation. Clinical motivation and validation Every time from the previous stage to the next stage, the number of branches will increasebyone,andthefeaturemapwidthofthenewlyadded branch is twice that of the previous branch. The ﬁnal feature map widths of the four branches are 48, 96, 192, and 384, respectively. Between each two stages, the high-resolution feature maps and the low-resolution feature maps will be fused to exchange information. After the fourth stage, the low-resolution feature maps are upsampled and then fused with the output of the ﬁrst branch to obtain a high-resolution feature map with 720 channels. structures are small with poorly deﬁned boundaries, segmen- tation is not desired. The remaining 4-structures detected in [9] have not been used in this study as they are considered less important for the surgery compared to other structures. The proposed model is measured by the performance of: (i) the semantic segmentation of the sella and clival recess, using the mean interval over union (mIoU) metric; and (ii) the landmark detection of the remaining 4-structures, using the meanpercentageofcorrectkeypointswithin20%(MPCK20) and mean distance (mDistance) metrics. MPCK20 is the per- centage of predicted landmarks that fall within a 144-pixel (20% of the image) radius of the ground truth, mean-averaged across the 4 structures. mDistance is the Euclidean distance betweenthepredictedandtheground-truthlandmarks,mean- averaged across the 4 structures. Clinical Validation: As many images in our dataset are not fully labelled, (i.e. some anatomical structures do not have ground truth on images), a clinical validation test was conducted on the proposed model validation outputs. 10 predicted outputs (without ground-truth labels) from 10 ran- domly selected patients were selected. For each landmark predicted on each image, the neurosurgeons were requested to rate them on a scale of 1 to 5, where (1) not accurate at all; (2) somewhat accurate but acceptable; (3) sufﬁciently accurate to be acceptable; (4) accurate; (5) very accurate. Fifteen neurosurgeons (4 consultants, 11 trainees) evaluated the outputs by questionnaire. Combined losses for highly imbalanced dataset efﬁciency. The open-source library torch2trt3 was used to convert our PyTorch model to the tensorRT engines directly. While focal loss (FL) and mean squared error (MSE) loss are commonly used for imbalanced datasets and landmark detection in a variety of works, highly imbalanced class distributions are found in our datasets (see section “Data description and preparation” for details). Therefore, it is nec- essary to design a set of optimal combinations to achieve high-quality segmentation and landmark detection. Through extensive ablation studies (see section “Ablation study”), it was found the following combination of four losses is very effective for our tasks: Data description and preparation The dataset used in this study is the same as those used in [9], which consists of 635 frames obtained from 64 endoscopic pituitary surgery videos. Due to the challenges of annotating these images, the task was completed by four experts with consensus. Please refer to [9] for more details about annota- tion. Even so, there are still many anatomical structures that are not annotated. Except for the two largest areas sella and clival recess, only at most 65% of the data for the remaining anatomical structures have been annotated. (1) Loss = w1Dice + w2BDL + w3Wing + w4FL, (1) where the combination of Dice and boundary loss (BDL) are responsible for segmentation [21]. The combination of Wing loss [22] and focal loss (FL) is used for landmark detection. w1, w2, w3, and w4 are hyperparameters which are used to balance the losses. To validate the performance of the proposed model, ﬁve- fold cross-validation is used. Images are randomly split such that the number of structures in each fold is similar. Images from the same patients are put into the same fold, presenting in either the training or validation dataset. The class distri- bution over ﬁve folds is presented in Fig. 3. The proposed method is implemented using PyTorch 1.12.0 on Python 3.8.17. The code is available here https:// github.com/ZH-Mao/PitSurgRT.git. Proposed PitSurgRT While an encoder–decoder architecture like UNet [20] has been demonstrated to be effective for segmentation tasks in biomedical images, the resolution reduction in continuous downsampling causes the loss of spatial detail information, especially in the pooling layers, which is detrimental to position-sensitive vision problems such as landmark deten- tion [9, 19]. Therefore, to improve the performance of PAINet [9], especially for landmark detection, we utilize In terms of head for landmark detection, the output feature maps are passed through 1×1 convolutional layer with stride 1, active average pooling with output size 1, ReLU activation, and fully connected layers to output the eight coordinates of four landmarks on the target image. 123 12 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 1056 Fig. 2 The architecture of PitSurgRT for simultaneous segmentation and landmark detection Fig. 2 The architecture of PitSurgRT for simultaneous segmentation and landmark detection 3 https://github.com/NVIDIA-AI-IOT/torch2trt. Training details While maintaining high-resolution representations and low representations together is promising to improve the per- formance of segmentation and landmark detection, such an architecture requires more computational resources and time, which is detrimental to intraoperative guidance that requires real-time performance. The training and validation processes are completed on an NVIDIA DGX A100 server on a single GPU with 48 GB memory. The proposed network is optimized by using an SGD optimizer during the training, with a momentum value of 0.9. The initial learning rate is set as 0.01 and a linearly decreasing scheduler is used for adjusting the learning rate every epoch. The minimum learning rate is 0.0001, and the model is trained for 500 epochs. For the ﬁrst 300 epochs, only the segmentation head was trained while the landmark detection head was frozen. In the subsequent 200 epochs, both were trained simultaneously. ThankstothemodelaccelerationengineTensorRT,wecan optimize and accelerate our proposed PitSurgRT on NVIDIA GPUs to achieve real-time performance. TensorRT offers options for accelerating trained models with various preci- sions such as 32-bit ﬂoating point precision (FP32), 16-bit ﬂoating point (FP16), and 8-bit integer precision (INT8). There is a trade-off between the model’s precision and 123 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 1057 Fig. 3 Class distribution per fold of the critical anatomical structures. The total number of images is 635 Given a limited number of annotated images for training, data augmentation is used. We shift images in the training dataset by up to 10% in any direction, zoom out or in images by up to 30%, and rotate them around the centre of images up to 30 degrees. In addition, we randomly increase or decrease brightness, contrast, and saturation by up to 30%, and hue by up to 10%. 50% of training data are augmented in each epoch. In addition, since many images in our datasets are not fully labelled, we use a sampler in our data loader to increase the probability of images with more anatomical structures on them. The probability is equal to the reciprocal of the number of images with the same number of anatomical structures. MPCK20). This is further improved with the proposed weighted loss, with +3.54% segmentation mIoU and +2.55% landmark MPCK20. Training details Although calibration parameters of endoscopes are not available, according to [23], the diameter of the sella is about 10–15mm, which is around 200–300 pix- els in our dataset. Thus, we estimate the scale of our images is about 0.05 mm/pixel. Therefore, according to Table 1, it can be estimated that the accuracy of landmark detection using our method is around 2.35−3.10 mm. The ablation studies displayed in Table 2 show the proposed weighted loss is most effective, with a −7.53 mDistance pixel improvement over the next best loss. While IoU of clival recess is compara- tively low, this is mainly because of this structure (a) not having a well-deﬁned boundary and (b) missing annotations. However, as mentioned in section “Clinical motivation and validation”, clival recess is not considered critically impor- tant by the surgeons. Ablation study Toﬁndthebestcombinationoflossesandtheircorresponding weights, extensive ablation studies are conducted. We start with the same loss combination as that used in PAINet, i.e. (FL + MSE), followed by testing various loss combination strategies, which are listed in the ﬁrst column in Table 2. For the preliminary tests about loss combination, the weight parameters are added empirically so that all losses are of the same order of magnitude. After the best combination of losses is found, the weight parameters are ﬁne-tuned. Figure 4 shows the qualitative results on images from four different surgeries also showcasing the inter-patient variabil- ity in such procedure. Note that all predictions appeared in anatomically correct regions. Figure 4a and b shows cases where the landmarks align 100% with the groundtruth, and this is also conﬁrmed by the strong agreement among the consultant and trainee neurosurgeons mostly rating these cases as precisely accurate. In Fig. 4c, left optic protuber- ance did not accurately align with the groundtruth. Figure 4d is the most challenging case, where the predicted landmarks, though within MPCK20, were not 100% aligned with the groundtruth. There were disagreement in surgeons’ rating for this case too, considering the visually different and clinically challenging nature of this case. In addition, we also investigate the precision selection during the model optimization process using tensorRT. We compare the results of the original model, the converted model with FP32 precision, and the converted model with FP16precisionintermsofbothaccuracyandinferencespeed. Results and discussion The bottom row is the proposed model, PitSurgRT Table 1 Comparison with PAINet (ﬁvefold cross-validation, results are displayed as mean ± std) Model Loss Sella Clival recess Sella Clival recess Landmarks IoU(%) Precision(%) MPCK20 (%) Distance (pixels) PAINet FL+MSE 62.69 ± 1.90 36.59 ± 5.40 84.12 ± 3.70 71.12 ± 4.80 51.20 ± 2.80 138.76 ± 2.30 HRNetv2 FL+MSE 63.18 ± 4.59 42.65 ± 8.75 79.44 ± 2.74 69.17 ± 11.22 95.35 ± 3.81 65.53 ± 10.21 HRNetv2 CE+MSE 63.58 ± 4.20 45.97 ± 5.27 79.67 ± 3.00 67.29 ± 7.87 97.31 ± 3.70 64.13 ± 7.60 PitSurgRT 0.9Dice+0.1BDL 67.00 ± 4.18 45.92 ± 5.21 81.3 ± 2.70 71.72 ± 8.81 97.90 ± 4.01 54.48 ± 7.45 +0.8Wing+0.2FL* Denotes resampled. Bold values indicate the best-performing model for that column’s metric Table 2 Ablation studies (single-fold) Loss Sella Clival recess Sella Clival recess Landmarks IoU(%) Precision(%) MPCK20 (%) Distance (pixels) CE+MSE+BCE 68.01 47.14 73.23 63.20 75.39 102.09 CE+MSE+FL 68.06 49.07 72.98 66.84 86.43 84.05 CE+Wing+FL 66.83 49.34 71.86 65.33 99.22 60.22 CE+Wing+FL 68.07 49.65 71.99 63.26 99.81 57.85 1.2CE+0.8ABL+Wing+FL* 68.12 49.65 73.83 67.50 99.61 62.94 CE+0.01BDL+Wing+FL* 67.87 47.50 72.42 65.55 99.22 60.00 gDice+0.01BDL+Wing+FL* 66.09 51.29 80.14 72.39 100.00 61.43 Dice+0.1BDL+Wing+FL* 69.28 49.06 79.65 68.14 99.81 57.68 0.9Dice+0.1BDL+0.8Wing+0.2FL* 72.06 47.96 82.51 81.16 100.00 50.15 Denotes resampled. gDice stands for generalized Dice. Bold values indicate the best-performing model for that column’s metric. The bottom row is the proposed model, PitSurgRT Table 3 Comparison of model acceleration (ﬁvefold cross-validation, results are displayed as mean ± std) Model IoU(%) MPCK20 (%) mDistance (pixels) Inference time (milliseconds) Frames per second (fps) Sella Clival recess PyTorch model 67.00 ± 4.18 45.92 ± 5.21 97.90 ± 4.01 54.48 ± 7.45 90.18 ± 5.15 11.12 ± 0.60 TensorRT engine (FP32) 67.00 ± 4.18 45.92 ± 5.21 97.90 ± 4.01 54.48 ± 7.45 44.13 ± 7.95 233.77 ± 39.81 TensorRT engine (FP16) 67.00 ± 4.18 45.93 ± 5.23 97.90 ± 4.01 54.48 ± 7.45 33.55 ± 1.65 298.81 ± 14.80 Bold values indicate the most efﬁcient model for that column’s metric Table 3 Comparison of model acceleration (ﬁvefold cross-validation, results are displayed as mean ± std) considered accurate and inaccurate to identify are displayed in Fig. 4a and d, respectively. considered accurate and inaccurate to identify are displayed in Fig. 4a and d, respectively. to random factors. The results demonstrate real-time perfor- mance of our model is feasible in practice. Results and discussion The results from the PitSurgRT output clinical validation study are displayed in Fig. 5. On mean-average, 88.67% of all neurosurgeons agreed the landmark detection outputs were acceptable, increasing to 89.4% of consultants. Less than 1.34% of neurosurgeons (0.00% of consultants) believed the outputs were (1) Not accurate at all. This is because images challenging for PitSurgRT are even difﬁcult for consultant neurosurgeons to identify landmarks on. This is the primary reason ground-truth landmarks were not available for such cases. The clinical validation study demonstrates the suc- cess of the network, and that clinical translation is desirable. Moreover, with PitSurgRT already having real-time imple- mentation, feasibility trials in mock operating room settings are planned next. Example images where landmarks were Results and discussion While half-precision generally leads to lower perfor- mance, it is found that our TensorRT-FP16 model has an over 25× speed improvement over PyTorch, with no appar- ent decline in segmentation and detection performance, as displayed in Table 3. The slight improvement of the model with FP16 in the segmentation of the clival recess was due From Table 1, it is clear HRNetv2 has signiﬁcantly improved performance over the current state-of-the-art, PAINet. When using the same loss (FL + MSE), there is a small improve- ment in segmentation performance (+3.28% mIoU) but a signiﬁcant improvement in landmark detection (+44.15% 12 3 3 3 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 1058 Table 1 Comparison with PAINet (ﬁvefold cross-validation, results are displayed as mean ± std) Model Loss Sella Clival recess Sella Clival recess Landmarks IoU(%) Precision(%) MPCK20 (%) Distance (pixels) PAINet FL+MSE 62.69 ± 1.90 36.59 ± 5.40 84.12 ± 3.70 71.12 ± 4.80 51.20 ± 2.80 138.76 ± 2.30 HRNetv2 FL+MSE 63.18 ± 4.59 42.65 ± 8.75 79.44 ± 2.74 69.17 ± 11.22 95.35 ± 3.81 65.53 ± 10.21 HRNetv2 CE+MSE 63.58 ± 4.20 45.97 ± 5.27 79.67 ± 3.00 67.29 ± 7.87 97.31 ± 3.70 64.13 ± 7.60 PitSurgRT 0.9Dice+0.1BDL 67.00 ± 4.18 45.92 ± 5.21 81.3 ± 2.70 71.72 ± 8.81 97.90 ± 4.01 54.48 ± 7.45 +0.8Wing+0.2FL Denotes resampled. Bold values indicate the best-performing model for that column’s metric Table 2 Ablation studies (single-fold) Loss Sella Clival recess Sella Clival recess Landmarks IoU(%) Precision(%) MPCK20 (%) Distance (pixels) CE+MSE+BCE 68.01 47.14 73.23 63.20 75.39 102.09 CE+MSE+FL 68.06 49.07 72.98 66.84 86.43 84.05 CE+Wing+FL 66.83 49.34 71.86 65.33 99.22 60.22 CE+Wing+FL 68.07 49.65 71.99 63.26 99.81 57.85 1.2CE+0.8ABL+Wing+FL* 68.12 49.65 73.83 67.50 99.61 62.94 CE+0.01BDL+Wing+FL* 67.87 47.50 72.42 65.55 99.22 60.00 gDice+0.01BDL+Wing+FL* 66.09 51.29 80.14 72.39 100.00 61.43 Dice+0.1BDL+Wing+FL* 69.28 49.06 79.65 68.14 99.81 57.68 0.9Dice+0.1BDL+0.8Wing+0.2FL* 72.06 47.96 82.51 81.16 100.00 50.15 *Denotes resampled. gDice stands for generalized Dice. Bold values indicate the best-performing model for that column’s metric. Conclusion The intraoperative localization of crucial anatomical struc- tures in the sellar phase of endoscopic pituitary surgery poses a formidable challenge due to the limited visibility of critical structures, the demand for high accuracy, and the imperative for real-time inference. In this paper, a multi- task model PitSurgRT is proposed to achieve real-time and simultaneous inference of anatomy semantic segmentation and landmark detection with improved accuracy. Compared to the current state-of-the-art, PAINet, PitSurgRT achieved 67.00% (+4.31%) and 45.92% (+9.33%) IoU for sella and clival recess segmentation, respectively. More impressively, 123 123 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 1059 Fig. 4 Qualitative evaluation of the predicted results Not accurate at all Somewhat accurate but acceptable Sufficiently accurate to be acceptable Accurate Very accurate Fig. 5 Clinical validation results in which 4 consultant neurosurgeons and 11 trainee neurosurgeons participated to validate the accuracy of PitSurgRT on surgical images from 10 patients it achieved 97.90% (+46.7%) MPCK20 and 54.48 (−84.28) mDistance for 4-structure landmark detection. In the clinical Acknowledgements This research was funded in whole, or in part, by the Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) [203145/Z/16/Z]; the Engineering and Physical Sciences Fig. 4 Qualitative evaluation of the predicted results Fig. 4 Qualitative evaluation of the predicted results Not accurate at all Somewhat accurate but acceptable Sufficiently accurate to be acceptable Accurate Very accurate Fig. 5 Clinical validation results in which 4 consultant neurosurgeons and 11 trainee neurosurgeons participated to validate the accuracy of PitSurgRT on surgical images from 10 patients Fig. 5 Clinical validation results in which 4 consultant neurosurgeons and 11 trainee neurosurgeons participated to validate the accuracy of PitSurgRT on surgical images from 10 patients it achieved 97.90% (+46.7%) MPCK20 and 54.48 (−84.28) mDistance for 4-structure landmark detection. 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Holder CJ, Shaﬁque M (2022) On efﬁcient real-time semantic seg- mentation: a survey. arXiv preprint arXiv:2206.08605 Informed consent Informed written patient consent was obtained for the data used for AI model development. 13. Li H, Xiong P, Fan H, Sun J (2019) Dfanet: deep feature aggre- gation for real-time semantic segmentation. In: Proceedings of the IEEE/CVF conference on computer vision and pattern recognition, pp 9522–9531 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adap- tation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indi- cate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitteduse,youwillneedtoobtainpermissiondirectlyfromthecopy- right holder. To view a copy of this licence, visit http://creativecomm ons.org/licenses/by/4.0/. 14. Zhang X, Zhou M, Sun J (2018) Shufﬂenet: an extremely efﬁcient convolutional neural network for mobile devices. In: Proceedings of the IEEE conference on computer vision and pattern recognition, pp 6848–6856 15. Sandler M, Howard A, Zhu M, Zhmoginov A, Chen L-C (2018) Mobilenetv2: Inverted residuals and linear bottlenecks. In: Pro- ceedings of the IEEE conference on computer vision and pattern recognition, pp 4510–4520 16. Wang J, Jin Y, Wang L, Cai S, Heng P-A, Qin J (2021) Efﬁ- cient global-local memory for real-time instrument segmentation of robotic surgical video. In: Medical image computing and computer assisted intervention–MICCAI 2021: 24th international conference, Strasbourg, France, September 27–October 1, 2021, proceedings, Part IV 24, pp 341–351 Conclusion HJM is supported by WEISS [NS/A000050/1] and by the National Institute for Health and Care Research (NIHR) Biomedical Research Centre at University College London (UCL). With thanks to Digital Surgery Ltd, a Medtronic com- pany, for access to Touch SurgeryTM Enterprise, a combined hardware An international Delphi consensus panel determined the phases for endoscopic transsphenoidal pituitary adenoma resection surgery [5]. This process identiﬁed that landmark detection is key to the success of this surgery. In this paper, wehavepresentedtechnological progress inidentifyingthese landmarks. Future work will deploy this system and assess clinical impact. 123 123 123 3 1060 International Journal of Computer Assisted Radiology and Surgery (2024) 19:1053–1060 and software solution for video recording, secure storage and annota- tion. work for anatomy identiﬁcation in endoscopic pituitary surgery. In: International conference on medical image computing and computer-assisted intervention, pp 472–482 10. Zhou Z, Rahman Siddiquee MM, Tajbakhsh N, Liang J (2018) Unet++: a nested u-net architecture for medical image segmenta- tion. 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https://openalex.org/W3164561784	http://journal.stikesborneocendekiamedika.ac.id/index.php/jbc/article/download/178/178	Indonesian	null	PENGARUH KONSUMSI BAWANG PUTIH TERHADAP KADAR KOLESTEROL PADA PENDERITA HIPERKOLESTEROLEMIA (Studi di Desa Handil Sohor Kecamatan Mentaya Hilir Selatan Kabupaten Kotawaringin Timur)	Jurnal Borneo Cendekia	2,018	cc-by	3,290	129 129 THE INFLUENCE OF CONSUMPTION OF GARLIC AGAINST CHOLESTEROL LEVELS IN PEOPLE WITH HYPERCHOLESTEROLEMIA (Study in the village of Handil Sohor Subdistric of Mentaya Hilir Selatan Regency of Kotawaringin Timur) THE INFLUENCE OF CONSUMPTION OF GARLIC AGAINST CHOLESTEROL LEVELS IN PEOPLE WITH HYPERCHOLESTEROLEMIA (Study in the village of Handil Sohor Subdistric of Mentaya Hilir Selatan Regency of Kotawaringin Timur) ABSTRAK Pendahuluan: Hiperkolesterolemia merupakan salah satu penyebab terjadinya penyakit jantung dan stroke. Hiperkolesterolemia dapat di atasi dengan konsumsi bawang putih. Tujuan dari penelitian ini adalah untuk menganalisa pengaruh konsumsi bawang putih terhadap kadar kolesterol pada penderita hiperkolesterolemia di Desa Handil Sohor. Metode penelitian:Desain penelitian ini menggunakan one group pre tes post tes design pada penderita hiperkolesterolemia di Desa Handil Sohor Tahun 2017 yang berjumlah 32 orang dengan teknik total sampling. Teknik analisis bivariat dengan analisis Wilcoxon sign Rank test dan distribusi frekuensi untuk univariat (kadar kolesterol) . Metode pengumpulan data menggunakan lembar observasi dan alat tes kadar kolesterol untuk variabel hiperkolesterolemia. Hasil penelitian: Kadar kolesterol sebelum konsumsi bawang putih sebagian besar responden mengalami kadar kolesterol kategori sedang dengan jumlah 26 orang (81%) dengan rata – rata 219 mg/dl. Sedangkan setelah konsumsi bawang putih, responden mengalami kadar kolesterol kategori normal dengan jumlah 20 orang (64%) dengan rata – rata 204 mg/dl dengan hasil uji wilcoxon 0,000 menunjukan nilai p < 0,05 menggunakan aplikasi SPSS V16.0. Kesimpulan: Berdasarkan hal tersebut maka dapat disimpulkan bahwa terdapat pengaruh yang signifikan antara konsumsi bawang putih terhadap kadar kolesterol pada penderita hiperkolesterolemia. Saran: Memberikan alternatif penanganan kolesterol saat penderita hiperkolesterolemia mengalami kadar kolesterol tinggi selain meminum obat. Kata kunci : bawang putih, kadar kolesterol, hiperkolesterolemia THE INFLUENCE OF CONSUMPTION OF GARLIC AGAINST CHOLESTEROL LEVELS IN PEOPLE WITH HYPERCHOLESTEROLEMIA (Study in the village of Handil Sohor Subdistric of Mentaya Hilir Selatan Regency of Kotawaringin Timur) Kata kunci : bawang putih, kadar kolesterol, hiperkolesterolemia Keywords: garlic, levels of cholesterol, hypercholesterolemia 50% serangan jantung yang di sebabkan oleh kadar kolesterol tinggi. Di Indonesia, penderita penyakit jantung koroner sebesar 2.650.340 jiwa, penyakit gagal jantung sebesar 229.696 jiwa, dan penderita penyakit stroke sebesar 1.236.825 jiwa yang berkaitan dengan tingginya kejadian hiperkolesterolemia (Kementerian Kesehatan RI, 2013). Kasus ini meningkat pertahunnya sebanyak 28% dan menyerang usia produktif yaitu usia di bawah 40 tahun (Harian Merdeka, 2013, dikutip dalam Meutia, 2014). Di Provinsi Kalimantan Tengah sebanyak 14.475 penderita hiperkolesterolemia risiko terjadinya penyakit jantung dan stroke (KemenKes RI,2013). Data dari DINKES Kabupaten Kotawaringin Timur (2015), terdapat 275 jiwa penderita hiperkolesterolemia di Kecamatan Mentaya Hilir Selatan. Data UPTD Puskesmas Samuda menyebutkan, ada 32 jiwa yang terkena kolesterol tinggi. 50% serangan jantung yang di sebabkan oleh kadar kolesterol tinggi. Di Indonesia, penderita penyakit jantung koroner sebesar 2.650.340 jiwa, penyakit gagal jantung sebesar 229.696 jiwa, dan penderita penyakit stroke sebesar 1.236.825 jiwa yang berkaitan dengan tingginya kejadian hiperkolesterolemia (Kementerian Kesehatan RI, 2013). Kasus ini meningkat pertahunnya sebanyak 28% dan menyerang usia produktif yaitu usia di bawah 40 tahun (Harian Merdeka, 2013, dikutip dalam Meutia, 2014). Di Provinsi Kalimantan Tengah sebanyak 14.475 penderita hiperkolesterolemia risiko terjadinya penyakit jantung dan stroke (KemenKes RI,2013). Data dari DINKES Kabupaten Kotawaringin Timur (2015), terdapat 275 jiwa penderita hiperkolesterolemia di Kecamatan Mentaya Hilir Selatan. Data UPTD Puskesmas Samuda menyebutkan, ada 32 jiwa yang terkena kolesterol tinggi. D t d t j k b h ABSTRACT Introduction: Hypercholesterolemia is one of the causes of the occurrence of heart disease and stroke. Hypercholesterolemia can be corrected with the consumption of garlic. The purpose of this study was to analyze the influence of garlic consumption against the cholesterol levels in people with hypercholesterolemia in the village of Handil Sohor. Redeach Mhetod: This research Design using one group pre test post 130 test design on hypercholesterolemia in the village of sufferers Handil Sohor Year 2017 which totaled 32 people with total sampling techniques. Bivariat analysis techniques with analysis of the Wilcoxon signed Rank test and frequency distribution for univariate (cholesterol levels). Data collection method using sheets of observation and tests for cholesterol levels of the variable hypercholesterolemia. Result and discussion: Cholesterol levels before consumption of garlic, most respondents experienced moderate category cholesterol levels with a total of 26 people (81%) with an average 219 mg/dl. Whereas after consumption of garlic, respondents undergo cholesterol levels normal category with a total of 20 people (64%) with an average 204 mg/dl with wilcoxon 0.000 test results show p value < 0.05 using SPSS 16.0 application. Conclusion: Based on this it can be inferred that there was significant influence between the consumption of garlic against cholesterol levels in people with hypercholesterolemia. PENDAHULUAN Makanan menjadi kebutuhan manusia sehari hari untuk menutrisi tubuh. Makanan mengandung gizi seperti protein, karbohidrat dan juga lemak. Lemak yang di gunakan oleh tubuh sebagai cadangan makan dan cadangan energi akan berguna baik bila jumlahnya dalam batas normal. Namun, jika jumlah lemak dalam tubuh terlalu berlebih maka akan terjadi gangguan – gangguan metabolisme yaitu hiperkolesterolemia. Faktor risiko terjadinya penyakit kardiovaskular seperti jantung koroner (PJK) dan stroke di sebabkan oleh hiperkolesterolemia. Selama ini, hiperkolesterolemia di tangani secara farmakologi seperti mengkonsumsi obat jenis statin, tetapi penggunaan tanaman herbal juga dapat mengatasi kadar kolesterol yang tinggi salah satunya yaitu bawang putih. Laporan Badan Kesehatan Dunia (WHO), September 2009, menyebutkan bahwa penyakit kardiovaskular merupakan penyebab kematian pertama sampai saat ini. Badan Kesehatan Dunia (WHO) menunjukan 20% serangan stroke dan Data – data menunjukan bahwa penyakit hiperkolesterolemia yang menjadi faktor resiko terjadinya penyakit kardiovaskular dan stroke menjadi masalah serius yang perlu di 131 perhatikan sebagia upaya pencegahan agar tidak berkelanjutan terjadinya penyakit kardiovaskular dan stroke. Bawang putih yang mengandung allicin dan alliin bermanfaat sebagai antikolesterol dan memperkecil gejala dari penyakit jantung dan menyembuhkan tekanan darah tinggi. Pada salah satu studi yang di edarkan dalam The Journal of The Royal Collage of Physicians oleh Silagy CS dan Neil HAW tahun 1994, mengungkapkan bahwa bawang putih merupakan pelopor untuk mengurangi lemak dalam tubuh dan yang terpenting ialah membantu proses penyembuhan dari kolesterol tinggi (Utami & Mardiana, 2013). Bawang putih di pakai sebagai pengobatan karena di percaya sebagai sumber alliin, yaitu bahan kimia yang mengandung sulfur dari asam amino. Alliin ini membantu meningkat kadar kolesterol HDL atau kolesterol baik sekaligus memperlambat sintesis endogen kolesterol. atau himpunan objek dengan ciri yang sama (Santoso, 2005:46) Populasi dalam penelitian ini yaitu penderita hiperkolesterolemia di Desa Handil Sohor Kecamatan Mentaya Hilir Selatan Kabupaten Kotawaringin Timur sebanyak 32 orang. Sampel adalah bagian dari populasi yang akan di teliti atau bagian jumlah dari karakteristik yang dimiliki oleh populasi (Hidayat & Alimun, 2010). Sampel dalam penelitian ini adalah seluruh penderita hiperkolesterolemia di Desa Handil Sohor Kecematan Mentaya Hilir Selatan Kabupaten Kotawaringin Timur yang berjumlah 32 orang dalam satu kelompok. 1 kelompok dilakukan pengukuran nilai kadar kolesterol, yang kemudian dilakukan konsumsi bawang putih, dan di ukur kembali nilai kadar kolesterolnya. Sampling penelitian adalah suatu proses seleksi sampel yang digunakan dalam penelitian dari populasi yang ada, sehingga jumlah sampel akan mewakili keseluruhan populasi yang ada (Hidayat,2010:81). Peneliti menggunakan teknik Probability sampling dengan metode total sampling. PENDAHULUAN Dari masalah yang terurai di atas, peneliti ingin melakukan penelitian yang berjudul “Pengaruh Konsumsi bawang Putih Terhadap Kadar Kolesterol Pada Penderita Hiperkolesterolemia” di Desa Handil Sohor Kecamatan Mentaya Hilir Selatan Kabupaten Kotawaringin Timur Provinsi Kalimantan Tengah. Instrumen yang digunakan dalam penelitian ini berupa timbangan, lembar observasi dan alat tes kadar kolesterol. METODE PENELITIAN Desain pada penelitian ini menggunakan preexperimental design.Rancangan penelitian ini menggunakan satu kelompok subjek yang dipilih secara acak. Kelompok perlakuan pengukuran satu kali sebelum dan setelah perlakuan. Efek perlakuan dapat dilihat pada pengukuran sebelum dan sesudah perlakuan. Populasi adalah keseluruhan Tabel 1. Distribusi Responden Berdasarkan umur responden di Desa Handil Sohor Juni 2017 Data umum Tabel 1. Distribusi Responden Berdasarkan umur responden di Desa Handil Sohor Juni 2017 Tabel 1. Distribusi Responden Berdasarkan umur responden di Desa Handil Sohor Juni 2017 132 Pekerjaan Jumlah Persentase (%) Tani 5 16% Swasta 12 37% PNS 4 12% Buruh 3 9% Ibu rumah tangga 5 16% Tidak bekerja 0 0% Total 32 100% Sumber : Data primer 2017 No Umur Jumlah Persentase (%) 1 20 - 29 7 22% 2 30 - 39 10 31% 3 > 40 15 47% Total 32 100% Sumber : Data primer 2017 Hampir dari setengahnya responden berusia > 40 yang berjumlah 15 orang (47%). Tabel 2. Distribusi Responden Berdasarkan Jenis kelamin Responden di Desa Handil Sohor Juni 2017 Hampir dari setengahnya responden bekerja sebagai swasta yang berjumlah 12 orang (37%). Jenis Kelamin Jumlah Persentase (%) Laki-laki 13 41% Perempuan 19 59% Total 32 100 Data : Data primer 2017 Tabel 5. Distribusi responden berdasarkan pendapatan responden di Desa Handil Sohor Juni 2017 Pendapatan Jumlah Persentase (%) < 1 juta 13 41% 1-3 juta 16 50% > 3 juta 3 9% Total 32 100% Sumber : Data primer 2017 Sebagian besar dari responden berjenis kelamin perempuan yang berjumlah 19 orang ( 59%). Tabel 3. Distribusi Responden Berdasarkan Tingkat Pendidikan di Desa handil Sohor Juni 2017 Setengah responden berpendapatan 1 - 3 juta yang berjumlah 16 orang (50%). Tingkat pendidikan Jumlah Persentase (%) Tidak sekolah 0 0% SD 8 25% SMP 16 50% SMA 5 16% Serjana 3 9% Total 32 100% Sumber : Data primer 2017 Tabel 6. Distribusi Responden Berdasarkan konsumsi makanan berlemak yang sering dikonsumsi Makanan berlemak Jumlah Persentase (%) Ikan 5 16% ayam 7 22% gorengan 5 16% telur 15 46% Daging merah 0 0% Total 32 100% Sumber : Data primer 2017 Setengah responden berpendidikan SMP yang berjumlah 16 orang ( 50%). Tabel 4. Distribusi Responden Berdasarkan tingkat pekerjaan di Desa Handil Sohor Juni 2017 Tabel 4. Distribusi Responden Berdasarkan tingkat pekerjaan di Desa Handil Sohor Juni 2017 Hampir dari setengahnya responden mengkonsumsi makanan berlemak jenis telur yang berjumlah 15 orang (46%). 133 Tabel 7. Data umum Distribusi responden berdasarkan kebiasaan minum di Desa Handil Sohor Juni 2017 Kebiasaan Merokok Jumlah Persentase (%) Ya 8 25% Tidak 24 75% Total 32 100% Sumber : Data primer 2017 Kebiasaan minum Jumlah Persentase (%) Susu 12 37,5% Kopi 14 43,8% Teh 6 18,7% Alkohol 0 0% Total 32 100% Sumber : Data primer 2017 Sebagian kecil dari responden memiliki kebiasaan merokok berjumlah 8 orang (25%). Data khusus Sumber : Data primer 2017 Kada r Ko lest ero l Wilcoxon Signed Rank Test Perlakuan ( konsumsi bawang putih) Sebel um Persen tase (%) Sesu dah Perse ntase (%) Nor mal 0 0% 20 64,5 % seda ng 26 81% 12 37,5 % Ting gi 6 19% 0 0% Juml ah 32 100% 32 100 % Hasil uji wilco xon 26 13.50 P = 0.00 Semakin bertambahnya usia manusia, semakin meningkat pula kadar kolesterolnya. Selain itu, jenis kelamin juga mempengaruhi kadar kolesterol. Wanita sebelum menopause mempunyai kadar kolesterol yang lebih rendah di bandingkan pria dengan usia yang sama. Namun setelah menopause, kadar koletserol wanita cenderung meningkat (Rusilanti, 2014, 22). Menurut Guyton (2007) yang menyatakan bahwa asupan diet tinggi lemak jenuh turut meningkatkan kadar kolesterol plasma dengan peningkatan sebanyak 15% - 25%. Hal ini karena terjadi deposit lemak di hati yang kemudian menyebabkan meningktanya unsur asetil-koA di hati untuk memproduksi kolesterol. Hasil pengujian statistik dengan menggunakan uji Wilcoxon Signed Rank Tes dengan tingkat kemaknaan α < 0,05 didapat hasil p value = 0,00 karena nilai sig.(2-tailed) 0,00 < 0,05 maka Ho ditolak dan H1 diterima, maka ada pengaruh konsumsi bawang putih terhadap kadar kolesterol pada penderita hiperkolesterolemia. Makanan yang dikonsumsi akan mengalami proses metabolisme dan menghasilkan adenosin triphosphate (ATP). ATP merupakan energi untuk melakukan aktivitas fisik. Pembentukan ATP disesuaikan dengan kebutuhan, sehingga tidak semua makanan yang dikonsumsi akan diubah langsung menjadi ATP melainkan ada yang disimpan dalam bentuk kolesterol. Semakin banyak aktivitas fisik yang dilakukan maka semakin banyak kebutuhan ATP dan akan menyebabkan sedikitnya pembentukan Makanan yang dikonsumsi akan mengalami proses metabolisme dan menghasilkan adenosin triphosphate (ATP). ATP merupakan energi untuk melakukan aktivitas fisik. Data khusus Tabel 11. Distribusi Responden Berdasarkan Kadar Kolesterol sebelum konsumsi bawang putih di Desa Handil Sohor Juni Tahun 2017 Hampir setengah responden memiliki kebiasaan minum kopi yang berjumlah 14 orang (43,8%). Tabel 8. Distribusi responden berdasarkan kejadian obesitas di desa Handil Sohor Juni 2017 Kadar Kolesterol Jumlah Persentase (%) Normal 0 0% sedang 26 81% Tinggi 6 19% Total 32 100% Sumber : Data primer 2017 Obesitas Jumlah Persentase (%) Ya 18 56 % Tidak 14 44 % Total 32 100% Sumber : Data primer 2017 diketahui hampir seluruhnya dari responden mengalami kadar kolesterol sedang yaitu sebanyak 27 orang (81%). sebagian besar dari responden yang mengalami obestitas berjumlah 18 orang (56%). Tabel 12. Distribusi Responden Berdasarkan Kadar Kolesterol sesudah konsumsi bawang putih di Desa Handil Sohor Juni 2017 Tabel 9. Distribusi responden berdasarkan kebiasaan olahraga di Desa Handil Sohor Juni 2017 Kadar Kolesterol Jumlah Persentase (%) Normal 20 64,5% Sedang 12 37,5% Tinggi 0 0% Total 32 100% Sumber : Data primer 2017 Kebiasan olahraga Jumlah Persentase (%) Ya 3 9% Tidak 29 91 % Total 32 100% Sumber : Data primer 2017 sebagian besar dari responden mengalami kadar kolesterol normal yaitu sebanyak 20 orang (64,5%). Hampir seluruhnya responden tidak pernah melakukan olahraga berjumlah 29 orang (91%). Tabel 13. Distribusi kadar kolesterol karena pengaruh konsumsi bawang putih terhadap kadar kolesterol di Desa Handil Sohor Juni 2017 Tabel 10. Distribusi responden berdasarkan kebiasaan merokok di Desa Handil Sohor Juni 2017 134 Tabel 11 diketahui hampir seluruhnya dari responden mengalami kadar kolesterol sedang sebelum diberikan bawang putih yaitu sebanyak 27 orang (81%). Hampir seluruhnya responden sebelum diberikan konsumsi bawang putih mengalami kadar kolesterol sedang sebanyak 26 orang (81%) dan setelah diberikan konsumsi bawang putih selama 21 hari sebagian besar dari responden mengalami kadar kolesterol normal sebanyak 20 orang (64,5%). Hampir seluruhnya responden sebelum diberikan konsumsi bawang putih mengalami kadar kolesterol sedang sebanyak 26 orang (81%) dan setelah diberikan konsumsi bawang putih selama 21 hari sebagian besar dari responden mengalami kadar kolesterol normal sebanyak 20 orang (64,5%). Menurut peneliti, meningkatnya kadar kolesterol disebabkan oleh beberapa faktor. Faktor tersebut antara lain Umur, jenis kelamin, kebiasaan makanan berlemak, kebiasaan minum, kejadian obesitas, kebiasaan olahraga dan kebiasaan merokok. PEMBAHASAN Kadar kolesterol sebelum diberikan konsumsi bawang putih 135 kolesterol total dan kolesterol Low- Density Lipoprotein (LDL) serta peningkatan Hight-Density Lipoprotein (HDL) (Zuhroiyyah S.F et al, 2017). kolesterol total dan kolesterol Low- Density Lipoprotein (LDL) serta peningkatan Hight-Density Lipoprotein (HDL) (Zuhroiyyah S.F et al, 2017). Menurut peneliti, berdasarkan hasil uji Wilcoxon signed rank test, terdapat pengaruh yang signifikan pada kadar kolesterol sebelum dan sesudah diberikan konsumsi bawang putih Menurut peneliti, berdasarkan hasil uji Wilcoxon signed rank test, terdapat pengaruh yang signifikan pada kadar kolesterol sebelum dan sesudah diberikan konsumsi bawang putih Menurut Veena et al (2014) nikotin yang merupakan komponen utama dari rokok dapat meningkatkan sekresi dari katakolamin sehingga meningkatkan lipolisis. Hal ini menyebabkan meningkatnya kadar trigliserida, kolesterol, dan VLDL. Senyawa Allicin bersaing dengan substrat enzim yaitu HMG-KoA, terdapat kemiripan struktur antara senyawa Allicin (inhibitor) dengan HMG-KoA (substrat), sehingga di duga senyawa Allicin ini merupakan inhibitor kompetitif dari enzim HMG- KoA reduktase (Brajawikalpa & Kautama, 2016). Senyawa Allicin bersaing dengan substrat enzim yaitu HMG-KoA, terdapat kemiripan struktur antara senyawa Allicin (inhibitor) dengan HMG-KoA (substrat), sehingga di duga senyawa Allicin ini merupakan inhibitor kompetitif dari enzim HMG- KoA reduktase (Brajawikalpa & Kautama, 2016). Kadar kolesterol sesudah konsumsi bawang putih Berdasarkan tabel. 12 diketahui sebagian besar dari responden mengalami kadar kolesterol normal yaitu sebanyak 20 orang (64,5%). KESIMPULAN DAN SARAN Kesimpulan Kesimpulan Menurut peneliti, kandungan kimia dalam bawang putih terutama allicin yang menghambat enzim HMG-KoA dalam pembentukan kolesterol dalam hati. 1. Sebelum diberikan konsumsi bawang putih kadar kolesterol pada penderita hiperkolesterolemia sebagian besar menderita hiperkolesterolemia sedang 2. Setelah diberikan konsumsi bawang putih kadar kolesterol pada penderita hiperkolesterolemia lebih dari setengah memiliki kadar kolesterol yang normal Senyawa Allicin bersaing dengan substrat enzim yaitu HMG-KoA, terdapat kemiripan struktur antara senyawa Allicin (inhibitor) dengan HMG-KoA (substrat), sehingga di duga senyawa Allicin ini merupakan inhibitor kompetitif dari enzim HMG- KoAreduktase (Brajawikalpa & Kautama, 2016). Senyawa Allicin bersaing dengan substrat enzim yaitu HMG-KoA, terdapat kemiripan struktur antara senyawa Allicin (inhibitor) dengan HMG-KoA (substrat), sehingga di duga senyawa Allicin ini merupakan inhibitor kompetitif dari enzim HMG- KoAreduktase (Brajawikalpa & Kautama, 2016). 3. Ada pengaruh konsumsi bawang putih terhadap kadar kolesterol pada penderita hiperkolesterolemia Saran Saran Pengaruh konsumsi bawang putih terhadap kadar kolesterol pada penderita hiperkolesterolemia Pengaruh konsumsi bawang putih terhadap kadar kolesterol pada penderita hiperkolesterolemia 1. Bagi responden Memberikan alternatif penanganan kolesterol saat mereka mengalami kadar kolesterol tinggi selain meminum obat. Berdasarkan tabel 13 menunjukkan secara diskriptif terlihat terdapat pengaruh konsumsi bawang putih terhadap kadar kolesterol pada penderita hiperkolesterolemia. analisa menggunakan uji Wilcoxon signed rank test, didapatkan P = 0.000, maka p < 0.05. 2. Bagi Unit Puskesmas Sebagai masukan bagi Puskesmas untuk penanganan kadar kolesterol tinggi mengenai manfaat bawang putih sebagai alternatif lain selain obat untuk mengatasi kadar kolesterol tinggi. 136 KEDOKTERAN DAN KESEHATAN: http://jurnal.unswagati.ac.id/i ndex.php/tumed/article/view/ 288 Guyton, A. C., & Hall, J. (2008). Buku Ajar Fisiologi Kedokteran. Jakarta: ECG. Handayani, A. (2006). 812 Resep Untuk Mengobati 236 Penyakit. Jakarta: Penebar Swadaya. M. U. (2014, Februari). Retrieved Mei 1, 2017, from Document Repository Universitas Andalas: http://repo.unand.ac.id/id/epr int/404 Notoatmodjo, S. (2014). Metodologi Penelitian Kesehatan. Jakarta: Renika Cipta. Nursalam. (2003). Konsep dan Penerapan Metodologi Penelitian Ilmu Keperawatan. Jakarta: Salemba Medika. Nursalam. (2013). Konsep dan Metode Penelitian Ilmu Keperawatan. jakarta: Salemba Medika. Priskilla, M. (2008). Pengaruh pemberian Ekstrak Bawang Putih (allium sativium, Linn.) Terhadap Penurunan R i A t K l t l KEDOKTERAN DAN KESEHATAN: http://jurnal.unswagati.ac.id/i ndex.php/tumed/article/view/ 288 KEDOKTERAN DAN KESEHATAN: http://jurnal.unswagati.ac.id/i ndex.php/tumed/article/view/ 288 Guyton, A. C., & Hall, J. (2008). Buku Ajar Fisiologi Kedokteran. Jakarta: ECG. Handayani, A. (2006). 812 Resep Untuk Mengobati 236 Penyakit. Jakarta: Penebar Swadaya. M. U. (2014, Februari). Retrieved Mei 1, 2017, from Document Repository Universitas Andalas: http://repo.unand.ac.id/id/epr int/404 Notoatmodjo, S. (2014). Metodologi Penelitian Kesehatan. Jakarta: Renika Cipta. Nursalam. (2003). Konsep dan Penerapan Metodologi Penelitian Ilmu Keperawatan. Jakarta: Salemba Medika. Nursalam. (2013). Konsep dan Metode Penelitian Ilmu Keperawatan. jakarta: Salemba Medika. Priskilla, M. (2008). Pengaruh pemberian Ekstrak Bawang Putih (allium sativium, Linn.) Terhadap Penurunan Rasio Antara Kolesterol Total Dengan Kolesterol 3. Bagi peneliti selanjutnya Agar melakukan penelitian tentang faktor lain yang berhubungan dengan konsumsi bawang putih terutama faktor yang mempengaruhi konsumsi bawang putih tentunya dengan dosis yang berbeda maupun jangka waktu pemberian yang berbeda. Guyton, A. C., & Hall, J. (2008). Buku Ajar Fisiologi Kedokteran. Jakarta: ECG. Handayani, A. (2006). 812 Resep Untuk Mengobati 236 Penyakit. Jakarta: Penebar Swadaya. DAFTAR PUSTAKA Adi, L. T. (2008). Tanaman obat Mengatasi Penyakit Jantung, Hipertensi, Kolesterol, dan Stroke. Jakara: Agromedia. M. U. (2014, Februari). Retrieved Mei 1, 2017, from Document Repository Universitas Andalas: http://repo.unand.ac.id/id/epr int/404 Arikunto, & Suharsimi. (2006). Prosedur Penelitian. Jakarta: Renika Cipta. Notoatmodjo, S. (2014). Metodologi Penelitian Kesehatan. Jakarta: Renika Cipta. Nursalam. (2003). Konsep dan Penerapan Metodologi Penelitian Ilmu Keperawatan. Jakarta: Salemba Medika. Bangun. (2003). Terapi Jus & Ramuan Tradisonal Untuk Kolesterol. Jakarta: Agromedia Pustaka. Budiarto, E. (2002). Biostatika Untuk Kedokteran dan Kesehatan Masyarakat. Jakarta: EGC. Nursalam. (2013). Konsep dan Metode Penelitian Ilmu Keperawatan. jakarta: Salemba Medika. Priskilla, M. (2008). Pengaruh pemberian Ekstrak Bawang Putih (allium sativium, Linn.) Terhadap Penurunan Rasio Antara Kolesterol Total Dengan Kolesterol HDL Pada Tikus Putih (Rattus Norvegicus) Yang Nursalam. (2013). Konsep dan Metode Penelitian Ilmu Keperawatan. jakarta: Salemba Medika. Priskilla, M. (2008). Pengaruh pemberian Ekstrak Bawang Putih (allium sativium, Linn.) Terhadap Penurunan Rasio Antara Kolesterol Total Dengan Kolesterol HDL Pada Tikus Putih (Rattus Norvegicus) Yang Brajawikalpa, R. S., & Kautama, M. G. (2016, 5 4). Pengaruh Pemberian Ekstrak Etanol Bawang Putih Terhadap Kadar Kolesterol Total, LDL Dan HDL Pada Tikus Putih Hiperkolesterol. Retrieved Mei 2, 2017, from TUNAS MEDIKA JURNAL 137 137 Hiperkolesterolemik. Universitas Sebelas Maret , 7 - 20. Rusilanti. (2014). Kolesterol Tinggi Bukan Untuk Di Takuti. FMedia. Santoso, G. S. (2005). Metodologi penelitian Kualitatif dan Kuantitatif. Jakarta: Prestasi Pustaka. Sugiyono. (2006). Metode penelitian Administrasi. Bandung: Alfabeta. Utami, P., & Mardiana, L. (2013). Umbi Ajaib Tumpas Penyakit. 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https://openalex.org/W4393427255	https://bmcbioinformatics.biomedcentral.com/counter/pdf/10.1186/s12859-024-05762-1	English	null	CITEViz: interactively classify cell populations in CITE-Seq via a flow cytometry-like gating workflow using R-Shiny	BMC bioinformatics	2,024	cc-by	5,052	Abstract Background: The rapid advancement of new genomic sequencing technology has enabled the development of multi-omic single-cell sequencing assays. These assays profile multiple modalities in the same cell and can often yield new insights not revealed with a single modality. For example, Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITE-Seq) simultaneously profiles the RNA transcriptome and the surface protein expression. The surface protein markers in CITE-Seq can be used to identify cell populations similar to the iterative filtration process in flow cytom- etry, also called “gating”, and is an essential step for downstream analyses and data interpretation. While several packages allow users to interactively gate cells, they often do not process multi-omic sequencing datasets and may require writing redundant code to specify gate boundaries. To streamline the gating process, we developed CITEViz which allows users to interactively gate cells in Seurat-processed CITE-Seq data. CITEViz can also visualize basic quality control (QC) metrics allowing for a rapid and holistic evaluation of CITE-Seq data. Panikar and John H. W. Cheney contributed equally to the project. Correspondence: braunt@ohsu.edu; maxsonj@ohsu.edu 1 Division of Oncologic Sciences, Knight Cancer Institute, Oregon Health and Science University, 3181 SW Sam Jackson Pk. Rd., KR‑HEM, Portland, OR 97239, USA 2 Earle A. Chiles Research Institute, Providence, Portland, OR 97213, USA 3 Knight Campus Graduate Internship Program ‑ Bioinformatics, University of Oregon, Eugene, OR 97403, USA Results: We applied CITEViz to a peripheral blood mononuclear cell CITE-Seq dataset and gated for several major blood cell populations (CD14 monocytes, CD4 T cells, CD8 T cells, NK cells, B cells, and platelets) using canonical surface protein markers. The visualization features of CITEViz were used to investigate cellular heterogeneity in CD14 and CD16-expressing monocytes and to detect differential numbers of detected antibodies per patient donor. These results highlight the utility of CITEViz to enable the robust classification of single cell populations. 4 Cancer Early Detection Advanced Research, Oregon Health and Science University, Portland, OR 97238, USA 5 Department of Biomedical Engineering, Oregon Health and Science University, Portland, USA 6 Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, USA Conclusions: CITEViz is an R-Shiny app that standardizes the gating workflow in CITE- Seq data for efficient classification of cell populations. Its secondary function is to gen- erate basic feature plots and QC figures specific to multi-omic data. © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the mate- rial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdo- main/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kong et al. BMC Bioinformatics (2024) 25:142 https://doi.org/10.1186/s12859-024-05762-1 Kong et al. BMC Bioinformatics (2024) 25:142 https://doi.org/10.1186/s12859-024-05762-1 BMC Bioinformatics Open Access CITEViz: interactively classify cell populations in CITE‑Seq via a flow cytometry‑like gating workflow using R‑Shiny Garth L. Kong1†, Thai T. Nguyen1†, Wesley K. Rosales2†, Anjali D. Panikar3†, John H. W. Cheney3†, Theresa A. Lusardi4, William M. Yashar1,5, Brittany M. Curtiss1, Sarah A. Carratt1, Theodore P. Braun1,6 and Julia E. Maxson1* †Garth L. Kong, Thai T. Nguyen, Wesley K. Rosales, Anjali D. Abstract The user interface and internal workflow of CITEViz uniquely work together to produce an organized workflow and sensible data structures for easy data retrieval. This package leverages the strengths of biologists and computational scientists to assess and analyze multi- omic single-cell datasets. In conclusion, CITEViz streamlines the flow cytometry gating workflow in CITE-Seq data to help facilitate novel hypothesis generation. Background g The development of high-throughput single-cell RNA-Sequencing (scRNA-Seq) meth- ods has revealed previously unappreciated levels of cellular heterogeneity [1]. Since the development of Drop-Seq in 2015, a number of scRNA-Seq assays have been developed to profile multiple macromolecules in the same cell. For example, CITE-Seq is a multi- omic variant of scRNA-Seq that captures the cell surface proteome using antibody- derived tags (ADT) [2]. Multi-omic assays like CITE-Seq introduce new dimensionality to the data, but often require nuanced analyses to extract meaningful results. For exam- ple, a common single cell analysis consists of unsupervised clustering of cells followed by the classification of cell populations. However, there can be low correlation of differ- ential gene signatures and cell cluster identity, and the process is often time-consuming and irreproducible. By using the ADT information in CITE-Seq data, we aim to approxi- mate a flow cytometry workflow to better classify cell clusters based on known surface identity markers. The gating workflow in flow cytometry is the gold standard to classify cell populations using cellular surface protein markers. During a typical flow cytometry experiment, flu- orescently-labeled antibodies stain cell surface proteins, and individual cells are identi- fied based on fluorescent signal intensity [3]. Cells are then plotted in two dimensions based on surface marker abundance (e.g. CD38 and CD34), and boundaries are drawn (called gates) around cell populations of interest. Selected cells are further re-plotted in a new set of surface markers and filtered again until a population of interest is identified and quantified [4]. The gating workflow is essential to investigate biological perturba- tions (e.g. drug treatment in cancer cells) in which the proportional changes in cell pop- ulations are tracked. The same principles of gating can be applied to CITE-Seq [5], but to the best of our knowledge, the bioinformatics field currently lacks a robust program that facilitates this interactive process in Seurat-processed CITE-Seq data. To efficiently gate cell populations in CITE-Seq data, we developed CITEViz. By using the R-Shiny platform, CITEViz allows users to interactively subset cell populations of interest using surface proteins and see those cells highlighted in latent space (e.g. PCA, tSNE, UMAP). Conversely, cell clusters can be selected in latent space and quickly located in a 2D feature scatter plot (called a back-gate). Background A secondary function of CITE- Viz is to provide basic multi-omic single/co-expression feature plots and quality control figures to allow biologists to quickly and holistically assess CITE-Seq data. In conclu- sion, CITEViz (1) streamlines the gating workflow in CITE-Seq data to identify cell pop- ulations and (2) facilitates basic visualization of multi-omic, single-cell sequencing data. Open Access T di ib i Kong et al. BMC Bioinformatics (2024) 25:142 Page 2 of 10 Keywords: CITE-Seq, Single-cell RNA-Seq, scRNA-Seq, R-Shiny, Single-cell, Multi-omic, Flow cytometry, Cluster classification Implementation A core design element of CITEViz is the Gate class—a custom S4 class written in base R (Fig. 1A). In this paper, a “Gate” refers to an R class, while a “gate” refers to a man- ual selection and filtration of a cell population. A Gate class holds important metadata such as a user-provided gate label, X and Y axes labels (e.g. CD34, CD38), gate selection Page 3 of 10 Kong et al. BMC Bioinformatics (2024) 25:142 Kong et al. BMC Bioinformatics Fig. 1 Implementation of CITEViz. A Example of a custom Gate class, which contains a counter, input cell barcodes, output cell barcodes, the feature of the x and y axes, gate coordinates, and more. B Back-end of CITEViz. Gate classes are created immediately by the input of an interactive cell selection plus the trigger of the Gate button. All attributes of the Gate class are intrinsic to a gate, except for the output cells which are passed between gates. Unlike other packages, this process can be repeated to the nth degree in CITEViz. C Screenshot of the gating page in CITEViz with an example PBMC CITE-seq dataset [5] Fig. 1 Implementation of CITEViz. A Example of a custom Gate class, which contains a counter, input cell barcodes, output cell barcodes, the feature of the x and y axes, gate coordinates, and more. B Back-end of CITEViz. Gate classes are created immediately by the input of an interactive cell selection plus the trigger of the Gate button. All attributes of the Gate class are intrinsic to a gate, except for the output cells which are passed between gates. Unlike other packages, this process can be repeated to the nth degree in CITEViz. C Screenshot of the gating page in CITEViz with an example PBMC CITE-seq dataset [5] Fig. 1 Implementation of CITEViz. A Example of a custom Gate class, which contains a counter, input cell barcodes, output cell barcodes, the feature of the x and y axes, gate coordinates, and more. B Back-end of CITEViz. Gate classes are created immediately by the input of an interactive cell selection plus the trigger of the Gate button. All attributes of the Gate class are intrinsic to a gate, except for the output cells which are passed between gates. Unlike other packages, this process can be repeated to the nth degree in CITEViz. Implementation C Screenshot of the gating page in CITEViz with an example PBMC CITE-seq dataset [5] Fig. 1 Implementation of CITEViz. A Example of a custom Gate class, which contains a counter, input cell barcodes, output cell barcodes, the feature of the x and y axes, gate coordinates, and more. B Back-end of CITEViz. Gate classes are created immediately by the input of an interactive cell selection plus the trigger of the Gate button. All attributes of the Gate class are intrinsic to a gate, except for the output cells which are passed between gates. Unlike other packages, this process can be repeated to the nth degree in CITEViz. C Screenshot of the gating page in CITEViz with an example PBMC CITE-seq dataset [5] coordinates, input and output cell barcodes, and more. Most variables are intrinsic to a Gate class except for the output cell barcodes, which are passed between Gates objects to facilitate the gating workflow. Gate classes are created by the simultaneous actions of a Gate button press and a rectangular or polygonal selection of cells in the feature scat- ter plot (Fig. 1B). The custom Gate class in CITEViz is necessary to store detailed gating information in an organized data structure. The typical workflow of CITEViz can be distilled down to 4 steps. After uploading a preprocessed Seurat object and choosing the gating tab (Fig. 1C), the user can then 1. Choose which cell surface markers to view in the 2D feature scatter plot on the left pane using a drop-down menu, 2. Select the cells of interest in the scatter plot, 3. Input into the text box a custom label, and 4. Click the “Gate” button to subset the cells of interest Kong et al. BMC Bioinformatics (2024) 25:142 Kong et al. BMC Bioinformatics (2024) 25:142 Page 4 of 10 Once a subset of cells is defined, steps 1–4 can be repeated to further analyze the fil- tered cells. As gates are created, they can be exported as an ordered list of Gate objects, which contains a variety of metadata (e.g. cell barcodes) to facilitate further analyses such as differential expression. In summary, the procedures to gate cells in CITEViz are to plot cell surface markers, select the cells, input a text label, and define the gate via the Gate button. CITEViz uniquely supports a back-gate function. Implementation In the context of CITE-Seq data, back-gates allow users to select cells in latent space and highlight them in the protein feature plots. This feature is useful to explore whether a cell population can be clearly separated by two antibody features, or determine if a better combination of features can properly identify the cell cluster. Cells are initially plotted as gray dots and are colored black based on the selection of cells in the UMAP. The contour plot underneath the dots highlights the density of points. The back-gate function of CITEViz allows users to inter- actively explore gates and feature combinations that define a specific cell cluster. ii At a minimum, CITEViz requires a Seurat object with a normalized ADT counts matrix. Normalization can be performed by the center-log ratio method [6], denoised and scaled by background [7], or a custom method that returns a data matrix under the ADT assay. Since the gating workflow relies on surface protein markers, RNA data nor- malization is optional but recommended for potential downstream analyses and basic QC visualization. The two types of input data currently supported by CITEViz are (1) an R Data Serial- ized (RDS) file containing a Seurat object, or (2) an RDS file with a SingleCellExperiment object derived from the as.SingleCellExperiment() function from the Seurat library. Furthermore, CITEViz can be adapted to accommodate more data structures in future updates (refer to Limitations sub-section in Discussions). CITEViz provides basic visualization of quality control (QC) metrics, single-feature, and feature co-expression plots. QC metrics include: RNA counts distribution, gene counts distribution, ADT counts distribution, and unique ADT antibodies; these plots can be split by any categorical metadata in the user’s Seurat object. Single feature expres- sion plots allow users to see RNA/ADT expression in latent space, while multi-omic co-expression feature plots can visualize data between assays. This can important to investigate the correlation between transcriptomic expression (RNA) and protein levels (ADT). CITEViz provides basic visualization of QC metrics and single/multi-omic fea- ture expression plots in addition to its primary function as a gating workflow in CITE- Seq data. PBMC CITE‑Seq gating analysis To demonstrate the utility of this program, CITEViz was used to gate the major cell pop- ulations in a PBMC CITE-Seq dataset [5]. Several gating schemes were used to show the utility of CITEViz and to identify CD14 monocytes, CD4 T-cells, CD8 T-cells, Natural Killer (NK) cells, B-cells, and platelets. To reduce overplotting, the dataset was randomly down-sampled to 10 K cells and then uploaded to CITEViz. One-step gating schemes were used to identify CD4 T-cells and CD14 monocytes using canonical surface protein markers [4]. Cells with a CD4-positive and CD3-positive Kong et al. BMC Bioinformatics (2024) 25:142 Page 5 of 10 protein profile were selected in the ADT Feature Plot, revealing a distinct cell population in the UMAP (Fig. 2A). CD14-expressing monocytes were identified as CD14-positive and CD16-negative cells in the feature scatter plot [8]. The selected cells corresponded to a discrete cell population in the upper left quadrant in the UMAP (Fig. 2B). CD8 T-cells were identified with a 2-step gating scheme. An initial CD19-negative and CD3-positive gate selected for both CD4 and CD8 T cells (Fig. 2C, left). From this gate, the cells were re-plotted and CD8 T cells were selected for a CD8-positive and CD4- negative protein expression profile [4]. i Natural killer (NK) cells were identified in the scatter plots via a back-gate. Within the back-gate tab of CITEViz, NK cells were selected in the latent space according to Fig. 2 CITEViz analysis of PBMC CITE-Seq data. A Identification of CD4-expressing T-cells using CD4-positive and CD3-positive cells, B Identification of CD14-expressing monocyte cells with CD14-positive and CD11b-positive markers, C 2-layer gate that selects for CD8 T-cells. The first gate consists of CD3-positive cells, followed by a CD4-negative and CD8-positive gate. D Example back-gate of natural killer cells shown in an ADT Feature Plot with features of CD3and CD56. E Single-feature expression plot of CD8 protein levels. F 2-feature co-expression plot using CD16 and CD14 to show population heterogeneity in the monocyte cluster. G CITE-Seq QC metric ‘Number of Detected Antibodies per Cell’ split by individual donors Fig. 2 CITEViz analysis of PBMC CITE-Seq data. A Identification of CD4-expressing T-cells using CD4-positive and CD3-positive cells, B Identification of CD14-expressing monocyte cells with CD14-positive and CD11b-positive markers, C 2-layer gate that selects for CD8 T-cells. The first gate consists of CD3-positive cells, followed by a CD4-negative and CD8-positive gate. PBMC CITE‑Seq gating analysis D Example back-gate of natural killer cells shown in an ADT Feature Plot with features of CD3and CD56. E Single-feature expression plot of CD8 protein levels. F 2-feature co-expression plot using CD16 and CD14 to show population heterogeneity in the monocyte cluster. G CITE-Seq QC metric ‘Number of Detected Antibodies per Cell’ split by individual donors Fig. 2 CITEViz analysis of PBMC CITE-Seq data. A Identification of CD4-expressing T-cells using CD4-positive and CD3-positive cells, B Identification of CD14-expressing monocyte cells with CD14-positive and CD11b-positive markers, C 2-layer gate that selects for CD8 T-cells. The first gate consists of CD3-positive cells, followed by a CD4-negative and CD8-positive gate. D Example back-gate of natural killer cells shown in an ADT Feature Plot with features of CD3and CD56. E Single-feature expression plot of CD8 protein levels. F 2-feature co-expression plot using CD16 and CD14 to show population heterogeneity in the monocyte cluster. G CITE-Seq QC metric ‘Number of Detected Antibodies per Cell’ split by individual donors Kong et al. BMC Bioinformatics (2024) 25:142 Page 6 of 10 prior annotations [5]. Once cells were selected, the ADT Feature Plot axes were adjusted to plot CD3 in the y-axis and CD56 in the x-axis based on known NK surface proteins [9]. The corresponding points were displayed in the scatter plot as dark-colored cells expressing a CD56-positive and CD3-negative profile. To identify gates for the remain- ing major cell populations in the dataset, back-gates for B cells and platelets are included in Additional file 1: Fig. S1. B cells and platelets were also validated using prior [5] and external annotations, respectively [10, 11]. The secondary function of CITEViz is to visualize commonly generated plots in multi-omic CITE-Seq data like single/co-expression plots and QC metrics. For exam- ple, we used CITEViz to generate a feature plot, revealing a distinctly high expression in the CD8 T-cell population (Fig. 2E). A protein co-expression feature plot of CD14 and CD16 shows monocyte expressing both markers in the lower arm of the monocyte cluster (Fig. 2F). This pattern was also noticeable in the bulk of the NK cells. An example of a QC metric that can be assessed with CITEViz is the number of unique antibodies detected. CITEViz can split this QC metric by individual patient donors, which clearly displayed a significant difference between patients 1–4 and patients 5–8 with a padj of 0 (Tukey HSD) (Fig. PBMC CITE‑Seq gating analysis 2G, Additional file 2: Table S1). In conclusion, the ability to visualize multi-omic CITE-Seq data allows for rapid data exploration and assessment of Seurat- processed datasets. Discussionsh The application of CITEViz to a PBMC CITE-Seq dataset [5] led to the identification of 6 major cell populations (CD4 T cells, CD14 monocytes, CD8 T cells, NK cells, B cells, platelets) using a mix of one- or two-step gates and back-gates (Fig. 2A–D, Additional file 1: Fig. S1). Protein expression data were explored using single and co-expression fea- ture plots, where the latter revealed cellular heterogeneity in CD14 and CD16-express- ing monocytes (Fig. 2E, F). By plotting the number of detected antibodies per sample, CITEViz displayed a significant difference between patients 1–4 and 5–8. These results are in line with prior analyses and suggest that the flow cytometry-like gating workflow in CITEViz provided an alternative approach to easily classify clusters in CITE-Seq data [5]. CITEViz compared to other programshi The bioinformatics field, to the best of our knowledge, currently lacks an open-source, R-Shiny package that can (1) streamline the flow cytometry gating process and (2) gen- erate basic multi-omic plots in Seurat-processed CITE-Seq data (Table 1). While the Single-Cell Virtual Cytometer by Pont et. al. is most functionally similar to CITEViz, it requires a custom tab-separated input file and is limited to exporting the cell names in the last gated population [12]. The Cascading Style Sheet and JavaScript framework in Pont et. al. also can introduce friction with common single-cell analysis packages writ- ten in R or Python, thus requiring the user to write additional scripts that import cell barcodes for downstream analyses. In contrast, CITEViz enhances reproducibility by including important gating metadata such as surface protein markers, gate coordinates, and previous filtration steps. Page 7 of 10 Kong et al. BMC Bioinformatics (2024) 25:142 Table 1 CITEViz compared to Single-Cell Virtual Cytometer, iSEE, and Seurat Programs Gating Back-Gating Multi-Omic Feature/QC Visualization Platform CITEViz ✓ ✓ ✓ R-Shiny Single-Cell Virtual Cytometer [12] ✓ – – Cascading Style Sheet & JavaS- cript iSEE [13] – – – R-Shiny Seurat [5] ✓ – ✓ R & R-Shiny Table 1 CITEViz compared to Single-Cell Virtual Cytometer, iSEE, and Seurat Another similar tool is the Interactive SummarizedExperiment Explorer (iSEE). iSEE is an R-Shiny package from BioConductor that provides a visual interface to explore single-cell datasets, but it lacks an iterative filtration feature that is essential to recreate the flow cytometry gating workflow [13]. Additionally, iSEE was originally optimized for CyTOF and scRNA-Seq data in SingleCellExperiment format, but is incompatible with the multi-assay structure of CITE-Seq datasets. Unlike other programs, CITEViz fills an unmet need by (1) implementing a seamless flow cytometry gating workflow and (2) generating basic multi-omic plots in Seurat-processed CITE-Seq data. While the flow cytometry gating workflow can be approximated using Seurat [5], the process can be cumbersome and inefficient. The typical workflow to gate cells in Seurat would be to (1) generate a scatter plot with FeatureScatter() and save it as a variable, (2) apply CellSelector() to the feature plot, (3) draw boundaries around the cells of interest in an interactive window, (4) exit the window and repeat steps 1–4 to further filter down cells of interest [5]. CITEViz compared to other programshi A disadvantage of this process is that the gated cells are not imme- diately highlighted in latent space, resulting in a loss of contextual information. Further- more, this method requires extensive attention from the user to write redundant code and keep track of many variables. CITEViz improves upon Seurat by displaying relevant parameters and plots in the R-Shiny interface, providing an efficient user experience with continuous visual feedback. Limitations A limitation of CITEViz pertains to data sparsity where gating cells by gene expression (RNA) results in a high rate of data dropout [14]. For example, plotting RNA scatter plots using two transcription factors like IRF8 and CEBPA lead to plots that are diffi- cult to biologically interpret (Additional file 1: Fig. S2). Fortunately, surface protein data (ADT assays) are not sparse and are a reliable resource to characterize cell populations. We speculate the development of better scRNA sequencing assays (and their multi-omic variants) will better resolve heterogeneous cell populations in the future, so CITEViz was built to gate cells based on any assays (RNA, ADT, SCT) and features to accommo- date future improvements in sequencing technology. In addition to sequencing assays, the ever-shifting landscape of bioinformatic file for- mats can affect compatibility with CITEViz in the future. Currently, CITEViz accepts Seurat and BioConductor SingleCellExperiment objects. To account for the imminent Kong et al. BMC Bioinformatics (2024) 25:142 Page 8 of 10 introduction of new file formats or data structures, CITEViz was modularly built to accept various input file types. This is done by various functions that check the input file types and data structures, then building new sub-functions that retrieve the necessary data. The modular design of CITEViz means it can be adequately maintained to accept new file formats and data structures in the future. Intended audience CITEViz is intended to be used by biologists familiar with flow cytometry and who can either (1) perform basic single-cell analysis or (2) collaborate in a team with a computational scientists. The input data format for CITEViz is a pre-processed Seurat object, which requires a basic level of coding skills in R and the ability to follow public Seurat vignettes. Since the essential feature of CITEViz is its iterative filtering process, it is not intended for any data preprocessing or normalization. In our experience, we found CITEViz to be a uniquely collaborative tool that leverages the strengths of both bench and computational scientists to explore and analyze data together. Conclusions CITEViz is an R-Shiny package that facilitates a seamless gating workflow in Seurat-pro- cessed CITE-Seq data. Its secondary function is to view basic quality control metrics and multi-omic co-expression plots for data exploration and assessment. By standardizing the gating process, we provide an alternative method for cell cluster classification that is (1) more intuitive for biologists to use, (2) avoids cumbersome and disorganized alterna- tive workflows, and (3) is biologically grounded in established techniques of flow cytom- etry. CITEViz was ultimately designed to facilitate novel hypothesis generation, and is available to download on GitHub [15]. Declarations Ethics approval and consent to participate Not applicable. Funding g This work was supported by the American Society of Hematology Research Restart Award; American Society of Hematol- ogy Scholar Award; National Cancer Institute [K08 CA245224] to TPB. Funding for SAC was provided by the American Society of Hematology Research Restart Award; Collin’s Medical Trust Award; Medical Research Foundation Early Clinical Award; and the National Cancer Institute [F32CA239422]. JEM is supported by a Leukemia & Lymphoma Society Scholar Award and R01 HL157147-01. Acknowledgements g We thank the following Oregon Health and Science University core facilities for their assistance: ExaCloud Cluster Com- putational Resource and the Advanced Computing Center. Availability of data and materials The original data underlying this article are available in GEO (Gene Expression Omnibus) at https://www.ncbi.nlm. nih.gov/geo/, and can be accessed with GSE164378. The dataset analyzed during the current study is available in the Zenodo repository, https://zenodo.org/records/10839852. The CITEViz documentation website can be accessed here https://maxsonbraunlab.github.io/CITEViz/. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1186/s12859-024-05762-1. Additional file 1. Back-gate schemes for B-cells and platelets, and an example gate using scRNA-Seq data. Additional file 2. Tukey Honestly Significant Difference Test of Detected Antibodies per Patient Donor. Author contributionsi TPB identified a need for a program like CITEViz. GLK conceived the design, managed development, and wrote the manuscript. TTN, WKR, ADP, JHWC developed the front and back-end of the program. SAC and BMC tested CITEViz prototypes. TAL and WMY contributed software. BMC, SAC, TPB and JEM interpreted results. All authors have read and approved the final manuscript. Received: 24 February 2023 Accepted: 26 March 2024 Received: 24 February 2023 Accepted: 26 March 2024 Availability and requirements y q Project name: CITEViz Project home page: https://github.com/maxsonBraunLab/CITEViz Operating system: Windows/Linux/MacOS Programming language: R Other requirements: R > = 4.2.0 License: MIT A t i ti t b d i li d d y q Project name: CITEViz Project home page: https://github.com/maxsonBraunLab/CITEViz Operating system: Windows/Linux/MacOS Programming language: R Other requirements: R > = 4.2.0 License: MIT Any restrictions to use by non academics: license needed Page 9 of 10 Kong et al. BMC Bioinformatics (2024) 25:142 Kong et al. BMC Bioinformatics Competing interests JEM receives funding or collaborates with Blueprint Medicines, Kura Oncology and Ionis Pharmaceuticals. WMY is a former employee of Abreos Biosciences, Inc. and was compensated in part with common stock options. Pursuant to the merger and reorganization agreement between Abreos Biosciences, Inc. and Fimafeng, Inc., WMY surrendered all of his common stock options in 03/2021. TPB has received research support from AstraZeneca, Blueprint Medicines as well as Gilead Sciences and is the institutional PI on the FRIDA trial sponsored by Oryzon Genomics. The other authors declare that they have no competing interests. Received: 24 February 2023 Accepted: 26 March 2024 References iSEE: Interactive SummarizedExperiment Explorer. F1000Res. 2018;7:741. 14. Qiu P. Embracing the dropouts in single-cell RNA-seq analysis. Nat Commun. 2020;11:116 14. Qiu P. Embracing the dropouts in single-cell RNA-seq analysis. Nat Commun. 2020;11:1169. 15. Kong G, Nguyen TT, Rosales WK, Panikar AD, Cheney JHW. CITEViz. 2022. References 1. Macosko EZ, Basu A, Satija R, Nemesh J, Shekhar K, Goldman M, et al. Highly parallel genome-wide expression profil- ing of individual cells using nanoliter droplets. Cell. 2015;161:1202–14. 1. Macosko EZ, Basu A, Satija R, Nemesh J, Shekhar K, Goldman M, et al. Highly parallel genome-wide expression profil- ing of individual cells using nanoliter droplets. Cell. 2015;161:1202–14. 2. Stoeckius M, Hafemeister C, Stephenson W, Houck-Loomis B, Chattopadhyay PK, Swerdlow epitope and transcriptome measurement in single cells. Nat Methods. 2017;14:865–8. 3. Vembadi A, Menachery A, Qasaimeh MA. Cell cytometry: review and perspective on biotechnological advances. Front Bioeng Biotechnol. 2019;7:147. 4. Tung JW, Heydari K, Tirouvanziam R, Sahaf B, Parks DR, Herzenberg LA, et al. Modern flow cytometry: a practical approach. Clin Lab Med. 2007;27:453–68. 5. Hao Y, Hao S, Andersen-Nissen E, Mauck WM, Zheng S, Butler A, et al. Integrated analysis of multimodal single-cell data. Cell. 2021;184:3573-3587.e29. 6. Ooi AT, editor. Single-cell protein analysis: methods and protocols. New York: Springer; 2022. 7. Mulè MP, Martins AJ, Tsang JS. Normalizing and denoising protein expression data from droplet-based single cell profiling. Nat Commun. 2022;13:2099. 8. Thomas GD, Hamers AAJ, Nakao C, Marcovecchio P, Taylor AM, McSkimming C, et al. Human blood monocyte sub- sets: a new gating strategy defined using cell surface markers identified by mass cytometry. ATVB. 2017;37:1548–58. 9. Pfefferle A, Jacobs B, Haroun-Izquierdo A, Kveberg L, Sohlberg E, Malmberg K-J. Deciphering natural killer cell homeostasis. Front Immunol. 2020;11:812. sets: a new gating strategy defined using cell surface markers identified by mass cytometry. ATVB. 2017;37:1548–58. 9. Pfefferle A, Jacobs B, Haroun-Izquierdo A, Kveberg L, Sohlberg E, Malmberg K-J. Deciphering natural killer cell homeostasis. Front Immunol. 2020;11:812. Page 10 of 10 Kong et al. BMC Bioinformatics (2024) 25:142 10. Sanz I, Wei C, Jenks SA, Cashman KS, Tipton C, Woodruff MC, et al. Challenges and opportunities for consistent clas- sification of human B cell and plasma cell populations. Front Immunol. 2019;10:2458. i 11. Saharia GK, Patra S, Bandyopadhyay D, Patro BK. Flow cytometry based platelet activation markers and state of inflammation among subjects with type 2 diabetes with and without depression. Sci Rep. 2022;12:10039. 12. Pont F, Tosolini M, Gao Q, Perrier M, Madrid-Mencía M, Huang TS, et al. Single-Cell Virtual Cytometer allows user- friendly and versatile analysis and visualization of multimodal single cell RNAseq datasets. NAR Genom Bioinform. 2020;2:lqaa025. 13. Rue-Albrecht K, Marini F, Soneson C, Lun ATL. Publisher’s Note Publisher s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
https://openalex.org/W4312687104	https://materconstrucc.revistas.csic.es/index.php/materconstrucc/article/download/3313/4094	es		Clasificador hidráulico para arena	Materiales de construcción	1,949	cc-by	915	A. B. Morris Materiales de Construcción, vol. 5 (1949) ^ 32 -^ 655-1 - CLASIFICADOR HII)MULXC^O_\|^mâ ARENA< A» Bé MorriBo Des "ROCK PRODUCTS^S 109, junio, 1949. En muclia^s industrials, la del vidrio por ejemplo, se necesita disponer de buena, arena silícea, bien lav^dr., completamen te desprovista de arcilla, lodo y tierra 37- con un contenido en hierro muy bajo (m.enoB del 0,03 f¿)* En los lavaderos usuales, que consisten en mi simple depósito con pogitadores, no es fácil impedir el contacto de la suciedad arrastrada por las suspensif nes arenosas, con la arena ya lavada* La calidad de las arenas y los rendimientos obtenidos con estos apara,tos son mediocres» El cla,sificador Morris Reflu.x tiene características ra-» dicálmente diferentes y su comportamiento es óptimo, no solo con arena, sino con cua^lquier material granular semejante* La f±g. 13 representa una sección transversal de mi Morris, que trabaja por el principio de contracorriente y consiste en una columna dividida en dos partes, mía de ellas ^nsaacíiada* Interiormente está dividida en una serie de cáraaras separadas por psn.tallas de forma cónica., constituidas por elementos anulares por entre los cuales asciende la corriente de agua» La, introducción de la. arena (en forma de papilla o .slurr;^) se hE^ce por el tu.bo central A que vierte a unos 2/3 del extremo su.perior de la columna. La -arena va descendiendo por entre estcis ppn.tallas, limpiándose gra dualmente y encontrándose en su recorrido con agua, cada vez más Instituto Técnico de la ConstrLicción y del Cemento (c) Consejo Superior de Investigaciones Científicas Licencia Creative Commons Reconocimiento 4.0 Internacional (CC BY 4.0) https://materconstrucc.revistas.csic.es - 33 limpia. Esta, entra por el tubo lateral que se ve en la figura, y que está provisto de una válvula de paso. La, arena lavada sa le por B. La cariara 2 situada en la parte alta de la columna -hace de rel)osa.dero j los limos, lodos y otras impurezas salen carrastrados por el agua por el tubo lateral C» La parte ensanchada de la coltimna lleva varios disposi-tivos auxiliares 3^ separadores en panta,lla similares a los de la. parte estreclia de la misma» Hay también un enrejado en forma de nido de abeja que tiene por objeto quitar toda turbulencia al chorro de agua {jj arena) que a^sciende; 3 es el distribuidor de material que, a.l mismo tiempo que regula el descenso de la agreña., impide que el producto 3^. lavado se ponga en conta.cto con las impureza^s* El recipiente superior 2 ha.ce de sedimentador en el cual pueden depositarse, por gravedad, todas la.s par tí culacs de un cierto taiaa.ño. Cuando se quieren obtener 8a?enas con diferentes tajiiaños de granoj se disponen variais de estas col^lmnas en batería, conectando el tubo C de sa-lida de la primera con el de entrada, de la. segunda y así sucesivam.ente« En este caso, la primera co lumna, en la. que se recoge el ma^terial más gru-eso, es de pequ^e ño diámetro -^j tra.baja con a.lta velocida.d de paso de agua.5 la segunda, posee ma3í^or diár-ietro y menor velocidad de pa.so de agna^^^ y a.sí sucesiva.menteo En la últim£\ se recogen los finos,» Las dis tintas fra.cciones de arena se separan en las pa.rtes bajas de las colLimna,s, mediaaite -:Brtura a mano ô.e las válvulas de descarga, correspondientes• Puede decirse, hcablamdo en términos generales, - Instituto Técnico de la Construcción y del Cemento (c) Consejo Superior de Investigaciones Científicas Licencia Creative Commons Reconocimiento 4.0 Internacional (CC BY 4.0) https://materconstrucc.revistas.csic.es , ' ^ 34 - que estos clasificadores se basan en un principio muy semejante al del f lucróme tro de We,gner, tan conocido en los laboratorios de ensaj^^o de materiales » En la ta.bla, siguiente se- indica el comportamiento de una instalación cla.sifiC8.dor8. de arena, que consta de dos coluiiine.s. Se muestra la composición de la arena original y de las dos fracciones separadas s ITamiz 1^ ColvTfirm. Original» Granos contenidos en la muestra Granos % 2Ô Columna Granos fo 8 mallas 16 It 37 37 200 20 tr 30 30 100 28 »• 80 80 100 35 827 568 68^9 259 100 48 2*062 292 14,2 1.770 100 50 895 20 2,2 875 100 80 4,319 5 0,1 4.314 100 100 1.652 5 0,3 1.647 100 2.207 97,4 150 I» 2»267 Puede observarse una n e t a separación en l o s taoiaños de l o s gra-nos, ©alrededor de 35 m a l l a s . Es d e c i r , l a primera COIUH- na seps-ra l o s granos de a.rera de taina^ño s u p e r i o r a 35 ms-lla-s y l a segunda todos l o s inferiospes. En el o r i g i n a l se dan. v e r i os ejemplos de a p l i c a c i ó n de e s t e i n t e r e s a n t e sistema c3-asificador-lavador (con f o t o g r a f í a s y esqueiii8.s) a d i v e r s a s i n d u s t r i a s t a l e s corao l a separación de minera,les fosfatados (fo r; f o r i t a s ) , lavado de carbón, etCt I n s t i t u t o Técnico de l a Construcción y del Cemento (c) Consejo Superior de Investigaciones Científicas Licencia Creative Commons Reconocimiento 4.0 Internacional (CC BY 4.0) https://materconstrucc.revistas.csic.es
https://openalex.org/W2042684628	https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0008622&type=printable	English	null	A Neurosemantic Theory of Concrete Noun Representation Based on the Underlying Brain Codes	PloS one	2,010	cc-by	15,617	Introduction grandmother is likely to be represented in terms of gender (female), generation level relative to a reference person (two generations older), and lineality (direct ancestor) [3]. The dimensions of kinship terms are easier to discern because of the well-structured biological and social domains to which they refer. The corresponding representational dimensions of apple are far less clear. However, new methods of neuroimaging and machine learning have the potential of revealing the dimensions of representation that the brain uses. How a simple concept like apple is represented in the human mind has been of interest to philosophers for centuries, but the question has not been amenable to scientific approaches until recently. The emerging technologies of brain imaging have now made it possible to examine the neural representation of such concepts in the human brain, in a way that has been revealing of the mental content. It is clear that the neural representation of such concepts involves multiple brain areas specialized for various types of information, indicating that the representations can be decomposed into components. In the case of discrete physical objects, the neural representations can be related to verbs of perception and action that apply to the objects [1]. For example, apple appears to be neurally represented in terms of an apple’s visual properties, graspability, purpose, etc., and the representa- tion is distributed across a number of relevant brain areas; for example, the information about the physical actions that can be applied to an object are represented in cortical areas related to control of hand actions [1,2]. p A new approach, combining fMRI neuroimaging and machine learning techniques, successfully characterized the neural repre- sentations of physical objects like apples [1]. This approach proposed that meanings of physical objects can be characterized in terms of 25 features, namely the nouns’ co-occurrence frequencies with 25 verbs of perception and action in a large text corpus. For example, one semantic feature (independent variable in a regression model) was the frequency with which the noun co- occurs with the verb taste. Marcel Adam Just1, Vladimir L. Cherkassky1, Sandesh Aryal1, Tom M. Mitchell2 1 Department of Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America, 2 Machine Learning Department, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America Abstract doi:10.1371/journal.pone.0008622 Editor: Olaf Sporns, Indiana University, United States of America Received June 5, 2009; Accepted December 8, 2009; Published January 13, 2010 Received June 5, 2009; Accepted December 8, 2009; Published January 13, 2010 Copyright: 2010 Just et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, use, distribution, and reproduction in any medium, provided the original author and source are credited. et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted roduction in any medium, provided the original author and source are credited. Funding: This research was supported by the W. M. Keck Foundation and the National Science Foundation, Grant No. IIS-0835797. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. E-mail: just@cmu.edu Competing Interests: The authors have declared that no competing interests exist. * E-mail: just@cmu.edu Abstract This article describes the discovery of a set of biologically-driven semantic dimensions underlying the neural representation of concrete nouns, and then demonstrates how a resulting theory of noun representation can be used to identify simple thoughts through their fMRI patterns. We use factor analysis of fMRI brain imaging data to reveal the biological representation of individual concrete nouns like apple, in the absence of any pictorial stimuli. From this analysis emerge three main semantic factors underpinning the neural representation of nouns naming physical objects, which we label manipulation, shelter, and eating. Each factor is neurally represented in 3–4 different brain locations that correspond to a cortical network that co-activates in non-linguistic tasks, such as tool use pantomime for the manipulation factor. Several converging methods, such as the use of behavioral ratings of word meaning and text corpus characteristics, provide independent evidence of the centrality of these factors to the representations. The factors are then used with machine learning classifier techniques to show that the fMRI-measured brain representation of an individual concrete noun like apple can be identified with good accuracy from among 60 candidate words, using only the fMRI activity in the 16 locations associated with these factors. To further demonstrate the generativity of the proposed account, a theory-based model is developed to predict the brain activation patterns for words to which the algorithm has not been previously exposed. The methods, findings, and theory constitute a new approach of using brain activity for understanding how object concepts are represented in the mind. Citation: Just MA, Cherkassky VL, Aryal S, Mitchell TM (2010) A Neurosemantic Theory of Concrete Noun Representation Based on the Underlying Brain Codes. PLoS ONE 5(1): e8622. doi:10.1371/journal.pone.0008622 Editor: Olaf Sporns, Indiana University, United States of America Received June 5, 2009; Accepted December 8, 2009; Published January 13, 2010 Citation: Just MA, Cherkassky VL, Aryal S, Mitchell TM (2010) A Neurosemantic Theory of Concrete Noun Representation Based on the Underlying Brain Codes. PLoS ONE 5(1): e8622. doi:10.1371/journal.pone.0008622 Editor: Olaf Sporns Indiana University United States of America ation: Just MA, Cherkassky VL, Aryal S, Mitchell TM (2010) A Neurosemantic Theory of Concrete Noun Representation Based on des. PLoS ONE 5(1): e8622. PLoS ONE \| www.plosone.org Introduction The farthest reaching contribution of this model was its generativity, enabling it to extrapolate sufficiently to predict the neural representation (fMRI-measured brain activity) of words that were new to the model, simply on the basis of (1) the new words’ co-occurrence frequencies with the 25 verbs, and (2) the weights associating those frequencies to patterns of brain activation in response to a fixed number of words. When presented with previously unseen brain activation patterns A central issue addressed here concerns the underlying semantic dimensions of representation of concrete nouns and the physical objects to which they refer. What are the underlying semantic, psychological, or neural dimensions in terms of which apple is represented? To take a simpler example, a kinship term such as PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 1 January 2010 \| Volume 5 \| Issue 1 \| e8622 Neurosemantic Theory Neurosemantic Theory generated by two new concrete nouns, the model was able to correctly match the two nouns to the two patterns 77% of the time, very far above chance level. representations of visually depicted objects, like screwdriver, drill, hut, or castle [14]. Here we examine the commonality of the representation of concrete nouns across people. The measure of commonality is whether a classifier (a mathematical function that here maps from fMRI activation patterns to word labels), trained on the brain activation patterns of a set of people, can accurately classify (label) patterns of activation obtained from people outside of that set. Although the issue of cross-person commonality of representation is dealt with succinctly, it yields one of the most far- reaching conclusions of this research, indicating whether one person’s neural representation of the meaning of a concrete noun closely resembles another person’s. The relative success of this previous model speaks to the choice of verbs used for co-occurrence measures. Many of the verbs pertain to physical manipulation such as touch, rub, lift, manipulate, push, and move. Some pertain to eating: taste, eat. The set of verbs was generated intuitively as actions and perceptions that seemed applicable to physical objects. The current study takes a different approach, asking whether there is some bottom-up analytic procedure that reveals the underlying dimensions of representation, perhaps more compactly. Is there a set of fundamental neural dimensions that arise in the representation of physical objects that such a procedure can reveal? Participants Eleven adults (eight right-handed females, two clearly right- handed males, and one male with right-handedness for tool use, with all 11 participants showing left-dominant activation) from the Carnegie Mellon community participated and gave written informed consent approved by the University of Pittsburgh and Carnegie Mellon Institutional Review Boards. Eight additional participants were excluded because of either excessive head motion (two participants) or insufficient stability of voxel activation profiles (six participants). Which particular brain locations are involved in the represen- tation of a concept depends in part on how the concept is evoked. Previous neuroimaging studies that presented a visual depiction of the object, such as a line drawing or photograph, have determined which specific brain areas play a role in the high-level visual representation of categories of physical objects (such as faces), indicating that there is a set of areas, particularly in ventral temporal cortex, that respond differentially to pictures of a set of disparate categories of objects, such as houses, faces, and chairs [8–10]. Moreover, by applying machine learning or pattern-based classification methods to fMRI data (reviewed in [11–13]), such studies have succeeded in finding a mapping between multivariate patterns of brain activity and a given object category. The remarkable successes in identifying the brain activity associated with viewing classes of visual depictions of objects has focused, unsurprisingly, on the brain’s primary and secondary (ventral temporal) visual areas. Here, with printed words as stimuli, we ask if it is possible to identify higher order cortical representations (in addition to the perceptual representations) of the semantic properties of a concrete noun. Moreover, we attempt to specify the cortical locations at which the different semantic factors are processed. Introduction The machine learning or pattern classification approach is also used in a more fundamental way, namely for determining whether a neural signature of each word’s meaning, derived from a subset of a given participant’s data, can be used to classify (label) the words from an independent subset of that same participant’s brain activation data. The classification approach is used to assess how well the factor analysis output characterizes individual neural representations. There is a rich history of applying dimension-reduction techniques, such as factor analysis and multidimensional scaling, to behavioral data to recover the underlying dimensions of meanings of words, including classic studies of color terms [4], verbs of motion [5], animals [6], and a variety of different domains [7]. Here we apply factor analysis to neural data obtained with fMRI to determine the semantic factors underlying the brain activation. To foreshadow our results, we found that factor analysis indicated three fundamental semantic dimensions of neural representation of the physical objects in the 60-item stimulus set. The findings reported here thus constitute several types of advances. The central focus concerns the semantic organization of the neural representation of familiar concrete objects, revealing the component building blocks of the brain’s representation of the meaning of physical objects. Second, we report the neural representation evoked by words rather than pictures. A third novel aspect of the findings is the discovery of significant cross- participant commonality in neural representations of word meaning, such that the activation patterns of an individual participant can be identified based on training data drawn exclusively from other people. Finally, we demonstrate the generativity of the proposed principles, allowing a model to predict the activation of a new concrete noun based on its semantic properties. A second innovation of this study is its exclusive focus on the representation of words rather than on pictures of objects. Much of the previous research has focused on or included visual depictions of the objects of interest, rather than focusing on words (Mitchell et al. [1] presented word-picture pairs). Various kinds of depictions (such as line drawings or photographs) inherently present a particular instantiation of a given object category, and they explicitly depict some of the object’s visual features, which in turn are represented in the perceiver’s brain. By contrast, words are symbols whose neural representations are entirely retrieved from previous knowledge rather than being at least partly visually perceived. Experimental Paradigm The stimuli were 60 words, containing five exemplar concrete objects from twelve taxonomic categories: body parts, furniture, vehicles, animals, kitchen utensils, tools, buildings, building parts, clothing, insects, vegetables, and man-made objects, as shown in Table 1. The 60 words were presented six times (in six different random permutation orders). Each word was presented for 3s, followed by a 7s rest period, during which the participants were instructed to fixate on an X displayed in the center of the screen. There were twelve additional presentations of a fixation X, 31s each, distributed across the session to provide a baseline measure. PLoS ONE \| www.plosone.org Data Preprocessing The data were corrected for slice timing, motion, and linear trend, and were normalized into MNI space without changing voxel size (3.12563.12566 mm). The gray matter voxels were assigned to anatomical areas using Anatomical Automatic Labeling (AAL) masks [15]. For some analyses, the gray matter voxels were partitioned into five bilateral brain areas or ‘‘lobes’’ using AAL masks: frontal, parietal, temporal, occipital, and an idiosyncratically-defined fusiform ‘‘lobe’’ which included the fusiform and parahippocampal gyri. This fusiform ‘‘lobe’’ was separated from the other areas because of its prominence in previous studies of object representations. (The temporal and occipital ‘‘lobes’’ are hence also idiosyncratically-defined because their definition excludes their usual share of the fusiform and parahippocampal gyri.) A later check found no voxels relevant to the reported outcomes outside of the five lobes. At the first level, a separate factor analysis was run on each lobe of each participant, using as input the matrix of intercorrelations among the activation profiles of the 50 most stable voxels in the lobe. (Prior to computing the intercorrelations, the voxels’ activation profiles within each lobe and participant were averaged over six presentations and normalized over the 60 words to have a mean = 0 and SD = 1. The choice of the particular number of voxels (50) used as input was motivated by similar analyses in other datasets where 50 was the smallest number of voxels that maximized classification accuracy.) The goal of each of these first-level factor analyses was to reduce the data from the activation profiles of many (50) stable voxels to a few factors that characterized the profiles of most of the stable voxels in each lobe of each participant. The percent signal change relative to the fixation condition was computed at each gray matter voxel for each stimulus presentation. The main input measure for the subsequent analyses consisted of the mean of the four brain images acquired within a 4s window, offset 4s from the stimulus onset (to account for the delay in hemodynamic response). The intensities of the voxels in this mean image for each word were then normalized (mean = 0, SD = 1). Then a second-level factor analysis was run to identify factors that were common across lobes and participants, a procedure known as higher-order factor analysis [16]. fMRI Procedures Functional images were acquired on a Siemens Allegra (Erlangen, Germany) 3.0T scanner at the Brain Imaging Research Center of Carnegie Mellon University and the University of Pittsburgh using a gradient echo EPI pulse sequence with TR = 1000 ms, TE = 30 ms and a 60u flip angle. Seventeen 5- mm thick oblique-axial slices were imaged with a gap of 1 mm between slices. The acquisition matrix was 64664 with 3.125- mm63.125-mm65-mm voxels. Initial data processing was per- formed using SPM2 (Wellcome Department of Cognitive Neurology, London). Factor Analysis Methods To factor the neural activity associated with the 60 different word stimuli into different components shared across participants and brain lobes, we used a two-level exploratory factor analysis based on principal axis factoring with varimax rotation, using the same algorithm as the SAS factor procedure (www.sas.com). Selecting Voxels with Stable Activation Patterns properties across the six presentations of a word, they were asked to generate a set of properties for each item prior to the scanning session (for example, the properties for the item castle might be cold, knights, and stone). Each participant was free to choose any properties for a given item, and there was no attempt to impose consistency across participants in the choice of properties. The analyses below generally focused on a small subset of all the voxels in the brain, namely those whose activation profile over the 60 words was stable across the multiple presentations of the set of words. The assumption here is that the activation levels of only the relatively stable voxels provide information about objects. A voxel’s stability was computed as the average pairwise correlation between its 60-word activation profiles across the multiple presentations that served as input for a given model (the number of presentations over which stability was computed was four or six, depending on the analysis). Here the 60-word activation profile of a voxel for a particular presentation refers to the vector of 60 responses of that voxel to the words during that presentation. A stable voxel is thus one that responds similarly to the 60 word stimulus set each time the set is presented. PLoS ONE \| www.plosone.org Task A third innovation of this study lies in its examination of the commonality of the neural representation of words across different people. Only recently has it been possible to demonstrate that there is a great deal of commonality across people in their neural When a word was presented, the participants’ task was to actively think about the properties of the object to which the word referred. To promote their consideration of a consistent set of January 2010 \| Volume 5 \| Issue 1 \| e8622 January 2010 \| Volume 5 \| Issue 1 \| e8622 2 Neurosemantic Theory Table 1. 60 stimulus words grouped into 12 semantic categories. Category Exemplar 1 Exemplar 2 Exemplar 3 Exemplar 4 Exemplar 5 body parts leg arm eye foot hand furniture chair table bed desk dresser vehicles car airplane train truck bicycle animals horse dog bear cow cat kitchen utensils glass knife bottle cup spoon tools chisel hammer screwdriver pliers saw buildings apartment barn house church igloo building parts window door chimney closet arch clothing coat dress shirt skirt pants insects fly ant bee butterfly beetle vegetables lettuce tomato carrot corn celery man-made objects refrigerator key telephone watch bell doi:10.1371/journal.pone.0008622.t001 doi:10.1371/journal.pone.0008622.t001 Selecting Voxels with Stable Activation Patterns Data Preprocessing The above two-level factor analysis was initially performed using data from only four of the participants, selected to optimize the discovery of semantic factors capturing neural activity across more of the cortex than just in visual areas. The four selected participants were the ones who had the greatest number of voxels with high stability in non-occipital portions of the cortex. Generally, in a task with visual input, the most stable voxels are found in occipital areas, where the stability is determined primarily by the low-level visual features of the written words. The presence of substantial numbers of stable non-occipital voxels in these four participants made it more likely that interpretable semantic factors would emerge during this initial discovery phase of analysis. The analysis was subsequently applied to all 11 participants, producing similar results, as reported below. ~Vi~ X j ~F1 j L1 ij ~Vi~ X j ~F1 j L1 ij After the first-level factor analysis is computed, we have the matrix of first-level loadings L1 ij (and we also have voxel profiles ~Vi for all 50 voxels in a lobe). The equations above (corresponding to i = 1…50) can be solved for the unknown factor profiles ~F1 j (using least squares), producing five first-level factor profiles. These factor profiles (which apply to all 50 voxels within that lobe of that participant) constitute the factor scores for each of the 60 words. Although the factors emerging from a factor analysis initially have to be subjectively interpreted, we report below how the recovered factors were subjected to several validation methods. In the results section, the four emergent factors are (1) analyzed for content; (2) independently substantiated by demonstrating consis- tency with two other measures of word meaning; (3) used as the basis of a machine learning cross-validation protocol that demonstrates the ability to identify the word from its fMRI pattern; and (4) used as the basis of a machine learning cross- validation protocol that demonstrates the ability to predict the fMRI pattern of a new word. This algorithm was applied separately for each set of 50 voxels selected from five lobes of four participants, resulting in 20 first- level factor analyses. (The motivation for choosing four partici- pants is given below.) The five dominant factors were selected from each of these first-level analyses, to produce a set of 100 first- level factors ~F1 n , where n = 1…100. Data Preprocessing (The search for commonality across lobes was motivated by the assumption that a semantic factor would be composed of a large-scale cortical network with representation in multiple brain lobes.) The input to PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 January 2010 \| Volume 5 \| Issue 1 \| e8622 3 Neurosemantic Theory Neurosemantic Theory the second-level analysis consisted of the five dominant first-level factors obtained from each lobe of each participant. (Below this two-step factor analysis is compared to a single-level analysis.) structure). Similarly, for the second level analysis, a first-level factor was uniquely assigned to one of the 10 second-level factors for which it had the highest (absolute value) loading, provided that this loading has was above the 0.4 threshold. Considered together, the above mappings allowed us to assign a set of voxels (from different lobes and participants) to each of the second-level factors. To define the factor analysis models precisely, we introduce the following notation: ~Vi is the 60-word mean activation profile of the i-th voxel (i = 1…50) ~Vi is the 60-word mean activation profile of the i-th voxel (i = 1…50) ~Vi is the 60-word mean activation profile of the i-th voxel (i = 1…50) ~F1 j is the first-level factor profile over 60 words of the j-th factor (j = 1…5) L1 ij is a first-level loading of i-th voxel on factor ~F1 j This assignment served the two purposes. First, it provided a basis for assessing the commonality of each factor across participants. A factor was defined as being common to N participants if it was mapped to voxels that originated in N participants. Second, the set of voxels assigned to a factor specified the brain locations associated with the factor. ~F1 j is the first-level factor profile over 60 words of the j-th factor (j = 1…5) ~F1 j is the first-level factor profile over 60 words of the j-th factor (j = 1…5) L1 ij is a first-level loading of i-th voxel on factor ~F1 j Then the following equation defines voxel activation profiles as a linear combination of factor profiles and serves as a model for the first-level factor analysis. Machine Learning Methods Now define ~F2 k as a second-level factor profile over 60 words (k = 1…10), L2 nk as a second-level loading of n-th first-level factor on second-level factor ~F2 k. Overview. The machine learning techniques used here can be separated into three stages: algorithmic selection of a small set of voxels believed to be useful for classification; training of a classifier on a subset of the data; and finally testing of the classifier on an independent subset of the data. The training and testing use cross-validation procedures that iterate through many cycles of all possible partitionings of the data into training and testing datasets. The training set and test set are always rigorously kept separate from each other. The two main machine learning modeling approaches used are a Gaussian Naı¨ve Bayes (GNB) classifier and linear regression. Throughout the paper, we use the term word identification to refer to the ability of a machine learning algorithm to determine (with some accuracy) which of many words a person is thinking about. Then the following equation defines the first-level factor profiles as a linear combination of second-level factor profiles and serves as a model for the second-level factor analysis. ~F1 n ~ X k ~F2 kL2 nk The second-level factor analysis produces a matrix of second- level L2 nk loadings, and we also have the first-level factor profiles ~F1 n . The number of factors to which the analysis was limited was 10 and of these 10 second-level factors, only the first four factors were common to all four of these participants. Solving the above equation for the unknown second-level factor profiles (using least squares) produces the vectors of second-level factor profiles over the 60 words. The factor profiles from these four factors constitute the factor scores for each word. Feature selection. First, there is an algorithmic feature selection, selecting 80 of the 15,000–20,000 brain voxels (each 3.12563.12566 mm) believed to be particularly useful for detecting the patterns of interest. (Several previous studies indicated that 80 voxels regularly produced considerably higher identification accuracies than using all of the voxels in the brain, and modest increases of the number of voxels above 80 tended not to systematically increase accuracy.) In the base machine learning model described later, the voxels selected were the 80 most stable voxels in the cortex. Data Preprocessing The choice of five factors from each first-level analysis was based on observing that the first five factors had eigenvalues greater than one, and that additional factors typically produced diminishing returns in characterizing the voxel activation profiles. These 100 first-level factors were used as input to the second-level factor analysis. PLoS ONE \| www.plosone.org Neurosemantic Theory and (b) independent participant ratings of the words. These additional approaches indicate strong correspondences with the factor analysis characterizations of the words. profiles across the four presentations in a training set for the within-participant identification. The activation values for the 80 voxels were normalized (mean = 0, SD = 1) across the 60 words, separately for the training and test set, to increase comparability across the six presentations. (For the cross-participant analyses, the 80 voxels were those that were most stable across the 60 words for the participants in the training set, excluding any data from the participant involved in the test of the classifier.) 3. We then apply a machine learning (or pattern classification) approach to determine whether the semantic characterization obtained by the bottom-up approach can be used to successfully identify a word by its fMRI activation signature. 4. We show that the neural representation of a concrete noun is common across people, allowing cross-participant identifica- tion of the words. Classifier training. In a second stage, a subset of the data (four out of the six presentations in the within-participant classification) was used to train a classifier to associate fMRI data patterns with a set of labels (the words). A classifier is a mapping function f of the form: f: voxel activation levelsRYi, i = 1,…,m, where Yi were the 60 words (leg, chair, car, dog,…), and where the voxel activation levels were the 80 mean activation levels of the selected voxels. The classifier used here was a Gaussian Naı¨ve Bayes (GNB)-pooled variance classifier. (Several other classifiers were also examined, such as variants of GNB- pooled, a support vector machine, and a k-nearest neighbor classifier, all of which sometimes produced comparable results. We make no claim of superiority for GNB-pooled.) GNB is a generative classifier that models the joint distribution of class Y and attributes and assumes the attributes X1,…,Xn are conditionally independent given Y. The classification rule is: 5. We express the theory of concrete noun representation explicitly and use a regression model to test the generativity of the theory by predicting the activation of words that the model has not previously encountered and matching the predictions to the observed activation. 1. Using Factor Analysis to Determine the Semantic Dimensions Underlying the Activation and the Factors’ Locations Common factors across participants. The factor analyses start with the four participants with the greatest number of stable anterior voxels and are then generalized to the entire group because the anterior voxels encode semantic information that is part of a concrete noun’s meaning. The 80 most stable voxel locations of the four participants with plentiful anterior voxels were very similar to each other and included inferior left frontal cortex, inferior parietal, and posterior temporal regions, whereas the remaining seven participants had few voxels in these anterior locations among the 80 most stable ones. We show below that the remaining seven participants also had informative anterior voxels, but there were enough stable posterior voxels among these seven participants to lower the stability rank of the anterior voxels. It was the four participants with plentiful anterior voxels (labeled P1, P2, P3, and P5 in a later Figure) who also tended to have the highest word identification accuracies using machine learning techniques. Y/ arg max yi P(Y~yi) P j P(XjjY~yi) where P(X\|Y = yi) is modeled as a Gaussian distribution whose mean and variance are estimated from the training data. In GNB- pooled variance, the variance of attribute Xj is assumed to be the same for all classes. This single variance is estimated by the sample variance of the pooled data for Xj taken from all classes (with the class mean subtracted from each value). where P(X\|Y = yi) is modeled as a Gaussian distribution whose mean and variance are estimated from the training data. In GNB- pooled variance, the variance of attribute Xj is assumed to be the same for all classes. This single variance is estimated by the sample variance of the pooled data for Xj taken from all classes (with the class mean subtracted from each value). Classifier testing. The classifier was tested on the mean of the two left-out presentations of each word. This procedure was reiterated for all 15 possible combinations (folds) of leaving out two presentations. (The between-participant classification always left out the data of the to-be-classified participant and trained the classifier on the remaining participants’ data.) Of the factors emerging in the second-level factor analysis, only four of them were common to all four of the participants with plentiful anterior voxels in the first-level factor analyses. 1. Using Factor Analysis to Determine the Semantic Dimensions Underlying the Activation and the Factors’ Locations (These four factors explained 29% of the variation in the input data (the 100 factors from the first-level factor analyses), whereas all 10 factors explained 56% of the variation.) The four common factors were initially interpreted by observing which words had the highest factor scores for a given factor and which had the lowest. For example, the factor we labeled as eating-related assigns the highest rank orders to vegetables and eating utensils. Another example is the factor labeled word length, which assigned the highest factor scores to the longest words and the lowest scores to the shortest words (cat, cow, car, leg, key), making it straightforward to interpret this factor. The rank accuracy (hereafter, simply accuracy) of the classification performance was computed as the normalized rank of the correct label in the classifier’s posterior-probability-ordered list of classes. For example, if the classification were operating at chance level, one would expect a mean normalized rank accuracy of 0.50, indicating that the correct word appeared on average between the 30th and 31st position in the classifier’s output of a ranked list of 60 items. A rank accuracy was obtained for each fold, and these rank accuracies were averaged across folds, producing a single value characterizing the prediction accuracy for each word. The mean accuracy across items (words) was then computed. There were three interesting semantic factors: manipulation, eating, and shelter-entry. The manipulation factor accords its highest scores to objects that are held and manipulated with one’s hands. The 10 words with the highest factor scores for this factor included all five of the tools, as well as key, knife, spoon, bicycle, and arm. The 10 words with the highest factor scores for each factor are shown in Table 2. The eating factor appears to favor objects that are edible (all five vegetables are in the top 10) or are implements for eating or drinking (glass and cup). Note that each word has a score for each of the factors, so a word’s neural representation is a composition of these four factors, such that glass and cup rank high not only in terms of eating, but they also have a substantial manipulation component (although not in the top 10). The shelter Machine Learning Methods Here a voxel’s stability was computed as the average pairwise correlation between its 60-word activation Factor loading matrices from all first-level and second-level analyses were also used to create a (simplified) mapping between factors and voxels. For the first-level analyses, a voxel was uniquely assigned to one of the five first-level factors for which it had the highest (absolute value) loading, provided that this loading was above a threshold value of 0.4 (a typical value for exploring factor PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 4 Neurosemantic Theory January 2010 \| Volume 5 \| Issue 1 \| e8622 Overview of Results 1. In the first section of the results, we report the outcome of a data-driven approach, a factor analysis of the brain activation, discovering three semantic factors and one visual factor underlying the representation of the 60 words that are common across participants. This section also describes the cortical locations associated with each factor. 1. In the first section of the results, we report the outcome of a data-driven approach, a factor analysis of the brain activation, discovering three semantic factors and one visual factor underlying the representation of the 60 words that are common across participants. This section also describes the cortical locations associated with each factor. 2. We then develop converging information about the word representations by obtaining two additional characterizations that are based on (a) text corpus statistics related to the words, PLoS ONE \| www.plosone.org PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 January 2010 \| Volume 5 \| Issue 1 \| e8622 5 Neurosemantic Theory Neurosemantic Theory Table 2. Ten words with highest factor scores (in descending order) for each of the 4 factors. Shelter Manipulation Eating Word length apartment pliers carrot butterfly church saw lettuce screwdriver train screwdriver tomato telephone house hammer celery refrigerator airplane key cow bicycle key knife saw apartment truck bicycle corn dresser door chisel bee lettuce car spoon glass chimney closet arm cup airplane doi:10.1371/journal.pone.0008622.t002 factors in the single-level analysis (having been displaced by a much less interpretable factor). The two different factor analysis approaches thus produce the same four factors. We have focused on the results of the two-level analysis because there we enforced certain assumptions (distribution across lobes and generality across participants) and because the resulting factor structure was more easily interpretable. Table 2. Ten words with highest factor scores (in descending order) for each of the 4 factors. To confirm that the factors obtained from the four participants with plentiful anterior voxels apply well to the activation of all 11 participants, an additional two-level factor analysis was performed on all 11 participants using the method described above. The first four factors (explaining 20% of the variation in the first-level factors data) were extremely similar to the corresponding factors from the original four-participant analysis, and also were shared by a substantial proportion of the participants. Finding the Multiple Brain Locations Corresponding to Each Factor Because the semantic factors emerge from the activation patterns of individual voxels, it is possible to trace the factors back to their root voxels and determine where the voxels associated with a given factor are located. Using the factor loading matrices from the second- and first-level factor analyses, the locations of voxels that are associated with each of the four common factors were computed from the analysis of all four participants with plentiful anterior voxels. Recall that voxels were uniquely assigned to one of the four factors by selecting their highest (absolute value) loading above a .4 threshold. For each factor, the associated voxels tended to cluster in three to five different locations in the brain. Voxel clusters were obtained by finding at least five neighboring voxels that belonged to a given factor. Then a sphere was defined at the centroid of the cluster having a radius equal to the mean radial dispersion of these voxels from the centroid. To foreshadow, all four factors were associated with multiple locations, distributed across multiple lobes. Moreover, many of the locations associated with a given factor have been previously characterized as nodes in networks of cortical areas related to the factor in fMRI studies without verbal stimuli, as described below. Two of the factors (manipulation and eating) were very strongly left- lateralized, possibly due to handedness considerations. The shelter and word length factors included voxel clusters in both hemispheres. The centroids and radii associated with each factor are shown in Figure 1 and Table 3. Figure 1 shows the multiple cluster locations for all of the factors in the brain as colored spheres. (Additionally, Figure S1 shows the locations of the actual voxels assigned by the above procedure to the four factors.) In the descriptions below of the correspondences between these locations and those reported in other studies, we cite the Euclidean distance from the centroid of a Alternative analyses yielding similar results. The impact of having used the two-level factor analysis can be assessed by comparing it to a single-level analysis that finds factors in a single step (eliminating the first-level within-lobe, within-participant analyses). The single-level analysis also recovers the four factors reported above. Overview of Results The correlation between four- and 11-participant-based factor scores for the 60 words for shelter was .91, and the factor was present in nine of the 11 participants; for manipulation the correlation was .88 and the factor was present in five of 11 participants; for eating the correlation was .85 and the factor was present in nine of 11 participants; for word length the correlation was .93 and the factor was present in all 11 participants. There were other factors emerging from the four- and 11-participant factor analyses that were present in fewer of the participants than these four factors, such as a factor that could be labeled containment, which assigned high scores to objects capable of being filled, such as cup and closet. Thus the alternative analyses described above (the one-level factor analysis and the two-level analysis on data from all 11 participants) show that the outcomes are not closely dependent on the main methods that were used. doi:10.1371/journal.pone.0008622.t002 factor appears to favor the objects that provide shelter or entry to a sheltering enclosure. The 10 words with the highest factor scores contained three of the dwellings, four of the vehicles that include an enclosure (such as train), as well as door, key, and closet. These interpretations of the factors are consistent with converging evidence presented below. (The percentage of variation accounted for by each of the four second-level factors in the data of the four participants with plentiful anterior voxels was eating: 7.26; shelter: 8.51; manipulation: 7.31; word length: 5.67.) Visual features of the printed word: the word-length factor. The word length factor presents an opportunity to separate a low-level, perceptual feature of the printed word from the high- level, semantic object features (encoded by the manipulation, eating, and shelter factors). The word length factor appears to represent the width or number of letters of the printed word. The word length factor scores of each word are highly correlated with word length (r = 0.90). The locations associated with this factor (reported below) also appear to be consistent with this interpretation. There was also a check made to determine whether word frequency might also be influencing the activation at the word length factor locations. Overview of Results However, a stepwise regression on the mean activation of the voxels in each factor location determined that after having entered word length as the independent variable in the first step, entering word frequency in the second step never produced a reliable increase in R2 in any of the analyses of the four factor locations in any of the 11 participants. In sum, this low-level word length factor demonstrates that the factor analysis method can recover a factor that matches a clearly measureable property of the stimuli, and thus serves as a validity check. Moreover, the factor captures an essential part of the representation of a written word as it progresses into the semantic system. Finding the Multiple Brain Locations Corresponding to Each Factor The shelter, manipulation, and word length factors strongly resemble the corresponding factors in the two-level analysis (the correlations between the two sets of 60 factor scores derived from the two approaches for these three factors were 0.89, 0.92, and 0.96 respectively). However, there was a modest difference in the eating factor scores from the two approaches (a correlation of 0.71 between the two sets of factor scores) and, moreover, the eating factor ranked fifth among the resulting PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 January 2010 \| Volume 5 \| Issue 1 \| e8622 6 January 2010 \| Volume 5 \| Issue 1 \| e8622 7 January 2010 \| Volume 5 \| Issue 1 \| e8622 Figure 1. Locations of the voxel clusters (spheres) associated with the four factors. The spheres (shown as surface projections) are centered at the cluster centroid, with a radius equal to the mean radial dispersion of the cluster voxels. doi:10.1371/journal.pone.0008622.g001 Neurosemantic Theory Neurosemantic Theory Figure 1. Locations of the voxel clusters (spheres) associated with the four factors. The spheres (shown as surface projections) are centered at the cluster centroid, with a radius equal to the mean radial dispersion of the cluster voxels. doi:10.1371/journal.pone.0008622.g001 Neurosemantic Theory Figure 1. Locations of the voxel clusters (spheres) associated with the four factors. The spheres (shown as surface projections) are centered at the cluster centroid, with a radius equal to the mean radial dispersion of the cluster voxels. doi:10.1371/journal.pone.0008622.g001 Figure 1. Locations of the voxel clusters (spheres) associated with the four factors. The spheres (shown as surface projections) are centered at the cluster centroid, with a radius equal to the mean radial dispersion of the cluster voxels. doi:10.1371/journal.pone.0008622.g001 Table 3. Locations (MNI centroid coordinates) and sizes of the voxel clusters associated with the four factors. Factor Cluster location x y z No. of voxels Radius (mm) shelter L Fusiform Gyrus/Parahippocampal Gyrus (PPA) 232 242 218 26 6 R Fusiform Gyrus/Parahippocampal Gyrus (PPA) 26 238 220 6 4 L Precuneus 212 260 16 40 8 R Precuneus 16 254 14 36 8 L Inf Temporal Gyrus 256 256 28 12 4 manipulation L Supramarginal Gyrus 260 230 34 51 10 L Postcentral/Supramarginal Gyri 238 240 48 21 12 L Precentral Gyrus 254 4 10 18 6 L Inf Temporal Gyrus 246 270 24 34 8 eating L Inf Frontal Gyrus 254 10 18 26 8 L Mid/Inf Frontal Gyri 248 28 18 10 6 L Inf Temporal Gyrus 252 262 214 7 4 word length L Occipital Pole 218 298 26 24 6 R Occipital Pole 16 294 0 47 10 L Lingual/Fusiform Gyri 228 268 212 20 8 R Lingual/Fusiform Gyri 30 276 214 14 6 doi:10.1371/journal.pone.0008622.t003 Locations (MNI centroid coordinates) and sizes of the voxel clusters associated with the four factors. 7 PLoS ONE \| www.plosone.org Neurosemantic Theory Neurosemantic Theory clusters that match some of the factor locations are shown as surface renderings in Figure S2. given cluster of a factor in the analysis above, to the peak voxel or the centroid of activation provided in the cited article. Note that the mean radius of our spheres is about 7 mm and the voxel size is 3.12563.12566 mm, so any centroid-to-centroid distance less than our radius constitutes an overlap of location. Figure 1. Locations of the voxel clusters (spheres) associated with the four factors. The spheres (shown as surface projections) are centered at the cluster centroid, with a radius equal to the mean radial dispersion of the cluster voxels. doi:10.1371/journal.pone.0008622.g001 Neurosemantic Theory To summarize, the four factors, which can be localized to 16 clusters in the brain, appear to reflect the semantic and visual properties of the 60 concrete words. In many cases, there is an amazingly close overlap between the locations that encode a given factor for the 60 concrete nouns in our experiment, and areas that activate during non-verbal tasks, such as actually performing or observing hand manipulations of objects (grasping, pointing). This correspondence provides an important link between the neural representation of concrete nouns and the representation of the different types of interactions a person can have with such objects. Moreover, the multiple locations of a factor can usefully be construed as differently-specialized nodes of a network, each of which contains a representation of the object. Finally, it is important to recall that each noun is represented as a mixture of factors, such as an apple being both an object of eating and an object of manipulation. These findings constitute the beginnings of a neurosemantic theory of concrete noun representations, further elaborated and tested in sections below. 2. Relating the Semantic Factors to Other Characterizations of Word Meaning: Latent Semantic Analysis (LSA) and Independent Participant Ratings Converging method 1: Latent Semantic Analysis (LSA). One test of the interpretation of the semantic factors was obtained by using LSA (http://lsa.colorado.edu/), which applies singular value decomposition to corpus-based metrics to provide a high-dimensional (300 in our case) representation of inter-text similarity [26]. LSA was used to determine the distance between each of the 60 words and a string of five to nine words (always excluding any stimulus word) intended to correspond to each factor. The string we defined for the eating factor was food vegetable meat utensil eat drink dish; for manipulation it was tool manipulate handle grip utensil; for shelter-entry it was: building dwelling residence shelter indoor enter entry drive travel. The resulting LSA-computed distances between each stimulus word and the strings were highly correlated with the words’ corresponding factor scores derived from the activation data: the correlations were, for manipulation: .70; eating: .57; and shelter: .46. This general type of correspondence between brain activation data and text corpus characteristics of a word was one of the main foci of the Mitchell et al. [1] analysis. Shelter factor locations. Bilateral fusiform/parahippo- campus and precuneus locations overlap well with networks of areas that activated in previous visual perception studies. The fusiform shelter clusters, obtained from a factor analysis of brain activation patterns in response to words, correspond well to the published ‘‘parahippocampal place area’’ (PPA) that activates when participants view pictures depicting buildings and landmarks [24]: the shelter centroids are within 2.8 mm and 4.2 mm of the PPA loci (Talairach coordinates of ((20, 239, 25) and (228, 239, Shelter factor locations. Bilateral fusiform/parahippo- campus and precuneus locations overlap well with networks of areas that activated in previous visual perception studies. The fusiform shelter clusters, obtained from a factor analysis of brain activation patterns in response to words, correspond well to the published ‘‘parahippocampal place area’’ (PPA) that activates when participants view pictures depicting buildings and landmarks [24]: the shelter centroids are within 2.8 mm and 4.2 mm of the PPA loci (Talairach coordinates of ((20, 239, 25) and (228, 239, 25)) on the right and left respectively). Equally striking is the fact that four of the five shelter locations correspond to four areas activated when judging familiarity of pictures of places (the participant’s own office or house) [25], emphasizing that the neural representation of shelter entails a network of areas. Relating the Factor Locations to Activation Locations in Other Tasks Even though the locations of the multiple clusters were obtained from a factor analysis of the activation in response to the presentation of printed words, many of the factor-related locations have previously been shown to activate in perceptual or motor tasks that do not involve verbal stimuli but appear to entail the same factor. Notably, the multiplicity of the locations per factor is echoed in these previous studies. Manipulation factor locations. fMRI studies of object manipulation yield activation sites very similar to the multiple locations of the manipulation factor, according to a meta-analysis of such studies [17]. For example, the manipulation factor’s four locations correspond extremely well (within 1.4 to 8.2 mm across the four locations) to areas that activate during actual and pantomimed hand-object interactions [18]. Similarly, three of the four locations activate during imagined grasping of tools [19]. The manipulation factor location in L Postcentral/Supramarginal Gyri has activated as part of a network involved in surface orientation discrimination ([20], d = 1.3 mm), object manipulation, and hand- object interaction ([21], d = 7.9 mm). The L Supramarginal area activated in hand-object interaction ([21], d = 9.5 mm) and was selectively activated during a pantomime grasping task ([22], d = 5.9 mm). L Precentral Gyrus activated in a visual pointing task ([23], d = 8.0 mm), presumably as part of the network related to visually-guided arm movement. The previous studies collectively indicate what the specializations of the separate manipulation factor locations might be, such the planning of motor movements, motor imagery of interaction with objects, abstract representation of motion, and lexical knowledge related to tools. Thus the manipulation factor appears to be decomposable in studies that focus on the components of a factor. PLoS ONE \| www.plosone.org 2. Relating the Semantic Factors to Other Characterizations of Word Meaning: Latent Semantic Analysis (LSA) and Independent Participant Ratings For the word length factor, the abscissa indicates the actual word length. doi:10.1371/journal.pone.0008622.g002 Figure 2. Correlation between LSA scores and activation-derived factor scores for the 60 words. For the word length factor, the abscissa indicates the actual word length. doi:10.1371/journal.pone.0008622.g002 corpus-based LSA distances, provide converging information consistent with the interpretation of the factors. mean values of the voxel’s activation level for the 60 words; the factor’s profile consists of the factor scores for the 60 words.) The similarity between the voxel and factor activation profiles was measured as the correlation between these two vectors. 2. Relating the Semantic Factors to Other Characterizations of Word Meaning: Latent Semantic Analysis (LSA) and Independent Participant Ratings Figure 2 plots these LSA distances (between the word and the factor-related-string) against the word’s factor score, for each of the 60 words. The 10 rightmost points in each graph correspond to the 10 words with the highest factor scores, shown in Table 2. (Also shown is the correlation between the length of the word and the factor score, in which LSA is not involved.) These findings illustrate that an independent, corpus-based characterization of word meaning, obtained without brain imaging data, bears a substantial relation to the characterization obtained through factor analysis of the brain activation patterns. ( (( , , ) ( , , 25)) on the right and left respectively). Equally striking is the fact that four of the five shelter locations correspond to four areas activated when judging familiarity of pictures of places (the participant’s own office or house) [25], emphasizing that the neural representation of shelter entails a network of areas. p The eating factor includes an L IFG cluster that is 4.5 mm away from the location associated with face-related actions like chewing or biting reported by Hauk et al. [2]. Converging method 2: Independent human ratings of the words. An independent set of ratings of each word with respect to each of the three semantic factors was obtained from a separate set of 14 participants. For example, for the eating-related factor, participants were asked to rate each word on a scale from 1 (completely unrelated to eating) to 7 (very strongly related). The mean ratings correlated well with the corresponding factor scores derived from the activation data: manipulation: .62; eating: .52; shelter: .72. For word length, the factor scores’ correlation with the actual word length was .90. Figure 3 plots these correlations. In summary, the participant ratings of word meaning, much like the The word length factor includes bilateral occipital pole primary visual cortex clusters that most likely reflect the low-level visual representation of the printed word. The outcome and advantage of this approach in comparison to a conventional univariate GLM analysis is presented in the Supporting Information section (Text S1). Table S1 shows the comparison of the locations of activation in taxonomic-category- based GLM contrasts to the factor locations; the GLM-derived January 2010 \| Volume 5 \| Issue 1 \| e8622 8 Neurosemantic Theory Figure 2. Correlation between LSA scores and activation-derived factor scores for the 60 words. 3. Using Machine Learning (Pattern Classification) Methods to Test the Factor Approach 2. a stability property, namely the stability of the voxel’s activation profile over the four distinct presentations of the set of 60 words that were included in the classifier’s training set. (Stability was calculated as the mean pairwise correlation between all possible pairs of the voxel’s four presentation- specific activation profiles.) Although factor analysis has long been a powerful discovery tool, it often suffers from a lack of an independent method to assess the explanatory and predictive power of the analysis. To assess how well the four factors (their profiles and locations) reflect the properties of the 60 words, machine learning (ML) methods were used to construct and compare several different models of the activation. These models were first trained on a subset of the relevant data and then used to make predictions over the remaining data, enabling us to quantitatively test the accuracies of competing models. The models differed primarily in the semantic characterization that governed the selection of features (voxels). 3. a location property, specified by the 16 locations associated with the four factors. These locations served as the centroids of search volumes that were similar to the spheres shown in Figure 1, but larger by one voxel and shaped as cuboids, for computational simplicity Combining the three properties above, five voxels were selected from each of the 16 search volumes, namely those five voxels with the highest product of semantic and stability scores, resulting in a feature set of 80 voxels. Voxels selected based on semantic factors. In the ML model based on factor analysis, a feature set consisting of 80 voxels was first algorithmically selected. (Sets of voxels larger than 80 do not systematically improve the classifiers’ performance.) The three properties that governed voxel selection were: To ensure independence between the training data and the test data in the ML cross-validation procedures, all of the factor-based ML analyses on a given participant used factor profiles and factor locations derived only from data from other participants. The factor profiles and cortical locations were derived from three of the four participants with plentiful anterior voxels, always excluding the participant under analysis. 1. a semantic property (or for the word length factor, a visual property), namely the similarity of the voxel’s mean activation profile to the profile of one of the four factors, specifically, the factor associated with one of 16 locations, described below. January 2010 \| Volume 5 \| Issue 1 \| e8622 3. Using Machine Learning (Pattern Classification) Methods to Test the Factor Approach (The mean activation profile of the voxel is the vector of 60 PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 9 Neurosemantic Theory Figure 3. Correlation between independent ratings of the words and activation-derived factor scores for the 60 words. For the word length factor, the abscissa indicates the actual word length. doi:10.1371/journal.pone.0008622.g003 Figure 3. Correlation between independent ratings of the words and activation-derived factor scores for the 60 words. For the word length factor, the abscissa indicates the actual word length. doi:10.1371/journal.pone.0008622.g003 Figure 4. Rank accuracy of identifying the 60 individual words for each participant and the group mean. The accuracies are based on either the participant’s own training set data (black) or on the data from the other 10 participants (gray), using factor-based feature selection (80 voxels) and the Gaussian Naı¨ve Bayes classifier. The dashed lines indicate levels with p,.001 greater than chance, obtained with random permutation testing (black, within participants; gray, between participants). doi:10.1371/journal.pone.0008622.g004 PLoS ONE \| www.plosone.org 4. Across-Participant Word Identification The semantic factor approach can also be used to determine whether the words have a neural signature that is common across people. The results show that it is in fact possible to identify which of the 60 words a person is viewing with accuracies far above chance level by extracting the semantically-driven neural signa- tures of each of the 60 words exclusively from the activation patterns of factor-related voxels of other people. The voxels were selected on the basis of their correspondence to the factors (again multiplied by stability, where stability was computed across all 10 of the participants in the training set). The model was based on the four factors and used 80 voxels. (The factor analysis that was used for selecting voxels was based on only three of the four participants with plentiful anterior voxels such that no participant’s own factor analysis was used when selecting voxels for that participant’s classification.) The classifier was trained on data from 10 participants and tested on the 11th left-out participant (averaging first over the six presentations within a participant, and then treating the mean data from the 10 participants as though there were 10 presentations). The mean across-participant identification accuracy, averaged across the 11 participants, was .720, as shown by the gray curve in Figure 4. All of the participants’ identification accuracies were well above chance level (a chance probability of p,.001 is shown by the dashed gray line). The mean accuracy for the cross-participant model was similar to the mean accuracy based on the corresponding within-participant identification, also using 80 factor-times-stability voxels (mean = .724). However, the cross-participant model had the benefit of more training data (from the 10 left out participants, averaged over their six presentations). Although the mean accuracies for the two models were similar, the cross-participant model had similar accuracies for all of the participants, whereas the within-participant model did much better on some participants than others. Word identification based on only the three semantic factors. If the classifier is based on only the three semantic factors (and the lower-level word length factor is not considered), the word mean identification accuracy was .676 (based on 60 voxels distributed among the locations of the three semantic factors), well above the p,.001 chance level and higher that any of the factors considered alone. Word Identification Accuracy Based on Recovered The first new machine learning finding is that it is possible to identify which noun (out of 60) a person is thinking about with accuracies far above chance level by training a classifier on a subset of that person’s activation data (four out of six presentations) and then making the identification over an independent dataset (the mean of the remaining two presentations). (The mean of two presentations is used simply to signal average.) This identification was based on a total of 80 voxels, five from each of the 16 locations associated with the four factors, chosen using the procedure described above. The rank accuracies of the word identification reached a maximum of .84 for two of the 11 participants (Participants P1 and P2), with a mean rank accuracy of .724 across the 11 participants. The accuracies for individual participants and the group means are shown in Figure 4 by the black curve. All of the individual participants’ identification accuracies are well above chance level (the dashed horizontal black line indicates the p,.001 level of statistical difference from chance, determined by random permutation tests). These findings establish the ability to identify which word a participant is considering, based on the operating characteristics of a small set of voxels that were chosen on the basis of their match to the four factor profiles obtained from other participants’ data. Figure 4. Rank accuracy of identifying the 60 individual words for each participant and the group mean. The accuracies are based on either the participant’s own training set data (black) or on the data from the other 10 participants (gray), using factor-based feature selection (80 voxels) and the Gaussian Naı¨ve Bayes classifier. The dashed lines indicate levels with p,.001 greater than chance, obtained with random permutation testing (black, within participants; gray, between participants). doi 10 1371/jo rnal pone 0008622 g004 Previous comparable studies of the brain activity associated with semantic stimuli have been based on the presentation of pictorial inputs (such as a sequence of photographs of physical objects from doi:10.1371/journal.pone.0008622.g004 PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 10 Neurosemantic Theory Neurosemantic Theory 11 participants. If the voxel selection procedure imposes a location constraint in addition to the stability constraint (using the 16 most stable voxels in each of five ‘‘lobes’’), the mean rank accuracy is .722. Word Identification Accuracy Based on Recovered The mean of such accuracies over all 12 taxonomic categories is .658, far above chance level, indicating that this method identifies more than just the category of the stimulus item. However, this accuracy is lower than when the identification is from among five randomly chosen items (which is .738), indicating that greater similarity among the alternatives decreases the identification accuracy. Identification within taxonomic categories. The classifier can still distinguish reasonably well even among the five words that all come from the same taxonomic category. For example, when the classifier is trained on all 60 words, the mean rank accuracy of the correct response among the five buildings (averaged over participants) is .684. The mean of such accuracies over all 12 taxonomic categories is .658, far above chance level, indicating that this method identifies more than just the category of the stimulus item. However, this accuracy is lower than when the identification is from among five randomly chosen items (which is .738), indicating that greater similarity among the alternatives decreases the identification accuracy. Word identification based only on a single factor. It is interesting to ask how well words can be identified by their activation when the voxels used by the classifier are selected on the basis of only one of the factors. The accuracy was somewhat similar for the four factors used individually. The manipulation factor alone provided a mean accuracy of .632 (based on 20 voxels); the shelter factor alone led to a mean identification accuracy of .655 (using 25 voxels); the eating factor alone provided .593 accuracy (15 voxels); and word length provided .663 accuracy (20 voxels). (All of these accuracies are above the p,.001 chance level.) These results demonstrate that the factors make comparable contributions to word identification, as suggested by the similarity in the variation they each accounted for. Word identification based only on a single factor. It is interesting to ask how well words can be identified by their activation when the voxels used by the classifier are selected on the basis of only one of the factors. The accuracy was somewhat similar for the four factors used individually. The manipulation factor alone provided a mean accuracy of .632 (based on 20 voxels); the shelter factor alone led to a mean identification accuracy of .655 (using 25 voxels); the eating factor alone provided .593 accuracy (15 voxels); and word length provided .663 accuracy (20 voxels). Word Identification Accuracy Based on Recovered (All of these accuracies are above the p,.001 chance level.) These results demonstrate that the factors make comparable contributions to word identification, as suggested by the similarity in the variation they each accounted for. Word Identification Accuracy Based on Recovered a given category, such as houses) whose visual forms were being represented (probably in an abstract form) in secondary visual processing areas, particularly ventral temporal cortex, and the activation patterns were then identified as being associated with a particular category [8]. Here, by contrast, the stimuli were printed words only, which were identified by their activation as one of 60 individual exemplars. To our knowledge, this is the first demonstration of the ability to identify the neural representation of individual words (although we have previously demonstrated the ability to do so for word-picture pairs [1]). Despite the comparable accuracies of the stability-based model and the model derived from the factor analysis (in combination with stability), there are several reasons to prefer the semantic- factor-times-stability model. The first is that the selected voxels are chosen based on the mapping of their activity to a semantic factor, according them an interpretable attribute, and hence providing some face validity to the model. A second important difference is that only the semantic-factor models provide a basis for a generative theory of object representation that is extensible to new words. The model based only on stability has no capability of doing so. This facet of the theory is explored below, where semantically-based activation predictions are generated and tested for words to which the model has not been exposed. A third difference is that the voxels selected on the basis of a semantic- factor-correlation-times-stability capture important but less stable representations distributed throughout the cortex, including frontal, parietal, and temporal areas that probably encode semantic information. By contrast, the voxels selected by the baseline model, solely on the basis of stability, strongly favor posterior locations in the primary and secondary visual areas where the voxels are apparently more stable. (In the factor analysis output, these posterior voxels are associated primarily with the word length factor.) Thus the semantic-factor-correlation-times- stability model captures semantic representations (as well as visual representations) distributed throughout the cortex, as well as providing a basis of extensibility for the theory. Identification within taxonomic categories. The classifier can still distinguish reasonably well even among the five words that all come from the same taxonomic category. For example, when the classifier is trained on all 60 words, the mean rank accuracy of the correct response among the five buildings (averaged over participants) is .684. 4. Across-Participant Word Identification This result indicates that word length contributes substantially to the .724 mean accuracy obtained when the classifier uses all four factors. Machine learning using voxels selected only by stability. The semantically-based model above, which uses voxels from locations associated with the derived factors, can be compared to a baseline model that uses voxels selected only for their stability, regardless of their location within cortex. (As above, a voxel’s stability is computed as the correlation of its presentation- specific activation profiles (profiles across the 60 stimulus words) across the four presentations in the training set.) The 80 whole- cortex stable voxels were located primarily in the left hemisphere (62.2% on average across participants), with a range of 43% to 80%, and were generally more posterior (visual) than the factor- based locations. This stability-only model attempts to identify which word the participant is thinking about without any consideration of word meaning, and instead characterizes only the statistical relation between the voxel activation levels and the words. The results from this model show that it is also possible to identify which noun (out of 60) a person is thinking about by selecting voxel locations simply on statistical grounds, without regard to the factor locations. The mean rank accuracy of the word identification of the stability-only model was .726 across the January 2010 \| Volume 5 \| Issue 1 \| e8622 January 2010 \| Volume 5 \| Issue 1 \| e8622 11 PLoS ONE \| www.plosone.org Neurosemantic Theory Neurosemantic Theory The cross-participant findings provide the first evidence of a neural representation of concrete nouns based on a set of semantic factors that is common across people. This finding is an important extension of the commonality found across participants in the representation of pictures of physical objects [14]. variables are directly derived from the ratings of the two words on the three semantic dimensions (obtained from the independent group of participants, as described above) and from the word length. Then the model can make a prediction for each of the two words, without using any information about any participant’s fMRI response to those two words. The model then attempts to match the two predicted images to the two observed fMRI images for the two held-out words, based on their relative similarity to each other (using a cosine measure). 5. Theory-Based Generative Prediction The new findings can be expressed as an initial, limited theory of concrete noun representation, stating how and where a given noun is neurally represented. Specifically, each noun of the type that we studied is proposed to be represented in terms of four underlying factors at a total of 16 cortical locations, where the locations for each factor code the degree and/or nature of the relatedness of the noun to that factor. This formulation constitutes a theoretical account whose fit to the data has been described above. Below, we develop a generative or predictive account, whereby the theory is used to predict the activation of words that are not included in the data analysis. To ensure that the predictive regression model had no information about the two left-out words by virtue of information from the factor analysis outcomes, a new factor analysis was run on each of the 1,770 sets of 58 words, producing a separate set of factor profiles and factor locations for each run. The underlying regression model then used the four factor profiles and the corresponding voxel locations (obtained from the data of three participants other than the one that was being analyzed). We have recently reported a new machine learning protocol that makes it possible to measure how well a model can generate a prediction for an item (the neural representation of a particular noun) on which it has not been trained [1]. The success of any such generative approach demonstrates more than just a mathematical characterization of a phenomenon. The ability to extend prediction to new items provides an additional test of the theoretical account of the phenomenon. The voxels were selected similarly to the other machine learning protocols. For each of the four factor locations (a total of 16 locations), five voxels with the highest product of the correlation with the corresponding factor profile times their stability were selected, for a total of 80 voxels. This selection procedure was performed separately for each of the 1,770 runs, leaving two words out at each iteration. In brief, two words are left out of the training set at each fold (say, apartment and carrot in one of the folds), and a regression model is trained using the data from the remaining 58 words to determine the regression weights to be associated with each of the four factors. 4. Across-Participant Word Identification There were 1,770 such attempts at matching (the number of unique word pairs that can be left out of 60 words), and the model was assessed in terms of its mean accuracy over these attempts within each participant. This approach tests whether the model developed for 58 words is extensible to two entirely new words. Semantic Factors The neural representation of physical objects was revealed to be underpinned by three major semantic dimensions: shelter, manip- ulation, and eating, which have several interesting properties. These dimensions have obvious face validity related to their ecological validity or survival value. It is plausible that there exist additional factors that underpin the representation of concrete nouns that were not captured by our analysis, either because of limitations of the set of stimulus words or limitations in the analysis procedures. This factor-based cross-participant generative model matched up the two unseen words with their fMRI images with a mean accuracy of .762 across participants, which is far above the p,.001 threshold of 0.537. The theory-based model is able to extrapolate to new words while it simultaneously generalizes across partici- pants, demonstrating the generativity of the theory. Comparison to a Previous Semantic Corpus-Based Model It is interesting to consider how well a previous model (based on co-occurrence frequencies with 25 verbs of perception and action) [1] can make generative predictions based on the data from the current study. When the generative regression model was applied to the current data using the 80 most stable voxels, the accuracy for discriminating between the two left-out words was .666, compared to .801 for the factor-based generative model, a reliable difference across the 11 participants (t(10) = 5.97, p,.001.). One limitation of the stimulus set is that it contained only count nouns (including apple) but no mass nouns (like milk or sand). Mass nouns cannot be grabbed or held like count nouns, requiring different types of manipulation, and hence possibly requiring a different type of representation of this factor or a different factor. Another limitation of the stimulus set was the absence of nouns referring to human beings (there was no sibling, lover, or attorney). Such nouns and considerations of ecological importance suggest that there may exist one or more additional dimensions related to human interaction, with factors such as emotion and attraction. The relative success of the previous model speaks to the choice of verbs of interaction that were used for co-occurrence measures. The full set of verbs was taste, eat, smell, touch, rub, lift, manipulate, run, push, fill, move, ride, say, fear, open, approach, near, enter, see, hear, listen, drive, wear, break, and clean. 5. Theory-Based Generative Prediction The factor-based generative classification accuracy was quite high: the mean accuracy across 11 participants was .801 (far above the p,.001 greater than chance threshold of 0.537). This finding confirms that the theory concerning the neural basis of concrete noun representation is sufficiently powerful to generate predictions that successfully discriminate between new pairs of concrete nouns. (The predictive accuracy of the regression model is not comparable to the non-generative mean rank accuracy of .724 for the classification of individual words obtained with the Gaussian Naı¨ve Bayes classifier. The regression model attempted to answer the question ‘‘What will the activation patterns be for these two new words, given the relation between word properties and activation patterns for the other 58 words?’’ The Gaussian Naı¨ve Bayes classifier attempted to answer the question of ‘‘Which of the 60 words produced this activation pattern, given information from an independent training set?’’) The study yielded several novel findings: 1. discovery of key semantic factors underlying the neural representation of concrete nouns; 2. relating the semantic factors to brain anatomical locations; 3. accurate identification of a thought generated by a concrete noun on the basis of the underlying brain activation pattern; Generative prediction across participants. Just above, we demonstrated the generativity of the factor model across words. Earlier in the paper, we demonstrated the generality of the model for concrete noun representations over participants. Here we describe how both kinds of extension/generalization can be made simultaneously. The generative model can make predictions concerning two previously unseen words for a previously unseen participant. The predictions for each participant are based on data acquired from the other 10 participants for the 58 remaining words. 4. determination of the commonality of the neural representation of concrete nouns across people; and 5. ability to predict the activation pattern for a previously unseen noun, based on a model of the content of the representation. 5. ability to predict the activation pattern for a previously unseen noun, based on a model of the content of the representation. 5. Theory-Based Generative Prediction To make the prediction, the values of the independent To illustrate examples of the predictions, Figure 5 shows the presence of observed and predicted activation in the parahippo- Figure 5. Observed and predicted images of apartment and carrot for one of the participants. A single coronal slice at MNI coordinate y = 46 mm is shown. Dark and light and blue ellipses indicate L PPA and R Precuneus shelter factor locations respectively. Note that both the observed and predicted images of apartment have high activation levels in both locations. By contrast, both the observed and predicted images of carrot have low activation levels in these locations. doi:10.1371/journal.pone.0008622.g005 Figure 5. Observed and predicted images of apartment and carrot for one of the participants. A single coronal slice at MNI coordinate y = 46 mm is shown. Dark and light and blue ellipses indicate L PPA and R Precuneus shelter factor locations respectively. Note that both the observed and predicted images of apartment have high activation levels in both locations. By contrast, both the observed and predicted images of carrot have low activation levels in these locations. doi:10.1371/journal.pone.0008622.g005 January 2010 \| Volume 5 \| Issue 1 \| e8622 January 2010 \| Volume 5 \| Issue 1 \| e8622 PLoS ONE \| www.plosone.org 12 Neurosemantic Theory Neurosemantic Theory the 58 modeled words, and then additionally used independent participant ratings to estimate semantic values for the left out words. campal area and precuneus areas (indicated by dark and light blue ellipses, respectively) for apartment, and the absence of such observed and predicted activation for carrot. Analogously (but not shown in the figure), L IFG (a location for the eating factor) shows both observed and predicted activity for carrot but not for apartment. A quantitative relation between the two approaches can be established by using multiple regression to determine how well each word’s co-occurrences with the 25 verbs can account for the word’s three semantic factor scores (separately). The co-occur- rences accounted for the factor scores reasonably well (R2 values of .70, .65, and .59 for shelter, eating, and manipulation, respectively). The three verbs (among the 25) with the highest beta weights in the accounts of the shelter, eating, and manipulation factor scores were near, fill, and touch, respectively. Thus the co-occurrence measures obtained from the text corpora can to a considerable degree predict the factor scores obtained from the fMRI data. Discussion The study yielded several novel findings: PLoS ONE \| www.plosone.org Semantic Factors These verbs are related to the semantic factors proposed here; for example, corresponding to the eating factor are taste, smell, and eat; corresponding to manipulation are touch, rub, lift, manipulate, push, fill, move, break, and clean; corresponding to shelter are open, enter, and approach. Abstract nouns such as kindness, anger, or innocence were also excluded from this study. Traits and emotions seem central to the representation of such concepts, whereas manipulation, for example, seems less relevant. A pilot study has demonstrated that there is systematicity underlying the activation for such abstract nouns because it is possible for a classifier to identify such concepts from the corresponding brain activation with approximately similar accuracy as identifying concrete nouns. The challenge remains to relate the systematicity to some interpretable factors. Both the factor model and the 25-verb-co-occurrences model capture some essential characteristics of the relation between brain activation and meaning. The 25-verbs model used co-occurrences of the words with an intuitive set of 25 verbs for its characterization of the 58 modeled words and the two left-out words. The factor model that was derived bottom-up from the activation data used the resulting factors for its characterization of Aside from the limitations imposed by the stimulus set, there are other reasons to suspect that, even for concrete nouns, there may exist additional neural dimensions of representation. It may be that there exist other neural representational factors that are used less consistently across participants. (Recall that our analysis excluded factors observed in only a minority of the participants’ January 2010 \| Volume 5 \| Issue 1 \| e8622 PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 13 Neurosemantic Theory Neurosemantic Theory data.) Two such less general factors that emerged from the analysis pertained to biological motion and to containment. The total number of semantic factors which are neurally represented may be related to the number of distinct ways that human beings can interact with an object. In this perspective, shelter, manipulation, and eating may simply be the most dominant factors for this particular set of stimuli. indicate that each factor corresponds to a network of cortical areas that co-activate during the factor-related processing. Future Questions Although many fascinating questions are raised by these findings, we briefly mention two that seem answerable in the near future. One such question concerns the way that two or more words or concepts combine neurally to form a novel concept, such as the phrase bird tape or the proposition John likes Mary. Perhaps the methods developed here will be applicable to discovering the neural chemistry of word combinations. The other question concerns systematic individual differences in the way concepts are Semantic Factors The previous studies also suggest that each cortical location associated with a factor is likely to be performing a distinguishable function from the other locations, although they may all be operating on a similar representation of the object. Identifiablity of Concepts from Activation It is also notable that the semantic factors do not directly correspond to particular visual properties of the objects to which the nouns refer. For example, neither size nor curvilinearity emerged as a factor (although it could be argued that shelter represents concavity and size, and the manipulation factor codes how one’s hand might conform to an object’s shape). This is not to deny that there may be a small set of visual ‘‘factors’’ or geometric primitives that underpin object recognition [27], which could potentially be discovered using methods like ours, but applied to visual brain area activation patterns in response to pictures of objects. It seems reasonable to assume that an object is represented in terms of both its visual properties and its semantic properties, with different tasks evoking different properties. The new findings demonstrate the ability for the first time to accurately identify the content of a thought generated by a concrete noun in the absence of a picture, on the basis of the underlying brain activation pattern. Several alternative classifiers were comparably effective at the classification, indicating (by the way that they differ) that there is more than one set of voxels (features) that contain the relevant information. Previous studies in thought identification have presented drawings of objects [14] or object-noun pairs [1], but human thought is not limited to what we can see or hear; it extends to ideas that can be referred to in language and in other symbolic systems such as mathematics. This first demonstration of identification of symbolically-evoked thoughts opens the possibility of studying the neural representation of virtually any concept that can be communicated. It is also worthwhile to note that these three dimensions are not done justice by the labels we gave them. For example, shelter may additionally refer to enclosure or to an allocentric frame of reference. Manipulation may more generally refer to physical interaction with one’s body. Eating could possibly correspond more generally to obtaining nourishment. At the same time, some validation of these labels is provided by the success of the predictive model. That model relied on the independent participant ratings of the two left-out words with respect to these three labels in making its predictions of neural activity. Generative Model The study demonstrated the ability to predict what the activation pattern would be for a previously unseen noun. Prediction goes beyond description because it entails an understanding of the underlying neurosemantic principles that relate meaning to brain activation. This demonstration of the model’s generative power indicates considerable promise for extensibility to all other comparable concrete nouns. The demonstration that it performs well when trained on individuals distinct from the test subject suggests the potential for developing a general, person-independent model of word representations in the human brain (and using this as a basis to study individual differences). The new findings thus suggest that the meanings of concrete nouns can be semantically represented in terms of the activation of a basis set of three main factors distributed across approximately 12 locations in the cortex. Several converging methods (use of LSA and subject ratings) lend additional credence to the interpretation of the three factors. There are some indications that these three dimensions are not the only ones used in the neural representation of concrete objects. Nevertheless, the current results do reveal the beginnings of a biologically plausible basis set for concrete nouns, and they furthermore have the potential to be extended to other factors for other types of concepts. Commonality The results importantly revealed a commonality of the neural patterns across people, permitting concept identification across individuals. This result establishes for the first time that different brains represent concrete nouns similarly. The similarity presum- ably arises from a shared sensorimotor system and the shared use of the three fundamental dimensions for neurally representing physical objects. It is important to note, however, that the location and activation levels did not have to be common across people. It could have been the case that association area locations are assigned or recruited more arbitrarily. The new results indicate that not only do people have concepts in common, but also their brain coding of the concepts is similar, similar enough to decode one person’s concept from other people’s brain activation patterns. This is a remarkable new finding for concepts that are contemplated without visual input. Moreover, each of the three dimensions has three to five subdimensions located at different cortical locations. Taken together, these suggest an expanded set of about 12 dimensions for the neurosemantic representation of concrete nouns (excluding the representation of the word length). Each factor appears to constitute a part of a cortical network whose constituent node specializations have been suggested by previous perceptual-motor studies, described above. Representation of all concrete nouns by voxels in about 12 locations, referred to as combinatorial coding, allows an enormous number of different individual entities to be encoded uniquely by a very modest number of voxels. In this view, there appears to be more than adequate capacity to represent all possible concrete nouns, which have been estimated to number about 1,600 concrete object types [27], as well as multiple tokens of each. Brain Locations The three semantic dimensions of representation were traced to particular sets of brain locations that have a plausible association with their interpretation. For all three semantic factors, at least some of the associated locations, derived from a factor analysis of the processing of concrete nouns, also activated in less abstract perceptual-motor tasks. The excellent matches of locations PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 14 Neurosemantic Theory Neurosemantic Theory Found at: doi:10.1371/journal.pone.0008622.s001 (0.03 MB DOC) Found at: doi:10.1371/journal.pone.0008622.s001 (0.03 MB DOC) represented. For the participants with the highest identification accuracies, the accuracies were lower when the classifier was trained on other participants’ activation, indicating that there was some systematic but idiosyncratic structure in the participant’s data. It may be possible that this systematicity can eventually be understood, in terms of such possible explanations as idiosyncratic interaction with some of the objects or greater expertise in some of the object categories. Similarly, there may be systematic differences in concept representations in special populations, such that participants with autism, for example, who often have a deficit in social processing, might represent social concepts differently. Given the new ability to determine much of the content of a representation, it should be possible to determine what distin- guishes the representations of individuals or special populations. Figure S1 Locations of the multiple voxel clusters associated with the four factors. Shelter-related voxels are shown in blue, manipulation-related voxels in red, eating-related in green, and word length in yellow. g y Found at: doi:10.1371/journal.pone.0008622.s002 (5.09 MB TIF) Figure S2 Taxonomic-category-specific GLM-derived clusters that have matching factor locations. The clusters that match shelter locations are shown in blue; the cluster that matches one of the manipulation locations is shown in red, and the cluster that matches the word-length location is shown in yellow. Found at: doi:10.1371/journal.pone.0008622.s003 (1.20 MB TIF) In summary, the research establishes a new way of describing brain activity, not just in terms of its anatomical location and its physical characteristics, but in terms of the informational codes that are being processed in association with a given item. Second, the work uses the underlying theory for generative prediction of brain activation, providing a set of hypothesized principles on which neural encodings of object meanings are based. References 15. Tzourio-Mazoyer N, Landeau B, Papathanassiou D, Crivello F, Etard O, et al. (2002) Automated anatomical labeling of activations in SPM using a macroscopic anatomical parcellation of the MNI MRI single-subject brain. NeuroImage 15: 273–289. 1. Mitchell TM, Shinkareva SV, Carlson A, Chang KM, Malave VL, et al. (2008) Predicting human brain activity associated with the meanings of nouns. Science 320: 1191–1195. 2. Hauk O, Johnsrude I, Pulvermuller F (2004) Somatotopic representation of action words in human motor and premotor cortex. Neuron 41: 301–307. g 16. Gorsuch RL (1983) Factor analysis. (2nd ed.). HillsdaleNJ: Erlbaum. pp 239–256. 3. Romney AK, D’Andrade RG (1964) Cognitive Aspects of English kin terms. Amer Anthropologist 66: 146–170. 17. Lewis JW (2006) Cortical networks related to human use of tools. Neuroscientist 12: 211–231. 4. Shepard RN, Cooper LA (1992) Representation of colors in the blind, color- blind, and normally sighted. Psych Sci 3: 97–104. 18. Hermsdorfer J, Terlinden G, Muhlau M, Goldenberg G, Wohlschlager AM (2007) Neural representations of pantomimed and actual tool use: evidence from an event-related fMRI study. NeuroImage 36: T109–T118. 5. Miller GA, Johnson-Laird P (1987) Language and perception. Cambridge, MA: Belknap Press. 760 p. y g 19. Creem-Regehr SH, Lee JN (2005) Neural representations of graspable objects: are tools special? Cogn Brain Res 22: 457–469. y g 19. Creem-Regehr SH, Lee JN (2005) Neural represe are tools special? Cogn Brain Res 22: 457–469. p p 6. Rips LJ, Shoben EJ, Smith EE (1973) Semantic distance an 6. Rips LJ, Shoben EJ, Smith EE (1973) Semantic distance and the verification of semantic distance. J Verb Learn Verb Behav 12: 1–20. semantic distance. J Verb Learn Verb Behav 12: 1–20. 7. Fillenbaum S, Rapoport A (1971) Structures in the subjective lexicon. San Diego: Academic Press. 266 p. 20. Shikata E, Hamzei F, Glauche V, Knab R, Dettmers C, et al. (2002) Surface orientation discrimination activates caudal and anterior intraparietal sulcus in humans: An event related fMRI study. J Neurophysiol 85: 1309–1314. 8. Haxby J, Gobbini M, Furey M, Ishai A, Schouten J, et al. (2001) Distributed and overlapping representations of faces and objects in ventral temporal cortex. Science 293: 2425–2430. 21. Binkofski F, Buccino G, Posse S, Seitz RJ, Rizzolatti G, et al. (1999) A fronto- parietal circuit for object manipulation in man: Evidence from an fMRI-study. Europ J Neurosci 11: 3276–3286. 9. Acknowledgments We thank the members of the Neurosemantics Research Group for their help with this project, Kai-Min Chang, Charles Kemp, Dean Pomerleau, and Svetlana Shinkareva for useful comments on previous versions of this manuscript. We thank the members of the Neurosemantics Research Group for their help with this project, Kai-Min Chang, Charles Kemp, Dean Pomerleau, and Svetlana Shinkareva for useful comments on previous versions of this manuscript. Brain Locations These new findings not only establish new knowledge about the neural representations of meaning, but they also provide an empirical and theoretical foundation for further investigation of the content of human thought. Table S1 Comparison of the locations of activation in taxonomic-category-based GLM contrasts to the factor locations. Found at: doi:10.1371/journal.pone.0008622.s004 (0.12 MB DOC) Supporting Information Conceived and designed the experiments: MAJ TMM. Performed the experiments: MAJ. Analyzed the data: VLC SA. Contributed reagents/ materials/analysis tools: VLC SA TMM. Wrote the paper: MAJ VLC TMM. Conceived and designed the experiments: MAJ TMM. Performed the experiments: MAJ. Analyzed the data: VLC SA. Contributed reagents/ materials/analysis tools: VLC SA TMM. Wrote the paper: MAJ VLC TMM. Text S1 Comparing factor analysis outcomes with traditional GLM contrasts for taxonomic categories. Text S1 Comparing factor analysis outcomes with traditional GLM contrasts for taxonomic categories. References Cox DD, Savoy RL (2003) Functioning magnetic resonance imaging (fMRI) ‘‘brain reading’’: Detecting and classifying distributed patterns of fMRI activity in human visual cortex. NeuroImage 19: 261–270. p J 22. Simon O, Mangin J-F, Cohen L, Le Bihan D, Dehaene S (2002) Topographical layout of hand, eye, calculation, and language-related areas in the human parietal lobe. Neuron 33: 475–487. 10. Hanson SJ, Matsuka T, Haxby JV (2004) Combinatorial codes in ventral temporal lobe for object recognition: Haxby (2001) revisited: Is there a ‘‘face’’ area? NeuroImage 23: 156–166. 23. Lacquaniti F, Perani D, Guigon E, Bettinardi V, Carrozzo M, et al. (1997) Visuomotor transformations for reaching to memorized targets: A PET study. NeuroImage 5: 129–146. g 11. Haynes JD, Rees G (2006) Decoding mental states from brain activity in humans. Nat Rev Neurosci 7: 523–534. 24. Epstein R, Harris A, Stanley D, Kanwisher N (1999) The parahippocampal place area: Recognition, navigation, or encoding? Neuron 23: 115–125. 12. Norman KA, Polyn SM, Detre GJ, Haxby JV (2006) Beyond mind-reading: multi-voxel pattern analysis of fMRI data. Trends Cogn Sci 10: 424–430. 25. Sugiura M, Shah NJ, Zilles K, Fink GR (2005) Cortical representations of personally familiar objects and places: functional organization of the human posterior cingulate cortex. J Cogn Neurosci 17: 183–198. 13. O’Toole AJ, Jiang F, Abdi H, Pe´nard N, Dunlop J, et al. (2007) Theoretical, statistical, and practical perspectives on pattern-based classification approaches to the analysis of functional neuroimaging data. J Cogn Neurosci 19: 1735–1752. p g J g 26. Deerwester S, Dumais ST, Furnas GW, Landauer TK, Harshman R (1990) Indexing by latent semantic analysis. J Am Soc for Informat Sci 41: 391–407. 14. Shinkareva SV, Mason RA, Malave VL, Wang W, Mitchell TM, et al. (2008) Using fMRI brain activation to identify cognitive states associated with perception of tools and dwellings. PLoS ONE 3(1): e1394. 27. Biederman I (1987) Recognition-by-components: A theory of human image understanding. Psych Rev 94: 115–147. PLoS ONE \| www.plosone.org January 2010 \| Volume 5 \| Issue 1 \| e8622 15
https://openalex.org/W2952945984	https://www.frontiersin.org/articles/10.3389/fpls.2019.00868/pdf	English	null	Assessing Chemical Diversity in Psilotum nudum (L.) Beauv., a Pantropical Whisk Fern That Has Lost Many of Its Fern-Like Characters	Frontiers in plant science	2,019	cc-by	12,596	ORIGINAL RESEARCH published: 09 July 2019 doi: 10.3389/fpls.2019.00868 Assessing Chemical Diversity in Psilotum nudum (L.) Beauv., a Pantropical Whisk Fern That Has Lost Many of Its Fern-Like Characters Dunja Šamec1,2, Verena Pierz1,3, Narayanan Srividya1, Matthias Wüst3 and B. Markus Lange1* Dunja Šamec1,2, Verena Pierz1,3, Narayanan Srividya1, Matthias Wüst3 and B. Markus Lange1* 1 Institute of Biological Chemistry and M.J. Murdock Metabolomics Laboratory, Washington State University, Pullman, WA, United States, 2 Ru ¯der Boškovi ´c Institute, Zagreb, Croatia, 3 Chair of Bioanalytics, Institute of Nutritional and Food Sciences, University of Bonn, Bonn, Germany Members of the Psilotales (whisk ferns) have a unique anatomy, with conducting tissues but lacking true leaves and roots. Based on recent phyogenies, these features appear to represent a reduction from a more typical modern fern plant rather than the persistence of ancestral features. In this study, extracts of several Psilotum organs and tissues were analyzed by Gas Chromatography – Mass Spectrometry (GC-MS) and High Performance Liquid Chromatography – Quadrupole Time of Flight – Mass Spectrometry (HPLC-QTOF-MS). Some arylpyrones and biﬂavonoids had previously been reported to occur in Psilotum and these metabolite classes were found to be prominent constituents in the present study. Some of these were enriched and further characterized by Nuclear Magnetic Resonance (NMR) spectroscopy. HPLC-QTOF-MS and NMR data were searched against an updated Spektraris database (expanded by incorporating over 300 new arylpyrone and biﬂavonoid spectral records) to aid signiﬁcantly with peak annotation. Principal Component Analysis (PCA) with combined GC-MS and HPLC- QTOF-MS data sets obtained with several Psilotum organs and tissues indicated a clear separation of the sample types. The principal component scores for below- ground rhizome samples corresponded to the vectors for carbohydrate monomers and dimers and small organic acids. Above-ground rhizome samples had principal component scores closer to the direction of vectors for arylpyrone glycosides and sucrose (which had high concentrations in above-and below-ground rhizomes). The unique position of brown synangia in a PCA plot correlated with the vector for biﬂavonoid glycosides. Principal component scores for green and yellow synangia correlated with the direction of vectors for arylpyrone glycosides and biﬂavonoid aglycones. Localization studies with cross sections of above-ground rhizomes, using Matrix-Assisted Laser Desorption/Ionization – Mass Spectrometry (MALDI-MS), provided evidence for a preferential accumulation of arylpyrone glycosides and biﬂavonoid aglycones in cells Edited by: Kazuki Saito, RIKEN Center for Sustainable Resource Science (CSRS), Japan Reviewed by: A. Daniel Jones, Michigan State University, United States Zhigang Yang, Lanzhou University, China *Correspondence: B. Markus Lange lange-m@wsu.edu Specialty section: This article was submitted to Plant Metabolism and Chemodiversity, a section of the journal Frontiers in Plant Science Received: 12 March 2019 Accepted: 18 June 2019 Published: 09 July 2019 Specialty section: This article was submitted to Plant Metabolism and Chemodiversity, a section of the journal Frontiers in Plant Science Received: 12 March 2019 Accepted: 18 June 2019 Published: 09 July 2019 INTRODUCTION We selected Psilotum nudum (L.) Beauv. to evaluate chemical diversity in the fern lineage, as only limited knowledge exists on this topic. Psilotin and 3’-hydroxypsilotin are unusual C11 arylpyrone glycosides unique to the Psilotaceae (McInnes et al., 1965; Tse and Towers, 1967; Balza et al., 1985; Takahashi et al., 1990). Psilotic acid is a C6-C4 organic acid that is structurally related to the psilotin aglycone (psilotinin) (Shamsuddin et al., 1985). Prominent ﬂavonoid glyosides in the Psilotaceae are O-glucosides of the biﬂavonoid, amentoﬂavone, and C- and O-glycosides of the ﬂavone, apigenin (Cooper-Driver, 1977; Wallace and Markham, 1978; Markham, 1984). A survey across sixteen pteridophytes (ferns and fern allies), including P. nudum, concluded that the sterol composition is generally similar to that of spermatophytes (seed plants), with β-sitosterol, campesterol and stigmasterol as principal constituents (Chiu et al., 1988). P. nudum tissues were also demonstrated to contain representatives of several phytohormone classes (auxins, cytokinins and gibberellins) (Takahashi et al., 1984; Abul et al., 2010). In this pilot study, which is the beginning of eﬀorts to chart out the most abundant classes of specialized metabolites in ferns, we demonstrate the utility of multi-platform analyses for capturing the unique chemical ﬁngerprints of diﬀerent P. nudum organs and tissues. In addition, we report the tissue- level localization of the most prominent arylpyrone glycoside and biﬂavonoid constituents. Free−sporing vascular plants encompass two distinct evolutionary lineages, the lycophytes and ferns, with the latter resolved as more closely related to seed plants (Kenrick and Crane, 1997; Pryer et al., 2001). Whisk ferns (order Psilotales), which comprise two genera (Psilotum and Tmesipteris) in the family Psilotaceae, have conducting tissues but no veins, and lack true leaves and roots. Water and mineral absorption occurs through underground, horizontally creeping rhizomes, sometimes in association with symbiotic fungi (mycorrhizae) (Ducket and Ligrone, 2005). Plants grow mostly as epiphytes (using other plants as physical support) in moist habitats. The stem-like aerial portion of rhizomes of members of the Psilotaceae is covered by an epidermis, followed inward by extensive cortical areas, a single-layered endodermis, and a thick-walled protostele that accommodates the water and nutrient-conducting tissues (Pittermann et al., 2011). The epidermal layer of the photosynthetic above-ground rhizomes contains stomata for gas exchange (Nilsen, 1995). In the genus Psilotum, above-ground rhizomes have many branches with scale-like appendages called enations. These structural outgrowths resemble miniature leaves but, unlike true leaves, have no internal vascular tissues. Abbreviations: AMT tag, accurate mass-time tag; CHCA, α-cyano-4- hydroxycinnamic acid; DBA, 2,5-dihydroxybenzoic acid; GC–MS, gas chromatography – mass spectrometry; HPLC–QTOF–MS, high performance liquid chromatography – quadrupole time of ﬂight – mass spectrometry; MALDI–MS, matrix-assisted laser desorption/ionization – mass spectrometry; NMR, nuclear magnetic resonance; PC, principal component; PCA, principal component analysis. INTRODUCTION Above these enations, positioned laterally along the distal portions of aerial shoots, are spore-containing synangia, which result from the fusion of three adjacent sporangia (Renzaglia et al., 2001). MATERIALS AND METHODS Because of its unusual anatomical characteristics, P. nudum was traditionally thought to be descended from the earliest vascular plants (Banks, 1975), and conﬂicting views regarding the placement of the Psilotales remained in the literature for decades. Recent phylogenies based on both morphological characters and extensive sequence data provided strong evidence that Psilotales, Ophioglossales (moonworts) and Marattiales (king ferns) – all eusporangiate ferns – form a monophyletic clade that is sister to leptosporangiate ferns, the largest group of living ferns (Doyle, 2018; Rothwell et al., 2018). The unique anatomy of extant Psilotales therefore appears to represent a reduction from a more typical modern fern plant rather than the persistence of ancestral features. While recent progress has been made with regard to resolving the classiﬁcation of vascular plants, there is still a notable lack of knowledge regarding the phytochemical diversiﬁcation associated with the adaptive radiation of ferns. Citation: Šamec D, Pierz V, Srividya N, Wüst M and Lange BM (2019) Assessing Chemical Diversity in Psilotum nudum (L.) Beauv., a Pantropical Whisk Fern That Has Lost Many of Its Fern-Like Characters. Front. Plant Sci. 10:868. doi: 10.3389/fpls.2019.00868 July 2019 \| Volume 10 \| Article 868 1 Frontiers in Plant Science \| www.frontiersin.org Šamec et al. Chemical Diversity in Psilotum nudum of the chlorenchyma. Our results indicate a differential localization of metabolites with potentially tissue-speciﬁc functions in defenses against biotic and abiotic stresses. The data are also a foundation for follow-up work to better understand chemical diversity in the Psilotales and other members of the fern lineage. of the chlorenchyma. Our results indicate a differential localization of metabolites with potentially tissue-speciﬁc functions in defenses against biotic and abiotic stresses. The data are also a foundation for follow-up work to better understand chemical diversity in the Psilotales and other members of the fern lineage. Keywords: arylpyrone, biﬂavonoid, mass spectrometry, metabolomics, nuclear magnetic resonance, whisk fern Keywords: arylpyrone, biﬂavonoid, mass spectrometry, metabolomics, nuclear magnetic resonance, whisk fern Chemicals and Solvents Solvents for extraction and chromatography were of the highest commercial grade and obtained from Sigma-Aldrich (St. Louis, MO, United States). Deuterated solvents for nuclear magnetic resonance (NMR) spectroscopy were obtained from Cambridge Isotope Laboratories Inc. (Andover, MA, United States), with details in Table 2. All authentic standards, reference materials (red phosphorus, α-cyano-4-hydroxycinnamic acid, 9-anthracenecarboxylic acid, sinapic acid and vanillic acid) and reagents (N-methyl-N-(trimethylsilyl)triﬂuoroacetamide) were generally purchased from Sigma-Aldrich (St. Louis, MO, United States); exceptions: 2,5-dihydroxybenzoic acid (TCI America, Portland, OR, United States) and leucine enkephalin (Waters, Milford, MA, United States). Metabolite Extraction for High Performance Liquid Chromatography – Quadrupole Time-of-Flight – Mass Spectrometry Frozen tissue homogenate from each sample (15 ± 3 mg) was transferred to 8 ml glass tubes and overlaid with 700 µL methanol (containing myristic acid-d27 (CDN Isotopes, Quebec, Canada) as internal standard at 1.5 mg/ml) and 25 µL water. Tubes were capped tightly and heated in a water bath to 70◦C for 15 min, centrifuged for 2 min at 3,500 × g, and supernatants transferred to new 8 ml glass vials. To each supernatant, 700 µL of water and 375 µL of chloroform were added and the contents of the tube mixed with a multi-tube vortexer (VWR Scientiﬁc, South Plainﬁeld, NY, United States) for 15 min at a speed setting of 4. Extracts were centrifuged for 15 min at 3,500 × g, the upper aqueous phase was combined with the ﬁrst methanol extract (henceforth referred to as aqueous methanol extract), and the lower organic phase was collected separately (chloroform extract). The two extracts were separately evaporated to dryness [Vacufuge Plus for aqueous methanol extract (Eppendorf, Hauppage, NY, United States); EZ-Bio Evaporator for chloroform extract (GeneVac LTD, Ipswich, United Kingdom)]. Dried samples were derivatized just-in-time by adding 10 µL of a 40 mg/ml solution of methoxyamine hydrochloride in pyridine and shaking gently at 30◦C for 90 min, then adding 50 µL of N-methyl-N- (trimethylsilyl)triﬂuoroacetamide (MSTFA; Sigma-Aldrich, St. Louis, MO, United States) and shaking gently at 37◦C for 30 min. Samples were allowed to cool to room temperature, and the extract was transferred to a glass insert, which was then placed in a 2 ml glass reaction vial. Frozen tissue homogenate from each sample (30 ± 5 mg) was transferred to a 2 ml reaction tube and extracted with 1 ml of 80% aqueous methanol (containing 6 mg/L anthracene-9-carboxylic acid as internal standard) for 10 min [multi-tube vortexer (VWR Scientiﬁc, South Plainﬁeld, NY, United States) at highest speed setting] and subsequent sonication for 20 min (ultrasonic bath at highest intensity setting, Fisher Scientiﬁc, Hampton, NY, United States). Following centrifugation for 10 min at 13,000 × g, supernatants were ﬁltered through 0.22 µm polypropylene ﬁlter material and collected in plastic inserts for 2 ml reaction vials. Plant Growth Psilotum nudum (L.) P. Beauv. plants had been established from rhizomes roughly 6 years before the initiation of the experiments described here. A voucher specimen was deposited with the John G. Searle Herbarium of the Field Museum (Chicago, July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org 2 Chemical Diversity in Psilotum nudum Šamec et al. Technologies, Santa Clara, CA, United States), GC; column: DB- 5MS + DG (30 m × 0.25 mm × 0.25 µm; J&W Scientiﬁc, Santa Clara, CA, United States); inlet temperature: 250◦C; temperature program: start at 60◦C, ramp to 320◦C at 3◦C/min, hold for 10 min; retention time locking: myristic acid-d27 at 42.06 min at an inlet pressure of 10.65 psi; MS instrument: 5975 MSD (Agilent Technologies, Santa Clara, CA, United States); transfer line temperature: 250◦C; electron ionization at 70 eV. Data analysis was performed using ChemStation, version E.02.00.493 (Agilent Technologies, Santa Clara, CA, United States). Custom spectral databases (specifying retention time, a quantiﬁcation signal and three qualiﬁer ions) were created using authentic standards from our in-house library for the identiﬁcation of GC–MS peaks (Supplementary Table S1). Peaks generated by unidentiﬁed analytes were annotated based on community reporting guidelines (Bino et al., 2004; Fiehn et al., 2007). Raw data values were normalized for sample weight and signal intensity associated with the internal standard. Normalized data values were z-transformed (autoscaled) prior to statistical analyses. IL, United States). Plants were maintained in a greenhouse under ambient lighting, with supplemental lighting during winter months provided by high-intensity discharge lamps. The daily light integral varied from 15 to 25 mol m−2 d−1. Temperatures ranged between 22 and 27◦C and the humidity was set to 70%. At the time of harvesting, P. nudum produced synangia that, based on color (green, yellow or brown), could be diﬀerentiated into three developmental stages (immature, mature, and senescent). Five biological replicates were harvested at the same time of day (11:00 AM, Paciﬁc Daylight Savings Time) for the following organs: below-ground rhizome, above-ground rhizome (stem), and (separately) green, yellow and brown synangia. Samples were immediately frozen in liquid nitrogen, freeze-dried (aerial parts for 5 days, rhizomes for 7 days). Lyophilized material was homogenized to a ﬁne powder under liquid nitrogen using mortar and pestle. Deﬁned quantities of homogenate were weighed out, placed in a 2 ml microfuge tube, and stored as aliquots at –20◦C until further use. High Performance Liquid Chromatography – Quadrupole Time-of-Flight – Mass Spectrometry Analysis High Performance Liquid Chromatography – Quadrupole Time-of-Flight – Mass Spectrometry (HPLC–QTOF–MS) was performed under the following conditions: HPLC system: 1290 system (Agilent Technologies, Santa Clara, CA, United States) consisting of thermo-controlled autosampler (set to 4◦C), binary pump (operated at 0.6 ml/min), isocratic pump [operated at 0.1 ml/min ﬂow rate to introduce a reference mass solution containing 300 nM purine (exact mass 120.043596 g/mol) and 250 nM hexakis-(1H, 1H,3H-tetraﬂuoropropoxy)-phosphazine (exact mass 921.002522 g/mol) in acetonitrile/water (95:5; v/v)], thermo-controlled column compartment (set to 60◦C), and diode array detector (scanning range 210–600 nm, resolution 1.2 nm); injection volume: 10 µl; Column: HD Zorbax SB-Aq (100 × 2.1 × mm; 1.8 µm pore size, Agilent Technologies, Santa Clara, CA, United States); Mobile phase: 0.1% (v/v) formic acid in water (solvent A) and 0.1% (v/v) formic acid Gas Chromatography – Mass Spectrometry Analysis Gradient: 5% B at start; linear gradients to 10% B at 5 min, 20% B at 10 min, 80% B at 35 min, 95% B at 45 min; QTOF–MS instrument: 6530 series with electrospray ion source (Agilent Technologies, Santa Clara, CA, United States); polarity: positive; drying gas ﬂow rate: 10 L/min; drying gas temperature: 325◦C; nebulizer pressure: 2.4 bar; m/z range: 100–1,200 (high gain mode); scan rate: 1.4 scans/s for MS and 4 scans/s for MS/MS. Data analysis was performed using the MassHunter Workstation software package [B.07.00, Qualitative Analysis and B.06.00, Proﬁnder, Agilent Technologies, Santa Clara, CA, United States). For each detected peak, molecular feature extraction (considering retention time (tolerance window 1.30 s) and high mass accuracy (m/z tolerance window 10 ppm)], deconvolution, and alignment across samples were performed using the recursive feature extraction algorithm (settings: threshold of 10,000 counts and peak spacing tolerance of 0.0025 m/z). Quasi-molecular ions and adducts were considered ([M+H]+, [M+Na]+, [M+K]+, [M+NH4]+), as were the corresponding dimers. The minimum absolute height required for feature extraction in the recursive step was set to 10,000 counts (sum of all peaks for a given molecular entity), which had to be fulﬁlled in at least three of ﬁve biological replicates. The global ﬁlter was limited to 2,000 results. Peak annotation was performed based on a combination of chromatographic, mass spectral (accurate mass and MS/MS fragmentation patterns), evaluation of the literature, and searches against spectral databases (Table 1). Peaks generated by unidentiﬁed analytes were annotated based on community reporting guidelines (Bino et al., 2004; Fiehn et al., 2007). MS/MS spectra for identiﬁed peaks were submitted to MassBank (Horai et al., 2010) to expand a widely used community spectral resource. Normalized data values for HPLC–QTOF–MS peaks were z-transformed (autoscaled) and combined with the normalized and z-transformed GC–MS data (Supplementary Table S2). The combined HPLC–QTOF–MS and GC–MS data set were processed by Principal Component Analysis (PCA) using the R statistical package1, for which the settings and outcomes are summarized in Supplementary Table S3. (1100 Series HPLC system; Agilent Technologies, Santa Clara, CA, United States). Metabolite Imaging by Matrix-Assisted Laser Desorption/Ionization – Mass Spectrometry Psilotum nudum above-ground rhizomes were cross-sectioned into 2 cm segments, embedded in 3% (w/v) agarose, and stored at –80◦C until further processing. On the day of the metabolite imaging analysis, the chamber of a CM 1950 Cryostat (Leica Biosystems, Buﬀalo Grove, IL, United States) was set to –20◦C, embedded samples were sectioned to 30 µm thickness and sections immediately transferred to an imaging target plate (Waters Corp., Milford, MA, United States). The ionization matrices tested for their suitability with P. nudum metabolites were 2,5-dihydroxybenzoic acid (DBA), α-cyano-4- hydroxycinnamic acid (CHCA), sinapic acid and vanillic acid (each at 40 mg/ml (w/v) in methanol/water (1:1; v/v)). Matrices were applied with a sample preparation system (TM-Sprayer of HTX Technologies, Chapel Hill, NC, United States) connected to an 1100 Series HPLC Binary Pump (Agilent Technologies, Santa Clara, CA, United States). The settings were: ﬂow rate at 0.05 ml/min; nozzle temperature at 80◦C; spraying velocity at 1,250 mm/min; 12 passes; and track spacing of 1 mm. The ﬁnal amount of matrix deposited per linear distance was 0.19 mg mm−2. Besides matrix-covered samples, the following chemicals were also spotted onto the imaging target plates: red phosphorus for instrument calibration (10 mg/ml in acetone), leucine-enkephalin to generate a lock mass [10 mg/ml mixed with 3.4 mg/ml CHCA in methanol/water (1:1; v/v)], and authentic standards [1 mg/ml of amentoﬂavone, psilotin and 3’- hydroxypsilotin mixed with 5 mg/ml DHB in methanol/water (1:1; v/v)]. Metabolite imaging was performed by Matrix-Assisted Laser Desorption/Ionization Mass Spectrometry (MALDI–MS) on a Synapt G2-S instrument equipped with an ion mobility drift tube and operated with MassLynx software version 4.1 (Waters, Milford, MA, United States). The imaging target plate was introduced into the sample chamber and the laser operated with the following settings: 1,000 Hz ﬁring rate; laser energy Gas Chromatography – Mass Spectrometry Analysis The mobile phase consisted of two solvents (A: 0.2% (v/v) acetic acid in water; B: 0.2% (v/v) acetic acid in methanol) and the separation of metabolites was achieved using the following gradient: 2% B at start, with a series of linear gradients to 35% B at 10 min, 60% B at 21 min, 90% B at 40 min, and 98% B at 50 min. The ﬂow rate was set to 1.3 ml/min. Trial runs indicated when metabolites of interest eluted and fractions were collected accordingly. The eluents of several runs were accumulated and each of these fractions evaporated to dryness in a rotary evaporator. Each residue was dissolved in a deuterated solvent and NMR spectra were acquired with the settings listed in Supplementary Table S4. Spectral records for bioﬂavonoids and arylpyrones were generated based on information extracted from the literature (listing in Supplementary Table S5) and integrated into the Spektraris database (Cuthbertson et al., 2013; Fischedick et al., 2015). The combined spectral data from HPLC–QTOF–MS and NMR were then used to search for matches in the Spektraris online resource (Table 2). 1https://www.r-project.org/ Gas Chromatography – Mass Spectrometry Analysis Gas chromatography – mass spectrometry (GC–MS) was performed under the following conditions: injection volume: 1 µL (splitless mode); GC instrument: 6890N (Agilent July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org 3 Chemical Diversity in Psilotum nudum Šamec et al. in acetonitrile (solvent B). Gradient: 5% B at start; linear gradients to 10% B at 5 min, 20% B at 10 min, 80% B at 35 min, 95% B at 45 min; QTOF–MS instrument: 6530 series with electrospray ion source (Agilent Technologies, Santa Clara, CA, United States); polarity: positive; drying gas ﬂow rate: 10 L/min; drying gas temperature: 325◦C; nebulizer pressure: 2.4 bar; m/z range: 100–1,200 (high gain mode); scan rate: 1.4 scans/s for MS and 4 scans/s for MS/MS. Data analysis was performed using the MassHunter Workstation software package [B.07.00, Qualitative Analysis and B.06.00, Proﬁnder, Agilent Technologies, Santa Clara, CA, United States). For each detected peak, molecular feature extraction (considering retention time (tolerance window 1.30 s) and high mass accuracy (m/z tolerance window 10 ppm)], deconvolution, and alignment across samples were performed using the recursive feature extraction algorithm (settings: threshold of 10,000 counts and peak spacing tolerance of 0.0025 m/z). Quasi-molecular ions and adducts were considered ([M+H]+, [M+Na]+, [M+K]+, [M+NH4]+), as were the corresponding dimers. The minimum absolute height required for feature extraction in the recursive step was set to 10,000 counts (sum of all peaks for a given molecular entity), which had to be fulﬁlled in at least three of ﬁve biological replicates. The global ﬁlter was limited to 2,000 results. Peak annotation was performed based on a combination of chromatographic, mass spectral (accurate mass and MS/MS fragmentation patterns), evaluation of the literature, and searches against spectral databases (Table 1). Peaks generated by unidentiﬁed analytes were annotated based on community reporting guidelines (Bino et al., 2004; Fiehn et al., 2007). MS/MS spectra for identiﬁed peaks were submitted to MassBank (Horai et al., 2010) to expand a widely used community spectral resource. Normalized data values for HPLC–QTOF–MS peaks were z-transformed (autoscaled) and combined with the normalized and z-transformed GC–MS data (Supplementary Table S2). The combined HPLC–QTOF–MS and GC–MS data set were processed by Principal Component Analysis (PCA) using the R statistical package1, for which the settings and outcomes are summarized in Supplementary Table S3. in acetonitrile (solvent B). Frontiers in Plant Science \| www.frontiersin.org July 2019 \| Volume 10 \| Article 868 Metabolite Isolation and Analysis by Nuclear Magnetic Resonance Spectroscopy Above-ground biomass from P. nudum was harvested and homogenized to a ﬁne powder in the presence of liquid nitrogen. A 300 mg aliquot of the homogenate was extracted with 10 ml of 80% aqueous methanol by vigorous mixing for 10 min (Vortex Mixer, VWR Scientiﬁc, South Plainﬁeld, NY, United States; operated at highest speed setting) and subsequent sonication in an ultrasonic bath for 20 min. Following centrifugation of this mixture for 10 min at 13,000 rpm, the supernatant was recovered and ﬁltered through a 0.22 µm polypropylene ﬁlter. The extract was stored at –20◦C until further processing. Aliquots (100 µl each) of the ﬁltered extracts were injected onto a C18 reversed phase and absorbance at 280 and 360 nm was monitored July 2019 \| Volume 10 \| Article 868 July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org 4 Šamec et al. Metabolite Isolation and Analysis by Nuclear Magnetic Resonance Spectroscopy Chemica 1ppm Molecular Formula MS (ESI-Positive) MS/MS(ESI-Positive) (Varying Collision Energies) Annotation References; Further Evidence 1.79 C17H20O9 [M+H]+ 369.1198 [M+Na]+ 391.0999 [M+K]+ 407.0696 [2M+Na]+ 759.2115 [2M+K]+ 775.1595 10 eV: 391.0999 (100), 123.0436 (80), 207.0649 (55), 189.0564 (30) 50 eV: 123.0438 (100), 189.0540 (35), 227.0002 (34), 98.9747 (26), 199.0080 (23), 110.9751 (19), 115.0537 (18), 171.0427 (17), 147.0451 (16), 231.0246 (15) 3’-Hydroxypsilotin Balza et al., 1985; NMR (Table 2; F2) 0.00 C23H30O14 [M+Na]+ 553.1530 30 eV: 553.1504 (100), 207.1641 (11) 50 eV: 123.0433 (100), 173.0570 (48), 85.0281 (23), 189.0512 (29), 115.0534 (26), 203.0539 (17), 116.9908 (15), 147.0437 (14) 3’-Hydroxypsilotinin-di- O-hexoside 0.08 C23H30O13 [M+H]+ 515.1751 [M+Na]+ 537.1591 [2M+Na]+ 1051.3232 30 eV: 537.1603 (100), 191.0746 (40), 391.0731 (15), 173.0627 (14), 107.0520 (7) 50 eV: 107.0538 (100), 173.0650 (87), 201.0111 (26), 229.0230 (20), 117.0743 (12), 145.0677 (12), 98.9808 (11) Psilotinin-di-O-hexoside I 2.79 C17H20O8 [M+H]+ 353.1250 [M+Na]+ 375.1075 [2M+Na]+ 727.2223 10 eV: 375.1075 (100), 173.0598 (70), 107.0487 (63), 191.0699 (45), 123.0434 50 eV: 107.0492 (100), 98.9753 (78), 173.0588 (66), 110.9858 (64), 183.0123 (44), 127.0544 (43), 167.0168 (42), 117.0706 (33), 201.0072 (31), 145.0635 (25), 229.0171 (23), Psilotin McInnes et al., 1965; Authentic Standard 0.12 C11H10O4 [M+H]+ 207.0652 [M+Na]+ 229.0475 30eV: 207.0677 (100), 189.0546 (81), 123.0443 (62) 50 EV: 123.0451 (100), 189.0566 (29), 173.0595 (27), 147.0451 (12) 3’-Hydroxypsilotinin 0.00 C23H30O13 [M+H]+ 515.1741 [M+Na]+ 537.1575 [2M+Na]+ 1051.3228 30 eV: 537.1757 (100) 50 eV: 173.0591 (100), 107.0476 (86), 201.0053 (69), 85.0275 (55), 229.0168 (49), 127.0540 (41), 145 0625 (36) 97 0267 (34) Psilotinin-di-O-hexoside II 1ppm Molecular Formula MS (ESI-Positive) MS/MS(ESI-Positive) (Varying Collision Energies) Annotation References; Further Evidence 1.79 C17H20O9 [M+H]+ 369.1198 [M+Na]+ 391.0999 [M+K]+ 407.0696 [2M+Na]+ 759.2115 [2M+K]+ 775.1595 10 eV: 391.0999 (100), 123.0436 (80), 207.0649 (55), 189.0564 (30) 50 eV: 123.0438 (100), 189.0540 (35), 227.0002 (34), 98.9747 (26), 199.0080 (23), 110.9751 (19), 115.0537 (18), 171.0427 (17), 147.0451 (16), 231.0246 (15) 3’-Hydroxypsilotin Balza et al., 1985; NMR (Table 2; F2) 0.00 C23H30O14 [M+Na]+ 553.1530 30 eV: 553.1504 (100), 207.1641 (11) 50 eV: 123.0433 (100), 173.0570 (48), 85.0281 (23), 189.0512 (29), 115.0534 (26), 203.0539 (17), 116.9908 (15), 147.0437 (14) 3’-Hydroxypsilotinin-di- O-hexoside 0.08 C23H30O13 [M+H]+ 515.1751 [M+Na]+ 537.1591 [2M+Na]+ 1051.3232 30 eV: 537.1603 (100), 191.0746 (40), 391.0731 (15), 173.0627 (14), 107.0520 (7) 50 eV: 107.0538 (100), 173.0650 (87), 201.0111 (26), 229.0230 (20), 117.0743 (12), 145.0677 (12), 98.9808 (11) Psilotinin-di-O-hexoside I 2.79 C17H20O8 [M+H]+ 353.1250 [M+Na]+ 375.1075 [2M+Na]+ 727.2223 10 eV: 375.1075 (100), 173.0598 (70), 107.0487 (63), 191.0699 (45), 123.0434 50 eV: 107.0492 (100), 98.9753 (78), 173.0588 (66), 110.9858 (64), 183.0123 (44), 127.0544 (43), 167.0168 (42), 117.0706 (33), 201.0072 (31), 145.0635 (25), 229.0171 (23), Psilotin McInnes et al., 1965; Authentic Standard 0.12 C11H10O4 [M+H]+ 207.0652 [M+Na]+ 229.0475 30eV: 207.0677 (100), 189.0546 (81), 123.0443 (62) 50 EV: 123.0451 (100), 189.0566 (29), 173.0595 (27), 147.0451 (12) 3’-Hydroxypsilotinin 0.00 C23H30O13 [M+H]+ 515.1741 [M+Na]+ 537.1575 [2M+Na]+ 1051.3228 30 eV: 537.1757 (100) 50 eV: 173.0591 (100), 107.0476 (86), 201.0053 (69), 85.0275 (55), 229.0168 (49), 127.0540 (41), 145.0625 (36), 97.0267 (34) Psilotinin-di-O-hexoside II 0.20 C11H10O3 [M+H]+ 191.0703 30 eV: 173.0589 (100), Psilotinin 1ppm Molecular Formula MS (ESI-Positive) MS/MS(ESI-Positive) (Varying Collision Energies) Annotation References; Further Evidence 1.79 C17H20O9 [M+H]+ 369.1198 [M+Na]+ 391.0999 [M+K]+ 407.0696 [2M+Na]+ 759.2115 [2M+K]+ 775.1595 10 eV: 391.0999 (100), 123.0436 (80), 207.0649 (55), 189.0564 (30) 50 eV: 123.0438 (100), 189.0540 (35), 227.0002 (34), 98.9747 (26), 199.0080 (23), 110.9751 (19), 115.0537 (18), 171.0427 (17), 147.0451 (16), 231.0246 (15) 3’-Hydroxypsilotin Balza et al., 1985; NMR (Table 2; F2) 0.00 C23H30O14 [M+Na]+ 553.1530 30 eV: 553.1504 (100), 207.1641 (11) 50 eV: 123.0433 (100), 173.0570 (48), 85.0281 (23), 189.0512 (29), 115.0534 (26), 203.0539 (17), 116.9908 (15), 147.0437 (14) 3’-Hydroxypsilotinin-di- O-hexoside 0.08 C23H30O13 [M+H]+ 515.1751 [M+Na]+ 537.1591 [2M+Na]+ 1051.3232 30 eV: 537.1603 (100), 191.0746 (40), 391.0731 (15), 173.0627 (14), 107.0520 (7) 50 eV: 107.0538 (100), 173.0650 (87), 201.0111 (26), 229.0230 (20), 117.0743 (12), 145.0677 (12), 98.9808 (11) Psilotinin-di-O-hexoside I 2.79 C17H20O8 [M+H]+ 353.1250 [M+Na]+ 375.1075 [2M+Na]+ 727.2223 10 eV: 375.1075 (100), 173.0598 (70), 107.0487 (63), 191.0699 (45), 123.0434 50 eV: 107.0492 (100), 98.9753 (78), 173.0588 (66), 110.9858 (64), 183.0123 (44), 127.0544 (43), 167.0168 (42), 117.0706 (33), 201.0072 (31), 145.0635 (25), 229.0171 (23), Psilotin McInnes et al., 1965; Authentic Standard 0.12 C11H10O4 [M+H]+ 207.0652 [M+Na]+ 229.0475 30eV: 207.0677 (100), 189.0546 (81), 123.0443 (62) 50 EV: 123.0451 (100), 189.0566 (29), 173.0595 (27), 147.0451 (12) 3’-Hydroxypsilotinin 0.00 C23H30O13 [M+H]+ 515.1741 [M+Na]+ 537.1575 [2M+Na]+ 1051.3228 30 eV: 537.1757 (100) 50 eV: 173.0591 (100), 107.0476 (86), 201.0053 (69), 85.0275 (55), 229.0168 (49), 127.0540 (41), 145.0625 (36), 97.0267 (34) Psilotinin-di-O-hexoside II 0.20 C11H10O3 [M+H]+ 191.0703 [M+Na]+ 213.0528 30 eV: 173.0589 (100), 107.0491 (82) 50 eV: 107.0472 (100), 173.0592 (76), 145.0669 (18) Psilotinin 0.02 C27H30O15 [M+H]+ 595.1654 [M+Na]+ 617.1470 10 eV: no fragmentation 50 eV: 271.0583 (100) Apigenin-6,8-di-C- glucoside (vicenin-2) Markham, 1984; Authentic Standard (Continued) pm Molecular Formula MS (ESI-Positive) MS/MS(ESI-Positive) (Varying Collision Energies) Annotation References; Further Evidence 21 C48H48O25 [M+H]+ 1025.2536 [M+Na]+ 1047.2336 10 eV: no fragmentation 50 eV: 539.0979 (100), 701.1499 (81), 269.1301(10) Amentoﬂavone-tri- hexoside I 44 C21H20O10 [M+H]+ 433.1130 [M+Na]+ 455.0945 10 eV: no fragmentation 50 eV: 271.0597 (100), 153.0175 (4) Apigenin-7-O-glucoside (apigentrin, cosmosin) Wallace and Markham, 1978; Authentic Standard 00 C27H30O14 [M+H]+ 579.1712 [M+Na]+ 601.1520 [2M+Na]+ 1179.3113 10 eV: no fragmentation 50 eV: 271.0598 (100) Apigenin-7-O- rhamnoglucoside (rhofolin) Wallace and Markham, 1978 03 C48H48O25 [M+H]+ 1025.2551 [M+Na]+ 1047.2352 10 eV: no fragmentation 50 eV: 539.0966 (100), 701.1482 (73), 863.1989 (14) Amentoﬂavone-tri- hexoside II 21 C42H38O20 [M+H]+ 863.2021 [M+Na]+ 885.1831 [M+K]+ 901.1516 10 eV: no fragmentation 50 eV: 539.0967 (100), 701.1482 (6) Amentoﬂavone-di- hexoside I 4 C42H38O20 [M+H]+ 863.2010 [M+Na]+ 885.1825 10 eV: no fragmentation 50 eV: 539.0963 (100), 701.1473 (34) Amentoﬂavone-di- hexoside II 38 C36H30O15 [M+H]+ 703.1642 [M+Na]+ 725.1487 10 eV: no fragmentation 50 eV: 421.0545 (100), 541.1130 (43), 311.0555 (17), 337.0343 (16), 271.0582 (10), 153.0175 (8), 137.0583 (7), 147.0434 (7), 297.0413 (6), 379.0452 (5) Dihydroamentoﬂavone- hexoside I 46 C36H28O15 [M+H]+ 701.1490 [M+Na]+ 723.1310 10 eV: no fragmentation 50 eV: 539.0976 (100), 403.0443 (12), 377.0654 (5) Amentoﬂavone- hexoside I 23 C36H30O15 [M+H]+ 703.1632 [M+Na]+ 725.1442 10 eV: no fragmentation 50 eV: 389.1015 (100), 541.1112 (65), 153.0958 (55), 415.0787 (20), 403.0439 (7) Dihydroamentoﬂavone- hexoside II 00 C36H28O15 [M+H]+ 701.1493 [M+Na]+ 723.1304 10 eV: no fragmentation 50 eV: 539.0965 (100), 403.0434 (19), 377.0658 (8), 153.017 (5) Amentoﬂavone- hexoside II 24 C30H18O11 [M+H]+ 555.0931 10 eV: no fragmentation 50 eV: 403.0641 (100), 153.0641 (94), 405.0951 (78), 377.0672 (70), 121.0297 (51), 347.0569 (40), 375.0844 (39), 335.0551 (36), 271.0600 (25), 283.0604 (24), 555.0880 (24) Hydroxy-amentoﬂavone Zhang Y.X. C C Metabolite Isolation and Analysis by Nuclear Magnetic Resonance Spectroscopy et al., 2011 64 C30H20O10 [M+H]+ 541.1125 [M+Na]+ 563.0948 [2M+Na]+ 1103.1994 10 eV: no fragmentation 50 eV: 311.0555 (100), 337.0350 (100), 283.0604 (94), 421.0558 (36), 312.0585 (19), 147.0433 (11), 335.055 (10), 253.0490 (8), 153.0189 (8), 2,3-Dihydro- amentoﬂavone Zhang Y.X. et al., 2011 NMR (Table 2; F8) (Continued) Authentic Standard 0.00 C27H30O14 [M+H]+ 579.1712 [M+Na]+ 601.1520 [2M+Na]+ 1179.3113 10 eV: no fragmentation 50 eV: 271.0598 (100) Apigenin-7-O- rhamnoglucoside (rhofolin) Wallace and Markham, 1978 0.03 C48H48O25 [M+H]+ 1025.2551 [M+Na]+ 1047.2352 10 eV: no fragmentation 50 eV: 539.0966 (100), 701.1482 (73), 863.1989 (14) Amentoﬂavone-tri- hexoside II 1.21 C42H38O20 [M+H]+ 863.2021 [M+Na]+ 885.1831 [M+K]+ 901.1516 10 eV: no fragmentation 50 eV: 539.0967 (100), 701.1482 (6) Amentoﬂavone-di- hexoside I 2.14 C42H38O20 [M+H]+ 863.2010 [M+Na]+ 885.1825 10 eV: no fragmentation 50 eV: 539.0963 (100), 701.1473 (34) Amentoﬂavone-di- hexoside II 0.38 C36H30O15 [M+H]+ 703.1642 [M+Na]+ 725.1487 10 eV: no fragmentation 50 eV: 421.0545 (100), 541.1130 (43), 311.0555 (17), 337.0343 (16), 271.0582 (10), 153.0175 (8), 137.0583 (7), 147.0434 (7), 297.0413 (6), 379.0452 (5) Dihydroamentoﬂavone- hexoside I 1.46 C36H28O15 [M+H]+ 701.1490 [M+Na]+ 723.1310 10 eV: no fragmentation 50 eV: 539.0976 (100), 403.0443 (12), 377.0654 (5) Amentoﬂavone- hexoside I 3.23 C36H30O15 [M+H]+ 703.1632 [M+Na]+ 725.1442 10 eV: no fragmentation 50 eV: 389.1015 (100), 541.1112 (65), 153.0958 (55), 415.0787 (20), 403.0439 (7) Dihydroamentoﬂavone- hexoside II 1.00 C36H28O15 [M+H]+ 701.1493 [M+Na]+ 723.1304 10 eV: no fragmentation 50 eV: 539.0965 (100), 403.0434 (19), 377.0658 (8), 153.017 (5) Amentoﬂavone- hexoside II 1.24 C30H18O11 [M+H]+ 555.0931 10 eV: no fragmentation 50 eV: 403.0641 (100), 153.0641 (94), 405.0951 (78), 377.0672 (70), 121.0297 (51), 347.0569 (40), 375.0844 (39), 335.0551 (36), 271.0600 (25), 283.0604 (24), 555.0880 (24) Hydroxy-amentoﬂavone Zhang Y.X. et al., 2011 0.64 C30H20O10 [M+H]+ 541.1125 [M+Na]+ 563.0948 [2M+Na]+ 1103.1994 10 eV: no fragmentation 50 eV: 311.0555 (100), 337.0350 (100), 283.0604 (94), 421.0558 (36), 312.0585 (19), 147.0433 (11), 335.055 (10), 253.0490 (8), 153.0189 (8), 2,3-Dihydro- amentoﬂavone Zhang Y.X. Metabolite Isolation and Analysis by Nuclear Magnetic Resonance Spectroscopy et al., 2011 NMR (Table 2; F8) (Continued) 0.64 Ša ec e a C e ca 1ppm Molecular Formula MS (ESI-Positive) MS/MS(ESI-Positive) (Varying Collision Energies) Annotation References; Further Evidence 1.67 C36H30O15 [M+H]+ 703.1641 [M+Na]+ 725.1468 10 eV: no fragmentation 50 eV: 541.1118 (100), 421.0543 (48), 393.0621 (10), 271.0578 (4) Dihydroamentoﬂavone- hexoside III 2.24 C30H18O10 [M+Na]+ 561.0785 [2M+H]+ 1077.1844 [2M+Na]+ 1099.1671 10 eV: no fragmentation 50 eV: 377.0657 (100), 403.0452 (98), 347.0551 (56), 335.0552 (55), 283.0600 (36), 153.0178 (34), 539.0964 (27), 121.0282 (25), 307.0601 (23), 387.0855 (21), 311.0549 (16) Amentoﬂavone Wallace and Markham, 1978; Wang et al., 2015; NMR (Table 2;F10); Authentic Standard 0.28 C30H20O10 [M+H]+ 541.1130 [M+Na]+ 563.0935 10 eV: no fragmentation 50 eV: 389.1016 (100), 153.0176 (86), 121.0281 (16), 270.0524 (10), 253.0485 (6), 377.0642 (6), 403.0457 (6), 347.0741 (5) 2′′ 3′′-Dihydro- amentoﬂavone Zhang Y.X. et al., 2011 0.00 C30H18O10 [M+H]+ 539.0979 10 eV: no fragmentation 50 eV: 153.0165 (100), 387.0853 (93), 403.0447 (84), 521.0858 (76), 413.0647 (60), 377.0664 (56), 539.0966 (52), 270.0523 (49), 283.0592 (43), 347.0577 (42), 121.0324 (39), 389.0987 (34), 335.0987 (30), 311.0538 (30) Robustaﬂavone Zhang Y.X. et al., 2011; Wang et al., 2015; NMR (Table 2; F11) 2.16 C31H22O10 [M+H]+ 555.1270 [M+Na]+ 577.1097 [2M+Na]+ 1133.2517 10 eV: no fragmentation 50 eV: 167.0316 (100), 389.0992 (33), 257.0411 (22), 123.0427 (17), 270.0510 (11) Dihydro-O-methyl- amentoﬂavone Markham, 1984 0.81 C31H20O10 [M+H]+ 553.1127 [M+Na]+ 575.0941 10 eV: no fragmentation 50 eV: 89.0586 (100), 193.0483 (83), 149.0224 (76), 73.0284 (56), 237.0731 (56), 275.0447 (33), 285.0382 (22), 268.0692 (16), 254.0553 (13), 553.1074 (10), 286.0421 (7), 387.0759 (6) O-Methyl- amentoﬂavone (tentative) Markham, 1984; Wang et al., 2015 0.18 C30H22O10 [M+H]+ 543.1291 [M+Na]+ 565.1101 [2M+K]+ 1123.1935 10 eV: no fragmentation 50 eV: 153.0180 (100), 271.0592 (75), 391.1183 (26), 147.0427 (21), 297.0376 (10), 166.9972 (10), 179.0342 (10), 423.0729 (5) Binaringenin Feuereisen et al., 2017 0.65 C30H20O10 [M+H]+ 541.1136 [M N ]+ 563 0941 10 eV: no fragmentation 50 eV: 153 1777 (100) 389 1015 (96) Dihydrohinokiﬂavone (t t ti ) [2M+H]+ 1077.1844 [2M+Na]+ 1099.1671 377.0657 (100), 403.0452 (98), 347.0551 (56), 335.0552 (55), 283.0600 (36), 153.0178 (34), 539.0964 (27), 121.0282 (25), 307.0601 (23), 387.0855 (21), 311.0549 (16) 1978; Wang et al., 2015; NMR (Table 2;F10); Authentic Standard 0.28 C30H20O10 [M+H]+ 541.1130 [M+Na]+ 563.0935 10 eV: no fragmentation 50 eV: 389.1016 (100), 153.0176 (86), 121.0281 (16), 270.0524 (10), 253.0485 (6), 377.0642 (6), 403.0457 (6), 347.0741 (5) 2′′ 3′′-Dihydro- amentoﬂavone Zhang Y.X. Metabolite Isolation and Analysis by Nuclear Magnetic Resonance Spectroscopy et al., 2011 0.00 C30H18O10 [M+H]+ 539.0979 10 eV: no fragmentation 50 eV: 153.0165 (100), 387.0853 (93), 403.0447 (84), 521.0858 (76), 413.0647 (60), 377.0664 (56), 539.0966 (52), 270.0523 (49), 283.0592 (43), 347.0577 (42), 121.0324 (39), 389.0987 (34), 335.0987 (30), 311.0538 (30) Robustaﬂavone Zhang Y.X. et al., 2011; Wang et al., 2015; NMR (Table 2; F11) 2.16 C31H22O10 [M+H]+ 555.1270 [M+Na]+ 577.1097 [2M+Na]+ 1133.2517 10 eV: no fragmentation 50 eV: 167.0316 (100), 389.0992 (33), 257.0411 (22), 123.0427 (17), 270.0510 (11) Dihydro-O-methyl- amentoﬂavone Markham, 1984 0.81 C31H20O10 [M+H]+ 553.1127 [M+Na]+ 575.0941 10 eV: no fragmentation 50 eV: 89.0586 (100), 193.0483 (83), 149.0224 (76), 73.0284 (56), 237.0731 (56), 275.0447 (33), 285.0382 (22), 268.0692 (16), 254.0553 (13), 553.1074 (10), 286.0421 (7), 387.0759 (6) O-Methyl- amentoﬂavone (tentative) Markham, 1984; Wang et al., 2015 0.18 C30H22O10 [M+H]+ 543.1291 [M+Na]+ 565.1101 [2M+K]+ 1123.1935 10 eV: no fragmentation 50 eV: 153.0180 (100), 271.0592 (75), 391.1183 (26), 147.0427 (21), 297.0376 (10), 166.9972 (10), 179.0342 (10), 423.0729 (5) Binaringenin Feuereisen et al., 2017 0.65 C30H20O10 [M+H]+ 541.1136 [M+Na]+ 563.0941 [2M+Na]+ 1103.1995 10 eV: no fragmentation 50 eV: 153.1777 (100), 389.1015 (96), 257.0438 (53), 270.0514 (33), 285.0385 (18), 421.0533 (17), Dihydrohinokiﬂavone (tentative) 0.74 C30H18O10 [M+H]+ 539.0979 [M+Na]+ 561.0785 [2M+H]+ 1077.1844 10 eV: no fragmentation 50 eV: 539.0971 (100), 254.0571 (87), 270.0517 (76), 257.0441 (76), 242.0569 (56), 286.0460 (47), 387.0870 (34), 153.0165 (30) Hinokiﬂavone Zhang Y.X. et al., 2011; Wang et al., 2015 NMR (Table 2; F14) F-MS and NMR spectroscopy data. Metabolite Isolation and Analysis by Nuclear Magnetic Resonance Spectroscopy The highest signal intensity for the analytes of interest (and thus most desirable signal-to-noise ratio) was achieved in positive polarity for psilotin and 3’-hydroxypsilotin, whereas for amentoﬂavone negative polarity was preferable. MS/MS experiments were performed by selecting a precursor ion and a collision energy of 30 eV in the transfer cell. MALDI– MS data were processed using the High Deﬁnition Imaging software version 1.2 (Waters, Milford, MA, United States) with lock mass correction. Metabolite identiﬁcation was achieved by comparing accurate mass, MS/MS fragmentation patterns, and ion mobility drift time with those of authentic standards. Signals for isomers of amentoﬂavone, for example robustaﬂavone and hinokiﬂavone, were detectable with authentic standards but not in tissue samples, where their concentrations were too low for MS-based imaging. online databases (MassBank2, Metlin3, and National Institute of Standards and Technology4). However, these searches were mostly unsuccessful due to a lack of relevant reference spectra in these databases, and we therefore decided to expand the Spektraris online resource5 with spectral records acquired as part of this study or extracted from information in the literature. Accurate mass, inferred molecular formula, NMR spectral data, and bibliographic information for 328 metabolites (arylpyrone and biﬂavonoid aglycones and corresponding glycosides) were integrated into Spektraris-NMR, which now contains spectral records for approximately 21,500 metabolites (status: February, 2019). The combination of accurate mass and retention time data (AMT-tags) acquired by HPLC–QTOF–MS were then searched against Spektraris records (for details of this approach see Cuthbertson et al., 2013), which provided tentative identiﬁcations for 27 metabolite peaks (4 annotations with high conﬁdence because of available authentic standards) (Table 1). By also including 1H-NMR data in Spektraris searches (Fischedick et al., 2015), eight metabolites could be identiﬁed with high conﬁdence (Table 2). Relevant structures of arylpyrones and bioﬂavonoids are shown in Figure 2 and the annotation process for selected peaks is outlined in more detail in the following paragraph. p g p g p Arylpyrone glycosides with a psilotinin aglycone eluted early (4.6–6.9 min), followed by ﬂavonoid glycosides (11.2– 14.6 min), biﬂavonoid glycosides (14.0–19.3 min), and then biﬂavonoid aglycones (19.9–24.7 min). In addition to the quasi- molecular ion ([M+H]+), adducts ([M+Na]+ and [M+K]+) and dimers ([2M+Na]+ and [2M+K]+) were detected consistently for almost all analytes (Table 1). An authentic standard of psilotin (Rt 5.20 min; m/z 353.1250 ([M+H]+); C17H20O8) (McInnes et al., 1965) allowed us to investigate the typical fragmentation patterns of this class of arylpyrone glycosides. Metabolite Isolation and Analysis by Nuclear Magnetic Resonance Spectroscopy gnals (chemical shift, with integral, signal licity, coupling constant and position in parentheses) Spektraris Search Score (out of 100) Annotation , 8 Hz, H-5’), 7.13-7.11 (1H, m, H-4), 6.94 (1H, -2’), 6.87 (1H, dd 8 and 7 Hz, H-6’), 6.07 (1H, 4 Hz, H-3), 5.42 (1H, dd, 8 and 4 Hz, H-6), 5.0 ’) 3.89 (1H, dd, 8 and 4 Hz, H-6), 3.72 (1H, dd, Hz, H-6), 3.63 (4H, m), 2.64 (2H, m, H-5a,b) 96 3’-Hydroxypsilotin , 4 Hz, H-2), 7.11 (1H, m, H-4), 6.08 (1H, ddd, Hz, H-3), 5.48 (1H, dd, 12 and 4 Hz, H-6), 3.89 2 and 4 Hz, H-6A’), 3.72 (1H, dd, 12 and 4 Hz, 6B’), 3.5 (4H, m), 2.65 (2H, m, H-5a,b) 90 Psilotin d, 12 Hz, H-2’′′ and H-6’′′), 7.45 (2H, m, H-2’ .04 (1H, d, 8 Hz, H-5’), 6.79 (2H, d, 8 Hz, H-3’′′ ′), 6.59 (1H, s, H-3′′), 6.33 (1H, s, H-6′′), 5.85 6 and H-8), 5.47 (1H, d, 4 Hz, H-2), 3.15(1H, m, H-3a), 2.75(1H, m, H-3b) 82 2,3-Dihydro- amentoﬂavone dd, 8 and 4 Hz, H-6’), 7.94 (1H, d, 4 Hz, H-2’), d, 8 Hz, H-2’′′ and H-6’′′), 7.13 (1H, d, 8 Hz, (1H, s,H-3), 6.8(1H, s, H-3′′), 6.7 (2H, d, 8 Hz, d H-5’′′), 6.63 (1H, d, 8 Hz, H-8), 6.35 (1H, s, H-6′′), 6.21 (1H, d, 4 Hz, H-6) 99 Amentoﬂavone (3’,8′′-biapigenin) , H-6’, H-2’′′ and H-6’′′), 7.2 (1H, d,4Hz, H-2’), d, 4Hz, H-5’), 6.91 (1H, d, 16 Hz, H-3’′′ and 82(1H, s, H-3). 6.73 (1H, s, H-3′′), 6.71 (1H, s, .43 (1H, d, 4 Hz, H-8), 6.14 (1H, d,4Hz, H-6) 87 Robustaﬂavone (3’,6′′-biapigenin) H-2’, H-2’′′ and H-6’′′), 7.18 (2H, d, 4 Hz, H-3’ 6.92 (2H, d, 4Hz, H-3’′′ and H-5’′′) 6.88 (3H, m, nd H-3′′), 6.75 (1H, s, H-3’), 6.72 (1H, s, H-8′′), (1H, d, 4 Hz, H-8), 6.13 (1H, d, 4Hz, H-6) 81 Hinokiﬂavone (4’,6′′-O-biapigenin) Chemical Diversity in Psilotum nudum Šamec et al. of 40 (arbitrary units); and a step size of 25 µm. Lock mass correction was repeated every 600 s for a duration of 5 s. Other settings: helium gas ﬂow at 90 ml min−1; trap wave velocity at 311 m s−1; trap wave height at 4 V; ion mobility wave velocity at 650 m s−1; ion mobility wave height at 40 V; transfer ware velocity at 191 m s−1; transfer wave height of 0.1 V; and ion mobility wave delay of 450 µs. RESULTS Strategy for Multi-Platform Analysis of Metabolites in P. nudum Organs Metabolite Isolation and Analysis by Nuclear Magnetic Resonance Spectroscopy At low fragmentation energy (10 eV), the loss of glucose generated a fragment representing the psilotinin aglycone (m/z 191.0699; [M–Glc]+; C11H10O3), a second fragment with additional loss of water (m/z 173.0598; [M–Glc–H2O]+; C11H10O3), a third fragment at m/z 123.0438 (C7H7O2), and a fourth fragment with m/z 107.0487 (C7H7O). The absorption spectrum of the peak in chromatograms and the authentic psilotin standard was essentially identical (Supplementary Figure S2). Furthermore, following puriﬁcation of the peak by HPLC, the NMR spectrum of the isolated metabolite matched literature reports (McInnes et al., 1965) (Table 2). The signature fragments generated from the psilotin HPLC–QTOF–MS peak (corresponding to C11H10O3 and C7H7O) were also detected in MS/MS spectra of four additional peaks (plus further common fragments at 50 eV). The molecular ions of two of these peaks indicated the potential presence of two hexose moieties (Rt 5.12 and 6.83 min; m/z 515.1751 ([M+H]+); C23H30O13), which was corroborated by fragmentation patterns ([M – 2 × Glc]+ and [M – 2 × Glc – H2O]+). The third peak of this series had a molecular ion consistent with 3’-hydroxypsilotin (Rt 4.66 min; m/z 369.1198 Frontiers in Plant Science \| www.frontiersin.org July 2019 \| Volume 10 \| Article 868 Strategy for Multi-Platform Analysis of Metabolites in P. nudum Organs g In an attempt to capture chemically diverse metabolites, we used a strategy that accessed ﬁve P. nudum organs/tissues (below- ground rhizome, above-ground rhizome, and synangia harvested at diﬀerent developmental stages [green (young), yellow (maturing) and brown (mature)], and generated hydrophilic (methanol/water) and hydrophobic (chloroform/methanol) extracts (Figure 1). These two types of extracts were processed separately for GC–MS analysis (Supplementary Figure S1). Methanol/water extracts were also subjected to HPLC–QTOF–MS analysis in positive ionization mode only (preliminary experiments indicated that chromatographic runs in negative polarity did not add signiﬁcant spectral information) (Supplementary Figure S1). These data sets were normalized, autoscaled, and then combined for multivariate statistical analyses (Figure 1). Fractions representing selected metabolites of interest were collected from chromatographic separations of extracts and further characterized by 1H-NMR. The diﬀerent metabolomics platforms (GC–MS and HPLC–QTOF–MS) were chosen because they provide complementary information about diﬀerent metabolites classes (details presented in the upcoming paragraphs). Cryosections of P. nudum above-ground rhizomes were sprayed with a chemical matrix and the cell type-level localization of the most abundant metabolites determined by MALDI–QTOF–MS (Figure 1). Peak annotation for GC–MS data was achieved based on comparisons of retention times and mass spectral characteristics with those of authentic standards, which led to the high- conﬁdence identiﬁcation of 83 metabolites in our extracts. MS and MS/MS data from HPLC–QTOF–MS runs (acquired in positive polarity mode) were searched against comprehensive 2https://massbank.eu/MassBank/ 3https://metlin.scripps.edu/ 4https://chemdata.nist.gov/ 5http://langelabtools.wsu.edu/spektraris/ Frontiers in Plant Science \| www.frontiersin.org July 2019 \| Volume 10 \| Article 868 9 Chemical Diversity in Psilotum nudum Šamec et al. FIGURE 1 \| Experimental design for the current study. For details and abbreviations see text. FIGURE 1 \| Experimental design for the current study. For details and abbreviations see text. likely corresponds to an apigenin di-hexoside. Interestingly, apigenin-6,8-di-C-glucoside (vicenin-2) was described before as an abundant constituent of P. nudum extracts (Markham,1984), which was used as a tentative annotation for the peak of interest (Table 1). ([M+H]+); C17H20O9) (Balza et al., 1985), an annotation that was conﬁrmed based on the NMR spectrum of the isolated metabolite (Tables 1, 2). The fourth peak appeared to contain the same aglycone but with two attached hexose moieties and was therefore tentatively annotated as 3’-hydroxypsilotinin-di-O- hexoside (Rt 4.76 min; m/z 553.1530 ([M+Na]+); C23H30O14). All biﬂavonoid glycosides thus far characterized from P. nudum extracts contained an amentoﬂavone (3′,8′′- biapigenin) aglycone with likely O-linked hexose moieties (Wallace and Markham, 1978; Markham, 1984). Strategy for Multi-Platform Analysis of Metabolites in P. nudum Organs The absorption spectrum of the amentoﬂavone standard in the ultraviolet and visible range was identical to that of the corresponding peak in our HPLC runs (Supplementary Figure S2). Two arylpyrone aglycones, 3′-hydroxypsilotinin (Rt 5.52; m/z 207.0652 ([M+H]+); C11H10O4) and psilotinin (Rt 8.31; m/z 191.0703 (M+H]+); C11H10O3), were tentatively identiﬁed based on chromatographic properties and similarity of MS/MS fragmentation patterns to those of their glycosides (Supplementary Figure S3). brought to bear on our combined GC–MS and HPLC– QTOF–MS data sets, the ﬁrst three PCs accounted for roughly 71% of the varied inﬂuences of the original characteristics (metabolite patterns across all sample types), and indicated a clear separation of the ﬁve sample types (P. nudum below- ground rhizome, above-ground rhizome, and synangia harvested at three diﬀerent developmental stages), with a tight clustering of biological replicates (Figures 3A,B). Below- ground rhizome samples were characterized by positive scores in PC1 and PC3, with neutral values in PC2. Above- ground rhizome samples also had positive scores in PC1 but negative scores in PC2 and PC3 (Figures 3A,B). All samples from synangia had negative scores in PC1, but were diﬀerentiated by a combination of negative PC2/positive PC3 scores (green synangia), negative PC2/PC3 scores (yellow synangia) or positive PC2/neutral PC3 scores (brown synangia) (Figures 3A,B). Component loadings were then evaluated for characteristics that contributed to the diﬀerences among sample clusters in PCA and visualized in a biplot (Figure 3C and Supplementary Table S3). The scores for below-ground rhizome samples (positive PC1 and PC2) corresponded to the vectors for carbohydrate monomers and dimers (e.g., glucose, fructose, galactose, and raﬃnose) and small organic acids (malic acid, citric acid, and succinic acid). Above-ground rhizome samples occupied a biplot position (positive PC1, negative PC2) closer to the direction of vectors for some arylpyrone glycosides (psilotin and psilotinin- di-O-hexoside II) and sucrose (which had high concentrations in both above- and below-ground rhizomes) (Figure 3C). The unique position of brown synangia (negative PC1/positive PC2) correlated with the vector for biﬂavonoid glycosides (e.g., dihydroamentoﬂavone hexoside I and amentoﬂavone-tri- O-hexoside II). Scores for green and yellow synangia were similar (negative scores in both PC1 and PC2) and correlated with the direction of vectors for arylpyrone glycosides (e.g., psilotinin-di- O-hexoside I) and biﬂavonoid aglycones (e.g., amentoﬂavone and hinokiﬂavone) (Figure 3C). To enable the diﬀerentiation of biﬂavonoid aglycones, four fractions collected by HPLC were subjected to 1H-NMR spectroscopy. Strategy for Multi-Platform Analysis of Metabolites in P. nudum Organs The amentoﬂavone authentic standard (C30H18O10) eluted at 21.15 min (Table 1). Six additional peaks with the characteristic m/z 539.0963 fragment (corresponding to this aglycone) plus common MS/MS fragments of the aglycone (Zhang Y.X. et al., 2011; Feuereisen et al., 2017) were detected in our extracts. Based on their quasi-molecular ion, these peaks were tentatively annotated as amentoﬂavone-hexosides (Rt 18.12 and 19.16 min; m/z 701.1490 ([M+H]+); C36H28O15), amentoﬂavone-di-hexosides (Rt 15.78 and 16.60 min; m/z 863.2021 ([M+H]+); C42H38O20) or amentoﬂavone- tri-hexosides (Rt 13.99 and 14.82 min; m/z 1025.2551 ([M+H]+); C48H48O25). Three peaks in the same retention Based on the characteristics of the peak corresponding to apigenin 7-O-glucoside, for which an authentic standard was available (Rt 14.26 min; m/z 433.1133 ([M+H]+); C21H20O10) (Wallace and Markham, 1978), the fragment indicative of an apigenin aglycone was m/z 271.0597 ([M– Glc]+; C15H10O5), with m/z 153.0175 (C7H5O4) representing a second prominent fragment obtained from this ﬂavone aglycone (Kachlicki et al., 2016). Two additional peaks had comparable fragmentation patterns, one of which showed a quasi-molecular ion corresponding to apigenin-7-O-rhamnoglucoside (Rt 14.50 min; m/z 579.1712 ([M+H]+); C27H30O14), a metabolite that had previously been reported to occur in P. nudum (Wallace and Markham, 1978). The mass spectrum of the second of these peaks was indicative of a metabolite with two hexose moieties (Rt 11.20 min; m/z 595.1654 ([M+H]+); C27H30O15) and therefore Frontiers in Plant Science \| www.frontiersin.org July 2019 \| Volume 10 \| Article 868 10 Chemical Diversity in Psilotum nudum Šamec et al. E 2 \| Structures of the main ﬂavonoid, biﬂavonoid and arylpyrone agylcones of P. nudum (positions for common glycosylation sites are indica FIGURE 2 \| Structures of the main ﬂavonoid, biﬂavonoid and arylpyrone agylcones of P. nudum (positions for common glycosylation sites are indicated with purple arrows). FIGURE 2 \| Structures of the main ﬂavonoid, biﬂavonoid and arylpyrone agylcones of P. nudum (positions for common glycosyla arrows). July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org July 2019 \| Volume 10 \| Article 868 11 Chemical Diversity in Psilotum nudum Šamec et al. time region (Rt 17.56, 18.28, and 20.96 min) had a quasi- molecular ion (m/z 703.1642 ([M+H]+); C36H30O15) and characteristic aglycone fragment (m/z 541.0545; C30H20O10) indicative of two additional mass units compared to amentoﬂavone-hexosides. The aglycone in these cases is dihydroamentoﬂavone (C–C-linked dimer of apigenin and naringenin), and the peaks were therefore annotated as dihydroamentoﬂavone-hexosides (Table 1). Strategy for Multi-Platform Analysis of Metabolites in P. nudum Organs Taking into account the previously published elution order of biﬂavonoids on reversed-phase HPLC materials (Zhang Y.X. et al., 2011), MS and MS/MS data, and by combining this information with MS and NMR data searches against the Spektraris database, four peaks could be identiﬁed with high conﬁdence (20.73 min, 2,3-dihydroamentoﬂavone; 21.15 min, amentoﬂavone; 22.03 min, robustaﬂavone; and 24.50 min, hinokiﬂavone (Figure 2 and Tables 1, 2). The peak at 19.96 min (m/z 555.0931 ([M+H]+); C30H18O11) was tentatively identiﬁed as hydroxyamentoﬂavone based on its earlier elution (compared to amentoﬂavone) and MS/MS fragmentation patterns (Zhang Y.X. et al., 2011). Analogous comparisons allowed the tentative identiﬁcation of dihydro-O-methyl-amentoﬂavone (Rt 22.59 min; m/z 555.1270 ([M+H]+); C31H22O10), O-methyl-amentoﬂavone (Rt 23.38 min; m/z 553.1127 ([M+H]+); C31H20O10), binaringenin (Rt 23.80 min; m/z 543.1291 ([M+H]+); C30H22O10), and dihydrohinokiﬂavone (Rt 24.14 min; m/z 541.1136 ([M+H]+); C30H20O10) (Markham, 1984; Zhang Y.X. et al., 2011; Wang et al., 2015; Feuereisen et al., 2017) (Table 1). Organ-Speciﬁc Accumulation of Metabolites A third class of metabolites with high abundance in HPLC– QTOF–MS runs had the chromatographic and mass spectral properties of highly functionalized triterpenoids (steroids) (Supplementary Table S2). While the typical membrane sterols of P. nudum have been reported before (Akihisa et al., 1992), the more functionalized steroids detected here have not been mentioned in previous studies. A more detailed characterization of these underexplored specialized metabolites will be the subject of future endeavors to further evaluate chemicals diversity in the fern lineage. The PCA component loadings indicated that speciﬁc metabolite classes might explain the separation of sample types. We therefore generated a heatmap of metabolite accumulation patterns across P. nudum organs (Figure 4). The relative quantities of ﬁve biﬂavonoid glycosides, based on normalized peak areas, were quite high in brown synangia, followed by yellow and green synangia. These metabolites were also of fairly high abundance in samples of above-ground rhizomes, but extremely low in below-ground rhizomes (Figure 4). The quantities of six additional biﬂavonoid glycosides were considerably lower in all samples. Amentoﬂavone was the by far most abundant biﬂavonoid aglycone, with very high amounts present in yellow and brown synangia, relatively high quantities in above-ground rhizomes and green synangia, and fairly low levels in below-ground rhizomes (Figure 4). Similar patterns were observed for ﬁve additional biﬂavonoid Principal Component Analysis Differentiates Metabolomics Data Sets From Different P. nudum Organs Multivariate statistical analyses, such as PCA, aid with reducing the complexity of extensive data sets into a smaller number of Principal Components (PCs). When this approach was July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org 12 Chemical Diversity in Psilotum nudum Šamec et al. FIGURE 3 \| Psilotum nudum organs have a unique metabolic ﬁngerprint, based on PCA of combined GC-MS and HPLC-QTOF-MS data. (A) PCA plot for PC1 and PC2. (B) PCA plot for PC1 and PC3. (C) Bi-plot with selected component loadings (metabolites) highlighted (the vectors of the remaining AMT tags are shown with red lines in the background). The full component loadings are provided in Supplementary Table S3. Symbols: rhizome (below-ground), purple cross; rhizome (above-ground), blue diamond; green synangium, green plus sign; yellow synangium, pink inverted triangle; brown synangium, red triangle. gl cones (three dih drobiapigenin isomers binaringenin and abundance comparable to that of psilotin Three other ar lp rone FIGURE 3 \| Psilotum nudum organs have a unique metabolic ﬁngerprint, based on PCA of combined GC-MS and HPLC-QTOF-MS data. (A) PCA plot for PC1 and PC2. (B) PCA plot for PC1 and PC3. (C) Bi-plot with selected component loadings (metabolites) highlighted (the vectors of the remaining AMT tags are shown with red lines in the background). The full component loadings are provided in Supplementary Table S3. Symbols: rhizome (below-ground), purple cross; rhizome (above-ground), blue diamond; green synangium, green plus sign; yellow synangium, pink inverted triangle; brown synangium, red triangle. FIGURE 3 \| Psilotum nudum organs have a unique metabolic ﬁngerprint, based on PCA of combined GC-MS and HPLC-QTOF-MS data. (A) PCA plot for PC1 and PC2. (B) PCA plot for PC1 and PC3. (C) Bi-plot with selected component loadings (metabolites) highlighted (the vectors of the remaining AMT tags are shown with red lines in the background). The full component loadings are provided in Supplementary Table S3. Symbols: rhizome (below-ground), purple cross; rhizome (above-ground), blue diamond; green synangium, green plus sign; yellow synangium, pink inverted triangle; brown synangium, red triangle. abundance comparable to that of psilotin. Three other arylpyrone glycosides were of relatively low abundance in all samples. aglycones (three dihydrobiapigenin isomers, binaringenin and hinokiﬂavone), albeit at much lower abundance compared to amentoﬂavone. Among arylpyrone glycosides, psilotin was most abundant in rhizomes and above-ground rhizomes, but was also accumulated to appreciable amounts in synangia (Figure 4). MALDI–MS Imaging Indicates Preferential Accumulation of Amentoﬂavone and Arylpyrone Glycosides in Stem Epidermis and Outer Cortex The orthogonal data sets acquired in this study (retention time on GC or HPLC, quasi-molecular ion (and inferred molecular formula), MS/MS data, and NMR spectra), combined with the use of authentic standards, aided substantially in peak annotation. The inclusion of NMR data was particularly impactful for the annotation of peaks for the biﬂavonoids (amentoﬂavone, robustaﬂavone, and hinokiﬂavone) that consist of two fused apigenin molecules (diﬀering only in the coupling position). Using our integrative approach, a total of 83 GC- MS and 8 HPLC–QTOF–MS peaks were identiﬁed with very high conﬁdence. An additional 23 HPLC–QTOF–MS peaks were tentatively identiﬁed (for example, amentoﬂavone-tri-O- hexoside I, where uncertainty pertains only to the position and exact nature of the hexose moiety) (Table 1). While we were able to determine the structures of some of the more abundant aglycones, the identiﬁcation of biﬂavonoid glycosides, which occur as larger families of closely related structures, has proven much more diﬃcult. Our data sets also contained a very large number of peaks that could not be identiﬁed. Some of these, based on peak area counts, appeared to be fairly abundant. These results indicate that signiﬁcant eﬀorts will be needed to generate a more comprehensive account of chemical diversity in P. nudum and, more broadly, in the fern lineage. Building on recent successes with MS-based imaging of sesquiterpene alkaloids and triterpenoids (Lange et al., 2017), MALDI–MS was employed for localizing metabolites of interest in the current study. Two arylpyrone glycosides, psilotin and 3′-hydroxypsilotin, and a biﬂavonoid aglycone, amentoﬂavone, were selected for because they were highly abundant in tissue samples (MS-based imaging is much less sensitive compared to tissue extraction followed by HPLC–QTOF–MS) and were available as authentic standards in suﬃcient quantities for methods development. Based on the results of preliminary experiments, 30 µm cryosections of above-ground rhizomes served as biological material, 2,5-dihydroxybenzoic acid was chosen as matrix substance to aid with ionization of metabolites desorbed from tissue sections, and leucine-enkephalin was selected to provide an external lock mass. The ionization of psilotin and 3′-hydroxypsilotin was most eﬀective in positive ionization mode, where potassium adducts (m/z 391.0797 and 407.0750, respectively) were readily detectable with unique drift times in the ion mobility cell. Mass spectrometric signals for psilotin, 3′-hydroxypsilotin and amentoﬂavone were highest in the epidermal and outer cortex layers, which collectively form the chlorenchyma (Figures 5A–D). The 3′-hydroxypsilotin signal was also apparent, albeit at signiﬁcantly lower abundance, in the protostele. MALDI–MS Imaging Indicates Preferential Accumulation of Amentoﬂavone and Arylpyrone Glycosides in Stem Epidermis and Outer Cortex Amentoﬂavone ionized particularly well in negative mode, with the quasi-molecular ion being more abundant than adducts (m/z 537.0827) and traveling through the ion mobility cell with a unique drift time (Figures 5B,C,E). Based on MALDI– MS experiments performed with above-ground rhizome extracts, the normalized peak area for amentoﬂavone was 5-fold higher than that of hinokiﬂavone and 47-fold higher than that of robustaﬂavone, and the abundance of the latter two metabolites was too low for localization studies. Principal Component Analysis Differentiates Metabolomics Data Sets From Different P. nudum Organs 3′-Hydroxypsilotin was primarily found in synangia, with an Sucrose was equally abundant in rhizomes, above-ground rhizomes and green synangia (Figure 4). Glucose, fructose and other small molecule carbohydrates were most abundant in rhizomes, with signiﬁcantly lower amounts being present in all July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org 13 Chemical Diversity in Psilotum nudum Šamec et al. FIGURE 4 \| Heat map visualizing the organ-speciﬁcity of metabolite accumulation in P. nudum. A color code (red-white-blue) is used to indicate the relative abundance of metabolites based on normalized mass spectral intensities. FIGURE 4 \| Heat map visualizing the organ-speciﬁcity of metabolite accumulation in P. nudum. A color code (red-white-blue) is used to indicate the relative abundance of metabolites based on normalized mass spectral intensities. July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org 14 Chemical Diversity in Psilotum nudum Šamec et al. a surprising paucity of spectral data relating to biﬂavonoids in publicly available MS and NMR databases. We therefore embarked on a literature search to gather phytochemical and spectral data for this important class of metabolites, which was then used to generate 328 new spectral records for the Spektraris online resource (Cuthbertson et al., 2013; Fischedick et al., 2015). Additionally, electronic ﬁles representing the MS/MS data acquired with biﬂavonoids were submitted to MassBank, a widely used online mass spectral repository (Horai et al., 2010). other samples. The highest levels of small organic acids were also found in rhizomes. While malic and citric acid were fairly abundant in all samples, other organic acids (e.g., α-ketoglutaric acid, glyceric acid and fumaric acid) were detected at considerably lower levels in rhizomes and yet lower levels in all other samples (Figure 4). Below-Ground Rhizome of P. nudum Contains High Levels of Soluble Sugars and Organic Acids, Possibly Indicating Differential Nutrient Allocation The above- and below-ground portions of the P. nudum rhizome are part of the same organ and it is thus notable that, in our study, signiﬁcantly higher amounts of soluble sugars (in order of abundance: fructose, glucose, raﬃnose and galactose) and organic acids (in order of abundance: malic acid, citric acid and phosphoric acid) were present in the below-ground part of the rhizome. The abundance of soluble sugars might be interpreted as evidence for a storage function for P. nudum rhizomes but, to the best of our knowledge, the corresponding storage sugar polymers have not been analyzed in this species. The chemical properties of rhizome starches have been reported for other ferns (Zhang S. et al., 2011; Yu et al., 2015) and this work indicates indirectly (based on the high abundance of sugar precursors) that storage function is a possibility. It is also conceivable that relatively high levels of soluble sugars and organic acids are a reﬂection of active metabolism to support horizontal rhizome growth in P. nudum. However, while information is available regarding the correlation of fern development and some classes of metabolites (White and Turner, 1995; Abul et al., 2010), we were not able to ﬁnd literature DISCUSSION Expanding the Coverage of Spectral Databases to Incorporate Information on Chemical Diversity in the Fern Lineage Biﬂavonoids have long been known to accumulate prominently across the bryophytes, pteridophytes and gymnosperms, with only sporadic occurrence in the angiosperms (Geiger and Quinn, 1988; Iwashina, 2000). When we began processing the data presented as part of the current study with P. nudum, we noticed Rhizomes Accumulate Particularly High Amounts of Psilotin, an Arylpyrone Glycoside With Demonstrated Biological Activities Our data indicated that psilotin and psilotinin, both arylpyrones unique to the Psilotaceae, were most abundant in the rhizome (both below- and above-ground), while being only half or one- third as abundant in samples from synangia. The biﬂavonoid amentoﬂavone was also highly abundant in the above-ground part of the rhizome but occurred at fairly low quantities in the below-ground parts (Figure 4). This begs the question if psilotin and its aglycone psilotinin might play a particular role in the below-ground rhizome, where arylpyrones are major constituents. Interestingly, it was demonstrated more than 40 years ago that psilotin acts as a germination inhibitor for turnip, onion and lettuce seeds (Siegel, 1976). It is, therefore, conceivable that psilotin (and possibly its aglycone as well) plays a defensive or allelochemical role in and around the below-ground rhizome. Psilotin was also shown to have antifeedant activities against the European corn borer (Ostrinia nubilalis) at concentrations below those present in P. nudum Expanding the Coverage of Spectral Databases to Incorporate Information on Chemical Diversity in the Fern Lineage Biﬂavonoids have long been known to accumulate prominently across the bryophytes, pteridophytes and gymnosperms, with only sporadic occurrence in the angiosperms (Geiger and Quinn, 1988; Iwashina, 2000). When we began processing the data presented as part of the current study with P. nudum, we noticed July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org 15 Šamec et al. Chemical Diversity in Psilotum nudum FIGURE 5 \| MALDI-MS imaging of specialized metabolites in cross sections of P. nudum above-ground rhizomes (stems). (A) Image of specimen for arylpyrone glycoside analysis; (B) [M+K]+ signal for psilotin (colored in red); (C) [M+K]+ signal for 3′-hydroxypsilotin (colored in green); (D) image of specimen for biﬂavonoid analysis; (E) [M–H]−signal for amentoﬂavone (colored in blue). Note the accumulation of metabolites of interest in the chlorenchyma (dark green tissue in specimen images). FIGURE 5 \| MALDI-MS imaging of specialized metabolites in cross sections of P. nudum above-ground rhizomes (stems). (A) Image of specimen for arylpyrone glycoside analysis; (B) [M+K]+ signal for psilotin (colored in red); (C) [M+K]+ signal for 3′-hydroxypsilotin (colored in green); (D) image of specimen for biﬂavonoid analysis; (E) [M–H]−signal for amentoﬂavone (colored in blue). Note the accumulation of metabolites of interest in the chlorenchyma (dark green tissue in specimen images) on soluble sugar quantities in fern rhizomes. Further research is clearly necessary to begin to appreciate the tissue specialization within fern rhizomes. (Arnason et al., 1986). However, in the absence of more complete data on the bioactivities of arylpyrones, this interpretation is highly speculative. It is also unknown how psilotin might be secreted into the rhizosphere to exert allelochemical activities. The fact that the inhibitory eﬀects of psilotin on germination can be reversed by the addition of GA3 (Siegel, 1976), a gibberellin hormone, can be interpreted as evidence for a possible role of this arylpyrone in growth regulation, but the mechanism and target(s) of such an activity have not yet been explored. In the above-ground rhizome, psilotin and amentoﬂavone (the latter also exerting high bioactivity; Yu et al., 2017) may act collectively as defense metabolites. Currently, information about such activities has been inferred from in vitro assays only and it would thus be informative to also assess potential defensive functions of arylpyrones and bioﬂavonoids in in vivo investigations. Frontiers in Plant Science \| www.frontiersin.org DATA AVAILABILITY FIGURE S1 \| Representative GC-MS and HPLC-QTOF-MS chromatograms (total ion current) of P. nudum extracts. FIGURE S1 \| Representative GC-MS and HPLC-QTOF-MS chromatograms (total ion current) of P. nudum extracts. All datasets generated for this study are included in the manuscript and/or the Supplementary Files. FIGURE S2 \| Absorbance spectra of peaks detected in HPLC-QTOF-MS runs and comparison with those of authentic standards. FIGURE S3 \| MS/MS spectra (acquired at 30 eV collision energy) of psilotin and psilotinin. ACKNOWLEDGMENTS We would like to thank the Institute of Biological Chemistry’s greenhouse staﬀ, Ms. Julie Thayer and Mr. Devon Thrasher, for plant maintenance. We are also indebted to Dr. Jordan Zager for establishing a pipeline for PCA. Ms. Ingrid Wokey and Mr. Nicholas Elms are acknowledged for their work on generating Spektraris records. SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpls.2019.00868/ full#supplementary-material AUTHOR CONTRIBUTIONS TABLE S1 \| Peak identiﬁcation in GC-MS runs. BL conceived the work and wrote the manuscript, with input from all authors. DŠ, VP, NS, and BL designed the experiments and analyzed the data. MW served as mentor for VP. VP generated GC-MS data. DŠ obtained HPLC-QTOF-MS and MALDI-MS data. NS produced and interpreted NMR data and contributed to the generation of new spectral records for the Spektraris online resource. BL conceived the work and wrote the manuscript, with input from all authors. DŠ, VP, NS, and BL designed the experiments and analyzed the data. MW served as mentor for VP. VP generated GC-MS data. DŠ obtained HPLC-QTOF-MS and MALDI-MS data. NS produced and interpreted NMR data and contributed to the generation of new spectral records for the Spektraris online resource. TABLE S2 \| Normalized peak areas for GC-MS and HPLC-QTOF-MS data. TABLE S3 \| Component loadings of a PCA analysis with combined GC-MS and HPLC-QTOF-MS data. TABLE S4 \| NMR acquisition parameters. TABLE S5 \| Bioﬂavonoids and related metabolites for which new Spektraris spectral records were generated. FUNDING This work was supported in part by seed funds from the USDA National Institute of Food and Agriculture, Hatch Umbrella project #1015621. DŠ acknowledges ﬁnancial support by the European Union’s Seventh Framework Programme under grant agreement # 291823, Marie Curie FP7-PEOPLE-2011-COFUND NEWFELPRO, project 64. Occurrence of Biﬂavonoids and Arylpyrones in Chlorenchyma Is Consistent With Function as Sunscreen Pigments Based on our MALDI–MS imaging data, psilotin and amentoﬂavone are accumulated preferentially in the photosynthetically active tissues of above-ground rhizomes (above-ground rhizomes) (Figure 5). Considering the absorption July 2019 \| Volume 10 \| Article 868 Frontiers in Plant Science \| www.frontiersin.org 16 Chemical Diversity in Psilotum nudum Šamec et al. characteristics of these metabolites (Supplementary Figure S2), a protective function against excess photosynthetically active radiation and certain wavelengths (e.g., high energy ultraviolet-B) radiation would be a reasonable hypothesis for their tissue-level localization (Yamaguchi et al., 2009; Waterman et al., 2017). Our localization data sets for amentoﬂavone (chlorenchyma) are also consistent with the literature for other plants. 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The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Renzaglia, K. S., Johnson, T. H., Gates, H. D., and Whittier, D. P. (2001). Architecture of the sperm cell of Psilotum. Am. J. Bot. 88, 1151–1163. doi: 10.2307/3558326 Copyright © 2019 Šamec, Pierz, Srividya, Wüst and Lange. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. 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https://openalex.org/W4323661972	https://bmcgastroenterol.biomedcentral.com/counter/pdf/10.1186/s12876-023-02675-w	English	null	Identification of inadequate responders to advanced therapy among commercially-insured adult patients with Crohn’s disease and ulcerative colitis in the United States	BMC gastroenterology	2,023	cc-by	8,193	© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Gibble et al. BMC Gastroenterology (2023) 23:63 https://doi.org/10.1186/s12876-023-02675-w Gibble et al. BMC Gastroenterology (2023) 23:63 https://doi.org/10.1186/s12876-023-02675-w BMC Gastroenterology Open Access Open Access Abstract Background The purpose of this analysis was to assess the frequency of inadequate response over 1 year from advanced therapy initiation among patients with Crohn’s disease (CD) or ulcerative colitis (UC) in the United States using a claims-based algorithm. Factors associated with inadequate response were also analyzed. Methods This study utilized claims data of adult patients from the HealthCore Integrated Research Database (HIRD®) from January 01, 2016 to August 31, 2019. Advanced therapies used in this study were tumor necrosis factor inhibi‑ tors (TNFi) and non-TNFi biologics. Inadequate response to an advanced therapy was identified using a claims-based algorithm. The inadequate response criteria included adherence, switching to/added a new treatment, addition of a new conventional synthetic immunomodulator or conventional disease-modifying drugs, increase in dose/frequency of advanced therapy initiation, and use of a new pain medication, or surgery. Factors influencing inadequate respond‑ ers were assessed using multivariable logistic regression. Results A total of 2437 patients with CD and 1692 patients with UC were included in this analysis. In patients with CD (mean age: 41 years; female: 53%), 81% had initiated TNFi, and 62% had inadequate response. In patients with UC (mean age: 42 years; female: 48%), 78% had initiated a TNFi, and 63% had an inadequate response. In both patients with CD and UC, inadequate response was associated with low adherence (CD: 41%; UC: 42%). Inadequate responders were more likely to be prescribed a TNFi (for CD: odds ratio [OR] = 1.94; p < 0.001; for UC: OR = 2.76; p < 0.0001). Conclusion More than 60% of patients with CD or UC had an inadequate response to their index advanced therapy within 1 year after initiation, mostly driven by low adherence. This modified claims-based algorithm for CD and UC appears useful to classify inadequate responders in health plan claims data. Keywords Advanced therapy, Biologics, Claims-based algorithm, Crohn’s disease, HealthCore Integrated Research Database®, Inadequate response, Inflammatory bowel disease, Tumor necrosis factor inhibitors/TNFi, Ulcerative colitis Correspondence: Theresa Hunter Gibble hunter_theresa_marie@lilly.com Full list of author information is available at the end of the article Identification of inadequate responders to advanced therapy among commercially‑insured adult patients with Crohn’s disease and ulcerative colitis in the United States Theresa Hunter Gibble1, April N. Naegeli1, Michael Grabner2, Keith Isenberg3, Mingyang Shan1, Chia‑Chen Teng2 and Jeffrey R. Curtis4 Theresa Hunter Gibble1, April N. Naegeli1, Michael Grabner2, Keith Isenberg3, Mingyang Sh Chia‑Chen Teng2 and Jeffrey R. Curtis4 Theresa Hunter Gibble1, April N. Naegeli1, Michael Grabner2, Keith Isenberg3, Mingyang Shan1, Chia‑Chen Teng2 and Jeffrey R. Curtis4 Data source and populationh This was a retrospective claim-based cohort study that utilized longitudinal claims data from the HealthCore Integrated Research Database® (HIRD®) from January 1, 2016 to August 31, 2019. The HIRD® contains data from January 2006 on patient enrollment, inpatient and out- patient medical care, prescription, and health care uti- lization. It is a large longitudinal medical and pharmacy claims database of health plan members comprising all regions of the US. The data were accessed and used in full compliance with the relevant provisions of the Health Insurance Port- ability and Accountability Act. The study was conducted under the research provisions of Privacy Rule 45 CFR 164.514(e). Researchers’ access to claims data was limited to data stripped of identifiers to ensure confidentiality. An Institutional Review Board did not review the study since only this limited data set was accessed. This study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki and that are consistent with Good Pharmacoepidemiology Practices as well as legal and regulatory requirements. y p p q y Conventional treatments for both CD and UC include corticosteroids, aminoacylates, antibiotics, and immu- nomodulatory drugs [3]. Advanced therapies, such as tumor necrosis factor inhibitors (TNFi), interleu- kin (IL) 23 p40 inhibitors, integrin inhibitors or Janus kinase inhibitors (only for UC) are usually reserved for patients with moderate-to-severe IBD, who do not adequately respond to conventional therapies [3, 4]. Despite the availability of newer therapies, TNFi drugs remain the first-line treatment of moderate-to-severe IBD. These drugs have been shown to be well-tolerated and effective for inducing and maintaining the remis- sion of CD and UC [5, 6]. However, about 10–40% of patients with IBD are primary non-responders [7] and up to 50% of patients experience secondary loss of response after 12 months on therapy [8]. Inadequate response to advanced therapies indicates a need for newer therapies to improve the management in patients with CD or UC. Therefore, investigating treatment effectiveness in patients with CD and UC would help clinicians make more informed treatment decisions and contribute to value-based reimbursement models of care. g g y q Adult patients aged ≥ 18 years with CD (International Classification of Diseases, 10th Revision, Clinical Modi- fication [ICD-10-CM] diagnosis codes: K50.x) or UC (ICD-10-CM diagnosis codes: K51.x) who initiated an advanced therapy during the index period of July 1, 2016 through August 31, 2018 were included in the study. Methods g Crohn’s disease (CD) and ulcerative colitis (UC) are chronic progressive inflammatory diseases of the gas- trointestinal (GI) tract, collectively referred to as inflammatory bowel disease (IBD). While CD can affect the entire GI tract, UC mostly remains limited to the colonic mucosa [1]. IBD is estimated to affect more than 6.8 million individuals globally [1]. In the United States (US), 3.1 million adults are known to be affected (2015 estimates); age-standardized prevalence in the US was estimated to be 464.5 patients per 100,000 population [1, 2]. IBD imposes significant health and economic burden on communities worldwide, and sub- stantially impacts patients’ quality of life [1]. © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Gibble et al. BMC Gastroenterology (2023) 23:63 Gibble et al. BMC Gastroenterology (2023) 23:63 Page 2 of 10 Page 2 of 10 Page 2 of 10 Data source and populationh Index date was defined as the first observed occur- rence of a claim (medical or pharmacy) for any eligible advanced therapy during the index period. For patients who started more than one therapy, only the earliest one observed was used. Included patients were enrolled in commercial, Medicare Advantage, or Medicare Sup- plemental plus Part D insurance plans for ≥ 6 months before the index date (pre-index period) and ≥ 12 months after index date (follow-up period). Eligible patients were required to have ≥ 2 medical claims for CD or UC from a provider of any specialty at least seven days apart during the study period, of which ≥ 1 claim occurred during the pre-index period. In the recent past, various algorithms have been used to assist researchers and clinicians in identifying patients with CD or UC, treatment patterns, treatment safety and healthcare resource utilization from insurance claims database studies [9–13]. While effectiveness and safety outcomes associated with effective treatment in CD and UC have been studied using these types of data [14, 15], methods of evaluating the inadequate response to med- ications in patients with CD and UC from claims data- bases are limited. The present study investigated the frequency of, and factors associated with, inadequate response over 1 year after advanced therapy initiation in adult patients from the US. Inadequate responses were identified by using a claims-based algorithm originally developed by Curtis et al. [16], validated for rheumatoid arthritis and adapted for use in IBD. In this study, advanced therapies for CD included TNFi (adalimumab, certolizumab, infliximab) and non- TNFi (natalizumab, ustekinumab, vedolizumab). For UC, advanced therapies included TNFi (adalimumab, golimumab, infliximab), non-TNFi (vedolizumab; usteki- numab as a potential switcher but not index drug), and other therapies (tofacitinib). Conventional therapies included 5-aminosalicylic acid derivatives (mesalazine and sulfasalazine) and immunosuppressants (azathio- prine, methotrexate, mycophenolate, cyclosporine, tac- rolimus, 6-mercaptopurine). Gibble et al. BMC Gastroenterology (2023) 23:63 Gibble et al. BMC Gastroenterology (2023) 23:63 Page 3 of 10 Gibble et al. BMC Gastroenterology (2023) 23:63 Patients were excluded if they had claims for ≥ 1 advanced therapy during the 6-month pre-index period to identify new initiators of advanced therapy. Statistical analysis D i i i Descriptive statistics including mean, standard devia- tion (SD), median, and absolute/relative frequencies for continuous and categorical data, respectively, were reported. Patient characteristics were statistically com- pared between responders and inadequate responders using Chi-square tests or Fisher’s exact tests for dichot- omous variables, and t-tests or Wilcoxon tests for con- tinuous variables. Characteristics during pre-index or on index date associated with inadequate response to the index advanced therapy were identified by a multivari- able logistic regression model using a stepwise selection with entrance and exit p value cut-offs of 0.15. Index drug class, age, and gender were included in the model a-priori. Variables with prevalence rate < 1% in any group (responder or inadequate responder) were excluded from model selection. Goodness-of-fit statistics includ- ing C-statistic (higher score preferred) and Hosmer– Lemeshow test (p value > 0.05 preferred) were reported for each logistic regression. An alpha level of 0.05 was considered as statistically significant without any adjust- ments made for multiple comparisons. Sample selection and creation of analytic variables were performed using the Instant Health Data platform (Panalgo, Boston, MA). Statistical analyses were performed using SAS version 9.3 (SAS Institute Inc., Cary, NC, USA). Criteria of inadequate responseh The algorithm to identify inadequate response to index advanced therapy was derived from a claims-based algorithm originally developed by Curtis et al. [16] and validated for rheumatoid arthritis. The first claim for advanced therapy is set as index date. Some modifications were made to the algorithm for UC and CD. The absence of all criteria listed in Table 1 denoted adequate response (stable disease); presence of one or more of them denoted inadequate response. For example, low index therapy adherence reflects inadequate response. All criteria were calculated based on the 1-year follow-up period for each patient. Details of the algorithm used are presented in Additional file 1: Table S1. In brief, the parameters of the algorithm included low adherence (defined as propor- tion of days covered [PDC] < 80%), switched/added new advanced therapy/new biologic, added a new conven- tional therapy, increased dose/frequency of advanced therapy/biologics, addition or dose increase of oral glu- cocorticoids, used a new pain medication, or had surgery for UC or CD. Table 1 Inadequate response criteria evaluated over 1-year follow-up for both Crohn’s disease and ulcerative colitis Table 1 Inadequate response criteria evaluated over 1-year follow-up for both Crohn’s disease and ulcerative c a Opioids, nonsteroidal anti-inflammatory drugs, non-narcotic analgesics, neuromodulators (anti-depressants, anticonvulsants, muscle relaxants) Criteria based on the reference algorithm [16] Low adherence to index advanced therapy (defined as proportion of days covered [PDC] < 80%) Switch/add non-index advanced therapy Add new conventional therapy (methotrexate, sulfasalazine, and others) Dose or frequency increase of index advanced therapy (> 20% higher than the index dose) Addition or dose increase of oral glucocorticoid Additional criteria for this study Use of pain medication classa not observed at pre-index period Use of surgery (Current Procedural Terminology codes for surgery are presented in Additional file 1: Table S2) a Opioids, nonsteroidal anti-inflammatory drugs, non-narcotic analgesics, neuromodulators (anti-depressants, anticonvulsants, muscle relaxants) Criteria based on the reference algorithm [16] Low adherence to index advanced therapy (defined as proportion of days covered [PDC] < 80%) Switch/add non-index advanced therapy Add new conventional therapy (methotrexate, sulfasalazine, and others) Dose or frequency increase of index advanced therapy (> 20% higher than the index dose) Addition or dose increase of oral glucocorticoid Additional criteria for this study Use of pain medication classa not observed at pre-index period Use of surgery (Current Procedural Terminology codes for surgery are presented in Additional file 1: Table S2) Data source and populationh Patients who had evidence for other autoimmune diseases including psoriasis, lupus, ankylosing spondylitis, pso- riatic arthritis, or rheumatoid arthritis (defined as ≥ 2 claims on different dates for the same disease) were also excluded in order to avoid misclassification of the esti- mated response rate (e.g., related to non-adherence) due to multiple indications. as any claim from start of the patient’s continuous plan enrollment time up until the beginning of the 6-month pre-index period. Inadequate response to advanced ther- apies was recorded during 1-year follow-up and com- pared between patients receiving TNFi and non-TNFi. Patient characteristics Patient characteristics (age, sex, geographic region, Quan-Charlson Comorbidity Index [QCI] score, and spe- cific comorbidities), provider specialty, and prior/histori- cal treatments were assessed during pre-index period or on the index date. Prior “historic exposure” was defined Of the 140,435 patients who initiated any advanced therapy identified in the HIRD®, 2437 patients with CD and 1692 with UC were included in this analysis. Patient selection details are presented in Additional file 1: Fig. S1. Table 1 Inadequate response criteria evaluated over 1-year follow-up for both Crohn’s disease and ulcerative colitis Discussion In this retrospective claim-based study, an algorithm was developed to assess the extent of inadequate response to prescription treatments for the management of CD and UC. Adherence, increase in dose/frequency, and addi- tion of new medications were the key indicators of inad- equate response in this study. Results showed that most of the patients with CD or UC had initiated TNFi as first advanced therapy (~ 80%), of which ~ 50% started with adalimumab. However, a considerable proportion (> 60%) of patients did not adequately respond during the 1-year follow-up. The majority of both CD and UC inadequate responders were classified as such based upon low adher- ence to their index treatment (> 40%). The next most common reasons for inadequate response were switching to or adding new advanced therapy and increasing dose of existing therapies or glucocorticoids. Criteria based on the reference algorithm [16] a Opioids, nonsteroidal anti-inflammatory drugs, non-narcotic analgesics, neuromodulators (anti-depressants, anticonvulsants, muscle relaxants) Gibble et al. BMC Gastroenterology (2023) 23:63 Gibble et al. BMC Gastroenterology (2023) 23:63 Page 4 of 10 Mean (SD) age of patients with CD was 41 (14.7) years. Approximately 53% of patients with CD were female and the majority (60%) was covered under preferred pro- vider organization (PPO) health plans. During the pre- index period, mean QCI score was 0.40, and infection was the most common (~ 38%) among all comorbidities. In patients with CD who initiated a TNFi as their index therapy, 53% received adalimumab. Over the 1-year follow-up period, 62% of patients with CD had an inad- equate response to their index biologic therapies. Com- pared with responders, the proportion of female patients (49% vs. 56%) was higher among inadequate responders. QCI score and mental health issues were higher in inad- equate responders compared with responders (p < 0.05). Use of any conventional therapy was higher in respond- ers except methotrexate versus inadequate responders (50% vs 42%, respectively). Overall, there was no differ- ence in the use of TNFi and non-TNFi therapies (vedoli- zumab and ustekinumab) as the starting medication on index date. Adalimumab use was higher in responder group, and certolizumab and infliximab were higher among inadequate responder (Table 2). frequency increase of their index advanced therapy, 12% had an addition/dose increase of oral glucocorticoids, and 5% had surgery (Table 4). Among patients with UC who had inadequate response, the majority had low adherence (42%), followed by 24% who switched/added new advanced therapy, and 18% added new conventional therapies. Approxi- mately 13% had a dose/frequency increase of their index advanced therapies. Addition or increase in oral gluco- corticoids dose was observed among 14% of patients, and 2% required surgery (Table 5). Factors influencing inadequate response to advanced therapy In patients with CD, inadequate responders were more likely to be female (odds ratio [OR] confidence interval [CI] = 1.36 [1.15 to 1.61]), have historical use of TNFi (OR [CI] = 1.94 [1.32 to 2.85]), and be on a consumer- driven health plan (OR [CI] = 1.28 [1.05 to 1.57]) (Fig. 1). In patients with UC, inadequate responders were more likely to be prescribed a TNFi (OR [CI] = 2.76 [2.17 to 3.50]) and have a higher pre-index QCI Index (OR [CI] = 1.15 [1.03 to 1.29]) (Fig. 2). In patients with CD, inadequate responders were more likely to be female (odds ratio [OR] confidence interval [CI] = 1.36 [1.15 to 1.61]), have historical use of TNFi (OR [CI] = 1.94 [1.32 to 2.85]), and be on a consumer- driven health plan (OR [CI] = 1.28 [1.05 to 1.57]) (Fig. 1). In patients with UC, inadequate responders were more likely to be prescribed a TNFi (OR [CI] = 2.76 [2.17 to 3.50]) and have a higher pre-index QCI Index (OR [CI] = 1.15 [1.03 to 1.29]) (Fig. 2). Mean (SD) age of patients with UC was 42 (14.9) years. Approximately 48% of patients with UC were female and the majority (62%) was covered under PPO health plans. During the pre-index period, infection was the most common (~ 37%) among all comorbidities. Approxi- mately 78% of patients with UC initiated a TNFi as index therapy, of which 48% received adalimumab. Over the 1-year follow-up period, 63% of patients with UC had an inadequate response to their index advanced thera- pies. Use of any conventional therapies such as 5-amino- salicylic acid derivatives (mesalazine and sulfasalazine) and immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclosporine, tacrolimus, 6-mercap- topurine) during the pre-index period was lower among inadequate responders (80%) compared with respond- ers (85%). Similarly, the use of non-TNFi therapies (ved- olizumab) as the starting medication was lower among inadequate responders (16%) versus responders (33%, p < 0.0001). In contrast, use of TNFi therapies as the index medication was higher among inadequate respond- ers (84%) compared with adequate responders (67%) (Table 3). Patients with CD and UC were more likely to be responder if they had pre-index use of any conventional therapy (OR [CI] = 0.72 [0.60 to 0.85]) or azathioprine (OR [CI] = 0.72 [0.54 to 0.96]), respectively (Figs. 1, 2). Inadequate response algorithm details among patients with Crohn’s disease and ulcerative colitisi Results of this study are consistent with those observed in claims-based algorithm studies in rheumatoid arthritis [16] and in ankylosing spondylitis and psoriatic arthri- tis [17]. Approximately 70% of patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthri- tis responded inadequately to advanced biologic treat- ments, where the most common reason for inadequate response was low adherence to the index medication [16, Among all patients with CD who were identified as hav- ing inadequate response to their index advanced therapy based on observed claims utilization patterns, 41% of patients had low adherence, 14% switched/added new advanced therapy, and 13% added new conventional therapies. Approximately 12% of patients had a dose/ Gibble et al. BMC Gastroenterology (2023) 23:63 Page 5 of 10 17]. Inadequate response algorithm details among patients with Crohn’s disease and ulcerative colitisi Adherence to medication is a major problem in the clinical outcomes including an increase in disease activ- Table 2 Baseline demographic and clinical characteristics of Crohn’s disease patients at biologic index date p < 0.05 was considered as statistically significant CD Crohn’s disease, CDHP Consumer-driven health plan, HMO Health management organization, ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification, PPO Preferred provider organization, TNFi Tumour necrosis factor alpha inhibitor a Based on US census regions; remainder is Other/Unknown b Includes ICD-10-CM diagnosis codes F01 to F69 (mental disorders due to known physiological conditions, psychoactive substance use, schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders, mood [affective] disorders, anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders, behavioural syndromes associated with physiological, disturbances and physical factors, disorders of adult personality and behaviour) c ICD-10-CM diagnosis codes (anxiety: F41-F48; depression: F32-F33) d Conventional therapy includes 5-aminosalicylic acid derivatives (mesalazine and sulfasalazine) and immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclosporine, tacrolimus, 6-mercaptopurine) were considered conventional therapy Patients with CD N = 2437 Responders n = 921 Inadequate responders n = 1516 p value Age, years; mean (SD) 40.8 (14.7) 41.0 (14.5) 40.7 (14.8) 0.5088 Gender, n (%) Female 1299 (53.3%) 447 (48.5%) 852 (56.2%) 0.0002 Health plan type, n (%) HMO 441 (18.1%) 171 (18.6%) 270 (17.8%) 0.6380 PPO 1441 (59.1%) 561 (60.9%) 880 (58.1%) 0.1631 CDHP 555 (22.8%) 189 (20.5%) 366 (24.1%) 0.0387 Geographic regiona; n (%) Northeast 352 (14.4%) 132 (14.3%) 220 (14.5%) 0.9027 Midwest 626 (25.7%) 253 (27.5%) 373 (24.6%) 0.1164 South 969 (39.8%) 348 (37.8%) 621 (41.0%) 0.1201 West 369 (15.1%) 147 (16.0%) 222 (14.6%) 0.3791 Index year, n (%) 2016 621 (25.5%) 223 (24.2%) 398 (26.3%) 0.2624 2017 1130 (46.4%) 434 (47.1%) 696 (45.9%) 0.5606 2018 686 (28.2%) 264 (28.7%) 422 (27.8%) 0.6594 Quan-Charlson comorbidity index, mean (SD) 0.40 (0.90) 0.36 (0.85) 0.42 (0.92) 0.0488 Comorbid conditions, n (%) Anemia 585 (24.0%) 208 (22.6%) 377 (24.9%) 0.2006 Dyslipidemia 632 (25.9%) 224 (24.3%) 408 (26.9%) 0.1570 Hypertension 518 (21.3%) 195 (21.2%) 323 (21.3%) 0.9378 Infections 936 (38.4%) 332 (36.1%) 604 (39.8%) 0.0619 Mental health issuesb 740 (30.4%) 249 (27.0%) 491 (32.4%) 0.0053 Anxiety or depressionc 528 (21.7%) 172 (18.7%) 356 (23.5%) 0.0052 Other mental health issue (excluding anxiety/ depression) 358 (14.7%) 116 (12.6%) 242 (16.0%) 0.0228 Any conventional therapyd, n (%) 1085 (44.5%) 456 (49.5%) 629 (41.5%) 0.0001 Historical use of TNFi, n (%) 152 (6.2%) 37 (4.0%) 115 (7.6%) 0.0004 Index advance therapy, n (%) TNFi Adalimumab 1279 (52.5%) 500 (54.3%) 779 (51.4%) 0.1640 Certolizumab 61 (2.5%) 14 (1.5%) 47 (3.1%) 0.0155 Infliximab 625 (25.7%) 224 (24.3%) 401 (26.5%) 0.2430 Non-TNFi Ustekinumab 198 (8.1%) 65 (7.1%) 133 (8.8%) 0.1328 Vedolizumab 270 (11.1%) 117 (12.7%) 153 (10.1%) 0.0464 Table 2 Baseline demographic and clinical characteristics of Crohn’s disease patients at biologic index date Table 2 Baseline demographic and clinical characteristics of Crohn’s disease patients at biologic index date clinical outcomes including an increase in disease activ- ity, relapse, and loss of response to TNFi [18]. Inadequate response algorithm details among patients with Crohn’s disease and ulcerative colitisi We used clinical outcomes including an increase in disease activ- ity, relapse, and loss of response to TNFi [18]. We used 17]. Adherence to medication is a major problem in the management of IBD as well which can lead to adverse 17]. Adherence to medication is a major problem in the management of IBD as well which can lead to adverse Gibble et al. Inadequate response algorithm details among patients with Crohn’s disease and ulcerative colitisi BMC Gastroenterology (2023) 23:63 Page 6 of 10 low adherence as a proxy for inadequate response to adverse events, any of which may result in lack of effec- Table 3 Baseline demographic and clinical characteristics of ulcerative colitis patients at biologic index date p<0.05 was considered as statistically significant CDHP Consumer-driven health plan, HMO Health management organization, ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification, PPO Preferred provider organization, TNFi Tumour necrosis factor alpha inhibitor, UC Ulcerative colitis a Based on US census regions; remainder is other/unknown b Includes ICD-10-CM diagnosis codes F01 to F69 (mental disorders due to known physiological conditions, psychoactive substance use, schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders, mood [affective] disorders, anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders, behavioural syndromes associated with physiological, disturbances and physical factors, disorders of adult personality and behaviour) c ICD-10-CM diagnosis codes (anxiety: F41-F48; depression: F32-F33) d Conventional therapy includes 5-aminosalicylic acid derivatives (mesalazine and sulfasalazine) and immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclosporine, tacrolimus, 6-mercaptopurine) were considered conventional therapy Patients with UC N = 1692 Responders n = 619 Inadequate responders n = 1073 p value Age, years; mean (SD) 42.3 (14.9) 42.3 (14.6) 42.3 (15.1) 0.9804 Gender, n (%) Female 806 (47.6%) 300 (48.5%) 506 (47.2%) 0.6039 Health plan type, n (%) HMO 270 (16.0%) 92 (14.9%) 178 (16.6%) 0.3503 PPO 1046 (61.8%) 391 (63.2%) 655 (61.0%) 0.3867 CDHP 376 (22.2%) 136 (22.0%) 240 (22.4%) 0.8502 Geographic regiona, n (%) Northeast 276 (16.3%) 98 (15.8%) 178 (16.6%) 0.6848 Midwest 378 (22.3%) 139 (22.5%) 239 (22.3%) 0.9312 South 616 (36.4%) 231 (37.3%) 385 (35.9%) 0.5539 West 335 (19.8%) 123 (19.9%) 212 (19.8%) 0.9552 Index year, n (%) 2016 384 (22.7%) 136 (22.0%) 248 (23.1%) 0.5891 2017 764 (45.2%) 279 (45.1%) 485 (45.2%) 0.9595 2018 544 (32.2%) 204 (33.0%) 340 (31.7%) 0.5902 Quan-Charlson comorbidity index, mean (SD) 0.40 (1.01) 0.32 (0.84) 0.44 (1.11) 0.1145 Comorbid conditions, n (%) Anemia 417 (24.7%) 157 (25.4%) 260 (24.2%) 0.6026 Dyslipidemia 456 (27.0%) 165 (26.7%) 291 (27.1%) 0.8357 Hypertension 332 (19.6%) 112 (18.1%) 220 (20.5%) 0.2293 Infections 632 (37.4%) 225 (36.4%) 407 (37.9%) 0.5170 Mental health issuesb 408 (24.1%) 139 (22.5%) 269 (25.1%) 0.2260 Anxiety or depressionc 323 (19.1%) 108 (17.5%) 215 (20.0%) 0.1917 Other mental health issue (excluding anxiety/depres‑ sion) 157 (9.3%) 48 (7.8%) 109 (10.2%) 0.1007 Any conventional therapyd, n (%) 1386 (81.9%) 524 (84.7%) 862 (80.3%) 0.0263 Historical use of TNFi, n (%) 46 (2.7%) 14 (2.3%) 32 (3.0%) 0.3800 Index advanced therapy, n (%) TNFi Adalimumab 806 (47.6%) 260 (42.0%) 546 (50.9%) 0.0004 Golimumab 57 (3.4%) 19 (3.1%) 38 (3.5%) 0.6042 Infliximab 450 (26.6%) 134 (21.7%) 316 (29.5%) 0.0005 Non-TNFi Vedolizumab 376 (22.2%) 205 (33.1%) 171 (15.9%) < 0.0001 Table 3 Baseline demographic and clinical characteristics of ulcerative colitis patients at biologic index date mographic and clinical characteristics of ulcerative colitis patients at biologic index date HP Consumer-driven health plan, HMO Health management organization, ICD-10-CM International Classification of Diseases, 10th Revision O Preferred provider organization, TNFi Tumour necrosis factor alpha inhibitor, UC Ulcerative colitis CDHP Consumer-driven health plan, HMO Health management organization, ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification, PPO Preferred provider organization, TNFi Tumour necrosis factor alpha inhibitor, UC Ulcerative colitis a Based on US census regions; remainder is other/unknown b Includes ICD-10-CM diagnosis codes F01 to F69 (mental disorders due to known physiological conditions, psychoactive substance use, schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders, mood [affective] disorders, anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders, behavioural syndromes associated with physiological, disturbances and physical factors, disorders of adult personality and behaviour) c ICD-10-CM diagnosis codes (anxiety: F41-F48; depression: F32-F33) d Conventional therapy includes 5-aminosalicylic acid derivatives (mesalazine and sulfasalazine) and immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclosporine, tacrolimus, 6-mercaptopurine) were considered conventional therapy adverse events, any of which may result in lack of effec- tiveness. Inadequate response algorithm details among patients with Crohn’s disease and ulcerative colitisi Switching to advanced therapy, adding a new conventional therapy, increasing dose or frequency of low adherence as a proxy for inadequate response to treatment as patients are unlikely to persist taking a medication that is ineffective or causes intolerance or Gibble et al. BMC Gastroenterology (2023) 23:63 Page 7 of 10 Table 4 Inadequate responders during 12-month post-index period in patients with Crohn’s disease based on treatment class Data presented as n (%) CD Crohn’s disease, PDC Proportion of days covered, TNFi Tumor necrosis factor alpha inhibitors a Conventional therapy includes methotrexate or sulfasalazine and others Patients with CD N = 2437 TNFi n = 1965 Non-TNFi n = 472 Inadequate response 1516 (62.2%) 1227 (62.4%) 289 (61.2%) Criteria for inadequate response, n (%) Low adherence to index biologic (PDC < 80%) 1000 (41.0%) 813 (41.4%) 187 (39.6%) Switch/add new biologic (on-label) 332 (13.6%) 284 (14.5%) 48 (10.2%) Add new conventional therapya 309 (12.7%) 262 (13.3%) 47 (10.0%) Dose or frequency increase of index biologic 286 (11.7%) 253 (12.9%) 33 (7.0%) Addition or dose increase of oral glucocorticoid 281 (11.5%) 210 (10.7%) 71 (15.0%) Use of new pain medication 192 (7.9%) 159 (8.1%) 33 (7.0%) Surgery 126 (5.2%) 96 (4.9%) 30 (6.4%) Table 4 Inadequate responders during 12-month post-index period in patients with Crohn’s disease based on treatment class ders during 12-month post-index period in patients with Crohn’s disease based on treatment class Table 5 Inadequate responders during 12-month post index period in patients with ulcerative colitis based on treatment class Data presented as n (%). Inadequate response algorithm details among patients with Crohn’s disease and ulcerative colitisi Inadequate response results were not reported for tofacitinib users due to small sample size TNFi Tumor necrosis factor alpha inhibitors, PDC Proportion of days covered, UC Ulcerative colitis, NA Not available (small cell size masked to preserve patient privacy) a Conventional therapy includes methotrexate, sulfasalazine and others b Denotes n < 10, which was blinded for privacy Patients with UC N = 1692 TNFi n = 1313 Non-TNFi n = 376 Inadequate response, n (%) 1073 (63.4%) 900 (68.6%) 171 (45.5%) Criteria for inadequate response, n (%) Low adherence to index biologic (PDC < 80%) 710 (42.0%) 608 (46.3%) 100 (26.6%) Switch/add new biologic (on-label) 405 (23.9%) 355 (27.0%) 49 (13.0%) Add new conventional therapya 300 (17.7%) 253 (19.3%) 47 (12.5%) Dose or frequency increase of index biologic 212 (12.5%) NAb NAb Addition or dose increase of oral glucocorticoid 233 (13.8%) 190 (14.5%) 42 (11.2%) Use of new pain medication 134 (7.9%) 109 (8.3%) 25 (6.7%) Surgery 34 (2.0%) 24 (1.8%) 10 (2.7%) ponders during 12-month post index period in patients with ulcerative colitis based on treatment class Table 5 Inadequate responders during 12-month post index period in patients with ulcerative colitis base are required to identify factors influencing inadequate response. In our study, factors influencing inadequate response in patients with CD included being female, his- torical use of TNFi, and having a consumer-driven health plan. While in patients with UC, these factors included baseline use of TNFi and higher QCI score. Consistent with the observations from some clinical trials, such as the one comparing infliximab plus azathioprine com- bination therapy [20], patients taking any conventional therapy (CD) or azathioprine (UC) in the pre-index period in our study were more likely to be responders. A similar finding was also reported in a retrospective cohort study based on German claims data: Patients with UC who received conventional therapies at index showed less likelihood of experiencing inadequate response ver- sus patients who were not on conventional therapy (Haz- ard ratio, 0.73; 95% CI 0.59–0.90); initial concomitant use medication including oral glucocorticoid, use of pain medication, are other prominent indicators to show that current therapies are not sufficient. In a proportion of patients, need for surgery may also indicate the insuffi- ciency of current therapies. Inadequate response to TNFi typically leads to discontinuation of treatment. Inadequate response algorithm details among patients with Crohn’s disease and ulcerative colitisi Historical use of TNFi: use of TNFi at any time prior to the 6-month pre-index period. Conventional therapy includes azathioprine, balsalazide, cyclosporine, hydroxychloroquine, leflunomide, mercaptopurine, mesalamine, methotrexate, minocycline, mycophenolate, olsalazine, sulfasalazine. TNFi Tumor necrosis factor alpha inhibitors Fig 2 Association between baseline patient characteristics and inadequate response to advance therapies for ulcerative colitis The 3 patients Fig. 2 Association between baseline patient characteristics and inadequate response to advance therapies for ulcerative colitis. The 3 patients receiving tofacitinib were excluded from this model. Conventional therapy includes azathioprine, balsalazide, cyclosporine, hydroxychloroquine, leflunomide, mercaptopurine, mesalamine, methotrexate, minocycline, mycophenolate, olsalazine, sulfasalazine. TNFi Tumor necrosis factor alpha inhibitors Inadequate response algorithm details among patients with Crohn’s disease and ulcerative colitisi Other studies using real-world data showed that approximately half of patients with IBD receiving infliximab or adali- mumab discontinued treatment during 1-year follow-up, and a substantial percentage were switched to a nonbio- logic [10, 19]. Moreover, in patients initiating a new bio- logic therapy for IBD, the likelihood of providers tapering therapy within the first year due to adequate response, such that it would result in low measured adherence, is less. Inadequate response to advanced therapy cannot be explained by biology alone; algorithm-based studies Gibble et al. BMC Gastroenterology (2023) 23:63 Page 8 of 10 Fig. 1 Association between baseline patient characteristics and inadequate response to advance therapies for Crohn’s disease. aExcluding anxiety and depression. Historical use of TNFi: use of TNFi at any time prior to the 6-month pre-index period. Conventional therapy includes azathioprine, balsalazide, cyclosporine, hydroxychloroquine, leflunomide, mercaptopurine, mesalamine, methotrexate, minocycline, mycophenolate, olsalazine, sulfasalazine. TNFi Tumor necrosis factor alpha inhibitors Fig. 2 Association between baseline patient characteristics and inadequate response to advance therapies for ulcerative colitis. The 3 patients receiving tofacitinib were excluded from this model. Conventional therapy includes azathioprine, balsalazide, cyclosporine, hydroxychloroquine, leflunomide, mercaptopurine, mesalamine, methotrexate, minocycline, mycophenolate, olsalazine, sulfasalazine. TNFi Tumor necrosis factor alpha inhibitors Fig. 1 Association between baseline patient characteristics and inadequate response to advance therapies for Crohn’s disease. aExcluding anxiety and depression. Historical use of TNFi: use of TNFi at any time prior to the 6-month pre-index period. Conventional therapy includes azathioprine, balsalazide, cyclosporine, hydroxychloroquine, leflunomide, mercaptopurine, mesalamine, methotrexate, minocycline, mycophenolate, olsalazine, sulfasalazine. TNFi Tumor necrosis factor alpha inhibitors Fig. 1 Association between baseline patient characteristics and inadequate response to advance therapies for Crohn’s disease. aExcluding anxiety and depression. Historical use of TNFi: use of TNFi at any time prior to the 6-month pre-index period. Conventional therapy includes azathioprine, balsalazide, cyclosporine, hydroxychloroquine, leflunomide, mercaptopurine, mesalamine, methotrexate, minocycline, mycophenolate, olsalazine, sulfasalazine. TNFi Tumor necrosis factor alpha inhibitors Fig. 1 Association between baseline patient characteristics and inadequate response to advance therapies for Crohn’s disease. aExcluding anxiety and depression. Historical use of TNFi: use of TNFi at any time prior to the 6-month pre-index period. Conventional therapy includes azathioprine, balsalazide, cyclosporine, hydroxychloroquine, leflunomide, mercaptopurine, mesalamine, methotrexate, minocycline, mycophenolate, olsalazine, sulfasalazine. TNFi Tumor necrosis factor alpha inhibitors Fig. 1 Association between baseline patient characteristics and inadequate response to advance therapies for Crohn’s disease. aExcluding anxiety and depression. Fig. 2 Association between baseline patient characteristics and inadequate response to advance therapies for ulcerative colitis. The 3 patients receiving tofacitinib were excluded from this model. Conventional therapy includes azathioprine, balsalazide, cyclosporine, hydroxychloroquine, leflunomide, mercaptopurine, mesalamine, methotrexate, minocycline, mycophenolate, olsalazine, sulfasalazine. TNFi Tumor necrosis factor alpha inhibitors which can sustain remission. In addition, this study showed that algorithms are a promising proxy to investi- gate inadequate response to advanced therapies utilizing claims databases, which could be useful for value-based contracts and other innovative reimbursement schemes relevant for health plans and other stakeholders with access to claims data. of conventional therapies was associated with fewer dose augmentations [21].i To our knowledge, this is the first study to use a claims- based algorithm to serve as a proxy for the clinical effec- tiveness of treatments for CD and UC in the United States. Results of the study suggest that there is a large unmet need in the management of CD and UC for more effective therapies and disease management strategies Gibble et al. BMC Gastroenterology (2023) 23:63 Gibble et al. BMC Gastroenterology (2023) 23:63 Page 9 of 10 Gibble et al. BMC Gastroenterology (2023) 23:63 Our study also has some limitations associated with claims-database analysis. Patients identified in this study may not be representative of the US population who receive health care through government organizations or who lack health insurance. The relationships described between baseline patient characteristics and responder status represent associations rather than causal chains; several important confounders, such as disease activ- ity metrics (e.g., CDAI) or provider behaviors, are una- vailable or incomplete in claims data. For patients who used multiple advanced therapies over time, we focused on the first of them to assess adequate response and did not examine subsequent treatments’ response rate. Prescription claims include medications dispensed by pharmacies, and do not necessarily reflect the actual con- sumption by patients. The possibility of coding errors associated with incorrect diagnoses cannot be completely avoided. Furthermore, the modified algorithm used in this analysis has yet to be validated against clinical UC or CD disease activity measures or biomarkers. The thera- peutic landscape of CD and UC is constantly changing with the introduction of novel treatments whose indica- tions also change over time; therefore, the use of thera- pies as assumed in this study may not fully reflect actual indications at each time point of the study period. Funding g This study was funded by Eli Lilly and Company. This study was funded by Eli Lilly and Company. Nev- ertheless, this study provides important insights into the ways in which biologic agents are currently used in clini- cal practice. Future studies are warranted for the valida- tion, augmentation, and application of these algorithms in CD and UC. Availability of data and materials The HealthCore database is a proprietary health claims database and is not accessible to the public. HealthCore researchers were provided access pursu‑ ant to Health Insurance Portability and Accountability Act. Further information concerning access to HealthCore’s database may be provided upon request; please contact Michael Grabner at mgrabner@healthcore.com. Acknowledgements Priyanka Bannikoppa (current) and Santanu Bhadra (former), employees of Eli Lilly Services India Pvt. Ltd at the time of manuscript preparation provided writing support. Moksha Shah, an employee of Eli Lilly Services India Pvt. Ltd, provided support in addressing peer reviewer comments from the journal. Ethics approval and consent to participate Researchers’ access to claims data was limited to data stripped of identifiers to ensure confidentiality. HealthCore maintains data use agreements with the covered entities in compliance with the Health Insurance Portability and Accountability Act. An Institutional Review Board did not review the study since only this limited data set was accessed. The study was conducted under the research provisions of Privacy Rule 45 CFR 164.514(e). The study used data that was previously collected and did not impose any form of interven‑ tion; the data was deidentified to protect subject privacy. Therefore, a formal consent was not required. This study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki and that are consistent with Good Pharmacoepidemiology Practices as well as legal and regulatory requirements. The HealthCore database is a proprietary health claims database and is not accessible to the public. HealthCore researchers were provided access pursuant to Health Insurance Portability and Account‑ ability Act. Further information concerning access to HealthCore’s database may be provided upon request. Author contributions THG, AN, MG, KI, MS, CT, and JC made substantial contributions to concep‑ tion and design, or acquisition of data, or analysis and interpretation of data. All authors were involved in drafting the manuscript or revising it critically for important intellectual content and gave final approval of the version to be published. All authors read and approved the final manuscript. Author details 1 Eli Lilly and Company, Indianapolis, IN, USA. 2 HealthCore, Inc., Wilmington, DE, USA. 3 Anthem, Inc., Indianapolis, IN, USA. 4 University of Alabama at Birming‑ ham, Birmingham, AL, USA. 1 Eli Lilly and Company, Indianapolis, IN, USA. 2 HealthCore, Inc., Wilmington, DE, USA. 3 Anthem, Inc., Indianapolis, IN, USA. 4 University of Alabama at Birming‑ ham, Birmingham, AL, USA. Consent for publication Not applicable. This study showed that 60% or more of patients with CD or UC had an inadequate response to their first advanced therapies within 1 year after initiation. The inadequate responses were mostly driven by low adherence and switching to or addition of a new treatment. Health plan claims data appear useful to classify inadequate respond- ers in CD or UC and additional research should be done to further validate this claims-based algorithm in a clini- cal setting. Competing interests JRC reported financial relationships with AbbVie, Amgen, BMS, Corrona, Eli Lilly and Company, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB. KI is an Anthem Inc. employee and shareholder. MG and CCT are employees of HealthCore, Inc., which was under contract with Eli Lilly and Company for the conduct of the study on which this manuscript is based. MG is a shareholder of Anthem Inc. THG, AN, and MS are employees and shareholders of Eli Lilly and Company, Indiana, Indianapolis, US. Supplementary Information The online version contains supplem org/10.1186/s12876-023-02675-w. The online version contains supplementary material available at https://doi. org/10.1186/s12876-023-02675-w. Received: 3 March 2022 Accepted: 13 February 2023 Received: 3 March 2022 Accepted: 13 February 2023 Additional file 1. Table S1. Details of the algorithm used to identify inadequate response for Crohn’s disease and ulcerative colitis. Table S2. Current procedural terminology codes for Crohn’s disease and ulcerative colitis surgery. Table S3. Oral corticosteroid conversions table [22–24]. Figure S1. Patient identification. Publisher’s Note S N Springer Nature remains neutral with regard to jurisdictional claims in pub‑ lished maps and institutional affiliations. 4. Fact Sheet. News from the IBD Help Center. Janus kinase inhibitors (JAK inhibitors). Crohn’s and Colitis Foundation 2018 [Available from: https://www.crohnscolitisfoundation.org/sites/default/files/legacy/ assets/pdfs/jak-inhibitors.pdf. 4. Fact Sheet. News from the IBD Help Center. Janus kinase inhibitors (JAK inhibitors). 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Ben-Horin S, Kopylov U, Chowers Y. Optimizing anti-TNF treatments in inflammatory bowel disease. Autoimmun Rev. 2014;13(1):24–30. l 8. Papamichael K, Cheifetz AS. Therapeutic drug monitoring in inflamma‑ tory bowel disease: For every patient and every drug? Curr Opin Gastro‑ enterol. 2019;35(4):302–10. 9. Perera S, Yang S, Stott-Miller M, Brady J. Analysis of healthcare resource utilization and costs after the initiation of biologic treatment in patients with ulcerative colitis and Crohn’s disease. J Health Econ Outcomes Res. 2018;6(1):96–112. 9. Perera S, Yang S, Stott-Miller M, Brady J. Analysis of healthcare resource utilization and costs after the initiation of biologic treatment in patients with ulcerative colitis and Crohn’s disease. J Health Econ Outcomes Res. 2018;6(1):96–112. 10. Brady JE, Stott-Miller M, Mu G, Perera S. Treatment patterns and sequencing in patients with inflammatory bowel disease. Clin Ther. 2018;40(9):1509-21.e5.f 11. Armuzzi A, DiBonaventura M, Tarallo M, Lucas J, Bluff D, Hoskin B, et al. Treatment patterns among patients with moderate-to-severe ulcerative colitis in the United States and Europe. PLoS ONE. 2020;15(1):e0227914. 12. Chen G, Lissoos T, Dieyi C, Null KD. Development and validation of an inflammatory bowel disease severity index using US administra‑ tive claims data: a retrospective cohort study. Inflamm Bowel Dis. 2021;27(8):1177–83. 13. Ye Y, Manne S, Bennett D. Identifying patients with inflammatory bowel diseases in an administrative health claims database: Do algorithms generate similar findings? References 1. Alatab S, Sepanlou SG, Ikuta K, Vahedi H, Bisignano C, Safiri S, Sadeghi A, Nixon MR, Abdoli A, Abolhassani H, Alipour V. The global, regional, and national burden of inflammatory bowel disease in 195 countries Page 10 of 10 Page 10 of 10 Gibble et al. BMC Gastroenterology (2023) 23:63 Gibble et al. BMC Gastroenterology (2023) 23:63 23. Markham A, Bryson HM. Deflazacort. 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Identify‑ ing inadequate response among patients with ankylosing spondylitis and psoriatic arthritis prescribed advanced therapy in a real-world, commercially insured adult population in the USA. Clin Rheumatol. 2022;41(9):2863–74. 18. Chan W, Chen A, Tiao D, Selinger C, Leong R. Medication adherence in inflammatory bowel disease. Intest Res. 2017;15(4):434–45. • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. 23. Markham A, Bryson HM. Deflazacort. A review of its pharmacological properties and therapeutic efficacy. Drugs. 1995;50(2):317–33. 24. Meikle AW, Tyler FH. Potency and duration of action of glucocorticoids. Effects of hydrocortisone, prednisone and dexamethasone on human pituitary-adrenal function. Am J Med. 1977;63(2):200–7. • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? 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https://openalex.org/W4285267113	https://aclanthology.org/2022.ltedi-1.13.pdf	English	null	IIITSurat@LT-EDI-ACL2022: Hope Speech Detection using Machine Learning	null	2,022	cc-by	4,559	1https://www.statista.com/statistics/1241323/ Abstract like Hindi, English, Japanese, Gujarati, Marathi, Tamil, and others are used to express success, life events like job promotion, being selected as the best team member, etc (Sampath et al., 2022; Ravikiran et al., 2022; Chakravarthi et al., 2022b; Bharathi et al., 2022; Priyadharshini et al., 2022). Tamil is one of the world’s longest-surviving classical lan- guages. Tamil is a member of the southern branch of the Dravidian languages, a group of about 26 languages indigenous to the Indian subcontinent. It is also classed as a member of the Tamil language family, which contains the languages of around 35 ethno-linguistic groups, including the Irula and Yerukula languages (Sakuntharaj and Mahesan, 2021, 2017, 2016; Thavareesan and Mahesan, 2019, 2020a,b, 2021). The earliest Old Tamil documents are small inscriptions in Adichanallur dating from 905 BC to 696 BC. Tamil has the oldest ancient non-Sanskritic Indian literature of any Indian lan- guage (Anita and Subalalitha, 2019b,a; Subalalitha and Poovammal, 2018; Subalalitha, 2019; Srini- vasan and Subalalitha, 2019; Narasimhan et al., 2018). This paper addresses the issue of Hope Speech detection using machine learning techniques. Designing a robust model that helps in pre- dicting the target class with higher accuracy is a challenging task in machine learning, es- pecially when the distribution of the class la- bels is highly imbalanced. This study uses and compares the experimental outcomes of the dif- ferent oversampling techniques. Many mod- els are implemented to classify the comments into Hope and Non-Hope speech, and it found that machine learning algorithms perform bet- ter than deep learning models. The English language dataset used in this research was de- veloped by collecting YouTube comments and is part of the task “ACL-2022:Hope Speech De- tection for Equality, Diversity, and Inclusion". The proposed model achieved a weighted F1- score of 0.55 on the test dataset and secured the first rank among the participated teams. Proceedings of the Second Workshop on Language Technology for Equality, Diversity and Inclusion, pages 120 - 126 May 27, 2022 ©2022 Association for Computational Linguistics IIITSurat@LT-EDI-ACL2022: Hope Speech Detection using Machine Learning Pradeep Kumar Roy1, Snehaan Bhawal2, Abhinav Kumar3, and Bharathi Raja Chakravarthi4 1Indian Institute of Information Technology Surat, Gujarat, India 2Kalinga Institute of Industrial Technology, Bhubaneswar, Odisha, India 3Siksha ‘O’ Anusandhan, Deemed to be University, Bhubanewar, Odisha, India 4Insight SFI Research Centre for Data Analytics, National University of Ireland Galway, Ireland (pkroynitp,mailtosnehaan,abhinavanand05)@gmail.com, bharathi.raja@insight-centre.org 1 Introduction Social networking platforms such as Instagram, Facebook, LinkedIn, and YouTube have become the default place for worldwide users to spend time (Chakravarthi et al., 2021, 2020; Priyadharshini et al., 2020). These social platforms are not only used to share success but also used to ask for help during emergency (Roy et al., 2021). As per the report1, on average, six hours in a week, every Indian uses the social networking platform. Among them, teenagers and some professionals are more active to share their life events. Everyone needs feelings like happiness, sadness, anger, and the motivation for failure in their hard time (Ghanghor et al., 2021b; Yasaswini et al., 2021). Among all, the comments having the con- text of "well-being" are termed as “hope speech". More specifically, Hope speech reflects the be- lief that one can discover and become motivated to use pathways to achieve one’s desired goals (Chang, 1998; Youssef and Luthans, 2007; Cover, 2013; Snyder et al., 1991). The other category of comments can be abuse, demotivate, neutral, race, or sexually oriented and similar ones which are termed as “Non-Hope speech". Such comments do not live long in the physical world where people speak something today that might not be remem- bered after a few days or months, even the reach- able to the limited region. However, if the same is communicated via a social platform, it will re- People have two images: one for the real world where they live and another for the virtual world, like the images on social platforms where people are connected to their close friends and commu- nicate with strangers in the virtual environment (Saumya and Mishra, 2021). Language is a pri- mary requirement for communication. Languages 120 main active and affect the victim for a long-time (Saumya and Mishra, 2021). concluded in Section 7 with limitation and future scope. The social platform is polluted with hateful con- tent (Roy et al., 2020) and is a challenging task to filter. Moreover, finding the hopeful message becomes another challenging task because of their low appearance. People who are in trouble are ex- pecting a solution for their issues. For example, if a person becomes a victim of cybercrime like bor- rowing money from a bank account. Then they will reach out to the concerned authority hoping that their money will be rolled back into the account. 2 Related works Even though the Hope speech is termed as posi- tive vibes, very less attention is received from the research community to address it. The reason be- hind less research in the domain may include the unavailability of the labeled dataset. In the last few years, this problem has received some fruitful atten- tion while the organizer of the LT-EDI-EACL2021 shared a labeled dataset. Some of the submitted frameworks in the LT-EDI-EACL2021 workshop is to address this Hope Speech detection issue. Many research works have reported to filter the Hateful, and Offensive comments from the social post in recent years (Roy et al., 2022; Ghanghor et al., 2021a). However, identifying the Hopeful com- ments received less attention (Chakravarthi, 2020; Hande et al., 2021; Saumya and Mishra, 2021). These social platforms receive huge content from worldwide users from different genres like entertainment, promotion, publicity, achievement, political news, etc. Every genre has both positive and negative comments. All of the mentioned sce- narios are common in human life, where directly or indirectly, people always expect some positive news with hope (Chakravarthi, 2020). Finding hope speech content from social platforms manually is challenging and not a feasible option. Hence there is a need of automated tools which can be helpful for hope-oriented comment detection (Chakravarthi and Muralidaran, 2021; Chakravarthi et al., 2022a). To address the said problem, this research uses both traditional machine learning (ML) models and deep learning (DL) based models to find the best- suited technique to detect such hope speech. The dataset used in this research was taken from LT- EDI-ACL2022 workshop. The major contributions are as follows: (Puranik et al., 2021) used transformer-based models like BERT, ALBERT, DistilBERT, and similar ones to classify the comments into three categories: hope, non-hope, and other categories. Dataset of three languages were used in their re- search, English, Malayalam, and Tamil. For the English language, the ULMFit model achieved the best weighted F1-score value of 0.9356. (Upad- hyay et al., 2021) also used the transformer-based model to classify the comments into hope, non- hope, and other categories. Deep learning models - Convolutional Neural Network (CNN), Long Short Term Memory (LSMT), and Bidirectional LSTM approaches were used by (Saumya and Mishra, 2021) on all three datasets. Their best-performing CNN-LSTM model achieved an F1-score of 0.91 on English. • We proposed an automated machine learning- based model to predict hope speech. 1 Introduction If people face issues with the company rules and regulations, they ask for opinions via social posts hoping that someone will suggest the right solution to get rid of it. 5 Experimental setup This section discusses a detailed experimental pro- cedure used for the model development. The tradi- tional ML techniques, namely, Logistic Regression (LR), Random Forest (RF), Naive Bayes (NB), and Extreme Gradient Boosting (XGB), are selected for the experiment. The performance of these models is evaluated with Precision, Recall, and F1 score (Roy et al., 2022). Firstly, a total of 5000 features were extracted from the processed data using TF- IDF vectorization with 1-5 n-grams, which was further scaled using the MIN-MAX scalar. The oversampling techniques mentioned above were used to balance the dataset before passing it to the model. Before oversampling, the total train data size was 22,740. After oversampling, the total num- ber of samples increased to 41,556, with both the 4.1 Oversampling The dataset used for this research is highly imbal- anced. The class-wise distribution of the dataset is shown in Table 1. The imbalanced dataset could lead to a biased model, and thus it is needed to balance the distribution of the class labels by oversampling the minority class. To make the dataset of both the classes comparable in the training sample, three oversampling techniques are used; namely, Random Oversampling (ROS) (Menardi and Torelli, 2014), Synthetic Minority Over-sampling Technique (SMOTE) (Chawla et al., 2002) and Adaptive Synthetic (ADASYN) (He et al., 2008). After oversampling, in both classes, the number of samples is 20778. Overall work- ing steps of the proposed framework are shown in Figure 1. Figure 1: Working steps of the proposed model dataset had a total of 20778 numbers of Non-Hope Speech sample whereas in Hope speech 1962 sam- ple. 2569 Non-Hope Speech and 272 Hope Speech samples were present in the validation dataset. Fi- nally, the test dataset was released without any label on which the final rank of the participated teams was decided (Chakravarthi and Muralidaran, 2021; Chakravarthi, 2020; Hande et al., 2021). 2https://pypi.org/project/demoji/ 3 Task and Dataset Overview • Performed data balancing techniques to bal- ance the samples in each category. In LT-EDI-ACL2022, Task 1 was Hope Speech De- tection for Equality, Diversity, and Inclusion, where the event organizer provided an annotated dataset for three languages Tamil, Malayalam, and English. The dataset was labeled into two categories: ’Hope Speech and Non-Hope Speech’. The shared task’s objective was to build an automated model that predicts the comments are Hope Speech or Non- Hope Speech. Initially, the training dataset was released. Later, the validation and test dataset was released by the organizer. This research uses only English comments for the experiment. The training • The machine learning model outperformed deep learning models on a balanced dataset. The rest of the paper is organized as follows: Section 2 discusses the relevant research works. Section 3 describes the overview of the task in detail. Section 4 explains the data preparation for the experiment followed by experimental setup in Section 5. Section 6 discusses the experimental outcomes of different models. Finally, the work is 121 Dataset Preprocessing Module Training Validation Test Feature Extraction Module Oversampling Model Training Trained Model Predicitons Figure 1: Working steps of the proposed model Table 1: Label Distribution of the dataset Data Set Hope Non-Hope Total Train 1,962 20,778 22,740 Validation 272 2,569 2,841 Table 2: Average accuracy obtained using ML class fiers on different data balancing approaches (No ove sampling (NO), Random Oversampling (ROS), SMOT and ADASYN) Data Set Hope Non-Hope Total Train 1,962 20,778 22,740 Validation 272 2,569 2,841 Data Set Hope Non-Hope Total Train 1,962 20,778 22,740 Validation 272 2,569 2,841 Table 2: Average accuracy obtained using ML classi- fiers on different data balancing approaches (No over- sampling (NO), Random Oversampling (ROS), SMOTE and ADASYN) Model NO ROS SMOTE ADASYN LR 0.926 0.920 0.921 0.893 RF 0.925 0.992 0.971 0.962 NB 0.915 0.848 0.866 0.836 XGB 0.924 0.910 0.939 0.928 4 Data Preprocessing As the dataset was compiled with comments col- lected from YouTube, it consisted of many irregu- larities like the use of emoticons/emojis, short text, customized fonts, and tagged users. All these need to be cleaned for the data to be passed onto the model for training. During the preprocessing of the data, the emojis were replaced with their mapped meaning by using Demoji library2. Tagged users and punctuation were removed and also removed all custom fonts and numerals, single-character words, and multiple spaces that were introduced by the previous steps. 122 Table 3: Detailed report of RF with different Oversam- pling techniques on validation data. Model Class Precision Recall F1-score Hope 0.83 0.19 0.32 NO + RF Non-Hope 0.92 1.00 0.96 Weighted Avg 0.91 0.92 0.90 Hope 0.78 0.26 0.39 ROS + RF Non-Hope 0.93 0.99 0.96 Weighted Avg 0.91 0.92 0.90 Hope 0.64 0.41 0.50 SMOTE + RF Non-Hope 0.94 0.98 0.96 Weighted Avg 0.91 0.92 0.92 Figure 2: Comparison of F1-scores of experimented models on balanced data Table 3: Detailed report of RF with different Oversam- pling techniques on validation data. classes divided equally. classes divided equally. The balanced dataset was then passed to the ML classifiers with the help of 10-fold cross-validation over the training dataset. We implemented all the combinations of the selected classifiers and over- sampling techniques. The average accuracy ob- tained using a 10-fold cross-validated approach is shown in Table 2. Based on these values, the SMOTE oversampling approach was selected for further experiments. The comparative outcomes of the ML classifiers on the imbalanced and balanced dataset are discussed in section 6. 4 Data Preprocessing p g q Model Class Precision Recall F1-score Hope 0.83 0.19 0.32 NO + RF Non-Hope 0.92 1.00 0.96 Weighted Avg 0.91 0.92 0.90 Hope 0.78 0.26 0.39 ROS + RF Non-Hope 0.93 0.99 0.96 Weighted Avg 0.91 0.92 0.90 Hope 0.64 0.41 0.50 SMOTE + RF Non-Hope 0.94 0.98 0.96 Weighted Avg 0.91 0.92 0.92 Figure 2: Comparison of F1-scores of experimented models on balanced data Model Class Precision Recall F1-score Hope 0.83 0.19 0.32 NO + RF Non-Hope 0.92 1.00 0.96 Weighted Avg 0.91 0.92 0.90 Hope 0.78 0.26 0.39 ROS + RF Non-Hope 0.93 0.99 0.96 Weighted Avg 0.91 0.92 0.90 Hope 0.64 0.41 0.50 SMOTE + RF Non-Hope 0.94 0.98 0.96 Weighted Avg 0.91 0.92 0.92 Figure 2: Comparison of F1-scores of experimented models on balanced data Further, deep learning techniques like DNN, DNN with embeddings (DNN+Emb), CNN, LSTM, and BiLSTM are implemented to address this issue. The DNN model is comprised of a sim- ple four-layer neural network with 256, 128, and 64 neurons at the hidden layer with a single output neuron. In DNN + Emb, we have implemented an additional embedding layer of 120 dimensions. A single convolution layer is used in CNN, followed by a MaxPooling layer and hidden layers of 128 and 64 neurons. Similarly, the LSTM and BiLSTM networks are implemented with 256 memory units with the same amounts of hidden layers. The out- put layer consisted of a single neuron with sigmoid activation for each model. After further hyperpa- rameter tuning, we concluded by using the Adam optimizer with a learning rate of 0.0001 and binary cross-entropy as the optimization function. The model was trained with the SMOTE oversampled train data and was validated with the provided vali- dation data set, the results of which are provided in Table 4. Figure 2: Comparison of F1-scores of experimented models on balanced data tent in all cases. This shows that model selection can vary with the oversampling technique chosen. The SMOTE technique is always outperforming the ADASYN while RF with ROS achieves 99% accuracy, which is probably due to the overfitting of the training samples. The validation data is used to validate the findings. Table 3 shows the results of the RF model with the different oversampling techniques. We can see that using Random Over- sampling results in over-fitting. Thus, we chose SMOTE and Random Forest as the final model. 4 Data Preprocessing The weighted F1-score of the RF model with a bal- anced dataset was compared with the deep learning techniques. The comparative outcomes are shown in Table 4. The RF model is performing better than the deep learning models. 6 Results In this section, the experimental outcomes of the different models will be discussed. We are com- paring the performances of the ML models based on the 10-fold cross-validated outcomes reported in Table 2. The table shows the average accuracy achieved by the individual models with the respec- tive oversampling techniques used on the train data. The experimental outcomes when no oversampling (‘NO’), i.e. the initial imbalanced dataset, was implemented in shown in Table 2. We can see that oversampling is not helpful for the NB and LR, where the performances are degraded in some cases. On the other hand, the RF model achieved the best performance with oversampled data. The performance of the XGB model remained consis- Table 4: Comparison with the deep learning models Table 4: Comparison with the deep learning m Model F1-score RF 0.92 DNN 0.91 DNN + Emb 0.83 CNN 0.87 LSTM 0.86 BiLSTM 0.87 7 Conclusion In Proceedings of the Sec- ond Workshop on Language Technology for Equality, Diversity and Inclusion. Association for Computa- tional Linguistics. Bharathi Raja Chakravarthi, Vigneshwaran Muralidaran, Ruba Priyadharshini, and John Philip McCrae. 2020. Corpus creation for sentiment analysis in code-mixed Tamil-English text. In Proceedings of the 1st Joint Workshop on Spoken Language Technologies for Under-resourced languages (SLTU) and Collabora- tion and Computing for Under-Resourced Languages (CCURL), pages 202–210, Marseille, France. Euro- pean Language Resources association. Bharathi Raja Chakravarthi, Ruba Priyadharshini, Then- mozhi Durairaj, John Phillip McCrae, Paul Buitaleer, Prasanna Kumar Kumaresan, and Rahul Ponnusamy. 2022b. Findings of the shared task on Homophobia Transphobia Detection in Social Media Comments. In Proceedings of the Second Workshop on Language Technology for Equality, Diversity and Inclusion. As- sociation for Computational Linguistics. 7 Conclusion Social platforms have become a medium to share opinions, achievements, successes, and failures. 123 Social networking users comment on all categories of posts. The comments having positive vibes is really help in boosting confidence and sometimes motivate to be strong in the odd situation. This paper suggested an ML model to predict the Hope Speech comments on the social platform. The sam- ples available for training were highly imbalanced; hence, the SMOTE oversampling technique was used to balance the dataset. Many models have experimented on both imbalanced and balanced datasets, and it was found that the Random Forest classifier performed best when the training sample was balanced. The proposed balanced model se- cured top rank among the participated teams for the English language with a weighted F1-score of 0.550 on the test dataset. The model can be further tuned with preprocessing steps as well as by in- creasing the size of the feature set to achieve better performance. In the future, the transformer based model can be implemented, also ensemble models can be explored for the same in the future. Social networking users comment on all categories of posts. The comments having positive vibes is really help in boosting confidence and sometimes motivate to be strong in the odd situation. This paper suggested an ML model to predict the Hope Speech comments on the social platform. The sam- ples available for training were highly imbalanced; hence, the SMOTE oversampling technique was used to balance the dataset. Many models have experimented on both imbalanced and balanced datasets, and it was found that the Random Forest classifier performed best when the training sample was balanced. The proposed balanced model se- cured top rank among the participated teams for the English language with a weighted F1-score of 0.550 on the test dataset. The model can be further tuned with preprocessing steps as well as by in- creasing the size of the feature set to achieve better performance. 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https://openalex.org/W2340507627	https://europepmc.org/articles/pmc4836702?pdf=render	English	null	Challenges and Enablers of Deprescribing: A General Practitioner Perspective	PloS one	2,016	cc-by	13,130	OPEN ACCESS OPEN ACCESS Citation: Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM (2016) Challenges and Enablers of Deprescribing: A General Practitioner Perspective. PLoS ONE 11(4): e0151066. doi:10.1371/journal. pone.0151066 Editor: Dermot Cox, Royal College of Surgeons, IRELAND Received: December 7, 2015 Accepted: February 23, 2016 Published: April 19, 2016 Copyright: © 2016 Ailabouni et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Citation: Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM (2016) Challenges and Enablers of Deprescribing: A General Practitioner Perspective. PLoS ONE 11(4): e0151066. doi:10.1371/journal. pone.0151066 Citation: Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM (2016) Challenges and Enablers of Deprescribing: A General Practitioner Perspective. PLoS ONE 11(4): e0151066. doi:10.1371/journal. pone.0151066 Methods A qualitative study was undertaken using semi-structured, face-to-face interviews from two cities in New Zealand and a purpose-developed pilot-tested interview schedule. Interviews were recorded with permission and transcribed verbatim. Transcripts were read and re-read and themes were identified with iterative building of a coding list until all data was accounted for. Interviews continued until saturation of ideas occurred. Analysis was carried out with the assistance of a Theoretical Domains Framework (TDF) and constant comparison tech- niques. Several themes were identified. Challenges and enablers of deprescribing were determined based on participants’ answers. Copyright: © 2016 Ailabouni et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Challenges and Enablers of Deprescribing: A General Practitioner Perspective Nagham J. Ailabouni1, Prasad S. Nishtala1, Dee Mangin2, June M. Tordoff1 1 School of Pharmacy, University of Otago, Dunedin, New Zealand, 2 David Braley Chair in Family Medicine, McMaster University, Hamilton, Canada and University of Otago, Christchurch, New Zealand Nagham.ailabouni@otago.ac.nz a1111 Results Ten GPs agreed to participate. Four themes were identified to define the issues around pre- scribing for older people, from the GPs’ perspectives. Theme 1, the ‘recognition of the prob- lem’, discusses the difficulties involved with prescribing for older people. Theme 2 outlines the identified behaviour change factors relevant to the problem. Deprescribing challenges were drawn from these factors and summarised in Theme 3 under three major headings; ‘prescribing factors’, ‘social influences’ and ‘policy and processes’. Deprescribing enablers, based on the opinions and professional experience of GPs, were retrieved and summarised in Theme 4. Data Availability Statement: Raw data includes identification of GPs who had participated in this study. As part of the ethics application, it was agreed that the GPs will not be identified and the details will be kept confidential. Therefore, raw data files of transcripts and audio recordings of interviews are kept on a secure university based network. Any queries regarding the data can be answered by contacting the corresponding author, NA, or other authors, if necessary. Aims Deprescribing is the process of reducing or discontinuing medicines that are unnecessary or deemed to be harmful. We aimed to investigate general practitioner (GP) perceived chal- lenges to deprescribing in residential care and the possible enablers that support GPs to implement deprescribing. RESEARCH ARTICLE Challenges and Enablers of Deprescribing influences were among the major challenges identified. Deprescribing enablers encom- passed support for GPs’ awareness and knowledge, improvement of communication between multiple prescribers, adequate reimbursement and pharmacists being involved in the multidisciplinary team. influences were among the major challenges identified. Deprescribing enablers encom- passed support for GPs’ awareness and knowledge, improvement of communication between multiple prescribers, adequate reimbursement and pharmacists being involved in the multidisciplinary team. Lottery-grants—Lottery-Health-Research); and the New Zealand Pharmacy Education and Research Foundation (NZPERF) provided funding for the employment of a transcriber for the interviews in this study (http://www.psnz.org.nz/Category?Action= View&Category_id=155). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Competing Interests: The authors have declared that no competing interests exist. Introduction Deprescribing describes the process of reducing or discontinuing medicines that are un-neces- sary or deemed harmful [1, 2]. Deprescribing is a proposed antidote to the harms of polyphar- macy and is associated with numerous health benefits including improvement in cognition [3], a reduction in falls [4], a decrease in fractures [5], better medication adherence [6] and improvement in quality of life [3]. Deprescribing is an inherent component of good prescribing practice [7], but is rarely implemented in routine clinical care, and physician practice or views on deprescribing vary greatly [8, 9]. It is important to recognise that deprescribing involves more than just identifying inappropriate medicine use (IMU) [6]. It involves reviewing all medicines prescribed for the patient, identifying those medicines which are deemed un-necessary and potentially harmful, deciding which medicines can be stopped and considering the order in which medicines are to be stopped, tapered or reduced, with adequate monitoring and follow up. A deprescribing med- ication management plan is a final step of this process, and should be centered on the patient’s preferences where possible. The prevalence of single-disease guidelines for initiating treatments is a significant driver to polypharmacy and is a hindrance to deprescribing [10]. As of late, drug-specific deprescribing guidelines have been a research focus as a potential solution. A recent study by Farrell et al. used Delphi processes to prioritize medications where guidelines for deprescribing would be of benefit to clinicians [9]. The feasibility of deprescribing proton pump inhibitors (PPI) was examined by Reeve et al. using an example of a drug-specific PPI deprescribing guideline [11]. The lack of availability of such deprescribing guidelines may be one of the barriers to GPs implementing deprescribing [12]. On the other hand, a possible enabler to deprescribing may include, physicians and pharmacists working together to carry out comprehensive medicine reviews aimed at reducing polypharmacy and inappropriate medication use (IMU) in older people [13–16]. However, to date, very limited information exists on such barriers or challenges and possible enablers for deprescribing. In addition, limited information on GPs’ opinions regarding work- ing closely with pharmacists in a multidisciplinary team, exists. Therefore, this study aimed to ascertain these challenges and enablers, by examining the views of GPs about deprescribing for older people in a residential care setting. The specific aims of this research are to: 1. Explore challenges faced by GPs to deprescribing in the residential care setting. 2. Conclusion Funding: New Zealand Lottery Health Research provided the scholarship for this PhD (http://www. communitymatters.govt.nz/Funding-and-grants— The process of deprescribing is laced with many challenges for GPs. The uncertainty of research evidence in older people and social factors such as specialists’ and nurses’ 1 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Competing Interests: The authors have declared that no competing interests exist. Introduction Explore enablers that facilitate deprescribing in the residential care setting. 3. Explore views on deprescribing guidelines and a possible role for pharmacists in the process 4. Use the Theoretical Domains Framework (TDF), consisting of theoretical constructs, to help understand the possible barriers and enablers of deprescribing in a residential care setting. 2 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Challenges and Enablers of Deprescribing Table 1. Interview questions and prompts. Table 1. Interview questions and prompts. How do you feel about prescribing for older people living in residential care? Prompts: Challenges of prescribing in this setting Ease or difﬁculty of reviewing older people’s medicine proﬁles Clarity of residents’ clinical notes and medicine charts Communication, including clarity of documentation, at transfer of points of medical care and (e.g.: hospital discharge) When prescribing medicines for these patients, what factors do you think are important to consider? Prompts: Patient factors (e.g.: quality of life, beneﬁt gained versus risk caused) Physician factors (e.g.: prescribing habits, personal preferences, past experience) Other factors (e.g.: residential care staff, other prescribers, patient/relatives’ wishes) How do you approach reducing or stopping medicines in older people living in rest homes? Prompts: Do they endorse this idea? Do they have any concerns? (patients’ or relatives’ views) Do they ﬁnd stopping medicines challenging? Why? How frequently do they tend to stop medicine(s)? What factors do they take into account when making those decisions? Do deprescribing decisions occur at the resident’s regular clinical review multi-disciplinary meetings or at another time? If there were a guideline designed to assist prescribers in making decisions around deprescribing in older people, would you consider this to be useful for your clinical practice? What type of guidance would they ﬁnd useful? Would they ﬁnd deprescribing guidelines helpful or burdensome? Would guidelines make it easier or more efﬁcient to review residents’ medicine lists? What do you think of a clinically trained pharmacist or a prescribing pharmacist being involved in the process of reviewing residents’ medicines? Could pharmacists make clinical recommendations for the GPs’ consideration and discuss them with the multi-disciplinary team during the regular clinical reviews? Do they think a pharmacist’s involvement in this process would reduce the GPs’ workload? What are the possible challenges in involving a pharmacist in this process? Is there anything you think you would like to help you with this process of reducing/stopping medicines (i.e. deprescribing)? Is there anything that could make this process easier? doi:10 1371/journal pone 0151066 t001 Table 1. Interview questions and prompts. How do you feel about prescribing for older people living in residential care? Methods A qualitative design was used for exploring the views of general practitioners prescribing for older people in a residential care setting. An interview schedule (Table 1) comprised of six questions was developed that aimed to explore GPs’ challenges when prescribing for older peo- ple in a residential care setting. The scope of the interview schedule also covered the factors taken into consideration by physicians when prescribing, opinions on deprescribing guidelines. The study’s interview schedule specifically explored GPs’ opinions on the possible role of phar- macists in the multidisciplinary team to conduct a deprescribing medicine review. The inter- view also included a hypothetical patient profile adapted with permission from a study published by Schuling et al. [12]. Adaptations included providing additional clinical informa- tion such as renal function and body weight. In addition, the physician who initially prescribed the medicine was identified. The interview schedule was piloted on three GPs and modified in light of their comments. The present study reports on the qualitative data collected from the six primary interview questions. Data and discussions arising from the hypothetical patient profile will be reported separately. Ethics approval was granted by the University of Otago Research Committee (Ethics Approval Number: 14/038). This was not a quantitative study requiring an epidemiologically representative sample. As information on doctor characteristics are not publicly available, doi:10.1371/journal.pone.0151066.t001 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Table 1. Interview questions and prompts. Prompts: Challenges of prescribing in this setting Ease or difﬁculty of reviewing older people’s medicine proﬁles Clarity of residents’ clinical notes and medicine charts Communication, including clarity of documentation, at transfer of points of medical care and (e.g.: hospital discharge) When prescribing medicines for these patients, what factors do you think are important to consider? Prompts: Patient factors (e.g.: quality of life, beneﬁt gained versus risk caused) Physician factors (e.g.: prescribing habits, personal preferences, past experience) Other factors (e.g.: residential care staff, other prescribers, patient/relatives’ wishes) How do you approach reducing or stopping medicines in older people living in rest homes? Prompts: Do they endorse this idea? Do they have any concerns? (patients’ or relatives’ views) Do they ﬁnd stopping medicines challenging? Why? How frequently do they tend to stop medicine(s)? What factors do they take into account when making those decisions? Do deprescribing decisions occur at the resident’s regular clinical review multi-disciplinary meetings or at another time? If there were a guideline designed to assist prescribers in making decisions around deprescribing in older people, would you consider this to be useful for your clinical practice? What type of guidance would they ﬁnd useful? Would they ﬁnd deprescribing guidelines helpful or burdensome? Would guidelines make it easier or more efﬁcient to review residents’ medicine lists? What do you think of a clinically trained pharmacist or a prescribing pharmacist being involved in the process of reviewing residents’ medicines? Could pharmacists make clinical recommendations for the GPs’ consideration and discuss them with the multi-disciplinary team during the regular clinical reviews? Do they think a pharmacist’s involvement in this process would reduce the GPs’ workload? What are the possible challenges in involving a pharmacist in this process? Is there anything you think you would like to help you with this process of reducing/stopping medicines (i.e. deprescribing)? Is there anything that could make this process easier? d i 10 1371/j l 0151066 001 3 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Challenges and Enablers of Deprescribing randomization was a convenient way to obtain our sample and start to investigate purposively to ensure it had a range of characteristics. Using information available from New Zealand dis- trict health board (DHB) websites, a list of all medical centres in the two cities was complied. A random number generator programme was used to produce 10 numbers. Table 1. Interview questions and prompts. The ten medical cen- tres that correlated to these numbers were approached for recruitment. NA used the medical centres’ websites to find the names of the doctors who currently worked in each medical centre. Personalized invitations were accordingly sent out to each potential participant. GPs that pro- vided clinical care for 10 residents living in residential care were invited to respond. After a month, invitation letters and information sheets were sent out to a second randomised list of medical practices in the same towns/cities. GPs who agreed to participate provided written consent. Signed consent forms were sent back in pre-paid reply envelopes. We have used the consolidated criteria for reporting qualitative research (COREQ-32) to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations (Table 2). The interviews conducted were in depth semi-structured face-to-face interviews, using the interview guide in Table 1. This interview method for data collection was chosen over a focus group method, as it was thought to be more time-efficient for the GPs, would avoid any partic- ular views being dominant in a meeting, and would allow them to express an opinion without fear of being judged by their colleagues. Interviews were recorded with permission and tran- scribed verbatim. Transcripts were read and re-read and themes identified, with iterative build- ing of a coding list until all data was accounted for. Interviews continued until saturation of ideas occurred. Analysis was carried out using constant comparison techniques, and the nVivo 10 software. A Theoretical Domains Framework (TDF) developed by Michie et al. [17], was used to assist with the analysis (Table 3). The Michie TDF was considered most appropriate as it was specifi- cally developed for the purposes of implementational research. It was developed by a robust consensus approach, is commonly used in health research. This framework consists of 12 domains or theoretical constructs that help determine the barriers and facilitators of imple- menting any change in behaviour or practice. In this study, the practice or behaviour that is being examined is deprescribing. Several sub-domains or specific beliefs were drawn up for each domain which relate to analysing the behaviour of the GPs in relation to deprescribing. Interview quotes to support each domain are listed, as appropriate in Table 3. Table 1. Interview questions and prompts. As the TDF does not include domains specific to the challenges/enablers of deprescribing, a simple thematic analysis was applied to Table 3 to draw themes that related to the challenges of deprescribing (Theme 3) and deprescribing enablers (Theme 4). Coding was initially conducted by NA, and independently checked by JT. Coding was discussed, and any possible discrepancies were resolved. Interpretations were checked by JT, PN and DM. Results and Discussion In total, forty invitations were sent to individual GPs and ten consented to take part in the study, giving a participation rate of 25%. Eight GPs were New Zealand European, one GP was Asian and one GP was Dutch. Participants had been prescribing for older people in residential care for 2–32 years. Four main themes were identified in the analysis of data from respondents which collectively describe prescribing in the residential care setting, from a GP perspective. Data also illustrate the various challenges involved in implementing deprescribing and possible deprescribing enablers. 4 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Challenges and Enablers of Deprescribing Table 2. COREQ-32 checklist. Domain 1: Research team and reﬂexivity Personal characteristics Interviewer Nagham Ailabouni (NA) Credentials PhD candidate Occupation Pharmacist Gender Female Experience and training Carried out research in residential care; worked in hospital and community pharmacy Relationship with participants Relationship established GPs were selected randomly; no relationship existed prior to interview Participant knowledge of the interviewer Participants did not know the interviewer prior to the interview. Interviewer characteristics No characteristics were reported Domain 2: Study design Theoretical Framework Methodological orientation and theory Content analysis. Findings, such as themes, were drawn from data collected during interviews. Participant selection Sampling Random sampling of medical centres Method of approach Mail Sample size 10 Non-participation No participants dropped out. 30 GPs did not reply to participate. Setting Setting of data collection Medical clinic Presence of non-participants No Description of sample Number of years’ experience prescribing in residential care: 2–32 years; Ethnicity: 8 NZ European, 1 European and 1 Asian participant; Gender: Male (7); Female (3) Data collection Interview guide The questions were written by the authors, and prompts were given during the interviews if needed (Table 1). Interview schedule was pilot tested on three GPs. Repeat interviews No Audio/visual recording Audio recording was used Field notes NA made ﬁeld notes during interviews when necessary Duration 15–25 minutes Data saturation Yes. Data saturation was reached when the major and minor themes were repeated in interviews. Coding was independently checked by a second investigator (JT). PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Results and Discussion Transcripts returned No Domain 3: Analysis and ﬁndings Number of data coders One (NA) Descriptions of the coding tree The Theoretical Domains Framework (TDF) was used as a basis for the coding tree Derivation of themes Themes were derived from data collected Software nVivo 10 Participant checking It was agreed with participants, that ﬁndings will be shared with them upon publication Reporting Quotations presented Yes Data and ﬁndings consistent Yes (Continued) Table 2. COREQ-32 checklist. Table 2. COREQ-32 checklist. (Continued) (Continued) PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 5 / 20 Challenges and Enablers of Deprescribing Table 2. (Continued) Clarity of major themes Major themes resulting from the interviews are outlined in this publication. Clarity of minor themes The patient proﬁle is considered a minor theme in this study. This will be reported in a follow up study. Participant responses were analysed in depth. Findings from this were discussed and compared with evidence based research available in older people and other similar studies carried out. doi:10.1371/journal.pone.0151066.t002 Major themes resulting from the interviews are outlined in this publication. Theme 1: Recognition of the problem In order to provide solutions to a problem, it is important to firstly define, recognise and acknowledge the extent of the problem. While several GPs stated that prescribing for older peo- ple in the residential care setting is no different to prescribing in general practice, the majority of them believed that prescribing is particularly challenging in residential care for a number of reasons. “Prescribing for older people in residential care, is no different than just general prescribing, but its harder.” GP10 “Always a little nervous about prescribing for older people in rest homes, you know, because they often have multiple pathologies.” GP6 Multimorbidity is a common occurrence in old age, affecting over 50% of people in primary care [18]. As a result, patients are often prescribed multiple medicines. In addition, advanced age and frailty contribute to a reduced life-expectancy [12]. Therefore, physicians often have to balance a multitude of factors including the disease(s) the patient may have, the benefit-risk profile of medicines prescribed, the patients’ personal views and the opinions of other prescrib- ers. This was identified as a key aspect of the perceived challenge in prescribing in rest home patients. “Firstly, there’s the patient themselves, and the fact that they are in a rest home, then there’s whatever disease you are treating. The point is, you know how the elderly are; they’ve got hun- dreds of things wrong with them, multiple pathologies and polypharmacy are the issues.” GP4 “Basically, older people especially those in rest homes tend to have a lot of co-morbidities, so they are being prescribed things for a lot of conditions. They also have seen lots of specialists who have also prescribed things, and one of the challenges is knowing when you can take con- trol and either stop or reduce doses.” GP1 Polypharmacy was highlighted as a major challenge for prescribing for older people by sev- eral GPs in this study. When GPs attempt to review prescribed medicines, they often queried the original indication these medicines were prescribed for. In addition, it was difficult for GPs to address polypharmacy as they are often trying to differentiate between medical conditions, or symptoms due to medicine side effects, and balance the potential for beneficial effects with the potential for side effects when making decisions around medication use. In another PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 6 / 20 Challenges and Enablers of Deprescribing Table 3. Behaviour change factors related to deprescribing. Domain Sub-domain/speciﬁc belief Knowledge GPs’ knowledge about deprescribing. Uncertainty about the relevance of evidence based guidelines to older people with multimorbidity. Lack of guidelines relevant to prescribing in older people with multimorbidity. Skills Difﬁculty determining medicines to deprescribe, and appropriate timing of deprescribing. Professional role and identity Trying to fulﬁl professional duties, despite struggles. Motivation and goals Competing factors (time, rest home policies, other prescribers etc.) decrease motivation to deprescribe. GPs’ motivation to deprescribe. Memory, attention and decision processes Attention and effort needed to deprescribe. Environmental constraints Access to clinical notes. Multiple competing demands of professional role Lack of decision-support systems. Accessibility of the resident or patients Time constraints Social inﬂuences Lack of adequate reimbursement. Communication at points of health care transfer Inﬂuence of nurses’ suggestions Patient’s ability to communicate. Table 3. Behaviour change factors related to deprescribing. Domain Sub-domain/speciﬁc belief Sample Quotes Knowledge GPs’ knowledge about deprescribing. “Why don’t we deprescribe? Is that a knowledge issue? Possibly. Its very complicated. Do we know all the interactions and side effects of all these drugs? Of course we don’t.” GP4 Uncertainty about the relevance of evidence based guidelines to older people with multimorbidity. “But you don’t have guidelines a lot in the elderly, do you? That’s the hardest thing.” GP10 Lack of guidelines relevant to prescribing in older people with multimorbidity. “Often research will say if you’re above for example, 80 (years of age) you’re excluded.” GP9 Skills Difﬁculty determining medicines to deprescribe, and appropriate timing of deprescribing. “And also there’s the challenges of when do you stop preventative stuff, when do you stop your statins and aspirin?” GP3 Professional role and identity Trying to fulﬁl professional duties, despite struggles. “By the time you’ve crossed some off and put some new ones on, you have to re-do the chart and that just takes time. I have to charge for that because it takes the time, I don’t know if there’s any better other way.” GP10 “I don’t have that much time. . . for those kind of moral routine stuff, because I already have a lot of acute stuff I got to deal with on the days that I go there.” GP9 Motivation and goals Competing factors (time, rest home policies, other prescribers etc.) decrease motivation to deprescribe. “I don’t really know what the evidence is, but I suspect that physicians don’t deprescribe very much.” GP4 GPs’ motivation to deprescribe. “Since I’ve started to look at that more globally, the number of medicines I’m prescribing on average for patients in rest homes is about 50% of what I was prescribing a year ago and they aren’t falling off their perch in greater numbers. Patients like it (being prescribed less medicines). They say oh, a whole big meal of pills, and you know, people are generally better. People wake up, they’re less nauseated, they have fewer falls, all those sorts of things, yeah. GP5 Memory, attention and decision processes Attention and effort needed to deprescribe. “It’s because, obviously you’ve got a clinical responsibility. Stopping a medicine is in a way no less a therapeutic position than starting a medicine. So you’ve still got to then consider the down ﬂow effects of that on the patient, so you need a management plan” GP4 Environmental constraints Access to clinical notes. “You rush at lunchtime or you rush before work, so you’re often ﬁtting it (rest home prescribing) in around other things.” GP2 Multiple competing demands of professional role “Well we’ve got the notes back at the surgery, but they’re not linking up with the rest home. Reality would be to move onto some kind of computerised system” GP3 Lack of decision-support systems. “Rest home prescribing doesn’t ﬁt well with my schedule. It is a bit of a juggling act, so I don’t personally like it. If you go to rest homes, some of them are like 15 minutes each side, so doesn’t really ﬁt with me, and even when you say ok I’ll go about 12 or something quickly, they’re eating. They’re in their lunch, so you just end up waiting. Other thing is that you see them at the end of the day, which is again you know, six or something, and then again if you need something, or medication, the pharmacies are closed up.” GP8 Accessibility of the resident or patients Time constraints Social inﬂuences Lack of adequate reimbursement. Communication at points of health care transfer “I do think sometimes, you wonder who are we treating? Are we treating the nursing staff who can’t face somebody calling out at night, or are we treating actual patient who may be very well, happen to be calling out once or twice a night at one o’clock, but then fall back to sleep, you know?” GP 9 Inﬂuence of nurses’ suggestions “If it is an important decision, then I’ll involve the family. But with some decisions, the family don’t need to know everything.” GP6 Patient’s ability to communicate. “Some patients are in hospital level care and the majority can’t even speak.” GP9 (Continued) Table 3. Behaviour change factors related to deprescribing. “By the time you’ve crossed some off and put some new ones on, you have to re-do the chart and that just takes time. I have to charge for that because it takes the time, I don’t know if there’s any better other way.” GP10 “I don’t have that much time. . . for those kind of moral routine stuff, because I already have a lot of acute stuff I got to deal with on the days that I go there.” GP9 “I don’t have that much time. . . for those kind of moral routine stuff, because I already have a lot of acute stuff I got to deal with on the days that I go there.” GP9 Competing factors (time, rest home policies, other prescribers etc.) decrease motivation to deprescribe. GPs’ motivation to deprescribe. “I don’t really know what the evidence is, but I suspect that physicians don’t deprescribe very much.” GP4 “I don’t really know what the evidence is, but I suspect that physicians don’t deprescribe very much.” GP4 “Since I’ve started to look at that more globally, the number of medicines I’m prescribing on average for patients in rest homes is about 50% of what I was prescribing a year ago and they aren’t falling off their perch in greater numbers. Patients like it (being prescribed less medicines). They say oh, a whole big meal of pills, and you know, people are generally better. People wake up, they’re less nauseated, they have fewer falls, all those sorts of things, yeah. GP5 “It’s because, obviously you’ve got a clinical responsibility. Stopping a medicine is in a way no less a therapeutic position than starting a medicine. So you’ve still got to then consider the down ﬂow effects of that on the patient, so you need a management plan” GP4 “You rush at lunchtime or you rush before work, so you’re often ﬁtting it (rest home prescribing) in around other things.” GP2 “Well we’ve got the notes back at the surgery, but they’re not linking up with the rest home. Reality would be to move onto some kind of computerised system” GP3 “Since I’ve started to look at that more globally, the number of medicines I’m prescribing on average for patients in rest homes is about 50% of what I was prescribing a year ago and they aren’t falling off their perch in greater numbers. Patients like it (being prescribed less medicines). They say oh, a whole big meal of pills, and you know, people are generally better. People wake up, they’re less nauseated, they have fewer falls, all those sorts of things, yeah. GP5 “Well we’ve got the notes back at the surgery, but they’re not linking up with the rest home. Reality would be to move onto some kind of computerised system” GP3 “Rest home prescribing doesn’t ﬁt well with my schedule. It is a bit of a juggling act, so I don’t personally like it. If you go to rest homes, some of them are like 15 minutes each side, so doesn’t really ﬁt with me, and even when you say ok I’ll go about 12 or something quickly, they’re eating. They’re in their lunch, so you just end up waiting. Other thing is that you see them at the end of the day, which is again you know, six or something, and then again if you need something, or medication, the pharmacies are closed up.” GP8 “I do think sometimes, you wonder who are we treating? Are we treating the nursing staff who can’t face somebody calling out at night, or are we treating actual patient who may be very well, happen to be calling out once or twice a night at one o’clock, but then fall back to sleep, you know?” GP 9 (Continued) PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 7 / 20 Challenges and Enablers of Deprescribing Table 3. (Continued) Domain Sub-domain/speciﬁc belief Sample Quotes Patient beliefs, ideas, concerns or preferences “The reverse of hospitals putting them on medications, is that hospi stop medications sometimes, and a week later they start them on all the medicines again, so that sort of communication needs to be take into consideration.” GP1 Involving family members or relatives “I think it’s also because the communication could be far better between the hospital and us” GP9 “The challenges are stopping hospital physicians giving unnecessary medicines.” GP5 “Once they go into a rest home, you haven’t got time to visit or a vis might not be relevant, so we’re relying on the nursing staff to feedba information to us, and often that’s not brilliant, hence we’ve lost that kind of one to one with the patient, which makes it much harder to decide how to prescribe, because you’re being biased by other people.” GP3 Emotion Fear of potential negative outcomes from Deprescribing. “The other reason people don’t like stopping medications, is uh, coincidentally people would die when you stop things.”GP3 Reluctance to change medicines prescribed by a specialist. “So if they’ve seen a cardiologist and were put on a statin, you feel v nervous about stopping it for example. There’s no doubt that you kn a specialist assessment, commenced on a speciﬁc drug, you know i does make you reluctant to the change. To change things, yeah, it d have that, it inﬂuences you.” GP7 Lack of acceptance of GP decisions from other health professionals. “Everyone is having a go at us. Every speciality across the land will t us that we should do things better. And pharmacists will tell us we should do things better, which is like; you need to come on our side the fence and be a general practitioner.” GP4 Behavioural regulation Recognising the need to try and discuss therapy options with the patient “I’d do some discussion with the patient if possible. And I would do on the basis of trying to work out the risks versus the beneﬁts.” Awareness of hindrances that prevent behavioural change “I suspect (deprescribing) guidelines and all the rest of it don’t chang our behaviours, because you’re talking about behavioural change.” G “I don’t tend to look at those (deprescribing) guidelines, that’s the problem. There has been some, and I’ve got them to read my one d pile. But you never sort of quite get round to it.” GP10 Nature of behaviour Variance in frequency of implementing deprescribing “I don't have that much time for those kind of moral routine stuff, ca there’s already a lot of acute stuff you have to deal with on the days that I go to the rest home.” GP9 “The reverse of hospitals putting them on medications, is that hospitals stop medications sometimes, and a week later they start them on all of the medicines again, so that sort of communication needs to be taken into consideration.” GP1 Patient beliefs, ideas, concerns or preferences “The challenges are stopping hospital physicians giving unnecessary medicines.” GP5 “Once they go into a rest home, you haven’t got time to visit or a visit might not be relevant, so we’re relying on the nursing staff to feedback information to us, and often that’s not brilliant, hence we’ve lost that kind of one to one with the patient, which makes it much harder to decide how to prescribe, because you’re being biased by other people.” GP3 “The other reason people don’t like stopping medications, is uh, coincidentally people would die when you stop things.”GP3 “So if they’ve seen a cardiologist and were put on a statin, you feel very nervous about stopping it for example. There’s no doubt that you know a specialist assessment, commenced on a speciﬁc drug, you know it does make you reluctant to the change. To change things, yeah, it does have that, it inﬂuences you.” GP7 “Everyone is having a go at us. Every speciality across the land will tell us that we should do things better. And pharmacists will tell us we should do things better, which is like; you need to come on our side of the fence and be a general practitioner.” GP4 “I’d do some discussion with the patient if possible. And I would do it on the basis of trying to work out the risks versus the beneﬁts.” “I don’t tend to look at those (deprescribing) guidelines, that’s the problem. There has been some, and I’ve got them to read my one day pile. Theme 2: Behavioural change factors It was pertinent to examine and understand the behavioural change factors or drivers which contribute to the problem or enable implementation of solutions. The results are presented using the Michie TDF analysis domain template (Table 3). But you never sort of quite get round to it.” GP10 “I don't have that much time for those kind of moral routine stuff, cause there’s already a lot of acute stuff you have to deal with on the days that I go to the rest home.” GP9 doi:10.1371/journal.pone.0151066.t003 qualitative study examining GPs’ views by Schuling et al., this was also found to be a significant contributor to the problem [12]. Clinical decisions made by GPs about the appropriateness of medicines were sometimes based on very scarce clinical information. qualitative study examining GPs’ views by Schuling et al., this was also found to be a significant contributor to the problem [12]. Clinical decisions made by GPs about the appropriateness of medicines were sometimes based on very scarce clinical information. “How long have they been on it?” I have seen people on statins in their 80’s and 90’s for good- ness sake, for non-STEMI’s, and you’re thinking, do they really need that?” GP10 “Probably that’s a big challenge. Trying to keep everything appropriate, the right treatment for the right problem, but without overdoing it or overmedicating. Trying to get a balance between you know a good outcome and the person doing well, and the side effects from those medications, so side effects would be another issue in elderly. You can start a medication, and you’re getting to know other effects from that medication, so I guess that’s a doctor-induced problem. That’s the challenge when you’re prescribing for the elderly.” 8 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Challenges and Enablers of Deprescribing “There’s also a challenge of when do you stop preventive medicines such as statins and aspi- rin?” GP3 “There’s also a challenge of when do you stop preventive medicines such as statins and aspi- rin?” GP3 The dilemma of continuing or stopping preventive medicines also concerned GPs who reviewed a patient profile in our recent qualitative study. Our study found that GPs felt more confident about symptom management and adjusting the dose of symptomatic medicines, according to patient response [12]), rather than reviewing the appropriateness of continuing preventive medicines. Lack of access to user friendly evidence based deprescribing guidelines: Few clinical trials have highlighted that nonadherence to disease-specific clinical guidelines may result in poor quality of patient care [20]. Paradoxically, there is growing evidence that older people with multiple conditions have poorer outcomes when treated according to disease-specific guide- lines compared to other patients [10, 21]. In addition, the presence of multiple guidelines dis- courages physicians from applying these guidelines in clinical practice [22]. One GP in the present study expressed their frustration regarding the complexity of guidelines. “I have seen these Best Practice Advisory Committee (bpacnz) articles, but I can’t remember what was in them, you know? Has it changed my prescribing? No it hasn’t, which I suspect applies to a lot of us. We get so many guidelines, there’s so many. . . that’s the other thing. You have all this stuff (different guidelines) coming at you and everybody’s saying you could do better, and well maybe we could, in this speciality, but actually, when you’re putting it alto- gether, maybe we’re not as bad as people like to make out because when you’re sitting there with a lot of stuff, I mean we basically see that balancing huge amounts of information.” GP4 “Well like you mentioned earlier, that Best Practice Advisory Committee (bpacnz) one they’ve written about it, and just making you more aware and giving the time so that I can actually read it, I think I’ve started it, but I haven’t read it. It’s in a pile, so makes you more aware and more confident of making the changes if and when needed.” GP10 Lack of easy-to-use guidelines or decision support is a particular challenge for GPs whilst implementing deprescribing and many physicians are forced to make decisions without much guidance. Theme 3: Deprescribing considerations and challenges Analyses of the behavioural change factors (Table 3) highlighted several deprescribing consid- erations and challenges (Fig 1). These were grouped under three main headings, prescribing factors, social influences and policy and processes. A. Prescribing factors. Overall, GPs acknowledged that it is important to consider the quality of life, health status and life expectancy of their patients, prior to initiating a medicine [12]. “Once they go into the rest home, they’re obviously only going to live for another 5 years potentially, I don’t know what the actual figures are. So you look at it in that view point. You know, everything changes. You look at the risks and benefits of every single decision you’re making.” GP3 “Patient factors would be um, their life expectancy. That’s putting it bluntly, isn’t it? Their age, I think you know, if someone’s you know, you might consider treating a 72 year old dif- ferent from a 92 year old, or a 102 year old, had a few of those.” GP 4 Fig 1. Deprescribing considerations and challenges. Fig 1. Deprescribing considerations and challenges. doi:10.1371/journal.pone.0151066.g001 doi:10.1371/journal.pone.0151066.g001 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 9 / 20 Challenges and Enablers of Deprescribing i. Uncertainties regarding applying evidence based medicine: GPs’ knowledge and ability to synergise and apply evidence based practice may be challenged when caring for older people with complex health problems [19]. GPs in this study acknowledged that they experienced a dilemma when applying research evidence to a patient with multimorbidity. This was the case particularly for preventive medicines such as aspirin and statins. PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 “There’s also a challenge of when do you stop preventive medicines such as statins and aspi- rin?” GP3 “Often research will say if you’re above for example, 80 (years of age) you’re excluded.” GP9 “And that’s the hard thing, whether a little bit of omeprazole, which you’re meant to slowly reduce from 40, to 20, to 10, to stop, and when should that be done? It’s not easy, because I mean guidelines say that you should reduce, but it is often not indicated why people are on say, omeprazole. I find those sort of things hard.” GP10 In a synthesis of ten qualitative studies, physicians highlighted that guidelines focus on health outcomes that may be of little relevance to their patients [22]. This leads to physicians deviating from guideline-directed care. In addition, they mentioned the lack of available tools PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 10 / 20 Challenges and Enablers of Deprescribing to help physicians quantify the benefits and harms of prescribed medicines, as this is often a dilemma whilst optimizing medicines in older people. As a result, physicians making a clinical decision, follow an approach that combines prioritizing the main problems most relevant to the patient, stratifying the risk of a disease outcome, modifying guideline-directed goals or interventions according to anticipated adverse effects the patient might experience and then making a clinical decision balancing potential benefits and harms [22, 23]. ii. Fear of consequences: Physicians have a genuine fear of patients experiencing deterioration in their health, shortly after they have stopped or reduced one or more of their medicines. They may also fear others (family or health care staff) having the misperception that coincidental adverse effects the patient may develop, are a direct outcome of the physician stopping medicines. “Coincidentally, people would die when you stop medicines. Not because you killed them, but they happened to.” GP3 In addition, physicians fear that patients may perceive deprescribing as withdrawal of care before their end of life. These misconceptions prevent physicians from implementing depre- scribing. For many GPs, ‘maintaining the status quo’ for multimorbid patients with polyphar- macy who are stable, is seen as the most reasonable course of action to undertake. “If they’re otherwise stable, and life’s going on, it’s the same as prescribing for anybody else really which doesn’t really help you very much. I don’t reduce or stop unless I think it’s needed. If you stop it, are you going to de-stablilise things? “There’s also a challenge of when do you stop preventive medicines such as statins and aspi- rin?” GP3 So, if the system is working, I have to say, although we look and we wonder, we tend to leave them on.” GP4 “It’s hard to give them the option sometimes, and you feel like you’re writing them off if you’re crossing off all this preventative sort of stuff.” Even though this fear of consequences exists, some GPs commented that through their per- sonal experience, patients have often improved once their medicines have been stopped. “I had a patient today, a 90 year old, I reduced her metformin and she said: I’m feeling much better since you did that, you now? So you can often get away with you know, reduc- ing down.” GP6 B. Social influences. i. Patient and family factors: Several GPs in our study felt the importance of delivering individualised patient-centered care to their patients. This is similar to the views of other GPs who felt the importance of considering the patient’s personal prefer- ence and patient empowerment when tailoring care [24]. To achieve this, taking into consider- ation individuals’ opinions or perceptions about their medicines is important. However, patients may not always be willing to stop or change medicines they have taken for a long time [12], despite the physician’s recommendations. “Sometimes it is hard because they have been on it for donkey’s years, and they totally believe in it.” GP9 In addition, certain patient characteristics, such as loss of cognition and memory, can fur- ther complicate this process and make delivering patient-centered care, even more challenging [22, 25]. ii. Other prescribers: Multimorbid patients tend to visit a greater number of physicians, which could include specialists. This can have several effects on the patients’ care. It has been 11 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Challenges and Enablers of Deprescribing shown that those patients who visit four or more physicians experience problems such as con- flicting medical advice, lack of access to laboratory test results and more commonly, duplica- tion of laboratory tests from multiple prescribers [26]. shown that those patients who visit four or more physicians experience problems such as con- flicting medical advice, lack of access to laboratory test results and more commonly, duplica- tion of laboratory tests from multiple prescribers [26]. It was apparent in our study, that GPs’ prescribing is influenced by specialist recommenda- tions. One GP disclosed, they considered which specialist initiated the medicine, before chang- ing the prescription. “So if they’ve seen a cardiologist and were put on a statin, you feel very nervous about stop- ping it for example. There’s no doubt that you know a specialist assessment, commenced on a specific drug, you know it does make you reluctant to change things, yeah, it does have that, it influences you.” GP7 In addition, GPs believed that patients have the perception that physicians in hospitals, or specialists in private clinics have more knowledge than GPs practising in primary health care. This could disrupt the trust in patient-GP relationships, leading to compromised shared-deci- sion making between the patient and the GP. “Yeah, look the big doctor in the white coat in the big house on the hill always knows more than the GP especially the house surgeon who might have a brief amount of experience and does what they’re told and one of the issues with this process is, experienced GP’s still think that the doctor up the road knows more.” GP9 Specialists who operate on a single disease paradigm without an overview of the ‘whole patient’ can lead to fragmented care. Single-disease care is antagonistic to the goals of GPs in primary care. GPs receive poor communication from other care providers in multimorbidity [22]. “Uh, some nurses do push for medicines to be prescribed.” GP8 “I do think sometimes you wonder who are we treating? Are we treating the nursing staff who can’t face somebody calling out at night, or are we treating (an) actual patient who may be very well, happen to be calling out once or twice a night at one o’clock, but then fall back to sleep, you know?” GP9 “Sometimes it is hard because they have been on it for donkey’s years, and they totally believe in it.” GP9 This uncertainty makes it more difficult for GPs to make prescribing decisions with confi- dence and impedes GPs from delivering patient-centred care to their patients [22]. iii. Residential care staff: Nurses have a significant role in caring for people living in resi- dential care. Most of the information GPs collect is sourced from nurses instead of a direct con- versation with the patient. As a result, biased opinions could be communicated and shared- decision making between the patient and the GP could be compromised. “We are relying on the nursing staff to feedback information to us, and often that’s not bril- liant, hence we’ve lost that kind of one to one with the patient, which makes it much harder to decide how to prescribe, because you’re being biased by other people.” GP3 In addition, nurses could encourage GPs to prescribe certain medicines; in particular those medicines with a sedative effect. “Uh, some nurses do push for medicines to be prescribed.” GP8 “Uh, some nurses do push for medicines to be prescribed.” GP8 C. Policy and processes i. Communication at transfer points of healthcare: Transfer points of healthcare include admission into hospital from a patient’s home or a residential care facility and discharge from PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 12 / 20 Challenges and Enablers of Deprescribing the hospital. At these points, older patients are particularly vulnerable as they find it more diffi- cult to adapt or adjust to different environments. the hospital. At these points, older patients are particularly vulnerable as they find it more diffi- cult to adapt or adjust to different environments. “I recently had a patient who went into hospital, and the hospital stopped stuff, which is great. Then they came back into the rest home, a different environment, and they were upset. So this is the battle, do you start it again? Because older people, patients, don’t do well from one place to another place. I think they would rather just always be in the same place.” GP9 Fragmented patient care may result at these points of transfer, consequent to multiple phy- sicians providing medical care and prescribing. GPs in this study highlighted that discharge summaries are usually written clearly, however they felt that they often lack detail around how long the new medicine should be continued for. This contributes to GPs continuing the pre- scription of medicines for longer than initially intended. “Discharge summaries are clear, but don’t necessarily mention whether medicines should be continued long-term.” GP1 Several GPs in this study spoke about the lack of communication between hospital physi- cians and GPs in primary care. The lack of communication led to patients being prescribed medicine regimens consistent with hospital formulary or guidelines, but potentially inappro- priate to a multimorbid older patient. “Some recognition of the problem from secondary care is important, because if people are admitted to hospital, they tend to be put on standard regimes without taking light of their medication and they tend to be looked at in a silos. If they have an MI (myocardial infarc- tion), they’d come out with 40mg of simvastatin and the other side of things won’t be looked at.” GP1 “The challenges are stopping hospital doctors giving unnecessary medicines. Hospitals are focussed on the single issues. They tend to focus on single issues and add, add, and add med- ications. PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 C. Policy and processes I think there also tends to be a “just keep going” because it’s been started.” GP5 Another previously documented challenge related to transitions in healthcare, is when the primary prescriber changes, and the knowledge of the rationale or indication for the medica- tion is lost at the transfer. In this case the responsibility for stopping inappropriate medicines is devolved to the new prescriber, but not the necessary information required for decision making [27]. ii. Time and funding constraints: The majority of GPs in this study visited residents at the residential care facility at unscheduled times. This meant patient care was fitted around other responsibilities, such as prioritizing time for their own patients in the medical practice. “You rush at lunchtime or you rush before work, so you’re often fitting it (rest home pre- scribing) around other things.” GP2 “As a goal, just to reduce the number of tablets for the sake of it. No, I don’t do that at all. Maybe I should, but life’s busy.” GP4 “As a goal, just to reduce the number of tablets for the sake of it. No, I don’t do that at all. Maybe I should, but life’s busy.” GP4 GPs felt that time constraints may have stopped them addressing all of the patient’s con- cerns, and led to suboptimal medicine management. 13 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Challenges and Enablers of Deprescribing “Time constraints, I’ve got 15 minutes, she’s worried about ‘x, y, & z’. I’m really concerned about this one, so we’ve got all that negotiation, and I’m not about to sit down and go through and spend 20 minutes or half an hour, because I’ve got the waiting room full. Those are real drivers.” GP4 Similar limitations were echoed in other studies. In a qualitative study conducted by Luijks et al., Dutch GPs revealed that there was insufficient time and compensation for consistently putting their main objectives into practice [24]. Fried et al. discussed that current reimburse- ment systems, fail to acknowledge the complexities of caring for older people with multiple conditions [23]. iii. Nursing home policies and a chaotic prescribing environment: GPs reported their frustrations regarding lack of clarity and consistency of clinical documentation among residential care facilities. Lack of decision-support systems in residential care challenged GPs. C. Policy and processes They found that routine paper work was burdensome, inefficient and increased the scope for error. Transmit- ting a hard copy of medicine charts via fax between the residential care facility, the pharmacy and the medical practice compromised the quality and legibility of the medicine charts leading to avoidable medicine and administration errors. As a result, the prescribing environment for GPs in residential care, can sometimes be chaotic. These issues may diminish in the future, as residen- tial aged care facilities in New Zealand adopt electronic prescribing systems[28]. “You can’t get consistency, you’ve got private rest homes, and they’ve all got different sys- tems. For instance; for three-monthly reviews: you go and see a patient; you look at the drug chart and examine the patient. You write something in the notes, and then they want another bit of paper to be filled out that says you’ve done a review on the medicines apparently.” GP3 “None of the local rest homes are set up for computerised records which drives me nuts. We are fully computerised (in) general practice these days and when we come to rest homes we go back to this antiquated system of having to handwrite things. Especially, I hate, hate, hate handwriting prescriptions because the room for error goes up exponentially, and then with the multiple faxing of charts.” GP5 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Theme 4: Deprescribing enablers So you could make it more certain with ideas from a pharmacist and a consultant about that. And I would see that as worth thinking about.” GP10 “Well the help of a clinical pharmacist, or certainly a very good nurse manager to help, or the cardiac nurse specialist, because if we’re decreasing medication we’ve got to keep an eye on heart failure, blood pressure, blood sugars (glycated haemoglobin) kind of thing. But having a clinical pharmacist involved would be great. I mean ideally a physician, a clinical pharmacist and the GP, and the nurse would be great. You know, the whole mixture” GP2 Several GPs embraced the idea of pharmacists’ involvement in a multidisciplinary team to review medicines, but had concerns about the delivery of the service. The primary concern was that pharmacists may offer recommendations that may have already been recognised by the GP and these may have not been implemented for compelling clinical reasons. These reasons are often not communicated to or recognised by the pharmacists. GPs were positive about the potential for inter-professional partnerships. In a residential care setting, pharmacists have access to residents’ clinical information and are well placed to make recommendations for GPs to consider. In contrast pharmacists working in the community do not have access to patient information. As a result, GPs fear that the pharmacists’ recommendations might not be rele- vant in this setting. In addition, lack of resources hinders these multidisciplinary meetings from occurring regularly in practice. “I think it’s good to know the pharmacists if you can, but it doesn’t have to be a local phar- macist. It’s just that locality means you build relationship with people more easily.” GP6 “The pharmacist down the road are sort of part of the team, but they’re in a different build- ing, and we never see them. They’re a voice on the phone, they do rollover and they lack information; there’s no doubt about that. They don’t know what Mrs. Bloggs has got or why we’re treating them for half the stuff. We would be better if they had the time to, for the pharmacists to sit down with the physician and say you know, it’s possible that you could stop ‘x’ and ‘y’. But how can they do that if they don’t know what the patient’s got? I guess, if you’re part of the treating team, you’re part of the treating team. Theme 4: Deprescribing enablers GPs in this study recognised the need for support when prescribing for multimorbid patients. Several possible deprescribing enablers came to light, which can serve as a platform for improv- ing medicine management in older people. 1) Pharmacist medicine reviews in a multidisciplinary integrated approach. In this study, time constraints were identified as a limitation preventing physicians from reviewing medicine lists for older people. This impedes the process of deprescribing medicines noted to be unnecessary and/or harmful. One way to implement deprescribing is to conduct compre- hensive deprescribing reviews. Physicians and pharmacists have worked together using a mul- tidisciplinary approach to reduce polypharmacy and inappropriate medication use (IMU) in older people by carrying out comprehensive medicine reviews [13–16]. The GPs in this study, perceived that treating multimorbid patients, required a collective effort from different health care professional groups. This approach could really help deliver patient-centred care, especially if the patient and/or their family are involved in the process. “I think if you made medicine reviews compulsory, I think it could be very useful. When people have incentives, for example, if they had to do it for accreditation, they will do it, PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 14 / 20 Challenges and Enablers of Deprescribing otherwise it’s not going to happen. It’s simple, you know? People just don’t have, I mean we’re all busy, and don’t have tons of time. I think we need to carry out medication reviews, and not miss people out. Sometimes its good to have somebody else look at it, so working together with a pharmacist is a good idea. Because I think two pairs of eyes looking at the same page, often gets better results than one person looking at a patient.” GP9 “Its little things you know, such as, how about considering a medicine review on this patient as they meet the criteria you know for a medicine review?” GP7 “I’m not against talking with a pharmacist or a geriatrician for half a dozen, ten patients that you look through and even a consultant, and say we’re looking at that for that person. I mean that to me (speaking to a pharmacist and a geriatrician about some patients) would be a reasonable thing, as well (if) it didn’t take too much time and it wasn’t too difficult to pre- pare. Theme 4: Deprescribing enablers And that’s the critical thing. And if you’re not, you’re not.” GP4 2) Adequate reimbursement. GPs in this study felt that the overall structure of residential care prescribing and reimbursement systems are disorganised. Prescribing for older people in residential care is viewed as cumbersome for many, as time constraints and limited resources 15 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Challenges and Enablers of Deprescribing prevent this process from being carried out efficiently. In addition, they felt that they received insufficient compensation for the amount of work and attention that this area of prescribing requires. These opinions were not exclusive to our study and are similar to the views of GPs in other studies [12, 19, 24]. “The challenges are around time coordination, and um, GPs invariably complain they don’t have enough time. But being cynical, not much here, and long enough in the tooth, that if you pay people adequately, they will make the time. A lot of this is under-funded, and it takes time outside people’s main surgery working hours. GP5 “Your first challenge is; you go to the rest home. You try and find a nurse. You can never find one. You try and find the notes, hard to find. You can’t find the medicine chart, it could be on the rounds somewhere. It’s not computerised, it doesn’t link with our technical notes at the medical practice, so quality just goes down. It shouldn’t be, but at the practice we’ve got the computer, we’ve got light, we don’t have a darkened room in a rest home, and we can actually see what’s going on.” GP3 If I don’t have my rest home rounds by 7:30 in the morning at least 4 days a week, I barely finish up with the rest of my rest home work then occurring jammed in at lunchtime or at 6 o’clock at night, 7 o’clock at night, when you. . . the nurse may no longer be on duty, the patient’s tired, it all turns to custard. So it is not accorded a high, a very high priority and does take place at these extreme ends of the day, and whereas if it’s adequately funded, for you know, 8–8:30 in the morning, and it’s properly funded, and everybody’s there and ready to go, GP’s will go. PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Theme 4: Deprescribing enablers But while it’s as ad-hoc, as it is, it’s seen as a chore and it’s not well done.” GP5 “Um, I think having adequate funding for older people so that you have time to really think about what they are having so, and Care Plus (a recent government funding initiative) has been good from that point of view, because it gives some extra funding for people like this who have complex health problems. So that has been a real help having enough you know, that recognition of the time involved in reviewing people adequately in rest homes. So that’s really, so that’s’ fine at the moment. I hope they don’t remove that, because it just puts the cost on patients if you’re going to give time to reviewing their medication. So you know there’s nothing additional that I would do, yeah.” GP6 3) Better communication between physicians at health interfaces. Clear and transparent communication is essential between GPs in primary care, specialists and hospital physicians. Integrated health care meetings between GPs and specialists, and information technology to clearly outline patient plans in terms of prognosis and care, are some strategies that can improve seamless care for a multimorbid older individual. Bidirectional communication between GPs in primary care and physicians at the hospital is crucial. This would improve the suitability of medicines prescribed to patients and in some cases, may prevent inappropriate medicines being prescribed. Furthermore, better communication would help physicians to ‘speak with one voice’ which would result in greater satisfaction for both physicians and patients, as different stories provoke distrust [12, 22]. “The reverse of hospitals putting them on medications, is that hospitals stop medications sometimes, and a week later they start them on all of the medicines again, so that sort of communication needs to be taken into consideration.” GP1 16 / 20 PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Challenges and Enablers of Deprescribing “If we could stop hospital physicians prescribing single issue medicines for compromised older people, we’d reduce our problems by 50% overnight.” GP5 “I think we are not daring enough, and I think the communication between the hospital and us (GPs in primary care) could be far better.” GP9 4) Deprescribing guidelines, GP education and GP empowerment. Theme 4: Deprescribing enablers Experiences of prac- tising physicians in this study and other studies, suggest that they struggle with the uncertain- ties of applying disease-specific guidelines to older people with multimorbidity [23]. One qualitative study, by Smith et al., reported that having a multimorbidity focus in GP training is important as GPs expressed that they lacked confidence and felt that they needed more training and clinical support [25]. Another study by Herzog et al., reported that specific geriatric train- ing for GPs is likely to have a positive effect and may help overcome some of the barriers out- lined earlier [19]. In the present study, one GP also highlighted the need for improving GPs’ awareness on such issues. “Improve GPs’ awareness or education on the issues (involved with prescribing for multi- morbid patients), and um, perhaps the medicine review service.” GP7 Improving GPs’ awareness can be augmented by positive testimonies from GPs. This may also help empower GPs, and could encourage them to deprescribe. One GP in this study spoke about the positive outcomes they observed after implementing deprescribing. “Since I’ve started to look at that more globally, the number of medicines I’m prescribing on average for patients in rest homes is about 50% of what I was prescribing a year ago and they aren’t falling off their perch in greater numbers. Patients like it (being prescribed less medicines). They say oh, a whole big meal of pills, and you know, people are generally bet- ter. People wake up, they’re less nauseated, they have fewer falls, all those sorts of things, yeah. GP5 In addition, this study illustrates that GPs feel pressured into continuing the prescription of certain medicines initiated by specialists; even if they question the medicines’ suitability. GPs also find it more difficult to convince their patients of certain changes, as people may perceive physicians in the hospital to have more experience or knowledge. PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 Strengths and Limitations A qualitative semi-structured design enabled us to capture the various challenges and opinions GPs faced with deprescribing. The qualitative methods used were appropriate for exploring the topic of deprescribing challenges and enablers, and they met the criteria for “trustworthiness” established by Lincoln and Guba in 1986 [30, 31]. Credibility was achieved through prolonged engagement with the data, reading and examining in-depth interviews and interview notes written by NA. Transcriptions were read twice, checked and coded initially by NA. Coding was independently checked by JT. Transferability was achieved by independent checking of inter- pretations made in this article, by JT, PN and DM. Implementation of the Theoretical Domains Framework [17], elicited both environmental and physician-related factors involved in implementing deprescribing; a practice which is cur- rently not widespread. The Theoretical Domains Framework covered a wide range of topics, and was easy to implement during the analysis of the interviews. Due to the limited participation of GPs, our respondent sample is not representative of all GPs, regions or jurisdictions. GPs were aware of the interviewer being a pharmacist hence their opinions on involving pharmacists could have been skewed. Their opinions might also have influenced positively or negatively by their experiences of working alongside pharmacists com- pared with physicians in other jurisdictions who have not worked with pharmacists. GPs might have provided a socially desirable response to some interview questions. For example, when asked if deprescribing guidelines would be useful in their everyday clinical practice, GPs may have expressed the need for them. However, in their everyday practice, they might not like to refer to them. Interviews were conducted face-to-face rather than utilising a focus group design. The advantages of such interviews may include that GPs would be more comfortable expressing their honest and unbiased opinions in this setting, rather than in a focus group, where peer pressure might play a role in influencing their responses. Disadvantages of conducting inter- views could include having limited discussion and expansion of the reasoning behind the dif- ferent responses. A focus group could have offered a greater deal of diversity and an opportunity to discuss different issues. However, a focus group would have been more difficult to conduct in an impartial manner to ensure that every participant’s opinions were heard and noted. This study is exploratory in nature with the sole purpose of understanding barriers and enablers to deprescribing in a residential care setting. Theme 4: Deprescribing enablers “Yeah, look the big doctor in the white coat in the big house on the hill always knows more than the GP especially the house surgeon who might have a brief amount of experience and does what they’re told and one of the issues with this process is, experienced GP’s still think that the doctor up the road knows more.” GP9 Therefore, it is important to ensure that current GP training meets the needs of GPs, and is focused around delivering patient-centered care for older people with multiple comorbidities. In addition, further work is required to create and disseminate clinical tools, suitable for use in primary care practice as GPs need different approaches, to help them deliver medical care that fulfills their patients’ priorities [23]. These strategies need to allow GPs to employ flexibility in implementing prescribing guidelines, while responding to the individuals’ needs and prefer- ences [29]. This will in turn empower GPs and provide them with the confidence needed to be experts in prioritising medicines and stopping medicines initiated by specialists who would PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 17 / 20 Challenges and Enablers of Deprescribing have dealt with one particular patient issue, without considering all other aspects of the patient’s care. have dealt with one particular patient issue, without considering all other aspects of the patient’s care. Strengths and Limitations The main limitation is the sample size, however saturation of ideas was reached within the sample. Despite some limitations, this study clearly highlights the challenges of deprescribing in the residential care setting. It also brought to light, based on the GPs’ cumulative opinions and experiences of prescribing for older people in this setting, possible enablers to deprescribing. Conclusion The process of deprescribing in a multimorbid older individual is laced with many challenges for GPs. These include time and process pressures, a chaotic prescribing environment, a lack of value assigned to deprescribing in medical care processes and in families’ perceptions and a lack of specific evidence-based guidelines applicable for the cessation of medicines in older people. Most GPs also felt cautious when deprescribing, because they feared causing disease relapse or drug withdrawal symptoms in patients. They also feared individuals’ misperception PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 18 / 20 Challenges and Enablers of Deprescribing of patients’ coincident deterioration. Social pressures such as feedback from nurses and a sense of taking on board specialist recommendations influenced GPs’ prescribing. Process barriers involved poor communication between physicians at different health care interfaces to deliver patient-centered care. Enablers of deprescribing included adequate imbursement, improved communication between physicians at health interfaces and appropriate deprescribing guide- lines. Involvement of pharmacists in multidisciplinary teams was perceived to be potentially beneficial. The results of this qualitative study invite further development and testing of depre- scribing guidance for GPs to follow in a residential care setting. Future research should be directed at investigating the benefits and risks of deprescribing as well as possible tools and changes to policies and processes to address barriers and enablers, and provide support for patient-centred care delivered in a residential care setting. Acknowledgments NA’s PhD scholarship has been funded by New Zealand Lottery Health Research. The funder had no involvement in the data analysis, interpretation or manuscript preparation. The study was supported by funding from the New Zealand Pharmacy Education and Research Founda- tion (NZPERF). Author Contributions Conceived and designed the experiments: NJA PSN DM JMT. Performed the experiments: NJA. Analyzed the data: NJA JMT. Contributed reagents/materials/analysis tools: NJA PSN DM JMT. Wrote the paper: NJA PSN DM JMT. PLOS ONE \| DOI:10.1371/journal.pone.0151066 April 19, 2016 References Reeve E, Andrews JM, Wiese MD, Hendrix I, Roberts MS, Shakib S. Feasibility of a patient-centered deprescribing process to reduce inappropriate use of proton pump inhibitors. Ann Pharmacother 2015 Jan; 49(1):29–38. doi: 10.1177/1060028014558290 PMID: 25385826 12. Schuling J, Gebben H, Veehof LJ, Haaijer-Ruskamp FM. 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https://openalex.org/W4286858776	https://zenodo.org/record/6784264/files/molecules-21-6774.pdf	English	null	The Participation of 3,3,3-Trichloro-1-nitroprop-1-ene in the [3 + 2] Cycloaddition Reaction with Selected Nitrile N-Oxides in the Light of the Experimental and MEDT Quantum Chemical Study	Zenodo (CERN European Organization for Nuclear Research)	2,021	cc-by	12,034	Abstract: The regioselective zw-type [3 + 2] cycloaddition (32CA) reactions of a series of aryl- substituted nitrile N-oxides (NOs) with trichloronitropropene (TNP) have been both experimentally and theoretically studied within the Molecular Electron Density Theory (MEDT). Zwitterionic NOs behave as moderate nucleophiles while TNP acts as a very strong electrophile in these polar 32CA reactions of forward electron density ﬂux, which present moderate activation Gibbs free energies of 22.8–25.6 kcal·mol−1 and an exergonic character of 28.4 kcal·mol−1 that makes them irreversible and kinetically controlled. The most favorable reaction is that involving the most nucleophilic MeO- substituted NO. Despite Parr functions correctly predicting the experimental regioselectivity with the most favorable O-CCCl3 interaction, these reactions follow a two-stage one-step mechanism in which formation of the O-C(CCl3) bond takes place once the C-C(NO2) bond is already formed. The present MEDT concludes that the reactivity differences in the series of NOs come from their different nucleophilic activation and polar character of the reactions, rather than any mechanistic feature. Citation: Zawadzi´nska, K.; Ríos-Gutiérrez, M.; Kula, K.; Woli´nski, P.; Mirosław, B.; Krawczyk, T.; Jasi´nski, R. The Participation of 3,3,3-Trichloro-1-nitroprop-1-ene in the [3 + 2] Cycloaddition Reaction with Selected Nitrile N-Oxides in the Light of the Experimental and MEDT Quantum Chemical Study. Molecules 2021, 26, 6774. https://doi.org/ 10.3390/molecules26226774 Academic Editor: Ionel Mangalagiu Keywords: [3 + 2] cycloaddition; nitrile oxides; nitroalkenes; reactivity; molecular mechanism; molecular electron density theory Karolina Zawadzi´nska 1, Mar Ríos-Gutiérrez 2,* , Karolina Kula 1 , Przemysław Woli´nski 1, Barbara Mirosław 3 , Tomasz Krawczyk 4 and Radomir Jasi´nski 1,* 1 Department of Organic Chemistry and Technology, Cracow University of Technology, Warszawska 24, 31-155 Cracow, Poland; karolina.zawadzinska@doktorant.pk.edu.pl (K.Z.); kkula@chemia.pk.edu.pl (K.K.); pwolinski@chemia.pk.edu.pl (P.W.) 2 Department of Organic Chemistry, University of Valencia, Dr. Moliner 50, Burjassot, 46100 Valencia, Spain 3 Department of General and Coordination Chemistry and Crystallography, Maria Curie-Sklodowska University in Lublin, Pl. Marii Curie-Sklodowskiej 3, 20-031 Lublin, Poland; barbara.miroslaw@mail.umcs.pl 4 Department of Chemical Organic Technology and Petrochemistry, Silesian University of Technology, Krzywoustego 4, 44-100 Gliwice, Poland; tomasz.krawczyk@polsl.pl * C d i @ t i (M R G ) d i @ h i k d l (R J ) 2 Department of Organic Chemistry, University of Valencia, Dr. Moliner 50, Burjassot, 46100 Valencia, Spain 3 Department of General and Coordination Chemistry and Crystallography, Maria Curie-Sklodowska University in Lublin, Pl. Marii Curie-Sklodowskiej 3, 20-031 Lublin, Poland; barbara.miroslaw@mail.umcs.pl 4 Department of Chemical Organic Technology and Petrochemistry, Silesian University of Technology, Krzywoustego 4, 44-100 Gliwice, Poland; tomasz.krawczyk@polsl.pl y g y p p * Correspondence: rios@utopia.uv.es (M.R.-G.); radomir@chemia.pk.edu.pl (R.J.) y g y p p * Correspondence: rios@utopia.uv.es (M.R.-G.); radomir@chemia.pk.edu.pl (R.J.) molecules molecules molecules Article The Participation of 3,3,3-Trichloro-1-nitroprop-1-ene in the [3 + 2] Cycloaddition Reaction with Selected Nitrile N-Oxides in the Light of the Experimental and MEDT Quantum Chemical Study Karolina Zawadzi´nska 1, Mar Ríos-Gutiérrez 2,* , Karolina Kula 1 , Przemysław Woli´nski 1, Barbara Mirosław 3 , Tomasz Krawczyk 4 and Radomir Jasi´nski 1,* 1. Introduction Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional afﬁl- iations. Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional afﬁl- iations. Organic compounds containing an isoxazoline motif as a core unit are known to provide an extensive variety of biological activities such as antibacterial, antifungal, anti- cancer, anticonvulsant, anti-inﬂammatory, antiviral, and antidepressant [1,2]. One of the most successful approaches to obtain these valuable skeletons, because of its simplicity, efﬁciency and high selectivity, is the [3 + 2] cycloaddition (32CA) reaction of nitrile oxides (NOs), participating as the three-atom-component (TAC), with an appropriate alkenes (Scheme 1) [3–5]. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// Scheme 1. General synthesis of 2-isoxazolines via 32CA reaction of NOs with substituted alkenes. creativecommons.org/licenses/by/ creativecommons.org/licenses/by/ 4.0/). Scheme 1. General synthesis of 2-isoxazolines via 32CA reaction of NOs with substituted alkenes. Molecules 2021, 26, 6774. https://doi.org/10.3390/molecules26226774 https://www.mdpi.com/journal/molecules 2 of 19 Molecules 2021, 26, 6774 The application of the Molecular Electron Density Theory (MEDT) to the study of 32CA reactions has allowed classifying these reactions into four different types depending on the electronic structure of TACs [6,7]. Thus, NOs, which usually present a zwitteri- onic electronic structure, participate in zwitterionic-type (zw-type) 32CA reactions, which demand favorable nucleophilic/electrophilic interactions between the reagents to take place easily experimentally. Substitution may change the parent electronic structure of the simplest TACs and, therefore, the reactivity of actual experimental TACs. p y p Aryl NOs are one of the most common types of experimentally used NOs. The theoretical study of the 32CA reactions of benzonitrile oxide with several alkenes such as N-vinyl pyrrol [8], carvone [9], tomentosin [10], 3-nitroprop-1-ene [11] and methyl acrylate [12] allowed conﬁrming the zwitterionic reactivity of aryl NOs in zw-type 32CA reactions, in which, interestingly, the C-C single bond was always formed prior to the O-C one. Trihalomethylated organic molecules also present valuable potential in pharmacy. Since the trihalomethyl group greatly withdraws electrons, its presence in compounds can hugely improve molecular properties such as bioactivity, lipophilicity and metabolic stabil- ity. Moreover, increased lipophilicity leads to an increase in therapeutic efﬁciency or the ability to penetrate the blood-brain barrier [13,14]. 1. Introduction Triﬂuoromethylated compounds are the most commonly used molecules of this type [15], however, in recent years, trichloromethy- lated compounds are gaining importance as sedative-hypnotic agents [16] and antitubercu- lar components [17], for instance. p The biological activity of these compounds can be additionally stimulated by the pres- ence of the nitro group [18,19]. The NO2 group gives interesting potential possibilities for different-type functionalization in amines, nitrosocompounds, oximes, nitronates and many other [20–23]. Consequently, structures containing CX3 and NO2 functional groups are very attractive materials for further applications. The synthesis of these type of compounds is relatively easy using the corresponding 3,3,3-trihalo-1-nitroprop-1-enes as precursors. In the literature, some examples of the application of 3,3,3-trichloro-1-nitroprop-1-ene (TNP) as component of cycloaddition processes are available [24,25]. The stability of cycloadducts obtained via 32CA reactions involving TNP is very variable. In some cases, the presence of the trichloromethyl CCl3 group strongly stabilizes the heterocyclic systems, compared to the analogs substituted with other functional groups. For example, 2,3,3-triphenyl-4-nitroisoxazolidine [26] is very unstable; it easily decomposes via retro-cycloaddition process even at 60–80 ◦C. However, structurally similar 2,3,3- triaryl-4-nitro-5-trichloromethylisoxazolidines melt at 106–195 ◦C with no decomposition (Scheme 2) [27,28]. Scheme 2. Different stability of cycloadducts obtained from 32CA reactions of triarylnitrones with different-type conjugated nitroalkenes. Scheme 2. Different stability of cycloadducts obtained from 32CA reactions of triarylnitrones with different-type conjugated nitroalkenes. In other cases, the presence of the CCl3 group is not enough to stabilize the corre- sponding cycloadduct. For instance, diaryldiazomethanes react with TNP yielding unstable 5-nitropyrazoline systems, which surprisingly converted very fast into the corresponding 4-dimethylvinylpyrazolines via hydrochloride extrusion (Scheme 3) [24,25]. It should be Molecules 2021, 26, 6774 3 of 19 3 of 19 underlined at this point that the HCl extrusion from molecular systems including the CCl3 group is very rare and was unobserved earlier in ﬁve-membered heterocycles. underlined at this point that the HCl extrusion from molecular systems including the CCl3 group is very rare and was unobserved earlier in ﬁve-membered heterocycles. Scheme 3. The course of the reaction between diaryldiazomethanes with TNP. Scheme 3. The course of the reaction between diaryldiazomethanes with TNP. 1. Introduction Given the importance of the isoxazoline framework and the biological activities originated by the presence of the CCl3 and NO2 groups, we decided to shed light on the participation of TNP 2 in the 32CA reactions with a series of substituted aryl nitrile N-oxides 1a–e of different nucleophilic character yielding isoxazolines 3a–e (Scheme 4), as a continuation of our comprehensive study about the reactivity of this type of TAC. In particular, we performed an experimental study of the reaction course and structural analysis of reaction products, as well as theoretical investigations regarding the molecular mechanism of cycloadduct formation and nature of relevant structures along the reaction paths, in the framework of MEDT as a modern view of organic chemical reactivity [29]. Our aim is to check on the stability of isoxazolines including the CCl3 group and the effect of substitution on the reactivity of aryl NOs, providing signiﬁcant experimental and theoretical insight to help future designs of syntheses of trichloromethyl-functionalized isoxazoline analogs with interesting potential applications. Scheme 4 Considered 32CA reactions of NOs 1a e with TNP 2 Scheme 4. Considered 32CA reactions of NOs 1a–e with TNP 2. Scheme 4. Considered 32CA reactions of NOs 1a–e with TNP 2. 2.1. Experimental Study First, the precursors for the ﬁve aforementioned NOs 1a–e were prepared by con- version of the corresponding aromatic aldehydes into the respective oximes via the well- known [30] reaction involving hydroxylamine hydrochloride Subsequent chlorination of the corresponding oximes to yield the hydroximinoyl chlorides precursors was carried out with N-chlorosuccinimide in N,N-dimethylformamide [31]. Next, the preparation of the TNP 2 was carried out via the Henry condensation between chloral hydrate and nitromethane [32]. The obtained trichloronitropropanol was converted into the expected nitroalkene via a two-step protocol consisting of esteriﬁcation and acetic acid extrusion stages [33]. g The considered 32CA reactions can in principle yield two regioisomeric cycloadducts (Scheme 4). The optimization of the reaction conditions was performed for the model reaction between 4-methylbenzonitrile N-oxide 1a and TNP 2. For the generation of NO 1a, different-type protocols were tested. The relatively highest yield of the expected product was obtained (temp: 25 ◦C, time: 24 h, molar ratio hydroxamoyl chlorides/nitroalkene Molecules 2021, 26, 6774 4 of 19 1:1.25). Regardless of the reaction conditions (Table 1), only one cycloadduct along with certain amounts of the respective furoxane (which is a secondary product of the dimer- ization of NOs) [34] was detected by comprehensive HPLC analysis of the reaction and post-reaction mixtures. Under optimized conditions, the yield of nitroisoxazoline 3a is about 45%, together with the furoxan mentioned above, whose yield signiﬁcantly depends on the reaction conditions (Table 1). The obtained 2-isoxazoline molecular system was isolated via simple fractional crystallization and identiﬁed based on the spectral data. Table 1. Optimization of reaction conditions for model 32CA reaction between TNP 2 and nitrile N-oxide 1a. Method Base Temp. [◦C] Time [h] Molar Ratio Hydroxamoyl Chlorides/Nitroalkene Yield [%] Isoxazoline Furoxan 1 K2CO3 25 (r.t.) 24 1:1.25 40.0 1.0 66 (reﬂux) 6 1:1.25 40.0 8.1 2 TEA 25 (r.t.) 24 1:1.25 44.4 0.9 66 (reﬂux) 6 1:1.25 43.5 5.0 1 K2CO3 25 (r.t.) 24 1:2 9.8 0.8 66 (reﬂux) 6 1:2 25.6 7.5 2 TEA 25 (r.t.) 24 1:2 20.8 0.7 66 (reﬂux) 6 1:2 47.6 10.6 ble 1. Optimization of reaction conditions for model 32CA reaction between TNP 2 and nitrile N-oxide 1a. For post-analysis, HR-MS data were analyzed first. It was found that the isolated compound (3a or 4a) gave a pseudo-molecular ion 320,9601mDa [M-H]−(see Supplementary Materials) which corresponds with the proposed C11H8N2O3Cl3 molecular formula. 2.2.1. Analysis of the Electronic Structures of the Reagents 2.2.1. Analysis of the Electronic Structures of the Reagents One appealing procedure that provides a straightforward connection between the electron density distribution and the chemical structure is the quantum chemical analysis of Becke and Edgecombe’s Electron Localization Function (ELF) [37]. Thus, to gain insight about the reactivity of the reagents involved in the aforementioned 32CA reactions, their electronic structure was characterized through the topological analysis of the ELF and Natural Population Analysis (NPA) of their charge distribution. Herein, only the results for NOs 1b and 1e, and TNP 2 are commented on (Figure 2), while those for the three remaining NOs are given in Table S4 in Supplementary Material. Figure 2. ωB97X-D/6-311G(d,p) ELF basin attractor positions together with some relevant valence basin populations, as well as the proposed Lewis-like structures together with the natural atomic charges, of NOs 1b,e and TNP 2. Populations and charges are given in average number of electrons, ¯e. Negative, negligible and positive charges are shown in red, green and blue colors, respectively. Figure 2. ωB97X-D/6-311G(d,p) ELF basin attractor positions together with some relevant valence basin populations, as well as the proposed Lewis-like structures together with the natural atomic charges, of NOs 1b,e and TNP 2. Populations and charges are given in average number of electrons, ¯e. Negative, negligible and positive charges are shown in red, green and blue colors, respectively. The topological analysis of the ELF (Figure 2) reveals a similar electronic structure for the ﬁve NOs. All of them present two V(O1) and V’(O1) monosynaptic basins integrating a total average of 5.67 ¯e, a V(O1,N2) disynaptic basin integrating 1.69 ¯e, two V(N2,C3) and V’(N2,C3) disynaptic basins integrating a total average of 6.00 ¯e, and a V(C3,C3′) disynaptic basin integrating an average of 2.48 ¯e. These features allow constructing Lewis- like structures with an O1 non-bonding region, an O1-N2 single bond, an N2-C3 triple bond and a C3-C3′ single bond. The absence of any reactive pseudoradical or carbenoid center and the presence of a multiple bond indicates that these NOs have a zwitterionic electronic structure just as the simplest acetonitrile oxide 5 [38] and, consequently, they will participate in zw-type 32CA reactions [39]. p p NPA shows (Figure 2) that all the NOs, regardless of the substitution, also present a similar charge distribution. In all of them, the O1 oxygen is negatively charged by ca. 2.1. Experimental Study Bands typical for the NO2 group [35], -N-O- [11,36], and -C=N- [11] moieties in the heterocyclic ring as well as C-Cl bond [35] vibrations were detected in its IR spectrum. Information about stereochemistry of the isolated compound was provided by 1H NMR spectroscopy. Protons associated with the isoxazoline ring form AX spin system. The values of J 4,5 isoxazoline ring coupling constants are found in the range of coupling constants typical for isoxazolines substituted at the 4- and 5- positions with trans conﬁguration of the substituents. The single crystal X-ray diffraction experiment conﬁrmed the formation of a hetero- cyclic compound with the structure presented in Figure 1. The heterocyclic 5-membered cycle is almost ﬂat (RMSD 0.038 Å) and is rotated by 20.6(3)◦relative to the aromatic ring, showing no or little electronic coupling. The torsion angle along the atoms N2-C1-C2-C4 (−128.5(2)◦) shows the ac arrangement of the heterocyclic substituents. Weak hydrogen C-H. . . O/N/Cl bonds stabilize the crystal structure in a centrosymmetric triclinic space group P-1. No π-stacking is observed in the crystal network; instead, pnictogen, chalcogen and halogen atoms participate in short Cl. . . Cl, O. . . O/N contacts (Table S1 in Supplemen- tary Materials). The crystal contains both enantiomers R,R and S,S. Figure 1. Molecular structure of NO 3a obtained from crystal X-ray diffraction experiment (stereoiso- mer 4R,5R). Figure 1. Molecular structure of NO 3a obtained from crystal X-ray diffraction experiment (stereoiso- mer 4R,5R). Molecules 2021, 26, 6774 5 of 19 Likewise, the other 32CA reactions involving NOs 1b–e were explored. In all cases, only 3-aryl-4-nitro-5-trichloromethylisoxazolines (3b–e) were isolated and identiﬁed by spectral analyses. 2.2. Theoretical Study To explain and understand the above experimental outcomes, a MEDT study of these 32CA reactions was carried out. This study is divided in the following sections: (i) analysis of the electronic structures of the reagents; (ii) analysis of the Conceptual DFT (CDFT) reactivity indicators; (iii) study of the potential energy surfaces associated with the ﬁve considered reactions; and (iv) characterization of the molecular mechanism associated with the 32CA reactions of NOs 1b and 1e with TNP 2. 2.2.2. Analysis of the CDFT Reactivity Indices of the Reagents 2.2.2. Analysis of the CDFT Reactivity Indices of the Reagents CDFT [41,42] is a powerful tool to predict and understand the reactivity in organic reactions as it allows the characterization of the electrophilic and nucleophilic behaviors of molecules both qualitative and quantitatively. Thus, to discern any reactivity changes asso- ciated with the aryl substitution at NOs 1a–e and characterize their behavior towards TNP 2, the global CDFT reactivity indices of every reagent, namely the electronic chemical po- tential µ, chemical hardness η, global electrophilicity ω and global nucleophilicity N, were computed and analyzed (Table 2). These global indices were calculated at the B3LYP/6- 31G(d) computational level to make proper classiﬁcations based on the electrophilicity and nucleophilicity scales, which were established at that level [41–44]. Table 2. B3LYP/6-31G(d) electronic chemical potential µ, chemical hardness η, electrophilicity ω and nucleophilicity N indices, in eV, of NOs 1a–e and TNP 2. Compound µ η ω N 1b −3.42 4.91 1.19 3.24 1a −3.69 4.97 1.37 2.95 1c −3.85 5.02 1.47 2.76 1d −4.12 4.96 1.71 2.52 1e −5.04 4.03 3.15 2.07 2 −5.84 5.22 3.27 0.67 Table 2. B3LYP/6-31G(d) electronic chemical potential µ, chemical hardness η, electrophilicity ω and nucleophilicity N indices, in eV, of NOs 1a–e and TNP 2. In polar reactions there is a ﬂux of electron density from the species with higher electronic chemical potential [43] to the ones with lower electronic chemical potential. In polar reactions there is a ﬂux of electron density from the species with higher electronic chemical potential [43] to the ones with lower electronic chemical potential. The electronic chemical potentials of NOs 1a–e, which range by between −3.42 (1b) and −5.04 (1e) eV, are considerably higher than that of TNP 2, −5.84 eV. Consequently, if the 32CA reactions between NOs 1a–e and TNP 2 are polar (see later), the electron density will ﬂux from the former to the latter species in a forward electron density ﬂux (FEDF) fashion [44,45]. The chemical hardness η of the NOs range by between 4.03 (1b) to 5.02 (1c) eV; only the η of 1e signiﬁcantly differs from the rest, being a softer species. TNP 2 is the hardest species with η = 22 eV. The electrophilicity ω indices [46] of the NOs range by between 1.19 (1b) and 3.15 (1e) eV. 2.2.1. Analysis of the Electronic Structures of the Reagents 0.4 e, while the N2 and C3 atoms are positively charged by ca. 0.2 e. This picture contrasts with Huisgen’s representation of NOs as 1,2-zwitterionic species [40]. On the other hand, the ethylene moiety at TNP 2 is negatively charged by −0.22 e at C4 and −0.06 e at C5, which Molecules 2021, 26, 6774 6 of 19 might be unexpected taking into account the electron-withdrawing character of both CCl3 and NO2 groups. might be unexpected taking into account the electron-withdrawing character of both CCl3 and NO2 groups. 2.2.2. Analysis of the CDFT Reactivity Indices of the Reagents According to the electrophilicity ω scale [47] 1a and 1b are classiﬁed as moderate elec- trophiles with ω values below 1.5 eV, 1c lays on the borderline between moderate and strong electrophiles, while 1d and 1e are strong electrophiles. Please note that 1e is actually a very strong electrophile with a ω value above 3.0 eV. On the other hand, the nucle- ophilicity N indices of NOs range from 2.07 (1e) to 3.24 (1b) eV. Within the nucleophilicity scale [48] 1b is classiﬁed as strong nucleophile, 1a lays on the borderline between moderate and strong nucleophiles, while 1c–e are classiﬁed as moderate nucleophiles. g p p Given that TNP 2 is classiﬁed as a very strong electrophile with ω = 3.27 eV and as a very poor nucleophile with N = 0.67 eV, and considering the zwitterionic nature of the NOs, it is expected that the zw-type 32CA reaction involving 1b should be the most favorable one, and that the reactivity should decrease in the order 1b > 1a > 1c > 1d > 1e. The global indices also suggest a favorable reaction between moderate-to-strong nucleophiles and a strong electrophile, in agreement with the computed activation Gibbs free energies (see later). By approaching a non-symmetric electrophilic/nucleophilic pair along a polar or ionic process, the most favorable reactive channel is that associated with the initial two-center interaction between the most electrophilic and nucleophilic centers of the reagents [49]. Thus, to characterize the most nucleophilic and electrophilic centers of these species, the 7 of 19 Molecules 2021, 26, 6774 nucleophilic Pk−Parr functions of NOs 1a–e and the electrophilic Pk+ Parr functions of TNP 2 were analyzed [50]. Parr functions were calculated at the ωB97X-D/6-311G(d,p) level. y p Analysis of the nucleophilic Pk−Parr functions at the reactive sites of NOs 1a–e clearly indicates that the most nucleophilic center is the O1 oxygen atom with values ranging from 0.39 (1b) to 0.53 (1e) (Figure 3 and Figure S1 in Supplementary Materials). Interestingly, NO 1e, with the strong electron-withdrawing nitro NO2 group, has the strongest nucleophilically activated O1 oxygen, while NO 1b, with the strong electron- donating methoxy MeO group, has the weakest, yet strong, activation. The C3 carbon is not nucleophilically activated in any case. 2.2.2. Analysis of the CDFT Reactivity Indices of the Reagents On the other hand, the C4 carbon adjacent to the trichloromethyl group at TNP 2 is more than twice as electrophilically activated, Pk+ = 0.32, as the C5 carbon near the NO2 group, Pk+ = 0.13. Consequently, the most favorable reaction path along a polar 32CA reaction between NOs 1a–e and TNP 2 would correspond to the O1-C4 interaction, which agrees with the experimental regioselectivity (Scheme 4). In addition, the null nucleophilic activation of the C3 carbon of these NOs accounts for the full regioselectivity experimentally found. Figure 3. Three-dimensional representations of the Mulliken atomic spin densities of the radical cation of NOs 1b,e and the radical anion of TNP 2, together with the nucleophilic Pk−and the electrophilic Pk+ Parr functions of NOs 1b,e and TNP 2, respectively. Figure 3. Three-dimensional representations of the Mulliken atomic spin densities of the radical cation of NOs 1b,e and the radical anion of TNP 2, together with the nucleophilic Pk−and the electrophilic Pk+ Parr functions of NOs 1b,e and TNP 2, respectively. Figure 3. Three-dimensional representations of the Mulliken atomic spin densities of the radical cation of NOs 1b,e and the radical anion of TNP 2, together with the nucleophilic Pk−and the electrophilic Pk+ Parr functions of NOs 1b,e and TNP 2, respectively. 2.2.3. Study of the Potential Energy Surfaces Associated with the 32CA Reactions between NOs 1a–e and TNP 2 Due to the non-symmetry of the reagents and the linear structure of NOs 1a–e, the 32CA reactions between NOs 1a–e and TNP 2 can only take place along two regioisomeric reaction paths depending on the relative position of the R-aryl substituent of NOs 1a–e with respect to the nitro NO2 group of TNP 2; namely A, associated with the O1-C4 two-center interaction leading to ortho isoxazolines 3a–e, and B, associated with the C3-C4 two-center interaction leading to meta isoxazolines 4a–e (Scheme 5). Analysis of the potential energy surfaces allowed ﬁnding only one TS for each reaction path, indicating that these reactions follow a one-step mechanism. Electronic energies in gas phase and in solvent are given in Table S6 in Supplementary Materials, full thermodynamic data are gathered in Table S7 in Supplementary Materials, while relative enthalpies and Gibbs free energies are graphically represented in Figure 4. Scheme 5. Regioisomeric reactions paths associated with the 32CA reactions of NOs 1a–e with TNP 2. ‡: the symbol indicates a transition state. Scheme 5. 2.2.2. Analysis of the CDFT Reactivity Indices of the Reagents Regioisomeric reactions paths associated with the 32CA reactions of NOs 1a–e with TNP 2. ‡: the symbol indicates a transition state. 8 of 19 Molecules 2021, 26, 6774 Figure 4. ωB97X-D/6-311G (d,p) enthalpy, in blue, and Gibbs free energy, in red, proﬁles, in kcal·mol−1, for the competitive reaction paths associated with the 32CA reactions of NOs 1a–e with TNP 2. Figure 4. ωB97X-D/6-311G (d,p) enthalpy, in blue, and Gibbs free energy, in red, proﬁles, in kcal·mol−1, for the competitive reaction paths associated with the 32CA reactions of NOs 1a–e with TNP 2. The activation enthalpies of the considered reaction paths range by between 8.4 (TS-o-b) and 12.6 (TS-m-e) kcal·mol−1, while the reaction enthalpies are found in the narrow range of −43.8 and −44.6 kcal·mol−1. After inclusion of room temperature and entropies to enthalpies, the relative Gibbs free energies are by between 13.6 and 15.8 kcal·mol−1 higher as a consequence of the unfavorable entropies associated with these bimolecular processes. Thus, the activation Gibbs free energies reach values of 22.8–26.8 kcal·mol−1, while formation of cycloadducts is exergonic by 28.3–28.9 kcal·mol−1. Some appealing conclusions can be drawn from these energy proﬁles: (i) in agree- ment with the experimental outcomes, the ﬁve 32CA reactions are ortho regioselective, as the meta TSs are found between 1.2 and 2.3 kcal·mol−1 above the ortho ones in the Gibbs free energy proﬁles (Figure 4); (ii) the activation Gibbs free energies decrease in the order NO2 > Cl > F > Me > MeO, in complete agreement with the analysis of the CDFT indices (see Section 2.2.2); (iii) these 32CA reactions are kinetically and thermodynamically favorable, and their strong exergonic character makes them irreversible, formation of the corresponding cycloadducts being therefore under kinetic control; (iv) the strong exergonic character of the reactions points out the very high stability of cycloadducts presenting the trichloromethyl CCl3 group. Please note that the corresponding analog of 3b without CCl3 is 1.8 kcal·mol−1 less stable; and ﬁnally, (v) the substitution at benzonitrile N-oxide has an important role increasing the reaction rates. Please note that the activation Gibbs free ener- gies of the reaction of unsubstituted benzonitrile N-oxide with TNP 2 is 23.5 kcal·mol−1, which means a reaction rate 3.5 times lower. The activation enthalpies of the considered reaction paths range by between 8.4 (TS-o-b) and 12.6 (TS-m-e) kcal·mol−1, while the reaction enthalpies are found in the narrow range of −43.8 and −44.6 kcal·mol−1. 2.2.2. Analysis of the CDFT Reactivity Indices of the Reagents This result indicates that while the ortho isoxazolines 3a–e are expected to be the major isomers, formation of the meta isoxazolines 4a–e should be negligible, in clear agreement with the experimental outcomes (Scheme 4). This result emphasizes that the extent of regioselectivity cannot be predicted simply by ∆∆G‡ between regioisomeric TSs. Table 3. Calculated composition of the reaction mixture for the 32CA reactions of NOs 1a–e with TNP 2. 3 4 Cl (d) 91.4 8.6 MeO (b) 98.0 2.0 NO2 (e) 88.7 11.3 F (c) 97.1 2.9 Me (a) 98.1 1.9 alculated composition of the reaction mixture for the 32CA reactions of NOs 1a–e with Table 3. Calculated composition of the reaction mixture for the 32CA reactions of NOs 1a–e with TNP 2. The optimized geometries of the regioisomeric TSs involved in the 32CA reactions of NO 1b with TNP 2 in THF are displayed in Figure 5, while the rest are given in Figure S1 in Supplementary Materials. The distances do not signiﬁcantly change with the substitution of the TAC. Thus, at the more favorable ortho TSs, the average O1-C4 distance is 2.074 Å, while the average C3-C5 distance is 2.234 Å. At the meta TSs, the average distance between the O1 and C5 atoms is 2.133 Å, while that between the C3 and C4 atoms is 2.184 Å. Some information can be extracted from these geometrical data: (i) the more favorable ortho TSs are geometrically more asymmetric, ∆d = 0.155 Å, than the meta ones, ∆d = 0.051 Å, which can be considered almost symmetrical; (ii) the O-C distance is always shorter than the C-C one; (iii) taking into account the C-C and C-O bond formation distances characterized from previous ELF topological analyses [6], it can be concluded that neither O-C nor C-C bond formation has started yet at any of these TSs; and (iv) the heterocyclic 5-membered cycle in NO 1b is rotated by 11.7◦relative to the aromatic ring and the torsion angle along the atoms N2-C1-C2-C4 is −117.3◦, which are 8.9◦and 11.2◦lower than the respective experimental X-ray diffraction data (see Section 2.1). The polar character of these zw-type 32CA reactions was evaluated by computing the global electron density transfer (GEDT) [52,53] at the TSs. The GEDT values in THF range by between 0.11 and 0.15 e. These values indicate that the corresponding zw-type 32CA reactions have somewhat polar character. 2.2.2. Analysis of the CDFT Reactivity Indices of the Reagents After inclusion of room temperature and entropies to enthalpies, the relative Gibbs free energies are by between 13.6 and 15.8 kcal·mol−1 higher as a consequence of the unfavorable entropies associated with these bimolecular processes. Thus, the activation Gibbs free energies reach values of 22.8–26.8 kcal·mol−1, while formation of cycloadducts is exergonic by 28.3–28.9 kcal·mol−1. y g y Some appealing conclusions can be drawn from these energy proﬁles: (i) in agree- ment with the experimental outcomes, the ﬁve 32CA reactions are ortho regioselective, as the meta TSs are found between 1.2 and 2.3 kcal·mol−1 above the ortho ones in the Gibbs free energy proﬁles (Figure 4); (ii) the activation Gibbs free energies decrease in the order NO2 > Cl > F > Me > MeO, in complete agreement with the analysis of the CDFT indices (see Section 2.2.2); (iii) these 32CA reactions are kinetically and thermodynamically favorable, and their strong exergonic character makes them irreversible, formation of the corresponding cycloadducts being therefore under kinetic control; (iv) the strong exergonic character of the reactions points out the very high stability of cycloadducts presenting the trichloromethyl CCl3 group. Please note that the corresponding analog of 3b without CCl3 is 1.8 kcal·mol−1 less stable; and ﬁnally, (v) the substitution at benzonitrile N-oxide has an important role increasing the reaction rates. Please note that the activation Gibbs free ener- gies of the reaction of unsubstituted benzonitrile N-oxide with TNP 2 is 23.5 kcal·mol−1, which means a reaction rate 3.5 times lower. Taking into account that these 32CA reactions take place through favorable kinetic control, the Eyring-Polanyi equation [51] was used to estimate the composition of the reaction mixture. k = kkBT h e−∆G‡ RT (1) (1) From this equation, the relative reaction rate constants krel can be obtained as: krel = e−∆∆G‡ RT (2) (2) were ∆∆G‡ is the difference between the relative activation Gibbs free energies of two TSs, R the gas ideal constant, and T the reaction temperature. The expected percentage of ortho and meta isoxazolines for each reaction are reported in Table 3. Considering the ωB97X-D/6-311G(d,p) Gibbs free energies in tetrahydrofuran Molecules 2021, 26, 6774 9 of 19 9 of 19 (THF) and the reaction temperature, the ortho and meta isoxazolines should be obtained in an average 94.7:5.3 relation; while the reactions of 1a–c present a similar regioselectivity, those involving 1d,e are slightly less regioselective. 2.2.2. Analysis of the CDFT Reactivity Indices of the Reagents The ortho TS are only a hundredth more polar than the meta ones. The GEDT increases in the order NO2 > Cl > F > Me > MeO, in agreement with the increased nucleophilic character in the same order (see Section 2.2.2). This trend in the polar character of the reactions follows the same trend as the computed activation energies, emphasizing the relation between the polarity and reactivity in zw-type 32CA reactions; [39] i.e., the stronger the polar character, the more favorable the reaction. Consequently, the different nucleophilic character of NOs 1a–e is responsible for their different reactivity. 2.2.4. Characterization of the Bond Formation Process 2.2.4. Characterization of the Bond Formation Process The Bonding Evolution Theory (BET) [54], which combines the topological analysis of the ELF with catastrophes theory [54], allows characterizing the electron density rear- rangement along a reaction path and, thus, enables a description of the bonding changes associated with a given molecular mechanism [55,56]. 10 of 19 10 of 19 Molecules 2021, 26, 6774 Figure 5. ωB97X-D/6-311G(d,p) optimized geometries in THF of the regioisomeric TSs involved in the 32CA reaction of NOs 1b with TNP 2. -D/6-311G(d,p) optimized geometries in THF of the regioisomeric TSs involved in the 32CA reaction of Figure 5. ωB97X-D/6-311G(d,p) optimized geometries in THF of the regioisomeric TSs involved in the 32CA reaction of NOs 1b with TNP 2 Figure 5. ωB97X-D/6-311G(d,p) optimized geometries in THF of the regioisomeric TSs involved in the 32CA reaction of NOs 1b with TNP 2. The molecular mechanism of zw-type 32CA reactions involving NOs and different types of ethylene derivatives has already been recently studied [2,9,10,12,53,57–61]. As a general outlook, these reactions start with the depopulation of the C≡N triple bond of the NO framework and the C=C double bond of the ethylene derivative, which gives rise to the creation of the corresponding carbon pseudoradical centers [62]. The electron density at the oxygen atom of the NO also experiences some rearrangement. Then, the bond formation takes place either by coupling of two carbon pseudoradical centers in the case of the C-C single bond [52], or by donation of the oxygen non-bonding electron density to the remaining carbon pseudoradical center in the case of the C-O single bond. In polar reactions, the formation of the ﬁrst single bond takes place between the most nucleophilic center of the nucleophile and the most electrophilic center of the electrophile as characterized by CDFT and the Parr functions. Accordingly, in zw-type 32CA reactions of NOs, this should be the C-O single bond (see Section 2.2.2); however, previous BET studies [57,63] have shown that regardless of the polar character, the C-C single bond forms ﬁrst in 32CA reactions of NOs. Thus, the characterization of the bond formation processes in the 32CA reactions of NOs 1a–e with TNP 2 would not only add valuable information about this question, but would also help identifying any remarkable change in the molecular mechanisms which may account for the observed reactivity differences. 2.2.4. Characterization of the Bond Formation Process To do so, BET was applied over the 32CA reactions of NOs 1b,e with TNP 2 in THF. Only the structures involved in the bond formation are reported and discussed herein. ELF attractor positions for the selected structures involved only in the most favorable reaction of NO 1b are displayed in Figure 6. 11 of 19 Molecules 2021, 26, 6774 Figure 6. Attractor positions of the ELF basins of the selected structures involved in the O1-C4 and C3-C5 single bond formation along the regioisomeric path A of the zw-type 32CA reaction between NO 1b and TNP 2. Electron populations, in average number of electrons, ¯e, are given in brackets. Figure 6. Attractor positions of the ELF basins of the selected structures involved in the O1-C4 and C3-C5 single bond formation along the regioisomeric path A of the zw-type 32CA reaction between NO 1b and TNP 2. Electron populations, in average number of electrons, ¯e, are given in brackets. Analysis of the bonding changes along the 32CA reactions of NOs 1b,e with TNP 2 shows very similar bond formation processes, regardless of the substitution of the TAC. This behavior is in agreement with the similar electronic structures of these NOs (see Section 2.2.1). At the two TSs, both the N2-C3 and C4-C5 bonding regions have been depopulated with respect to the separated reagents (see Section 2.2.1) to 4.29 (TS-o-b) and 4.40 (TS-o-e) ¯e, which can already be considered a double bond and an overpopulated single bond, respectively, but no pseudoradical center is observed yet. Further approach of the two molecular frameworks leads to the creation of pseudoradical centers at the three carbon atoms involved. At S1, the two C3 and C5 pseudoradical centers reach populations of ca. 0.5 and 0.8 ¯e, just before merging each other at S2 to give rise to the formation of the ﬁrst C3-C5 single bond, at a C-C distance of ca. 1.97 Å, with an electron population of 1.48 (S2-b) and 1.33 (S2-e) ¯e. At S3, right before the formation of the second O1-C4 single bond, the non-bonding electron densities associated with both the O1 oxygen and the C4 carbon reach ca. 5.74 and 0.19 ¯e. At S4, formation of the O1-C4 single bond takes place at an O-C distance of ca. 1.76 Å by donation of ca. 2.2.4. Characterization of the Bond Formation Process 0.6 ¯e of the O1 oxygen electron density to the C4 pseudoradical center, whose population has slightly decreased to ca. 0.2 ¯e. The new O1-C4 bond has a population of ca. 0.8 ¯e. At the ﬁnal isoxazolines 3b,e, the O1-C4 and C3-C5 bonds reach ca. 1.34 and 2.02 ¯e. As formation of the second O1-C4 single bond occurs when the ﬁrst C3-C5 formed bond has already reached 78% (1b) and 83% (1e) of its ﬁnal population at 3b,e, it can be considered that these polar zw-type 32CA reactions follow a two-stage one-step mechanism [64]. Indeed, the evolution of the forming bond distances is considerably synchronous (Tables 4 and 5), thus emphasizing that geometrical analyses are not valid to characterize the stage of the bond formation progress. Molecules 2021, 26, 6774 12 of 19 12 of 19 Table 4. Electron populations of the most relevant ELF valence basins and O1-C4 and C3-C5 distances for TS-o-b, isoxazoline 3b and the structures S1-b–S4-b involved in the formation of the O1-C4 and C4-C5 single bonds along the more favorable regioisomeric path A of the 32CA reaction between NO 1b and TNP 2. Populations are given in average number of electrons, ¯e, and distances in angstroms, Å. TS-o-b S1-b S2-b S3-b S4-b 3b d(O1-C4) 2.051 1.865 1.856 1.760 1.751 1.428 d(C3-C5) 2.253 1.999 1.988 1.862 1.850 1.512 V(O1,N2) 1.40 1.31 1.30 1.23 1.23 1.07 V(N2) 2.09 2.44 2.46 2.58 2.60 2.80 V(N2,C3) 2.17 1.81 1.80 1.75 1.74 1.67 V′(N2,C3) 2.12 1.90 1.89 1.81 1.81 1.60 V(C4,C5) 3.45 2.47 2.45 2.29 2.27 2.03 V(O1) 2.83 2.73 2.72 2.65 2.62 2.47 V′(O1) 2.82 2.89 2.89 2.59 2.56 2.42 V′′(O1) 0.51 V(C4) 0.26 0.27 0.18 V(C3) 0.51 V(C5) 0.79 V(C3,C5) 1.32 1.56 1.57 2.01 V(O1,C4) 0.79 1.33 Table 5. Electron populations of the most relevant ELF valence basins and O1-C4 and C3-C5 distances for TS-o-e, isoxazoline 3e and the structures S1-e–S4-e involved in the formation of the O1-C4 and C4-C5 single bonds along the more favorable regioisomeric path A of the 32CA reaction between NO 1e and TNP 2. Populations are given in average number of electrons, ¯e, and distances in angstroms, Å. Table 5. Cycloaddition between Nitrile N-Oxides and 3,3,3-Trichloro-1-nitroprop-1-ene— General Procedure Erlenmeyer ﬂask containing 10 cm3 of THF was placed in an ice bath. Next, 0.003 mole of 3,3,3-trichloro-1-nitroprop-1-ene and 0.0024 mole of hydroximinoyl chloride was added and stirred for 10 min. Then 0.0015 mole of K2CO3 was dosed in small portions during 30 min period. After that time, the ice bath was removed. Change of mixture color and turbidity was observed. The mixture was left for 24 h with constant stirring. The solvent was evaporated and remaining solid was mixed with diethyl ether and ﬁltrated to remove insoluble side products. The ether was removed under vacuum, and remaining crude product was washed with light petroleum ether and crystallized from ethanol. A white crystalline solid was obtained. 3.1.1. Analytical Techniques 3.1.1. Analytical Techniques HPLC analyses was done using a Knauer device with a UV-VIS detector (LiChrospher 18-RP 10 µm column, eluent: 80% methanol). M.p. values were measured on the Boetius apparatus and were uncorrected. IR spectra were derived from the FTS Nicolet IS 10 spectrophotometer. UV/Vis spectra were recorded using spectrometer UV-5100 BIOSENS and was determined for the 200–500nm range. NMR spectra were registered on an Agilent 400 MHz spectrometer using CDCl3 as a solvent. HR-MS spectra were acquired on a UPLC-MS-MS Waters Xevo G2 QTof instrument with ESI ionization. 3.1.2. RTG Analysis The diffraction intensities were collected at room temperature with the use of Super- Nova X-ray diffractometer with Atlas S2 CCD detector using the mirror-monochromatized CuKα radiation (λ = 1.54184 Å). The phase problem was solved by direct methods using the SHELXS-97 program and the structure model reﬁned by the full-matrix least-squares method on F2 using the SHELXL-97 program implemented in Olex2.reﬁne package [65,66]. Details on crystal structure reﬁnement and geometry are given in Tables S1 in Supplemen- tary Materials. y CCDC No. 2,115,222 contains the supplementary crystallographic data for this paper. These data can be obtained free of charge via http://www.ccdc.cam.ac.uk/conts/retrieving. html (accessed on 20 August 2021) (or from the Cambridge Crystallographic Data Centre, 12, Union Road, Cambridge CB2 1EZ, UK; fax: +44-1223-336033). 3.1. Experimental 3.1.1. Analytical Techniques 2.2.4. Characterization of the Bond Formation Process Electron populations of the most relevant ELF valence basins and O1-C4 and C3-C5 distances for TS-o-e, isoxazoline 3e and the structures S1-e–S4-e involved in the formation of the O1-C4 and C4-C5 single bonds along the more favorable regioisomeric path A of the 32CA reaction between NO 1e and TNP 2. Populations are given in average number of electrons, ¯e, and distances in angstroms, Å. TS-o-e S1-e S2-e S3-e S4-e 3e d(O1-C4) 2.105 1.932 1.924 1.770 1.761 1.429 d(C3-C4) 2.217 1.972 1.960 1.771 1.761 1.509 V(O1,N2) 1.44 1.34 1.33 1.23 1.23 1.08 V(N2) 2.01 2.39 2.41 2.61 2.62 2.79 V(N2,C3) 2.25 1.83 1.83 1.74 1.73 1.67 V′(N2,C3) 2.15 1.91 1.90 1.78 1.78 1.61 V(C4,C5) 3.43 2.49 2.47 2.23 2.21 2.04 V(O1) 2.82 2.74 2.73 2.64 2.62 2.47 V′(O1) 2.79 2.84 2.85 2.57 2.54 2.40 V′′(O1) 0.53 V(C4) 0.23 0.24 0.20 V(C3) 0.56 V(C5) 0.75 V(C3,C5) 1.33 1.67 1.68 2.02 V(O1,C4) 0.81 1.34 The most relevant ﬁnding from this BET study is that despite the Parr functions accounting for the solely isolation of regioisomeric isoxazolines 3b,e, formation of the C3-C5 single bond involving the least nucleophilic and electrophilic centers of the reagents The most relevant ﬁnding from this BET study is that despite the Parr functions accounting for the solely isolation of regioisomeric isoxazolines 3b,e, formation of the C3-C5 single bond involving the least nucleophilic and electrophilic centers of the reagents takes place before the expected more favorable O1-C5 one. This unexpected pattern is also observed in previous BET studies of polar zw-type 32CA reactions of NOs [57,63]. On the other hand, the similar bonding changes taking place along the 32CA reactions of the two most electronically different NOs 1b and 1e with TNP 2 indicates that the computed reactivity changes among the series of NOs 1a–e are mainly due to their different nucle- ophilic character and polarity of the corresponding reactions, rather than any structural or mechanistic reason. 13 of 19 13 of 19 Molecules 2021, 26, 6774 3.1.3. Materials The components of the cycloaddition were prepared according to procedures de- scribed in the literature. In particular, nitrile N-oxides were generated in situ from respec- tive hydroxamoyl chlorides, obtained via chlorination of respective oximes according to known procedures [31]. The 3,3,3-trichloro-1-nitroprop-1-ene was synthetized via three- step protocol starting from nitromethane and chloral hydrate [32]. Commercially available (Sigma Aldrich, St. Louis, MO, USA) chemicals were used as solvents and as components for the preparation of addends. 3.2. Computational DFT calculations were performed using the hybrid ωB97X-D functional [67] which includes long-range exchange (denoted by X) correction as well as the semiclassical London- dispersion correction (indicated by sufﬁx-D). The standard 6-311G(d,p) [68] basis set was used, which includes d-type polarization for second row elements and p-type polarization functions for hydrogen atoms. The Berny method was used in optimizations [69,70]. A similar theory level has been commonly used for the mechanistic research aspects of cycloaddition reactions [71–75] The TSs were characterized through frequency analysis, presenting only one imaginary frequency. The intrinsic reaction coordinate (IRC) paths [76] Molecules 2021, 26, 6774 14 of 19 14 of 19 were computed to ﬁnd the unique connection between the TSs and the minimum stationary points using the second order González-Schlegel integration method [77,78]. Solvent effects of THF were considered by full optimization of the gas-phase structures at the same computational level using the polarizable continuum model (PCM) [79,80] in the framework of the self-consistent reaction ﬁeld (SCRF) [81–83]. Values of ωB97X-D/6- 311G(d,p) enthalpies, entropies and Gibbs free energies in THF were calculated with standard statistical thermodynamics at 298.15 K and 1 atm [68]. y The GEDT [52] values were estimated by a natural population analysis (NPA) [84,85] using the equation GEDT(f) = Σq∈f q, were q are the atoms of a framework (f) at the TSs. CDFT reactivity indices [41,42] were calculated at the B3LYP/6-31G(d) computational level because the electrophilicity and nucleophilicity scales were established at that level. The global electrophilicity ω index [46] is given by the following expression, ω = µ2 2η , in terms of the electronic chemical potential µ and chemical hardness η. Both quantities may be approached in terms of the one-electron energies of the frontier molecular orbitals HOMO and LUMO, εH and εL, as µ = (εH+εL) 2 and η = εL −εH, respectively [41]. The global nucleophilicity N index, ref. [86] based on the HOMO energies obtained within the Kohn- Sham scheme, ref. [87] is deﬁned as N = εH(Nu) −εH(TCE), where tetracyanoethylene (TCE) is the reference. Parr functions were calculated at the ωB97X-D/6-311G(d,p) level. All computations were carried out with the Gaussian 16 suite of programs [88]. p p g The topology of the ELF [37] of the ωB97X-D/6-311G(d,p) monodeterminantal wave- functions was carried out using the TopMod [89] package with a cubical grid of step size of 0.1 Bohr. 3.2. Computational The analysis of the bond formation processes was performed by applying the Bonding Evolution Theory (BET) along the corresponding reaction paths; 312 (methoxy) and 337 (nitro) nuclear conﬁgurations along the IRC paths were considered. GaussView program [90] was used to visualize molecular geometries of all the systems as well as the position of the ELF basin attractors. 4. Conclusions Interestingly, despite the more favorable two-center interaction between the O1 and C4 atoms, formation of the C3-C5 bond takes place ﬁrst, through a two-stage one-step mechanism in which formation of the second O1-C4 bond takes place once the C3-C5 bond is practically formed by up to 80%. differences in the series of NOs 1a–e come from the different nucleophilic activation of the TACs and polar character of the reactions, rather than any mechanistic feature. Interestingly, despite the more favorable two-center interaction between the O1 and C4 atoms, formation of the C3-C5 bond takes place ﬁrst, through a two-stage one-step mechanism in which formation of the second O1-C4 bond takes place once the C3-C5 bond is practically formed by up to 80%. Supplementary Materials: The following are available online. Table S1: Crystal X-ray diffraction data for ∆2-isoxazoline (3a); Table S2: Bond lengths (Å) and valence angles (◦) for ∆2-isoxazoline (3a); Table S3: Geometry of interactions in of crystal ∆2-isoxazoline (3a); Table S4: Populations of the most relevant ELF valence basins of NOs 1a,c,d, in average number of electrons, e; Table S5: B3LYP/6-31G(d) HOMO and LUMO energies used for the calculation of the global CDFT indices of NOs 1a–e, in eV; Table S6: Nucleophilic Pk−Parr functions at the O1 and C3 atoms of NOs 1a,c,d; Table S7: ωB97X-D/6-311G(d,p) electronic energies in gas phase and in tetrahydrofuran (THF), in a.u., of the reagents and stationary points involved in the 32CA reactions of NOs 1a–e with TNP 2; Table S8: ωB97X-D/6-311G(d,p) enthalpies (H, in a.u.), entropies (S, in cal·mol−1K−1), and Gibbs free energies (G, in a.u.), and the relative ones with respect to the separated reagents, computed at 25 ◦C, in THF, of the reagents and stationary points involved in the 32CA reaction of NOs 1a–e with TNP 2; Figure S1: ωB97X-D/6-311G(d,p) optimized geometries, in THF, of the regioisomeric TSs involved in the 32CA reaction of NOs 1a,c,d with TNP 2; Figure S2: ωB97X-D/6-311G(d,p) intrinsic reaction coordinate paths, in THF, of the 32CA reactions between NOs 1a,e and TNP 2. Author Contributions: Conceptualization, R.J. and M.R.-G.; methodology, K.Z., P.W., B.M., T.K. and M.R.-G.; software, K.Z., R.J. and M.R.-G.; formal analysis, K.Z., M.R.-G., K.K., P.W., B.M., T.K. and R.J.; investigation, K.Z., M.R.-G., K.K. and R.J.; resources, K.Z. and P.W.; writing—original draft preparation, R.J. and M.R.-G.; writing—review and editing, K.Z. and K.K.; visualization, K.Z., M.R.-G., K.K., B.M. and R.J.; supervision, K.Z., M.R.-G., K.K. 4. Conclusions The zw-type 32CA reactions of a series of aryl-substituted NOs 1a–e with TNP 2 have been both experimentally and theoretically studied within the framework of MEDT. These reactions, carried out at room temperature, during 24 h and using THF as solvent, lead to the formation of single regioisomeric isoxazolines 3a–e with moderate to high yields. Regioisomeric isoxazolines 4a–e were not detected and only little amounts of furoxan, coming from the dimerization of the NOs, were isolated. The topological analysis of the ELF of NOs 1a–e allows characterizing their zwitteri- onic structure, just as that of the simplest acetonitrile oxide, thus being able to participate in zw-type 32CA reactions. No relevant change is observed in the electronic structure within this series of TACs upon substitution, suggesting that the substitution would not lead to major changes in reactivity. j g y Thus, CDFT shows that NOs 1a–e behave as moderate nucleophiles while TNP 2 acts as a very strong electrophile in 32CA reactions of FEDF. According to the nucle- ophilic character of NOs 1a–e, it is expected that the zw-type 32CA reaction involving 1b should be the most favorable one, and that the reactivity should decrease in the order 1b > 1a > 1c > 1d > 1e. The nucleophilic and electrophilic Parr functions characterize the O1 oxygen of the NOs as their most nucleophilic center and the C4 carbon of TNP 2 as its most electrophilic center. Therefore, the expected more favorable regioisomeric isoxazolines are 3a–e, in agreement with the experimental outcomes. The activation Gibbs free energies of the ﬁve 32CA reactions are very similar, ranging from 22.8 to 25.6 kcal·mol−1, while formation of isoxazolines 3a–e is exergonic by ca. 28.4 kcal·mol−1, thus being irreversible and kinetically controlled. All of them present an ortho regioselectivity, in agreement with the experimental obtaining of only 3a–e. The values of GEDT computed at the TSs conﬁrm the polar character of these zw-type 32CA reactions. The BET study of the bond formation processes along the 32CA reactions involving NOs 1b,e indicates a similar bonding pattern for both reactions. Consequently, the reactivity Molecules 2021, 26, 6774 15 of 19 15 of 19 differences in the series of NOs 1a–e come from the different nucleophilic activation of the TACs and polar character of the reactions, rather than any mechanistic feature. 1. Prajapti, S.K.; Shrivastava, S.; Bihade, U.; Gupta, A.K.; Naidu, V.G.M.; Banerjee, U.C.; Babu, B.N. Synthesis and biological evalua- tion of novel ∆2-isoxazoline fused cyclopentane derivatives as potential antimicrobial and anticancer agents. MedChemComm 2015, 6, 839–845. [CrossRef] 2. Domingo, L.R.; Emamian, S.; Salami, M.; Ríos-Gutiérrez, M. Understanding the molecular mechanism of [3 + 2] cycloaddition reaction of benzonitrile oxide toward an N-vinylpyrrole derivative with the aid of ELF topological analysis. J. Phys. Org. Chem. 2016, 29, 368–376. [CrossRef] 4. Conclusions and R.J.; project administration, M.R.-G., K.K. and R.J. All authors have read and agreed to the published version of the manuscript. Funding: The research was carried out with the equipment purchased thanks to the ﬁnancial sup- port of the European Regional Development Fund in the framework of the Operational Program Development of Eastern Poland 2007–2013 (Contract No. POPW.01.03.00-06-009/11-00, Equipping the laboratories of the Faculties of Biology and Biotechnology, Mathematics, Physics and Informat- ics, and Chemistry for studies of biologically active substances and environmental samples. This work has also been supported by the Ministry of Science and Innovation (MICINN) of the Spanish Government, project PID2019-110776GB-I00 (AEI/FEDER, UE), and by the European Union’s Hori- zon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No. 846181 (M.R.-G.). Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Informed Consent Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: The data presented in this study are available on request from the corresponding author. Acknowledgments: All calculations reported in this paper were performed on “Prometheus” super- computer cluster in the CYFRONET computational center in Cracow. Support of this research is gratefully acknowledged. Conﬂicts of Interest: The authors declare no conﬂict of interest. Conﬂicts of Interest: The authors declare no conﬂict of interest. Sample Availability: Samples of the compounds are not available from the authors. References 1. Prajapti, S.K.; Shrivastava, S.; Bihade, U.; Gupta, A.K.; Naidu, V.G.M.; Banerjee, U.C.; Babu, B.N. Synthesis and biological evalua- tion of novel ∆2-isoxazoline fused cyclopentane derivatives as potential antimicrobial and anticancer agents. MedChemComm 2015, 6, 839–845. [CrossRef] 16 of 19 16 of 19 Molecules 2021, 26, 6774 3. Ren, J.; Wang, S.; Ni, H.; Yao, R.; Liao, C.; Ruan, B. 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https://openalex.org/W2052172948	https://www.shs-conferences.org/10.1051/shsconf/20120200036/pdf	English	null	Patient groups in art therapies: A case study of the health care field in Latvia	SHS web of conferences	2,012	cc-by	2,805	This is an Open Access article distributed under the terms of the Creative Commons Attribution License 2.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. SHS Web of Conferences 2, 00036 (2012) DOI: 10.1051/shsconf/20120200036 C ⃝Owned by the authors, published by EDP Sciences, 2012 SHS Web of Conferences 2, 00036 (2012) DOI: 10.1051/shsconf/20120200036 C ⃝Owned by the authors, published by EDP Sciences, 2012 SHS Web of Conferences 2, 00036 (2012) DOI: 10.1051/shsconf/20120200036 C ⃝Owned by the authors, published by EDP Sciences, 2012 Patient groups in art therapies: A case study of the health care ﬁeld in Latvia A. Upmale1, K. Martinsone2, I. Vaverniece3 and K. Vende4 1VSIA BKUS children hospital “Gail¸ezers”, Latvia 2R¯ıga Stradin¸š University, Latvia 3Arts Therapies Centre, Latvia 4 Society “Dzintarkrasta service”, social care centre“, Latvia Abstract. The aim of the paper is to introduce the reader with an example of the arts therapies work in a children hospital in Latvia in order to describe art therapies work similarities and differences in three different specializations. Comparison will take place of patient groups in the work of art therapists in each specialization (art therapy, dance movement therapy and music therapy). The question of the research is: with which patient groups’ a specialist from a particular arts therapies specialization has worked within a year in VSIA BKUS children hospital “Gail¸ezers” during the time period from 05.2009 to 05.2010?The results were gained by comparing patient groups at the age from 2,5 to 17 years in the children hospital and they showed that the art therapists and dance movement therapist most frequently were working with patients who have behaviour and emotional disorders. However music therapists are working more frequently with patients who have mental retardation. Key words: arts therapies, patient groups, health care, children hospital Key words: arts therapies, patient groups, health care, children hospital A new integrative health care facilitating and maintenance possibility – arts therapies – has developed in the second quarter of the 20th century. In some countries arts therapies have been applied in psychiatric and somatic clinics in order to facilitate patient’s rehabilitation already since 40–50-ies of the 20th century. Arts therapies in Latvia have become a ﬁeld of the health care since 2005 when professional standards were recognized by the Latvian Ministry of Education (M¯artinsone K., 2011). Art therapist is a heath care person, who has got a second level of the professional higher education (master degree) in the health care and a professional qualiﬁcation in one of the arts specialties (art, dance movement, drama or music). The arts therapies and the professional work of art therapists in Latvia have been recognized in the normative documentation and in the documents of professional associations. Arts therapies have been approved as medical technologies in 2010 as well. So in order to work as an art therapist and to offer professional services in the particular arts therapies specialisation one must gain appropriate education and a professional qualiﬁcation. Nowadays the question about the patient groups the art therapist from particular arts therapies specialisations work with is widely actualized in many different countries (Coats, 2004; Karkou, Sanderson, 2006; Karkou, 2010). Art therapists in Latvia work in health care, social care and education ﬁelds with patients who gave got somatic, psychic disorders and psychological difﬁculties. Often they work in a multiprofessional team. The aim of this research is to look for the patient groups in different arts therapies specialisations in Latvian by describing one of the working examples – art therapists’ work at the VSIA BKUS Children hospital “Gail¸ezers”. Here similarities and differences of arts therapies’ characteristics in different specializations (art therapy, dance and movement therapy and music therapy) have been emphasized. The comparison has been implemented by the analyses of the different client groups in SHS Web of Conferences Figure 1. Patient groups in the AT at the VSIA BKUS children hospital “Gail¸ezers”. Figure 1. Patient groups in the AT at the VSIA BKUS children hospital “Gail¸ezers”. each specialization. The question of the research is as follows: with which patients groups’ art therapists from different arts therapies specializations have worked within a year in VSIA BKUS children hospital “Gail¸ezers” from 05.2009 to 05.2010. each specialization. Participants Patients of the VSIA BKUS children hospital “Gail¸ezers” in the age from 2, 5 to 17 years, who have been hospitalised in the hospital from 05.2009 to 05.2010. Key words: arts therapies, patient groups, health care, children hospital The question of the research is as follows: with which patients groups’ art therapists from different arts therapies specializations have worked within a year in VSIA BKUS children hospital “Gail¸ezers” from 05.2009 to 05.2010. The method of the research is document analyzes. The method of the research is document analyzes. Procedure Patients’ medical cards are analyzed in which the consultations of doctors and other health care professionals (including all specialization arts therapists) are stated. Only those patients’ medical cards are included in the research who are referred to any of arts therapies by their attending psychiatrist. The diagnoses are used in the medical card in order to describe and state patients difﬁculties, according to VSIA BKUS children hospital “Gail¸ezers” rehabilitation service policy. Method Participants Results Results will be reviewed according the each arts therapies specialisation. The total number of the art therapy (AT further on) patients during 12 months is 130. Average number of sessions in an inpatient unit per one patient is 4 sessions, age of the patients are from 5 to 17 years. Most common diagnoses and patient groups in the AT – behavioural and emotional disorders with onset usually occurring in childhood and adolescence 21% (F90–F98); organic personality and behaviour disorders 17% (F06–F07); schizophrenia 16% (F20); neurotic stress-related somatoform disorders 15% (F40–F45); depressive disorders 13% (F32–F33). p The total amount of patients who participated the dance movement therapy (further on DMT) is 192 (see Figure 2). Average session number for one patient – 4 sessions, age of the patients from 2,5 to 17 years. Most common patient diagnoses and patient groups in the DMT – behavioural and emotional disorders with onset usually occurring in the childhood and adolescence 27% (F90–F98); mental 00036-p.2 00036-p.2 Int. Conf. SOCIETY. HEALTH. WELFARE; Congr. of Rehabilitation Doctors of Latvia Figure 2. Patient groups in the DMT at the VSIA BKUS children hospital “Gail¸ezers”. Figure 3. Patient groups in the MT at the VSIA BKUS children hospital “Gail¸ezers”. retardation 23% (F70–F71); pervasive developmental disorders 20% (F84); speciﬁc developmen disorders of speech and language 19% (F80). Total amount of patients in the music therapy (further on MT) is 251 (see ﬁgure Nr.3). Avera number of sessions for one patient in the MT – 4 sessions, age of the patients from 2,5 to 17 years o Patient’ diagnosis and patient groups – mental retardation 23% (F70–F79); behavioural and emotion disorders with onset usually occurring in the childhood and adolescence 22% (F90 F98); pervasi Figure 2. Patient groups in the DMT at the VSIA BKUS children hospital “Gail¸ezers”. Figure 2. Patient groups in the DMT at the VSIA BKUS children hospital “Gail¸ezers”. Figure 3. Patient groups in the MT at the VSIA BKUS children hospital “Gail¸ezers”. Figure 3. Patient groups in the MT at the VSIA BKUS children hospital “Gail¸ezers”. retardation 23% (F70–F71); pervasive developmental disorders 20% (F84); speciﬁc developmental disorders of speech and language 19% (F80). Total amount of patients in the music therapy (further on MT) is 251 (see ﬁgure Nr.3). Average number of sessions for one patient in the MT – 4 sessions, age of the patients from 2,5 to 17 years old. Results Patient’ diagnosis and patient groups – mental retardation 23% (F70–F79); behavioural and emotional disorders with onset usually occurring in the childhood and adolescence 22% (F90–F98); pervasive developmental disorders 18% (F84); speciﬁc developmental disorders of speech and language 16% (F80). Discussion To discuss the results of the particular survey it is relevant to do a small retrospection about the establishment of arts therapies as a profession in Latvia. Historically as an inﬂuence to the development of arts therapies in Latvia the Russian and German tradition should be pointed out as prior (M¯artinsone, 2011). However since 2005 when the profession of arts therapies has been established with clear requirements regarding the professional membership as well for the education of arts therapies association members, their further education, supervision, certiﬁcation and so on, based on the GB tradition, the “British model” has been adapted to the situation in Latvia (Karkou, Martinsone, Nazarova, Vaverniece, 2011). 00036-p.3 SHS Web of Conferences Basic to the connection between Latvian and the GB, The Great Britain’s experience and data of a broad national research, done by Vicky Karkou and Patricia Sanderson, have been implemented for the discussion of the results (Karkou, Sanderson, 2006). The Latvia’ and Great Britain’s (further on GB) data overview is considered as a comparison of tendencies in both countries as Karkou and Sanderson have gathered the information about the patient groups art therapists are working with in the GB as part of a wider research. It is necessary to note that the patient group division in the GB research is related to a model which is called by authors as a model from pedagogy. It means also avoidance to use medical terminology in that research (Karkou, Sanderson, 2006). When they look to the patients they do not use particular diagnoses and divide them into the groups according to the problems such as: emotional and behaviour difﬁculties, learning difﬁculties, physical/medical or sensor disorders and so on. However in Latvia’s research the International Classiﬁcation of Mental and Health Disorders (ICD 10) has been used, according to organisational policy. One of the tendencies in Latvia is that DMT and MT are working more with patients to which a nonverbal communication. It is stated in the literature that for this patient group nonverbal communication is frequently the only one mean of self expression and communication – delivery of information and emotional attitudes, (Mac Donald, 2006; Sherbourne, 2001). AT in comparison comparatively often work with patients to which verbal communication is used in order to talk over the creative process as well as for making connections between the creative process and/ or its result and also the language expresses the content of the ones’ inner world, experience and relationship system. As it is shown above in the results the most common diagnoses and patient groups in the AT are behavioural and emotional disorders, and also according the Karkou and Sanderson survey – the patient difﬁculties AT work with are the same in the GB. Karkou and Sanderson suggest that these ﬁndings might reﬂect the pioneering work of Adamson and Champernowne who worked with people with mental issues at the beginning of the AT development (Karkou, Sanderson, 2006; 159). According to the VSIA BKUS children hospital “Gail¸ezers” research data the main patient group for the MT are patients with mental retardation. SHS Web of Conferences The GB data of Karkou and Sanderson show that also a half of the British MT are working with this patient group while in other arts therapies specializations the work with this patient group takes considerably less place. British authors explain those results with the MT development in which Alvin has given a signiﬁcant contribution with her work with children who had autisms by deﬁning professional basic approaches, including value of improvisation in the therapeutic process. Also Nordoff and Robbins who worked with this patient group gave a great impact to Mt professional development (Karkou, Sanderson, 2006; 120). MT work in Latvia is running according to the British example and above mentioned professionals. Historical signiﬁcance of establishing these traditions is due to Dr. Rer. Med. Reineram Haus and Vestische Kinder-und Jugendklinik Datteln, Universität Witten, Herdecke (M¯artisone, 2011; 61). Following arts therapists work with different patient groups worldwide the historical signiﬁcance of professional development can be highlighted (V¯averniece, 2011). Although according to the VSIA BKUS Children hospital “Gail¸ezers” data, exactly this patients is the biggest in the MT and DMT, those data about Latvia does not show such a notable difference in amount of patients group with emotional and behaviour disorders, where professional development and inﬂuence of pedagogy ﬁeld is appears. Similarly to AT, also DMT ﬁeld the main patient group in both countries is people with emotional and behaviour disorders. Karkou and Sanderson pointed to the DMT pioneer’, American Chase impact on this profession development as she worked with people suffering form chronic mental health problems. Authors mention also that the DMT training and placements mostly take place in these settings. British research, mainly qualitative, indicate that DMT is successful with adolescents who have behaviour difﬁculties or disorders (Capello, 2009; Karkou, Sanderson, 2006), victims of sexual abuse, people suffering from demence, brain injury and eating disorders. The difference between both countries is in fact that in GB DMt are mostly working in the educational ﬁeld, accordingly not so much in the health care. 00036-p.4 00036-p.4 References [1] Capello, P. (2009) BASICS: An Intra/Interactional Model of DMT with the Adult Psychiatric Patient. In Chaiklin, S. & Wengrower, H. (eds.) The Art and Science of Dance/Movement Therapy: Life is Dance. London: Routledge. [1] Capello, P. (2009) BASICS: An Intra/Interactional Model of DMT with the Adult Psychiatric Patient. In Chaiklin, S. & Wengrower, H. (eds.) The Art and Science of Dance/Movement Therapy: Life is Dance. London: Routledge. f g [2] Coats, E. (ed.) (2004) Creative Arts and Humanities in Healthcare: Swallows to Other Continents: A strategic paper prepared by a collaborative inquiry group. London: Nufﬁeld Trust. [2] Coats, E. (ed.) (2004) Creative Arts and Humanities in Healthcare: Swallows to Other Continents: A strategic paper prepared by a collaborative inquiry group. London: Nufﬁeld Trust. [3] Karkou, V. (2005) Dance movement therapy in the community: group work with people with enduring mental health difﬁculties In Levy, F. (ed.). Dance movement therapy: a healing art. London: Routledge. [3] Karkou, V. (2005) Dance movement therapy in the community: group work with people with enduring mental health difﬁculties In Levy, F. (ed.). Dance movement therapy: a healing art. London: Routledge. g [4] Karkou, V. (ed.) (2009) Arts Therapies in Schools: Research and Practice. London: Jessica Kingsley Publishers. [4] Karkou, V. (ed.) (2009) Arts Therapies in Schools: Research and Practice. London: Jessica Kingsley Publishers. [5] Karkou, V. (2010) Arts Therapies. Art, Dance Movement, Drama and Music Therapy. Hitting the HEAT Targets. http://www.badth.org.uk/downloads/information/ ArtsTherapiesReportHittingtheHEATTargets.pdf [5] Karkou, V. (2010) Arts Therapies. Art, Dance Movement, Drama and Music Therapy. Hitting the HEAT Targets. http://www.badth.org.uk/downloads/information/ ArtsTherapiesReportHittingtheHEATTargets.pdf [6] Karkou, V., Martinsone, K., Nazarova, N., Vaverniece, I. (2010) Art therapy in the postmodern world: Findings from a comparative study across the UK, Russia and Latvia. In The Arts in Psychotherapy. (in Press). Available online 24 Dec. 2010. [7] MacDonald, J. (2006) Dance? Of cource I can! Dance Movement therapy for people with leartning difﬁculties. In Payne, H. (ed.) Dance movement therapy: theory and practise. London: Routledge. [8] M¯artinsone, K. (ed.) (2011) M¯akslu terapija. R¯ıga: RaKa. [9] M¯artinsone, K. (2011) M¯akslu terapijas izveide un att¯ıst¯ıba Latvij¯a. Martinsone, K. (ed.) M¯akslu terapija. R¯ıga: Raka. [10] M¯artinsone, K., Mihailova, S., Mihailovs, I.J., Majore-D¯ušele, I., Paipere, M. (2008) M¯akslu terapijas un t¯as att¯ıst¯ıbas konteksti (integrat¯ıvi eklektisk¯a pieeja Latvij¯a). R¯ıga: RSU. [11] Payne, H. (2006) Shut in, shut out: Dance movement therapy with children and adolescents. In Payne, H. (ed.) Dance movement therapy: theory and practise. Conclusions Authors of the this paper came to conclusions by comparing three arts therapies specializations and their patient groups during the 1 year period at the VSIA BKUS children hospital “Gail¸ezers” that the AT most frequently have been working with patients who are suffering from emotional and behaviour disorders. Unlike DMT and MT, AT are more often working with patients diagnosed with schizophrenia, neurotic stress-related somatoform disorders and depressive disorders. The patient groups for the DMT and MT specialisation are more similar. DMT and MT more frequently are working with patients who are mentally retarded and have emotional and behaviour disorders. Unlike AT, DMT and MT also work more with patients suffering from pervasive developmental disorders and speciﬁc developmental disorders of speech and language. Some similarities arouse by comparing patient groups in Latvia’s VSIA BKUS Children hospital “Gail¸ezers” and the Great Britain’s research. Both Latvia’s and The GB art therapists in all three specializations more commonly work with patients who have emotional and behaviour disorders or difﬁculties, mental retardation or learning difﬁculties. It is signiﬁcant to continue and expand started research by including various patient groups from all art therapy specializations and from the health care, educational and social ﬁelds. 00036-p.4 Int. Conf. SOCIETY. HEALTH. WELFARE; Congr. of Rehabilitation Doctors of Latvia References London: Routledge. [12] Sherbourne, V. (2001) Developmental Movement for Children: Mainstream, Special needs and preschool. Second edition. London: Worth Publishing. [13] V¯averniece, I. (2011) M¯akslu terapija: vesel¯ıbas apr¯upes profesijas izveide un att¯ıst¯ıba. M¯artinsone, K. (ed.) M¯akslu terapija. R¯ıga: Raka. 00036-p.5
https://openalex.org/W49688146	https://www.impan.pl/shop/publication/transaction/download/product/111225?download.pdf	English	null	On approximations of nonzero-sum uniformly continuous ergodic stochastic games	Applicationes Mathematicae	1,999	cc-by	3,315	APPLICATIONES MATHEMATICAE 26,2 (1999), pp. 221–228 APPLICATIONES MATHEMATICAE 26,2 (1999), pp. 221–228 APPLICATIONES MATHEMATICAE 26,2 (1999), pp. 221–228 A. S. NOWAK (Wroc law) A. S. NOWAK (Wroc law) A. S. NOWAK (Wroc law) 1991 Mathematics Subject Classiﬁcation: Primary 90D10, 90D20; Secondary 90D05, 93E05. Key words and phrases: nonzero-sum Markov game, Nash equilibrium, long run av- erage reward criterion, general state space. This research was supported by KBN grant 2PO3A 05810. 1991 Mathematics Subject Classiﬁcation: Primary 90D10, 90D20; Secondary 90D05, 93E05. Key words and phrases: nonzero-sum Markov game, Nash equilibrium, long run av- erage reward criterion, general state space. This research was supported by KBN grant 2PO3A 05810. ON APPROXIMATIONS OF NONZERO-SUM UNIFORMLY CONTINUOUS ERGODIC STOCHASTIC GAMES Abstract. We consider a class of uniformly ergodic nonzero-sum stochas- tic games with the expected average payoﬀcriterion, a separable metric state space and compact metric action spaces. We assume that the pay- oﬀand transition probability functions are uniformly continuous. Our aim is to prove the existence of stationary ε-equilibria for that class of ergodic stochastic games. This theorem extends to a much wider class of stochastic games a result proven recently by Bielecki [2]. 1. Introduction. The existence of stationary equilibria for discounted or limiting average payoﬀstochastic games with uncountable state spaces is still an open problem. Positive answers to this question are known only for some special classes of stochastic games where the transition probabilities satisfy certain very speciﬁc conditions. Some results concerning correlated equilibria are also available. For a good survey of the existing literature the reader is referred to [11, 12]. The existence of stationary ε-equilibria for discounted stochastic games was ﬁrst proved by Whitt [13] who considered a separable metric state space model in which the daily payoﬀand transition probability functions are uni- formly continuous. His proof is based on an approximation technique of the original model by “smaller” models with countably many states for which stationary equilibria are known to exist. Another ε-equilibrium theorem for a class of discounted stochastic games with an abstract measurable state space and the transition probability having a density function is included in [221] 222 A. S. Nowak our paper [9]. The proof in [9] is based on a completely diﬀerent approxi- mation method compared with Whitt’s technique [13]. (That is because the state space need not be metric.) Some extensions of the result in [9] are given in our recent paper with Altman [11] where unbounded (in the state variable) daily payoﬀfunctions are allowable and the expected average pay- oﬀcriterion is also considered. Bielecki [2] extended Whitt’s theorem [13] to a class of limiting aver- age payoﬀstochastic games satisfying a very strong ergodicity condition. Stochastic games studied in [2] are in some sense equivalent to discounted stochastic games [2, 3]. In this paper, we consider uniformly continuous stochastic games as studied by Whitt [13] and Bielecki [2] but under a much weaker ergodicity assumption. Using an extension of Ueno’s inequality given in [10], we prove that any stochastic game with uniformly ergodic transition structure can be approximated (in some sense) by games studied by Bielecki [2]. ON APPROXIMATIONS OF NONZERO-SUM UNIFORMLY CONTINUOUS ERGODIC STOCHASTIC GAMES This result combined with those of Bielecki [2] and Whitt [13] implies a new existence theorem for stationary ε-equilibria for nonzero-sum stochastic games with a separable metric state space. 2. The model and results. Let Y be a Borel space, i.e., a non-empty Borel subset of a complete separable metric space. Let B(Y ) be the family of all Borel subsets of Y. 2. The model and results. Let Y be a Borel space, i.e., a non-empty Borel subset of a complete separable metric space. Let B(Y ) be the family of all Borel subsets of Y. An N-person nonzero-sum stochastic game is deﬁned by the following objects: • S is a Borel space of states for the game, • Xk is a non-empty compact metric space of actions for player k. We put X = X1 × . . . × XN, • rk : S × X →R is a bounded Borel measurable payoﬀfunction for player k. • q is a Borel measurable transition probability from S × X to S, called the law of motion among states. If s is a state at some stage of the game and the players select an x ∈X, then q(· \| s, x) is the probability distribution of the next state of the game. In this paper, we adopt the following conditions: In this paper, we adopt the following conditions: C1: The functions rk are uniformly continuous on S × X. C2: The function q(B\|s, x) is uniformly continuous on S ×X, uniformly in B ∈B(S). The game is played in discrete time with past history as common know- ledge for all the players. Suppose that at the beginning of each period n of the game the players are informed of the outcome of the preceding period and the current state sn. Then the information available to them at time n is 223 Approximations of stochastic games a vector hn = (s1, x1, . . . , sn−1, xn−1, sn), where si ∈S, xi = (xi 1, . . . , xi N) ∈ X. We denote the set of such vectors by Hn and assume that it is endowed with the Borel (or equivalently product) σ-algebra. A strategy for player k is a sequence πk = (π1 k, π2 k, . . .), where every πn k is a Borel measurable transition probability from Hn into Xk. ON APPROXIMATIONS OF NONZERO-SUM UNIFORMLY CONTINUOUS ERGODIC STOCHASTIC GAMES A stationary strategy for player k is a strategy πk = (π1 k, π2 k, . . .) such that each πn k de- pends on the current state sn only. In other words, a strategy πk for player k is called stationary if there exists a transition probability fk from S into Xk such that for every period n of the game and each history hn ∈Hn, we have πn k (· \| hn) = fk(· \| sn). We put Πk(Fk) to denote the set of all strategies (stationary strategies) for player k. Let H = S × X × S × . . . be the space of all inﬁnite histories of the game, endowed with the product σ-algebra. For any multi-strategy π = (π1, . . . , πN) of the players and every initial state s1 = s ∈S, a probability measure P π s and a stochastic process {σn, αn} are deﬁned on H in a canon- ical way, where the random variables σn and αn describe the state and the actions chosen by the players, respectively, on the nth stage of the game (cf. Chapter 7 of [1]). Thus, for each multi-strategy π = (π1, . . . , πN), any ﬁnite horizon T, and every initial state s ∈S, the expected T-stage payoﬀ to player k is JT k (s, π) = Eπ s T X n=1 rk(σn, αn) . Here Eπ s is the expectation operator with respect to the probability measure P π s . s The expected average payoﬀper unit time for player k is deﬁned as Jk(s, π) = lim sup T →∞ 1 T JT k (s, π). Jk(s, π) = lim sup T →∞ 1 T JT k (s, π). Let π∗= (π∗ 1, . . . , π∗ N) be a ﬁxed multi-strategy for the players. For any strategy πk of player k, we write (π∗ −k, πk) to denote the multi-strategy obtained from π∗by replacing π∗ k with πk. k Let ε ≥0. A multi-strategy π∗= (π∗ 1, . . . , π∗ N) is called an ε-equilibrium for the average payoﬀstochastic game if and only if ε + Jk(s, π∗) ≥Jk(s, (π∗ −k, πk)) for every player k and πk ∈Πk. A 0-equilibrium is called a Nash equilibrium. for every player k and πk ∈Πk. A 0-equilibrium is called a Nash equilibrium. for any B ∈B(S). for any B ∈B(S). The basic assumption made in this paper is: ON APPROXIMATIONS OF NONZERO-SUM UNIFORMLY CONTINUOUS ERGODIC STOCHASTIC GAMES Before we formulate further assumptions and state our results, we adopt Before we formulate further assumptions and state our results, we adopt some useful notation. Let F be the set of all stationary multi-strategies of the players. For any f = (f1, . . . , fN) ∈F, rk(s, f) = \ X1 . . . \ XN rk(s, x1, . . . , xN)f1(dx1 \| s) . . . fN(dxN \| s) A. S. Nowak 224 and q(B \| s, f) = \ X1 . . . \ XN q(B \| s, x1, . . . , xN)f1(dx1 \| s) . . . fN(dxN \| s) for any B ∈B(S). The basic assumption made in this paper is: C3 (Uniform geometric ergodicity): There exist scalars α ∈(0, 1) and γ > 0 for which the following holds: for any f ∈F, there exists a probability measure pf on B(S) such that ∥qn(· \| s, f) −pf(·)∥≤γαn for each n ≥1. Here qn(· \| s, f) is the n-step transition probability of the Markov chain induced by q and f ∈F, pf(·) is the unique invariant probability distribution of this Markov chain, and ∥· ∥is the total variation norm in the space of ﬁnite signed measures on B(S). It is well known that C3 is equivalent to the following condition: C4: There exist a positive integer m and a positive number c < 1 such that ∥qm(· \| s, f) −qm(· \| z, f)∥≤2c for all s, z ∈S and f ∈F. Clearly C3 implies C4. C4 implies C3 by Ueno’s inequality [10]. For details consult pages 275 and 276 of [4]. Condition C3 (or C4) is rather diﬃcult to check. Much easier to verify are assumptions implying C3 which can be formulated on the basis of a recent result by Meyn and Tweedie (see Theorem 2.3 of [7]). C5 (“Drift inequality”): There exist a bounded Borel measurable func- tion w : S →[1, ∞) and a set C ∈B(S) such that for some λ ∈(0, 1) and η > 0, we have [ η > 0, we have \ S w(t)q(dt \| s, x) ≤λw(s) + η1C(s) for each (s, x) ∈S × X. Here 1C is the characteristic function of the set C. C6: There exist b ∈(0, 1) and a probability measure p concentrated on the Borel set C such that q(D \| s, x) ≥bp(D) for each D ∈B(C), x ∈X and s ∈C. For a further discussion of uniform geometric ergodicity of Markov chains consult Theorem 16.0.2 in [6]. In a recent paper Bielecki [2] considered stochastic games under the following strong assumption: 225 Approximations of stochastic games M (Minorization property): There exist a constant b ∈(0, 1) and a probability measure p on B(S) such that q(D \| s, x) ≥bp(D) for every D ∈B(S), x ∈X and s ∈S. for every D ∈B(S), x ∈X and s ∈S. It is easy to prove that M implies C3 (see page 185 in Neveu [8]). Note that M is much stronger than C6 and if it is satisﬁed then C5 holds trivially with η = sups∈S w(s). Let G (resp. GM) be the class of nonzero-sum stochastic games satisfying condition C3 (resp. M). Every game G ∈GM is said to satisfy a strong ergodicity condition. Using some ideas from Chapter 7 of [3] Bielecki showed that the problem of ﬁnding a stationary ε-equilibrium in any game G ∈ GM which satisﬁes C1 and C2 can be reduced to ﬁnding a stationary εβ- equilibrium in some β-discounted stochastic game with a new transition probability and β = 1 −b < 1 (see Theorem 2.1 of [2]). In other words, stationary ε-equilibria can be constructed in any game G ∈GM by using the approximation technique developed for discounted stochastic games by Whitt [13]. In this paper, we prove that any game G ∈G can be in some sense approximated by games from the class GM. Before we state our results we point out that for any multi-strategy f ∈F the expected average payoﬀJk(s, f) to player k is under condition C3 independent of the initial state s ∈S and therefore it will be denoted by Jk(f). Clearly, C3 implies that Jk(f) = \ S rk(s, f) pf(ds). Our approximation result is formulated as follows: Theorem 1. For any ε > 0 and any game G ∈G there exists a game Gε ∈GM such that max 1≤k≤N sup f∈F \|Jk(f) −Jε k(f)\| ≤ε/2 here Jε k(f) is the expected average payoﬀto player k in Gε, f ∈F. where Jε k(f) is the expected average payoﬀto player k in Gε, f ∈F. P r o o f. Assume that G ∈G. Then C4 holds with some positive integer m and c ∈(0, 1). Choose any probability measure p on B(S). For any δ ∈(0, 1) deﬁne qδ(· \| s, f) = (1 −δ)q(· \| s, f) + δp(·) where s ∈S and f ∈F. Clearly, qδ satisﬁes condition M for any δ ∈(0, 1). It is easy to show that (1) qm δ (· \| s, f) = (1 −δ)mqm δ (· \| s, f) + m−1 X n=0 δ(1 −δ)npqn f (·) (1) A. S. Nowak 226 where pq0 f := p and where pq0 f := p and pqn f (·) = \ S q(· \| s, f) p(ds) pqn f (·) = \ S q(· \| s, f) p(ds) for n = 1, . . . , m −1. Note that for n = 1, . . . , m −1. Note that (1 −δ)m + m−1 X n=0 δ(1 −δ)n = 1. Using this and (1), we obtain Using this and (1), we obtain ∥qm(· \| s, f) −qm δ (· \| s, f)∥≤ m−1 X n=0 δ(1 −δ)n∥pqn f (·) −qm(· \| s, f)∥ ≤2 m−1 X n=0 δ(1 −δ)n = 2[1 −(1 −δ)m] for every s ∈S and f ∈F. Put ξ = 2[1 −(1 −δ)m]. By the Theorem of [10] we have ∥qm(· \| s, f) −qm δ (· \| s, f)∥≤ m−1 X n=0 δ(1 −δ)n∥pqn f (·) −qm(· \| s, f)∥ ≤2 m−1 X n=0 δ(1 −δ)n = 2[1 −(1 −δ)m] for every s ∈S and f ∈F. Put ξ = 2[1 −(1 −δ)m]. By the Theorem of [10], we have for every s ∈S and f ∈F. Put ξ = 2[1 −(1 −δ)m]. By the Theorem of [10], we have (2) ∥qmn(· \| s, f) −qmn δ (· \| s, f)∥≤ξ(1 + c + . . . + cn−1) + 2cn for each s ∈S, f ∈F and n ≥1. Hence (3) ∥pf −pδ f∥≤ ξ 1 −c (3) for each f ∈F, where pδ f is the invariant probability distribution for the Markov chain induced by qδ and f. Put K = max 1≤k≤N sup s∈S,x∈X \|rk(s, x)\|. here Jε k(f) is the expected average payoﬀto player k in Gε, f ∈F. Using (3) we obtain \|Jk(f) −Jδ k(f)\| ≤ \ S rk(s, f) pf(ds) − \ S rk(s, f) pδ f(ds) ≤K∥pf −pδ f∥≤K ξ 1 −c ≤K∥pf −pδ f∥≤K ξ 1 −c for all f ∈F. Let ε > 0 be ﬁxed. Choose any δε ∈(0, 1) with Kξ/(1 −c) = K[1 −(1 −δε)m]/(1 −c) ≤ε/2. The game Gε ∈GM we are looking for is simply the stochastic game with the transition probability qδε. [ ( ) ]/( ) / simply the stochastic game with the transition probability qδε. Theorem 2. Any nonzero-sum stochastic game satisfying conditions C1–C3 has a stationary ε-equilibrium for any ε > 0. P r o o f. Let ε > 0. Consider a game that satisﬁes C1–C3. By Corollary 2.1 of [2] and Theorem 1 there exists some f ∗∈F such that (4) ε + Jk(s, f ∗) ≥Jk(s, (f ∗ −k, fk)) Approximations of stochastic games 227 227 Approximations of stochastic games for every player k and any stationary strategy fk ∈Fk. From standard results in dynamic programming [5], it follows that (5) sup fk∈Fk Jk(s, (f ∗ −k, fk)) = sup πk∈Πk Jk(s, (f ∗ −k, πk)) (5) for every player k. Clearly, (4) and (5) complete the proof. for every player k. Clearly, (4) and (5) complete the proof. 3. Concluding remarks. In this paper, we obtain stationary ε-equilib- ria for uniformly continuous ergodic nonzero-sum stochastic games with a separable metric state space using a simple approximation of any such game by stochastic games (from the class GM) studied in [2] with strongly ergodic transition structure. Our result is based on an extension of Ueno’s inequal- ity given in [10]. We point out that Whitt’s approximation technique [13] (which is in fact applied in [2]) makes use of the separability of the state space. The approach taken in [9] and further extended in [11] is based on a diﬀerent idea. In [11] we make weaker ergodicity assumptions than C1, allow for unbounded daily payoﬀfunctions but assume that the transition probability has a density function. In [11], we approximate the original game by games with countably many states having analogous ergodic properties. In the present case, we approximate uniformly ergodic stochastic games by games having the same state space but satisfying a much stronger ergodicity condition. Received on 23.12.1998; revised version on 13.1.1999 References [1] D. P. Bertsekas and S. E. Shreve, Stochastic Optimal Control: The Discrete Time Case, Academic Press, New York, 1979. [ ] , p Time Case, Academic Press, New York, 1979. Time Case, Academic Press, New York, 1979. [2] T. R. Bielecki, Approximations of dynamic Nash games with general state and action spaces and ergodic costs for the players, Appl. Math. (Warsaw) 24 (1996), 195–202. [3] E. B. Dynkin and A. A. Yushkevich, Controlled Markov Processes, Springer, New York, 1979. [4] J. P. Georgin, Contrˆole de chaˆınes de Markov sur des espaces arbitraires, Ann. Inst. H. Poincar´e S´er. B 14 (1978), 255–277. [5] O. Hern´andez-Lerma and J. B. Lasserre, Discrete Time Markov Control Pro- cesses: Basic Optimality Criteria, Springer, New York, 1996. [5] O. Hern´andez-Lerma and J. B. Lasserre, Discrete Time Markov Control Pro- B i O ti lit C it i S i N Y k 1996 [5] O. Hern´andez-Lerma and J. B. Lasserre, Discrete Time cesses: Basic Optimality Criteria, Springer, New York, 1996. cesses: Basic Optimality Criteria, Springer, New York, 1996. [6] S. P. Meyn and R. L. Tweedie, Markov Chains and Stochastic Stability, Springer, New York, 1993. [7] —, —, Computable bounds for geometric convergence rates of Markov chains, Ann. Appl. Probab. 4 (1994), 981–1011. [8] J. Neveu, Mathematical Foundations of the Calculus of Probability, Holden-Day, San Francisco, 1965. [9] A. S. Nowak, Existence of equilibrium stationary strategies in discounted noncoop- erative stochastic games with uncountable state space, J. Optim. Theory Appl. 45 (1985), 591–602. 228 A. S. Nowak [10] A. S. Nowak, A generalization of Ueno’s inequality for n-step transition probabili- ties, Appl. Math. (Warsaw) 25 (1998), 295-299. [10] A. S. Nowak, A generalization of Ueno’s inequality for n-step transition probabili- ties, Appl. Math. (Warsaw) 25 (1998), 295-299. [11] A. S. Nowak and E. Altman, ε-Nash equilibria for stochastic games with uncount- able state space and unbounded costs, technical report, Inst. Math., Wroc law Univ. of Technology, 1998 (submitted). ( ) [12] A. S. Nowak and K. Szajowski, Nonzero-sum stochastic games, Ann. Dynamic Games 1999 (to appear). [13] W. Whitt, Representation and approximation of noncooperative sequential games, SIAM J. Control Optim. 18 (1980), 33–48. Andrzej S. Nowak Institute of Mathematics Wroc law University of Technology Wybrze˙ze Wyspia´nskiego 27 50-370 Wroc law, Poland E-mail: nowak@im.pwr.wroc.pl Received on 23.12.1998; revised version on 13.1.1999 Andrzej S. References Nowak Institute of Mathematics Wroc law University of Technology Wybrze˙ze Wyspia´nskiego 27 50-370 Wroc law, Poland E-mail: nowak@im.pwr.wroc.pl Andrzej S. Nowak Received on 23.12.1998; revised version on 13.1.1999
https://openalex.org/W2743510859	https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-017-2741-3	English	null	Evolutionary impact of copy number variation rates	BMC research notes	2,017	cc-by	2,294	© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Introductionh then genome complexity [5, 6]. For that, duplications have to be fixed in the population, a process that mainly occurs, according to the classical theory, by random genetic drift under effectively neutral selective conditions thanks to a reduction in effective population size [6]. However, the balance between duplication and deletion, at a given locus, regulates the power of drift in fixation, as it is illustrated here with a simple quantitative analysis. The advent of genomic systems biology is leading, in very recent years, to the discovery of widespread genetic fea- tures, previously unrecognized in complex organisms like humans; they can then have strong implications in bio- medicine. One of these fascinating features is copy num- ber variation [1], which is already considered one of the major sources of genetic variation. Thereby, in natural populations, some individuals have significant portions of the genome repeated, even entire genes, something until now believed to occur at a large scale only in microbes [2]. Recently, genomic studies with populations of different model organisms are serving to estimate copy number variation rates [1, 3], revealing great differences among them. However, the generation of genetic diver- sity, here genome rearrangements, cannot be fully under- stood without accounting for an evolutionary perspective [4]. In this regard, what is the impact of these rates? Abstract Objective: Copy number variation is now recognized as one of the major sources of genetic variation among indi- viduals in natural populations of any species. However, the relevance of these unexpected observations goes beyond diagnosing high diversity. Results: Here, it is argued that the molecular rates of copy number variation, mainly the deletion rate upon variation, determine the evolutionary road of the genome regarding size. Genetic drift will govern this process only if the effec- tive population size is lower than the inverse of the deletion rate. Otherwise, natural selection will do. Keywords: Birth–death process, Gene duplication, Genome size, Neutral evolution, Population genetics rth–death process, Gene duplication, Genome size, Neutral evolution, Population genetics Correspondence: guillermo.rodrigo@csic.es Institute for Integrative Systems Biology, CSIC-UV, 46980 Paterna, Spain Guillermo Rodrigo Guillermo Rodrigo* Rodrigo BMC Res Notes (2017) 10:393 DOI 10.1186/s13104-017-2741-3 Rodrigo BMC Res Notes (2017) 10:393 DOI 10.1186/s13104-017-2741-3 BMC Research Notes Main text Theoryh The complex process of copy number variation in a single organism, which involves widely different mechanisms [7], can be simplified to a birth–death process. This allows creating a toy model from which to make predic- tions (see “Limitations”). If μ denotes the duplication rate of a locus and λ the deletion rate upon duplication, the frequency of the genotype with two copies (x) in a pop- ulation of size N is governed by the following stochastic differential equation In this short piece, it is argued that these rates greatly determine the way by which the genome can increase its size, i.e., the evolutionary force that controls this process. Indeed, the acquisition of genetic redundancy is believed to be the major mechanism to increase genome size, and (1) dx dt = µ −(µ + )x + x(1 −x) N z(t), (1) where t is measured in generations, and z(t) is a stochas- tic process with mean zero and correlation delta, hav- ing assumed a Wright-Fisher reproduction model and *Correspondence: guillermo.rodrigo@csic.es Institute for Integrative Systems Biology, CSIC-UV, 46980 Paterna, Spain Rodrigo BMC Res Notes (2017) 10:393 Page 2 of 3 Fig. 1 Phase space between effective population size (N) and dele- tion rate upon duplication (λ) showing the region where genome size can increase by genetic drift (shaded region). The solid line corre- sponds to the limit λN = 1/12 (strict), whilst the dashed line to λN = 1 (soft). λ ≫ μ is assumed. Six different organisms are contextualized (S. enterica, S. cerevisiae, D. melanogaster, C. elegans, A. thaliana, and H. sapiens). All λ values correspond to empirical estimations, except the value for the plant, which is a prediction strictly neutral selective conditions [8]. This means that the stationary solution will be x = μ/(μ + λ), and that the eventual fixation of genetic variants will only occur tran- siently. This is an important consideration, implying that duplicates will be preserved for long time if they quickly accumulate, upon fixation, beneficial [9] or complemen- tary, degenerative mutations [10], escaping from the birth–death process. The system has two different time scales, one given by 1/(μ + λ), associated with copy number variation, the other by N, associated with genetic drift. Certainly, if (μ + λ)N ≪ 1, the system can be assumed dominated by genetic drift at short times. Main text Theoryh Accordingly, the typical fluc- tuation amplitude in frequency (Δx, around the station- ary solution) can follow the Einstein’s theory of Brownian particles [11]. A fixation time of t ≈ 6N can be derived if we integrate over [0, 1] the variance of the stochastic pro- cess, x(1 − x)/N, to have constant diffusion, in good tune with the Kimura’s calculation [8]. But, in general, we have Fig. 1 Phase space between effective population size (N) and dele- tion rate upon duplication (λ) showing the region where genome size can increase by genetic drift (shaded region). The solid line corre- sponds to the limit λN = 1/12 (strict), whilst the dashed line to λN = 1 (soft). λ ≫ μ is assumed. Six different organisms are contextualized (S. enterica, S. cerevisiae, D. melanogaster, C. elegans, A. thaliana, and H. sapiens). All λ values correspond to empirical estimations, except the value for the plant, which is a prediction (2) x = 1 √12(µ + )N . (2) Fixation will occur in displacements that reach x = 1 [i.e., Δx = λ/(μ + λ)], which yields the condition of λN < 1/12, when λ ≫ μ (typically in nature) [1]. Fluc- tuations can even be three times the typical value, although they will occur sporadically. This yields the soft condition of λN < 1 to have chances for fixation. By contrast, if (μ + λ)N ≫ 1, the system is mostly domi- nated by the balance between duplication and deletion. Therefore, Δx ≪ 1, which entails that duplications can- not be fixed. cerevisiae, where μ ≈ 3·10−6/locus/gen. and λ ≈ 2·10−6/ locus/gen. [3], with N ≈ 107, give (μ + λ)N ≈ 50 ≫ 1. However, the scenario is different in higher eukaryotes. For Drosophila melanogaster, μ ≈ 2·10−7/locus/gen. and λ ≈ 10−6/locus/gen. [15], with N ≈ 106. This results in (μ + λ)N ≈ λN ≈ 1, the soft limit, suggesting that tran- sient fixation of duplications could occur. Better is the case for Caenorhabditis elegans, as μ ≈ 10−7/locus/gen. and λ ≈ 2·10−7/locus/gen. [16], with N ≈ 105, lead to (μ + λ)N ≈ 0.03 ≪ 1. For Homo sapiens, μ + λ ≈ 10−6/ locus/gen. [1], with N ≈ 104, ensures many momentary fixations by drift, as (μ + λ)N ≈ 0.01 ≪ 1. Remarkh The deletion rate that was considered here is the rate at which a repeated portion of the genome is deleted. Cer- tainly, duplication imposes a genetic instability that is generally resolved by deletion [12]; sometimes by other means, like relocation [13]. Experimentally, such a dele- tion rate needs to be estimated from populations with individuals carrying duplications. The deletion rate of significant, but unique fragments is expected to be only a lower bound. Despite, this has already been proposed as a determinant of genome size [14]. i But the rates (μ and λ) confidently estimated until now (in mutation accumulation experiments) are really scarce, only available for some model organisms [17]. In addition, the deletion rates might be underestimated (see “Remark”). For Arabidopsis thaliana, e.g., only bioinfor- matic estimates have been produced, although these give values that differ from experimental estimates in several orders of magnitude. Based on the values of D. mela- nogaster and C. elegans, one can predict λ ≈ 10−7–10−6/ locus/gen. for A. thaliana, resulting in λN ≈ 0.03–0.3 < 1, as N ≈ 3·105. Higher eukaryotes have indeed more chances to transiently fix duplications by drift due to a reduced effective population size [6]. Conclusioni Publication Support Initiative through its Unit of Information Resources for Research (URICI). Definitely, λN < 1 has to be satisfied in order to reach transient fixation of duplications by genetic drift. Other- wise, the population remains stably polymorphic regard- ing copy number. If this were the case, positive selective conditions should be invoked to explain an increase in genome size. After all, the precise characterization at the molecular level of the genome rearrangement rates, espe- cially the deletion rate upon duplication, will shed much light to recognize how fortuitous was the path to reach the life that today we see on the Earth [18]. References 1. Conrad DF, et al. Origins and functional impact of copy number variation in the human genome. Nature. 2010;464:704–12. 1. Conrad DF, et al. Origins and functional impact of copy number variation in the human genome. Nature. 2010;464:704–12. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. Received: 23 June 2017 Accepted: 8 August 2017 Applicationh This simple theory can be applied to analyze the fixation ability in different organisms (Fig. 1). For Salmonella enterica, μ ≈ 10−4/locus/gen. and λ ≈ 2·10−2/locus/gen. [12], with N ≈ 108. In this case, (μ + λ)N ≈ λN ≈ 2·106 ≫ 1, which entails that this bacte- rium cannot acquire genetic redundancy, at least by drift. Similar is the case for the lower eukaryote Saccharomyces Rodrigo BMC Res Notes (2017) 10:393 Page 3 of 3 Ethics approval and consent to participate Funding Work funded by the Spanish Ministry of Economy (MINECO/FEDER), Grant BFU2015-66894-P. Support of the publication fee by the CSIC Open Access Availability of data and materialsf 15. Schrider DR, et al. Rates and genomic consequences of spontaneous mutational events in Drosophila melanogaster. Genetics. 2013;194:937–54 15. Schrider DR, et al. Rates and genomic consequences of spontaneous mutational events in Drosophila melanogaster. Genetics. 2013;194:937–54 y Copy number variation rates in different model organisms obtained from Refs. [1, 3, 12, 15, 16]. Copy number variation rates in different model organisms obtained from Refs. [1, 3, 12, 15, 16]. p g 16. Lipinski KJ, et al. High spontaneous rate of gene duplication in Caeno- rhabditis elegans. Curr Biol. 2011;21:306–10. 16. Lipinski KJ, et al. High spontaneous rate of gene duplication in Caeno- rhabditis elegans. Curr Biol. 2011;21:306–10. g 17. Katju V, Bergthorsson U. Copy-number changes in evolution: rates, fitness effects and adaptive significance. Front Genet. 2013;4:273. 17. Katju V, Bergthorsson U. Copy-number changes in evolution: rates, fitness effects and adaptive significance. Front Genet. 2013;4:273. fi 18. Lynch M. The frailty of adaptive hypotheses for the origins of organismal complexity. Proc Natl Acad Sci USA. 2007;104:8597–604. Limitationsh Competing interests The author declares that he has no competing interests. g The author declares that he has no competing interests. 14. Petrov DA, et al. Evidence for DNA loss as a determinant of genome size. Science. 2000;287:1060–2. Limitationsh 2. Anderson P, Roth J. Spontaneous tandem genetic duplications in Salmo- nella typhimurium arise by unequal recombination between rRNA (rrn) cistrons. Proc Natl Acad Sci USA. 1981;78:3113–7. The following limitations associated with the mathemati- cal model were identified: 3. Lynch M, et al. A genome-wide view of the spectrum of spontaneous mutations in yeast. Proc Natl Acad Sci USA. 2008;105:9272–7. • • Simplification to a birth–death process, while genome rearrangements may be more complex pro- cesses (e.g., gene relocation in the chromosome to stabilize a duplicate). 4. Ayala FJ. Darwin’s greatest discovery: design without designer. Proc Natl Acad Sci USA. 2007;104:8567–73. 5. Ohno S. Evolution by gene duplication. New York: Springer Verlag; 1970. h h f l 5. Ohno S. Evolution by gene duplication. New York: Springer Verlag; 1970 6. Lynch M, Conery JS. The origins of genome complexity. Science. 2003;302:1401–4. 7. Hastings PJ, et al. Mechanisms of change in gene copy number. Nat Rev Genet. 2009;10:551–64. • • No consideration of high-order variations, such as gene triplications or quadruplications, while these are found in nature. No consideration of individuals with zero copies, assuming they are deleterious and then quickly diluted. 8. Kimura M, Ohta T. The average number of generations until fixation of a mutant gene in a finite population. Genetics. 1969;61:763–71. 9. Zhang J, et al. Positive Darwinian selection after gene duplication in primate ribonuclease genes. Proc Natl Acad Sci USA. 1998;95:3708–13. 9. Zhang J, et al. Positive Darwinian selection after gene duplication in primate ribonuclease genes. Proc Natl Acad Sci USA. 1998;95:3708–13. 10. Force A, et al. Preservation of duplicate genes by complementary, degen erative mutations. Genetics. 1999;151:1531–45. 10. Force A, et al. Preservation of duplicate genes by complementary, degen- erative mutations. Genetics. 1999;151:1531–45. • • Population size assumed constant, while this may vary with time due to multiple environmental factors. 11. Einstein A. On the movement of small particles suspended in stationary liquids required by the molecular-kinetic theory of heat. Ann d Phys. 1905;17:549–60. 12. Reams AB, et al. Duplication frequency in a population of Salmonella enterica rapidly approaches steady state with or without recombination. Genetics. 2010;184:1077–94. 13. Wong S, Wolfe KH. Birth of a metabolic gene cluster in yeast by adaptive gene relocation. Nat Genet. 2005;37:777–82. 13. Wong S, Wolfe KH. Birth of a metabolic gene cluster in yeast by adaptive gene relocation. Nat Genet. 2005;37:777–82.
https://openalex.org/W2617029612	https://www.matec-conferences.org/10.1051/matecconf/201710603030/pdf	English	null	Production of functional materials on the basis of tungsten multicomponent mineral resources	MATEC web of conferences	2,017	cc-by	3,061	Production of functional materials on the basis of tungsten multicomponent mineral resources 1 * 2 3 1 Evgenii Kuzmichev1,, Khosen Ri2, Sergei Nikolenko3 , Evgenii Drozdov 1, Denis Balakhonov1 1Far Eastern State Transport University, Seryshev Str., 47, Khabarovsk, 680021, Russia 2Pacific State University, Tikhookeanskaya Str., 136, Khabarovsk, 680035, Russia 3Russian Academy of Sciences, Tikhookeanskaya Str., 153, Khabarovsk, 680035, Russia Abstract. We produced tungsten and tungsten carbide as a result of the synthesis of multicomponent tungsten mineral resource with the employment of high density energy flow. The results of experiments concerned with the possibility of using high-density energy to synthesize functional materials for industrial use are presented as well. © The Authors, published by EDP Sciences. This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (http://creativecommons.org/licenses/by/4.0/). 1 Introduction The growing difficulties in supply of raw materials and the high cost of expansion of steel production require attention to the problem of the use of resource-saving technologies in all sectors. The objective is to obtain the maximum number of higher quality and low-cost steel products from a certain amount of source raw material. These problems have set a series of urgent tasks and identified strategic directions for materials science in the fields of development and production of materials: - production of materials involving complex use of raw materials and in consideration of their distribution in nature; - design and development of innovative, environmentally friendly technologies for the production of structural, instrumental, welding and surfacing materials from mineral raw materials without deep technological processing and locating these technologies closer to the production sites and mining areas. - design and development of innovative, environmentally friendly technologies for the production of structural, instrumental, welding and surfacing materials from mineral raw materials without deep technological processing and locating these technologies closer to the production sites and mining areas. Cyclic circulation of substances and materials can be considered as the basis for the resolution for the problem of producing new materials. Such approach was first proposed within the framework of the concept of sustainable development as the transition to a fundamentally new technology, allowing the society to fit into the "endless circle" of natural processes on the planet, is the only possible way of the radical improvement of the whole spectrum of interaction between the society and the environment [1]. The so-called “cycle of materials” has been studied in Germany for more than 10 years [2]. At the same time there is a significant impact of the new approach on the formation of a new unifying science of materials – “Integral Material Science”. This means that the “life” of all groups Corresponding author: e_kuzmichev@mail.ru , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 DOI: 10.1051/ 71060 matecconf/201 3030 , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 DOI: 10.1051/ 71060 matecconf/201 3030 of materials in use as a means of human activity is traced “from nucleation to death” and their further reuse in the form of other means of action. of materials in use as a means of human activity is traced “from nucleation to death” and their further reuse in the form of other means of action. This approach based on the environmental safety is of great importance for the future Analysis of dynamics in the initial stages of substances and materials (Geology - Mining - Metallurgy - Materials Science) shows that efficiency of the materials production increases if the distance between the cycles and cycle time is minimal. Therefore, sustainable development of the region requires organization of processing minerals at their mining areas using high technologies for processing raw materials under environmentally sound conditions, which contributes to the minimum increase in entropy within the framework of cycle and between cycles [3]. A number of studies [2,4] indicate the prospects of using concentrated energy flows to obtain materials and products from mineral raw materials in their mining areas. The research is based on the multipurpose use of mineral raw materials when exposed to concentrated energy flows, in order to extract the alloying elements and oxides. This fact corresponds to the proposed theory of cross-entropy minimization when producing final material, leaving aside the stages of the primary beneficiating and reprocessing. Reducing the production period of material is possible by use of modern technologies, which exclude the use of environmentally hazardous pyro- and hydrometallurgical processes. The use of such technologies will not only ensure complex and rational processing of mineral resources, but also the compliance with environmental requirements and transformation of mining regions dealing with extracting resources into developed suppliers of materials and products. Tungsten containing mineral raw material is a rebellious complex difficult for concentration, and the method of its decomposition includes complex processes of reprocessing and preparation. According to the ways of processing tungsten containing raw materials two groups of methods are distinguished: hydrometallurgical and thermochemical. Among the hydrometallurgical methods of processing raw materials, the lion’s share belongs to their decomposition with mineral acids or alkalis at normal or high-top pressure. The most common way of breaking-down mineral raw materials is the use of toxic chemicals: hydrochloric, sulfuric and nitric acids [1,3], but this causes significant environmental damage. * Corresponding author: e_kuzmichev@mail.ru © The Authors, published by EDP Sciences. This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (http://creativecommons.org/licenses/by/4.0/). , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 DOI: 10.1051/ 71060 matecconf/201 3030 significantly reduce the consumption of an alkaline reagent and energy for technological needs [6]. significantly reduce the consumption of an alkaline reagent and energy for technological needs [6]. The method based on soda sintering of tungsten concentrates at temperature of about 850-880 °C ensures 90-93% transformation of tungsten into water soluble tungsten compound, according to works [7-10], describing the method of preparation of the charge in the furnace in the way that it does not melt but takes the form of lumps. Such result can be achieved by adding the leaching tailings of sintered mass in the amount that is sufficient to reduce WO3 content up to 20-22%. The break-down degree reaches 99-99.5% WO3. There also exist several processes that were described [11] and have practical use. But all these processes have a multi-stage structure with a large share of use of various kinds of chemical raw materials, acids, alkalis, etc. All of the above described methods have a detrimental effect on the environment, soil and rivers. One of the trends towards the creation of tungsten ore processing technologies that meet modern requirements is the transition to the processes employing highly concentrated energy flows, such as low- temperature plasma technology and laser technology [12,13]. The goal of our research was to produce tungsten carbide from scheelite concentrate by using direct-action plasma arc. , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 Upon an exploitation of an ore deposit up to 5% in average is considered to be the shipping ore, up to 35% is concentrated and up to 60% of base ore is left in the ore deposit [5]. Only 2% of mined rock turns into useful products and 98% is lost in the waste, and the biggest losses occur at the stages of concentration and technological conversion. The method, that has found its use in the practice of processing scheelite concentrates, is conducted using sodium hydroxide solution. Complete decomposition is achieved in the processing of finely divided concentrate of 25-40% sodium hydroxide solution at 110-120 ° C, and the excess alkali makes 50% or more. The process is not applicable to low grade concentrates, and self-decomposition takes a long time. Method of autoclave-soda leaching, developed in the USSR, is widespread these days. This method is one of the most common in the hydrometallurgy of tungsten on the decomposition of tungsten products, and is noted in numerous studies [4,5,6] on autoclave- soda process of decomposing. But along with its benefits we can also point to its significant disadvantages: high consumption of soda, insufficiently high degree of decomposition in a single process stage and considerable consumption of hydrochloric acid for neutralization of solutions as well as pressure operated devices. An alternative to this decomposition method is hydrothermal treatment with alkali solutions at moderate temperatures (150-170 °C) in order to reduce the working pressure (4-6 atm) to intensify leaching process and 2 , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 2 Methods and materials The chemical composition of “Lermontov Mining and Concentrating Mill” scheelite concentrate is presented in the Table. 1. Table 1. Chemical composition of scheelite concentrate of the “Lermontov Mining and Concentrating Mill” proportion of tungsten against other elements. The chemical composition of “Lermontov Mining and Concentrating Mill” scheelite concentrate is presented in the Table. 1. Table 1. Chemical composition of scheelite concentrate of the “Lermontov Mining and Concentrating Mill” ble 1. Chemical composition of scheelite concentrate of the “Lermontov Mining and Concentrating Mill”. The content of components in the concentrate , W % SiO2 Al2O3 Fe2O3 FeO MnO CaO MgO Na2O K2O 7.96 0.78 5.29 0.72 0.02 19.8 2.45 0.18 0.17 P2O5 As TiO2 WO3 SO3 H2O H2O+ CO2 – 4.9 0.45 0.25 55.4 0.1 0.68 1.56 0.43 – We used a mixture of scheelite concentrate and carbonaceous reducing agent for the experiment. In one case the mixture was preliminarily milled with the reducing agent, and in the other we used the mixture without pretreatment with particles sized approximately 500 – 800 microns. The experiments were conducted using the equipment with the output power density at the plasma burner between the cathode and anode reaching about g>106-108W/cm2. Exposure was performed for 30-50 seconds. The process temperature of the synthesis was about 4-6 thousand °C. The reactor that received the mixture reacted in the plasma flow, and the burner, through which the mixture was fed, were tightly connected and the access of air to the reactor chamber was minimized. The entire process of synthesis proceeded in the atmosphere of inert argon gas. After melting the mixture and its removal from the plasma burner, all the material from the reactor chamber got through the tube into the reservoir with distilled water, where the resulting material in the form of reduced tungsten and tungsten monocarbide was produced in addition to the rest of the slag. Obtained particles of resulting compounds of W-WnC were sifted through a set of sieves, and represented samples of 0.2 - 0.5 mm in diameter (Figure 1). 2 Methods and materials Phase analysis of the fusion products was performed by the scanning electron microscope «VEGA 3 LMH» (TESCAN), equipped with energy dispersive spectrometer «X-Max 80» (Oxford Instruments). Photographing samples and micro-search was conducted mainly in the mode of backscattered electrons (BSE-detector). In the image obtained, phases with higher average atomic number are reflected in the contrast more vividly in comparison with the phases with lower average atomic number. Phase analysis was also carried out using a ZEISS Libra-120 transmission electron microscope equipped with a detector and HAADF-Ω-energy filter. Samples were examined in the modes of transmitted light, dark field and electron microdiffraction. The samples for transmission electron microscopy were prepared by electrolytic polishing and ion etching. The compositions of the slag and the synthesized product were examined with diffractometer “Dron 7” with a tube of Co on the X-ray К-line. 4 Exposure of refractory materials to high-density energy flows in the range of g>104- 105W/сm2, g>106-108W/cm2 leads to molecular destructuring of the crystal lattice and the subsequent formation of a new one. This process causes the formation of materials with both mechanical and chemical properties changed. This can be used with some success in various technological processes, such as welding, overlay welding on the surface of machine parts subjected to heavy wear during service. The use of high-temperature methods of impact on the mineral raw material of refractory origin and consequences of this impact are understudied and thus allow us not only to develop new methods of producing various functional materials based on mineral resources, but also to create new materials with a wide range of necessary properties, different from former ones produced by conventional methods. Such methods as plasma can solve the problem of changes in the properties of the workpiece surface. Plasma flow will deliver a certain chemical element in the crystal lattice of the metal. This chemical element processes the properties needed to create the desired effect, like increase in strength or endurance, preserving the integrity of one-piece structural elements, and increase in service life [14,15]. For this reason, our task is to find alternative ways to produce tungsten and tungsten- containing compounds from tungsten containing raw materials using the above mentioned methods. As a material, we took CaWO4 scheelite concentrate with up to 30-55% 3 3 , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 DOI: 10.1051/ 71060 matecconf/201 3030 proportion of tungsten against other elements. 3 Results and discussions The proportion of WC in a dispersed material was about 58%, while the content of tungsten reached about 21%. The remaining approximately 11% of the material was presented by the slag. It is important to note that the proportion of the evaporated material was about 10% of the total amount of the entire portion taken for the experiment (1 portion of the mixture for the experiment was taken in the amount of 100 g). Subsequently, during the same experiments under the same input parameters, the amount of evaporated material did not change. Fig. 1. The picture of tungsten carbide obtained using a scanning electron microscope VEGA 3 LMH. Fig. 1. The picture of tungsten carbide obtained using a scanning electron microscope VEGA 3 LMH. 4 , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 DOI: 10.1051/ 71060 matecconf/201 3030 SPbWOSCE-2016 Table 2. The content of chemical elements in synthesized materials based on W/WC. Chemical element (wt.%) C O Al Si P S Ca W Spectrum 5 4.82 37.86 0.94 1.19 0.27 0.57 53.83 0.52 Spectrum 4 7.9 0.8 - - - - 0.01 92.1 Fig. 2. Spectrogram of produced tungsten carbide after exposure to a high-density energy g>104- 105W/cm2, g>106-108W/cm2. Table 2. The content of chemical elements in synthesized materials based on W/WC. Fig. 2. Spectrogram of produced tungsten carbide after exposure to a high-density energy g>104- 105W/cm2, g>106-108W/cm2. Fig. 2. Spectrogram of produced tungsten carbide after exposure to a high-density energy g>104- 105W/cm2, g>106-108W/cm2. Chemical analysis of the synthesized material showed the presence of CaCO3, W2C, WC, carbon residue not involved in the reduction reaction and samples of tungsten in the form of fused particles. Fig.3. Fused tungsten carbide WC crystals of hexagonal structure. А – photo after «VEGA 3 LMH», В – scanning electron microscope. Fig.3. Fused tungsten carbide WC crystals of hexagonal structure. А – photo after «VEGA 3 LMH», В – scanning electron microscope. Experiments performed with unprocessed concentrate have shown relatively similar results except for the increased proportion of resulting synthesized material W-WnC. We can assume that synthesis proceeds much better with mechanical activation, aided by the reactions occurring at the time of grinding of the two components at the molecular level. Under such conditions the amount of produced material W-WnC is about 68-72%. The type of the synthesized material after determination of its phase composition is WC with hexagonal structure of crystals. 3 Results and discussions It is presented in Figure 3 after being washed with distilled water. The content of tungsten W was about 94 - 95% out of the total amount, and the content of carbon C was within the range of 6-5%. 5 5 , 03030 (2017) MATEC Web of Conferences 106 SPbWOSCE-2016 DOI: 10.1051/ 71060 matecconf/201 3030 4 Conclusion 1. The reduction of the tungsten carbide phase (WC, W2C) from multi-component tungsten mineral resources by high-density energy about g>104 – 105 W/cm2 is possible and it significantly reduces the time for its synthesis; 1. The reduction of the tungsten carbide phase (WC, W2C) from multi-component tungsten mineral resources by high-density energy about g>104 – 105 W/cm2 is possible and it significantly reduces the time for its synthesis; 2. The purity of the synthesized material reaches 92-95%, which requires further study to increase the amount of tungsten carbide in the products of synthesis. Another possible prospect is the shift to producing carbon free tungsten and mineral resources; 3. the research has shown the prospects of employing high-density energy for the synthesis of refractory compounds from tungsten mineral resources, which will allow us to shift from the traditional forms of production; p 4. During the preliminary mechanical activation of mixture components, high-temperature synthesis proceeds with the release of larger amounts of tungsten-containing synthesized products in the form of WC and WnC. 5. During the exposure to plasma the process temperature in the transition passage between the reactor and the burner reached about 5500 K and decreased with distance from the arcing zone to 3500 K, which allowed us to use only carbon-containing material as a reducing agent. It is also necessary to consider that in the experiments carbon was added to mixture with 10% excess, but due to specific features of the synthesis process, this amount of carbon must be increased on account of the sublimation of carbon in the form of oxides СО and СО2. References 1 E.N. Kuz’michev, A.D. Verkhoturov, D.S. Shtarev, Applied Mechanics and Materials 775, 165-169 (2015) 2 Y.N. Tumanov, Plazmennye, vysokochastotnye, mikrovolnovye i lazernye tehnologii v himiko-metallurgicheskih protsessah (FIZMALIT, Мoscow, 2010) 3 S.A. Pegov, Vestnik RAN 84, 1082–1089 (2004) 4 A.D. Verkhoturov, E.G. Babenko, E.N. Kuzmichev, Journal of Advanced Materials 1, 75-78 (2003) 5 D. Chen, H. Wen, H. Zhai, H. Wang, X. Li, R. Zhang, J. Sun, L. Gao, J. Am. Ceram. Soc. 93(12), 3997-4000 (2010) 6 R. Koc, S.K. Kodamaka, T. Carbide, J. of the European Ceramic Society 20, 1859- 1869 (2000) 7 M.F. Zawrah, J. Ceramics International 33, 155-161 (2007) 8 K.M. Reddy, T.N. Rao, J. Joardar, Materials chemistry and physics 128, 121-126 (2011) 9 G.A. Meerson, A.N. Zelikman, Mettalurgiya redkih metallov (Metallurgizdat, Мoscow, 1973) 10 A.D. Verkhoturov, E.G. Babenko, E.N. Kuz’michev, Theoretical Foundations of Chemical Engineering September 48, 716-721 (2014) 11 Metal Powders: Technologies and Applications (Elsevier, 2009) 12 D.V. Onishchenko, Inorganic Materials 48, 1096-1101 (2012) 13 E. Hornbogen, Werkstoffe (Springer, Germany, 2006) 14 E. Hornbogen, G. Eggeler, E. Werner, Werkstoffe (Springer, Berlin, 2012) 6
https://openalex.org/W2760258467	https://www.aclweb.org/anthology/W17-4759.pdf	English	null	Predicting Translation Performance with Referential Translation Machines	null	2,017	cc-by	3,903	1 Introduction and Task 3 is about binary classiﬁcation of phrase- level quality. and Task 3 is about binary classiﬁcation of phrase- level quality. Quality estimation task (QET) in WMT17 (Bo- jar et al., 2017) (QET17) is about prediction of the quality of machine translation output at the sentence- (Task 1), word- (Task 2), and phrase- level (Task 3) in IT and pharmaceutical domains without using reference translations. Prediction of translation performance can help in estimating the effort required for correcting the translations dur- ing post-editing by human translators if needed. RTMs are capable to model different domains and tasks while achieving top performance in both monolingual (Bic¸ici and Way, 2015) and bilingual settings (Bic¸ici, 2016b). We develop RTM mod- els for all of the three subtasks of QET17, which include English to German (en-de), and German to English (de-en) translation directions. Task 1 is about predicting HTER (human-targeted trans- lation edit rate) scores (Snover et al., 2006), Task 2 is about binary classiﬁcation of word-level quality, Predicting Translation Performance with Referential Translation Machines Ergun Bic¸ici orcid.org/0000-0002-2293-2031 bicici.github.com n Bic¸ici -0002-2293-2031 ithub.com Figure 1: RTM depiction: ParFDA selects inter- pretants close to the training and test data using parallel corpus in bilingual settings and mono- lingual corpus in the target language or just the monolingual target corpus in monolingual set- tings; an MTPPS use interpretants and training data to generate training features and another use interpretants and test data to generate test features in the same feature space; learning and prediction takes place taking these features as input. Abstract Referential translation machines achieve top performance in both bilingual and monolingual settings without accessing any task or domain speciﬁc information or resource. RTMs achieve the 3rd system re- sults for German to English sentence-level prediction of translation quality and the 2nd system results according to root mean squared error. In addition to the new fea- tures about substring distances, punctua- tion tokens, character n-grams, and align- ment crossings, and additional learning models, we average prediction scores from different models using weights based on their training performance for improved results. Figure 1: RTM depiction: ParFDA selects inter- pretants close to the training and test data using parallel corpus in bilingual settings and mono- lingual corpus in the target language or just the monolingual target corpus in monolingual set- tings; an MTPPS use interpretants and training data to generate training features and another use interpretants and test data to generate test features in the same feature space; learning and prediction takes place taking these features as input. Proceedings of the Conference on Machine Translation (WMT), Volume 2: Shared Task Papers, pages 540–544 Copenhagen, Denmark, September 711, 2017. c⃝2017 Association for Computational Linguistics Proceedings of the Conference on Machine Translation (WMT), Volume 2: Shared Task Papers, pages 540–544 Copenhagen, Denmark, September 711, 2017. c⃝2017 Association for Computational Linguistics 540 2 Referential Translation Machines Referential translation machine (RTM) models are predict data translation between the instances in the training set and the test set. RTMs use inter- pretants, data close to the task instances, to de- rive features measuring the closeness of the test sentences to the training data, the difﬁculty of translating them, and to identify translation acts between any two data sets for building predic- tion models. RTMs are applicable in different domains and tasks and in both monolingual and bilingual settings. Figure 1 depicts RTMs and explains the model building process. RTMs use ParFDA (Bic¸ici, 2016a) for instance selection and machine translation performance prediction sys- tem (MTPPS) (Bic¸ici and Way, 2015) for generat- 540 Task Model DeltaAvg rP rS RMSE MAE RAE MAER MRAER Rank Task 1 en-de MIX 4 8.64 0.4544 0.4768 0.1707 0.1296 0.8483 0.7594 0.7962 9 PLS GBR 8.22 0.4302 0.4518 0.1727 0.1311 0.8586 0.7769 0.8099 10 de-en MIX 4 8.94 0.6004 0.5704 0.1566 0.1085 0.7034 0.7201 0.6921 4 TREE 9.18 0.5845 0.5729 0.158 0.1186 0.7685 0.9013 0.7627 5 Task Model DeltaAvg rP rS RMSE MAE RAE MAER MRAER Rank Task 1 en-de MIX 4 8.64 0.4544 0.4768 0.1707 0.1296 0.8483 0.7594 0.7962 9 PLS GBR 8.22 0.4302 0.4518 0.1727 0.1311 0.8586 0.7769 0.8099 10 de-en MIX 4 8.94 0.6004 0.5704 0.1566 0.1085 0.7034 0.7201 0.6921 4 TREE 9.18 0.5845 0.5729 0.158 0.1186 0.7685 0.9013 0.7627 5 Table 1: Task 1 test results of the top 2 individual RTM models. RTM becomes the 2nd system accord- ing to RMSE and 3rd system in de-en and 6th system in en-de. rP is Pearson’s correlation and rS is Table 1: Task 1 test results of the top 2 individual RTM models. RTM becomes the 2nd system accord- ing to RMSE and 3rd system in de-en and 6th system in en-de. rP is Pearson’s correlation and rS is Spearman’s correlation. RTM Interpretants Task Train Test Training LM Task 1, 2, 3 (en-de) 24000 2000 1.1M 17.6M Task 1, 2, 3 (de-en) 26000 2000 1.1M 17.6M Table 2: Number of instances used as interpretants by the RTM models. source sentence and its translation and their longest common preﬁx, sufﬁx, and sub- string (Tian et al., 2017) normalized by the minimum length of the compared sentences. Table 2: Number of instances used as interpretants by the RTM models. Table 2: Number of instances used as interpretants by the RTM models. 2 Referential Translation Machines • number of tokens about punctuation in the source sentence and the translation (Kozlova et al., 2016) and the cosine between them. ing features where the total number of features be- comes 514, increasing depending on the order of n-grams used and we used up to 5-grams for trans- lation features and 7-grams for language model (LM) at QET17. • modiﬁed CHRF3 (Popovi´c, 2015) to com- pute character n-grams split by word bound- ary space with n ∈ [3, 7] whereas the F1 (Bic¸ici, 2011) we already use compute with word n-grams up to n = 5. We use ridge regression (RR), k-nearest neighors (KNN), support vector regression (SVR), AdaBoost (Freund and Schapire, 1997), and ex- tremely randomized trees (TREE) (Geurts et al., 2006) as learning models in combination with fea- ture selection (FS) (Guyon et al., 2002) and partial least squares (PLS) (Wold et al., 1984). We use scikit-learn 1 for most of these models. The following parameters are optimized: λ for RR, k for KNN, γ, C, and ϵ for SVR, minimum number of samples for leaf nodes and for splitting an in- ternal node for TREE, the number of features for FS, and the number of dimensions for PLS. For AdaBoost, we do not optimize but use exponential loss and 500 estimators like we use also with the TREE model. We use grid search for SVR. Evalu- ation metrics we use are Pearson’s correlation (r), mean absolute error (MAE), relative absolute er- ror (RAE), MAER (mean absolute error relative), and MRAER (mean relative absolute error rela- tive) (Bic¸ici and Way, 2015). DeltaAvg (Callison- Burch et al., 2012) calculates the average quality difference between the top n −1 quartiles and the overall quality for the test set. Ofﬁcial evaluation metrics include r, MAE, and DeltaAvg. • proportion of alignments that cross ( ≮ ) the link (Sagemo and Stymne, 2016) of any other alignments: s 0.5 × \|a ≮ A\| \|A\| (1) (1) • word alignment correspondence fea- tures (Sagemo and Stymne, 2016). • word alignment correspondence fea- tures (Sagemo and Stymne, 2016). • additional learning models including KNN, AdaBoost, and gradient boosting regressor (GBR) (Tian et al., 2017; Hastie et al., 2009). 1http://scikit-learn.org/ 3.2 Recomputing QET 2016 Results QET17 also compares results on QET16 test sets. QET16 test set domain was different than the do- main of QET17, overlapping on the IT domain. We use the RTM models built for QET17 to obtain results on the QET16 test sets, which is catego- rized as transductive transfer learning. 4 Transfer learning attempt to re-use and transfer knowledge from models developed in different domains or for different tasks such as using models developed for handwritten digit recognition for handwritten character recognition (Guyon et al., 2012). The results are in Table 5 for Task 1, which does not show improvement, and in Table 7, which show improvements with RTM models built for QET17. Table 3: RTM Task 2 training results where GLMd parallelized over 4 splits is referred as GLMd s4 and GLMd with 5 splits as GLMd s5. Table 3: RTM Task 2 training results where GLMd parallelized over 4 splits is referred as GLMd s4 and GLMd with 5 splits as GLMd s5. Model F1 BAD F1 OK wF1 Word en-de GLMd s4 0.318 0.8844 0.2813 GLMd s5 0.36 0.8778 0.3158 de-en GLMd s4 0.3363 0.9386 0.3157 GLMd s5 0.3381 0.9395 0.3176 Phrase en-de GLMd s4 0.4043 0.8079 0.3283 GLMd s5 0.4114 0.8079 0.3323 de-en GLMd s4 0.2472 0.9073 0.2242 GLMd s5 0.3598 0.8884 0.3197 Table 4: RTM Task 2 results on the test set after the challenge. wF1 is average weighted F1 score. 4www.youtube.com/watch?v=9ChVn3xVNDI; we use the RTM models for the same task in different domains. 3.3 Comparison with Previous Results Table 4: RTM Task 2 results on the test set after the challenge. wF1 is average weighted F1 score. We compare the difﬁculty of tasks according to MRAER levels achieved. In Table 6, we list the RTM test results when predicting sentence-level HTER in 2013–2017. Compared with QET16, we observe improvements in MRAER and both MAE and RAE are improved when QET17 is compared with others. 2016b) for word- and phrase-level translation per- formance prediction. GLMd uses weights in a range [a, b] to update the learning rate dynamically according to the error rate. 2https://github.com/moses-smt/ mosesdecoder/tree/master/scripts 2 Referential Translation Machines RTM be- comes the 2nd system according to RMSE and 3rd system in de-en and 6th system in en-de. Model splits % error weights 2017 word en-de GLMd 4 0.0773 [0.5, 2] GLMd 5 0.0668 de-en GLMd 4 0.0468 GLMd 5 0.0469 phrase en-de GLMd 4 0.0068 GLMd 5 0.0059 de-en GLMd 4 0.0129 GLMd 5 0.0125 2016 word en-de GLMd 4 0.0688 GLMd 5 0.0757 phrase en-de GLMd 4 0.0051 GLMd 5 0.0051 Table 3: RTM Task 2 training results where GLMd parallelized over 4 splits is referred as GLMd s4 and GLMd with 5 splits as GLMd s5. Model F1 BAD F1 OK wF1 Word en-de GLMd s4 0.318 0.8844 0.2813 GLMd s5 0.36 0.8778 0.3158 de-en GLMd s4 0.3363 0.9386 0.3157 GLMd s5 0.3381 0.9395 0.3176 Phrase en-de GLMd s4 0.4043 0.8079 0.3283 GLMd s5 0.4114 0.8079 0.3323 de-en GLMd s4 0.2472 0.9073 0.2242 GLMd s5 0.3598 0.8884 0.3197 Table 4: RTM Task 2 results on the test set after the challenge. wF1 is average weighted F1 score. we obtain after the challenge for cohe tation on the training sets in Table 3 an set in Table 4. The results we obtained lenge are similar. Ranks for Task 1 a submissions and 9 systems. Top RTM competed in Task 1 were MIX 4, whic top 4 predictions, PLS GBR, and TRE comes the 2nd system according to RM system in de-en and 6th system in en- 3.2 Recomputing QET 2016 Resul QET17 also compares results on QET QET16 test set domain was different main of QET17, overlapping on the We use the RTM models built for QET results on the QET16 test sets, whic rized as transductive transfer learning learning attempt to re-use and transfer from models developed in different for different tasks such as using model for handwritten digit recognition for character recognition (Guyon et al., results are in Table 5 for Task 1, whi show improvement, and in Table 7, improvements with RTM models built 3.3 Comparison with Previous Res We compare the difﬁculty of tasks a MRAER levels achieved. In Table 6 4 Conclusion Table 2 lists the number of sentences in the train- ing and test sets for each task and the number of instances used as interpretants in the RTM mod- els (M for million). We tokenize and truecase all of the corpora using Moses’s (Koehn et al., 2007) processing tools. 2 LMs are built using KENLM (Heaﬁeld et al., 2013). Referential translation machines achieve top per- formance in automatic, accurate, and language in- dependent prediction of translation performance and achieve to become the 2nd system according to RMSE when predicting the translation perfor- mance from German to English. RTMs pioneer a language independent approach for predicting translation performance and remove the need to access any task or domain speciﬁc information or resource. 3We calculate rS using scipy.stats. 2https://github.com/moses-smt/ mosesdecoder/tree/master/scripts 3We calculate rS using scipy.stats. 2 Referential Translation Machines We also use prediction averaging (Bic¸ici, 2017), where the performance on the training set is used to obtain weighted average of the top k predic- tions, ˆy with evaluation metrics indexed by j ∈J: ˆyˆyˆyµk = 1 k Pk i=1 ˆyˆyˆyi MEAN ˆyˆyˆyj,wj k = 1 Pk i=1 1 wj,i Pk i=1 1 wj,i ˆyˆyˆyi ˆyˆyˆyk = 1 \|J\| P j∈J ˆyˆyˆyj,wj k MIX (2) ˆyˆyˆyµk = 1 k Pk i=1 ˆyˆyˆyi MEAN ˆyˆyˆyj,wj k = 1 Pk i=1 1 wj,i Pk i=1 1 wj,i ˆyˆyˆyi ˆyˆyˆyk = 1 \|J\| P j∈J ˆyˆyˆyj,wj k MIX (2) (2) We improved RTM models (Bic¸ici, 2016b) with additional features: We improved RTM models (Bic¸ici, 2016b) with additional features: MAER is used to select the predictions and weights are inverted to decrease error. • normalized Levenshtein distance between the We use Global Linear Models (GLM) (Collins, 2002) with dynamic learning (GLMd) (Bic¸ici, 1http://scikit-learn.org/ 541 Model splits % error weights 2017 word en-de GLMd 4 0.0773 [0.5, 2] GLMd 5 0.0668 de-en GLMd 4 0.0468 GLMd 5 0.0469 phrase en-de GLMd 4 0.0068 GLMd 5 0.0059 de-en GLMd 4 0.0129 GLMd 5 0.0125 2016 word en-de GLMd 4 0.0688 GLMd 5 0.0757 phrase en-de GLMd 4 0.0051 GLMd 5 0.0051 Table 3: RTM Task 2 training results where GLMd parallelized over 4 splits is referred as GLMd s4 and GLMd with 5 splits as GLMd s5. we obtain after th tation on the traini set in Table 4. The lenge are similar. submissions and 9 competed in Task top 4 predictions, comes the 2nd sys system in de-en an 3.2 Recomputin QET17 also comp QET16 test set do main of QET17, We use the RTM m results on the QE i d d Model splits % error weights 2017 word en-de GLMd 4 0.0773 [0.5, 2] GLMd 5 0.0668 de-en GLMd 4 0.0468 GLMd 5 0.0469 phrase en-de GLMd 4 0.0068 GLMd 5 0.0059 de-en GLMd 4 0.0129 GLMd 5 0.0125 GLMd 4 0 0688 we obtain after the challenge for coherent presen- tation on the training sets in Table 3 and on the test set in Table 4. The results we obtained in the chal- lenge are similar. Ranks for Task 1 are out of 14 submissions and 9 systems. Top RTM models that competed in Task 1 were MIX 4, which combines top 4 predictions, PLS GBR, and TREE. 3.1 QET 2017 Results Ondrej Bojar, Christian Buck, Rajen Chatterjee, Chris- tian Federmann, Barry Haddow, Matthias Huck, Ji- meno Antonio Yepes, Julia Kreutzer, Varvara Lo- gacheva, Aurelie Neveol, Mariana Neves, Philipp Koehn, Christof Monz, Matteo Negri, Matt Post, Stefan Riezler, Artem Sokolov, Lucia Specia, Karin Verspoor, and Marco Turchi. 2017. Proc. of the sec- ond conference on Machine Translation. In Proc. of the Second Conference on Machine Translation. Association for Computational Linguistics, Copen- hagen, Denmark. Chris Callison-Burch, Philipp Koehn, Christof Monz, Matt Post, Radu Soricut, and Lucia Specia. 2012. Findings of the 2012 workshop on statistical ma- chine translation. In Proc. of the Seventh Work- shop on Statistical Machine Translation. Montr´eal, Canada, pages 10–51. Michael Collins. 2002. Discriminative training meth- ods for hidden markov models: theory and ex- periments with perceptron algorithms. In Proc. of the ACL-02 conference on Empirical meth- ods in natural language processing - Volume 10. Stroudsburg, PA, USA, EMNLP ’02, pages 1–8. https://doi.org/10.3115/1118693.1118694. Yoav Freund and Robert E Schapire. 1997. A decision-theoretic generalization of on-line learn- ing and an application to boosting. Journal of Computer and System Sciences 55(1):119–139. https://doi.org/10.1006/jcss.1997.1504. Model wF1 F1 OK F1 BAD 2017 Word GLMd s4 0.2857 0.8775 0.3256 GLMd s5 0.3053 0.8653 0.3528 Phrase GLMd s4 0.3421 0.8192 0.4176 GLMd s5 0.3504 0.817 0.4289 2016 Word GLMd s4 0.2725 0.8884 0.3068 GLMd s5 0.3081 0.8820 0.3494 Phrase GLMd s4 0.3070 0.8145 0.3770 GLMd s5 0.3274 0.8016 0.4084 Table 7: QET16 Task 2 and Task 2p results show improvement. Ergun Bic¸ici and Andy Way. 2015. Referential trans- lation machines for predicting semantic similarity. Language Resources and Evaluation pages 1–27. https://doi.org/10.1007/s10579-015-9322-7. Ondrej Bojar, Christian Buck, Rajen Chatterjee, Chris- tian Federmann, Barry Haddow, Matthias Huck, Ji- meno Antonio Yepes, Julia Kreutzer, Varvara Lo- gacheva, Aurelie Neveol, Mariana Neves, Philipp Koehn, Christof Monz, Matteo Negri, Matt Post, Stefan Riezler, Artem Sokolov, Lucia Specia, Karin Verspoor, and Marco Turchi. 2017. Proc. of the sec- ond conference on Machine Translation. In Proc. of the Second Conference on Machine Translation. Association for Computational Linguistics, Copen- hagen, Denmark. Table 7: QET16 Task 2 and Task 2p results show improvement. 3.1 QET 2017 Results The results on the Task 1 test set are listed in Ta- ble 1. 3 For Task 2 and Task 3, we list the results 542 Model DeltaAvg r MAE RMSE RAE MAER MRAER 2017 ST TREE 5.14 0.2052 0.1456 0.1875 0.9634 0.8844 0.8666 PLS GBR 3.71 0.1875 0.1474 0.1914 0.9755 0.8706 0.8966 2016 SVR 6.38 0.3581 0.1359 0.1806 0.8992 0.7509 0.8567 FS SVR 6.66 0.3764 0.1346 0.1781 0.8905 0.7537 0.8388 Table 5: QET16 Task 1 results are not improved with QET17 Task 1 RTM models. Table 5: QET16 Task 1 results are not improved with QET17 Task 1 RTM models. Task Translation Model r MAE RAE MAER MRAER QET17 Task 1 HTER en-de MIX 4 0.4544 0.1296 0.8483 0.7594 0.7962 de-en MIX 4 0.6004 0.1085 0.7034 0.7201 0.6921 QET16 Task 1 HTER en-de FS SVR 0.3764 0.1346 0.8905 0.7537 0.8388 QET15 Task 1 HTER en-es FS+PLS SVR 0.349 0.1335 0.903 0.8284 0.8353 QET14 Task 1.2 HTER en-es SVR 0.5499 0.134 0.8532 0.7727 0.8758 QET13 Task 1.1 HTER en-es PLS-SVR 0.5596 0.1326 0.8849 2.3738 1.6428 Table 6: Test performance of the top RTM results when predicting sentence-level HTER in 2 Model wF1 F1 OK F1 BAD 2017 Word GLMd s4 0.2857 0.8775 0.3256 GLMd s5 0.3053 0.8653 0.3528 Phrase GLMd s4 0.3421 0.8192 0.4176 GLMd s5 0.3504 0.817 0.4289 2016 Word GLMd s4 0.2725 0.8884 0.3068 GLMd s5 0.3081 0.8820 0.3494 Phrase GLMd s4 0.3070 0.8145 0.3770 GLMd s5 0.3274 0.8016 0.4084 Table 7: QET16 Task 2 and Task 2p results show improvement. References Ergun Bic¸ici. 2011. The Regression Model of Machine Translation. Ph.D. thesis, Koc¸ University. Supervi- sor: Deniz Yuret. 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https://openalex.org/W4361867450	https://zenodo.org/record/7804632/files/591-593.pdf	Kirghiz, Kyrgyz	null	YORDAMCHI FE'LLAR USLUBIYATI VA LEKSIK-GRAMMATIK XUSUSIYATLARI	Zenodo (CERN European Organization for Nuclear Research)	2,023	cc-by	1,086	1 Ҳожиев А. Ўзбек тилида кўмакчи феъллар. “Фан” нашриёти. Тошкент, 1966. Б.15-16. Rahmatova Sevaraxon Alisherovna O‘zMU 1-bosqich doktoranti Annotatsiya: Yetakchi va yordamchi fe’llardan tashkil topgan birikmalar komponentlarining birikish shakli, o‘zaro ma’no munosabatlari, yordamchi fe’llarning uslubiyati, leksik-grammatik xususiyatlari sistem-struktor tilshunoslik olimlar diqqat markazidagi asosiy o‘rganish obyektlardandir. Maqolada, asosan, yordamchi fe’llarning uslubiyati, lug‘aviy shakl yasovchi affikslardan farqi, leksik- grammatik xususiyatlari haqida fikrlar keltirib o‘tilgan. Kalit so‘zlar: yordamchi fe’l, yetakchi fe’l, affiks, tilshunoslik, ma’no munosabati, shakl yasovchi, birikma, uslubiyat. O‘zbek tilida to‘liq holda yordamchi fe’l vazifasida keladigan fe’llar mavjud emas. Ular o‘rni bilan mustaqil fe’l, o‘rni bilan esa yordamchi fe’l funksiyasida qo’llanadi. Jumladan, boshla, yot, tur, yur, bo‘l, bit, ol, ber, qol, qo‘y, chiq, bor, kel, yubor, tashla, yoz va shu kabilar. Fikrimizni asoslash uchun quyidagi misollarni keltirishimiz mumkin: Yodgor ertalabdan buyon Abdulla Qodiriyning “O‘tkan kunlar” romanini o‘qib yuribdi.( yordamchi fe’l) Yodgor ertalabdan buyon ko‘chada yuribdi. (mustaqil fe’l) Charchaganidanmi yoki eringanidanmi, bilmadim-u, lekin Salima yo‘lni yarmida aravaga yotib oldi.( yordamchi fe’l) Bu sinfdoshlarga havasim keldi, chunki ular ota-onalari bergan pullariga kitoblar oladi. (mustaqil fe’l) Yuqoridagi fe’llarni gap orasida mustaqil fe’lmi yoki yordamchi fe’lmi, aniqlash ba’zi o‘rinlarda qiyin bo‘lib qoladi. Shu sababli yordamchi fe’llarning leksik- grammatik xususiyatlari haqida ma’lumot berishni joiz bildik. Yordamchi fe’llarning leksik-grammatik xususiyatlari deyilganda bu fe’llarning yordamchi fe’l vazifasida qo‘llanganda mustaqil ma’no bildirmasligi, o‘zi birikib kelgan fe’lning ma’nosiga turli qo‘shimcha ma’no berishi va yetakchi fe’l bilan birgalikda gap bo‘lagi bo‘lib kelishi tushuniladi. 591 https://t.me/openidea_uz Multidisciplinary Scientific Journal March, 2023 591 https://t.me/openidea_uz Multidisciplinary Scientific Journal March, 202 Innovative Development in Educational Activities ISSN: 2181-3523 VOLUME 2 \| ISSUE 6 \| 2023 Scientific Journal Impact Factor (SJIF): 5.938 http://sjifactor.com/passport.php?id=22323 Innovative Development in Educational Activities ISSN: 2181-3523 VOLUME 2 \| ISSUE 6 \| 2023 Scientific Journal Impact Factor (SJIF): 5.938 http://sjifactor.com/passport.php?id=22323 Innovative Development in Educational Activities ISSN: 2181-3523 VOLUME 2 \| ISSUE 6 \| 2023 Scientific Journal Impact Factor (SJIF): 5.938 http://sjifactor.com/passport.php?id=22323 Shaklan bir xil bo‘lgan birliklar ham mustaqil fe’l, ham yordamchi fe’l vazifasida qo‘llanish holatlari ham kuzatiladi. Ravishdosh shaklidagi fe’l bilan shaxsli fe’lning o‘zaro birikuvida shaxs-son bilan tuslangan fe’lda shu xususiyatni ko‘rish mumkin: Jumladan, irg‘ib tushdi birikuvida tushdi fe’li ko‘makchi fe’l bo‘lishi ham mumkin, mustaqil fe’l bo‘lishi ham mumkin: otdan irg‘ib tushdi. Bunda tush fe’li harakatni bildiradi. Ravishdosh formasidagi fe’l shu harakatning qanday bajarilganligini anglatadi (shunga ko‘ra bu birikuvda tush fe’li mustaqil fe’l hisoblanadi); Kamolxonov bir irg‘ib tushdi, gangidi…Bu gapdagi irg‘ib tushdi birikuvida tush fe’li harakat bildirmaydi. O‘zi biror so‘zni boshqarib ham, gapning mustaqil bo‘lagi bo‘lib ham kelmaydi. Bu birikuvda asosiy ma’no irg‘i fe’li ifodalagan ma’nodir. Tush fe’li shu fe’l bildirgan harakatning xarakteristikasini, ya’ni harakatning yo‘nalishini ko‘rsatadi va ma’noni kuchli ottenka bilan ifodalaydi. Shunga ko‘ra, u ko‘makchi fe’l hisoblanadi1. Aksariyat holatlarda yordamchi fe’llarning ma’nosi shu fe’llarning mustaqil ma’nosidan tubdan farqlanadi. Ularning bunday ma’nolari ostida ish-harakat tushunchasi bo‘lmaydi: ayta qolmoq, ko‘ra olmoq kabilar shular jumlasidandir. Bunday hollarda ravishdosh shaklidagi fe’lning asosiy fe’l ekanligiga, unga birikib kelgan fe’lning yordamchi fe’l ekanligini anglash oson bo‘ladi. Masalan, ko‘ra olmoq birikuvida ol fe’li harakat ma’nosini emas, balki imkoniyat, shu ishga qodirlik ma’nosini ifodalaydi. Bundan uning mustaqil fe’l emas, aksincha, yordamchi fe’l ekanligi yaqqol anglashinib turadi. Lekin shunday yordamchi fe’llar borki, ular ifodalaydigan ma’no shu fe’llarning mustaqil fe’l sifatida ifodalaydigan ma’nosidan tamomila boshqa ma’no bo‘lmay balki mustaqil ma’nolaridan biriga to‘g‘ri keladi. Masalan, bo‘l ko‘makchi fe’lining ma’nosi uning mustaqil fe’l sifatida ifodalaydigan ma’nosiga to‘g‘ri keladi: o‘qib bo‘ldim – o‘qishni tugatdim. Ana shunday hollarda ravishdosh shakliga birikib kelgan fe’lning mustaqil fe’l yoki yordamchi fe’l ekanligini aniqlash birmuncha mushkuldir. Biror fe’lning yordamchi fe’l yoki mustaqil fe’l ekanligini uning quyidagi birikuvda o‘z ma’nosini ifodalashi yoki o‘z ma’nosidan tamomila boshqa ma’no ifodalashiga qarabgina belgilanmaydi. Jumladan, o‘qiy boshladi, aytib bo‘ldi birikmalarida boshlamoq va bo‘lmoq fe’llari ifodalaydigan ma’no shu fe’llarning mustaqil fe’l sifatida qo‘llanganda ifodalaydigan ma’nosiga to‘g‘ri keladi. Ammo o‘qiy boshladi birikuvida boshlamoq fe’li yordamchi fe’l hisoblanadi. Bunda asosiy harakat yetakchi fe’l anglatgan harakatdir. Bilamizki, yordamchi fe’llar o‘zi birikib kelgan fe’lning ma’nosiga qo‘shimcha ma’no yuklab keladi. Bu tomondan yordamchi fe’llar lug‘aviy shakl yasovchi affikslarga yaqin turadi. Lekin ularni affikslarga tenglashtirib bo‘lmaydi. Innovative Development in Educational Activities ISSN: 2181-3523 VOLUME 2 \| ISSUE 6 \| 2023 Scientific Journal Impact Factor (SJIF): 5.938 http://sjifactor.com/passport.php?id=22323 Yordamchi 592 Multidisciplinary Scientific Journal March, 2023 592 March, 2023 https://t.me/openidea_uz Multidisciplinary Scientific Journal Multidisciplinary Scientific Journal Innovative Development in Educational Activities ISSN: 2181-3523 VOLUME 2 \| ISSUE 6 \| 2023 Scientific Journal Impact Factor (SJIF): 5.938 http://sjifactor.com/passport.php?id=22323 fe’llar o‘zining leksik ma’nosini tamomila yo‘qotmaydi, ular so‘zligicha qoladi. Ularning affikslardan asosiy farqi ham shundadir. Yordamchi fe’llar va affikslar o‘rtasida quyidagicha farqlar mavjud: fe’llar o‘zining leksik ma’nosini tamomila yo‘qotmaydi, ular so‘zligicha qoladi. Ularning affikslardan asosiy farqi ham shundadir. Yordamchi fe’llar va affikslar o‘rtasida quyidagicha farqlar mavjud: fe’llar o‘zining leksik ma’nosini tamomila yo‘qotmaydi, ular so‘zligicha qoladi. Ularning affikslardan asosiy farqi ham shundadir. Yordamchi fe’llar va affikslar o‘rtasida quyidagicha farqlar mavjud: fe’llar o‘zining leksik ma’nosini tamomila yo‘qotmaydi, ular so‘zligicha qoladi. Ularning affikslardan asosiy farqi ham shundadir. Yordamchi fe’llar va affikslar o‘rtasida quyidagicha farqlar mavjud: Yordamchi fe’llarning barchasi mustaqil fe’l sifatida ham qo‘llanadi. 1. Yordamchi fe’llarning barchasi mustaqil fe’l sifatida ham qo‘llanadi. 2. Affikslar so‘zlarga bevosita bog‘lana oladi. Yordamchi fe’llar esa ravishdosh shakli orqali yetakchi fe’lga bog‘lanadi. 2. Affikslar so‘zlarga bevosita bog‘lana oladi. Yordamchi fe’llar esa ravishdosh shakli orqali yetakchi fe’lga bog‘lanadi. 3. Ayrim yordamchi fe’llarning ma’nosi shu fe’llarning mustaqil fe’l sifatida ifodalaydigan ma’nosiga to‘g‘ri keladi. Jumladan, boshla, bo‘l, qol fe’llari 3. Ayrim yordamchi fe’llarning ma’nosi shu fe’llarning mustaqil fe’l sifatida ifodalaydigan ma’nosiga to‘g‘ri keladi. Jumladan, boshla, bo‘l, qol fe’llari 4. Fe’l turkumiga xos shakl yasovchi affikslar o‘zi birikib kelgan fe’lning biror qo‘shimcha grammatik ma’no ifodalaydi. 5. Ko‘makchi fe’lning ayrimlari ba’zi fe’llar bilan birikkanda bir xil ma’noni, boshqa fe’llar bilan birikkanda esa boshqa ma’nolarni ifodalab keladi. Jumladan, dumalab ketmoq birikmasida ketmoq yordamchi fe’li yo‘nalish ma’nosini ifodalasa, semirib ketmoq birikmasida harakat-holatning yuqori darajada yuz berishi ma’nosini anglatadi. Lug‘aviy shakl yasovchi affikslar esa hamma vaqt ma’lum bir grammatik ma’noni ifodalaydi. 6. Yordamchi fe’llarning shakl yasovchi affikslardan yana bir farqi shuki, ular so‘zlarga xos tashqi belgisini, ya’ni shaklini saqlab qoladi. Masalan, ko‘ra olmoq, ayta ko‘rmoq, gapira boshlamoq. Ko‘rinib turibdiki, yordamchi fe’llarning uslubiyati, leksik-grammatik xususiyatlari o‘rganish talab qilinadigan, tahlilga tortiladigan yo‘nalishlardan biri hisoblanadi. Bu soha juda keng qamrovli bo‘lib, yordamchi fe’llarni ma’lum bir badiiy asar yoki she’riy asar misolida tadqiq va tahlil qilish maqsadga muvofiqdir. Adabiyotlar: 1. Ҳожиев А. Ўзбек тилида кўмакчи феъллар. “Фан” нашриёти. Тошкент, 1966. 2. О. Акбаров, Узбек тилида қўшма феъллар, Тошкент, 1953; 3. Н. А. Баскаков, Қаракалпакский язьш, II, Фонетика и морфология, ч. 1, М., 1952. 4. Aксёнoвa A.A. Ресептивныйе aспекты визуaлнoгo в литерaтуре. // Нoвый филoлoгический вестник 2020. №3 (54) https://t.me/openidea_uz Multidisciplinary Scientific Journal March, 2023 593 593 Multidisciplinary Scientific Journal March, 2023 593
https://openalex.org/W2973065348	https://hal.inria.fr/hal-02510115/file/I3E2019_paper_44.pdf	English	null	Use of Social Media by b2b Companies: Systematic Literature Review and Suggestions for Future Research	Lecture notes in computer science	2,019	cc-by	5,584	To cite this version: Yogesh Dwivedi, Elvira Ismagilova, Nripendra P. Rana, Vishanth Weerakkody. Use of Social Media by b2b Companies: Systematic Literature Review and Suggestions for Future Research. 18th Con- ference on e-Business, e-Services and e-Society (I3E), Sep 2019, Trondheim, Norway. pp.345-355, 10.1007/978-3-030-29374-1_28. hal-02510115 Use of Social Media by b2b Companies: Systematic Literature Review and Suggestions for Future Research Yogesh Dwivedi, Elvira Ismagilova, Nripendra P. Rana, Vishanth Weerakkody Distributed under a Creative Commons Attribution 4.0 International License Use of social media by b2b companies: systematic literature review and suggestions for future research Yogesh Dwivedi1, Elvira Ismagilova2, Nripendra Rana1, Vishanth Weerakkody2 1 Emerging Markets Research Centre, School of Management, Swansea University, UK {y.k.dwivedi, n.p.rana}@swansea.ac.uk Yogesh Dwivedi1, Elvira Ismagilova2, Nripendra Rana1, Vishanth Weerakkody2 1 Emerging Markets Research Centre, School of Management, Swansea University, UK {y.k.dwivedi, n.p.rana}@swansea.ac.uk 2 Faculty of Management, Law and Social Sciences, University of Bradford, Bradford, UK {e.ismagilova, v.weerakkody}@bradford.ac.uk 2 Faculty of Management, Law and Social Sciences, University of Bradford, Bradford, UK {e.ismagilova, v.weerakkody}@bradford.ac.uk Abstract. Social media plays an important role in the digital transformation of businesses. This research provides a comprehensive analysis of the use of social media by b2b companies. The current study focuses on a number of aspects of social media such as: the effect of social media; social media tools; social media use; adoption of social media use and its barriers; social media strategies; and measuring the effectiveness of the use of social media. This research provides a valuable synthesis of the relevant literature on social media in the b2b context by analysing and discussing the key findings from existing research on social media. The findings of this study can be used as an informative framework on social media for both academics and practitioners. Keywords: Social media; B2B; Literature review Keywords: Social media; B2B; Literature review HAL Id: hal-02510115 https://inria.hal.science/hal-02510115v1 Submitted on 17 Mar 2020 L’archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d’enseignement et de recherche français ou étrangers, des laboratoires publics ou privés. HAL is a multi-disciplinary open access archive for the deposit and dissemination of sci- entific research documents, whether they are pub- lished or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. Distributed under a Creative Commons Attribution 4.0 International License Keywords: Social media; B2B; Literature review 1 Introduction The Internet has changed social communications and social behaviour, in turn leading to the development of new forms of communication channels and platforms [1]. So- cial media plays an important role in the digital transformation of businesses. Where- as, in the past, social networks were used to provide information about a company or brand, nowadays businesses use social media to support their marketing aims and strategies to improve consumer’s involvement, relationship with customers and to get useful consumers’ insights [2]. Business to consumer (b2c) companies widely use social media and enjoy its benefits such as an increase in sales, brand awareness, and customer engagement to name a few [3]. More recently, business to business (b2b) companies started using social media as part of their marketing strategy. Even though b2b companies are benefitting from social media used by marketers, it is argued that research on that area is still in the embryonic stage and future research is needed [4-6]. The topic of Social media in the context of b2b companies has started to attract at- tention from both academics and practitioners. This is evidenced by the growing number of research output within academic journals and conference proceedings. Some studies provided a comprehensive literature review on social media use by b2b 2 companies [4, 7], but focused only on the adoption of social media by b2b or social media influence, without providing the whole picture of the use of social media by b2b companies. Thus, this study aims to close this gap in the literature by conducting a comprehensive analysis of the use of social media by b2b companies. The findings of this study can provide an informative framework for research on social media in the context of b2b companies for academics and practitioners. The remaining sections of the study are organised as follows. Section 2 offers a brief overview of the methods used to identify relevant studies to be included in this review. Section 3 synthesises the studies identified in the previous section and pro- vides their detailed overview. Section 4 presents limitations of current studies on so- cial media use by b2b companies and outlines directions for future research. Finally, section 4 discusses the key aspects of the research, outlining limitations of the current research and proposing direction for future research. 2 Literature search method This study used a keyword search based approach for identifying relevant articles [8, 9]. Keywords such as "Advertising" OR "Marketing" OR "Sales" AND TITLE ( "Social Media" OR "Web 2.0" OR "Facebook" OR "LinkedIn" OR "Instagram" OR "Twitter" OR "Snapchat" OR "Pinterest" OR "WhatsApp" OR "Social Net- working Sites" ) AND TITLE-ABS-KEY ( "B2B" OR "B to B" OR "Business to Business" OR "Business 2 Business") were searched via the Scopus database. Only results in English language were included. All studies were processed by the authors in order to ensure relevance and that the research offered a contribution to the social media in the context b2b discussion. The search and review resulted in 70 articles and conference papers that formed the literature review for this study. The selected studies appeared in 33 separate journals and conference proceedings, including Industrial Marketing Management Journal, Journal of Business and Industrial Marketing and Journal of Business research. 3.1 Effect of social media Some studies focus on the effect of social media for b2b companies which include customer satisfaction, value creation, post sales service behavior, sales, building rela- tionships with customers, brand awareness, intention to purchase, knowledge creation, perceived corporate credibility, acquiring of new customers, salesperson performance and employee brand engagement. For example, Agnihotri et al. [10] investigated how the implementation of social media by b2b salesperson affects consumer satisfaction. Salesperson social media use is defined as a “salesperson's utilization and integration of social media technology to perform his or her job” [10]. The study used data of 111 sales professionals involved in b2b industrial selling to test the proposed hypotheses. It was found that a salesperson's use of social media will have a positive effect on information communication, which will, in turn, lead to improved customer satisfac- tion with the salesperson. Also, it was investigated that information communication will be positively related to responsiveness, which impacts customer satisfaction. Another study by Kho [32] states the advantages of using social media by B2B companies, which include faster and more personalised communications between customer and vendor, which can improve corporate credibility and strengthen the relationships. Thanks to social media companies can provide more detailed infor- mation about their products and services. Kho [32] also mentions that customer fo- rums and blog comments in b2b environment should be carefully monitored in order to make sure that inappropriate discussions are taken offline and negative eWOM communications should be addressed in a timely manner. Another group of studies investigated the effect of social media on the level of sales. For example, Itani et al. [13] use theory of reasoned actions to develop a model that tests the factors affecting the use of social media by a sales person and its impact. By collecting data from 120 salespersons from different industries and using SmartPLS to analyse the data, it was found that attitude towards social media useful- ness did not affect the use of social media. It was found that social media use positive- ly affects competitive intelligence collection, adaptive selling behaviour which in turn influenced sales performance. The study conducted by Rodriguez et al. [15] examines the effect of social media on b2b sales performance by using social capital theory and collecting data from 1699 b2b salespeople from over 25 different industries. Social media use [19] [20] [21] [22] Adoption of social media use [5, 23-26] Social media strategies [27-30] Measuring effectiveness of use of SM [5, 31] * Note: just some studies out of 70 were included in this review due to the page limit. The full list of studies can be requested from authors. Social media use [19] [20] [21] [22] Adoption of social media use [5, 23-26] Social media strategies [27-30] Measuring effectiveness of use of SM [5, 31] * Note: just some studies out of 70 were included in this review due to the page limit. The full list of studies can be requested from authors. 3 Literature synthesis The studies on the use of social media by b2b companies were divided into the fol- lowing themes: effect of social media, social media tools, social media use, adoption and barriers of social media use, social media strategies, and measuring the effective- ness of the use of social media (see Table 1). The following subsections provide an overview of each theme. Table 1. Themes in social media research (b2b context)* Theme Studies Effect of social media [10-15] Social media tools [16-18] 3 3 3.1 Effect of social media By em- ploying SEM Amos the study found that social media usage has a positive significant relationship with selling companies’ ability to create opportunities and manage rela- tionships. The study also found that social media usage has a positive and significant relationship with sales performance (based on relational measurers of sales that focus on behaviours that strengthen the relationship between buyers and sellers), but not 4 with outcome-based sales performance (reflected by quota achievement, growth in average billing size, and overall revenue gain). Some researchers argued that social media can influence brand awareness. For in- stance, Hsiao et al. [12] investigated the effect of social media in fashion industry. By collecting 1395 posts from lookbook.nu and employing regression analysis it was found that inclusion national brand and private fashion brands in the post increased the level of popularity which lead to purchase interest and brand awareness. Meire et al. [14] investigated the impact of social media on acquiring B2B cus- tomers. By using commercially purchased prospecting data, website data and Face- book data from beverage companies the study conducted an experiment and found that social media us an effective tool in acquiring B2B customers. Agnihotri et al. [11] proposed theoretical framework to explain the mechanisms through which salespeople’s use of social media operates to create value, and propose a strategic approach to social media use to achieve competitive goals. The proposed framework describes how social media tools can help salespeople perform service behaviours leading to value creation. 3.2 Adoption of social media Some scholars investigated factors affecting the adoption of social media by b2b companies. For instance, Lacka and Chong [23] investigated factors affecting the adoption of social media by b2b companies from different industries in China. The study collected the data from 181 respondents and used the Technology Acceptance Model with Nielsen's Model of Attributes of System Acceptability as a theoretical framework. By using SEM Amos for analysis the study found that perceived usabil- ity, perceived usefulness, and perceived utility positively affect the adoption and use of social media by b2b marketing professionals. The usefulness is subject to the as- sessment of whether social media sites are suitable means through which marketing activities can be conducted. The ability to use social media sites for B2B marketing purposes, in turn, is due to those sites learnability and memorability attributes. Lashgari et al. [24] studied the adoption and use of social media by using face-to- face interviews with key managers of four multinational corporations and observa- tions from companies’ websites and social media platforms. It was found that the elements essential in forming the B2B firm’s social media adoption strategies are content (depth and diversity), corresponding social media platform, structure of social media channels, the role of moderators, information accessibility approaches (public vs. gated-content), and online communities. These elements are customised to the goals and target group the firm sets to pursue. Similarly, integration of social media into other promotional channels can fall under an ad-hoc or continuous approach de- pending on the scope and the breadth of the communication plan, derived from the goal. Another study by Müller et al. [25] investigated factors affecting the usage of so- cial media. By using survey data from 100 polish and 39 German sensor suppliers, it was found that buying frequency, the function of a buyer, the industry sector and the 5 5 country does not affect the usage of social media in the context of sensor technology from Poland and Germany. The study used correlation analysis and ANOVA. Shaltoni [26] applied technology organisational environmental framework and dif- fusion of innovations to investigate factors affecting the adoption of social media by b2b companies. By using data from marketing managers or business owners of 480 SMEs, the study found that perceived relative advance, perceive compatibility, organ- izational innovativeness competitor pressure and customer pressure influence the adoption of social media by b2b companies. 3.2 Adoption of social media The findings also suggest that many de- cision makers in b2b companies think that internet marketing is not beneficial, as it is not compatible with the nature of b2b markets. While most of the studies focused on the antecedents of social media adoption by b2b companies, Michaelidou et al. [5] investigated its perceived barriers. By using data from 92 SMEs the study found that over a quarter of B2B SMEs in the UK are currently using SNS to achieve brand objectives, the most popular of which is to at- tract new customers. The barriers that prevent SMEs from using social media to sup- port their brands were lack of staff familiarity and technical skills. Innovativeness of a company determined the adoption of social media. 3.3 Social media strategies Another group of studies investigated types of strategies b2b companies apply. For example, Cawsey and Rowley [27] focused on social media strategies of b2b compa- nies. By conducting semi-structured interviews with marketing professional from France, Ireland, UK and USA it was found that enhancing brand image, extending brand awareness and facilitating customer engagement were considered the most common social media objective. The study proposed b2b social media strategy framework which includes six components of a social media strategy: 1) monitoring and listening 2) empowering and engaging employees 3) creating compelling content 4) stimulating eWOM 5) evaluating and selecting channels 6) enhancing brand pres- ence through integrating social media. Kasper et al. [28] proposed the Social Media Matrix which helps companies to de- cide which social media activities to execute based on their corporate and communi- cation goals. The matrix includes three parts. The first part is focusing on social me- dia goals and task areas, which were identified and matched. The second part consists of five types of social media activities (content, interaction/dialog, listening and ana- lysing, application and networking). The third part provides a structure to assess the suitability of each activity type on each social media platform for each goal. The ma- trix was successfully tested by assessing the German b2b sector by using expert inter- views with practitioners. McShane et al. [33] proposed social media strategies to influence online users’ en- gagement with b2b companies. Taking into consideration fluency lens the study ana- lysed Twitter feeds of top 50 social b2b brands to examine the influence of hashtags, text difficulty embedded media and message timing on user engagement, which was evaluated in terms of likes and retweets. It was found that hashtags and text difficulty 6 are connected to lower levels of engagement while embedded media such as images and video improve the level of engagement. Another study by Swani et al. [30] aimed to investigate message strategies which can help in promoting eWOM activity for b2b companies. By applying content analy- sis and Hierarchical Linear Modeling the study analysed 1143 wall post messages from 193 fortune 500 Facebook accounts. The study found that b2b account posts will be more effective if they include corporate brand names and avoid hard sell or explic- itly commercial statement. 3.3 Social media strategies Also, companies should use emotional sentiment in Face- book posts Most of the studies investigated the strategies and content of social media commu- nications of b2b companies. However, the limited number of studies investigated the importance of CEO engagement on social media in companies strategies. Mudambi et al. [29] emphasise the importance of CEO of b2b companies to be present and active on social media. The study discusses the advantages of social media presence for CEO and how it will benefit the company. For example one of the benefits for CEO can be perceived as being more trustworthy and effective and non-social CEOs, which will benefit the company in increased customer trust. Mudambi et al. [29] also dis- cussed the platforms CEO should use and posting frequencies depending on the con- tent of the post. 3.4 Social media use Most of the studies employed context analysis and surveys to investigate how b2b companies use social media. For example, Vasudevan and Kumar [22] investigated how b2b companies use social media by analysing 325 brand posts of Canon India, Epson India, and HP India on Linkedin, Facebook and Twitter. By employing content analysis the study found that most of the post has a combination of text and message. More than 50% of the posts were about product or brand centric. The study argued that likes proved to be an unreliable measure of engagement, while shares were con- sidered more reliable metric. The reason was that likes had high spikes when brand posts were boosted during promotional activities. Müller et al. [21] investigated social media use in the German automotive market. By suing online analysis of 10 most popular car manufacturers online social networks and surveys of 6 manufacturers, 42 car dealers, 199 buyers the study found that Social Media communication relations are widely established between manufacturers and (prospective) buyers and only partially established between car dealers and prospec- tive buyers. In contrast to that, on the business-to-business (b2b) side, Social Media communication is rarely used. Social Online Networks (SONs) are the most popular Social Media channels employed by businesses. Manufacturers and car dealers focus their Social Media engagement, especially on Facebook. From the perspective of prospective buyers, however, forums are the most important source of information. Moore et al. [20] investigated the use of social media between b2b and b2c sales- people. By using survey data from 395 sales professional from different industries they found that B2B sales managers use social selling tools significantly more fre- quently than B2C managers and B2C sales representatives while conducting sales 7 presentations. Also, it was found that B2B managers used social selling tools signifi- cantly more frequently than all sales representatives while closing sales. Katona and Sarvary [19] presented a case of using social media by Maersk-the largest container shipping company in the world. The case provided details on the programme launch and the integration strategy which focused on integrating the largely independent social media operation into the company’s broader marketing efforts. Keinänen and Kuivalainen [16] investigated factors affecting the use of social me- dia by b2b customers by conducting an online survey among 82 key customer ac- counts of an information technology service company. 3.4 Social media use Partial least squares path mod- eling was used to analysed the proposed hypotheses. It was found that social media private use, colleague support for using SM, age, job position affected the use of so- cial media by b2b customers. The study also found that corporate culture, gender, easiness to use and perception of usability did not affect the use of social media by b2b customers. 3.5 Measuring effectiveness of social media It is important for a business to be able to measure the effectiveness of social media by calculating return on investment (ROI). ROI is the relationship between profit and the investment that generate that profit. Some studies focused on the ways companies can measure ROI and the challenges they face. For example, Gazal et al. [31] investi- gated the adoption and measuring of the effectiveness of social media in the context of US forest industry by using organizational-level adoption framework and TAM. By using data from 166 companies it was found that 94% of respondents do not measure the ROI from social media use. The reason is that the use of social media in marketing is relatively new and companies do not possess the knowledge of measuring ROI from the use of social media. Companies mostly use quantitative metrics (number of site visits, number of social network friends, number of comments and profile views) and qualitative metrics (growth of relationships with the key audience, audience par- ticipation, moving from monologue to dialogue with consumers. Another study by Michaelidou et al. [5] found that most of the companies do not evaluate the effectiveness of their SNS in supporting their brand. The most popular measures were the number of users joining the groups/discussion and the number of comments made. 3.6 Social media tools Some studies proposed tools, which could be employed by companies to advance their use of social media. For example, Mehmet and Clarke [17] proposed Social Se- miotic Multimodal (SSMM) framework that improved analysis of social media com- munications. This framework employs multimodal extensions to systemic functional linguistics enabling it to be applying to analysing non-language as well as language constituents of social media messages. Furthermore, the framework also utilises ex- pansion theory to identify, categorise and analyse various marketing communication 8 8 resources associated with marketing messages and also to reveal how conversations are chained together to form extended online marketing conversations. This semantic approach is exemplified using a Fairtrade Australia B2B case study demonstrating how marketing conversations can be mapped and analysed. The framework emphasis- es the importance of acknowledging the impact of all stakeholders, particularly mes- sages that may distract or confuse the original purpose of the conversation. Yang et al. [18] proposed the temporal analysis technique to identify user relation- ships on social media platforms. The experiment was conducted by using data from Digg.com. The results showed that the proposed techniques achieved substantially higher recall but not very good at precision. This technique will help companies to identify their future consumers based on their user relationships. 4 Limitations and future research directions Studies on social media in the context of b2b companies have the following limita- tions. First, studies investigated the positive effect of social media such as consumer satisfaction, consumer engagement, and brand awareness. However, it will be inter- esting to consider the dark side of social media use such as an excessive number of request on social media to salespeople, which can result in the reduction of the re- sponsiveness. Second, a limited number of studies discussed the way b2b companies can measure ROI. Future research should investigate how companies can measure intangible ROI, such as eWOM, brand awareness, and customer engagement [34]. Also, future research should investigate the reasons why most of the users do not assess the effectiveness of their SNS. Furthermore, most of the studies focused on likes, shares, and comments to evaluate social media engagement. Future research should focus on other types of measures. Third, studies were performed in China [23, 35], USA [36-38], India [21, 22, 39], UK [5, 37, 40]. It is strongly advised that future studies conduct research in other countries as findings can be different due to the culture and social media adoption rates. Future studies should pay particular attention to other emerging markets (such as Russia, Brazil, and South Africa) as they suffer from the slow adoption rate of social media marketing. Some companies in these countries still rely more on traditional media for advertising of their products and services, as they are more trusted in comparison with social media channels [41, 42]. Lastly, most of the studies on social media in the context of b2b companies use a cross-sectional approach to collect the data. Future research can use longitudinal ap- proach to advance understanding of social media use and its impact over time. 5 Conclusion The aim of this research was to provide a systematic review of the literature on the use of social media by b2b companies. It was found that b2b companies use social media, but not all companies consider it as part of their marketing strategies. The studies on social media in b2b context focused on the effect of social media, anteced- 9 ents and barriers of adoption of social media, social media strategies, social media use, and measuring the effectiveness of social media. The summary of the key observations provided from this literature review is the following: • Facebook, Twitter and LinkedIn are the most famous social media platforms used by b2b companies. y p • Social media has a positive effect on customer satisfaction. • In systematically reviewing 70 publications on social media in the context of b2b companies it was observed that most of the studies use online surveys and online content analysis. y • Companies still look for ways to evaluate the effectiveness of social media. • Innovativeness has a significant positive effect on companies’ adoption to use social media. • Lack of staff familiarity and technical skills are the main barriers affect adoption of social media by b2b. This research has a number of limitations. First, only publications from the Scopus database were included in literature analysis and synthesis. Second, this research did not use a meta-analysis. 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https://openalex.org/W3187811533	http://real.mtak.hu/128162/1/27322688-ScientiaetSecuritasValtozoeghajlatvaltozokornyezetvaltozokorokozok._Meddigtartajarvanyokkora_.pdf	Hungarian	null	Változó éghajlat, változó környezet, változó kórokozók. Meddig tart a járványok kora?	Scientia et securitas	2,021	cc-by	6,175	Összefoglalás Az eddigi összes világjárványt olyan zoonotikus kórokozók, vírusok vagy baktériumok okozták, amelyek könnyen tudnak emberről emberre is terjedni. Minden egyes felbukkanó fertőzés egészségügyi, társadalmi és gazdasági költ ségeket von maga után. Az országhatárok nem tudják hatékonyan korlátozni a betegségek terjedését. Az eddigi trendek alapján jóval több mint félmillióféle, zömmel teljesen ismeretlen vírus lehet képes embereket megfertőzni. Az ember által letarolt vagy urbanizált területeken olyan állatfajok lesznek dominánsok, amelyek kifejezetten jó kór okozó-fenntartók. A hangsúlyt mostantól kezdve a megelőzésére kell helyezni, melynek a feltételei végrehajtható tervek formájában adottak. A hatékony megelőzés költséges, de jóval olcsóbb, mint egy világjárvány gazdasági követ kezményeit viselni. Kulcsszavak: felbukkanó kórokozók, járvány, klímaváltozás, biodiverzitás csökkenés, biológiai invázió Változó éghajlat, változó környezet, változó kórokozók. Meddig tart a járványok kora? Földvári Gábor1, Garamszegi László Zsolt2, Szathmáry Eörs1* 1Evolúciótudományi Intézet, ELKH Ökológiai Kutatóközpont, Budapest, Magyarország 2Ökológiai és Botanikai Intézet, ELKH Ökológiai Kutatóközpont, Vácrátót, Magyarország Beérkezett: 2021. 05. 08.; Elfogadva: 2021. 06. 14. Changing climate, changing environment, changing pathogens. How long will the era of pandemics last? Gábor Földvári1, László Zsolt Garamszegi2, Eörs Szathmáry1 1Institute of Evolution, ELKH Centre for Ecological Research, Budapest, Hungary 2Institute of Ecology and Botany, ELKH Centre for Ecological Research, Vácrátót, Hungary TUDOMÁNYOS KÖZLEMÉNY TUDOMÁNYOS KÖZLEMÉNY Bevezetés da csapódik be. A globális pusztítás minimális esélye ele gendő a kormányoknak arra, hogy jelentős összegeket fordítsanak az ilyen ritka események megelőzésére és a várható kár csökkentésére. Az e sorok írásakor tomboló SARS‑CoV‑2 (Severe acute respiratory syndrome coronavirus 2) koronavírus-jár vány érkezésére nem számított az emberiség. Hetek alatt körbeért a bolygónkon, alig egy év leforgása alatt megölt 3 millió embert és megfertőzött százmilliókat. Az anyagi kár nehezebben becsülhető, de dollárbilliókban mérhető (Dobson et al. 2020), és a járvány, illetve a megfékezésére hozott intézkedések miatt világszerte sokakat sújt a munkanélküliség és az elszegényedés. Megelőzhető lett volna ez a járvány? Lesznek még hasonló járványok a jö vőben? Mindkét kérdésre határozott igen a válasz. De akkor miért nem teszünk meg mindent, hogy fel készüljünk az újonnan felbukkanó betegségekre, ame lyek megjelenési valószínűsége jelentősen nagyobb? Ha a felbukkanó kórokozók nemzetbiztonsági fenyegetést je lentenek, nagyon is fel kellene készülnünk minden esz közzel, hogy proaktív lépéseket tegyünk. Írásunkban arra teszünk kísérletet, hogy áttekintsük a kórokozók felbukkanásának és a járványok kitörésének hátterében lévő hajtóerőket, valamint hogy javaslatot tegyünk az előrejelzésüket és megelőzésüket szolgáló proaktív in tézkedésekre. g Az újonnan felbukkanó betegségek (EIDs: emerging infectious diseases) egymással szoros összefügésbe hoz zák az egészségvédelmet, az élelmiszer-biztonságot, a nemzetgazdaságot és a határvédelmet. Emiatt kijelent hetjük, hogy komoly fenyegetést jelentenek bolygónk minden országának nemzetbiztonságára nézve. A fel bukkanó betegségek nem a távoli trópusi országok prob lémái, hanem kézzelfogható közelségben vannak ha zánkban is. Olyan harcot kell vívnunk, melyben a mai ember túlélése a tét, és jelenleg ebben a háborúban vesz tésre állunk. Mindig van remény, azonban minden nap, amely cselekvés nélkül telik el, rontja az esélyeinket a túlélésre. Két okból mondhatjuk joggal, hogy az emberi ség háborúban áll. Az első az, hogy a minket fenyegető kórokozók nem a kényelmünket, hanem az életben ma radásunkat veszélyeztetik. A második pedig, hogy olyan típusú preventív intézkedések szükségesek, amilyeneket a hadseregek is alkalmaznak hazájuk védelmének érde kében. Az új világjárványok megelőzése Az új világjárványok megelőzése One such plan is the DAMA protocol (Document, Assess, Monitor, Act). We must document the occurrence of potential pathogens in candidate host species. Then we assess the threat level associated with identified potential pathogens, followed by a systematic monitoring of the most dangerous pathogens, looking for early signs of potential outbreaks. Action means advice by experts on possible preventive measures by experts and their evaluation and exe cution by decision makers. Similar ecological diagnostics seem possible for biological invasions in general. Efficient prevention is costly, but considerably less so than bearing the economic consequences of pandemics by (re-)emerging infectious diseases. Keywords: emerging pathogens, pandemic, climate change, biodiversity loss, biological invasion Scientia et Securitas Summary So far, all pandemics have been caused by zoonotic pathogens, viruses or bacteria that could easily spread from hu man to human. Emerging infectious diseases entail huge costs for the health system, as well as for society and econ omy in general. Experience tells us that national borders are insufficient to prohibit the spread of infectious diseases. Extrapolation from current trends suggests that the number of largely unknown virus species able to infect humans is well over half a million. Overall, we seem to lack knowledge about 90% of the pathogens of the world. A striking experience is that pathogens can jump hosts based on their standing genetic variation and phenotypic plasticity. Mu tations tend to follow later and lead to evolutionary finetuning of the pathogenic lifecycle. Human activity has con tributed a great deal to the current dangerous rise of emerging infectious diseases. Climate change induces migration, biological invasions, and a higher incidence of the encounter of species with potential pathogens. Invading species tend to disrupt local ecosystems, resulting in lower biodiversity and higher susceptibility to disease of the remaining endemic species as well as the agriculturally important, domestic plant and animal populations. Habitats devastated by human activity as well urban areas will be dominated by species (such as rodents) that can harbour several poten tial and actual pathogens. Urbanization is a major risk factor for several reasons, including the elevated temperature in cities that contributes to the increase in pathogen survival during winter and the high population density and consequential contact rate of the local human population. Globalization adds to the security hazard posed by patho gens. From now on, emphasis should be put on the prevention of pandemics, for which we have executable plans. 2021 ■ 2. évfolyam, 1. szám ■ 114–122. 114 DOI: 10.1556/112.2021.00018 ■ © A Szerző(k), 2021 Unauthenticated \| Downloaded 08/06/21 10:12 AM UTC Természetpusztítás és klímaváltozás: a fő rizikófaktorok a Föld színéről. Ez az emberiség széles földrajzi elter jedtsége, és a kórokozók biológiája miatt sem valószínű. Sokkal inkább várható egymással párhuzamosan zajló, több kisebb, de biztos adagokban bekövetkező csapások sorozata. Minden egyes felbukkanó fertőzés egészség ügyi, társadalmi és gazdasági költségeket von maga után. Ráadásul, még ha az immunrendszerünk vagy a gyógy kezelés látszólag vissza is szorítja az új kórokozót, attól az még nem fog eltűnni az életünkből örökre: továbbra is jelen lesz „patogén szennyezésként”. A nyugat-nílusi vírus, amely nemrég ütötte fel a fejét hazánkban, halálos áldozatokat is szedve (Zana et al. 2020), már nem akut probléma többé Észak-Amerikában, de soha nem fog teljesen eltűnni, és ezért továbbra is okozhat a jövőben gondokat. Az ellene való védekezésre folyamatosan szükséges humán erőforrásokat és anyagi javakat fordíta ni. A koronavírusok mellett sok más vírus térnyerése is zajlik, ilyen például a Zika, amely egész biztosan nem a legutolsó és nem is a legsúlyosabb következményekkel járó betegség, ami az emberi populációban felüti a fejét. Ezek a kórokozók jól szemléltetik azt a hibás elképze lést, miszerint az országhatárok korlátozni tudják a be tegségek terjedését. A felismerés, hogy a Zika-vírus nemcsak szúnyog csípésével, hanem szexuális úton is fertőzőképes (Apari et al. 2019), valamint a gyors észak- amerikai terjedése alapos leckét adott abból, hogy men� nyire fontos, hogy globális szintű, részletes és pontos információ álljon rendelkezésre a felbukkanó fertőzések potenciális és valós veszélyeiről mind helyi, mind globá lis léptékben. A fentiek ismeretében talán már nem annyira meglepő, hogy az egyik fő hajtóerő a kórokozók felbukkanásában maga az emberi tevékenység. Számos trópusi, nagy faj gazdagságú tájon vonnak be természetes élőhelyeket óriási ütemben mezőgazdasági termelésbe (pl. pálma olaj, cukornád, avokádó termesztése vagy szarvasmarha- tenyésztés céljából). Szintén nagy beavatkozásokkal jár az elektronikai iparnak fontos ritka ásványi anyagok bá nyászata, vagy amikor a ruhaipar számára tenyésztenek vagy vadásznak állatokat a prémjükért. Ráadásul ezeket a jellemzően szegényebb országokban zajló természet pusztító folyamatokat elsősorban a világ gazdagabbik részének túlzó fogyasztási igénye indukálja. A természe tes élőhelyek pusztítása azok feldarabolódásával és a bio lógiai sokféleség csökkenésével jár. Ennek pedig súlyos következményei vannak a kórokozók ökológiájára és evolúciójára nézve is. A monokultúrás termesztés helyein lényegesen kevesebb növényevő és ragadozó fog túlélni. Ahol pedig kicsi a fajszám, ott azok a fajok lesznek domi nánsak, amelyek kifejezetten jó kórokozó-fenntartók (Gibb et al. 2020). Ez nem véletlen, azok az állatok a leginkább túlélőképesek, amelyek szaporák, nagy sűrű ségben és nagy területen tudnak jelen lenni, mint például a rágcsálók. Természetpusztítás és klímaváltozás: a fő rizikófaktorok Az úgynevezett gerinces rezervoárok, azaz bizonyos madarak és emlősök sokkal sűrűbben lesznek jelen, és nagyobb hányadát teszik ki az ottani teljes állat világnak. Ők pedig sokkal inkább képesek fenntartani a különböző vírusokat, baktériumokat és egyéb kórokozó kat. Végeredményben a természetpusztítás hosszú távon elősegíti a kórokozókat fenntartó állatok elterjedését. Eltűnőben van tehát az a biodiverzitási puffer, ami meg gátolná a kórokozók átadását az emberre. Mindezeknél is nagyobb probléma azonban, hogy a világon előforduló patogének mindösszesen 10%-áról van tudomásunk (Brooks–Hoberg–Boeger 2019). Így nem állíthatjuk, hogy ismerjük az ellenségünket, ez pedig se bezhetővé tesz minket. Még a zoonózisok és a világjár ványok szempontjából kiemelt fontosságú madár- és em lősvírusokból is csak néhány ezret ismerünk. Ezek becsült diverzitása 1,7 millióra tehető, ami azt jelenti, hogy az eddigi trendek alapján jóval több mint félmillióféle, zömmel teljesen ismeretlen vírus lehet képes embereket megfertőzni (Carroll et al. 2018). Jelentős mértékben a bioszférával kapcsolatos tudatlanságunk vezetett minket a jelenlegi krízisbe: egyszerűen nem ismerjük eléggé a természetet. És „amiről nem tudunk, az nem fáj”, tartja a mondás. Az eddig fel nem fedezett patogének és az őket hordozó vektorok itt vannak az orrunk előtt, akár csak egy evolúciós taposóakna, és arra várnak, hogy új élőhelyeket vegyünk birtokba, és átrendezzük az öko szisztémát. A bolygónkon élő szervezetek több mint 50%-a élősködő életmódot folytat valamilyen formában (Windsor 1998). Ellentmondásnak tűnhet, de a paraziták (és velük a kórokozók) a bioszféra közönséges és esszen ciális elemeit képezik, és ennek ellenére veszélyt jelente nek mindennemű társadalmi és gazdasági tevékenysé günkre. g Emellett az ember természet felé történő terjeszkedé se megnöveli a vadon élő állatok és az ember, valamint a vadon élő állatok és a háziállataink közötti kontaktusok számát, így a zoonotikus kórokozók terjedési esélyét is (Daszak et al. 2020). Hiszen a természetes élőhelyek be szűkülése tökéletes lehetőséget ad a kórokozóknak arra, hogy számukra alkalmas és legfőképpen addig nem is mert gazdaszervezetekkel kerüljenek kapcsolatba, ame lyeknek ebből kifolyólag nincs idejük alkalmazkodni hozzájuk, és védelmet fejleszteni ellenük. Az olyan be tegségek, amelyek 50 évvel ezelőtt ismeretlenek vagy je lentéktelenek voltak számunkra, mint a HIV, az Ebola, a nyugat-nílusi láz, a madárinfluenza vagy a Zika, mára mindennaposak. Néhány korábban is ismert betegség, mint a malária és a sárgaláz minden eddiginél súlyosabb csapást mértek ránk, míg mások, mint a pestis, ezekben a pillanatokban ütik fel ismét a fejüket az emberi populáci ókban. A mai világunkban ezek a folyamatok mindenna posak (1. ábra). A felbukkanó kórokozók jellemzően zoonotikusak és jellemzően alig ismerjük őket Az újonnan megjelenő kórokozók egy közös tulajdonsá ga, hogy általában valamilyen gerinces állatról (jellemző en madárról vagy emlősről) kerül át emberre, azaz zoo nózis. Az elmúlt öt évtizedben regisztrált, korábban nem ismert, emberben felbukkanó mintegy 400 kórokozó (vírusok, baktériumok, protozoonok, gombák) 70 szá zaléka állatról került át emberre (Jones et al. 2008). Köz ismert példák a Lyme-kór, az Ebola, a nyugat-nílusi vírus vagy a Zika-vírus. Az utóbbi évszázad összes világjárvá nyát egytől egyig zoonotikus vírusok okozták, mégpedig olyanok, amelyek könnyen tudnak emberről emberre is terjedni. Ilyen a HIV, az influenza, a SARS‑CoV‑1, a MERS és a SARS‑CoV‑2. Ezek a kórokozók akkor ter jednek közvetlenül vadon élő állatról vagy egy köztes, pl. háziállat hordozón keresztül emberre, azaz bukkannak fel, amikor ezek valamilyen kontaktusba kerülnek egy mással. A katonai vezetők jól tudják, hogy a nagy krízisek kis konfliktusokkal kezdődnek, és jellemzően nem kulturális vagy szocio-ökonómiai vákuumban alakulnak ki. Követ kezésképpen mindent megtesznek egy olyan háborúra való felkészülésért, amelyet reményeik szerint sosem kell majd megvívni. Ehhez hasonlóan a NASA vagy az Euró pai Űrügynökség (ESA) mindent megtesz az olyan asz teroidák becsapódására való felkészülésért, amelyek re ményeik szerint sosem fognak becsapódni. Annak az esélye, hogy egy adott aszteroida (pláne egy adott válasz tási cikluson belül) becsapódjon a Földbe, elhanyagolha tó. A kutatók ugyanakkor tisztában vannak vele, hogy 100% annak a valószínűsége, hogy valamikor a jövőben egy, a Földünk egészét érintő pusztításra képes aszteroi A fent említett pandémiát okozó példák viszonylag jól ismertek, mivel gyakran kerülnek a tudományos és köz egészségügyi mellett a közérdeklődés homlokterébe is. Noha ezek járnak rendszerint a legtöbb emberi áldozat tal, korántsem lehet eltekinteni attól a jelentős számú kórokozótól, amelyek folyamatos jelenlétükkel egyfajta parazitaterhelésként vannak jelen. Nem gondoljuk azt, hogy egyetlen szuperbaktérium leselkedik ránk odakint, amely az egész emberiséget egyszerre eltüntetheti majd 115 2021 ■ 2. évfolyam, 1. szám Unauthenticated \| Downloaded 08/06/21 10:12 AM UTC Földvári et al. Természetpusztítás és klímaváltozás: a fő rizikófaktorok A koronavírus világjárvány előtt is alig volt olyan hét, hogy a híradásokban ne bukkantak volna fel újonnan felfedezett kórokozók, amelyek embereket vagy éppen az európai sertéseket, a diótermésünket, a 116 Scientia et Securitas 2021 ■ 2. évfolyam, 1. szám Unauthenticated \| Downloaded 08/06/21 10:12 AM UTC Az új világjárványok megelőzése al. 2014) világossá teszi, hogy a kórokozók új helyen vagy új gazdában való felbukkanása a bioszféra beépített eszköztárát képezi, halkan ketyegő időzített bombaként. A korábbi elképzelésekkel ellentétben ugyanis nincs szükség genetikai változásokra ahhoz, hogy egy kóroko zó új gazdában vagy új élőhelyen bukkanjon fel. Az eh hez szükséges teljes biológiai arzenálja (ún. fenotipikus plaszticitása) lehetővé teszi számára, hogy a változó kö rülmények esetén is túléljen (Brooks–Hoberg–Boeger 2019). A kórokozók tehát nemcsak abban jók, hogy megtaláljanak minket, de abban is, hogy észrevétlenül túléljenek az ún. rezervoár gazdákban (Jones et al. 2008; Daszak et al. 2020; Gibb et al. 2020). Azok a patogének fogják a jövőben az új járványkitöréseket okozni, ame lyek a legjobbak a túlélésben. Számos ilyen kórokozó várja, hogy „rá kerüljön a sor”. Arra várnak, hogy kihasz nálják a klímaváltozás, a fajok behurcolása, vagy akár az ember új helyen való megjelenése okozta megváltozott környezetet. Fel kell tehát készülnünk arra, hogy a kór okozók új helyeken és új gazdákban (így emberben és háziállatban) való felbukkanása inkább szabályszerű és nem kivétel (Brooks et al. 2020). paradicsomot, a növényeket beporzó rovarokat, vagy akár a tengeri uborkákat betegítik meg. A teljes ökoszisz téma és benne minden faj veszélynek van kitéve, hiszen azok számos szinten állnak összeköttetésben egymással, legyen szó szárazföldi, vagy akár tengeri életterekről. En nél fogva az ember maga is veszélyben van, mivel ezen ökoszisztémákhoz erős társadalmi és gazdasági kapcsolat fűzi. Ezt a krízist az újonnan felbukkanó fertőző beteg ségek krízisének nevezzük, a kort, amelyben élünk, pe dig a járványok korának. Jelentős részben az emberi tevékenységnek köszönhe tő korunk másik legaggasztóbb globális folyamata, az éghajlatváltozás. A folyamatosan növekvő átlaghőmér séklet és a szélsőséges éghajlati események (pl. villámár víz, aszály) háromféleképpen hathatnak az élő szerveze tekre: kipusztulnak, alkalmazkodnak vagy elvándorolnak. Utóbbi két esetben feltétlenül számítanunk kell a kór okozók új földrajzi régiókban és új gazdaszervezetekben való megjelenésére, hiszen a korokozók, a vektoraik, va don élő és házi rezervoár gazdáik, sőt az emberek is je lentős vándorlásokba kezdenek (Földvári–Szathmáry 2020). Ez új találkozási pontokat hoz létre, azaz növeli az új fertőző betegségek felbukkanásának esélyét. Egy további jelentős rizikófaktor: az urbanizáció Mivel számos élőlény számára von zó ökoszisztéma a nagyváros (zöld foltok, szemét), ezért olyan bonyolult közösségi dinamika bontakozik ki az ember, kórokozók és más fajok között, amely a mai napig kevéssé feltérképezett (Földvári et al. 2014; Szekeres et al. 2019). (4) A városban nagy egyedsűrűségben élnek em berek, és egy járvány kitörésekor a fertőzésveszély nagy sága egyenesen arányos a városban élők számával. Emel lett a városi emberek alacsonyabb rokonsági fokkal rendelkeznek a falusi lakossághoz képest, emiatt kisebb a kooperáció és a bizalom a körükben. (5) Egy nagyváros ban mindig találunk olyan réteget, amelynek tagjai kevés sé képzettek, rossz anyagi helyzetűek, alultápláltak, fizi kailag kimerítő munkát végeznek gyakran rossz higiénés körülmények között. Ezek az emberek gyakorlatilag lát hatatlanok a közegészségügyi és a szociális hálózatok szá mára, emiatt a városok Achilles-sarkát jelentik. Ha azon ban megjelenik egy betegség a nagyvárosban, az nem csupán a szegény és láthatatlan rétegeket fogja érinteni. (6) A nagyvárosok többnyire fontos kereskedelmi és tu risztikai központok, forgalmas közúti, vasúti és/vagy lé giforgalmi hub-ként működnek, amely megkönnyíti a távoli területek kórokozói és az őket hordozó inváziós vektorfajok behurcolását, így az emberek közti fertőzé sek létrejöttét. Ez meg is mutatkozott a SARS‑CoV‑2 nagyvárosi gócaiban Európa- és Amerika-szerte. A más biogeográfiai régióból érkező jövevényfajok megtelepedése és térhódítása az elmúlt évszázadban fel gyorsult, így hazánkban is több új faj jelent meg, és idé zett elő jelentős ökológiai változásokat. Az inváziós állat- és növényfajok megjelenésének Magyarország területén számos és sokszor súlyos társadalmi, gazdasági és termé szetvédelmi következménye van. A kórokozóktól és azok vektoraitól, a terjeszkedő növényevőkön át a betelepülő ragadozókig, az allergén hatású növényektől a horgásza ti / dísznövény célra betelepített fajokig egy sor gyakor lati vonatkozású kérdés köthető az invázió jelenségéhez. Ez nemcsak a hazai természetes flórát és faunát veszé lyezteti, hanem haszonfajokra és fontos ökoszisztéma- szolgáltatást nyújtó fajokra is kihat, jelentősen csökkent ve az erdő- és mezőgazdasági termelés hatékonyságát. Egészségügyi szempontból a jövevényfajok új betegsé geket terjeszthetnek, allergiás reakciókat, mérgezési tü neteket válthatnak ki az emberben. A több szinten je lentkező hatások súlyát jelzi, hogy az Európai Unió évente több mint 12 milliárd eurót költ az inváziós fajok elleni védelemre, és az általuk okozott károk kiküszöbö lésére, és ez a szám évről évre nő. Az invázió elleni haté kony védekezés kulcsa azonban egy megelőző stratégia lenne, melyhez első lépésben óriási szükség van az invá zióbiológiai jelenségek megértésére és folyamatainak rendszerszintű és távoli szakterületeket is átfogó feltárá sára. Egy további jelentős rizikófaktor: az urbanizáció jedésének drasztikus változása önmagában is számos egészségügyi, élelmiszerbiztonsági, gazdasági kockáza tot rejt. Az ember által kiváltott gyors környezeti válto zások számos új ökológiai helyzetet teremtenek, így sok faj életfeltétele, elterjedése és az ökoszisztémákban be töltött funkcionális szerepe megváltozik. E környezeti hatások nagymértékben felgyorsítják a biológiai invázi ót, mely során számos, földrajzilag távoli helyről szár mazó, idegenhonos növény-, állat- és gombafaj, illetve alacsonyabb rendű szervezet (pl. vírusok, baktériumok) új területekre sodródik (vagy maga az ember hurcolja és telepíti be), ott túlél és szaporodik, és ezáltal nagy terü leteken alkot stabilis populációkat. Az inváziós fajok si kere azonban legtöbbször az őshonos flóra és fauna ká rára valósul meg, mert az új fajok megjelenésével az eredeti közösségek tagjainak ökológiai kapcsolatrend szere átrendeződik, és e változások következtében a ter mészetes ökoszisztémák összetétele és működése meg sérül. A jövevényfajok legismertebb környezeti hatása, hogy ökológiai szerepük (kompetitív kizárás, kóroko zók terjesztése, növényevés, illetve predációs nyomás, mérgező anyagcseretermékek termelése) következtében számos őshonos faj visszaszorul vagy kipusztul. A bioló giai invázió összességében tehát alapjaiban veszélyezteti Földünk élő rendszerét, amin az emberiség jólléte áll vagy bukik.i A Föld népessége jelenleg 7,9 milliárd, és évente német országnyi lakossal (kb. 81 millió fő) növekszik. Az el múlt negyven év elegendő volt ahhoz, hogy megduplá zódjon a bolygónkon élő emberek száma (World Population Clock). Ez a túlnépesedés már önmagában is számos problémával jár, de a megnövekedett népesség nagyobbik része már jelenleg is nagyvárosokban lakik, és ez az arány folyamatosan nő. A városlakók számos tech nológiai vívmányt élveznek, miközben egy téves bizton ságérzetben vannak, azt gondolva, hogy biztos távolság ra vannak a klímaváltozás különböző hatásaitól, mint például az újonnan felbukkanó betegségektől. Pedig a városok, legyenek látszólag bármilyen gazdagok vagy ha talmasok, rendkívül érzékenyek a betegségekre. Ennek alapvetően hat különböző oka van. p (1) A hősziget jelenség, vagyis hogy a metropoliszok központjában 3–5 fokkal is melegebb van a környezetük höz képest, amely sokszor elég meleg ahhoz, hogy a kórokozók, vektoraik és rezervoárjaik könnyebben át vészeljék az amúgy őket megtizedelő téli hónapokat. (2) A városok nagymértékben függenek a különböző for rások (pl. energia, víz, élelmiszer) kívülről történő folya matos ellátásától. (3) A városok kedvező élőhelyet bizto sítanak sünök, patkányok, egerek, mókusok, rókák, galambok számára is, amelyek az emberre és háziállataira nézve veszélyes kórokozókat fenntartó rezervoár gazdák (Rizzoli et al. 2014). Természetpusztítás és klímaváltozás: a fő rizikófaktorok A kö zelmúltban kidolgozott Stockholm-paradigma (Brooks et A fenti folyamatok a bioszféra egészét érintik, így a kórokozók mellett a növény- és állatfajok földrajzi elter 1. ábra Az ázsiai tigrisszúnyog számos kórokozó terjesztéséért felelős, és egyre nagyobb területen telepszik meg Európában is Forrás: https://szunyogmonitor.hu/index.php/albopictus/ és https://www.ecdc.europa.eu/en/publications-data/aedes-albopictus-current- known-distribution-september-2020 1. ábra Az ázsiai tigrisszúnyog számos kórokozó terjesztéséért felelős, és egyre nagyobb területen telepszik meg Európában is Forrás: https://szunyogmonitor.hu/index.php/albopictus/ és https://www.ecdc.europa.eu/en/publications-data/aedes-albopictus-current- known-distribution-september-2020 117 2021 ■ 2. évfolyam, 1. szám Scientia et Securitas Scientia et Securitas Unauthenticated \| Downloaded 08/06/21 10:12 AM UTC Földvári et al. Egy további jelentős rizikófaktor: az urbanizáció Ez a feladat egy szélesebb körű ökológiai diagnosz tikai protokoll kidolgozását kívánja meg. 118 2021 ■ 2. évfolyam, 1. szám Scientia et Securitas Unauthenticated \| Downloaded 08/06/21 10:12 AM UTC Az új világjárványok megelőzése Mit tehetünk? A DAMA-protokoll: megelőzés tűzoltás helyett Mit tehetünk? A DAMA-protokoll: megelőzés tűzoltás helyett megelőzésre irányuló vizsgálatainkat, amellyel jelentős pénz és idő takarítható meg. A kórokozók egy népes és kiemelt jelentőségű csoportja vektorokkal, azaz vérszívó ízeltlábúakkal terjednek (pl. kullancsokkal vagy szúnyo gokkal, 2. ábra), rájuk kiemelt hangsúlyt kell helyezni a dokumentáció során. Ezek vizsgálatában nagy segítséget nyújthat a lakosság is (citizen science), hiszen segítsé gükkel szélesebb földrajzi régiókban és nagyobb minta szám gyűjthető. Ennek megvalósítására két hazai gya korlati példa az Ökológiai Kutatóközpont két ilyen jellegű monitoring projektje, a Szúnyogmonitor (https://szunyogmonitor.hu/) és a Kullancsfigyelő (https://www.kullancsfigyelo.hu/) kezdeményezések. A kórokozók felbukkanásának hátterében lévő hajtóerők ismeretében kijelenthetjük, hogy a korábban véletlensze rűnek hitt és előre jelezhetetlennek tartott jelenségek mögött egyre jobban ismert ökológiai és evolúciós folya matok állnak. Ezek ismeretében került kidolgozásra a Stockholm-paradigmára épülő DAMA-protokoll, amely ben folyamatosan rögzítjük (Document) a kórokozók különböző gazdákban való megjelenését, majd a megfe lelő tudományos elemzéseket (Assess) követően azono sítjuk a számunkra veszélyes szervezeteket, és irányítjuk ezek célzott monitorozását (Monitor). Így lehetséges a döntéshozók számára adekvát javaslatokat tenni a meg felelő megelőző intézkedések (Act) foganatosítására. Elemzés Egy olyan világban, amelyet az emberi tevékenység és a klímaváltozás formál, nem akadályozhatjuk meg a kór okozókat a földrajzi elterjedésük növelésében, de felké szülhetünk rájuk kockázatbecsléssel, ami az értékelés lé nyege. A kockázatbecsléshez minél többet kell tudnunk azokról a fajokról, amelyek eddig is körülöttünk voltak, továbbá azokról, amelyek megjelenésére számíthatunk. A tudományos név egy fontos elsődleges adat. A patogé nek esetében további alapinformáció, hogy hol és milyen gazdaszervezetben fordulnak elő. Az ismert kórokozók esetében is szükség van a fajnév mellett a terjedésének módjára, az esetleges tünetekre, a gazdaszervezetben fertőzött szövetekre, az előfordulási területükre, az oko zott mortalitásra és morbiditásra, a genetikai változé konyságra, a jellemzően fertőzött ökoszisztémákra, to vábbá, hogy milyen országokban vagy régiókban milyen betegséget okoztak, és hogy milyen gazdaszervezetek ben dokumentálták őket eddig. Ezért szükséges minden Dokumentáció Ahhoz, hogy proaktívak lehessünk, az előtt kell rátalál nunk a kórokozókra, mielőtt ők találnak ránk. Nem le hetséges minden potenciális gazdaszervezetben az ös� szes lehetséges kórokozót dokumentálni, viszont felhasználhatjuk e kórokozók evolúciójáról, ökológiájá ról és természetes ciklusáról meglévő tudásunkat arra, hogy kutatásaink irányát fókuszáljuk. A kórokozókat tü netmentesen hordozó rezervoár gazdákat kell kiemelt figyelemmel kísérnünk. Ezek a kórokozók természetben való fenntartásáért felelős fajok gyakran az emberi tele pülésekkel vagy mezőgazdasági területekkel közvetlenül határos élőhelyeken találhatóak. A kórokozók átvitele sokszor itt, a rezervoár fajok élőhelye és a haszonállatok és -növények élőhelye közötti határterületen történik. Így az előhelyek szempontjából is szűkíteni tudjuk a 2. ábra Balra: az ázsiai tigrisszúnyog (Aedes albopictus) kiemelt fontosságú vektor. Terjesztője a sárgaláz, a dengue, a Chikungunya-vírusoknak, valamint számos fonálféregnek, pl. a kutyák szívférgességét okozó Dirofilaria immitis-nek. Jobbra: a Hyalomma rufipes kullancsfaj a magas halálozási arányú krími-kongói vérzéses láz vírusát terjeszti. Mindkét vektorfaj megjelent már Magyarországon. Az újból történő behurcolásukból és helyi terjedésükből fakadó veszélyek csak célzott folyamatos monitorozással előzhetők meg. Forrás: https://hu.wikipedia.org/wiki/%C3%81zsiai_tigrissz%C3%BAnyog#/media/F%C3%A1jl:Aedes_Albopictus.jpg és https://commons.wiki media.org/wiki/File:Hyalomma-rufipes-female-male.jpg 2. ábra Balra: az ázsiai tigrisszúnyog (Aedes albopictus) kiemelt fontosságú vektor. Terjesztője a sárgaláz, a dengue, a Chikungunya-vírusoknak, valamint számos fonálféregnek, pl. a kutyák szívférgességét okozó Dirofilaria immitis-nek. Jobbra: a Hyalomma rufipes kullancsfaj a magas halálozási arányú krími-kongói vérzéses láz vírusát terjeszti. Mindkét vektorfaj megjelent már Magyarországon. Az újból történő behurcolásukból és helyi terjedésükből fakadó veszélyek csak célzott folyamatos monitorozással előzhetők meg. Forrás: https://hu.wikipedia.org/wiki/%C3%81zsiai_tigrissz%C3%BAnyog#/media/F%C3%A1jl:Aedes_Albopictus.jpg és https://commons.wiki media.org/wiki/File:Hyalomma-rufipes-female-male.jpg 2. ábra krími kongói vérzéses láz vírusát terjeszti. Mindkét vektorfaj megjelent már Magyarországon. Az újból történő behurcolásukból és helyi terjedésükből fakadó veszélyek csak célzott folyamatos monitorozással előzhetők meg. Forrás: https://hu.wikipedia.org/wiki/%C3%81zsiai_tigrissz%C3%BAnyog#/media/F%C3%A1jl:Aedes_Albopictus.jpg és https://commons.wiki media.org/wiki/File:Hyalomma-rufipes-female-male.jpg Forrás: https://hu.wikipedia.org/wiki/%C3%81zsiai_tigrissz%C3%BAnyog#/media/F%C3%A1jl:Aedes_Albopictus.jpg és https://commons.wiki media.org/wiki/File:Hyalomma-rufipes-female-male.jpg 119 2021 ■ 2. évfolyam, 1. szám Scientia et Securitas Scientia et Securitas Unauthenticated \| Downloaded 08/06/21 10:12 AM UTC Földvári et al. Monitorozás A monitoring meghatározza, hogy mennyire vagyunk felkészültek a kórokozók felbukkanására. Dokumentál juk azokat a kórokozókat, amelyekkel együtt élünk, és ami a legfontosabb, azokat, amelyek még az utunkba ke rülhetnek. Amennyire csak lehet, felbecsüljük a veszélyt, amelyet felbukkanásuk jelent. A folyamatosan növekvő információhalmaz lehetővé teszi, hogy nyomon követ hessük a kórokozók előretörését, és egyúttal saját felké szültségünket is. A monitorozás egyfajta korai jelzőrend szer, amely a lehető leghamarabb figyelmeztet minket, ha egy potenciálisan veszélyes kórokozóval kerülhetünk kapcsolatba. A krími-kongói vérzéses láz életveszélyes állapotot eredményez. Megelőzésében nagy szerepet játszik a lakosság bevonásával (citizen science) zajló monitorozás, amely lehetővé teszi, hogy a vírust terjesztő Hyalomma kullancsok megjelenéséről tudomást szerezzünk A krími-kongói vérzéses láz életveszélyes állapotot eredményez. Megelőzésében nagy szerepet játszik a lakosság bevonásával (citizen science) zajló monitorozás, amely lehetővé teszi, hogy a vírust terjesztő Hyalomma kullancsok megjelenéséről tudomást szerezzünk Forrás: Elaldı–Kaya 2014 Forrás: Elaldı–Kaya 2014 Forrás: Elaldı–Kaya 2014 Cselekvés Megelőzésében nagy szerepet játszik a lakosság bevonásával (citizen science) zajló monitorozás, amely lehetővé teszi, hogy a vírust terjesztő Hyalomma kullancsok megjelenéséről tudomást szerezzünk F á El ld K 2014 Cselekvés alapos kockázatbecslést megfelelő taxonómiai dokumen tációval kezdeni, és azt kiegészíteni a kapcsolódó ökoló giai információval az értékelés során. A tudományos információ önmagában nem elegendő. Fel kell használnunk azt az információt, amit a doku mentációs, értékelő és monitoring szakaszokból nyer tünk, és cselekednünk kell! Eredményeinkre épül egy Akciótanács működése, amelyben a kutatók mellett he lyet kapnak az érintett hatóságok képviselői (közegész ségügy, állategészségügy, katasztrófavédelem, turizmus), és amely konkrét javaslatokat tesz a döntéshozók felé. A kormányzati döntéshozók számára hozzáférhetővé fogjuk tenni a lehető legjobb és legfrissebb tudományos eredményeket. Ezt az információt közérthető módon kell eljuttatnunk hozzájuk, hogy a szakhatóságok megta lálják az egyensúlyt a tudományos szempont és a számos más társadalmi és gazdasági prioritás között. Az egyenes és érthető kommunikáció megvalósítása tehát mind a ku tatók, mind a döntéshozók érdeke és feladata is egyben. A hosszú távú siker kulcsa pedig az, hogy a cselekvési oldalon be kell vonnunk a lakosságot is, ahogy a fent említett két citizen science projekt esetében is történik (3. ábra). Annak érdekében, hogy megszakítsuk a betegségek terjedését, gyakran az ökológiai diverzitás bizonyos ele meire (kiemelt kórokozók és rezervoárjaik) kell koncent rálnunk. De nem monitorozhatunk mindenhol és min dent, emiatt a kockázatbecslés során az egyes kórokozók relatív fontosságát szükséges megállapítani. Kiemelt je lentőséget kapnak azok a vírus-, baktérium- vagy parazi tafajok, amelyek ismert kórokozók, és a hozzájuk geneti kailag legközelebb álló rokon fajok is magasabb rizikócsoportba kerülnek. A fajok leszármazási viszonya it vizsgáló filogenetika segítségével epidemiológiai előre jelzéseket fogunk tenni a múltban konzervatívnak bizo nyult tulajdonságok alapján. Az így felhalmozódó, a kockázatbecslésre vonatkozó járványökológiai információ létfontosságú lesz a további munkánk szempontjából, és fontos kiegészítőjét képezi a publikált adatok alapján végzett metaanalíziseinknek. A végeredményként kiépült adatbázisunkat olyan mate matikai modelleknek és gépi tanulási rendszernek vetjük alá, amely az újonnan felbukkanó fertőző kórokozók evolúciós dinamikájáról és ökológiájáról szerzett tudá sunkon alapszik. Így tesztelhetjük majd a Stockholm- paradigma gyakorlati alkalmazhatóságát. Ha a tapasz talatok nem teljesen csengenek össze az elméleti elvárásokkal, akkor finomításokat szükséges elvégezni a keretrendszeren és a DAMA akcióterven. 3. ábra A krími-kongói vérzéses láz életveszélyes állapotot eredményez. Megelőzésében nagy szerepet játszik a lakosság bevonásával (citizen science) zajló monitorozás, amely lehetővé teszi, hogy a vírust terjesztő Hyalomma kullancsok megjelenéséről tudomást szerezzünk Forrás: Elaldı–Kaya 2014 3. ábra A krími-kongói vérzéses láz életveszélyes állapotot eredményez. Következtetések, stratégiai javaslatok A matematikai modellek nagy segítséget nyújthatnak előrejelzéseinkhez. A mindeddig ismeretlen, de kockáza tot jelentő kórokozók, rezervoárjaik és vektoraik közül azokra kell összpontosítanunk, amelyek láthatólag növe lik a földrajzi elterjedésüket és az ökológiai forrásbázisu kat. A DAMA-protokoll ezen eleme erősen ökológia-, evolúció- és populációbiológia központú. Ahogy a mole kuláris dokumentálási technológiáik egyre inkább fej lődnek, illetve a filogenetikai és ökológiai kapcsolatokat tartalmazó adatbázisunk is növekszik, annál költséghaté konyabban tudjuk majd folyamatosan monitorozni a ve szélyforrásokat. Ahhoz, hogy elkerülhessük a jövőben kitörő járványo kat, alapvetően kell változtatnunk a gondolkodásmó dunkon. Egyrészt a döntéshozói és a kutatói, egészség ügyi oldalon a reaktív üzemmódból proaktívba kell váltani (ld. DAMA-protokoll, vagy egy szélesebb körű ökológiai diagnosztika az invázió vonatkozásában). Más részt a társadalom legszélesebb körében szükséges egy alapvető, gondolkozásbeli és viselkedésbeli változás (Daszak et al. 2020), amely a fenntartható fejlődés révén mérsékelheti a járványveszélyt. Mindehhez számos terü leten átfogó változtatások szükségesek, amelyeket az 120 2021 ■ 2. évfolyam, 1. szám 2021 ■ 2. évfolyam, 1. szám Scientia et Securitas Unauthenticated \| Downloaded 08/06/21 10:12 AM UTC Az új világjárványok megelőzése 1. táblázat A jövőbeli járványok kitörésének megelőzéséhez elengedhetetlen alapvető gondolkozásbeli és viselkedésbeli változások (Daszak et al. 2020 alapján) FELADAT RÉSZLETEK Magas szintű kormány közi járványmegelőzési testület létrehozása • Az IPCC (klímaügyi) és az IPBES (biodiverzitással kapcsolatos) kormányközi testületek mintájára • Tanácsadás, előrejelzés a döntéshozók számára • Monitoring feladatok koordinálása (ld. Következtetések, stratégiai javaslatok R., Hoberg, E., Boeger, W., Gardner, S., Araujo, S., Bajer, K., Botero-Cañola, S., Byrd, B., Földvári, G., Cook, J., Dunnum, J., Dursahinhan, A., Garamszegi, L., Herczeg, D., Jakab, F., Juarrero, A., Kemenesi, G., Kurucz, K., León-Règagnon, V., Mejía- Madrid, H. H. Molnár, O., Nisbett, R. A., Preiser, W., Stuart, M., Szathmary, E. & Trivellone, V. (2020) Before the Pandemic Ends: Making Sure This Never Happens Again. World Complexity Science Academy Journal, Vol. 1. No. 1. 1–10. 1. táblázatban foglaltunk össze. A kérdés nem az, hogy hogyan, hanem az, hogy mikor kezdődnek el ezek a vál tozások, hiszen nemcsak anyagi értelemben megtérülő befektetés lenne, hanem kortársaink és utódaink jelentős részének az élete múlik rajta. Brooks, D. R., Hoberg, E., Boeger, W., Gardner, S., Araujo, S., Bajer, K., Botero-Cañola, S., Byrd, B., Földvári, G., Cook, J., Dunnum, J., Dursahinhan, A., Garamszegi, L., Herczeg, D., Jakab, F., Juarrero, A., Kemenesi, G., Kurucz, K., León-Règagnon, V., Mejía- Madrid, H. H. Molnár, O., Nisbett, R. A., Preiser, W., Stuart, M., Szathmary, E. & Trivellone, V. (2020) Before the Pandemic Ends: Making Sure This Never Happens Again. World Complexity Science Academy Journal, Vol. 1. No. 1. 1–10. Brooks, D. R., Hoberg, E., Boeger, W., Gardner, S., Araujo, S., Bajer, K., Botero-Cañola, S., Byrd, B., Földvári, G., Cook, J., Dunnum, J., Dursahinhan, A., Garamszegi, L., Herczeg, D., Jakab, F., Juarrero, A., Kemenesi, G., Kurucz, K., León-Règagnon, V., Mejía- Madrid, H. H. Molnár, O., Nisbett, R. A., Preiser, W., Stuart, M., Szathmary, E. & Trivellone, V. (2020) Before the Pandemic Ends: Making Sure This Never Happens Again. World Complexity Science Academy Journal, Vol. 1. No. 1. 1–10. Következtetések, stratégiai javaslatok DAMA) Gazdasági ösztönzők bevezetése • Járványveszéllyel kapcsolatos költségek integrálása a termelői, fogyasztói és állami költségvetésekbe • Zöld befektetési formák létrehozása a természet- és klímavédelmi, valamint a járványmegelőzési célok finanszíro zására • Megújuló energiaforrások támogatása Intézkedések a természetpusztítás megállítására • Felbukkanó kórokozók és járványok egészségügyi kockázatának felmérése beruházásoknál és földhasználati projekteknél • Anyagi támogatások reformja, amely figyelembe veszi a beruházások biodiverzitásra és egészségre gyakorolt káros és előnyös hatásait • Annak felmérése, hogy milyen mértékben csökkenthető a kórokozók felbukkanásának veszélye élőhelyek természetközelibb állapotba hozásával (restaurációs ökológia) • Gondolkozásmód és viselkedés alapvető változásának elősegítése annak érdekében, hogy csökkenjen a nem fenntartható fogyasztás és mezőgazdasági terjeszkedés (pálmaolaj, egzotikus fák, extenzív szarvasmarha-tenyésztés stb.) Intézkedések a vadkereskedelem visszaszorítására • Egyezmény létrehozása a nemzetközi vadkereskedelem jelentette járványveszély csökkentésére az OIE, CITES, CBD, WHO, FAO, IUCN közreműködésével • A valószínűsíthető járványkitörési pontokon a lehető legszélesebb körű oktatás a vadállatok használata és kereskedelme mint járványveszély témájában • A kórokozók felbukkanása szempontjából magas rizikójúnak bizonyult fajok teljes kivonása a vadkereskedelemből • Élőállatpiacok szabályozása (hűtőkapacitás, higiénia, kórokozó monitoring) • Kórokozó monitoring a kereskedelembe vont állatfajok, vadászok, tenyésztők és kereskedők körében • Bűnmegelőzés erősítése az illegális vadállat-kereskedelem visszaszorítására Kritikus tudáshiányunk pótlása • Evolúciós és ökológiai szemlélet erősítése a járványmegelőzésben (Stockholm-paradigma, DAMA) • A természetben található kórokozódiverzitás alaposabb feltérképezése • Gyógyszerek és vakcinák szempontjából kiaknázni a felfedezésre váró mikróbákat • A klímaváltozás, ökoszisztéma-pusztulás hatásai és a járványok kitörése közti összefüggések pontosabb megértése • A pandémiás veszélyt csökkentő természetvédelem gazdasági megtérülését vizsgáló ökonómiai vizsgálatok • Kulcsfontosságú viselkedésmódok vizsgálata a pandémiás helyzet létrehozásában (globális fogyasztás, járványgó cokban élő helyi közösségek, privát és állami szektor szerepe) • Bennszülött és helyi lakosság bevonása és tudásának értékelése a prevenciós programokban • A One Health szemlélet operatívvá tétele és intézményesítése a járványmegelőzési stratégiáink optimalizálása érdekében (ld. DAMA) Széles körű társadalmi szerepvállalás erősítése a járványmegelőzésben való részvétel erősítésére • A járványok kialakulásáról való ismeretterjesztés és oktatás a társadalom minden rétegében, de hangsúlyosan a fiatal generációban • Járványtani szempontból kockázatos fogyasztói szokások azonosítása és megjelölése az alternatívák támogatása érdekében (pl. prémjükért tenyésztett vadállatok) • Fenntarthatóság ösztönzése a mezőgazdaságban • Egészségesebb és fenntarthatóbb táplálkozás felé való elmozdulás támogatása (pl. felelős húsfogyasztás) • Fenntartható eszközök támogatása a nagyobb élelmiszer-biztonság és a vadhúsfogyasztás csökkentése érdekében • Magas pandémiás rizikó esetén a hús és egyéb termék fogyasztására és előállítására kirótt adó megfontolása • Fenntartható támogatások vállalatok számára olyan tevékenységek elkerülésére (pl. természetpusztítás, mezőgaz daság, vadhúsfeldolgozás és -kereskedelem), amely igazoltan kiemelt zoonotikus kockázattal jár Brooks, D. 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W4232398045.txt	https://zenodo.org/records/2248503/files/article.pdf	null		Die Glottis	Pflügers Archiv für die gesamte Physiologie des Menschen und der Tiere/Pflügers Archiv	1,908	public-domain	10,922	131 Die Glottis. Von Dr. P . J . M i n k . (Deventer.) (Mit 10 Textflguren.) Gewi}hnlich wird der Teil des Respirationstraktus, der sich oberhalb der Glottis befindet, mit dem 5Tamen ,obere Luftwege" angedeutet. In ihrer Gesamtheit stellen sie einen Raum dar, der wi~hrend der htmung immerfort mit Luft angefallt ist. Dieser Luftraum ist zwischen der Aussenluft und dem eigentlichen subglottiscben Atmungsapparate eingeschaltet. Er kann als ein Ansatzstiick der Trachea betrachtet werden, wodurch diese indirekt mit tier Atmosphi~re in Verbindung steht, Bis jetzt galt dieser obere Luftraum nur als Vorportal fQr die eintretende und als Resonanzkasten fiir die austretende ti}nende Luft. Manometrische Untersuchungen 2) haben aber gezeigt, dass die respiratorischen Druckschwankungen in hohem Maasse durch diesen l:taum beeinflusst werden. Damit musste die Frage aufkommen, ~)b er fiir die Atmung selbst und demzufolge auch ftir den Stoffwechsel yon Bedeutung sei. Klinisch war diese Frage schon in bejahendem Sinne beantwortet, da man die Nachteile der Mundatmung wohl erkannt hatte. Hierbei wird namlich der obere Luftraum ge0ffnet und in direkte Verbindung mit der Aussenluft gesetzt. Dadurch werden die respiratorischen Druckschwankungen in ihm nahezu aufgehoben, so class man yon einer freien Kommunikation der Trachea mit der Aussenluft reden kann. Es zeigte sich nun, dass diese Ausschaltung des oberen Luftraumes als Ansatzstiick fast regelm~tssig die Gesundheit beeintriichtigte. Sobald man den DruckgrSssen einen bedeutenderen Einfluss auf den Atmungsprozess zukennt, kommen verschiedene Vor1) Schutter, Annal. d. malad, de l'or. etc. de Gougenheim. 9* 1892. 132 P.J. Mink: g~nge in ein anderes Licht. So wurde es uns mSglich in der Beweglichkeit der Naseneingange eine Vorrichtnng yon hohem physiologischen Werte zu erkennen 2). Zugleich wurde damit unsere Aufmerksamkeit auf die Glottis hingezogen. Denn bTasenVentil und Glottis stehen in etwa gleicher Beziehung zum oberen Luftraume. Sie beherrschen namlich die beiden Zug~nge zu diesem Raume, aber nicht zu gleicher Zeit. Wahrend die Nasenventile bei der Inspiration ais PfSrtner fungieren, ffdlt der Glottis die n~tmliche Rolle bei der Exspiration zu. Wie yon selbst stellt man sich die Frage, ob auch diese letzte yon gleich grosser Bedeutung for die Respiration sei wie die Funktion der erstgenannten. Die beiden Zug~nge zum oberen Luftraume liegen in Flachen, die wagerecht aufeinanderstehen. Die nasale, die ffir uns durch die inneren ~asenlScher repfftsentiert wird, ist frontal gestellt, indem die tracheale nahezu horizontal zur KSrperachse steht. Das steht im Einklang mit den Schenkeln, woraus man sich den Luftraum zusammengesetzt denken kann. Denn der Pharynx, wozu die Glottis den Zugang bildet, liegt in der Achsenrichtung der Trachea, wahrend der nasale Luftweg rechtwinklig zu dieser Achse v e r l a u f t . - Am besten kann man sich diese Verh~dtnisse durch nebenstehendes Schema vergegenwartigen. Hierbei haben wir den Pharynx als iiberall gleich weit und die Conchae als einfache Verengung des Luftweges vorgestellt. (Fig. 1.) Wie gesagt, drangt das Verhalten zum oberen Luftraume uns dazu~ die beiden Klappenapparate an seinen Enden vom gleichea Gesichtspunkte aus zu betrachten. :Nachdem wir das Nasenventil beschrieben haben, ist demnaeh der erste Schritt die Glottis naher ins Auge zu fassen. Bei der Vergleichung der beiden Apparate f~llt sofort einig~ _~hnlichkeit auf. Das Septum nasi wirkt zwar etwas verwirrend, aber man kann es sich wegdenken. Umgekehrt w~rde man die Mittellinie der Glottis als ein immaterielles Septum betrachten k~nnen. In beiden Fhllen wird es uns deutlich, dass wir mit Doppelapparatea zu schaffen haben. Klappenpaare, die sich beim Funktionieren einer zwischenliegenden Mitte nahern, bilden das Essentielle beider Vorrichtungen. Beide sind also eingericbtet auf die Einengung 1) P. J. Mink, Das Spiel der N~senfiiigel. Pfli]ger's Arch. Bd. 120. !33 Die Glottis. tier 0ffnungen, die sie beherrschen. Beide verftigen aber zugleich tiber ein System, das der Erweiterung anstrebt. In er~ster Linie stehen wir also vor der Frage, welche yon beiden Funktionen als die primare zu gelten hat. Mit Bezug auf die Nasenventile haben wir uns dahin ausgesprochen (siehe ,Spiel der Nasenfltigel"), dass ihr Zweck auf die inspiratorische u gerichtet sei. Wir schrieben dieser einen grossen physiologischen ~Nutzen zu, da wir den Wert einer Inspiration nach ihrem hndauern und dem zur Geltung kommenden negativen Drucke bemessen. D i e Erweiterung kam an die zweite Hasenventil r 5epl'urn Jnneres Nasenloch ......... Naso: pharynx lllll l /it Rlflll Nasenvenl'il haryn _Shmmlippe ---~ ~ -- Skimrnlipp'e IT~acbe~ Fig. 1. Stelle, da sie nur zur Aufgabe hatte, den i~ussersten Konsequenzen der Verengung vorzubeugen. Wie es in dieser Beziehung mit der Glottis steht, wird uns spiiter klar werden. Wenn wir ein l~asenventil und eine Stimmlippe mit den yon ihnen beherrschten Offnungen nebeneinander betrachten, so bemerken wir auch eine merkwtirdige J(hnlichkeit in der Form. Wir beniltzen hierzu einen Frontalschnitt durch das innere Nasenloch, wie er schon in ,,Das Spiel der Nasenfltigel" angefahrt wird, und einen halbierten Horizontalschnitt durch die Glottis. Denkt man sich die Fasern hinter dem Giessbeckenknorpel, die wir mit a angegeben haben, fort, so fallt die l)bereinstimmung noch mehr auf. Das sieht einer Licentia po~tica i~hnlich, einfach eine feste Masse wegzudenken. Wenn man 134 P.J. Mink: aber darauf achtet, dass diese Masse gleiehwie der angrenzende Teil der Stimmritze zum Bewegungsgebiet (les hryknorpels gehSrt, so ist die genommene Freiheit nicht so sehr gross. (Fig. 2.) Man fahlt sich wie herausgefordert,~ eine Parallele zu ziehen zwischen der Membran in 1 und dem Giessbeckenknorpel in I1. Dieser Vergleieh gilt vornehmlich der Funktion. Beide Gebilde machen es ni~mlich mSglich, dass der lange Schenkel der Klappe zur Mittellinie heranri~ckt. Da aber in 1 dessen langer Schenkel, ni~mlich die Ala septb knorplieh ist, musste der Tell, der ihm seine Bewegung gestattet, faserig sein. Und da er in / / als Stimmband _7- iT ...... 5 1 " i m m b a n d la 5epti /~embran .b~ ~ ' .... Giessbeckenknorpel "CI~ ! i Mittellinie d, Glottis Fig. 9. faserig ist, so musste der kurze Schenkel knorplich sein. Denn das Festere muss da sein um die Bewegung zu geleiten, und ebenso das Weichere, um sie zu gestatten. Mit Bezug auf das Nasenventil wird der Satz, dass der Knorpel die Bewegung leitet, won nicht auf Widerspruch stossen. Bei der Glottis aber kSnnte der Umstand, dass das Stimmband einen Muskel in sich birgt, eiae andere Auffassung hervorrufen. Das ist auch wirklich geschehen, und die herrschende Kehlkopfphysiologie sagt uns, dass die Spannung der Stimmbi~nder durch ihre eigene Kontraktion hervorgebracht wird (vgl. E w a l d in H e y m a n n ' s Hdb. Bd. 1 (l) S. 172). Z u c k e r k a n d l sagt wSrflich im niimlichen Buche S. 194: ,,Dass der Musculus vocalis das Stimmband zu spannen berufen ist, beweist schon seine Lage in einer Falte, deren Tatigkeit nicht auf Entspannung gerichtet sein kann, ferner der Umstand, dass er ja auf Die GlottiS:: 135 die schon vorher yon seiten tier Cricothyreoidei aus gedehnte Stimmmembran einzuwirken berufen ist." Wir lassen diese Beweisfiihrung dahingestellt sein, konstatieren aber, dass Z u c k e r k a n d 1 eine vorangehende Dehnung gelten lassen will. Wir sind der gleichen Meinung, stellen aber die Frage, ob es wirklich der Musculus cricothyreoideus ist, der diese Dehnung bewirkt. Das Dehnen setzt ein Auseinanderriicken der hnsatzpunkte voraus. Diese sind einerseits durch den Schildknorpel, andererseits dutch die Aryknorpel gegeben. Die Anheftung an der Cartilago thyreoidea muss als fixer Punkt betrachtet werden, denn, wie E w a l d ( H e y m a n n ' s Hdb. Bd. 1 [1] S. 196) sagt, ist es sicherlich richtig, dass sich eigentlich nur der Ringknorpel am Schildknorpel bewegt und nicht umgekehrt ( J e l ~ n f f y , S c h e c h ) . Der Schildknorpel ist durch die an ihm befestigten Halsmuskeln fixiert und der Ringknorpel dagegen sehr leicht beweglich. Am freigelegten Kehlkopf des Hundes kann man sich yon diesen Verhi~ltnissen aufs deutlichste tiberzeugen, besonders wenn man in die beiden Knorpel ]ange Nadeln eingestossen hat. Es bleibt also nur der Giessbeckenknorpel um das Auseinanderriicken der Ansatzpunkte und damit die Dehnung der Stimmembran zu erwirken. Am deutlichsten muss sich der Vorgang an der Chorda vocalis, die eigentlich nur die verdickte Randpartie der Membran darstellt~ abspielen. Wir fassen darum diese speziell ins Auge. Der vordere fixe Ansatzpunkt der Chorda findet sich ziemlich genau am Halbierungspunkte der HShe des Winkels der Cartilago thyreoidea, dicht neben dem Bande der entgegengesetzten Seite. Der hintere Ansatzpunkt am Processus vocalis des Aryknorpels muss in sagittaler Richtung nach hinten ausweichen, u m das Ligament anzuspannen. Man hat sich die Frage gestellt, durch welche verschiedenartige Bewegungen diese Spannung bewirkt werden kann, und dieses am ausgeschnittenen Kehlkopf ausprobiert. Aber diese Fragestellung ist unrichtig. Man hat nur zu rechnen mit den Bewegungen die wirklich beim Lebenden vorkommen. Fraglich ist nur, welche yon diesen die Anspannung hervorruft. Da kommen in erster Linie die Atembewegungen in Betracht. Laryngoskopisch kann man wahrnehmen, dass eine Exspiration manchmal eine hnspannung hervorruft. Man kann zwar S e m o n beipflichten, wo er sagt, dass bei der ruhigen Respiration in 80 % 136 P.J. Mink: der FMle keine Bewegung der Stiwmbander zu sehen ist. Aber bei etwaiger verstarkter Atwung sieht man die Anspannung doch jedesmal deutlich hervortreten. Hier haben wir also einen Konnex vor uns, der in Wirklichkeit besteht und also als Ausgangspunkt ftir unser Raisonnen]ent dienen kann. Die Frage ist, wie wir uns diesen Zusan]menhang zu denken haben. Es ist bekannt, dass die Trachea sich schon infolge der gewiihnlichen Atewbewegungen hebt und senkt. Bei der Inspiration zieht das Zwerchfell die Lunge und somit die LuftrShre abwarts~ bei der Exspiration findet die entgegengesetzte Bewegung statt. Bei starken Ausatmungsbewegungen ist schon deutlich das Aufsteigen des ganzen Kehlkopfes zu sehen. Im Ruhezustande ist der Larynx aber nicht als eine Einheit zu betrachten. Er zeigt eine Zusammensetzung aus zwei Stilcken, die sich bis zu einer gewissen HShe unabhi~ngig yon einander bewegen kiinnen. Das untere der beiden Stlicke, nawlich der Ringknorpel, ist nur als ein besonders forn]ierter Trachealring zu betrachten. Er ist n]it dew sogenannten obersten Trachealringe verbunden auf eine Weise, die sich in nichts unterscheidet yon den Verbindungen tier Trachealringe untereinander. Nur gestaltet er durch die Ungleichheit seiner HShe vorn und hinten den Mund der Luftriihre schief, etwa wie das Mundstiick einer Fli~te. Durch den festen Zusamn]enhang muss er die Bewegungen tier Trachea so gut wie unverandert witmachen. Ganz anders steht es un] das obere der beiden Stiicke, aus dem der Kehlkopf aufgebaut ist, namlich un] den Schildknorpel. Dieser ist gewissern]aassen am Zungenbein aufgehangt und, wie schon bewerkt, durch die vorderen Halsmuskeln fixiert. Da seine Verbindung n]it dew Ringknorpel dutch Bander und Gelenke eine ziewlich schlaffe ist, so behauptet er der LuftrOhre gegeniiber einige Selbstandigkeit. Die Muskeln, die ihn mit dew Ringe verbinden, kowwen in dieser Beziehung nur bei ihrer Kontraktion in Betracht. Die relative Unabhi~ngigkeit des Schildknorpels muss aufgehoben werden, bevor der Kehlkopf als Ganzes betrachtet werden darf. Wenn also die LuftrShre und dan]it der Ringknorpel den Ruhezustand verli~sst und sich hebt, hat zuerst diese Aufhebung zu erfolgen. E s muss sich wit anderen Worten das untere Stack des Kehlkopfes erst an] oberen Stticke verschieben, bevor es dieses 'mitbewegen kann. Die Glottis. 137 Gross ist diese Verschiebung freilich nicht. E w a l d untersuchte eine sehr magere Person darauf und fand eine Differenz yon hSchstens 1 mm. Bei anderen Personen konnte er sie aberhaupt nicht konstatieren. ( H e y m a n n ' s Handbuch Bd. 1 [1], S. 198.) Man hat aber das Recht zu bezweifeln, ob es mSglich sei, genau zu messen ohne Blosslegung des Kehlkopfes. Es whre w~nschenswert, die Messungen beim Menschen in vivo unter obenstehender Bedingung zu wiederholen. Schade, class Tracheotomierten nur ausnahmsweise far diesen Zweck zu benutzen sind, da man hier meistens pathologische F~lle vor sich hat. Es gen~gt abet fur unseren Zweck zu wissen, dass das anatomische VerhNtnis uns berechtigt, anzunehmen, dass jede Hebung des Ringknorpels mit einer Verschiebung dem Schildknorpel enflang einzusetzen hat. Diese Bewegung wird sich am deutlichsten da zeigen, wo die beiden Knorpel einander unmittelbar berahren. d. h. also im Cricothyreoidalgelenk. Dieses Gelenk lasst Schlotterbewegungen in tier Richtung nach oben, unten, vorn und hinten zu. Nach H a r 1e s s 1) erfolgt aber lediglich eine Bewegung in Vertikalebenen. Mit ,,vertikale Richtung" wird wohl diejenige gemeint sein, die der Trachealachse entspricht. Wir sehen ab yon miigliehen Abi~nderungen in tier Richtung dieser hchse selbst, die bei der kleinen Verschiebung, die wir im huge haben, normaliter ausserhalb des Spieles steht. Der Processus vocalis ist als ein Punkt einer Trachealachse zu betrachten (Fig. 3). Solange der hryknorpel seine Stellung zum Ringknorpel nicht andert, hat dieser Processus als ein Teil der TrachealrShre zu gelten, der nach der Mitte hin gerackt ist. Es macht nichts aus, ob er gerade in der Mittelachse der Trachea liegt; es genagt, dass er sich dieser mehr oder weniger nahert. Das Stimmband verbindet diesen Punkt der Trachealaehse mit dem Schildknorpel. Solange diese Verbindung schlaff ist, kann dieser Punkt sich gleich wie die hchse bewegen. Eine gewisse Rigiditat des Zusammenhangs mit dem Ringknorpel gestattet ihm, treu dessen Bewegungen mitzumachen, da er hierauf ruht. Sobald das Band aber angespannt ist, i~ndert sich die Sache. Von hiichster Bedeutung ist es also, zu wissen, wie welt sich die freie Bewegung des Processus vocalis erstreckt. 1) Harless~ Artikel ,Stimme" in Wagner's Handw0rterb. d. Physiol. Bd. 4. 138 P.J. Mink: Am besten vergegenwartigt man sich die Sachlage an untenstehender Zeichnung, der eine Figur aus L u s c h k a' s Kehlkopf zugrunde liegt. (Fig. 3.) Wir haben yon a, dem vorderen Ansatz des Stimmbandes, aus einen Zirkelbogen beschrieben, der dessen hinteren hnsatz am Processus vocalis b trifft. Die Linie ec stellt die Trachealachse vor, die man sich durch b gezogen denken kann. Es leuchtet ein, dass der Processus vocalis sich vom Zirkelbogen entfernt, wean er sich in a_. ., t 9 I 9 . f , . . :.;.e, -" . ~ v j r , i Fig. 3. J , " -'~ Fig. 4. der Riehtung der Traehealaehse naeh oben bewegt. Damir wird der Abstand zwisehen a und b grSsser~ so dass das Stimmband angespannt wird, wenn n~mlieh a fix bleibt. Hieraus geht hervor, dass eine Hebung der Trachea, wie sie bei der Exspiration vorkommt, imstande ist, diese Anspannung zu erwirken. Die Abstandsvergr/)sserung zwisehen a und b wird bestimmt dureh den Winkel, den die Aehslinie e b mit dem Zirketbogen bildet. Ziehen wir dureh b e i n e Tangente dr, so ist der Winkel d b c das Maass fi~r diese VergrSsserung. Wenn man yon einer gleiehen Ersehlaffung des Stimmbandes ausgeht, so ist aueh dessert L~nge yon Bedeutung. Die Sehlaftheit Die Glottis. 139 eines regelmiissig gebogenen Bandes kann niimlieh bemessen werden nach dem Winkel, welcher der Biegung entspricht. So wtirde man die Bi~nder a b und a c (Fig. 4) gleich schlaff nennen darfenl weil a d b ~-- ~A a e c ist. Wenn a f die Li~nge des gestreckten Bandes ab vorstellt, so wird a g dem gestreckten Band ac entsprechen mtissen. Wenn die Streckung des ersten durch eine Verschiebung yon b bis f zustande kommt, so erfordert eine gleichgerichtete Verschiebung yon c den Abstand cg um das Band a c zu strecken. Es ist ohne weiteres klar, dass b f u n d c g sich verhalten wie die Bogenli~ngen a b und a e und andererseits bestimmt werden durch die Winkel dbf-~- e c g ~ - adb. Wir kommen solcherweise zu folgendem Satze: B e i g 1e i c h e r Stellung und S c h l a f f h e i t der Stimmbiinder ist die d d,' , ",ib i a i a' Z /,] d ~ i "': i Jb" E a" !! / s 1 Fig. 5. zur Streckung d e r Bi~nder e r f o r d e r l i c h e H e b u n g d e r P r o c e s s u s v o c a l e s in d e r R i c h t u n g d e r T r a c h e a l a c h s e p r o p o r t i o n e l l m i t i h r e n Li~ngen. Bis jetzt haben wir eine Stellung der Stimmbiinder vorausgesetzt, wie wir sie in der L u s c h k a ' s c h e n Figur (Fig. 3) vorfanden. Das heisst also, class wir annahmen, der hintere hnsatzpunkt des Bandes stehe hOher als der vordere mit Bezug auf die Trachealachse. Wir fragen uns ob dieser Fall immer vorkommt, und ob er tiberhaupt fiir den Lebenden Geltung hat. Denn es konnten am ausgeschnittenen Kehlkopfe die Verhiiltnisse anders sein als in vivo. Ein einfaches Raisonnement geniigt, um diese Frage zu 15sen. Es gibt ausser dem HOherstehen des hinteren Ansatzpunktes noch zwei MSglichkeiten. Denn erstens kSnnte dieser Punkt gleich hoch i40 P.J. Mink: stehen wie der vordere Ansatz, zweitens kSnnte er auch niedriger stehen. Wir haben die drei F~lle in Fig. 5 vorgestellt und sie durch die Zeichen I , / / und 111 unterschieden. Die vorderen Ansatzpunkte a, a' und a" wurden als Mittelpunkte genommen far Bogen, die mit den Stimmbandlangen als Radius gezogen wurden. Die zugehSrige Trachealachse und deren Verli~ngerungen werden durch die Linien c d, c' d' und c" d" vorgestellt. Wenn der hintere Ansatzpunkt des Stimmbandes b i m Fall 1 sich hebt, so wird sein hbstand yon a grOsser, senkt b sich aber der Trachealachse entlang, so wird sein hbstand yon a verktirzt. Im F a l l / / w i r d das Verschieben yon b' auf der hchse c'd' sowohl nach oben wie nach unten eine grSssere Entfernung yon a' hervorrufen. Im Fall I l I dagegen fiihrt die Hebung yon b" in der Richtung b" d" eine Verkiirzung, eine Senkung yon b" in der Richtung b"c" eine Verlangerung der Linie a" b" herbei. Die Hebung des Punktes b, der dem Processus vocalis entspricht, wird durch die Exspiration, die Senkung durch die Inspiration bewirkt. Die Streckung des Stimmbandes kommt also im Fall 1 nur bei der Ausatmung, im Fall / / b e i der hus- und Einatmung und im Fall l I I nur bei der Einatmung zustande. Die laryngoskopische Untersuchung hat uns gelehrt, dass nut das Verhalten wie im ersten Falle zutrifft und die Verhi~ltnisse wie im Fall 11 und 11I geradezu pervers genannt werden mtissen. Wir formulieren unseren Schluss also folgendermaassen: Beim Menschen muss der Processus vocalis immer h S h e r s t e h e n als der v o r d e r e A n s a t z p u n k t des L i g a mentum vocale mit Beziehung auf die Trachealachse. :Noch bleibt zu ermitteln, wieviel der Processus vocalis hSher steht. Werfen wir einen Blick auf Fig. 3, so ist es einleuchtend, dass dieses Wieviel seinen Ausdruck findet in der Griisse des Winkels dbc. Man bekommt den ni~mlichen Winkel, wenn man durch a eine Horizontale auf der Achse der Trachea c e zieht, und b m i t a durch eine Gerade vereinigt. Wir bemerkten schon, dass die AbstandsvergrSsserung yon a und b und also das Strecken des Stimmbandes durch diesen Winkel bestimmt wird. Umgekehrt wi]rde man also aus den Vorgi~ngen bei der Streckung (ohne Dehnung) den Winkel berechnen kiinnen. Am ausgeschnittenen Kehlkopf scheint mir das beschwerlich, da die Achse tier Trachea dabei nicht mehr fix ist. In vivo ist dagegen das Messen der Hebung des Processus Die Glottis. 141 vocalis ohne Blosslegung des Kehlkopfes sehr schwer, wie wir schon betonten. Wir brauchen also ein anderes Maass. Dieses ist Sehr wahrscheinlich zu findeu in der GrSsse der Exspirationsbewegung, welche die Anspannung bewirkt. Diese aber lasst sich bestimmen nach dem zur Geltung kommenden Exspirationsdrucke. Man musste dann versuchen, laryngoskopisch oder stroboskopisch den Augenblick zu bestimmen, wo die Streckung des Stimmbandes vollendet ist, die Dehnung aber noch nicht angefangen hat. Zugleich hittte man manometrisch den Exspirationsdruck zu messen. Besser scheint mir aber noch der entgegengesetzte Weg, nl. auszugehen yon der Stimmbanddehnung und diese herabzumindern~ bis nur noch Streckung besteht. Wenn einmal die Chorda vocalis angespannt ist, so kann sich der Processus vocalis nicht mehr unabhangig vom Sehildknorpel weiter erheben. Solange die Rigiditlit der Befestigung des Aryknorpels noch aushi~lt, braucht dieser Knorpel aber nicht yon der Stelle zu riicken. Es erfolgt abet flits weitere eine Dehnung des Stimmbandes, die den Processus in der Richtung des vorderen Ansatzes des Ligaments zieht. Dieser Gegenzug wachst fortwi~hrend an, je mehr die Hebung fortschreitet. Es muss also ein Moment kommen, wo er der genanuten Rigiditiit die Wage halt. Jetzt t~bernimmt auch der~ Processus vocalis die Rolle als fixer Punkt, so dass ~das Stimmband als stillstehend betrachtet werden muss. Bei noch weiterer Hebung hat der Aryknorpel nachzugeben. Form und Art der Bewegung, die nachher erfolgen muss, werden bestimmt durch die Befestigungsweise dieses Knorpelstticks. Am besten kSnnen wit uns davon eine Vorstellung bilden mittelst einer Hintenansicht des Ringknorpets. Wir reproduzieren zu diesem Zwecke eine solche aus L u s c h k a ' s Kehlkopf (Fig. 6). Wie wir sehen, ist die Spitze des Aryknorpels abgestumpft und nach hinten gebogen. Sie triigt einen kurzen, kegelf6rmigen, biegsamen Knorpelaufsatz, die Cartilago corniculata s. Santorini. Dieser Knorpel ist durch zellenhaltiges Fasergewebe mit dem Giessbeckenknorpel verbunden. Z u c k e r k a n d l, dem wir bei diesel" Beschreibung folgen, sprieht statt yon verbunden yon geschieden und nennt die Selbsti~ndigkeit des Santorinischen Knorpels schei~bar. Die Spitzen dieser KnSrpelchen sind beiderseits auf eigentiimliche Weise miteinander verbunden. Jede iuseriert ni~mlich an einem Bi~ndchen. und diese beiden Bi~ndchen vereinigen sich in ihrem weiteren Verlaufe und haften I42 p.J. Mink: am oberen Rande des Ringknorpels. h'icht selten findet man inmitten der gabelfOrmigen Verbindung ein Knorpelstiickchen, die Cartilago interarytaenoidea. Das so gebildete Ligamentum jugale ist ziemlich straff; S a n t o r i n i gebraucht die Bezeichnungen ,,alba, firma, teretia corpora ligamentis similia" far dessert beiden Schenkel. Es muss sich also einem Auseinanderweichen der Spitzen der Aryknorpel widersetzen. Diese Apices mfissen daher als relativ fix betrachtet werden mit Bezug auf eine Bewegung lateralwarts. Der Giessbeckenknorpel hangt andererseits durch ein Gelenk mit dem Ringknorpel zusammen. Der Kapsel dieser Articulatio cricoarytaenoidea ist schlaff und a h nur an einer Stelle durch ein Seitenband, das Ligamentum triquetrum, verstiirkt. Dieses entspringt am oberen Rande des Ringknorpels, und zwar nach innen yore Gelenkkopfe, d ~ und inseriert tells an der hinteren Fli~che des Aryknorpels, teits an der Innenseite der hSckerig aufgetriebenen Wurzel des Processus vocalis. Da die Insertionslinie eine viel grSssere Li~nge als die Ursprungsstelle besitzt, acquiriert das genannte Band die Form eines Fgtchers. Fig. 6. Diese Ursprungsstelle muss als ein indirekter fixer Punkt des Aryknorpels betrachtet werden. Wir kfnnen uns eine Achse denken, welche dutch die beiden fixen Punkte (das relative und das indirekte) gelegt ist, die wir haben kennen lernen. Die Achsen yon beiden Seiten schneiden einander etwa in der Mitte der Hinterflache des Ringknorpels unter einem Winkel, den wir als Arywinkel bezeichnen kOnnen. Eine VergrSsserung dieses Winkels wird durch das Ligamentum jugale angehalten. Bei der Hebung des Ringknorpels kommen an sich keine Momente in Betracht, die eine Verkleinerung des Arywinkels anstreben. Man muss sich denselben bei diesem Vorgange also unver~indert denken. Wir nannten die Urspungsstelle des Ligamentum triquetrum am Ringknorpel einen indirekten fixen Punkt des Aryknorpels, weil er sich Die Glottis. 143 ausserhalb derselben befiadet. Nebenan, im Giessbeckenknorpel selbst, muss man sich eineu anderen Punkt denken, wo dieAehse aus- oder, wie man will, eintritt. Zwisehen den beiden Punktea zieht sich das Crico-arytaenoidalgelenk hin. Man kann sieh diesen unteren Achsenpunkt des Aryknorpels mit dem Processus vocalis dutch eine Gerade verbunden de,ken. Verbindet man aueh noeh den oberea hchsenpunkt am Santorini'schen Knorpel mit diesem Processus~ so hat man sieh die mediale Flitehe d 1. i il a Fig, 7, des Aryknorpels dureh ein Dreieck vergegenwartigt. Zum leiehteren Verstiindnis denken wir uns den Wiakel am unteren Achsenpunkte als einen reehten. Wie wit gesehen haben, liegt in einer Sagittalebene der vordere hnsatz des Stimmbandes niedriger als der Proeessus voeatis. Das Verhiiltais zum obengenaanten rechtwinkelig'en Dreieck kann also vorgestellt werden wie a b c d in Fig. 7 (siehe auch Fig. 3). Hierbei wird angenommen, dass das Sfimmband a b gestreckr nicht gedebut ist. Wenn der Ringknorpel sich hebt, so wiM das Dreieck bed, das in b c auf ibm ruht, mit gehoben. Die Bewegung findet statt in der Richtung der Traehealachse, die wit als vertikal annehmen. Das Dreieok wird also, wenn sich dem niehts widersetzt, parallel an sich selbst hinauf raeken. Solcherweisewiirde es z. B. in die Stelluag b' e' d' kommen kOnnen. 144 P.J. Mink: Da a b' liinger ist als a b, so miisste hierbei das Stimmband gedehnt werden. Diese Dehnung ist eine Kraft, die b' in der Richtung y o n a zu ziehen sucht. Sie kann entbunden werden in zwei andere Krafte, deren Richtung wir durch Pfeilchen angegeben haben. Eine Verschiebung yon b' in horizontaler Richtung nach vorn ist nicht mSglich, da die Befestigung des Aryknorpels diese nicht erlaubt. Die Bewegung in der Richtung nach unten wird aber nicht gehemmt. Demzufolge muss der Punkt b' sich senken. c' aber ist unverriickbar, da er die fixe Verbindung durch das Ligamentum triquetrum vorstellt. Das ganze Dreieck muss sich also um diesen fixen Punkt nach vorn drehen um z. B. die Stellung b" c' d" einzunehmen. Dadurch fi~llt die Dehnung des Stimmbandes geringer aus, denn a b" ist zwar li~nger als a b, aber bedeutend weniger als ab'. Der langen Rede kurzer Sinn ist also, dass bei g e s t r e c k t e m S t i m m b a n d e eine Hebung des R i n g k n o r p e l s zur V o r n i i b e r n e i g u n g des A r y k n o r p e l s f i i h r t . Wean wir uns diese Bewegung mit Hilfe yon Fig. 6 vorstellen, so wird es uns deutlichl dass sie zustande kommen kann bei unveri~ndertem Arywinkel. Sie finder um eine horizontale Achse d e statt, die man sich durch die beiden indirekten fixen Punkte gelegt denken kann. Der ganze Rahmen a k c l b bewegt sich so, dass k und l auf der Stelle bleiben, wgthrend a und b sich nach vorn und unten drehen. Dagegen muss der Punkt c sich in einer Richtung nach hinten und oben vom Ringknorpel entfernen. Es leuchtet ein, dass die beiden Processus musculares der hryknorpel, die wir mit f u n d g (Fig. 6) angedeutet haben, sich mit Bezug auf die beschriebene Drehung verhalten wie der virtuelle Punkt c. Denn wenn man z. B. f dutch Linien mit den beidea fixen Punkten in tier Achse a c vereinigt, so wird unterhalb der Achse de ein Dreieck beschrieben mit f als Spitze, das sich in glcichen Umsti~nden befindet wie J k c l. Bei der Neigung der hryknorpel nach vorn wird f also versuchen nach hinten und oben auszuweichen. Da dieser Punkt aber beinern verbunden ist mit dem Processus vocalis, so masste dieser der Bewegung folgen. Das Stimmband, das an ibm verbunden ist, widersetzt sich aber einer Ausweichung yon f nach hinten. Das gilt nicht fiir dessert Bewegung nach oben. Um das zu verstehen, muss man sich eine Vorstellung bilden vom Crico-arytaenoidalgelenk. Die Glottis. 145 Wenn man sich den unteren Achsenpunkt eines Aryknorpels und seinen Processus vocalis nebst dem Processus muscularis ~durch gerade Linien untereinander verbunden denkt, so repriisentiert das gebildete Dreieck die Gelenkflache dieses Knorpels. Diese wird gequert durchdie derselben entsprechenden Gelenkfli~che des Ringknorpels. Z u c k e r kandl sagt dazu ( H e y m a n n ' s Handb. Bd. 1 [1], S. 66) folgendes: ,Partes constituentes der Articulatio crico-arytaeno~dea sind je ein am oberen Rande der Ringknorpelplatte aufsitzender Gelenkkopf und die Basis des Aryknorpels~ welche die Gelenkpfanne tragt. Der Gelenkkopf bildet einen elliptisch konturierten, konvex vorspringenden K0rper mit wulstig aufgeworfenem, dorsal tiberhi~ngendem Rande. Infolge der Ringform des Knorpels und seiner allmiihlichen HShenzunahme in der Richtung yon vorn nach hinten fallt der konvexe Gelenkk0rper gleich einer schiefen Ebene ab. Die litngere Achse der Gelenkflgtche ist, dem Laufe des oberen Ringknorpelrandes folgend, schri~g, die kiirzere mehr frontal gestellt." Die Pfanne des Gelenkes beginnt knapp hinter dem Processus vocalis und nimmt die ganze Lange der Aryknorpelbasis fiir sich in Anspruch, woraus hervorgeht, dass der Processus muscularis an der Pfannenbildung mitbeteiligt ist. An der Cavitas glenoYdalis ist (lie langere Achse mehr frontal, die ktlrzere schri~g gelagert. Es kreuzen sich demnach die langen Achsen der beiden Gelenkbildner. Bei L u s c h k a finden wir noch folgendes: ,,Die Kontaktfli~chen der Cricoarytaenoidalgelenke stimmen in der Gr0sse unter sich nicht tiberein, so dass sie sich in keinem Moment der Bewegung allseitig berahren. Der elliptisehe, zylindrisch gew01bte, yon der oberen Ecke tier Platte des Ringknorpels sehr steil lateralwarts abfallende Gelenkkopf besitzt durchschnittlich eine der abfallenden Richtung des oberen Randes des Ringknorpelbogens folgende Li~nge yon 6 ram, wi~hrend der gerade, mit diesem sich kreuzende Durchmesser sich auf 3 mm bel~uft. Die 5 mm lange und im Maximum 4 mm breite Kontaktflhche des Giessbeckenknorpels besitzt die Gestalt eines Ovales, dessert spitzes Ende nach vorn und innen, das stumpfe nach aussen und hinten schaut, dessen L~ngsachse sich daher mit: jener des Gelenkkopfes der Cartilago cricoidea unter einem mehr oder weniger spitzen Winkel kreuzt. Diese Kontaktflache ist konkav, stellt jedoch kein Segment einer Hohlkugel, sondern eine Schraube dar, so dass dutch die Artic. crico-arytaenoldeae schraubenartige Bewegungen ausgefiihrt werden k0nnen. E. P f l f i g e r , Archiv fiir Physiologie. B4. 123. 10 146 P. J. Mink: Mit Hilfe der gewonnenen Vorstellung wird untenstehende Fig. 8 erkli~rlich sein. Wir haben eine ziemlich weit geSffnete Glottis vorausgesetzt, da die Bewegung, die wir beschreiben, Beziehung hat auf den Anfang einer Exspiration. Der Stand der Artikulationsflache des rechten hryknorpels wird durch das Dreieck a b c vorgestellt, wobei a den unteren Achsenpunkt, b den Processus muscularis und c den Processus vocalis repriisentiert. Wir nehmen b c an als Li~ngsachse yon der Facies glenoidalis des Giessbeckenknorpels. Diese wird gekreuzt durch die Li~ngsachse der Gelenkfi~che des Ringknorpels, die durch die Linie a f angedeutet wird. Wenn der Ringknorpel sich weiter hebt, nachdem das Stimmband dc schon gestreckt ist, so versucht der Punkt c unter dem Einflusse des Gegenzuges zuriickzubleiben. Der Punkt a muss aber weiter mit, da er fest mit dem Ringknorpel verbunden ist. Solcherweise kommt a, wie w i r e s in Fig. 7 skizziert haben, mit Beziehung auf c hSher zu stehen. Der Punkt b kann, wie wir schon bemerkten, nicht nach hinten ausweichen, aber sich wohl heben, wi~hrend c als Fig. 8. relativ fixer Punkt funktioniert. Die Achse b c muss dann sozusagen, nach vorn iiberkippen. Diese Achse ist aber ebensowenig wie der ganze Aryknorpel aktiv, sie wird also umgekippt, Die Kraft, die das bewirkt, riihrt her yon dem hufsteigen des Ringknorpels und deshalb yon der Hebung der Gelenkachse a f. Sie wird ilbermittelt durch den Kreuzungspunkt der beiden hchsen q. Wenn aber q aufsteigt und c zuriickbleibt, so muss der Abstand q c grSsser werden; dann aber muss bq kleiner werden. Da die Achse a f sieh parallel an sich selbst hebt, behiilt sie ihre Richtung bei. Die Verkleinerung yon b q bedeutet also ein Abgleiten yon b in der Richtung yon c. Da der Punkt a fix ist, muss b und damit auch tier Processus vocalis c sich um a als Mittelpunkt nach der Mitte tier Stimmritze hin drehen. Noch einfacher stellt man sich die Sache d Die Glottis. 147 v0r, wenn man in Betracht zieht, dass die Entfernung yon a und d grSsser werden muss wenn der erste Punkt sich hebt, wahrend der zweite fix bleibt. Diese u erfordert eine Streckung der gebrochenen Linie a c d , und also eine Bewegung von c in der Richtung yon g. Die Facies glenoidalis, die wir durch a bc vorgestellt haben, wird dem Gesagten nach in linearer Richtung gehoben, w~hrend sie sich zugleich dreht. Das Produkt einer linearen Bewegung mit einer Drehung ist eine Schraubenbewegung. Wie wir sahen, hat L u s c h k a diese Art yon Bewegung schon aus der Form der Gelenkfl~tche abgeleitet. ~eigung und Drehung des Aryknorpels konnten auf ganz bestimmte Weise aus der Hebung des Ringknorpels abgeleitet werdem Wir glauben uns darum berechtigt anzunehmen, dass zwischen beiden ein mathematisches VerhMtnis besteht. Dana aber muss man annehmen, dass die Glottisweite in direkter Beziehung steht zur Hebung der Trachealachse und solcherweise zur Tiefe der Exspiration. Je tiefer die Ausatmung, je enger die Stimmritze. Die ~atur strebt also keinesfalls eine so schnell mSgliche AusstrSmung der L u f t aus den Lungen an. Demgegeniiber besitzt sie in der Glottis eine Vorrichtung, die gesetzmi~ssig diese Ausstriimung verzSgert. Die bTatur ki~me also mit sich selbst in Widerspruch, wenn die husatmung nur den Zweck h~tte, Exkretionsprodukte fortzuschaffen. Nur wenn man annimmt, wie wires in ,,die Nase als Luftweg" schon taten, dass der Wert einer Exspiration auch bestimmt wird durch die Zeit, die sie anhi~lt, wird uns die Glottisvorrichtung erkli~rlich. Da eine tiefere Exspiration zugleich eine grSssere VerzSgerung mit sich bringt, kommen die so wechselnden Kri~fte stets zu' ihrem l~echte. - - Graphisch muss sich diese Regulierung in der Form der Exspirationskurve kundgeben. Die hTeigung des absteigenden Schenkels der Respirationskurve wird, wenigstens hauptsi~chlich, durch die Glottis beherrscht und in dieser Beherrschung gipfelt ihr physiologischer Nutzen. Jetzt steht uns die Analogie zwischen l~asenventil und Glottis Mar vor Augen. Werfen wir noch einen Blick zuriick auf Fig. 1, so erscheinen uns die Klappenapparate an den Zugi~ngen zum oberen Luftraume hiichst rationelh Wie treue PfSrtner iiberwachen sie einerseits die eintretende Aussenluft, andererseits die austretende Lungenluft. Aber nicht nur PfSrtner, auch Herrscher sind sie. Es m~ge der lO* 148 P.J. Mink: Brustkasten toben wie er wolle, er bleibt den Gesetzen der beiden Apparate unterworfen. Weder die Inspiration noch die Exspiration kann willkiMich schalten, Zwar behaupten sie beim Einsetzen ihre Selbstandigkeit, aber sofort greifen die Klappenvorrichtungen ein~ um ihnen die Gesetze ffir ihr zeitliches Verhalten vorzuschreiben. Solcherweise wird einer Verschwendung yon Kratt u Diese Fi~rsorge ist eine physiologische Notwendigkeit, denn eine Bewegung, die sich Tag und Nacht etwa tausendmal pro Stunde wiederholt, l~isst auch eine kleine Verschwendung nieht zu ohne schwere Folge. Die his jetzt beschriebene Bewegung des Aryknorpels wurde yon uns abhangig gemacht yon dem Gegenzug, der durch das gestreckte Stimmband ausge~bt wurde. Dieser Gegenzug wird, bemesSen dutch den Widerstand, den das elastische Band seiner Dehnung entgegensetzt. Demgemi~ss strebt dieses Band der Stellung zu,:wobei seine Dehnung am geringsten ist. ,, Betrachten wlr in Figur 8 die gebrochene Linie a cd, so lenchtet es ein, dass dc sich verkt'lrzen kann, wenn der Proeessus u c sich nach der Mittellinie der Glottis hin bewegt. Wenn aber die gebrochene Linie ganz gestreckt und c also in g angekommen ist, ist das Band dg aueh am kiirzesten. Wenn g sich noch welter der Mittellinie ni~hern wiirde, so mi~sste die Chorda dg wieder anfangen sich zu verlangern. Auch wenn das Stimmband die Bewegung aktiv leitete, so wiirde beim Erreichen der Stellung dg seine hiichste Leistung vollbracht sein. Die Theorie, die die Spannung der Stimmbander auf ihre eigene Kontraktion zurt~ckfi~hren will, kSnnte aber auch nur bis an diese Grenze gelten, da eine weitere Anni~herung non d und g auch bei starkster Kontraktion nicht mehr mSglich ist. Jedenfalls bedeutet also die Stellung dg den Endpunkt der Anspannung des Stimmbandes. Die Hebung des Ringknorpels dem Schildknorpel gegentiber ist nieht unbeschrankt. Die anatomischen u schreiben dieser Bewegung ihre Grenze vor. Diese findet sich abgezeichnet im Cricothyreo~dalgelenk. Wenn die Bander dieses Gelenkes eine weitere Verschiebung des Ringes naeh oben nicht mehr gestatten, hat auch die respiratorische Verengung ihren hSchsten Punkt erreicht. Zwar kann die Trachea sich noch weiter heben, aber dann nimmt sie den Schildknorpel mit. Die beiden Ansatzpunkte des Stimmbandes werden somit in gleicher Weise gehoben und andern ihre gegenseitige Stellung nicht mehr. Die Glottis. 149 Solange die Glottisverengung ohne Vermittelung yon Muskeln vor sich geht, kSnnen wir sie automatisch nennen. Die grSsstmSgliche automatische Yerengerung muss zusammenfallen mit dem Glottisstand, den wir durch die punktierte Linie in Fig. 8 angegeben haben. Es ware mi~glich, dass eine weitere Hebung des hinteren Ansatzpunktes des Stimmbandes noch eine Dehnung dieses Bandes bewirkte, aber ein weiteres Hineinrt~cken iiber g hinaus ist auf automatischem Wege nicht denkbar. Das Analogon dieser Position der Stimmlippen ist auch am Nasenventil zu finden. Denn die hi~chste Leistung der automatischen Funktion ist hier an die tiefste Inspiration gebunden. Die Grenze hierfiir ist in der Dehnbarkeit der Membran zu suchen (siehe Fig. 2 I.). Gleich wie am ~aseneingange finden wir auch an der Glottis Muskeln, die imstande sind den automatischen Vorgang zu fixieren und zu verstarken. In erster Linie kommt hierft~r der Musculus Crico-thyreolde,ls in Betracht. Zweifellos dient dieser Muskel dazu, um den Abstand zwischen Ring- und Schildknorpel zu verkleinern. Fraglich ist es nur, in welcher Richtung diese Funktion zur A_usserung kommt. Es k0nnte die untere Halfte des Kehlkopfs zur oberen oder umgekehrt die obere zur unteren herangezogen werden. Die dritte MSglichkeit ware, dass beides zugleich stattfande und die beiden Halften also einander naherten. Viele glauben, dass der Musculus crico-thyreo~deus der eigentliche Stimmbandspanner sei. Da die Anspannung, wie erSrtert wurde, auf eine Hebung des Ringknorpels zurilckzuf[lhren ist~ so s011te die Funktion dieser Muske] darin bestehen, diese Hebung zu erwirken. ~ach tier yon uns gegebenen Darstellung ist das Aufsteigen des Ringes nur eine Teilerscheinung yon der namlichen Bewegung yon LuftrShre und Lungen. Man kann sich beschwerlich vorstellen, dass die kleinen Crico-thyreoidei zu diesem Kl'aftaufwande imstande sein wi~rden. Mit gutem Willen kSnnte man noch annehmen~ dass sie den Ringknorpel an sich heben kOnnten. Das aber wiirde ein Ausziehen des ziemlich straffen Bindegewebes erfordern, womit der KnorpeI am ersten Trachealringe verbundei~ ist. Bei schnell aufeinanderfolgenden Stimmbandspannungen wie beim Sprechen und Singen wtirde diese Arbeit durch das Muskelchen ,Sele Male kurz nacheinander wiederholt werden miissen. Das klingt zu unwahrscheinlich. 150 P.J. Mink: Ich hoffe, dass man meinen Zweifel an solch einer Funktion der ziemlich winzigen Muskeln begreiflich finde. Damit ist aber nicht ausgeschlossen, dass ihre Arbeit die Hebung des Ringknorpels etwas fSrdert; auch ein Kind kann eine Maschine drehen helfen. Viel eher kann man sich vorstellen, dass die Crico-thyreoidei den Schildknorpel herunterziehen. Die Dehnbarkeit der Membrana und der Ligamenta thyreo-hyo'~dea, womit dieser Knorpel am Zungenbein aufgehangt ist, warde eine geringe Bewegung nach unten zulassen. Der Musculus tbyreo-byo'tdeus braucht dafar auch kein bedeutendes Hindernis zu sein. Es w~re also mSglich, dass diese Wirkung dann und wann durch die Kontraktion der Cricothyreotdei hervorgerufen warde. Solcherweise massten diese Muskeln als Depressoren des Schildknorpels aufgefasst werden. Diese Depression darf aber nicht gelten als die Hauptfunktion der Stimmbandspannung, wie wir schon fl'aher betont haben. Sie muss aber yon Bedeutung sein far die Fixation des vorderen Ansatzpunktes des Stimmbandes, die eine conditio sine qua non far diese Anspan~ung ist. Die Musculi sterno-thyreo~dei wirken im gleichen Sinne. Sie sind viel grSsser und starker als die Crico-thyreoidei, aber sie aberbracken nicht direkt gleichwie diese letzten die Spalte zwischen den beiden Halften des Kehlkopfs. Man ist geneigt, die Hauptfunktion bei der Fixierung des Schildknorpeis den grossen Sternothyreo'idei zuzuschreiben und die Wirkung d e r Crico-thyreoidei mehr in direkte Verbindung mit der aberbrackten Spalte zu bringen. Am liebsten stellen wir uns die Sache auf folgende Weise vor: Die Zwerchfellbewegung hebt respiratorisch den Ringknorpel, spannt die Stimmbander und bestimmt die Weite der Stimmritze. Der Gegenzug, nStig zur Fixierung des Schildknorpels, wird hauptsacblich geliefert durch die Sterno-thyreoldei. Da das Sternum sich bei der Exspiration senkt, genagt schon ein Tonus dieser Muskeln, den Schildknorpel mit nach unten zu ziehen. Die beiden Partes constituentes des Kehlkopfs werden also bei der Ausatmung in entgegengesetzter Richtung bewegt. Die Verschiebung ist gebun'den, wie schon bemerkt wurde, an das Gelenk zwischen Schild- und Ringknorpel und findet also ihre Grenzen in der Beweglichkeit dieser Verbindung. Das Gelenk ist aber sehr klein und liegt ziemlicb welt nach hinten. Wenn man Die Glottis. 151 sich eine vertikale Ebene durch die beiderseitigen Gelenke gelegt denkt, so warde diese ungefi~hr die Processcus vocales treffen. Die Spalte an der Vorderseite des Kehlkopfs zwischen Schild- und Ringknorpel warde noch Bewegungen zulassen, und dadurch die erreichte Stimmbandspannung unsicher gestalten. Wenn sich aber die Musculi crico-thyreo'idei kontrahieren, so ziehen sie die beiden KehlkopfhMften an der Vorderseite nacheinander zu. Sie f0rdern sowohl die Hebung des Ringes wie die Senkung des Schildknorpels. Man muss aber annehmen, dass sie zu schwach sind, um eine weitere Ann~herung yon einiger Bedeutung zu erwirken. Ihre Funktion muss also vielmehr als eine Fixierung des schon bestehenden Zustandes aufgefasst werden. Sie sichern solcherweise die Stellung der vorderen Ansatzpunkte der Stimmbander. Wenn sie nicht fortwahrend kontrabiert bleiben, sondern rhythmisch erscblaffen, so muss die Unsicberheit in der Stimmbandspannung abwechselnd hervortreten. Vielleicht kann hieraus das tremolo der Stimme erkli~rt werden. Wie yon selbst betreten wir bei der Besprechung der Musculi crico-tbyreoidei das Gebiet der phonetischen Funktion des Kehlkopfs. Die automatische Funktion, wovon bis jetzt die Rede war, braucht die Fixierung des Glottisstandes nicht. Vielmehr hat man hierbei eine labile MitteIstellung der Glottis zu erwarten, die sich leicht den respiratorischen Druckschwankungen anpassen kann. Dass diese Anpassung wirklich besteht, li~sst sich laryngoscopisch manchmal deut]icb genug verfolgen. Eine Fixierung der Glottis kSnnte diese Anpassung nur erscbweren und gehi~rt also nicht mehr in den Rahmen der automatischen oder respiratorischen Kehlkopffunktion. Deshalb kann der Musculus crico-tbyreoideus auch nicht als Atmungsmuskel aufgefasst werden, gleichwie der Sternothyreo]deus. Mit seiner Kontraktion tritt der Kehlkopf in einer neuen Rolle auf. Wenn die beiden Halften des Larynx hinten durch die Cricothyreo'idgelenke, vorn durch Muskelwirkung in ihrer Verscbiebung gehemmt sind, machen sie weitere Bewegungen zusammen mit. Der Kehlkopf kann sich zwar nocb heben und senken, aber nur als Ganzes. Eine weitere Anspannung der Stimmbi~nder kann nicht mehr stattfinden, weil ihre vorderen und hinteren Ansatzpunkte sich nicht mehr voneinander entfernen. Die Glottisstellung. die beim Anfang der Kontraktion der Crico-tbyreo~dei bestand, i~ndert sich daher nicht mebr infolge der Respirationsbewegungen. Die Glottis- 152 P.J. Mink: :verengerung, wie sie automatisch hervorgebracht wurde, bMbt also auf ihrem hSchsten Punkte stehen. Dieser Zustand der Glottis muss sich vorfinden bei der tiefst:mSglichen Exspiration, wenn jede Muskelwirkung ausgeschlossen ist. :Beide Bedingungen findet man erf~llt beim Kadaver. Hier haben wit also die hSchste Leistung der automatischen Verengung der Stimmritze zu erwarten. Wir wissen dass an der Leiche eine ziemlich starke Ann;therung der Stimmlippen an die Mittellinie vorgefunden wird, die seit v. Z i e m s s e n den Namen Kadaversteltung tragt. Diese Stellung muss also nahezu erreicht sein, wenn der Musculus crico-thyreoldeus anfhngt zu funktionieren. Wir sagen ,,nahezu", da wir es far mSglich und selbst ft~r wahrseheinlieh halten, dass die Muskelkontraktion die beiden schon anliegenden Kehlkopfhalften etwas genauer anschmiegt und soleherweise die Stimmritze noeh um ein weniges -qerengt. Wir halten das aber ffir nebens~tchlich und fassen unsere Meinung zusammen in dem Satz: d i e M u s c u l i crico-thyreoidei f i x i e r e n d i e G l o t t i s in d e r K a d a v e r s t ell u n g. Diese Fixierung markiert das Ende der respiratorischen Funktion des Kehlkopfes. Zugleieh bildet sie den Anfang einer anderen Funktion yon diesem Organe, n~mlich die phonetische. Die Kontraktion der Crieo-thyreoidei stellt sozusagen die BrOcke dar, die beide Funktionen verbindet. Sie bildet den Ubergang yon der gewShnliehen zur tSnenden Exspiration. Gleiehwie man beim Heben eines Gewichtes an die Zugrolle, das Sell befestigt um zu behalten, was man schon erreieht hat, so sichert die Kontraktion der Cricothyreo'/dei den Effekt der respiratorischen u Und ebenso wie das Erreichte mit der Zug~'olte tier weiteren Hebung zugrunde liegt, so hat die fixierte Kadaverstellung als die Basis der phonetischen Wirksamkeit der Glottis zu gelten. Von diesem Standpunkte aus sind wir genStigt einen Zusammenhang anzunehmen zwischen dieser Glottisstellung und dem Anfang der Lautbildung. Wir b r i n g e n also d i e K a d a v e r s t e l l u n g d e s K e h l k o p f e s mit dem G r u n d t o n tier S t i m m e in Verbindung. Da dieser Grundton bei verschiedenen Individuen auch verschieden ist, so massen wir aueh eine Ungleichheit in der Kada~,erstellung annehmen. In Wirklichkeit schwankt die Glottisweite bei diesem Zustande auch zwischen ziemlieh welt auseinanderliegenden Grenzen. Zum Beweise reproduzieren wir hier eine Figur au~ S e m o n ' s Artikel in H e y m a n n ' s Handbuch Bd. 1 (l) S. 640. (Fig, 9.) Die Glottis. 153 Wie man sieht i~hnelt die Kadaverstellung (am wenigsten in maximaler Weite) dem u wie wires durch die punktierten Linien iu Fig. 8 angegeben haben. Es leuchtet ein, dass die Gri~sse des Dreieekes adh sowohl durch die Liinge yon ah wie durch die Lfinge yon a d bestimmt wird. Beide Li~ngen kSnnen wechseln und solcherweise sehr versehiedene Dreiecke gebildet werden. Diese Versehiedenheit kann sowohl Beziehung haben auf die GrSsse wie auf die Form des Dreieckes. Es liegt ausserhalb des Rahmens dieser Arbeit, die physischen Gesetze zu besprechen, die die Tonbildung dutch die Glottis beherrschen. Wir kSnnen aber nicht umhin, mit Bezug auf die Haupt- ~inimum /V~aximum der cadaver6sen Posil-ion der 51-immlippen Fig. 9. sache Stellung zu nehmen. Wenn wir nochmals die Fig. 8 betrachten, so ist es deutlich, dass das Stimlnband in der Position dg am kiirzesten ist. Das Band ist zwar gestreckt, aber yon einer bedeutenden Dehnung kann schwer]ich die Rede sein. Das springt noch besser ins Auge, wenn wir einen Blick auf Fig. 7 werfen. Beim Anni~hern des Processus vocalis g (Fig. 8) zr Mittellinie ist nur noch eine minimale Verli~ngerung des Stimmbandes mSg!ich. Und doch ist in dieser Anni~herung die Bildung einer ganzen Tonreihe enthalten. Es ist won ausgescblossen, dass diese auf die winzige passive Dehnung des Stimmbandes zuri~ckzufiihren sei. Das nimmt man denn auch nicht an. Nach dem schon zitierten Satze von Z u c k e r k an d I ist tier Musculus vocalis berufen, die schon vorher gedehnte Stimmmembran anzuspannen. Ich vermute, dass mit dieser vorherigen Dehnung der Zustand gemeint wird, den wir dutch die 154 P.J. Mink: punktierte Linie in Fig. 8 vorgestellt haben. Der Musculus thyreoarytaenoideus internus oder M. vocalis wie Z u c k e r k a n d l ihn nennt, liiuft neben und parallel an der Chorda dg. Mir ist es unbegreiflich, was eine Kontraktion dieser Muskel noch an dieser Stimmbandstellung andern kann. Denn in dieser Stellung ist die Muskel am ktirzesten u n d hat er also seine h5chste Leistung erreicht. Eine weitere Verengerung der Stimmritze muss wieder eine 9wenn auch unbedeutende Verlangerung der Muskel bewirken. Wie das aber mit einer aktiven Anspannung zu vereinbaren ist, ist mir vollkommen unklar. Man kann sich denken, dass der M. vocalis die Chorda zur Stellung dg hinzieht, wenn diese in tier einen oder der anderen Richtung davon abweicht. Soleherweise wiirde er dann in gleichem Sinne arbeiten wie die Elastizitftt der Chorda selbst. Seine Kontraktion warde dann aufzufassen sein als das Zuft~gen einer aktiven Elastiziti~t zu der passiven der Chorda. Das scheint uns eine natzliehe Aufgabe, die gross genug ist far dieses Muskelchen. Aber damit verdient es den Namen Stimmuskel nicht. Wenn das Stimmband in der Kadaverstellung angekommen ist, hat es seine Arbeit schon vollbracht; seine Wirksamkeit liegt also ganz im Gebiete der respiratorischen Funktion des Kehlkopfs. Der sogenannte M. vocalis muss deshalb als Respirationsmuskel aufgefasst werden. Mit t i e r Tonbildung hat er nut insoweit zu schaffen, dass er gleich wie der Crico-thyreo'ideus die Glottis in der Kadaverstellung fixieren hilft. Auch er bildet solcherweise eine Bracke far den Ubergang yon der gewiihnlichen zur tSnenden Exspiration. Uns erabrigt nut, die Tonbildung ganz und gar yon Weite und Form der Stimmritze abhi~ngig zu stellen. Reine TOne erfordern aber eine gewisse Festigkeit yon den Rfmdern dieser ()ffnung. Indem der Musculus internus dieselbe besorgt, ist er yon grundlegender Bedeutung air die phonetisehe Funktion des Kehlkopfes, ohne zu den Tonbildnern gerechnet werden zu darfen. Die laryngoskopische Untersuchung lehrt uns, dass ein hSherer Ton einer engeren Stimmbandritze entspricht. Das muss auch schon ftir den Grundton gelten. Wenn unsere Voraussetzung aber den Zusammenhang der Kadaverstellung mit dem Grundton riehtig ist, werden wir z. B. bei Frauenkadaver fast regelm~ssig eine kleinere Stimmritze finden. Dabei hat man nicht allein m i t der Lftnge der Stimmbander zu rechnen. Der Bemerkung yon Die Glottis. 155 M o r i t z S c h m i d t l ) : ,ich habe Tenoristen untersucht, welche verhaltnismassig sehr lange Stimmb[mder, und Bassisten, die auffallend kurze hatten" wird wohl jeder Laryn~ologe beipflichten. Aus Fig. 8. ist ersichtlich, dass auch der Abstand zwischen den Aryknorpeln ia Betracht gezogen werden muss. Wie schon bemerkt, kann bei gleicher GrSsse auch die Form der dreieckigen Spalte wechseln, was vielleicht far das Timbre der Stimme durchschlaggebend ist Beim gewShnlichen Gebrauch der Stimme kommt der tiefst erreichbare Ton wohl nut ausnahmsweise (dagegen wohl beim Husten) zur Geltung. Wit miissen also annehmen, dass die phonetische Funktion tier Glottis selten Beziehung hat auf die Kadaverstellung. Als Regel hat man eine Stimmritze zu erwarten, die enger ist. Diese weitere Verengerung beruht auf Muskelwirkung und hat mit der Respiration nichts mehr zu schaffen. Sie wird erwirkt durch eine willkarliche Weiterdrehung des Processus vocalis nach der Mittellinie zu. Diese Aufgabe wird (lurch den Glottisschliesser, den Musculus crico-arytaenoideus lateralis, erledigt. Diese Muskel greift am Processus muscularis (Fig. 8 b) an und dreht den Aryknorpel weiter in der Richtung, die schon automatisch gefolgt wurde. Der Processus v0calis c, der sich in Stellung g (Kadaverstellung) befand, nahert sich infolgedessen noch mehr der Mittellinie. Am Ende ber~hren die Processus der beiden Seiten einander, sodass auch die Chordae aneinander liegen. Angeblich wird bei dieser Bewegung der Processus vocalis noch wieder ein wenig gesenkt. Damit muss auch die Dehnung des Stimmbandes (siehe Fig. 4~) geringer ausfallen. Bis jetzt kam keine Bewegung ins Spiel, die den Abstand ah (Fig. 8) zu verkleinern suchte. Das braucht auch noch nicht der Fall zu sein, wenn die Processus vocales einander berOhren. Es eriibrigt dann zwischen den Stimmlippen noch ein Raum, der ah als Basis und den Vereinigungspunkt der beiden Processus als Spitze hat. Man ist gewShnt, demselben den Namen Yon Glottis respiratoria zu geben, obwohl jeder Grund fiir diese Benennung fehlt. Die Ann~herung der beiden Punkte a und h wird bewirkt durch Muskeln, die an der Hinterseite zwischen den beiden Aryknorpeln ausgespannt sind. In erster Linie steht hierbei der Musculus ary' taenoideus transversus. Wenn man sich die Wirkung dieses Muskels 1) M. S c h m i d t , Die Krankheiten der oberen Luftwege. t. Ed. S. 48. 156 P.J. Mink: an Fig. 6 vergegenwartigt, so sieht man ein, dass es mSglieh w~ire, dass er die Punkte k und 1 naeheinander zu ziehen k~nnte~ ohne dass der Arywinkel sieh zu andern braueht. Hierbei wtlrden die Aehsen ab und be sieh p~rallel an sieh selbst naeh der Mitte hin versehieben, wahrend ihr Sehneidepunkt c entspreehend hSher zu liegen kame. Wit glauben aber, dass eine isolierte Kontraktion des Transyersus wohl nieht vorkommt, und dass der Konstruktor vestibuli immer zugleieh mit in Wirkung tritt. Die gekreuzten Bandel dieses letzten Muskels sind geeignet, die Spitzen der Aryknorpel aneinander zu schmiegen und soleherweise den Arywinkel zu sehliessen. Hiermit ist der vollstandige Verschluss der Glottis erreieht. Am Nasenventil fanden wir das Analogon der bis jetzt besehriebenen Muskelwirkung vor. Aueh da fanden wir im Ansehluss an die automatisehe Verengerung einen Muskelapparat, um diese noeh weiter durehzuftlhren. Wenn wir die aktive Verengerung des ~'aseneinganges naher betraehten, sehrieben wit in ,das Spiel der Nasenflagel", so sehen wit, dass der ganze untere Nasenteil an der t3ewegung teilnimmt. Am auffallendsten ist das Absteigen der Nasenfltigel und damit aueh der Nasenspitze und Septum mobile. Wit sehen, dass wir uns gleieh wie bei der Glottis gedrangt fiihlen, die Depression in erster Linie zu nennen. Denn wir haben gesehen, dass nach unserer Vorstellung der Musculus erico-thyreo~deus hauptsachlich als Depressor zu gelten hat. Wir vergleichen also diese Keblkopfmuskeln mit den Depressoren yon Nasenflagel und Septum mobile. In beiden Fallen wird die automatisch erreicbte Verengerung dureh die Depression gesichert. W i r fanden bei der Nase die Depression begleitet yon einer Kompression. Wir vermuten, dass bei der Glottis das namliche anzutreffen ist. Die Kompressoren der Glottis sind, wie wir gesehen haben, die beiden Musculi crico-arytaeno~dei laterales und der Musculus interarytaenoideus transversus. Die funktionelle ZusammengehOrigkeit dieser drei Muskeln kommt auch in ihrem Faserverlauf zum Ausdruck. Wenn der Processus musculosus keine Unterbrechung darstellte, so wllrde man die B~ndel des Transversus als eine Fortsetzung yon denen der Laterales betrachten kOnnen. In einer der Figuren yon L u s c h k a (Tar. VI Fig. 5) sieht man selbst, wie einige Fasern des Lateralis sich ohne Unterbrechung bis in den Transversus fortsetzen. Wenn dieses far alle Fasern g~lte, so warde der M. transversus im n~tmlichen Verhaltnisse stehen zu den beiden Laterales, wie an Die Glottis. 157 der Nase die Aponeurose zu ihren beidcn Kompressoren. So kon~te man den Transversus gewissermaassen als eine muskuli~se hponeurose der Laterales betrachten. Der vollkommene Glottisschluss kann nattirlich nur kurze Zeit whhren. Eine Vorrichtung ist ni~tig, die der ErSffnung wieder anstrebt. Der antagonistische Vorgang muss zeitlich in eine der Schliessung vollstiindig entgegengesetzter Reihenfolge stattfinden. Er hat also anzufangen mit der Aufhebung des letzten Aktes des Glottisschlusses. Die ErSffnung muss daher mit der Wiederherstellung des Arywinkels beginnen. Wir haben gesehen, dass es tier Konstriktor vestibuli war, der diesenWinkel aufhob, um die Spitzen der Aryknorpel nacheinander zu ziehen. Das Entgegengesetzte wird dutch den Dilatator vestibuli erwirkt. Dieser Muskel inseriert nicht am Giessbeckenknorpel selbst, sondern an tier Membrana quadrangularis, die sich an diesen Knorpel heftet. Ausnahmsweise~ jedoch nicht selten, kommt es vor, class sich si~mtliche Fasern dieses Muskels an die Konvexiti~t eines sehr flachen Sehnenbogens ansetzen, welcher zwischen der Mitte des lateralen Randes der Cartilago arytaeno'idea und des Knorpels der Epiglottis ausgespannt ist (Lus c h k a). Solcherweise wird auch die Teilnahme des Kehldeckels an der GlottiserOffnung begreiflich. Die ni~chste Aufgabe der antagonistischen Vorrichtung, nachdem der Arywinkel wieder gebildet ist, besteht in dem Auseinanderziehen der unteren Achsenpunkte. Wir brauchen dazu Muskeln, die an der lateralen Fli~che der Aryknorpel angreifen und diese lateralwarts ziehen. Hierffir kSnnen nur Btindel des Musculus thyreoarytaenoideus externus in Betracht kommen. Der verwickelte Verlauf der Fasern dieses Muskels gibt aber einer anderen Deutung seiner Wirkung Raum. Nachdem die Aryknorpel lateralwi~rts gezogen sind, ist die Wirkung des Musculus interarytaeno:ideus transversus ausgeschaltet. Die Achsen, die den Arywinkel bilden, befinden sich wieder in der Stellung wie sie in Fig. 6 angegeben ist, aber noch immer nach vorn iibergebeugt. Den virtuellen Punkt c milssen wir also als noch nach hinten yon der Ringknorpelplatte abgewichen denken. Processus ~ocales und chordae liegen noch aneinander, aber die sogenannte Glottis respiratoria ist schon formiert. Die nachste Aufgabe der ErSffnung ist die Zuri~ckfilbrung der Stimmbiinder bis in die Kadaverstellung. Diese fallt dem Musculus crico-arytaeno'ideus posticus zu. 158 P.J. Mink: Dieser Muskel, kurzweg Posticus genannt~ ist der Antagonist des Lateralis oder Glottisschliessers. Seine Kontraktion zieht den Processus museularis nach hinten und unten. Die Bewegung nach hinten kann fi'ei erfolgen und erwirkt eine Drehung des Aryknorpels, solcherweise, dass der Processus vocalis zuri]ckgedreht wird his in die Kadaverstellung. Die Bewegung nach unten ist aber nicht mi~glich, solange der Ringknorpel seine Stellung beibehiilt. Vorlitufig kann also nur yon einem Andriicken des Processus muscularis an den Ring die Rede sein. Jetzt ist die Kadaverstellung, wie wit sie friiher beschrieben haben, wieder hergestellt. Am .Nasenventil wird die ErSffnung des verkleinerten inneren l~asenloches durch die Hebung des bTasenfliigels erzwungen. Der Levator alae nasi tritt da also in der nitmlichen Rolle auf wie der Posticus an der Glottis. Wir haben deshalb bei der Yergleichung der beiden Zugi~nge zum oberen Luftraume, den Posticus als das Analogon des Nasenflagelhebers zu betrachten. Wir erwi~hnten in ,Das Spiel der Nasenfliigel" auch zwei kleine Muskelchen, den M. levator alae nasi proprius anterior und den M. levator alae nasi proprius posterior. Ihr Hauptzweck schien uns zu sein, den Nasenfltigel zu steifen und auf diese Weise die Hebung dieses Flagels als Ganzes zu fOrdern. Die Dilatation des ausseren Nasenloches, die yon diesen kleinen Muskeln erwirkt wird, kann also als eine Vorbereitung far die ErSffnung des eigentlichen Nasenzuganges aufgefasst werden. Wir kSnnen eine Parallele ziehen zwischen dieser Vorbereitung und der Bildung der Glottis respiratoria bei noch anliegenden Stimmbi~ndern. Sodann kSnnen die Dilatatoren des :Nasenflt~gels als Analoga betrachtet werden yon den Dilatatoren des Hinter endes der Stimmritze. Ob wir auch eine Muskulatur am Kehlkopfe anzunehmen haben, die in gleichem Sinne wirkt wie der Musculus procerus an tier Nase, ist fraglich. Beachtung verdient jedenfalls folgende )kusserung yon L u s c h k a : Dass abet eine eigene auf die aktive Erweiterung der oberen Kehlkopfapertur und des Cavum vestibuli berechnete Muskulatur wirklich als gesetzmi~ssige Bildung existiert~ ist schon yon C a r l L u d w i g M e r k e 1 mit gutem Grunde eingeri~umt worden. Dem seit den Arbeiten S a n t o r i n i' s als Thyreo-epiglotticus bekannten Muskel, welcher mit dem sogenannten Ary-epiglotticus yon spi~teren Autoren nach dem Vorgange Theile's als ,Reflektor epiglottidis" zusammengefasst worden ist, hat M e r k e l , wie mir scheint, mit vollem Rechte die Aufgabe zugesehrieben, die Membrana quadran- Die Glottis. 159 gularis lateralwarts zuziehen und ihn, weil er vom Schildknorpel hauptsi~chlich auf jene Grundlage der Plica ary-epiglottica tibergreift, ,,Stratum thyreo-membranosum" genannt. Die u der Muskelfasern, die unter dem Sammelnamen yon Dilatator vestibuli Laryngis zusammengefasst werden, sind ziemlich ,~erwickelt. Wenn bier ein Analogon des Procerus zu finden ist, dann kommt umgekehrt die Frage auf, ob dieser Muskel vielleicht auch als ein Dilatator vestibuli nasi zu getten hiitte. Die Beschreibung der Eriiffnung der Glottis ist jetzt bis an die Kadaverstellung fortgeschritten. Die Glottis wird in dieser Stellung festgehalten, wie wir gesehen haben, durch den Musculus cricothyreoideus. Dessen Kontraktion muss nachlassen, bevor eine weitere ErSffnung mSglich ist. Wenn dieselbe stattgefunden hat, ist die Einheit des Kehlkopfes aufgeliist, so dass wir wieder mit seinen beiden Halften zu schaffen haben. Dieser Vorgang markiert das Ende tier phonetischen und den Wiederanfang der respiratorischen Funktion des Larynx. Letztere hat aber nun Beziehung auf die Inspiration. Wirhaberi deshalb zugleich mit einer Hebung des Sternums Rechnung zu schaffen. Wenn das Brustbein aufsteigt, muss der Musculus sternothyreo'ideus dutch die Ann~therung seiner beiden Ansatzpunkte erschlaffen. Dadurch kommt der Musculus thyro-hyo~deus, der bei der vorangehenden Exspiration vielleicht etwas gedehnt war, Gelegenheit, sich zu kontrahieren. Lasst die Kontraktion der Crico-thyreo~dei nach, so kann der Schildknorpel unter dem Einflusse des Thyreohyo'ideus nach oben gezogen werden. Der Ringknorpel folgt dieser Bewegung nicht, da er bis auf eine gewisse Hiihe unabh~ngig geworden ist ~Ton der oberen Hiilfte des Kehlkopfes. Dagegen steht er unter der Herrschaft yon Trachea und Lungen, die sich mit dem Zwerchfell senken. Es ist also in der Inspirationsbewegung selbst eine doppelte Ursache enthalten fiir das Auseinanderriicken der beiden Kehlkopfh~lften. Eine Hebung des Schildknorpds bedeutet eine hShere Lage ftir die vorderen Ansatzpunkte der Stimmbi~nder. Eine Senkung des Ringknorpels bringt dagegen eine niedrigere Lage der hinteren Ansatzpunkte dieses Bandes mit sich. Vergegenwi~rtigen wir uns diesen Vorgang an Fig. 3, so ist es deutlich, dass der Winkel dbc kleiner werden muss. Die beiden Ansatzpunkte kommen dadurch mehr auf gleiche Hi,he zu liegen mit Bezug auf die Trachealachse. Wenn die Bewegung des Schildknorpels parallel an dieser Achse erfolgt, so nahern sich die A n s a t z - 1(30 P.J. Mink: punkte, so dass das Stimmband erschlaffen muss. Auch wenn der vordere Ansatz auf der Stelle bleibt, muss das Sinken der Processus vocales an sich schon diese Erschlaffung herbeift~hren, was ohne weiteres aus Fig. 5 deutlich ist. Jedenfalls dtirfen wii" annehmen, (lass dieser Processus nach dem Einsetzen der Inspiration d aufhOrt als fixer Punkt z u fungieren. Wit stellen uns den Sachbestand vor durch untenstehende Fig. 10. Absichtlich haben wir die Chordae vocales etwas gebogen iI! gezeichnet, um anzudeuten, dass dc nicht mehr als gespannt betrachtet werden muss. Die erste ~ Folge dieses Zustandes muss sein, dass c nicht mehr nach unten gezogen bleibt mit Beziehung auf a, wie es durch die Fig. 7 angegeben 1;.'.~[j wurde. E s i s t leicht begreiflich, dass beim Zuri]cksinken des Ary1 Fig. 10. knorpels auch ein Wiederaufrichten durch die elastische Befestigung stattfinden muss. Indem die Achsen dieser Knorpel solcherweise den:friiheren Stand (siehe Fig. 6) einnehmen, ngthert sich der virtuelle Punkt c wieder der Hinterfiiiche des Ringes. Zugleich mit dieser Bewegung findet aber eine andere statt. Denn wenn a (Fig. 10) sich senkt, ist das auch der Fall mit b, der Processus muscularis, der durch die vorangehende Kontraktion des Posticus am Ringknorpel angedriickt gehalten wird. Dieser Processus liegt aber niedriger als a und man muss solcherweise annehmen, dass er etwa auf gleicher H6he wie dliegt mit Bezug auf die Trachealachse. Vielleicht liegt b selbst niedriger. Das Verhi~ltnis zwischen d und b wird also gedacht werden miissen, als dasjenige, welches zwischen a' und b', oder als das, welches zwischen a" und b" in / / und ]11 yon Fig. 5 gezeichnet ist. Es leuchtet daher ein~ dass beim Senken yon b in der Richtung der Trachealachse der Abstand I zwischen b und d sich vergr6ssern muss. Da d als fix zu gelten hat, so muss b nach hinten rticken. Der Winkel bed wird gestreckt~ c muss sich um a drehen und kommt 9in k zu liegen, wenn b his in ~ zuriickgedreht ist. Wieder haben wir es mit der Kombination einer linearen Bewegung (Senkung) und einer Die GlottiS. 161 Drehung zu tun. Auch hierbei findet eine Schraubenbewegung statt~ jetzt aber der Richtung bei der Glottisschliessung entgegengesetzt. 9 Laryngoskopisch kann man die Uberzeugung gewinnen, dass bei sehr tiefen Inspirationen die Er5ffnung der Glottis so weit fortschreiten kann, dass die Stimmbiinder ganz an die Wand des Larynx angedriickt erscheinen. Bei der gewShnlichen Respiration wird aber diese Stellung bei weitem nicht erreicht. Ebensowenig findet man die Kadaverstellung, die einer tiefen Exspiration entspricht. Ftlr gewShnlich nehmen die Stimmbiinder eine Mittelstellung zwischen diesen beiden extremen Zustiinden ein. So land S e m o n , dass bei ruhiger Respiration die Glottisweite durchschnittlich beim Manne 13,5 ram, bei Frauen 11,5 mm betrug, wi~hrend die Maasse ftlr die Kadaversteilung 5 und 4 mm waren. Die Mittelstellung der Glottis ist unabhitngig yon irgendwelcher Muskelwirkung des Kehlkopfes. Sie wird ganz und gar bestimmt dutch das gegenseitige Verhaltnis der beiden Kehlkopfhtilften. 1Nur die Musculi sterno-thyreo'idei und thyreo-hyo'idei verhalten sich gewissermaassen aktiv als Folge der Hebung und Senkung des Brustbeines. Sie mtissen also zu den Respirationsmuskeln gerechnet werden. Bei der gewOhnlichen Respiration wird ihre Aktivitat sich wohl beschri~nken auf eine kleine Schwankung des Tonus. Eben die Unabhangigkeit yon Muskelwirkung macht die Glottisstellung sehr labil. Aatomatisch kann diese sich sofort den Luftdruckschwankungen anpassen, ohne dass diese mit der relativ tri~gen Kontraktion und Erschlaffung yon Muskeln zu schaffen hat. Diese leichte, selbsti~.ndige Anpassung ist yon so iiberwiegender Bedeutung fiir den KSrper, dass die auf Muskelwirkung beruhende Phonation nut sehr nebensiichlich heissen kann. Charakteristisch far den respiratorischen Kehlkopf ist seine Zweiteilung. Es ist nur zu nattlrlich, dass sich das auch in der Innervation kundgibt. Ein gemeinsamer :Nerv far beide Hi~lften ist schwerlich denkbar ohne ein fortwi~hrendes Zerren bei der funktionellen Verschiebung. Der Ringknorpel, der sich im Anschluss an den Brustinhalt bewegt, erfordert einen Nerv, der diese Bewegung ganz mitmachen kann. Der Recurrens markiert sozusagen diesen Zusammenhang mit den Brustorganen. Solcherweise litsst sich eine physiologische Basis ausfindig machen ftlr sein merkwtirdiges anatomisches Verhalten. Vom namlichen Gesichtspunkte aus scheint es uns auch begreiflich, dass die obere Kehlkopfhiilfte absonderlich innerviert wird. Ihre relative Unabhitngigkeit vindiziert einen eigenen Nerv. E. P f l i i g e r , Archiv ffir Physiologie. Bd. 123. 11 162 1). J. Mink: Die Glottis. Wie man sieht, nehmen wir eine Scheidung im Innervationsgebiete an auf Grund der Verschiedenheit in Bewegungsrichtung bei der Funktion. Wir erwarten also, dass die Muskeln, die nur Beziehung haben auf die untere Hi~lfte des Larynx yore unteren Kehlkopfnerven, und dass d i e der oberen Halfte yore Laryngeus superior versorgt werden. Dari~ber erhebt sich auch kein Zweifel. 7Nur mit Bezug auf MUskeln, die zwischen beiden Hi~lften ausgespannt sind, gibt es streitige Fragen. Am ]iebsten wi~rde man an eine Innerwtion von beiden Seiten aus glauben. Aber dieser Schematismus trifft schon beim Museulus crico-thyreoYdeus nicht zu~ da dieser yore Laryngeus superior allein versorgt wird. Viel umstritten ist die F r a g e der sensibelen Innervation des Kehlkopfes. Sie bleibt hier ausserhalb unserer Betrachtungen, da wir die Glottis nur als Klappenapparat, d. h. yon mechanischem Standpunkte aus, ins Auge fassen. Es gibt aber einen Punkt~ der erwahnt zu werden verdient, niimlich die Refiexerregbarkeit. Verschiedene Untersucher, unter denen R o s e n t h a 11) genannt werden muss, haben Reizversuche am ~. laryngeus superior angestellt. Sie fanden, dass zureichend starke elektrische Reizung der sensibeln Fasern dieses Nerven eine v011ige Erschlaffung des Zwerchfells zur Folge hatte. Wir haben also einen Refiexbogen anzunehmeni der vom oberen Kehlkopf ausgehend, im Diaphragma einen Endpunkt findet. Hier aber erfolgt Erschlaffung, d. h. also eine exspiratorische Bewegung. Nach unserer Darstellung muss diese begleitet sein von einer Verengerung d e r Glottis. Die Abwehrbewegung des Larynx, denn so muss diese refiektorische Verkleinerung der Stimmritze wohl aufgefasst werden, kommt bier also in erster Linie auf dem Wege der Atmung zustande. Auch eine sieh anschliessende phonetische Funktion des Kehlkopfes, wie z. B. der Husten, kann beschwerlich einen anderen Weg wahlen. Auf zudringliche Weise scheint uns durch diesen Reflex der enge Zusammenhang Yon Glottis- und Atembewegungen betont zu werden. N o t e : Meine abweichende Darstellung wird mOglicherweise auf Widerspruch stossen. Ich bitte darum die Herren Opponenten, mir ihre Artikel zuzuschicken~ da ich reich gerne, nach bestem Wissen, meiner Pfiicht erledigen will. 1) Rosenthal, Die Atembewegungen und ihre Beziehungen zum 5~ervus vagus. Berlin 1862.
https://openalex.org/W4390777528	https://molmed.biomedcentral.com/counter/pdf/10.1186/s10020-023-00770-y	English	null	IRF4 affects the protective effect of regulatory T cells on the pulmonary vasculature of a bronchopulmonary dysplasia mouse model by regulating FOXP3	Molecular medicine	2,024	cc-by	8,138	Zhu et al. Molecular Medicine (2024) 30:6 https://doi.org/10.1186/s10020-023-00770-y Zhu et al. Molecular Medicine (2024) 30:6 https://doi.org/10.1186/s10020-023-00770-y Molecular Medicine Open Access © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ying Zhu1†, Langyue He1†, Yue Zhu1, Huici Yao1, Jianfeng Jiang1 and Hongyan Lu1* Ying Zhu1†, Langyue He1†, Yue Zhu1, Huici Yao1, Jianfeng Jiang1 and Hongyan Lu1* Abstract Background Bronchopulmonary dysplasia (BPD) is a common chronic lung disease in preterm infants, character- ised by compromised alveolar development and pulmonary vascular abnormalities. Emerging evidence suggests that regulatory T cells (Tregs) may confer protective effects on the vasculature. Knockdown of their transcription factor, interferon regulatory factor 4 (IRF4), has been shown to promote vascular endothelial hyperplasia. However, the involvement of Tregs and IRF4 in the BPD pathogenesis remains unclear. This study aimed to investigate the regu- lation of Tregs by IRF4 and elucidate its potential role in pulmonary vasculature development in a BPD mouse model. Methods The BPD model was established using 85% hyperoxia exposure, with air exposure as the normal control. Lung tissues were collected after 7 or 14 days of air or hyperoxia exposure, respectively. Haematoxylin–eosin staining was performed to assess lung tissue pathology. Immunohistochemistry was used to measure platelet endothelial cell adhesion molecule-1 (PECAM-1) level, flow cytometry to quantify Treg numbers, and Western blot to assess vascu- lar endothelial growth factor (VEGFA), angiopoietin-1 (Ang-1), forkhead box protein P3 (FOXP3), and IRF4 protein levels. We also examined the co-expression of IRF4 and FOXP3 proteins using immunoprecipitation and immuno- fluorescence double staining. Furthermore, we employed CRISPR/Cas9 technology to knock down the IRF4 gene and observed changes in the aforementioned indicators to validate its effect on pulmonary vasculature development in mice. Results Elevated IRF4 levels in BPD model mice led to FOXP3 downregulation, reduced Treg numbers, and impaired pulmonary vascular development. Knockdown of IRF4 resulted in improved pulmonary vascular development and upregulated FOXP3 level. Conclusion IRF4 may affect the protective role of Tregs in the proliferation of pulmonary vascular endothelial cells and pulmonary vascular development in BPD model mice by inhibiting the FOXP3 level. Keywords Bronchopulmonary dysplasia, Pulmonary vascular development, Pulmonary vascular endothelial cells, Regulatory T cells, Interferon regulatory factor 4, Forkhead box protein P3 © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. Abstract If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. †Ying Zhu and Langyue He are co-first authors. Correspondence: Hongyan Lu lhy5154@163.com Full list of author information is available at the end of the article †Ying Zhu and Langyue He are co-first authors. Correspondence: Hongyan Lu lhy5154@163.com Full list of author information is available at the end of the article Background Treg transcription factor primarily involved in immu- nomodulation. Some studies have indicated that IRF4 might regulate Treg expression by acting on the FOXP3 gene (Hwang et al. 2010; Trujillo-Ochoa et al. 2023; Dominguez-Villar et al. 2018). For instance, Wenlin et al. indicated that IRF4 may be involved in the regulation of vascular intimal hyperplasia by acting on smooth muscle cells and macrophages, and the IRF4−/− mouse model can significantly promote intimal hyperplasia and contribute to angiogenesis (Cheng et al. 2017).ff g Bronchopulmonary dysplasia (BPD) is a chronic lung disease characterised by impaired alveolar and pulmo- nary vascular development. Its pathogenesis remains poorly understood and primarily affects preterm infants exposed to various prenatal or postnatal factors, includ- ing intrauterine infection, mechanical ventilation, oxygen therapy, and inflammation (Doyle et al. 2021; Gilfillan et al. 2021). Hyperoxia exposure is a significant contrib- utor to BPD, activating pro-inflammatory factors and inflammatory mediators via oxidative stress. This leads to impaired pulmonary vascular formation and branch- ing, resulting in pulmonary vascular injury and dyspla- sia, often leading to pulmonary hypertension (Jobe et al. 2001; Wang et al. 2020; Gentle et al. 2023). Severe BPD can be associated with pulmonary hypertension and associated cardiovascular diseases, leading to lifelong respiratory disease. Pulmonary vascular endothelial cells (PVECs) are an important component of pulmonary vas- culature growth and development through proliferation, migration, and tube formation. They are a primary target of oxidative stress (Zhang et al. 2019). Platelet endothe- lial cell adhesion molecule-1 (PECAM-1) serves as a proliferation marker for PVECs, while vascular endothe- lial growth factor (VEGFA) and angiopoietin-1 (Ang-1) regulate PVEC function and promote pulmonary vascu- lar development (You et al. 2020; Perrone et al. 2023; Sun et al. 2013). Nonetheless, whether Tregs offer protective effects on pulmonary vascular development in BPD model mice and whether this effect is related to immune regulation between IRF4 and FOXP3 remains unclear. In this study, we investigated the effects of Tregs and the mechanism of action of its transcription factors IRF4 and FOXP3, on both the proliferation of PVECs and pulmonary vas- cular development by establishing a hyperoxia-exposure mouse BPD model. Correspondence: Hongyan Lu lhy5154@163.com Full list of author information is available at the end of the article Correspondence: Hongyan Lu lhy5154@163.com Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine (2024) 30:6 Page 2 of 15 Zhu et al. Molecular Medicine Materials and methods Experimental animals All experimental animal protocols were reviewed by the the Experimental Animal Management and Use Commit- tee of Jiangsu University.Twenty-four C57BL/6 pregnant mice (gestation 17–18 d) were procured from the Experi- mental Animal Centre of Jiangsu University. In order to exclude the influence of sex differences on the results of the study, we chose male neonatal mice for the study. Newborn mice delivered from C57BL/6 pregnant mice, six male neonatal mice were randomly selected from each group and divided into normoxia for 7 d, hyperoxia for 7 d, normoxia for 14 d, and hyperoxia for 14 d. IRF4−/− mice were obtained from Jiangsu Jicui Pharmachem Bio-technology. Two female IRF4−/− mice and six male IRF4−/− mice were caged together, and after pregnancy was confirmed, the IRF4−/− pregnant mice (17–18 d of gestation) were housed individually, and six male neona- tal mice were randomly selected as the IRF4−/− group. Regulatory T cells (Tregs), a subset of immunosuppres- sive T cells, have shown protective effects on vasculature in conditions such as pulmonary arterial hypertension. However, the impact of Tregs on pulmonary vascu- lar development in BPD, particularly due to hyperoxia exposure, and the underlying mechanisms remain unclear (Tamosiuniene et al. 2018). Forkhead box pro- tein P3 (FOXP3), a core transcription factor of Tregs, plays a pivotal role in regulating Treg development and function (Ohkura et al. 2020). Xu et al. demonstrated that decreased FOXP3 level is associated with reduced tumour angiogenesis (Xu et al. 2020). Impaired Treg function due to reduced FOXP3 level may contribute to pulmonary vascular remodelling and subsequent pulmo- nary hypertension (Chen et al. 2023). Beyond FOXP3, various co-transcription factors also regulate Treg dif- ferentiation. Additionally, FOXP3 has been found to pro- mote pulmonary angiogenesis and development in BPD model mice and is negatively correlated with the protein level of the interferon regulatory factor 4 (IRF4), a co- transcription factor of Treg. IRF4 is broadly expressed in immune system cells and has been linked to condi- tions such as asthma, inflammatory bowel disease, and autoimmune diseases (Shi et al. 2020; Xu et al. 2012). Sequencing analyses have identified IRF4 as an important Histopathological examination of the lungsfi Paraffin-embedded lung tissues were serially sectioned at a thickness of 4 μm, stained with HE, and the morpho- logical changes were observed under the microscope. Western blot detection of VEGFA, Ang‑1, FOXP3, and IRF4 protein level in lung tissue RIPA lysate (Beijing Kangwei Century Company Bio- technology, Beijing, China), containing PMSF and pro- tease inhibitors (Shanghai Biyuntian Biotechnology, Shanghai, China) was used to extract the total proteins of the 20 mg lung lobe tissue cells of each group. Total protein concentration of about 3 μg/μL by BCA method and 10 μL total proteins were taken from each lane and subjected to sodium dodecyl sulfate–polyacrylamide gel electrophoresis(SDS-PAGE). Subsequently, the proteins were wet-transferred to a polyvinylidene fluoride mem- brane and blocked at 37 °C for 1 h with 5% skimmed milk powder. Primary antibodies, including anti-VEGFA (1:500; Abcam, Cambridge, UK), anti-Ang-1 (1:2,000; Abcam, Cambridge, UK), anti-FOXP3 (1:500; Santa Cruz Biotechnology, Santa Cruz, CA, USA), anti-IRF4 (1:1,000; Cell Signaling Technology, Danvers, MA, USA), and β-actin (1:1,000; Cell Signaling Technology, Danvers, Immunohistochemistry (IHC) detection of PECAM‑1 expression in lung tissue Mouse lung lobe tissue weighing 0.1 g was homogenised in 1 mL Non-Denaturing Lysis Buffer (Abbkine, Wuhan, China, Wuhan, China) with 1 μL Proteinase Inhibitor Cocktail (Abbkine, Wuhan, China) on ice for 5 min. Fol- lowing centrifugation at 12,000 rpm for 10 min at 4 ℃, and the total protein concentration was determined to be about 3 μg/μL by BCA method. Then, 20 μL supernatant was taken as input and added to 5 × SDS-PAGE Load- ing Buffer and boiled for 10 min. A total of 20 μL Pro- tein A/G Magnetic Beads (Abbkine, Wuhan, China) was added to each centrifuge tube and placed on the mag- netic separation rack. The supernatant was aspirated and discarded, and 1 mL 1 × Wash Buffer (Abbkine, Wuhan, China) was added to the tube. After resuspending and washing the beads three times with 1 × Wash Buffer (Abbkine, Wuhan, China), 10 μL FOXP3 antibody and 2 μL Mouse IgG (Abbkine, Wuhan, China) were added respectively. The mixture was incubated for 30 min at 25 °C with shaking. Following washing and discarding the supernatant three times, 0.25 mL protein supernatant was added and incubated overnight at 4 °C. Then, 30 μL 1 × SDS-PAGE Loading Buffer was added, and the mix- ture was heated at 100 °C for 5 min. After centrifugation at 800 rpm for 1 min, the supernatant was collected for Western Blotting. Lung lobe tissue sections at each time point for each group were routinely processed for antigen retrieval, endogenous peroxidase blocking, bovine serum albumin(BSA) closing, and incubated with rabbit-derived primary antibody anti-PECAM-1 (1:300; Abcam, Cam- bridge, UK), followed by secondary anti-IgG (1:200; Abcam, Cambridge, UK). Staining was performed with DAB, counterstained with haematoxylin, and dehydrated to seal the sections. Three non-overlapping areas were independently selected by two senior pathologists in each group, totalling six non-overlapping areas. Analy- sis was performed using the Image J acquisition system: brownish-yellow particles in the cells were taken as posi- tive staining, and the positive cell integral optical density value was recorded as the PECAM-1 content of that lung tissue specimen. The pulmonary vascular density was cal- culated as follows: pulmonary vascular density (%) = the area occupied by the endothelial cells of the lung tissue immunostained positively for PECAM-1/the total area of the lung parenchyma cells × 100% (Hussnain and Shi 2021). BPD model construction and grouping Using hyperoxia exposure to simulate the BPD model, mice were randomly divided into an air control group and a hyperoxia group. The hyperoxia group was placed in an oxygen tank with 85% oxygen concentration, while the control group was exposed to atmospheric air in the same room. To prevent oxygen toxicity and eliminate the influence of surrogate lactating mothers, surrogate moth- ers were swopped between the air and hyperoxia groups every 12 h. The conditions of the mice and mothers were monitored and recorded daily (Yao et al. 2023). At 7 d and 14 d after respective exposures, six mice in each group were anaesthetised, tracheal intubated, fixed in situ with Page 3 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine MA, USA) were added respectively, and incubated at 4 °C overnight. After washing the membrane, secondary anti- body IgG (1:5000; Immunoway, Plano, Texas, USA) was added, and the membrane was incubated at 37 °C for 1 h. Enhanced chemiluminescence was used for visualisation. The relative level of the target protein was determined as the ratio of the grey value of the target protein to the β-actin band. 4% paraformaldehyde intratracheal injection for 10 min, and the lung lobe tissue was removed. The lung lobe tis- sue was stored in the refrigerator at − 80 °C and used for related experimental studies. Immunofluorescence double staining detection of IRF4 and FOXP3 co‑localisationi After fixing mouse lung tissue with 4% paraformalde- hyde, paraffin-embedded, serial slices were cut at a thick- ness of 4 μm, and the slices were baked at 60 ℃ for 1 h. The slices were deparaffinized by means of xylene and gradient alcohols, and antigenic repair was performed by the high-pressure method. Then the endogenous peroxidase activity was blocked by incubation with 3% H2O2 at room temperature for 10 min.The sections were incubated with 5% BSA for 20 min for blocking and then washed 3 times with phosphate buffer solution (PBS) for 5 min/session. Next, they were incubated with two anti- bodies, anti-FOXP3 (1:200;Santa Cruz Biotechnology, Santa Cruz, CA, USA) and anti-IRF4 (1:100;Cell Signal- ing Technology, Danvers, MA, USA), overnight at 4 °C. Page 4 of 15 Page 4 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine The sections were allowed to warm up at 37 °C for 30 min the following day, and then incubated with secondary antibodies mouse IgG and rabbit IgG (1:1,000; Abcam, Cambridge, UK) for 1 h. After washing with PBS three times, the sections were stained with DAPI (Abbkine, Wuhan, China) for nuclei visualisation. Immunofluores- cence staining was observed using a fluorescence micro- scope. Red fluorescence indicated positive expression of FOXP3, green fluorescence indicated positive expression of IRF4, and blue fluorescence represented DAPI-labelled nuclei. Co-localisation of FOXP3 and IRF4 was depicted in orange. the IRF4 gene structure were selected as the knockdown region, which contains a 421 bp coding sequence. Knock- down of this region results in disruption of protein func- tion. Based on available MGI data, purebred mice with disruption of this gene exhibited abnormalities in the immune system, including T and B cell development, and have altered susceptibility to bacterial and viral infec- tions. They also demonstrate impaired thermogenic gene expression and energy expenditure. IRF4−/− male and female mice were mated in a 3:1 ratio within combined cages. After confirming pregnancy, mice delivered from IRF4−/− pregnant mice (16–17 d of gestation) and C57BL/6 pregnant mice (16–17 d of ges- tation) were divided into IRF4−/− and C57 groups. Both groups were placed in an oxygen chamber with the oxy- gen concentration maintained at 85%, and surrogate lac- tating females were changed every 12 h. The mice were exposed to high oxygen for 14 d following exposure. Fig. 1 Impaired pulmonary vascular development in BPD model mice, with increased IRF4 and decreased FOXP3 protein levels and number of Tregs. A BPD model simulated using hyperoxia exposure, and mouse lung tissues taken at 7 d and 14 d after air or hyperoxia exposure, respectively. B HE staining to observe the morphology of mouse lung tissues (× 400; scale bar, 50 μm). Black arrows refer to thickened alveolar septa, red arrows refer to fused and enlarged alveolar lumina. C IHC of PECAM-1 level in mouse lung tissues (× 400; scale bar, 50 μm). D Western blot of VEGFA, Ang-1, FOXP3, and IRF4 protein levels in mouse lung tissue. E Flow cytometry to detect the number of Tregs and the expression of IRF4 and FOXP3 in the lung tissues of the mice. F Pearson correlation analysis to derive a positive correlation between the number of Tregs and the level of PECAM-1 (r = 0.730). Data are expressed as mean ± SD. n = 6. Significant differences are indicated by p < 0.05 (i g p g ) Flow cytometry for measuring Treg count as well as IRF4 and FOXP3 transcription factor expression in lung tissue p p g Mouse lung lobe tissue weighing 40 mgwas taken from each group at each time point. The tissue was rinsed with PBS, mechanically sheared, ground, and then passed through a 70 μm cell filter. After erythrocytes lysis using ammonium-chloride-potassium lysis buffer (Leagene, Beijing, China, Beijing, China), the cell suspension from a single mouse was used for T-lymphocyte isolation with a mouse organ tissue lymphocyte isolation solu- tion kit (Solarbio, Beijing, China). The isolated cells were washed with PBS, centrifuged, and stained with surface antibodies using PE anti-cluster of differentiation 4(CD4) (Thermo Fisher Scientific, Waltham, MA, USA), APC anti-cluster of differentiation 25(CD25) (Thermo Fisher Scientific), and PE-cy7 anti-IRF4 (Cell Signaling Tech- nology, Danvers, MA, USA) for 45 min. After that, the cells were fixed and permeabilised with a cell-fixing and permeabilisation reagent for 1 h. Subsequently, intranu- clear cytokine AF488 anti-FOXP3 (Thermo Fisher Sci- entific, Waltham, MA, USA) staining was performed. Cells labelled as CD4+ CD25+ FOXP3+ were identi- fied as Tregs, and their expression was assessed using flow cytometry (BD FACS Canto; BD, Franklin Lake, NJ, USA). Flow Jo v10 (BD) software was used for data analysis. Immunofluorescence double staining detection of IRF4 and FOXP3 co‑localisationi At 14 d after exposure to hyperoxia, lung tissues from six mice in each group were used for subsequent experimen- tal studies. Statistical analyses b Data were subjected to statistical analysis using Graph- Pad Prism v8.0 (GraphPad Software, San Diego, CA, USA). Measurement information was expressed as mean ± standard deviation(SD), and a t-test was used for comparison between the two samples. The correlation between the two samples was analysed by Pearson cor- relation analysis. A p-value less than 0.05 was considered statistically significant. Impaired pulmonary vascular development in BPD model mice, along with decreased Treg and FOXP3 expression and increased IRF4 expressionh The BPD model was established by hyperoxia expo- sure (Fig. 1A). HE staining results showed that lung tis- sues from the hyperoxia group, compared to the control group at corresponding time points, displayed struc- tural disorganisation, thickened lung septa, enlarged and fused alveoli with a reduced number and varying sizes. These findings were consistent with classical BPD (See figure on next page.) Fig. 2 IRF4 inhibited the expression of FOXP3. A Co-IP detection of IRF4 and FOXP3 co-expression in lung tissues. B Immunofluorescence double staining detection of IRF4 and FOXP3 co-localisation (× 400; scale bar, 50 μm). Red fluorescence indicated positive expression of FOXP3, green fluorescence indicated positive expression of IRF4, and blue fluorescence represented DAPI-labelled nuclei. Co-localisation of FOXP3 and IRF4 was depicted in orange. C Pearson correlation analysis to show a negative correlation between IRF4 and FOXP3 protein level (r = − 0.846). Data are expressed as mean ± SD. n = 6. Significant differences are indicated by p < 0.05 Construction and grouping of IRF4−/− miceh The CRISPR/Cas9 technology was used to knock down the IRF4 gene. Exons 3–5 of the Irf4-201 transcript in Page 5 of 15 (2024) 30:6 hu et al. Molecular Medicine (2024) 30:6 ine (2024) 30:6 Zhu et al. Molecular Medicine nd on previous page.) Fig. 1 (See legend on previous page.) Fig. 1 (See legend on previous page.) Page 6 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine Fig. 1 continued Fig. 1 continued Fig. 1 continued Page 7 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Fig. 1 continued Fig. 1 continued group compared to the control group, aligning with the trend in Treg levels (Fig. 1D).l pathological characteristics, confirming the success of the model (Fig. 1B). IHC results indicated a decrease in PECAM-1-positive cell integral optical density and pul- monary vascular density in the hyperoxia group (Fig. 1C). Furthermore, Western blot results showed significantly reduced protein levels of VEGFA and Ang-1 in the lung tissues of hyperoxia-exposed mice at 7 d and 14 d postna- tally compared with the control group (Fig. 1D). We used both flow cytometry and Western blot to detect IRF4 quantity and protein level. Flow cytometry results demonstrated an increase in IRF4 counts at all time points in the hyperoxia group compared with the control group at the corresponding time points (Fig. 1E). Similarly, Western blot results indicated significantly higher IRF4 protein levels in the lung tissues of the hyperoxia group compared to the control group at the same time points (Fig. 1D), confirming upregulation of IRF4 in the BPD model mice. To investigate whether the Treg counts changed in the BPD model mice, we used flow cytometry. The results showed a decrease in Treg numbers at all time points in the hyperoxia group compared to the control group at the corresponding points (Fig. 1E). Moreover, changes in Treg number were consistent with trends observed in the PECAM-1 mean integral optical density values and the protein levels of VEGFA and Ang-1. To further clarify whether Tregs were related to the proliferation of PVECs, correlation analysis further indicated a positive relation- ship between Treg numbers and PECAM-1 expression (Fig. 1F). Knockdown of IRF4 increased FOXP3 expression and Treg numbers and reduced hyperoxia‑induced impaired pulmonary vascular development and lung injuryf To determine whether IRF4 affected FOXP3 level and Treg proliferation in BPD model mice, we employed CRISPR/Cas9 technology to knock down the IRF4 gene (Fig. 3A). Both C57 mice and IRF4−/− mice were exposed to hyperoxia for 14 d (Fig. 3B). Western blot results dem- onstrated a significant increase in FOXP3 protein level in the lung tissues of IRF4−/− mice compared with C57 mice (Fig. 3C). Furthermore, flow cytometry results showed an increased Treg count in the lung tissues of IRF4−/− mice compared with C57 mice (Fig. 3D).f PVECs play a decisive role in pulmonary angiogen- esis and contribute to the endothelial barrier function. The pulmonary vasculature actively promotes alveolar growth during lung development, which helps to main- tain alveolar structure and promote lung development (Surate et al. 2017). However, hyperoxia exposure can lead to oxidative stress in PVECs, resulting in cellu- lar oedema, dysfunction, and reduced survival and growth (Zhang et al. 2018). PECAM-1 is an abundant endothelial cell surface receptor that is highly enriched at endothelial cell junctions and mediates the prolif- eration and migration of PVECs. Therefore, we chose PECAM-1 to assess the status of PVECs and vascular development according to previous researchs(Hennigs et al. 2021; Liao et al. 2018; Lertkiatmongkol et al. 2016).. In this study, we observed decreased PECAM-1 protein level and reduced pulmonary vascular den- sity in the lung tissues of BPD model mice exposed to hyperoxia. This suggests that hyperoxia inhibits PVEC proliferation, impacting pulmonary vascular develop- ment and vascularisation. VEGFA, a potent PVEC- specific mitogen and survival factor, promotes PVEC proliferation and differentiation, thereby facilitating pulmonary vasculature growth and remodelling. It serves as a key regulator of early pulmonary vascular development, contributing to neonatal hyperoxic lung injury (Wiszniak et al. 2021). Additionally, Ang-1, a vascular growth factor acting specifically on PVECs, cooperates with VEGFA to induce neonatal pulmonary vascularisation in vivo and maintain vascular stabil- ity (Kamp et al. 2022). In the present study, we found significant reductions in VEGFA and Ang-1 protein levels in the lung tissues of mice exposed to hyperoxia compared to those in the control group. Fig. 3 IRF4−/− mice with increased FOXP3 level and Treg numbers show reduced pulmonary vascular dysplasia and lung injury. A Demonstration of gene ablation.In this project we use CRISPR/Cas9 technology to modify IRF4 gene. The IRF4 gene has 3 transcripts. According to the structure of IRF4 gene, exon3-ex on5 of IRF4-201(ENSMUST00000021784.9) transcript is recommended as the knockout region.The region contains 421 bp coding sequence. Knock out the region will result in disruption of protein function. B C57 and IRF4.−/− mice exposed to hyperoxia for 14 d. Mouse lung tissues are used for experiments. C Western blot of VEGFA, Ang-1 and FOXP3 protein levels in mouse lung tissues. D Flow cytometry of the number of Tregs and FOXP3 level in mouse lung tissues. E HE staining of the morphology of mouse lung tissues (× 400; scale bar, 50 μm). Black arrows refer to alveolar septa, red arrows refer to alveolar lumina. F IHC of PECAM-1 level in mouse lung tissue (× 400; scale bar, 50 μm). Data are expressed as mean ± SD. n = 6. Significant differences are expressed as *p < 0.05 (See figure on next page.) Knockdown of IRF4 increased FOXP3 expression and Treg numbers and reduced hyperoxia‑induced impaired pulmonary vascular development and lung injuryf This reduc- tion in VEGFA and Ang-1 protein levels could hinder PVEC migration and tube formation, thus impeding pulmonary vasculature development under hyperoxia To study the effect of IRF4 knockdown on pulmonary vascularity and lung development in hyperoxia-induced mice, we conducted HE staining on lung tissues from IRF4−/− mice exposed to hyperoxia for 14 d. Results showed that IRF4−/− mice exhibited smaller alveolar lumens, increased alveolar number, thinner septa, and improved lung histopathology compared to C57 mice at the same time point (Fig. 3E). Additionally, IHC results showed elevated PECAM-1-positive cell integral opti- cal density values and pulmonary vascular density in the lung tissues of IRF4−/− mice (Fig. 3F). These observa- tions agree with the Western Blot data (Fig. 3C), wherein increased expression of angiogenesis-related proteins was noted. IRF4 inhibited FOXP3 level To investigate whether there were interactions between IRF4 and FOXP3, we conducted experiments on mouse lung tissues exposed to hyperoxia for 14 d. Immunopre- cipitation results confirmed protein interactions between IRF4 and FOXP3 (Fig. 2A). Additionally, immunofluo- rescence results also showed partial co-localisation of FOXP3 and IRF4 (Fig. 2B). Flow cytometry and Western blot results indicated that IRF4 protein level increased, while FOXP3 level decreased in the hyperoxia group. Correlation analysis further demonstrated a negative cor- relation between the IRF4 protein level and the FOXP3 level (Fig. 2C), suggesting that IRF4 inhibited the FOXP3 protein level. To determine whether the level of FOXP3 correlated with Treg numbers, flow cytometry was used to detect FOXP3 counts. The results indicated a decrease in FOXP3 factors at all time points in the hyperoxia group compared to the control group at the same time points (Fig. 1E). Western blot results also showed reduced FOXP3 protein levels at all time points in the hyperoxia Page 8 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine Fig. 2 (See legend on previous page.) Fig. 2 (See legend on previous page.) Fig. 2 (See legend on previous page.) Fig. 2 (See legend on previous page.) Page 9 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine Knockdown of IRF4 increased FOXP3 expression and Treg numbers and reduced hyperoxia‑induced impaired pulmonary vascular development and lung injuryf BPD model through hyperoxia exposure. The observed changes in lung histomorphology, such as pulmonary septal thickening, alveolar simplification, and varia- tions in size, were consistent with classical BPD pathol- ogy, confirming the success of our model(Pozarska et al. 2017). Discussion BPD is a chronic lung disease commonly observed in preterm infants, characterised by vascularisation disor- ders and pulmonary vascular dysplasia. Preterm infants are highly susceptible to neonatal respiratory distress syndrome (NRDS) due to imperfect lung development, and hyperoxia therapy is an important means of treat- ing NRDS. Due to the immaturity of antioxidant defence mechanisms, preterm infants are highly susceptible to oxidative stress in the lung, leading to oxidative damage (Kalikkot et al. 2017). In addition to pulmonary lesions, hyperoxia therapy is also an important cause of pulmo- nary hypertension and retinopathy in preterm infants, as well as lesions in other systemic systems (Green et al. 2023). In this study, we successfully established a mouse (2024) 30:6 Page 10 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine Fig. 3 (See legend on previous page.) Fig. 3 (See legend on previous page.) Fig. 3 (See legend on previous page.) Page 11 of 15 (2024) 30:6 Zhu et al. Molecular Medicine (2024) 30 Zhu et al. Molecular Medicine Fig. 3 continued Fig. 3 continued Fig. 3 continued Fig. 3 continued of mice exposed to hyperoxia, suggesting that hyper- oxia inhibits Treg proliferation. Treg count was posi- tively correlated with PECAM-1 protein level. The Treg and PECAM-1 expression are not close to 1. It may be related to the fact that multiple other factors are involved in BPD vascular endothelial injury together with Treg, such as endothelial progenitor cells, placen- tal growth factor, and Ang-1/Tie-2 pathway. In previous studies, we found that M2 macrophages enrichment may have an important role in LPS induced BPD model mice by regulating type 2 immune responses (Mi et al. 2020). Research has found that Treg enhances auto- crine signalling in macrophages by stimulating the production of IL-10 thereby causing inflammation to subside(Proto et al. 2018). However, it is unclear exposure conditions. Sudhadevi et al. found that a decrease in Ang-1 protein level was associated with the activity of PVECs and the impairment of alveolisation both in vitro and in mice (Sudhadevi et al. 2021). There- fore, together with our results, it is suggested that the decrease in VEGFA and Ang-1 protein levels, related to the proliferation of PVECs, represents impaired pulmo- nary vascular development under hyperoxia exposure. Discussion Tregs are a group of T cells with immunosuppressive functions that play a crucial role in immune activation and developmental control of tissue damage in pre- term infants (Pagel et al. 2020). Tregs have protective effects against PVECs in diseases such as pulmonary hypertension (Tamosiuniene et al. 2011). Our study revealed a decrease in Treg numbers in the lung tissues Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine (2024) 30:6 Page 12 of 15 Page 12 of 15 IRF4, a member of the IRF family, primarily expressed in immune cells, serves as a co-transcription factor for Tregs. It plays roles in various immune functions, including cell development, differentiation, prolifera- tion, and apoptosis, as well as the regulation of intrinsic and adaptive immune responses induced by pathogens (Nam et al. 2016). IRF4 is involved in the pathological process of a variety of inflammatory diseases, including the promotion of interleukin(IL)-6 production in inflam- matory bowel disease, which induces STAT3 expres- sion in T lymphocytes to promote apoptosis followed by intestinal inflammation (Zhu et al. 2016). Furthermore, IRF4 deficiency reduces inflammation and renal fibro- sis following acute kidney injury induced by folic acid (Sasaki et al. 2021). Studies have also shown that IRF4 is involved in regulating immune responses such as oxida- tive stress in the lungs, and lung intrinsic lymphocytes depend on IRF4 to exert pro-inflammatory effects. For instance, IRF4 knockdown in mice markedly attenuates pro-inflammatory responses in response to external envi- ronmental stimuli, suggesting the involvement of IRF4 in inflammatory responses in the lungs (Liu et al. 2018). In addition, IRF4 can be expressed in vascular smooth mus- cle cells, regulating vascular wall integrity and functions. whether there is an interaction between Treg and mac- rophages in hyperoxia induced BPD, which requires further research. Moreover, Treg count was consistent with the trends observed in VEGFA and Ang-1 protein levels. This indicates that Tregs may protect the pul- monary vasculature by promoting PVEC proliferation. Thus, the impaired pulmonary vasculature develop- ment in BPD model mice may be linked to the attenu- ated protective effect of Tregs. pf g FOXP3, a nuclear transcription factor, is an impor- tant marker for Tregs (along with other classical mark- ers such as CD4+, CD25+, and FOXP3+), which exert their immunosuppressive functions under its control (Wang et al. 2020). Kurebayashi et al. Funding g This research was funded by the National Natural Science Foundation of China (82171702) and the Natural Science Foundation of Jiangsu Province (BK20201226). Acknowledgements We thank the Animal Center of Jiangsu University for providing valuable input on the establishment of the BPD animal model and the Laboratory of Cardiol- ogy, Affiliated Hospital of Jiangsu University for technical support. We also thank Bullet Edits Limited for the linguistic editing and proofreading of the manuscript, and Figdraw software because the mechanism diagram is drawn by Figdraw (www.figdraw.com). In this study, we focused on the protective effect of IRF4 on the pulmonary vasculature through the regu- lation of FOXP3 affecting Treg in BPD model mice. However, there may be some limitations in this experi- ment. We were unable to co-culture Treg with PVECs or deplete Treg at the cellular level to observe functional changes such as proliferation and migration of PVECs. In addition, the experimental approaches have been per- formed in lung, as an organ, and therefore exposed to multiple systemic signals, which control tissue response. In the future, using lung organoid model to study the cellular and molecular regulatory mechanisms in BPD, understanding the interactions among multiple lung cells, can better reveal the pathological and physiological processes of the disease. Discussion demonstrated that antagonism of FOXP3 expression in tumour vas- culature decreases vascular density (Kurebayashi et al. 2021). Another study showed that in pulmonary hyper- tension, FOXP3 has also been associated with promot- ing pulmonary angiogenesis and development (Tian et al. 2021). Our study revealed consistent FOXP3 pro- tein level and Treg proliferation in both control and hyperoxia-exposed C57 mice, suggesting that the pro- tective effects of Tregs on the pulmonary vasculature are mediated through FOXP3. Fig. 4 Mechanism diagram. Hyperoxia increases IRF4 levels and affects the protective effect of Tregs on the proliferation of PVECs and pulmonary vascular development by inhibiting FOXP3 levels, which ultimately leads to impaired pulmonary vascular development and BPD Fig. 4 Mechanism diagram. Hyperoxia increases IRF4 levels and affects the protective effect of Tregs on the proliferation of PVECs and pulmonary vascular development by inhibiting FOXP3 levels, which ultimately leads to impaired pulmonary vascular development and BPD Fig. 4 Page 13 of 15 Page 13 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine (2024) 30:6 In our hyperoxia-induced BPD model, we observed sig- nificantly increased IRF4 protein levels in lung tissues, especially after 14 vs. 7 days of hyperoxia exposure. This suggests that upregulation of IRF4 may be involved in BPD development. Conclusion In summary, our findings suggest that reduced PVEC proliferation and impaired pulmonary vascular devel- opment in hyperoxia-induced BPD model mice may be associated with IRF4’s inhibitory effect on FOXP3. Knocking down IRF4 can regulate FOXP3 and Tregs, improving lung development and mitigating impaired lung vascular development. This offers a new strategy for potential clinical treatments of BPD. p FOXP3 and IRF4, as two co-transcription factors of Tregs, are jointly involved in the signalling pathway to regulate their expression. It has been observed that FOXP3 is significantly upregulated in IRF4−/− Th cells cultured in the co-presence of IL-21 and transforming growth factor-β (Huber et al. 2008). Decreased FOXP3 expression and enhanced IRF4 expression were also detected in a mouse model of allergic asthma (Übel et al. 2014). On this basis, we also investigated the interac- tion between IRF4 and FOXP3 in the lung tissues of BPD model mice. We found a significant negative correlation between IRF4 and FOXP3 protein levels, suggesting that IRF4 exerts an inhibitory effect on FOXP3. This inhibi- tion may influence the protective effect of Tregs on PVEC proliferation and pulmonary vascular development, con- tributing to BPD development (Fig. 4). Abbreviations BPD Bronchopulmonary dysplasia PVECs Pulmonary vascular endothelial cells PECAM-1 Platelet-endothelial cell adhesion molecule 1 VEGFA Vascular endothelial growth factor A Ang-1 Angiopoietin-1 Tregs Regulatory T cells FOXP3 Forkhead box protein P3 IRF4 Interferon regulatory factor 4 HE Haematoxylin–eosin IHC Immunohistochemistry BSA Bovine serum albumin SDS-PAGE Sodium dodecyl sulfate–polyacrylamide gel electrophoresis Co-IP Co-immunoprecipitation IF Immunofluorescence PBS Phosphate-buffered saline DAPI 4′,6-Diamidino-2-phenylindole CD4+ Cluster of differentiation 4-positive CD25+ Cluster of differentiation 25-positive CRISPR/Cas9 Clustered regularly interspaced short palindromicrepeats/ CRISPR-associated protein 9 SD Standard deviation IL Interleukin NRDS Neonatal respiratory distress syndrome g p g To explore this further, we used CRISPR/Cas9 tech- nology to knock down the IRF4 gene in mice and con- ducted hyperoxia exposure experiments. Knocking down IRF4 resulted in increased FOXP3 protein level, pro- moting Treg proliferation. Additionally, IRF4−/− mice exposed to hyperoxia exhibited improved lung histopa- thology, enhanced lung structure organisation, increased PECAM-1 protein level, higher lung vascular density, and elevated levels of angiogenesis-related proteins VEGFA and Ang-1. These results indicate that IRF4 knockdown mitigates lung injury and impaired lung vascular devel- opment under hyperoxia conditions.f Author contributions ZYing, HLY and ZYue conceived and designed the work. ZYing, HLY and JJF were expected to have made substantial contributions to the the acquisition, analysis and interpretation of data. ZYing, HLY and YHC made the creation of new software used in the work. ZYing and LHY drafted the work and sub- stantively revised it. All authors have read and approved the final submitted manuscript. References Chen CN, Hajji N, Yeh FC, Rahman S, Ali S, Wharton J, et al. 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Rapid depletion of intratumoral regulatory T cells induces synchronized CD8 T and NK cell activation and IFN-γ-dependent tumor vessel regression. Cancer Res. 2021;81(11):3092–104. Wiszniak S, Schwarz Q. Exploring the intracrine functions of VEGF-A. Biomol- ecules. 2021;11(1):128. Xu WD, Pan HF, Ye DQ, Xu Y. Targeting IRF4 in autoimmune diseases. Autoim- mun Rev. 2012;11(12):918–24. Lertkiatmongkol P, Liao D, Mei H, Hu Y, Newman PJ. Endothelial functions of platelet/endothelial cell adhesion molecule-1 (CD31). Curr Opin Hematol. 2016;23(3):253–9. Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information files. Page 14 of 15 Page 14 of 15 Zhu et al. Molecular Medicine (2024) 30:6 Zhu et al. Molecular Medicine Received: 4 October 2023 Accepted: 12 December 2023 Pozarska A, Rodríguez-Castillo JA, Surate Solaligue DE, Ntokou A, Rath P, Mižíková I, et al. Stereological monitoring of mouse lung alveolarization from the early postnatal period to adulthood. Am J Physiol Lung Cell Mol Physiol. 2017;312(6):L882–95. Declarations Liao D, Mei H, Hu Y, Newman DK, Newman PJ. CRISPR-mediated deletion of the PECAM-1 cytoplasmic domain increases receptor lateral mobility and strengthens endothelial cell junctional integrity. Life Sci. 2018;193:186–93. Consent for publication Not applicable. Nam S, Lim JS. Essential role of interferon regulatory factor 4 (IRF4) in immune cell development. Arch Pharm Res. 2016;39(11):1548–55. Nam S, Lim JS. Essential role of interferon regulatory factor 4 (IRF4) in immune cell development. Arch Pharm Res. 2016;39(11):1548–55. Ethics approval and consent to participate Ethics approval and consent to participate The experimental procedures and animal use plan were approved by the Experimental Animal Management and Use Committee of Jiangsu University (approval number: UJS-IACUC-AP-2020030304). 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Baicalin ameliorates experimental inflammatory bowel disease through polarization of macrophages to an M2 phenotype. Int Immunopharmacol. 2016;35:119–26. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. • fast, convenient online submission • thorough peer review by experienced researchers in your ﬁeld • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year • At BMC, research is always in progress. Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? 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https://openalex.org/W3080843541	https://www.epj-conferences.org/10.1051/epjconf/202023810002/pdf	English	null	Temperature wave-like oscillations on ultra-short and ultra-fast time scales -INVITED	EPJ web of conferences	2,020	cc-by	1,132	Temperature wave-like oscillations on ultra-short and ultra-fast time scales -INVITED Gandolfi Marco1,2, Benetti Giulio3, Glorieux Christ1, Giannetti Claudio2, Banfi Francesco4,* 1Laboratory of Soft Matter and Biophysics, Department of Physics and Astronomy, KU Leuven, Celestijnenlaan 200D, B-3001 Leuven, Belgium 2Interdisciplinary Laboratories for Advanced Materials Physics (I-LAMP) and Dipartimento di Matematica e Fisica, Università Cattolica del Sacro Cuore, Via Musei 41, 25121 Brescia, Italy 3Department of Pathology and Diagnostics – Medical Physics Unit, Azienda Ospedaliera Universitaria Integrata – Verona, P.le Stefani, 1, 37126 Verona, Italy 4Université de Lyon, Institut Lumière Matière (iLM), Université Lyon 1 and CNRS, 10 rue Ada Byron, 69622 Villeurbanne cedex, France. Abstract. Recent findings in the frame of temperature wave-like oscillations on the ultra-short, ultra-fast time scales in solid states devices are here reviewed. The possibility for wave-like temperature oscillations are investigated at the light of the pass-band characteristic in w-k space for the temperature scalar field. The bandpass filter characteristics are accessed in terms of the heat carriers scattering times. The concepts here reviewed are of interest for perspective design of novel thermal nano-devices. 1 Introduction , where α = k0 C ⁄ is the thermal diffusivity. The hyperbolic equation encompasses wave-terms (first two- terms) with damping (last two terms). The parabolic case is retrieved on “long” time scales when the second and third terms dominate. Coherent control of wave-like phenomena is driving a technological revolution in fields ranging from electronics, photonics, to phononics 1. Recently a user-friendly, intuitive approach [4] has been proposed to investigate under which conditions the temperature propagation safeguards coherent (wave-like) effects. This is achieved calculating the complex dispersion relation, f(k, ω) = 0, for the hyperbolic equation linking the wave vectors k to the angular frequency ω. Specifically, the case ω ∈ℂ and k ∈ℝ describes the physical situation of a temperature pulse propagating in the material, where the real part ω> = ℛe(ω) is an oscillation angular frequency, whereas the imaginary part ωK = ℑm(ω) has the physical meaning of damping. Wave-like oscillations are sustained provided the quality factor Q = ω> ωK ⁄ > 1. Materials sustaining temperature waves on short timescales are addressed, in the current work as Temperonic materials. Although temperature has been historically taken as the paradigmatic example of an incoherent field, undergoing diffusive as opposed to wave-like propagation, on short space and time scales the Fourier law fails and the possibility for temperature wave propagation sets in (1) The ultimate goal is to devise materials exploiting the wave nature of the temperature scalar field arising in the non-Fourier heat transport regime. We here review recent progress made in this context [4-6] 2 Discussion The Dual Phase Lag (DPL) model (2) has been introduced to correct for the instantaneous onset of the heat flux, q, upon establishment of a thermal gradient, ∇T, entailed in Fourier law. The DPL model generalizes earlier attempts – made by Cattaneo (1958) and Vernotte (1962) – to correct this pitfall by introducing causality between the cause ∇T (q), and the effect, q (∇T): In general a material can sustain the following dynamics: (i) overdamped, Q < 1, (no transient temperature oscillations sustained) when q is the cause (τ0/τ+ > 1) (ii) either over, critically or underdamped when ∇T is the cause (τ0/τ+ < 1), the best case scenaro to observe transient temperature wave- behaviour being τ0/τ+ = 0 (Cattaneo-Vernotte limit). q%x, t+τ+, = −k0∇T(x, t+τ0) (1) (1) (1) The complex-valued ω −k dispersion relation is investigated for the cases of a localised temperature pulse in space, linking the temperature wave angular frequencies ω and wave vectors k. The modal Q-factor allows discerning which temperature oscillations modes are practically accessible and allows inspecting the material as a frequency filter for the propagation of temperature oscillations. The optimal region in parameters space is discussed in a variety of systems, ranging from graphite to quantum materials [4-6]. In cases where τ+ < τ0 the heat flux is the cause, whereas if τ+ > τ0 the temperature gradient is the cause. Coupling the DPL with thermal energy conservation, the well- known heat diffusion equation (parabolic) is modified into a hyperbolic one: 5 67 8 9 :;0 :<; − :;0 :=; + 5 > 89 :0 :< −τ0 :?0 :=; :< = 0 (2) (2) EPJ Web of Conferences 238, 10002 (2020) EPJ Web of Conferences 238, 10002 (2020) EPJ Web of Conferences 238, 10002 (2020) EOSAM 2020 https://doi.org/10.1051/epjconf/202023810002 © The Authors, published by EDP Sciences. This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (http://creativecommons.org/licenses/by/4.0/). DP Sciences. This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 ses/by/4.0/). * Corresponding author: francesco.banfi@univ-lyon1.fr © The Authors, published by EDP Sciences. This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (http://creativecommons.org/licenses/by/4.0/). © The Authors, published by EDP Sciences. This is an open access article distributed under the terms of the Creative (http://creativecommons.org/licenses/by/4.0/). EPJ Web of Conferences 238, 10002 (2020) EPJ Web of Conferences 238, 10002 (2020) EOSAM 2020 https://doi.org/10.1051/epjconf/202023810002 2 Conclusions This presentation applies an easy-to-adopt analytical means to inspect the optimal conditions to observe temperature wave oscillations. The idea parallels the approach successfully employed in solid state physics and optics to investigate electronic wavefunction and electromagnetic wave propaga- tion in solid state devices. The calculations are applied in a variety of systems of technological interest. The present discussion is of relevance in view of engineering nanoscale thermal devices operating on ultra-fast and ultra-short time scales 1. M. Wegener, Science 342, 939 (2013) 2. M. Maldovan, Nature 503, 209 (2013) 3. D.Y. Tzou, Macro-to Microscale Heat Transfer: The Lagging Behavior (John Wiley & Sons, 2014) 4. M. Gandolﬁ, G. Benetti, C. Glorieux, C. Giannetti, and F. Banﬁ, Int. J. Heat Mass Transf. 143, 118553 (2019) 5. M Gandolfi, G L Celardo, F Borgonovi, G Ferrini, A Avella, F Banfi and C Giannetti, Phys. Scr. 92, 034004 (2017) 6. S. Huberman, R.A. Duncan, K. Chen, B. Song, V. Chiloyan, Z. Ding, A.A. Maznev, G. Chen, K.A. Nelson, Science 364, (2019) References 1. M. Wegener, Science 342, 939 (2013) 2. M. Maldovan, Nature 503, 209 (2013) 3. D.Y. Tzou, Macro-to Microscale Heat Transfer: The Lagging Behavior (John Wiley & Sons, 2014) 4. M. Gandolﬁ, G. Benetti, C. Glorieux, C. Giannetti, and F. Banﬁ, Int. J. Heat Mass Transf. 143, 118553 (2019) 5. M Gandolfi, G L Celardo, F Borgonovi, G Ferrini, A Avella, F Banfi and C Giannetti, Phys. Scr. 92, 034004 (2017) 6. S. Huberman, R.A. Duncan, K. Chen, B. Song, V. Chiloyan, Z. Ding, A.A. Maznev, G. Chen, K.A. Nelson, Science 364, (2019) 6. S. Huberman, R.A. Duncan, K. Chen, B. Song, V. Chiloyan, Z. Ding, A.A. Maznev, G. Chen, K.A. Nelson, Science 364, (2019) 2 2
https://openalex.org/W4380568513	https://zenodo.org/records/8039721/files/205-207.pdf	Latin	null	ERTAKLARNING BOSHLANG'ICH SINF O'QUVCHILARI TARBIYASIDAGI O'RNI	Zenodo (CERN European Organization for Nuclear Research)	2,023	cc-by	2,439	Use Of Didactic Games. The American Journal of Social Science and Education Innovations 3 (31), 540-545 8.Adizova, Nodira, and Uktamova Mohinur. "INTERFAOL MASHQLAR ASOSIDA BOSHLANG‘ICH SINF O‘QUVCHILARIDA IJTIMOIY KO‘NIKMALARINI SHAKLLANTIRISH." E Conference Zone. 2023. 9 B ti Adi N di d J l L b t Ilh "FAOL TA’LIM ASOSIDA Jumayev R. Joy nomlarining tarkibiy tahlil usullari //ЦЕНТР НАУЧНЫХ ПУБЛИКАЦИЙ (buxdu. uz). –2020. –Т. 2. –No. 2. 20. Ahmadovich K. H., Nodirkulovna A. I. Theory of Fairy Tales in Primary Grades, The Nature of the Fairy Tale Genre //American Journal of Social and Humanitarian Research. – 2022. – Т. 3. – №. 7. – С. 130-133. Use Of Didactic Games. The American Journal of Social Science and Education Innovations 3 (31), 540-545 8.Adizova, Nodira, and Uktamova Mohinur. "INTERFAOL MASHQLAR ASOSIDA BOSHLANG‘ICH SINF O‘QUVCHILARIDA IJTIMOIY KO‘NIKMALARINI SHAKLLANTIRISH." E Conference Zone. 2023. 9 B ti Adi N di d J l L b t Ilh "FAOL TA’LIM ASOSIDA Use Of Didactic Games. The American Journal of Social Science and Education Innovations 3 (31), 540-545 8.Adizova, Nodira, and Uktamova Mohinur. "INTERFAOL MASHQLAR ASOSIDA BOSHLANG‘ICH SINF O‘QUVCHILARIDA IJTIMOIY KO‘NIKMALARINI SHAKLLANTIRISH." E Conference Zone. 2023. 9 B ti Adi N di d J l L b t Ilh "FAOL TA’LIM ASOSIDA f 9. Baxtiyorovna, Adizova Nodira, and Jamolova Lubat Ilhomovna. "FAOL TA’LIM ASOSIDA DARSLARNI TASHKIL QILISH‒ TA’LIM SAMARADORLIGINI OSHIRISH OMILI SIFATIDA." PEDAGOGS jurnali 1.1 (2022): 52-53. 9. Baxtiyorovna, Adizova Nodira, and Jamolova Lubat Ilhomovna. FAOL TA LIM ASOSIDA DARSLARNI TASHKIL QILISH‒ TA’LIM SAMARADORLIGINI OSHIRISH OMILI SIFATIDA." 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Toponymics-a Linguistic Phenomenon in The Work of Sadriddin Ain European Scientific Bulletin. –2021. –Т. 8. 18. Xoliqulovich J. R. Toponymics-a Linguistic Phenomenon in The Work of Sadri //Middle European Scientific Bulletin. –2021. –Т. 8. 19. D.Nuritdinova D.Nuritdinova BuxDPI magistranti D.B.Axmedova BuxDU doktoranti Annotatsiya: Maqolada boshlang‘ich sinf o‘quvchilari nutqining boyligi, erkin fikrlashini o‘stirish, izlanuvchanligi, xotirasining yaxshilanishi, topqirligi, ziyrakligi, ilg‘orligi va xalq og‘zaki ijodining mahsuli bo‘lmish ertaklarga bo‘lgan qiziqishi va muhabbatini orttirish borasidagi fikr-mulohazalar yoritilgan. g g q q g f y g Tayanch so‘z va iboralar: darslik, his-tuyg‘u, halollik, to‘g‘rilik, ziyraklik, tafakkur, tahlil, xotira, ertak. Ertak ‒ xalq og‘zaki poetik ijodining asosiy janrlaridan biri; toʻqima va uydirmaga asoslangan, sehrli, sarguzasht va maishiy xarakterdagi epik badiiy asar. Asosan, nasriy shaklda yaratilgan. Mahmud Koshgʻariyning "Devonu lugʻotit turk" asarida “etuk” shaklida uchraydi va biror voqeani ogʻzaki tarzda hikoya qilish maʼnosini bildiradi. Ertak Surxondaryo, Samarqand, Fargʻona oʻzbeklari orasida matal, Buxoro atrofidagi tuman va qishloqlarda ushuk, Xorazmda 205 varsaqi, Toshkent shahri va uning atrofida choʻpchak deb ataladi. Ertak hayot haqiqatining xayoliy va hayotiy uydirmalar asosida tasvirlanganligi, tilsim va sehr vositalariga asoslanishi, voqea va harakatlarning ajoyib-gʻaroyib holatlarda kechishi, qahramonlarning gʻayritabiiy jasorati bilan folklorning boshqa janrlaridan farq qiladi. Ertaklarda uydirma muhim mezon boʻlib, syujet voqealarining asosini tashkil etadi, syujet chizigʻidagi dinamik harakatning konflikt yechimini taʼminlaydi. y y Ertaklar – yaxshilikka yetaklar. Ertaklarni har bir bola sevib o‘qiydi, tinglaydi. Chunki bola uchun bu juda ham qiziqarli tuyuladi. Shuning uchun ham biz pedagoglar bolalarning ilk yoshidanoq, ilk maktab chog‘idanoq ertaklarga bo‘lgan qiziqishini orttirib borishimiz kerak. Bola yoshlikdan xalq og‘zaki ijodiga qiziqsa, kelajakda albatta kitobga mehri oshadi, fikrlashi, dunyoqarashi kengayadi. Biz tahlil uchun 4-sinf “O‘qish” darsligida keltirilgan “Hiylagarning jazosi” deb nomlangan xalq og‘zaki ijodi mahsuli sanalgan ertakni tanladik tahlillarni umumlashtirilib, kerakli xulosalar chiqarib olamiz. q Ikki o‘rtoq bor edi. Biri sodda, ikkinchisi esa hiylagar edi. Ular bir kuni savdogarchilik qilish uchun bir yoqqa ketayotganlarida yo‘ldan bir xalta tilla topibdilar. Soddadil hiylagarga: – Omadimiz keldi, endi bularni bo‘lib, orqaga qaytamiz, – desa, hiylagar: – Taqsim qilib o‘tiramizmi? Hozir kimga qancha kerak bo‘lsa olib, qolganini ehtiyot qilib berkitib ketaylik. Zarur bo‘lganda yana kelib keragini olarmiz, – debdi. Soddadil uning so‘ziga kirib «xo‘p» debdi. Oltindan keragicha olib, qolganini bir daraxt ostiga ko‘mibdilar. Shaharga yetib kelib, har biri o‘z uyiga ketibdi. O‘zini aqlli deb hisoblagan hiylagar ertasi kun borib, ko‘milgan tillaning hammasini olib ketibdi. Soddadil o‘z qo‘lidagini xarjlab bo‘lgach, hiylagar qoshiga kelib debdi: – Yur, oltindan picha olib kelaylik, juda muhtoj bo‘lib qoldim. Hiylagar u bilan birga tilla ko‘milgan joyga boribdi, lekin ular hech narsa topmabdilar. Hiylagar soddadilning yoqasidan ushlab: – Tillalarni sen olgansan, chunki sendan bo‘lak hech kimning bundan xabari yo‘q edi, – debdi. Soddadil bechora: «Olmadim», – deb har qancha ont ichsa ham foydasi bo‘lmabdi. BuxDU doktoranti Hiylagar uni qoziga olib borib, bo‘lgan gapni aytib beribdi va tillalarni topib berishini da’vo qilibdi. Qozi: – Guvoh va dalil bormi? – deb so‘rabdi. Hiylagar: Guvoh va dalil bormi? – deb so‘rabdi. Hiylagar: – Ostiga tilla ko‘milgan daraxt guvohlik berib, tillani shu noinsof olib ketgan, dedi, – debdi. Qozi bu so‘zni eshitib, hayron bo‘libdi. Ancha gap-so‘zdan keyin ertasiga guvohlik bergan daraxt yoniga borishga qaror qilishibdi. Hiylagar sevinib uyiga kelib otasiga: – Bu tilla hangomasini o‘z foydamizga hal etish sizga bog‘liq bo‘lib qoldi. Sizga ishonib, daraxt guvohlik beradi, dedim. Endi mening gapimga ko‘nsangiz, olib kelgan tillalarim o‘zimizga qoladi va yana qo‘shimcha shuncha tillaga ega bo‘lamiz, – debdi. Otasi: – Men nima qilishim kerak? – deb so‘rabdi. Hiylagar: – U daraxtning ichi kovak bo‘lib, unga o‘n odam bemalol yashirinsa bo‘ladi. Kechasi borib, u yerga joylashib olishingiz kerak, ertasiga qozi daraxt tagiga kelganida, daraxt nomidan guvohlik bersangiz bo‘ldi, – debdi. Ertasi kuni qozi shahardan chiqib, daraxt oldiga boribdi. Tomosha qilish uchun anchagina odamlar ham unga ergashib kelgan ekan. Qozi daraxtga qarab, tillalarning qayerdaligini so‘rabdi. Daraxtdan: «Tillalarni soddadil olib ketgan», – Ostiga tilla ko‘milgan daraxt guvohlik berib, tillani shu noinsof olib ketgan, dedi, – debdi. Qozi bu so‘zni eshitib, hayron bo‘libdi. Ancha gap-so‘zdan keyin ertasiga guvohlik bergan daraxt yoniga borishga qaror qilishibdi. Hiylagar sevinib uyiga kelib otasiga: – Bu tilla hangomasini o‘z foydamizga hal etish sizga bog‘liq bo‘lib qoldi. Sizga ishonib, daraxt guvohlik beradi, dedim. Endi mening gapimga ko‘nsangiz, olib kelgan tillalarim o‘zimizga qoladi va yana qo‘shimcha shuncha tillaga ega bo‘lamiz, – debdi. Otasi: – Men nima qilishim kerak? – deb so‘rabdi. Hiylagar: – U daraxtning ichi kovak bo‘lib, unga o‘n odam bemalol yashirinsa bo‘ladi. Kechasi borib, u yerga joylashib olishingiz kerak, ertasiga qozi daraxt tagiga kelganida, daraxt nomidan guvohlik bersangiz bo‘ldi, – debdi. Ertasi kuni qozi shahardan chiqib, daraxt oldiga boribdi. Tomosha qilish uchun anchagina odamlar ham unga ergashib kelgan ekan. Qozi daraxtga qarab, tillalarning qayerdaligini so‘rabdi. Daraxtdan: «Tillalarni soddadil olib ketgan», – degan sado chiqibdi. Taajjublangan qozi daraxt atrofida aylanib yurib, unga diqqat bilan razm solibdi. Daraxtning katta kovagi borligini ko‘ribdi-da, hamma gapga tushunibdi. O‘ziga-o‘zi: «Xiyonatga marhamat yo‘q», – deb daraxt atrofiga shox qalatib o‘t qo‘ydiribdi. Chol biroz chidab jim turibdi, lekin halok bo‘lishini bilib, yolvora boshlabdi. Qozining buyrug‘i bilan uni daraxt ichidan chiqaribdilar. Qozi savol-javob qilib, haqiqatni bilibdi, soddadilning to‘g‘riligi, hiylagarning makri ma’lum bo‘libdi. Chol chekkan azobiga va nomusga chiday olmay, shu yerning o‘zidayoq jon beribdi. Foydalanilgan adabiyotlar 1. S.Matchonov, A.Shojalilov, X.G‘ulomova, Sh.Sariyev, Z.Dolimov. O‘qish”, 4-sinf uchun darslik, Toshkent, “Yangiyo‘l poligraf servis” nashriyoti, 2017. – 55-57-betlar. 2. 7.AN Bakhtiyorovna, E Dilsora. Visual Aids, Which Are Used In The Educational Process In The Use Of Didactic Games. The American Journal of Social Science and Education Innovations 3 (31), 540- 545 3. 8.Adizova, Nodira, and Uktamova Mohinur. "INTERFAOL MASHQLAR ASOSIDA BOSHLANG‘ICH SINF O‘QUVCHILARIDA IJTIMOIY KO‘NIKMALARINI SHAKLLANTIRISH." E Conference Zone. 2023. 3. 8.Adizova, Nodira, and Uktamova Mohinur. "INTERFAOL MASHQLAR ASOSIDA BOSHLANG‘ICH SINF O‘QUVCHILARIDA IJTIMOIY KO‘NIKMALARINI SHAKLLANTIRISH." E Conference Zone. 2023. f 4. 9. Baxtiyorovna, Adizova Nodira, and Jamolova Lubat Ilhomovna. "FAOL TA’LIM ASOSIDA DARSLARN TASHKIL QILISH‒TA’LIM SAMARADORLIGINI OSHIRISH OMILI SIFATIDA." PEDAGOGS jurnali 1.1 (2022): 52-53. 4. 9. Baxtiyorovna, Adizova Nodira, and Jamolova Lubat Ilhomovna. "FAOL TA’LIM ASOSIDA DARSLARN TASHKIL QILISH‒TA’LIM SAMARADORLIGINI OSHIRISH OMILI SIFATIDA." PEDAGOGS jurnali 1.1 (2022): 52-53. 9 a iyo o a, A i o a No i a, a Ja o o a u a I o o a AO A I A O I A DARSLARN TASHKIL QILISH‒TA’LIM SAMARADORLIGINI OSHIRISH OMILI SIFATIDA." PEDAGOGS jurnali 1.1 (2022): 52-53. 5 10 Bakhtiorovna Adizova Nodira and Jamolova Lubat Ilhomovna "BASIC PRINCIPLE OF j ( ) 5. 10. Bakhtiorovna, Adizova Nodira, and Jamolova Lubat Ilhomovna. "BASIC PRINCIPLE OF PERSONALIZED EDUCATIONAL TECHNOLOGY." BARQARORLIK VA YETAKCHI TADQIQOTLAR ONLAYN ILMIY JURNALI 2.10 (2022): 296-298. j 5. 10. Bakhtiorovna, Adizova Nodira, and Jamolova Lubat Ilhomovna. "BASIC PRINCIPLE OF PERSONALIZED EDUCATIONAL TECHNOLOGY." BARQARORLIK VA YETAKCHI TADQIQOTLAR ONLAYN ILMIY JURNALI 2.10 (2022): 296-298. 5 0 a io o a, A i o a No i a, a Ja o o a u a I o o a ASIC INCI E O PERSONALIZED EDUCATIONAL TECHNOLOGY." BARQARORLIK VA YETAKCHI TADQIQOTLAR ONLAYN ILMIY JURNALI 2.10 (2022): 296-298. 6. 11. Адизова, Нодира Бахтиёровна. "ЭТИМОЛОГИЯ НЕКОТОРЫХ ТОПОНИМОВ Й PERSONALIZED EDUCATIONAL TECHNOLOGY. BARQARORLIK VA YETAKCHI TADQIQOTLAR ONLAYN ILMIY JURNALI 2.10 (2022): 296-298. 6. 11. Адизова, Нодира Бахтиёровна. "ЭТИМОЛОГИЯ НЕКОТОРЫХ ТОПОНИМОВ БУХАРСКОЙ ОБЛАСТИ." BARQARORLIK VA YETAKCHI TADQIQOTLAR ONLAYN ILMIY JURNALI 2.1 (2022): 513-516. J ( ) 6. 11. Адизова, Нодира Бахтиёровна. "ЭТИМОЛОГИЯ НЕКОТОРЫХ ТОПОНИМОВ БУХАРСКОЙ ОБЛАСТИ." BARQARORLIK VA YETAKCHI TADQIQOTLAR ONLAYN ILMIY JURNALI 2.1 (2022): 513-516. ( ) 7. 12.Adizova, Nodira. "BOSHLANG ‘ICH SINF ONA TILI DARSLARIDA O‘QUVCHILAR NUTQINI O‘STIRISH OMILLARI: XORAZM MA’MUN AKADEMIYASI AX OROTNOMАSI." Buxoro davlat universitetining Pedagogika instituti jurnali 2.2 (2022). g g g j ( ) 8. 13.Amonov U. S., Saparova S. R. BuxDU doktoranti Hiylagarni jazolab, adabini beribdilar va otasining jasadini yelkasiga orttirib, shaharga jo‘natibdilar. Soddadil esa to‘g‘riligi tufayli hamma tillalarga ega bo‘libdi. g q g q y g g – degan sado chiqibdi. Taajjublangan qozi daraxt atrofida aylanib yurib, unga diqqat bilan razm solibdi. Daraxtning katta kovagi borligini ko‘ribdi-da, hamma gapga tushunibdi. O‘ziga-o‘zi: «Xiyonatga marhamat yo‘q», – deb daraxt atrofiga shox qalatib o‘t qo‘ydiribdi. Chol biroz chidab jim turibdi, lekin halok bo‘lishini bilib, yolvora boshlabdi. Qozining buyrug‘i bilan uni daraxt ichidan chiqaribdilar. Qozi savol-javob qilib, haqiqatni bilibdi, soddadilning to‘g‘riligi, hiylagarning makri ma’lum bo‘libdi. Chol chekkan azobiga va nomusga chiday olmay, shu yerning o‘zidayoq jon beribdi. Hiylagarni jazolab, adabini beribdilar va otasining jasadini yelkasiga orttirib, shaharga jo‘natibdilar. Soddadil esa to‘g‘riligi tufayli hamma tillalarga ega bo‘libdi. – degan sado chiqibdi. Taajjublangan qozi daraxt atrofida aylanib yurib, unga diqqat bilan razm solibdi. Daraxtning katta kovagi borligini ko‘ribdi-da, hamma gapga tushunibdi. O‘ziga-o‘zi: «Xiyonatga marhamat yo‘q», – deb daraxt atrofiga shox qalatib o‘t qo‘ydiribdi. Chol biroz chidab jim turibdi, lekin halok bo‘lishini bilib, yolvora boshlabdi. Qozining buyrug‘i bilan uni daraxt ichidan chiqaribdilar. Qozi savol-javob qilib, haqiqatni bilibdi, soddadilning to‘g‘riligi, hiylagarning makri ma’lum bo‘libdi. Chol chekkan azobiga va nomusga chiday olmay, shu yerning o‘zidayoq jon beribdi. Hiylagarni jazolab, adabini beribdilar va otasining jasadini yelkasiga orttirib, shaharga jo‘natibdilar. Soddadil esa to‘g‘riligi tufayli hamma tillalarga ega bo‘libdi. Ertakda soddadil va hiylagarlik do‘stligi va ularning bir tilla deb orasi buzilganini ko‘rishimiz mumkin. Soddadil va hiylagarga xos xususiyatlar yaqqol o‘z ifodasini topgan. Hiylagarning qilgan hiylasi ertak oxirida xalqning oldida. o‘zini sharmanda qiladi Bunga chiday olmagan otasi esa voqea joyida halok bo‘ladi. Ertak bilan tanishgan har bir yosh bola darhol o‘ziga kerakli xuloasani chiqarib oladi. 206 Xulosa qilib aytadigan bo‘lsak, ertaklar o‘quvchilarning tarbiyasiga, dunyoqarashiga katta ta’sir ko‘rsatadi, milliy urf-odatlarni sevishga, qadriyatlarni qadrlashga, aqliy rivojlanishiga, nutqiy faoliyatiga beqiyos yordam beradi. O‘zbek xalq ertaklari juda qadimiy tarixga ega. Xalq ertaklarida insonparvarlik, do‘slik va boshqa xuxusiyatlar mujassamlashgan. Xalq ertaklari 206 barchamizning ko‘nglimizga birdek yoqadi hamda sevib o‘rganishimiz, mutolaa qilishimiz uchun munosib namunalardir. Foydalanilgan adabiyotlar The mother tongue textbook of the primary school in elbek's interpretation //ACADEMICIA: An International Multidisciplinary Research Journal. – 2021. – Т. 11. – №. 6. – С. 403-407. 9. 14.Amonov U. S. FOLKLORE IN THE WORKS OF ABDURAUF FITRAT //Theoretical & Applied Science. – 2016. – №. 10. – С. 9-12. pp 10. 15.Ulug‘murod Sultonovich Amonov S. R. et al. BOSHLANG ‘ICH SINF ONA TILI DARSLIGINING ELBEK TALQINIDAGI KO‘RINISHI: Ulug‘murod Sultonovich Amonov BDU o‘qituvchisi Sh. R. Safarova, BDU magistranti, 14-maktab o‘qituvchisi //Научно-практическая конференция. – 2021. 11. 16.Jumayev R. САДРИДДИН АЙНИЙНИНГ ОДИНА ҚИССАСИДА НОМ ҚЎЙИШ САНЪАТИ //ЦЕНТР НАУЧНЫХ ПУБЛИКАЦИЙ (buxdu. uz). –2021. –Т. 2. –No. 2. 12. 17.Xoliqulovich J. R. Influence of Sadriddin Aini life and works in spiritual and moral J y Д ДД Д Қ Д Қ САНЪАТИ //ЦЕНТР НАУЧНЫХ ПУБЛИКАЦИЙ (buxdu. uz). –2021. –Т. 2. –No. 2. 12. 17.Xoliqulovich J. R. Influence of Sadriddin Aini life and works in spiritual and moral development of students //Middle European Scientific Bulletin. –2021. –Т. САНЪАТИ //ЦЕНТР НАУЧНЫХ ПУБЛИКАЦИЙ (buxdu. uz). 2021. Т. 2. No. 2. 12. 17.Xoliqulovich J. R. Influence of Sadriddin Aini life and works in spiritual and moral development of students //Middle European Scientific Bulletin. –2021. –Т. development of students //Middle European Scientific Bulletin. –2021. –Т. 13. 18.Xoliqulovich J. R. Toponymics-a Linguistic Phenomenon in The Work of Sadriddin Aini //Middle European Scientific Bulletin. –2021. –Т. 8. 13. 18.Xoliqulovich J. R. Toponymics-a Linguistic Phenomenon in The Work of Sadriddin Aini //Middle European Scientific Bulletin. –2021. –Т. 8. p 14. 19.Jumayev R. Joy nomlarining tarkibiy tahlil usullari //ЦЕНТР НАУЧНЫХ ПУБЛИКАЦИЙ (buxdu. uz). –2020. –Т. 2. –No. 2. 15. 20.Ahmadovich K. H., Nodirkulovna A. I. Theory of Fairy Tales in Primary Grades, The Nature of the Fairy Tale Genre //American Journal of Social and Humanitarian Research. – 2022. – Т. 3. – №. 7. – С. 130-133. BOSHLANG‘ICH SINF MATEMATIKA DARSLARIDA PEDAGOGIK TEXNOLOGIYALAR ASOSIDA O‘QITISHNI TASHKIL ETISH TEXNOLOGIYALAR ASOSIDA O‘QITISHNI TASHKIL ETISH notatsiya. “Texnologiya” yunoncha so`z bo`lib, “texno” – o`qitish jarayonini yuksak mahorat, san’at shkil etish borasida ma’lumotlar beruvchi fan ma’nosini anglatadi. j f g Kalit so‘zlar: ta’lim texnologiyasi, pedagogik texnologiya, o‘qitish texnologiyasi, zamonaviy pedagogik texnologiya 207
https://openalex.org/W4293728663	https://repository.ubn.ru.nl/bitstream/handle/2066/283610/1/283610.pdf	English	null	Chemical composition of the young massive cluster NGC 1569-B	Astronomy & astrophysics	2,022	cc-by	16,015	Version of the following full text: Publisher’s version Downloaded from: https://repository.ubn.ru.nl/handle/2066/283610 Download date: 2024-10-24 Download date: 2024-10-24 Chemical composition of the young massive cluster NGC 1569-B Gvozdenko, A.; Larsen, S.S.; Beasley, M.A.; Brodie, J. 2022, Article / Letter to editor (Astronomy & Astrophysics, 666, (2022), pp. 1-16, article 159) Doi link to publisher: https://doi.org/10.1051/0004-6361/202243415 ABSTRACT galaxies: star clusters: individual: NGC 1569-B – galaxies: stellar content – galaxies: abundances – supergiants – techniques: spectroscopic A. Gvozdenko1 , S. S. Larsen1, M. A. Beasley2,3, and J. Brodie4,5 1 Department of Astrophysics/IMAPP, Radboud University, PO Box 9010, 6500 GL The Netherlands e-mail: a.gvozdenko@astro.ru.nl 1 Department of Astrophysics/IMAPP, Radboud University, PO Box 9010, 6500 GL The Netherlands e-mail: a.gvozdenko@astro.ru.nl g 2 Instituto de Astrofíica de Canarias, Calle Vía Láctea, 38206 La Laguna, Spain g 2 Instituto de Astrofíica de Canarias, Calle Vía Láctea, 38206 La Laguna, Spain 3 p g g p Centre for Astrophysics and Supercomputing, Swinburne University, John Street, Hawthorn, VIC 3122, Australia 4 Centre for Astrophysics and Supercomputing, Swinburne University, John Street, 5 4 Centre for Astrophysics and Supercomputing, Swinburne University, John Street, Haw 5 5 University of California Observatories, 1156 High Street, Santa Cruz, CA 95064, 5 University of California Observatories, 1156 High Street, Santa Cruz, CA 95064, USA Received 24 February 2022 / Accepted 9 August 2022 Received 24 February 2022 / Accepted 9 August 2022 ABSTRACT Context. The chemical composition of young massive clusters (YMCs) provides stellar population information on their host galaxy. As potential precursors of globular clusters (GCs), their properties can help us understand the origins of GCs and their evolution. Aims. We present a detailed chemical abundance analysis of the YMC NGC 1569-B. The host galaxy, NGC 1569, is a dwarf irregular starburst galaxy at a distance of 3.36 ± 0.20 Mpc. We derive the abundances of the α, Fe-peak, and heavy elements. Methods. We determined the abundance ratios from the analysis of an optical integrated-light (IL) spectrum of NGC 1569-B, obtained with the HIRES echelle spectrograph on the Keck I telescope. We considered diﬀerent red-to-blue supergiant ratios (NRSG/NBSG), namely: the ratio obtained from a theoretical isochrone (NRSG/NBSG = 1.24), the ratio obtained from a resolved colour–magnitude diagram of the YMC (NRSG/NBSG = 1.53), and the ratio that minimises the χ2 when comparing our model spectra with the observations (NRSG/NBSG = 1.90). We adopted the latter ratio for our resulting chemical abundances. p g Results. The derived iron abundance is sub-solar with [Fe/H] = −0.74 ± 0.05. In relation to the scaled solar composition, we ﬁnd enhanced α-element abundances, [⟨Mg, Si, Ca, Ti⟩/Fe] = +0.25 ± 0.11, with a particularly high Ti abundance of +0.49 ± 0.05. Other super-solar elements include [Cr/Fe] = +0.50 ± 0.11, [Sc/Fe] = +0.78 ± 0.20, and [Ba/Fe] = +1.28 ± 0.14, while other Fe-peak elements are close to scaled solar abundances: ([Mn/Fe] = −0.22 ± 0.12 and [Ni/Fe] = +0.13 ± 0.11). Conclusions. The composition of NGC 1569-B resembles the stellar populations of the YMC NGC 1705-1, located in a blue compact dwarf galaxy. The two YMCs agree with regard to α-elements and the majority of the Fe-peak elements, except for Sc and Ba, which are extremely super-solar in NGC 1569-B – and higher than in any YMC studied so far. The blue part of the optical spectrum of a young population is still a very challenging wavelength region to analyse using IL spectroscopic studies. This is due to the uncertain contribution to the light from blue supergiant stars, which can be diﬃcult to disentangle from turn-oﬀstars, even when resolved photometry is available. We suggest that the comparison of model ﬁts at diﬀerent wavelengths oﬀers a route to determining the red-to-blue supergiant ratio from IL spectroscopy. Key words. Note: To cite this publication please use the final published version (if applicable). Astronomy & Astrophysics Astronomy & Astrophysics Astronomy & Astrophysics A&A 666, A159 (2022) https://doi.org/10.1051/0004-6361/202243415 c⃝A. Gvozdenko et al. 2022 A&A 666, A159 (2022) https://doi.org/10.1051/0004-6361/202243415 c⃝A. Gvozdenko et al. 2022 Open Access article, published by EDP Sciences, under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4 which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article is published in open access under the Subscribe-to-Open model. Subscribe to A&A to support open access publication. Open Access article, published by EDP Sciences, under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article is published in open access under the Subscribe-to-Open model. Subscribe to A&A to support open access publication. A159, page 1 of 16 1. Introduction Thus, it is important to study extragalactic clusters Beyond the Local Group, detailed information on the chem- ical composition of stellar populations is much more scarce, A&A 666, A159 (2022) to explore their chemical composition, and YMCs can serve as ideal targets thanks to their intrinsic high luminosities. Fig. 1. Image of the NGC 1569 using F555W ﬁlter from HST ACS. The slit is located on top of the NGC 1569-B, indicating the region the spectra were obtained from. g g The high light-to-mass ratios of young clusters, such as YMCs, allow us to study their abundances using integrated-light (IL) spectroscopy. The IL spectra for the majority of star clusters are broadened by only up to 10 km s−1 which implies that rela- tively high spectral resolutions (λ/∆λ ≳10 000) are accessible; thus, detailed chemical abundances can be extracted from their IL spectra. In general, this is done by modelling the IL spec- tra using information from the Hertzsprung–Russell diagram (HRD), combined with atmospheric models and synthetic stel- lar spectra (Davies et al. 2010; Larsen et al. 2012; Sakari et al. 2021). One method that uses this technique was introduced and described in Larsen et al. (2012), and it has been used to derive abundances for iron and α-elements, as well as light- and n- capture elements for old GCs in Local Group dwarf and spiral galaxies (Larsen et al. 2014, 2022). Extragalactic YMCs stud- ied with this method include the clusters NGC 1313-379 (in the barred spiral NGC 1313) and NGC 1705-1, in a blue compact dwarf (Hernandez et al. 2017). The derived metallicities were: [Fe/H] = −0.84±0.07 and [Fe/H] = −0.78±0.10 for NGC 1313- 379 and NGC 1705-1, respectively; while the α abundance is solar like for NGC 1313-379 with [α/Fe] = +0.06 ± 0.11 and a super-solar [α/Fe] = +0.32 ± 0.12 for NGC 1705-1. Fig. 1. Image of the NGC 1569 using F555W ﬁlter from HST ACS. The slit is located on top of the NGC 1569-B, indicating the region the spectra were obtained from. p It is important to increase the number of YMCs for which the chemical composition has been measured in detail. In Larsen et al. (2006), iron and α abundances were derived for a young super-star cluster SSC in the nearby spiral galaxy NGC 6946 using near-infrared (NIR) observations from the Near Infrared Spectrograph (NIRSPEC) instrument on the Keck II telescope. Table 1. Basic parameters of NGC 1569. Quantity Observed value References D 2.2 ± 0.6 Mpc 1 3.36 ± 0.20 Mpc 2 d 1.85 kpc 3 Mgas (1.5 ± 0.3) × 108 M⊙ 1 Mtot 3.3 × 108 M⊙ 1 Z 0.004 4 SFR ∼0.5 M⊙yr−1 5 0.32 M⊙yr−1 6 Notes. D – the distance to the galaxy; d – maximum optical size; Mgas – total atomic gas mass (H I + He); Mtot – total galaxy mass. References. (1) Israel (1988), (2) Grocholski et al. (2008), (3) Stil & Israel (2002), (4) González Delgado et al. (1997), (5) Greggio et al. (1998), (6) Hunter & Elmegreen (2004). p Such patterns can be used to infer star-to-star variations of some light elements (e.g., Na–O anticorrelation), which are linked to the presence of ‘multiple populations’ (MPs) in GCs (Bastian & Lardo 2018). In particular, it is interesting to try and identify the ﬁrst signs of the MPs within the YMCs that would lead to the patterns seen in the GCs. However, no clear indications of the abundance patterns associated with MPs have yet been found in any clusters younger than about 2 Gyr (Martocchia et al. 2018, 2019). Notes. D – the distance to the galaxy; d – maximum optical size; Mgas – total atomic gas mass (H I + He); Mtot – total galaxy mass. References. (1) Israel (1988), (2) Grocholski et al. (2008), (3) Stil & Israel (2002), (4) González Delgado et al. (1997), (5) Greggio et al. (1998), (6) Hunter & Elmegreen (2004). In this study, we derive the detailed chemical abundances of a YMC NGC 1569-B. It is located in a dwarf irregular galaxy (dIrr) NGC 1569, which has two bright YMCs: NGC 1569-A (a binary cluster) and NGC 1569-B. The masses were esti- mated to be ≈106 M⊙for the binary cluster and (4.4 ± 1.1) × 105 M⊙for NGC 1569-B (Ho & Filippenko 1996; Sternberg 1998; Larsen et al. 2008). Both of these clusters are more massive than any of the young clusters in the MW or LMC (Anders et al. 2004). The cluster investigated in this work is the older and less bright one out of the two YMCs. Figure 1 shows a Hubble Space Telescope (HST) image of the target with the slit used for our spectroscopic observations. 1. Introduction especially with regard to detailed abundance patterns. Based on observations of Hii regions, abundances of a limited set of ele- ments (such as oxygen and nitrogen) can be inferred in galax- ies with ongoing or recent SF (Shields 1990), and the spec- troscopy of individual supergiant (SG) stars has been used to measure overall metallicities (Larsen et al. 2008; Davies et al. 2013). However, diﬀerences in the elements typically included in these types of analyses have made it diﬃcult to compare these results directly with the data for old stellar populations in nearby galaxies. The element abundances of star clusters can reveal information on their star formation (SF) history and the evolution of their host galaxies. Indeed, obtaining accurate abundances for star clusters is a crucial goal for both galactic and extragalactic targets, since these parameters facilitate studies of the evolution of both stars and galaxies. In recent decades, the availability of 8–10 m class telescopes has made it possible to study the spectra coming from stars outside of the Milky Way (MW), including those located in neighbouring galaxies such as the Small and Large Magellanic Clouds (SMC and LMC) as well as nearby dwarf galaxies (Hill 1999). It has been found that for old stellar populations with low iron abundances ([Fe/H]), the α-abundances of stars in dwarf galaxies exhibit similar patterns to those characterising the MW, with enhanced abundances (relative to scaled-solar composi- tion). However, as [Fe/H] increases, the [α/Fe] ratio in dwarfs reaches lower values than in the MW (Tolstoy et al. 2009). The chemical composition of young massive clusters (YMCs) provides valuable information on stellar population. These objects allow us to gain insight into SF under more extreme conditions than those encountered in nearby star- forming regions, and they are of particular interest, particularly since an ongoing debate in the literature has questioned whether these objects might be the progenitors of the old globular clusters (GCs) that we see today (Lardo et al. 2017; Cabrera-Ziri et al. 2020). Additionally, it is interesting to compare the chemical abundance patterns that we see in our Local Group with systems outside of it. 1. Introduction These authors found a super-solar [α/Fe] and sub- solar metallicity of [Fe/H] = −0.45 ± 0.08. Other studies of YMCs include Lardo et al. (2017) and Cabrera-Ziri et al. (2016) where YMCs were studied to search for GC-like abundance patterns. Table 1. Basic parameters of NGC 1569. 3.1. Models and stellar parameters g g p Here, we study the chemical composition of YMC NGC 1569-B, using a high-resolution optical IL spectrum and applying the same method and software created by Larsen et al. (2012). We derive abundance ratios for a larger set of elements than those previously measured, including several α-elements (Mg, Si, Ca, Ti), Fe-peak elements (Sc, Cr, Mn, Ni) and the neutron capture element: Ba. Section 2 presents the observations we used, which are described together with the data reduction pipeline. The main stages of the analysis method are explained in Sect. 3, including the investigation of an important uncertainty for this study: the red-to-blue supergiant ratio (Sect. 3.2). The results are given in Sect. 4. We discuss and compare our ﬁndings to other YMCs, the MW stars, and LMC stars in Sect. 5. We oﬀer a discussion of the supergiant ratios in Sect. 5.5. In Sect. 6, we present our main conclusions. The analysis of high-resolution IL data for star clusters is described in detail in Larsen et al. (2012, 2014), Hernandez et al. (2017). Here, we give a brief overview of the steps particularly relevant to the present study. p y The ﬁrst step in the analysis is to split the cluster HRD into bins(upto100)ofdiﬀerentstellarevolutionarystages.Thiscanbe done using a combination of the isochrone and available photom- etry or the isochrones alone. Here, only the isochrone was used to create the bins because the photometry of the NGC 1569-B is not suﬃciently deep to properly sample the CMD (see Fig. 2), preventing us from performing an accurate cluster and ﬁeld sepa- ration. Each bin is described by mass, eﬀective temperature (Teﬀ), logarithm of surface gravity (log(g)), radius of the star, weight of the bin, logarithm of microturbulent velocity (log(νt)), and the atmosphericmodelusedtoproducethesyntheticspectra. The two diﬀerent atmospheric models used are: ATLAS9 for stars with Teﬀ> 4000 K (Kurucz 1970) and for the cool stars (Teﬀ< 4000 K) MARCS models (Gustafsson et al. 2008). The weight of each bin is calculated using the IMF and the mass of stars in the bins. We use the power law for the IMF, dN/dM ∝M−α, with the exponent α = 2.35 from Salpeter (1955). The microturbulent velocities were allocated depending on the stellar eﬀective tem- perature (similarly to Lyubimkov et al. 2004; Hernandez et al. 2.1. IL spectrum NGC 1569-B was observed with the high-resolution echelle spectrometer (HIRES) on the Keck I 10-m telescope on the 1st of November 2018. The exposure time was 2 × 1800 s with the C5 decker, a 7′′ × 1′′.148 slit. This gives a resolving power of R = λ/∆λ = 37 500. The right ascension and declination are 04:30:49.01 and +64:50:52.7 (J2000), respectively. These data were reduced using the highly automated MAKEE package (written by T. Barlow) that was speciﬁcally designed for HIRES data. The pipeline performs bias subtraction and ﬂat ﬁelding, determines the location of the echelle orders on the images and extracts the spectra. The spectra of Th-Ar calibration lamps mounted in HIRES were used to calibrate the wavelength. After- wards, the reduced two spectra were used to produce the ﬁnal IL spectrum and an error spectrum. The ﬁnal spectrum consists of a sum of two observations covering the ≈3900–8150 Å wave- length range; whereas the error spectrum is a diﬀerence between the two observations, providing an uncertainty for every pixel in the spectrum. The error spectrum was convolved with a boxcar kernel, using the running mean with window of N = 100 pixels, this helped to remove the anomalies from the error spectrum, such as telluric absorption (TA), cosmic rays, and so on. The signal-to-noise ratio (S/N) increases from the blue to the red end of the spectrum, with typical values of ∼50 at 4000 Å and ∼70 at 6000 Å. NGC 1569-B was observed with the high-resolution echelle spectrometer (HIRES) on the Keck I 10-m telescope on the 1st of November 2018. The exposure time was 2 × 1800 s with the C5 decker, a 7′′ × 1′′.148 slit. This gives a resolving power of R = λ/∆λ = 37 500. The right ascension and declination are 04:30:49.01 and +64:50:52.7 (J2000), respectively. These data were reduced using the highly automated MAKEE package (written by T. Barlow) that was speciﬁcally designed for HIRES data. The pipeline performs bias subtraction and ﬂat ﬁelding, determines the location of the echelle orders on the images and extracts the spectra. The spectra of Th-Ar calibration lamps mounted in HIRES were used to calibrate the wavelength. After- wards, the reduced two spectra were used to produce the ﬁnal IL spectrum and an error spectrum. Table 1. Basic parameters of NGC 1569. NGC 1569-B is particu- larly interesting given its mass, since such clusters are rare in the Milky Way and even in the Local Group. The massive clusters can provide clues about the MPs seen in old GCs. ber of clusters (≈150) were formed, including the massive clus- ters NGC 1569-A and NGC 1569-B. Evidence of older episodes of SF from 1.5 Gyr to 150 Myr ago has been presented by Vallenari & Bomans (1996). NGC 1569 is found to have an age gradient, where the youngest stars are mainly concentrated in the super star clusters (NGC 1569-A and NGC 1569-B), intermediate-age stars are more uniformly distributed, and the oldest stars are located in the outskirts of the star bursting regions (Aloisi et al. 2001). The stellar content of the B cluster (together with some abundances) were previously investigated with NIRSPEC in Larsen et al. (2008). Those derived abundances are: Fe abun- dance of [Fe/H] = −0.63 ± 0.08, α-abundance [α/Fe] = +0.31 ± 0.09, and [O/H] = −0.29 ± 0.07. In the same work, the age was estimated to be between 15 and 25 Myr (Larsen et al. 2008). Table 1 lists the basic parameters of NGC 1569. The stel- lar population in this dIrr is dominated by stars that are younger than a few tens of Myrs, while some old stars are also present (Greggio et al. 1998). Anders et al. (2004) conﬁrmed a major burst 25 Myr ago in NGC 1569. During this time, a large num- We wanted to see what eﬀect the diﬀerent ratios of red-to- blue supergiants, NRSG/NBSG, would have on the derived chem- ical abundances. This ratio in NGC 1569-B has been previously discussed in the literature. For example, in Larsen et al. (2008), A159, page 2 of 16 A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B the derived ratio was NRSG/NBSG = 2.50 ± 0.66. However, Larsen et al. (2011) used resolved photometry and identiﬁed 69 red SGs (RSGs) and 45 blue SGs (BSGs) giving NRSG/NBSG = 1.53 ± 0.09. The diﬀerence between the ratios in the Larsen et al. (2008) and Larsen et al. (2011) studies is mainly due to the way the BSGs were selected, which illustrates that it is challenging to separate BSGs and the bright main sequence (MS) stars into two distinguishable groups. Table 1. Basic parameters of NGC 1569. B photometry was used to ﬁnd the best-ﬁt isochrone, indicating an age of ∼25 Myr. The isochrone was used to perform the pho- tometry test to see the contribution of light from red and blue supergiants (see Sect. 3.2). 2.1. IL spectrum The ﬁnal spectrum consists Å Using the Kurucz and MARCS models, the model atmo- spheres and synthetic spectra are computed for each bin. The codes used for the spectral synthesis are SYNTHE (Kurucz & Furenlid 1979) and Turbospectrum (Plez 2012). Then these spectra are scaled to the stellar luminosity with respect to each bin. Afterwards, these are all combined into a single integrated synthetic spectrum. The abundances used in the modelling are then iteratively adjusted until the best ﬁt to the observed spectra is obtained. of a sum of two observations covering the ≈3900–8150 Å wave- length range; whereas the error spectrum is a diﬀerence between the two observations, providing an uncertainty for every pixel in the spectrum. The error spectrum was convolved with a boxcar kernel, using the running mean with window of N = 100 pixels, this helped to remove the anomalies from the error spectrum, such as telluric absorption (TA), cosmic rays, and so on. The signal-to-noise ratio (S/N) increases from the blue to the red end of the spectrum, with typical values of ∼50 at 4000 Å and ∼70 at 6000 Å. The method we use in this paper is based on the spectra of Arcturus (Hinkle et al. 2000) and the Sun (2005 version of Kurucz et al. 1984) to deﬁne the spectral windows used for the ﬁtting procedures. A crucial step is to ensure that each win- dow contains lines with a range of equivalent widths, while also including the strong lines (equivalent width > 100 mÅ). The full and updated list of spectral windows can be found in Larsen et al. (2022), whereas the list used for this study is pre- sented in Table B.1. 3.1. Models and stellar parameters 2017): for stars with Teﬀ< 6000 K the microturbulent veloci- ties were νt = 2.0 km s−1; for stars with 6000 < Teﬀ< 22 000 K – νt = 4.0 km s−1; and stars with Teﬀ> 22 000 K had νt = 8.0 km s−1. 2.2. HST photometry Element/molecule Wavelength [Å] Reference Ti 4293.0–4315.0 1 4397.0–4429.0 1 4442.0–4475.0 1 4521.0–4540.0 1 4570.0–4575.0 1 TiO1 5960.0–5994.0 2 Si 4367.0–4377.0 1 4382.0–4397.0 1 4420.5–4430.5 1 4596.0–4606.0 1 4622.0–4632.0 3 4701.0–4711.0 1 4716.0–4726.0 3 4743.0–4753.0 1 4942.0–4952.0 1 Cr 4253.0–4260.0 1 4270.0–4276.0 1 4565.0–4570.0 1 4578.0–4597.0 1 References. (1) Kudritzki et al. (2014) and references therein, (2) Salvador-Rusiñol et al. (2021), (3) Herrero et al. (2020). 3 2 1 0 1 2 3 F555W-F814W 9 8 7 6 5 4 3 2 1 F555W logT=7.40 photometry bins Fig. 2. CMD of NGC 1569-B using ACS photometry (black dots), with an isochrone (over plotted in blue) of logarithmic age 7.4 (25 Myrs) and Z = 0.008 from the Padua catalogue (Girardi et al. 2000). Red empty circles show the theoretical isochrone bins used for the HRD ﬁle (Girardi et al. 2000). GCs due to the higher metallicity (although GCs up to nearly solar metallicity were included in Larsen et al. 2022). Therefore, to account for this, the analysed windows had to be carefully arranged to ensure that the element lines do not overlap with others produced by diﬀerent types of elements. The spectral win- dows ﬁtted are a combination of the previously used set of wave- length regions (Larsen et al. 2022) and a new set of lines for the blue part of the spectrum (Table 2). References. (1) Kudritzki et al. (2014) and references therein, (2) Salvador-Rusiñol et al. (2021), (3) Herrero et al. (2020). References. (1) Kudritzki et al. (2014) and references therein, (2) Salvador-Rusiñol et al. (2021), (3) Herrero et al. (2020). 2.5 and Teﬀ≤5000 K for RSGs, while log(g) ≤2.5 and Teﬀ≥5000 K for BSGs. The number of blue and red SGs were then calculated using the weight of each bin based on the IMF (Salpeter 1955). The original ratio within the isochrone used for 25 Myrs and Z = 0.008 from the 2008 version of the Padua isochrones has NRSG/NBSG = 1.24 (Girardi et al. 2000, 2008; Marigo et al. 2008). However, another way to ﬁnd the optimal red-to-blue SG ratio is to use statistics on the exist- ing spectroscopic data. It is possible to combine the reduced χ2 values of multiple elements best ﬁts to calculate the total χ2 value characterising the runs with diﬀerent red-to-blue SGs ratios. 3.2. Ratio of red-to-blue supergiants One of the major uncertainties that we aim to tackle in this analy- sis is the impact of the ratio of red-to-blue supergiant stars. RSG stars are cool stars which are the brightest stars in NIR light for young stellar populations. These stars evolve from the MS as their hydrogen is depleted and heavy elements come closer to the stellar surface. The following step of the stellar evolution is the BSG star phase, which are hot stars and the most luminous in the blue optical part of the spectrum (Pagel 2009). p p p ( g ) Given the very diﬀerent eﬀective temperatures of blue and red SG stars, they aﬀect diﬀerent parts of the spectrum. This eﬀect is shown in Figs. 3 and 4, which provide a comparison between the best-ﬁt model of a stellar population with only BSG (shown in blue) and with only RSG (shown in red). It can be seen that at shorter wavelengths, the blue model spectrum tends to provide a better match overall to the observations; while at longer wavelengths, the RSGs with their more numerous fea- tures start dominating the integrated light. The wavelength range of the analysed IL spectrum is ∼4000−8000 Å and the main con- tribution in the blue up to about 5500 Å is from BSGs; while the red part of the spectrum is more dominated by the light from RSGs. Since the light from RSGs dominates the spectrum at redder wavelengths and has almost no eﬀect at the shorter wavelengths (see Sect. 5.5.2), by increasing NRSG/NBSG the IL spectrum will become redder. As expected, the BSGs have the opposite eﬀect on the spectrum, and decreasing the ratio will mainly aﬀect the bluer part of the spectrum. These wavelength ranges indicate that the optimal contribution between the blue and the red SG stars has to be achieved. 2.2. HST photometry Figure 5 shows how χ2 varies for ratios between 0.5 and 2.0, namely, higher ratios between 2.0 and 4.0 fail to ﬁt multiple Fe lines; hence, those ratios were not considered in the search for the lowest χ2. A visible trend is that the higher ratios of RSGs to BSGs are favoured by the analysis. The ratio with the lowest χ2 value and therefore the most statistically accurate is NRSG/NBSG = 1.90. 2.2. HST photometry Since the method uses full spectral synthesis, blends are automatically accounted for and it is possible to access a wide variety of elements: α-abundances (Mg, Si, Ca, Ti), Fe-peak ele- ments (Cr, Mn, Fe, Ni, and Sc), heavy elements (Cu, Zn, Zr, Ba, and Eu), and lighter elements such as Na. The photometry data were obtained with the Advanced Camera for Surveys (ACS) onboard HST, for the programme GTO-9300 (P.I.: H. Ford). This provided us with F555W and F814W bands, which can be approximated to V and I (see Fig. 2). The exposure time was 390 s (3 × 130) for both ﬁlters. These data were previ- ously used in Larsen et al. (2008) and the photometry is taken directly from it. As described in this paper, the photometry was foreground extinction-corrected and is not insigniﬁcant in the blue-optical (AV = 1.74 Israel 1988). The available NGC 1569- The blending of the lines is an important detail and a main challenge for the IL spectrum analysis. The Larsen et al. (2012) method was previously applied to high-resolution spectra of GCs, however, young stellar clusters such as NGC 1569-B tend to have a higher degree of blending compared to metal-poor, old A159, page 3 of 16 A&A 666, A159 (2022) 3 2 1 0 1 2 3 F555W-F814W 9 8 7 6 5 4 3 2 1 F555W logT=7.40 photometry bins Fig. 2. CMD of NGC 1569-B using ACS photometry (black dots), with an isochrone (over plotted in blue) of logarithmic age 7.4 (25 Myrs) and Z = 0.008 from the Padua catalogue (Girardi et al. 2000). Red empty circles show the theoretical isochrone bins used for the HRD ﬁle (Girardi et al. 2000). Table 2. Newly added lines to the analysis. Element/molecule Wavelength [Å] Reference Ti 4293.0–4315.0 1 4397.0–4429.0 1 4442.0–4475.0 1 4521.0–4540.0 1 4570.0–4575.0 1 TiO1 5960.0–5994.0 2 Si 4367.0–4377.0 1 4382.0–4397.0 1 4420.5–4430.5 1 4596.0–4606.0 1 4622.0–4632.0 3 4701.0–4711.0 1 4716.0–4726.0 3 4743.0–4753.0 1 4942.0–4952.0 1 Cr 4253.0–4260.0 1 4270.0–4276.0 1 4565.0–4570.0 1 4578 0 4597 0 1 Table 2. Newly added lines to the analysis. Table 2. Newly added lines to the analysis. A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B We have used 38 windows containing lines of Fei and Feii includ- ing the new wavelength regions to include the lines from the blue 1 From here onwards the index at the bottom of the element abundance 5160 5165 5170 5175 5180 5185 5190 Wavelength (Å) 0.8 0.9 1.0 1.1 Flux Fe I Nd II Fe I Fe I Mg I Fe I Ni I Ni I Fe I Fe II Fe I Fe I Mg I Ti I Ni I Mg I Fe I Ti II Ti I Fe I Ti II Ca I observation only RSG only BSG model NRSG/NBSG=1.24 model NRSG/NBSG=1.53 model NRSG/NBSG=1.90 Fig. 4. Fit for the window with Mg B triplet lines, plotted as in Fig. 3. Fig. 4. Fit for the window with Mg B triplet lines, plotted as in Fig. 3. Section 5.5.2 shows that the isochrones reproduce the observed fraction of light from the RSGs quite well. However, for this particular spectral data the χ2 argument favours the higher ratio. For some elements, there is some disagreement between the blue and the red part of the spectrum (see the bot- tom plot in Fig. 6 or the numerical values for Ca and Cr in the Table B.1). In general, the scatter in abundances increases towards the blue where the light is increasingly dominated by BSG and MS stars. The uncertainties on the ﬁnal abundance ratios are the weighted standard deviation average; this way, all the scatter is accounted for (see Sect. 4.2). The separate abun- dance values for every ﬁtted wavelength window are listed in the Table B.1. Windows for which the spectral ﬁtting procedure failed to converge to a value within an allowed margin (e.g., −1 < [X/Fe] < +1) are marked as “−”. The individual errors tabulated are the formal errors based on the χ2 analysis. 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Ratio of red to blue SGs 3.8 4.0 4.2 4.4 4.6 4.8 5.0 2 total mean reduced 2 mean reduced 2 for Fe mean reduced 2 for Ti 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Ratio of red to blue SGs 3.8 4.0 4.2 4.4 4.6 4.8 5.0 2 total mean reduced 2 mean reduced 2 for Fe mean reduced 2 for Ti Fig. 5. Diﬀerent ratios of NRSG/NBSG vs. the reduced χ2 values derived for the runs with these red-to-blue SG stars ratios. 1 From here onwards the index at the bottom of the element abundance indicates the ratio of red-to-blue SGs used to derive this value. A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Ratio of red to blue SGs 3.8 4.0 4.2 4.4 4.6 4.8 5.0 2 total mean reduced 2 mean reduced 2 for Fe mean reduced 2 for Ti Fig. 5. Diﬀerent ratios of NRSG/NBSG vs. the reduced χ2 values derived for the runs with these red-to-blue SG stars ratios. χ2 values were summed over all Ti and Fe lines that were ﬁtted. The values of Fe χ2 best model ﬁts are in blue, Ti χ2 values in orange, and the combined χ2 values in red. from Larsen et al. (2011), and 1.90 – based on the best χ2 value Section 5.5.2 shows that the isochrones reproduce the observed fraction of light from the RSGs quite well. However, for this particular spectral data the χ2 argument favours the higher ratio. For some elements, there is some disagreement between the blue and the red part of the spectrum (see the bot- tom plot in Fig. 6 or the numerical values for Ca and Cr in the Table B.1). In general, the scatter in abundances increases towards the blue where the light is increasingly dominated by BSG and MS stars. The uncertainties on the ﬁnal abundance ratios are the weighted standard deviation average; this way, all the scatter is accounted for (see Sect. 4.2). The separate abun- dance values for every ﬁtted wavelength window are listed in the Table B.1. Windows for which the spectral ﬁtting procedure failed to converge to a value within an allowed margin (e.g., −1 < [X/Fe] < +1) are marked as “−”. The individual errors tabulated are the formal errors based on the χ2 analysis. We derive sub-solar iron abundance ratios of [Fe/H]1.24 = −0.57 ± 0.05, [Fe/H]1.53 = −0.68 ± 0.04, and [Fe/H]1.90 = −0.74 ± 0.05 for 1.24, 1.53, and 1.90 ratios, respectively1. from Larsen et al. (2011), and 1.90 – based on the best χ2 value from iteratively ﬁtting the spectrum (Fig. 5). A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B 4500.0 4502.5 4505.0 4507.5 4510.0 4512.5 4515.0 4517.5 4520.0 Wavelength (Å) 0.9 1.0 1.1 Flux Cr I Ti II Cr I Ti II Ti II Ti II Ti II Ti II Nd II Mn I Mn I Mn I Mn I Fe I Ti I Fe I Zr I Fe II Fe I Fe I Cr I Ti I Fe I Fe I Cr I Fe I Fe II Fe I Fe I Ti I Ti II Fe I Ti I observation only RSG only BSG model NRSG/NBSG=1.24 model NRSG/NBSG=1.53 model NRSG/NBSG=1.90 4975.0 4977.5 4980.0 4982.5 4985.0 4987.5 4990.0 4992.5 4995.0 Wavelength (Å) 0.9 1.0 1.1 Flux Ti I Ni I Ni I Ti I Ti I Fe I Fe I Ni I Ni I Ti I Fe I Fe I Fe I Ni I Fe I Fe I Fe I Fe I Ti I Ti I Fe I Fe I observation only RSG only BSG model NRSG/NBSG=1.24 model NRSG/NBSG=1.53 model NRSG/NBSG=1.90 5960 5965 5970 5975 5980 5985 5990 5995 Wavelength (Å) 0.9 1.0 1.1 Flux Ti I Fe I Ti I Fe I observation only RSG only BSG model NRSG/NBSG=1.24 model NRSG/NBSG=1.53 model NRSG/NBSG=1.90 Fig. 3. Example of the ﬁts for three diﬀerent Ti windows, grey is the observed spectrum, red is the model with no BSGs, blue is the model with no RSGs, yellow is the model with NRSG/NBSG = 1.24, light blue is the model with NRSG/NBSG = 1.53, and orange is the model with NRSG/NBSG = 1.90. Fig. 3. Example of the ﬁts for three diﬀerent Ti windows, grey is the observed spectrum, red is the model with no BSGs, blue is the model with no RSGs, yellow is the model with NRSG/NBSG = 1.24, light blue is the model with NRSG/NBSG = 1.53, and orange is the model with NRSG/NBSG = 1.90. 5160 5165 5170 5175 5180 5185 5190 Wavelength (Å) 0.8 0.9 1.0 1.1 Flux Fe I Nd II Fe I Fe I Mg I Fe I Ni I Ni I Fe I Fe II Fe I Fe I Mg I Ti I Ni I Mg I Fe I Ti II Ti I Fe I Ti II Ca I observation only RSG only BSG model NRSG/NBSG=1.24 model NRSG/NBSG=1.53 model NRSG/NBSG=1.90 Fig. 4. Fit for the window with Mg B triplet lines, plotted as in Fig. 3. 4.1. Chemical abundances We derived the abundances for a number of individual elements from the NGC 1569-B IL spectrum, starting with the elements with the highest number of lines. The ﬁrst step was to ﬁt for the broadening and overall scaling of the solar reference abun- dances, [Z/H], modelling the whole wavelength range for every order. Once derived, the broadening can be ﬁxed for all the sub- sequent runs of this YMC. The ﬁrst individual element to ﬁt is Fe since it has the largest number of absorption lines, we subse- quently ﬁt for Ti and so on. This procedure allows us to obtain the individual element abundances values for NGC 1569-B (Table B.1). Table 3 lists all the values of the averaged abun- dances derived for three diﬀerent ratios of red to blue SGs: 1.24 – the original ratio from the isochrone, 1.53 – the observed ratio The RSGs and BSGs bins were selected using the surface gravity and eﬀective temperature from an isochrone: log(g) ≤ A159, page 4 of 16 A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B from Larsen et al. (2011), and 1.90 – based on the best χ2 value from iteratively ﬁtting the spectrum (Fig. 5). 4.2. Uncertainties Each element had a number of spectral windows ﬁtted. Table B.1 provides the full list of wavelength ranges, the derived values, and their uncertainties from iSPy3. Those values were then com- bined to produce the ﬁnal value for single elements. The values and uncertainties listed in the Table 3 are the weighted average of the values derived for the spectral windows for every individual element: 6250 Wavelength (Å) g 4250 4500 4750 5000 5250 5500 5750 6000 Wavelength (Å) 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 [Ti/Fe] 0.51 ± 0.05 0.53 ± 0.05 0.49 ± 0.05 ⟨[X/Fe]⟩= P wi[X/Fe]i P wi , (1) (1) where the weights are deﬁned as where the weights are deﬁned as wi = 1 σ2 i + σ2 0 , (2) (2) and where σ0 = 0.05 dex is used to account for non-random uncertainties on the derived individual window abundances. Then the uncertainties were calculated using the following for- mula: Fig. 6. [Fe/H] abundances derived for each of the ﬁtted wavelength win- dows, shown at the top. The blue dots represent NRSG/NBSG = 1.24, the red points – NRSG/NBSG = 1.53, and yellow – NRSG/NBSG = 1.90 runs. The lines of corresponding colours indicate the averaged values of [Fe/H] for there runs. [Ti/Fe] abundances derived for each of the ﬁt- ted wavelength regions shown at the bottom. The blue dots represent NRSG/NBSG = 1.24, the red points – NRSG/NBSG = 1.53, and yellow – NRSG/NBSG = 1.90 runs. The lines of corresponding colours indicate the averaged values of [Ti/Fe] for there runs. σ⟨X⟩= X wi −1/2. (3) (3) A diﬀerent approach is to take the standard errors (S X) on the mean of the weighted standard deviations (S DX,w): SDX,w = " N N −1 P(X/Fei −⟨X/Fe⟩)2wi P wi #1/2 , (4) S X = S DX,w/ √ N. (5) (4) part of the spectrum (see Table 2). The α-abundances, [⟨Mg, Si, Ca, Ti⟩/Fe], for all of the ratios are ‘super-solar’, with a mean α-element enhancement of [α/Fe]1.90 = +0.25 ± 0.11. S X = S DX,w/ √ N. (5) The comparison between the random and systematic uncertain- ties are listed in Table 4. In particular, σ⟨X⟩is always lower than S X, except for the errors of Cu (this element had a single spec- tral window). A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B The listed errors are weighted standard deviation average (S X). g g 4250 4500 4750 5000 5250 5500 5750 6000 6250 Wavelength (Å) 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 [Fe/H] -0.57 ± 0.05 -0.68 ± 0.04 -0.74 ± 0.05 4250 4500 4750 5000 5250 5500 5750 6000 Wavelength (Å) 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 [Ti/Fe] 0.51 ± 0.05 0.53 ± 0.05 0.49 ± 0.05 Fig. 6. [Fe/H] abundances derived for each of the ﬁtted wavelength win- dows, shown at the top. The blue dots represent NRSG/NBSG = 1.24, the red points – NRSG/NBSG = 1.53, and yellow – NRSG/NBSG = 1.90 runs. The lines of corresponding colours indicate the averaged values of [Fe/H] for there runs. [Ti/Fe] abundances derived for each of the ﬁt- ted wavelength regions shown at the bottom. The blue dots represent NRSG/NBSG = 1.24, the red points – NRSG/NBSG = 1.53, and yellow – NRSG/NBSG = 1.90 runs. The lines of corresponding colours indicate the averaged values of [Ti/Fe] for there runs. 4250 4500 4750 5000 5250 5500 5750 6000 6250 Wavelength (Å) 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 [Fe/H] -0.57 ± 0.05 -0.68 ± 0.04 -0.74 ± 0.05 is derived to be +0.50 ± 0.11. Cu was determined using the 5105 Å Cui line, while the other frequently used line at 5782 Å coincides with a diﬀuse interstellar band and was not included. Four windows with Baii lines, at 4554, 5854, 6142, and 6497 Å, were used to determine [Ba/Fe]. The resulting Ba abun- dance ratios indicate an extremely super-solar ratio, [Ba/Fe] = +1.28 ± 0.14. A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B χ2 values were summed over all Ti and Fe lines that were ﬁtted. The values of Fe χ2 best model ﬁts are in blue, Ti χ2 values in orange, and the combined χ2 values in red. Fig. 5. Diﬀerent ratios of NRSG/NBSG vs. the reduced χ2 values derived for the runs with these red-to-blue SG stars ratios. χ2 values were summed over all Ti and Fe lines that were ﬁtted. The values of Fe χ2 best model ﬁts are in blue, Ti χ2 values in orange, and the combined χ2 values in red. We derive sub-solar iron abundance ratios of [Fe/H]1.24 = −0.57 ± 0.05, [Fe/H]1.53 = −0.68 ± 0.04, and [Fe/H]1.90 = −0.74 ± 0.05 for 1.24, 1.53, and 1.90 ratios, respectively1. We have used 38 windows containing lines of Fei and Feii includ- ing the new wavelength regions to include the lines from the blue from Larsen et al. (2011), and 1.90 – based on the best χ2 value from iteratively ﬁtting the spectrum (Fig. 5). 1 From here onwards the index at the bottom of the element abundance indicates the ratio of red-to-blue SGs used to derive this value. A159, page 5 of 16 A&A 666, A159 (2022) Table 3. Individual element abundances derived for three diﬀerent ratio of red-to-blue SGs. Table 3. Individual element abundances derived for three diﬀerent ratio of red-to-blue SGs. Table 3. Individual element abundances derived for three diﬀerent ratio of red-to-blue SGs. NRSG/NBSG [Fe/H] [Mg/Fe] [Ca/Fe] [Ti/Fe] [Si/Fe] [α/Fe] 1.24 −0.57 ± 0.05 +0.04 ± 0.10 +0.42 ± 0.14 +0.51 ± 0.05 +0.04 ± 0.15 +0.25 ± 0.11 1.53 −0.68 ± 0.04 +0.13 ± 0.08 +0.32 ± 0.16 +0.53 ± 0.05 +0.09 ± 0.18 +0.27 ± 0.12 1.90 −0.74 ± 0.05 +0.22 ± 0.05 +0.16 ± 0.16 +0.49 ± 0.05 +0.15 ± 0.18 +0.25 ± 0.11 NRSG/NBSG [Cr/Fe] [Mn/Fe] [Sc/Fe] [Ba/Fe] [Ni/Fe] [Cu/Fe] 1.24 +0.61 ± 0.12 +0.03 ± 0.17 +0.95 ± 0.16 +1.28 ± 0.21 +0.40 ± 0.14 +0.21 ± 0.17 1.53 +0.55 ± 0.11 −0.17 ± 0.14 +0.87 ± 0.19 +1.27 ± 0.19 +0.23 ± 0.12 −0.03 ± 0.19 1.90 +0.50 ± 0.11 −0.22 ± 0.12 +0.78 ± 0.20 +1.28 ± 0.14 +0.13 ± 0.11 −0.17 ± 0.18 Notes. The listed errors are weighted standard deviation average (S X). Notes. The listed errors are weighted standard deviation average (S X). Notes. 4.2. Uncertainties This indicates that the errors calculated using the weighted average tend to underestimate the uncertainties, even if the ﬂoor value is used (σ0). Therefore, weighted standard devi- ation average errors are used as a more accurate estimate of the true uncertainties. The abundances of Fe-peak elements Cr, Mn, Ni, and Sc were determined from a collection of spectral lines. [Mn/Fe] and [Ni/Fe] are sub-solar and slightly super-solar, respectively ([Mn/Fe] = −0.22 ± 0.12 and [Ni/Fe] = +0.13 ± 0.11), while [Cr/Fe] and [Sc/Fe] abundance ratios are found to be super- solar. In particular, Sc appears to be high for all three val- ues of NRSG/NBSG: [Sc/Fe]1.24 = +0.95 ± 0.16, [Sc/Fe]1.53 = +0.87±0.19, and [Sc/Fe]1.90 = +0.78±0.20. The value of [Cr/Fe] A159, page 6 of 16 A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B SF timescale, [α/Fe] is also sensitive to the ratio of former SNII to SNIa and, therefore, to the ratio of massive stars to intermedi- ate mass binaries. As soon as the SNIa start to contribute, [α/Fe] decreases. This happens due to the longer time scale of SNIa compared to SNII, on a plot of [α/Fe] vs. [Fe/H] this feature is referred to as the ‘knee’. The ratio decreases because the main products from SNII are α-elements, in contrast to SNIa, which mainly produce Fe and only a few α-elements (Tolstoy et al. 2009). Table 4. Error table. Table 4. Error table. Abundance ratio Weighted average σ⟨X⟩ S X [Fe/H] −0.74 0.01 0.05 [Mg/Fe] +0.22 0.03 0.05 [Ca/Fe] +0.16 0.03 0.16 [Ti/Fe] +0.49 0.02 0.05 [Si/Fe] +0.15 0.04 0.18 [α/Fe] +0.25 0.03 0.11 [Cr/Fe] +0.50 0.02 0.11 [Mn/Fe] −0.22 0.04 0.12 [Sc/Fe] +0.78 0.04 0.20 [Ba/Fe] +1.28 0.06 0.14 [Ni/Fe] +0.13 0.03 0.11 [Cu/Fe] −0.17 0.18 0.18 Our observations show that NGC 1569-B is α-enhanced with a super-solar abundance of [α/Fe] = +0.25 ± 0.11, which resembles the α-abundances of NGC 1705-1 and the SSC in NGC 6946 ([αFe] = +0.32 ± 0.12 and [α/Fe] = +0.22 ± 0.11) α abundances. Figure 7 shows the α-abundance versus the iron abundance. These abundance ratios indicate a rapid and bursty SF, where chemical enrichment is dominated by SNII, which have a massive progenitor star and a short life (McWilliam 1997). 5. Discussion Observations of ﬁeld stars and star clusters indicate that NGC 1569 experienced a major recent burst of SF about 25 Myr ago (Greggio et al. 1998; Anders et al. 2004). According to the chemical evolution models from Romano et al. (2006), follow- ing such bursty SF the cluster would be enriched with α ele- ments, which is consistent with the enhanced α-element abun- dances that we measure ([α[Fe] = +0.25 ± 0.11). Currently, we have no information about abundance variations between the ﬁeld star populations in NGC 1569 and its YMCs, NGC 1569-A, and NGC 1569-B. Therefore, it would be interesting to search for signatures of a bursty SFH also in other clusters of this dwarf galaxy. In addition to atomic Tii and Tiii lines, we also ﬁt the TiO1 band, which is sensitive to Teﬀand the IMF. The derived Ti abun- dances using only the TiO1 molecular band for three diﬀerent ratios are: [Ti/Fe]1.24 = +0.31 ± 0.04, [Ti/Fe]1.53 = +0.34 ± 0.04, and [Ti/Fe]1.90 = +0.33 ± 0.04, which behaves similarly to the overall α-abundance ratio. This behaviour of the TiO band com- pared to the total Ti abundance ratio is expected because as we go redder the RSGs will increasingly dominate, making the analysis less sensitive to the ratio of RSG to BSG stars. TiO1 is slightly more sensitive than TiO2 to [Ti/Fe] (La Barbera et al. 2013). This method only uses the IMF from Salpeter (1955), hence, the above stated values might change if a diﬀerent IMF is used. However, given that we haven’t explored other IMF choices, it is currently unclear how strong the constraint on the IMF from the TiO bands is for NGC 1569-B. Analyses of the blue part of the spectrum are not a com- mon method for studying young stellar populations such as NGC 1569-B (usually studied using the IR band), due to chal- lenges inherent in modelling BSG stars. This aspect can be clearly seen in Fig. 6, where the scatter in individual elements in blue region is signiﬁcantly larger than that seen at redder wave- lengths. However, the blue region of the IL spectrum not only provides more lines for abundance analysis, but it also helps with determining and constraining the blue-to-red SGs ratios. 5.3. Fe-peak element abundances The Fe-peak element abundances are shown in (Fig. 9). These elements are the heaviest elements produced through thermonu- clear reactions in SNIa and massive stars (Kobayashi et al. 2020; Minelli et al. 2021). The abundances derived for the Cr and Mn are close to the values of the extragalactic YMCs. The [Mn/Fe] value of NGC 1569-B and that of NGC 1705-1 are in good agreement, while the [Cr/Fe] abundance more closely resembles that of NGC 1313-379. The value of Ni for NGC 1569-B lies closer to the MW and LMC environ- ments, while the derived values of [Ni/Fe] in NGC 1705-1 and NGC 1313-379 show enrichment in Ni. The high val- ues of Ni in these YMCs were discussed in Hernandez et al. (2017), oﬀering two possible explanations: either there is a dif- ferent contribution from massive stars and SNIa in these clus- ters versus the contribution in the MW and LMC or due to the inclusion of a 7700–7800 Å bin, which increased the ﬁnal value. In particular, if the bin was excluded from the calcula- tion, the [Ni/Fe] values for NGC 1705-1 and NGC 1313-379 5.1. Iron abundance The iron abundance derived previously in the literature for NGC 1569-B, namely, [Fe/H] = −0.63 ± 0.08, is in agreement with the iron abundances derived with NRSG/NBSG = 1.24 and NRSG/NBSG = 1.53 (Larsen et al. 2008). The values of [Fe/H] derived decrease as the ratio or red-to-blue SGs increases. This behaviour is expected, as the more the RSGs the stronger the stellar lines (see Sect. 5.5). Even though the isochrone repro- duces the photometry light (see Sect. 5.5.2), the ﬁnal value for the iron abundance is the one obtained with the ratio 1.90 as it is statistically favoured for these spectroscopic data, [Fe/H] = −0.74 ± 0.05. 5. Discussion Thus, while it is not perhaps the most eﬃcient wavelength range for abundance analysis, it still gives us additional constraints on the properties of the BSG and MS stars and remains to be fully explored. 4.2. Uncertainties Individual α-elements are consistent with other YMCs pre- viously studied, such as NGC 1705-1 whose abundance ratios [Mg/Fe], [Ca/Fe], and [Ti/Fe] resemble those in NGC 1569-B very closely (see Fig. 8), as expected in the bursty models from Romano et al. (2006). For [Si/Fe] Fig. 8 suggests the similarity with Fornax, LMC, and MW thick disk, however, these stars are older and currently there are no YMCs with a similar [Fe/H]. Therefore, it is more diﬃcult to conclude whether this super- solar value of [Si/Fe] is expected, nevertheless this α element is close to the total α-abundance. 5.4. Heavy elements abundances Heavy elements are those with atomic number Z > 30 (e.g., Ba and Eu) and they are neutron-capture elements. In this study, we derived a very high abundance ratio of Ba (the fourth plot in Fig. 9). Ba is an s-process element, which is produced mainly in low-mass asymptotic giant branch (AGB) stars (1–3 M⊙) (Busso et al. 1999). However, it is highly unlikely that AGB stars would be present in a young population of 15–25 Myrs. Unlike the case of Sc, all of the ﬁtted spectral windows yield consis- tently high Ba values, which suggests that it is a more reliable measurement. One possible explanation for such a high value of [Ba/Fe] could be pollution of the ISM in NGC 1569 coming from AGB stars belonging to earlier bursts of SF. The main outlier is the abundance ratio of Sc (produced in both SNIa and SNII), which seems extremely enhanced. We considered that this might be caused by an issue in measure- ment. However, despite changing the ﬁtting combinations of the spline function used for continuum matching of the observed and model spectra (e.g., the power and the number of knots), [Sc/Fe] remained high at all times. We see a large range of Sc values across the various spectral window regions which might indicate that our Sc measurements are quite uncertain. For example, if we would exclude the spectral windows at 5522.2– 5531.0 Å and 5638.0–5690.0 Å, the value of [Sc/Fe] would become 0.17 ± 0.08, which places it very close to the stars of NGC 1705-1 with a Sc abundance ratio of 0.192 ± 0.052. The analysis of NGC 1705-1 had only a single window ﬁtted between 6222.0 and 6244.0 Å, therefore, there is no overlap in the two analyses for Sc. g g The Ba abundance is often diﬀerent from the MW disk stars. For example, in Van der Swaelmen et al. (2013) [BaII/FeI] increases along with an increase of metallicity in the LMC bar, which indicates that LMC chemical enrichment was slower than the one of the MW. Other high values of Ba were obtained for Fornax, which is dominated by slow neutron capture (s-process) at iron-abundance of ≈−1; this shows the strong role of the (metal-poor) AGB in its evolution (Letarte 2007). A minor con- tribution of Ba comes from massive stars (Busso et al. 1999). 5.2. α element abundances Generally, [α/Fe] is a commonly used tracer for a system’s timescale of star-formation. In addition to the dependency on A159, page 7 of 16 A&A 666, A159 (2022) A&A 666, A159 (2022) 2.0 1.5 1.0 0.5 0.0 0.5 [Fe/H] 0.2 0.0 0.2 0.4 [ /Fe] MW thin disk (Reddy et al. 2003) MW thick disk (Reddy et al. 2006) MW disk (Bensby et al. 2005) Fornax LMC bar LMC disc M31 GCs NGC1705-1 NGC1313-379 NGC6946 NGC1569-B (this work) Fig. 7. [α/Fe] plotted against iron abundance, [Fe/H]. Turquoise rhombus refers to this work; red triangles show the alpha abundances estimated for NGC 1313-379; red squares display the measurements for NGC 1705-1 (Hernandez et al. 2017); red circles display the measurements for the SSC in NGC 6946 (Larsen et al. 2006); green circles show the abundance of the M 31 GCs from Colucci et al. (2009); red crosses and black Xs present MW disc abundances from Reddy et al. (2003, 2006), respectively; black open circles are the MW disc abundances from Bensby et al. (2005); teal triangles are the abundances of the individual stars in the centre of the Fornax dwarf spheroidal galaxy (Letarte et al. 2010); blue squares and stars belong to LMC bar and inner disc abundances presented by Van der Swaelmen et al. (2013). 2.0 1.5 1.0 0.5 0.0 0.5 [Fe/H] 0.2 0.0 0.2 0.4 [ /Fe] MW thin disk (Reddy et al. 2003) MW thick disk (Reddy et al. 2006) MW disk (Bensby et al. 2005) Fornax LMC bar LMC disc M31 GCs NGC1705-1 NGC1313-379 NGC6946 NGC1569-B (this work) Fig. 7. [α/Fe] plotted against iron abundance, [Fe/H]. Turquoise rhombus refers to this work; red triangles show the alpha abundances estimated for NGC 1313-379; red squares display the measurements for NGC 1705-1 (Hernandez et al. 2017); red circles display the measurements for the SSC in NGC 6946 (Larsen et al. 2006); green circles show the abundance of the M 31 GCs from Colucci et al. (2009); red crosses and black Xs present MW disc abundances from Reddy et al. (2003, 2006), respectively; black open circles are the MW disc abundances from Bensby et al. (2005); teal triangles are the abundances of the individual stars in the centre of the Fornax dwarf spheroidal galaxy (Letarte et al. 2010); blue squares and stars belong to LMC bar and inner disc abundances presented by Van der Swaelmen et al. (2013). 5.2. α element abundances would become +0.25 and +0.31, respectively – instead of +0.74 ± 0.49 and +0.46 ± 0.14 (as shown at the bottom plot of Fig. 9). 5.4. Heavy elements abundances Conceivably, at low Z, the Ba peak nuclei do not receive the main contribution from the AGB stars, but from the short-lived mas- sive stars instead. These stars produce heavy r-process nuclei that dominate the contribution (Truran 1981; Cowan et al. 1996; Busso et al. 1999). Neither of the previously studied SSCs and YMCs have shown such high abundance ratios for this element (see the top plot in Fig. 9). It is true that Sc is often a tracer of α-abundance and while we do ﬁnd that [α/Fe] is enhanced, this does not fully explain the high value of [Sc/Fe]. If the derived enhancement of Sc is real, this would imply that the contribution from SNIa and SNII in NGC 1569-B diﬀers from the contributions in the MW, LMC, and other studied galaxies. A159, page 8 of 16 A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569 B 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.4 0.2 0.0 0.2 0.4 [Mg/Fe] MW thin disk (Reddy et al. 2003) MW thick disk (Reddy et al. 2006) MW disk (Bensby et al. 2005) LMC bar LMC disk Fornax NGC 6946 NGC 1705-1 NGC 1313-379 NGC 1569-B (this work) 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.50 0.25 0.00 0.25 0.50 [Ca/Fe] 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.2 0.0 0.2 0.4 0.6 [Ti/Fe] 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 [Fe/H] 0.50 0.25 0.00 0.25 0.50 0.75 [Si/Fe] ig. 8. Individual α-elements plotted against iron abundance, [Fe/H]. Top: [Mg/Fe] vs. [Fe/H]. Second row: [Ca/Fe] vs. [Fe/H]. Third row: [Ti/Fe s. [Fe/H]. Bottom: [Si/Fe] vs. [Fe/H]. Symbols as in Fig. 7. Fig. 8. Individual α-elements plotted against iron abundance, [Fe/H]. Top: [Mg/Fe] vs. [Fe/H]. Second row: [Ca/Fe] vs. [Fe/H]. Third row: [Ti/Fe] vs. [Fe/H]. Bottom: [Si/Fe] vs. [Fe/H]. Symbols as in Fig. 7. 5.5. Red-to-blue supergiants scopically conﬁrmed the increase of this ratio when the metal- licity decreases, additionally providing a normalised relation. A study of this ratio in stellar clusters (in the MW, the LMC and the SMC) was performed by Meylan & Maeder (1982), who reach a similar conclusion, namely, that the ratio of red-to-blue decreases steeply with increasing metallicity. These authors found a dif- ference in the ratio between the MW and the SMC of approxi- mately an order of magnitude. These results were revisited and corrected for incompleteness by Humphreys & McElroy (1984) who found that the centre of the MW has a red-to-blue SGs ratio that is ten times lower than of the SMC. In summary, the 5.5.1. Constraints on trends with metallicity from ﬁeld stars in different environments 5.5.1. Constraints on trends with metallicity from ﬁeld stars in different environments The red-to-blue SGs ratio greatly inﬂuences the IL spectra of young stellar populations. However, it is extremely sensitive to details of the stellar evolution models such as the mass loss, con- vection, and mixing processes, and this has posed a problem in stellar astrophysics for some time (Langer & Maeder 1995). This ratio was ﬁrst shown to vary signiﬁcantly among diﬀerent galax- ies by van den Bergh (1968). Eggenberger et al. (2002) spectro- A159, page 9 of 16 A&A 666, A159 (2022) A&A 666, A159 (2022) 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.5 0.0 0.5 [Sc/Fe] MW thin disk (Reddy et al. 2003) MW thick disk (Reddy et al. 2006) LMC bar LMC disk NGC1705-1 NGC1313-379 NGC1569-B (this work) 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.5 0.0 0.5 [Cr/Fe] MW disk (Bensby et al. 2005) Fornax 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.6 0.4 0.2 0.0 0.2 [Mn/Fe] 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.5 0.0 0.5 1.0 1.5 [Ba/Fe] 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 [Fe/H] 0.5 0.0 0.5 1.0 [Ni/Fe] peak and heavy elements plotted against iron abundance, [Fe/H]. Top: [Sc/Fe] vs. [Fe/H]. Second row: [Cr/Fe] vs. [Fe/ [Fe/H]. Fourth row: [Ba/Fe] vs. [Fe/H]. Bottom: [Ni/Fe] vs. [Fe/H]. Symbols as in Fig. 7. e SGs ratio is a decreasing function of metallicity, med by studies in the MW, the Magellanic Clouds, Triangulum galaxy, M 33 (Robertson 1973, 1974; van den Bergh 1974; Ivanov 1998). A study of NGC 1569-B using the CMD h signiﬁcant diﬀerence between the observed and t (with single stellar populations (SSP) and multipl to-blue SG ratios, the latter being three times 10 of 16 Fig. 9. Fe-peak and heavy elements plotted against iron abundance, [Fe/H]. Top: [Sc/Fe] vs. [Fe/H]. Second row: [Cr/Fe] vs. [Fe/H]. Third row: [Mn/Fe] vs. [Fe/H]. Fourth row: [Ba/Fe] vs. [Fe/H]. Bottom: [Ni/Fe] vs. [Fe/H]. Symbols as in Fig. 7. red-to-blue SGs ratio is a decreasing function of metallicity, as conﬁrmed by studies in the MW, the Magellanic Clouds, and the Triangulum galaxy, M 33 (Robertson 1973, 1974; Hagen & van den Bergh 1974; Ivanov 1998). 5.5.3. Abundance trends for varying red-to-blue supergiant ratios The abundance trends seen with the increase of the NRSG/NBSG ratio act in an expected manner. Particularly there is an appar- ent decrease in metallicity as NRSG/NBSG increases. This occurs because in general, the spectral lines become stronger as a greater number of RSGs dominate the spectrum. To compensate, the abundances have to decrease to match the observed spec- trum. However, α-abundance ratios relative to Fe stays approxi- mately constant since the abundances of two of the α elements, [Mg/Fe] and [Si/Fe], increase as the ratio increases, while two other element abundances, [Ca/Fe] and [Ti/Fe], decrease. The rest of the element abundance ratios relative to Fe measured tend to decrease with the increase of the NRSG/NBSG. In the recent past, the study of red and blue SGs became one of the fundamental ways to explore the extragalactic young stellar populations. This tool allows one to obtain accurate abun- dance measurements outside of the Local Group (Bresolin et al. 2006; Bergemann et al. 2013; Gazak et al. 2014). The advan- tage of working with the RSGs is that the IL spectrum of a stellar cluster can be modelled with a single red SG star, sim- ply because the NIR continuum of young stellar populations is almost entirely dominated by RSG stars (Davies et al. 2013). This approach to modelling the IL as a single RSG was used in Larsen et al. (2008) to study NGC 1569-B in the NIR. The ratio of red-to-blue SGs within the isochrone uses an SSP which does not always describe the population of this YMC accurately. For our case, the isochrone ratio was not the optimal one since it lead to signiﬁcantly poorer solutions in the spec- tral ﬁt although it reproduced the observed fraction of light from RSGs quite well. We also explored NRSG/NBSG derived from the photometry in Larsen et al. (2011). However, this photometry was not of ideal quality, hence, the task of resolving and sift- ing the members of the cluster was challenging. The ﬁnal ratio used was derived from the minimum χ2 method using the spec- troscopic data available. We decided to use the set of abundance ratios derived with this approach (with NRSG/NBSG = 1.90), because it was determined statistically for the data used in this study. 5.5.2. Fraction of light versus wavelength (NGC 1569-B photometry vs. isochrone) The reason why the red-to-blue SG ratio is crucial for NGC 1569-B is that it is too young to have AGB or RGB stars. Therefore, most of the light of its spectrum comes from the RSGs and BSGs. Moreover, the impact of BSGs becomes more important at optical wavelengths, compared to previous studies in the IR, and must be properly taken into account. A key dif- ﬁculty in implementing red and blue SGs in this analysis is the disagreement between the stellar evolution tracks and the obser- vations. Evolutionary tracks tend to underestimate the extent of blue loops (He burning stage). The isochrones suggest a gap in the CMD between the H and He burning stellar stages – the BHG (Mengel et al. 1979). However, this gap is not always clear in the CMD, which results in larger uncertainties of the observed NRSG/NBSG, rather than when the uncertainties are predicted by Poissonian errors. The availability of the photometry can help to constrain some of the stellar types, for instance, BSGs or RSGs. However, not all targets have observed photometry or it is simply not possi- ble to obtain the photometric data. For these cases, the solution with a total χ2 of varying the ratio of the most luminous stel- lar types (such as BSGs and RSGs for the YMCs) might help in determining the favoured and optimal solution. Additionally, a comparison among the blue and the red sides of spectrum might provide a useful route to determine the ratio in the integrated spectrum. In our spectral analysis, the ratio of red-to-blue SGs can be varied within the input ﬁle containing the stellar population of the cluster, HRD ﬁle. We altered the ratio while keeping the total sum of the SG stars constant. Keeping the total number of SGs constant while varying the NRSG/NBSG ratio is motivated by the fact that the total amount of time a star spends as a SG (blue or red) is determined mainly by the total luminosity and amount of fuel available. Since the (bolometric) luminosity does not vary signiﬁcantly between the BSG and RSG phases, we then expect that the total number of SGs is roughly independent of the ratio. 5.5.1. Constraints on trends with metallicity from ﬁeld stars in different environments A study of NGC 1569-B using the CMD has shown a signiﬁcant diﬀerence between the observed and the simulated (with single stellar populations (SSP) and multiple-bursts) red- to-blue SG ratios, the latter being three times smaller for A159, page 10 of 16 A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B NGC 1569-B (Larsen et al. 2011). The number of observation- ally detected BSGs is aﬀected by the magnitude cuts and the lack of a clear Blue Hertzsprung Gap (BHG; see below). This makes it challenging to clearly distinguish between BSGs and stars on the upper part of the main sequence. Eldridge et al. (2008) com- pared the observations with their models and found that the best results are achieved by including binary stars; otherwise, either there are too many RSGs, too few BSG, or a combination of the two issues. However, this alone is not enough to explain the observed ratios, and the challenge of the eﬀect of enhanced mass loss and rotation still stands. NGC 1569-B (Larsen et al. 2011). The number of observation- ally detected BSGs is aﬀected by the magnitude cuts and the lack of a clear Blue Hertzsprung Gap (BHG; see below). This makes it challenging to clearly distinguish between BSGs and stars on the upper part of the main sequence. Eldridge et al. (2008) com- pared the observations with their models and found that the best results are achieved by including binary stars; otherwise, either there are too many RSGs, too few BSG, or a combination of the two issues. However, this alone is not enough to explain the observed ratios, and the challenge of the eﬀect of enhanced mass loss and rotation still stands. for the photometry. Therefore, for NGC 1569-B, the isochrones reproduce the observed contributions of RSGs to the V- and I- band luminosities quite accurately. However, the fact that stars other than RSGs contribute signiﬁcantly to the light shows that full SSP modelling is indeed necessary. 5.6. Multiple populations The detailed chemical composition of a YMC can indicate the presence of MP, for example, Al variations or a strong [Na/Fe] enhancement (Lardo et al. 2017; Bastian et al. 2020). While neither of these elements were measured for NGC 1569-B, another sign for MP could be a lower [Mg/Fe] abundance when compared to [Ca/Fe] and [Ti/Fe] (Shetrone 1996; Kraft et al. 1997; Gratton et al. 2004; Colucci et al. 2009; Larsen et al. 2014). For this YMC, the derived [Mg/Fe] ratio, +0.22 ± 0.05 is not signiﬁcantly lower than [Ca/Fe] and [Ti/Fe], +0.16 ± 0.16 and +0.49 ± 0.05, respectively. Therefore, we do not ﬁnd evi- dence of MPs in NGC 1569-B. To test how well the isochrone reproduces the observed num- ber of RSGs, we calculated the total integrated magnitudes in F555W (V-band) and F814W (I-band) for the observed CMD of NGC 1569-B and for the isochrone used. For NGC 1569-B, this was measured on the HST image within the radial range 15 < r < 50 pixels, where photometry for individual RSG stars was also available. The total integrated magnitudes were compared with those of RSGs only, measured in the magnitude range of 21.0 < MV < 23.6 and for colours 2.0 < MV −MI < 3.0. 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References Chemical abundances for NGC 1569-B Element Wavelength (Å) Abundance NRSG/NBSG = 1.24 NRSG/NBSG = 1.53 NRSG/NBSG = 1.90 [Fe/H] 4170.0-4180.0 -0.243 ± 0.058 - - 4232.4-4240.0 -0.253 ± 0.050 - - 4293.0-4316.0 -0.403 ± 0.041 -0.350 ± 0.038 -0.299 ± 0.034 4400.0-4424.0 -1.003 ± 0.045 -1.055 ± 0.048 -1.095 ± 0.051 4500.0-4530.0 -0.786 ± 0.042 -0.853 ± 0.047 -0.916 ± 0.046 4573.0-4600.0 -0.828 ± 0.045 -0.964 ± 0.045 -1.042 ± 0.044 4631.0-4660.0 -0.887 ± 0.060 -0.896 ± 0.068 -1.007 ± 0.078 4706.0-4711.0 -1.007 ± 0.127 -1.116 ± 0.126 -1.216 ± 0.119 4724.0-4750.0 -0.651 ± 0.057 -0.797 ± 0.054 -0.873 ± 0.052 4869.0-4883.0 -0.568 ± 0.049 -0.639 ± 0.052 -0.718 ± 0.053 4897.0-4915.0 -1.017 ± 0.057 -1.103 ± 0.057 -1.142 ± 0.056 4918.0-4926.0 0.101 ± 0.057 - - 4936.0-4944.0 -0.513 ± 0.082 -0.667 ± 0.087 -0.765 ± 0.089 4945.5-4953.0 -0.338 ± 0.132 -0.455 ± 0.137 -0.440 ± 0.165 4963.0-4976.0 -1.361 ± 0.091 - - 5122.4-5150.0 -0.861 ± 0.036 -1.00 ± 0.037 -1.132 ± 0.036 5224.0-5235.0 -0.159 ± 0.037 -0.272 ± 0.036 -0.293 ± 0.049 5266.0-5289.0 -0.481 ± 0.022 -0.517 ± 0.024 -0.536 ± 0.027 5250.0-5259.0 -0.699 ± 0.054 -0.784 ± 0.056 -0.813 ± 0.059 5300.0-5345.0 -0.833 ± 0.021 -0.923 ± 0.022 -1.007 ± 0.022 5358.0-5375.0 -0.216 ± 0.022 -0.248 ± 0.021 -0.255 ± 0.022 5378.0-5400.0 -0.686 ± 0.024 -0.769 ± 0.026 -0.811 ± 0.025 5400.0-5420.0 -0.542 ± 0.025 -0.599 ± 0.025 -0.654 ± 0.025 5420.0-5449.0 -0.236 ± 0.016 -0.270 ± 0.019 -0.257 ± 0.018 5460.0-5475.5 -1.022 ± 0.057 -1.167 ± 0.056 -1.285 ± 0.051 5494.0-5510.0 -0.598 ± 0.053 -0.791 ± 0.048 -0.792 ± 0.046 5529.0-5539.0 -0.458 ± 0.040 -0.557 ± 0.038 -0.598 ± 0.037 5566.5-5590.0 -0.598 ± 0.046 -0.801 ± 0.041 -0.896 ± 0.038 5610.2-5630.0 -0.390 ± 0.052 -0.568 ± 0.047 -0.695 ± 0.044 5682.0-5708.0 -0.842 ± 0.037 -0.872 ± 0.035 -0.903 ± 0.034 A&A 666, A159 (2022) Table A.1. continued. References MASS TEFF LOGG RSTAR WEIGHT LOGVT SYNT NRSG/NBSG = 1.24 NRSG/NBSG = 1.53 NRSG/NBSG = 1.90 10.677 9772.4 1.8828 59.004 4.838e-05 4.289e-05 3.741e-05 0.602 A9S 10.694 10497.8 2.0002 50.750 6.432e-05 5.702e-05 4.974e-05 0.602 A9S 10.723 11071.3 2.0840 45.245 1.098e-04 9.737e-05 8.495e-05 0.602 A9S 10.764 10136.8 1.9261 55.671 1.533e-04 1.359e-04 1.186e-04 0.602 A9S 10.780 9313.2 1.7798 68.492 5.974e-05 5.296e-05 4.620e-05 0.602 A9S 10.791 8480.1 1.6190 82.935 4.138e-05 3.668e-05 3.200e-05 0.602 A9S 10.798 7730.4 1.4618 102.336 2.766e-05 2.452e-05 2.139e-05 0.602 A9S 10.803 7104.0 1.3192 119.728 1.852e-05 1.641e-05 1.432e-05 0.602 A9S 10.807 6478.9 1.1655 144.114 1.433e-05 1.270e-05 1.108e-05 0.602 A9S 10.810 5833.1 0.9920 176.415 1.101e-05 9.764e-06 8.518e-06 0.301 A9S 10.812 5311.3 0.8432 213.002 6.727e-06 5.963e-06 5.202e-06 0.301 A9S 10.815 4305.3 0.5574 304.855 1.287e-05 1.404e-05 1.521e-05 0.301 A9S 10.820 4102.0 0.4059 366.941 1.900e-05 2.074e-05 2.247e-05 0.301 A9S 10.822 4080.4 0.3882 374.272 6.567e-06 7.167e-06 7.764e-06 0.301 A9S 10.825 3994.8 0.2721 418.586 1.138e-05 1.242e-05 1.346e-05 0.301 MT 10.829 3879.7 0.0817 533.224 1.528e-05 1.668e-05 1.807e-05 0.301 MT 10.834 3769.6 -0.0637 630.534 1.552e-05 1.694e-05 1.835e-05 0.301 MT References Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B Appendix A: HRD FILE MASS TEFF LOGG RSTAR WEIGHT LOGVT SYNT NRSG/NBSG = 1.24 NRSG/NBSG = 1.53 NRSG/NBSG = 1.90 0.250 3742.8 5.0615 0.264 2.599e+00 2.599e+00 2.599e+00 0.301 MT 0.350 3892.2 4.9995 0.333 1.179e+00 1.179e+00 1.179e+00 0.301 MT 0.450 4037.4 4.9064 0.412 6.531e-01 6.531e-01 6.531e-01 0.301 A9S 0.550 4257.0 4.8160 0.497 4.075e-01 4.075e-01 4.075e-01 0.301 A9S 0.700 4719.5 4.6872 0.658 3.468e-01 3.468e-01 3.468e-01 0.301 A9S 0.900 5679.4 4.5922 0.812 2.562e-01 2.562e-01 2.562e-01 0.301 A9S 1.100 6376.8 4.4495 1.040 1.599e-01 1.599e-01 1.599e-01 0.602 A9S 1.300 7074.6 4.3546 1.245 1.080e-01 1.080e-01 1.080e-01 0.602 A9S 1.500 8087.2 4.3711 1.310 7.713e-02 7.713e-02 7.713e-02 0.602 A9S 1.700 9084.5 4.3967 1.355 5.747e-02 5.747e-02 5.747e-02 0.602 A9S 1.900 9954.1 4.4096 1.397 4.425e-02 4.425e-02 4.425e-02 0.602 A9S 2.200 11043.3 4.4087 1.465 4.704e-02 4.704e-02 4.704e-02 0.602 A9S 3.000 13418.4 4.3808 1.708 6.051e-02 6.051e-02 6.051e-02 0.602 A9S 3.500 14608.3 4.3537 1.892 2.633e-02 2.633e-02 2.633e-02 0.602 A9S 4.500 16795.8 4.3123 2.211 2.917e-02 2.917e-02 2.917e-02 0.602 A9S 5.000 17762.3 4.2852 2.386 1.139e-02 1.139e-02 1.139e-02 0.602 A9S 6.000 19494.0 4.2216 2.772 1.484e-02 1.484e-02 1.484e-02 0.602 A9S 7.000 20979.7 4.1437 3.225 1.033e-02 1.033e-02 1.033e-02 0.602 A9S 7.960 21973.5 4.0359 3.772 7.330e-03 7.330e-03 7.330e-03 0.602 A9S 8.783 22356.3 3.8979 4.653 4.990e-03 4.990e-03 4.990e-03 0.903 A9S 9.094 22371.8 3.8351 5.102 1.733e-03 1.733e-03 1.733e-03 0.903 A9S 10.119 20682.4 3.4763 8.149 4.454e-03 4.454e-03 4.454e-03 0.602 A9S 10.375 19865.5 3.3399 9.883 1.048e-03 1.048e-03 1.048e-03 0.602 A9S 10.443 21488.2 3.4329 8.681 2.764e-04 2.764e-04 2.764e-04 0.602 A9S 10.447 22610.0 3.4851 8.031 1.358e-05 1.358e-05 1.358e-05 0.903 A9S 10.448 20936.3 3.3937 9.184 6.971e-06 6.971e-06 6.971e-06 0.602 A9S 10.449 19257.5 3.2362 11.377 3.873e-06 3.873e-06 3.873e-06 0.602 A9S 10.450 17910.2 3.0969 13.134 2.989e-06 2.989e-06 2.989e-06 0.602 A9S 10.451 16421.0 2.9354 16.494 3.122e-06 3.122e-06 3.122e-06 0.602 A9S 10.452 14746.9 2.7428 21.223 3.391e-06 3.391e-06 3.391e-06 0.602 A9S 10.452 13329.1 2.5668 25.592 2.684e-06 2.684e-06 2.684e-06 0.602 A9S 10.453 12075.4 2.3982 31.745 2.188e-06 2.188e-06 2.188e-06 0.602 A9S 10.453 11043.3 2.2477 39.213 1.697e-06 1.697e-06 1.697e-06 0.602 A9S 10.454 9988.5 2.0805 45.618 1.554e-06 1.554e-06 1.554e-06 0.602 A9S 10.454 9017.8 1.9116 59.362 1.339e-06 1.339e-06 1.339e-06 0.602 A9S 10.454 8352.2 1.7860 69.308 9.172e-07 9.172e-07 9.172e-07 0.602 A9S 10.454 7622.5 1.6377 82.409 9.210e-07 9.210e-07 9.210e-07 0.602 A9S 10.455 6935.9 1.4865 97.593 8.442e-07 8.442e-07 8.442e-07 0.602 A9S 10.455 6181.6 1.3067 119.795 8.480e-07 8.480e-07 8.480e-07 0.602 A9S 10.455 5393.9 1.1062 153.595 8.480e-07 7.517e-07 6.558e-07 0.301 A9S 10.455 4842.8 0.9659 185.366 6.331e-07 6.909e-07 7.485e-07 0.301 A9S 10.455 4478.2 0.8931 204.328 9.898e-07 1.080e-06 1.170e-06 0.301 A9S 10.456 4272.7 0.7605 235.374 7.865e-07 8.583e-07 9.299e-07 0.301 A9S 10.456 4066.3 0.4630 336.095 9.591e-07 1.047e-06 1.134e-06 0.301 A9S 10.456 4004.1 0.3326 390.427 1.661e-06 1.813e-06 1.964e-06 0.301 A9S 10.459 3944.6 0.2259 436.590 9.516e-06 1.038e-05 1.125e-05 0.301 MT 10.489 3980.2 0.2752 410.120 1.213e-04 1.324e-04 1.435e-04 0.301 MT 10.538 4077.6 0.4221 354.545 1.917e-04 2.093e-04 2.267e-04 0.301 A9S 10.611 4220.9 0.5417 306.315 2.848e-04 3.108e-04 3.367e-04 0.301 A9S 10.640 4462.7 0.5851 291.341 1.136e-04 1.240e-04 1.343e-04 0.301 A9S 10.644 5862.7 1.0110 171.486 1.513e-05 1.341e-05 1.170e-05 0.301 A9S 10.646 6858.0 1.2818 123.846 7.295e-06 6.467e-06 5.642e-06 0.602 A9S 10.649 7585.8 1.4575 101.760 9.522e-06 8.441e-06 7.364e-06 0.602 A9S 10.655 8369.5 1.6262 83.102 2.399e-05 2.126e-05 1.855e-05 0.602 A9S 10.664 9046.9 1.7554 73.575 3.704e-05 3.283e-05 2.864e-05 0.602 A9S A&A 666, A159 (2022) Table A.1. References continued. MASS TEFF LOGG RSTAR WEIGHT LOGVT SYNT NRSG/NBSG = 1.24 NRSG/NBSG = 1.53 NRSG/NBSG = 1.90 10.677 9772.4 1.8828 59.004 4.838e-05 4.289e-05 3.741e-05 0.602 A9S 10.694 10497.8 2.0002 50.750 6.432e-05 5.702e-05 4.974e-05 0.602 A9S 10.723 11071.3 2.0840 45.245 1.098e-04 9.737e-05 8.495e-05 0.602 A9S 10.764 10136.8 1.9261 55.671 1.533e-04 1.359e-04 1.186e-04 0.602 A9S 10.780 9313.2 1.7798 68.492 5.974e-05 5.296e-05 4.620e-05 0.602 A9S 10.791 8480.1 1.6190 82.935 4.138e-05 3.668e-05 3.200e-05 0.602 A9S 10.798 7730.4 1.4618 102.336 2.766e-05 2.452e-05 2.139e-05 0.602 A9S 10.803 7104.0 1.3192 119.728 1.852e-05 1.641e-05 1.432e-05 0.602 A9S 10.807 6478.9 1.1655 144.114 1.433e-05 1.270e-05 1.108e-05 0.602 A9S 10.810 5833.1 0.9920 176.415 1.101e-05 9.764e-06 8.518e-06 0.301 A9S 10.812 5311.3 0.8432 213.002 6.727e-06 5.963e-06 5.202e-06 0.301 A9S 10.815 4305.3 0.5574 304.855 1.287e-05 1.404e-05 1.521e-05 0.301 A9S 10.820 4102.0 0.4059 366.941 1.900e-05 2.074e-05 2.247e-05 0.301 A9S 10.822 4080.4 0.3882 374.272 6.567e-06 7.167e-06 7.764e-06 0.301 A9S 10.825 3994.8 0.2721 418.586 1.138e-05 1.242e-05 1.346e-05 0.301 MT 10.829 3879.7 0.0817 533.224 1.528e-05 1.668e-05 1.807e-05 0.301 MT 10.834 3769.6 -0.0637 630.534 1.552e-05 1.694e-05 1.835e-05 0.301 MT Appendix B: Chemical abundances Table B.1. Appendix B: Chemical abundances Table B.1. Chemical abundances for NGC 1569-B Element Wavelength (Å) Abundance NRSG/NBSG = 1.24 NRSG/NBSG = 1.53 NRSG/NBSG = 1.90 [Fe/H] 4170.0-4180.0 -0.243 ± 0.058 - - 4232.4-4240.0 -0.253 ± 0.050 - - 4293.0-4316.0 -0.403 ± 0.041 -0.350 ± 0.038 -0.299 ± 0.034 4400.0-4424.0 -1.003 ± 0.045 -1.055 ± 0.048 -1.095 ± 0.051 4500.0-4530.0 -0.786 ± 0.042 -0.853 ± 0.047 -0.916 ± 0.046 4573.0-4600.0 -0.828 ± 0.045 -0.964 ± 0.045 -1.042 ± 0.044 4631.0-4660.0 -0.887 ± 0.060 -0.896 ± 0.068 -1.007 ± 0.078 4706.0-4711.0 -1.007 ± 0.127 -1.116 ± 0.126 -1.216 ± 0.119 4724.0-4750.0 -0.651 ± 0.057 -0.797 ± 0.054 -0.873 ± 0.052 4869.0-4883.0 -0.568 ± 0.049 -0.639 ± 0.052 -0.718 ± 0.053 4897.0-4915.0 -1.017 ± 0.057 -1.103 ± 0.057 -1.142 ± 0.056 4918.0-4926.0 0.101 ± 0.057 - - 4936.0-4944.0 -0.513 ± 0.082 -0.667 ± 0.087 -0.765 ± 0.089 4945.5-4953.0 -0.338 ± 0.132 -0.455 ± 0.137 -0.440 ± 0.165 4963.0-4976.0 -1.361 ± 0.091 - - 5122.4-5150.0 -0.861 ± 0.036 -1.00 ± 0.037 -1.132 ± 0.036 5224.0-5235.0 -0.159 ± 0.037 -0.272 ± 0.036 -0.293 ± 0.049 5266.0-5289.0 -0.481 ± 0.022 -0.517 ± 0.024 -0.536 ± 0.027 5250.0-5259.0 -0.699 ± 0.054 -0.784 ± 0.056 -0.813 ± 0.059 5300.0-5345.0 -0.833 ± 0.021 -0.923 ± 0.022 -1.007 ± 0.022 5358.0-5375.0 -0.216 ± 0.022 -0.248 ± 0.021 -0.255 ± 0.022 5378.0-5400.0 -0.686 ± 0.024 -0.769 ± 0.026 -0.811 ± 0.025 5400.0-5420.0 -0.542 ± 0.025 -0.599 ± 0.025 -0.654 ± 0.025 5420.0-5449.0 -0.236 ± 0.016 -0.270 ± 0.019 -0.257 ± 0.018 5460.0-5475.5 -1.022 ± 0.057 -1.167 ± 0.056 -1.285 ± 0.051 5494.0-5510.0 -0.598 ± 0.053 -0.791 ± 0.048 -0.792 ± 0.046 5529.0-5539.0 -0.458 ± 0.040 -0.557 ± 0.038 -0.598 ± 0.037 5566.5-5590.0 -0.598 ± 0.046 -0.801 ± 0.041 -0.896 ± 0.038 5610.2-5630.0 -0.390 ± 0.052 -0.568 ± 0.047 -0.695 ± 0.044 5682.0-5708.0 -0.842 ± 0.037 -0.872 ± 0.035 -0.903 ± 0.034 Table B.1. Chemical abundances for NGC 1569-B Table B.1. Chemical abundances for NGC 1569-B A159, page 14 of 16 A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B A. Gvozdenko et al.: Chemical composition of the young massive cluster NGC 1569-B Table B.1. continued. tinued. Appendix B: Chemical abundances continued. Appendix B: Chemical abundances Element Wavelength (Å) Abundance NRSG/NBSG = 1.24 NRSG/NBSG = 1.53 NRSG/NBSG = 1.90 5708.0-5714.0 -0.768 ± 0.058 -0.793 ± 0.058 -0.789 ± 0.059 5858.5-5865.0 -0.717 ± 0.095 -0.781 ± 0.097 -0.847 ± 0.101 5970.0-5980.0 -0.707 ± 0.083 -0.854 ± 0.077 -0.937 ± 0.070 6001.0-6030.0 -0.682 ± 0.035 -0.776 ± 0.033 -0.839 ± 0.031 6053.0-6082.0 -0.574 ± 0.038 -0.700 ± 0.037 -0.779 ± 0.034 6131.0-6140.0 -0.220 ± 0.031 -0.335 ± 0.031 -0.409 ± 0.032 6144.0-6160.0 -0.309 ± 0.032 -0.371 ± 0.034 -0.386 ± 0.035 6170.0-6185.0 -0.651 ± 0.056 -0.777 ± 0.060 -0.853 ± 0.059 [Mg/Fe] 4347.0-4357.0 -0.004 ± 0.111 0.162 ± 0.087 0.361 ± 0.068 4565.0-4576.0 -0.184 ± 0.113 0.017 ± 0.091 0.219 ± 0.072 4700.0-4707.0 0.313 ± 0.117 0.487 ± 0.125 0.365 ± 0.120 5160.0-5190.0 0.065 ± 0.020 0.133 ± 0.019 0.236 ± 0.022 5523.0-5531.5 0.327 ± 0.050 0.300 ± 0.042 0.274 ± 0.040 5705.0-5715.0 -0.317 ± 0.054 -0.135 ± 0.050 -0.014 ± 0.048 [Ca/Fe] 4220.0-4234.0 -0.596 ± 0.073 -0.617 ± 0.066 -0.673 ± 0.064 4420.0-4440.0 0.811 ± 0.074 0.943 ± 0.079 0.753 ± 0.090 4451.0-4461.0 0.132 ± 0.148 0.113 ± 0.177 -0.192 ± 0.168 4521.0-4531.0 -0.49 ± 0.274 -0.639 ± 0.254 -0.643 ± 0.231 4573.0-4590.0 -0.981 ± 0.149 -1.123 ± 0.142 -1.226 ± 0.140 5256.0-5268.0 0.664 ± 0.097 0.573 ± 0.124 0.425 ± 0.112 5347.0-5357.0 0.364 ± 0.124 0.351 ± 0.134 0.280 ± 0.135 5507.0-5517.0 -0.484 ± 0.149 -0.560 ± 0.130 -0.573 ± 0.114 5576.0-5602.0 0.557 ± 0.050 0.442 ± 0.058 0.209 ± 0.052 5852.0-5862.0 0.532 ± 0.055 0.489 ± 0.059 0.402 ± 0.059 6098.0-6127.0 0.844 ± 0.021 0.823 ± 0.022 0.722 ± 0.024 6151.0-6174.0 0.366 ± 0.034 0.185 ± 0.038 -0.009 ± 0.036 [Sc/Fe] 4665.0-4675.0 0.520 ± 0.165 0.487 ± 0.188 0.381 ± 0.189 4739.0-4758.0 -0.236 ± 0.191 -0.135 ± 0.163 -0.076 ± 0.148 5522.5-5531.0 1.127 ± 0.059 1.202 ± 0.059 1.191 ± 0.058 5638.0-5690.0 1.049 ± 0.036 0.949 ± 0.041 0.833 ± 0.040 6206.0-6216.0 0.588 ± 0.171 0.328 ± 0.123 0.243 ± 0.106 [Ti/Fe] 4293.0-4315.0 0.210 ± 0.054 0.444 ± 0.056 0.445 ± 0.059 4442.0-4475.0 0.521 ± 0.030 0.622 ± 0.028 0.622 ± 0.028 4521.0-4540.0 0.519 ± 0.043 0.598 ± 0.042 0.541 ± 0.042 4570.0-4575.0 0.651 ± 0.063 0.731 ± 0.062 0.693 ± 0.062 4500.0-4519.5 0.756 ± 0.050 0.813 ± 0.051 0.715 ± 0.051 4551.0-4570.0 0.671 ± 0.040 0.752 ± 0.038 0.731 ± 0.037 4638.0-4660.0 0.857 ± 0.089 0.665 ± 0.101 0.512 ± 0.094 4680.0-4698.0 0.555 ± 0.129 0.460 ± 0.108 0.399 ± 0.106 4802.0-4821.0 0.785 ± 0.109 0.548 ± 0.087 0.459 ± 0.074 4975.0-4995.1 0.359 ± 0.053 0.265 ± 0.056 0.191 ± 0.055 5510.0-5520.0 0.593 ± 0.092 0.388 ± 0.083 0.260 ± 0.075 5860.0-5875.0 0.362 ± 0.073 0.343 ± 0.070 0.360 ± 0.070 5912.0-5922.0 0.326 ± 0.077 0.256 ± 0.070 0.211 ± 0.067 5960.0-5994.0 0.269 ± 0.045 0.301 ± 0.042 0.304 ± 0.042 [Cr/Fe] 4253.0-4260.0 0.872 ± 0.110 1.260 ± 0.093 1.417 ± 0.086 4270.0-4276.0 0.589 ± 0.101 0.306 ± 0.107 0.384 ± 0.107 4565.0-4570.0 -0.284 ± 0.285 -0.551 ± 0.272 -0.683 ± 0.285 4578.0-4597.0 -0.046 ± 0.052 0.051 ± 0.052 0.100 ± 0.051 4537.0-4550.0 -0.265 ± 0.195 -0.376 ± 0.198 -0.430 ± 0.187 4612.0-4631.0 0.281 ± 0.057 0.326 ± 0.064 0.314 ± 0.065 4646.0-4657.0 -0.760 ± 0.190 -0.782 ± 0.172 -0.790 ± 0.161 4703.0-4723.0 0.406 ± 0.111 0.314 ± 0.110 0.260 ± 0.103 A159, page 15 of 16 A&A 666, A159 (2022) Table B.1. Appendix B: Chemical abundances Element Wavelength (Å) Abundance NRSG/NBSG = 1.24 NRSG/NBSG = 1.53 NRSG/NBSG = 1.90 4751.0-4761.0 -0.075 ± 0.171 0.028 ± 0.153 0.102 ± 0.143 4796.0-4806.0 -0.240 ± 0.374 -0.190 ± 0.366 -0.318 ± 0.286 4824.0-4834.0 0.476 ± 0.087 0.589 ± 0.091 0.566 ± 0.092 4931.0-4947.0 -1.029 ± 0.258 -0.855 ± 0.212 -0.717 ± 0.195 5117.0-5127.0 1.551 ± 0.133 1.516 ± 0.127 1.532 ± 0.113 5270.0-5281.0 0.194 ± 0.070 0.199 ± 0.067 0.238 ± 0.063 5292.0-5304.0 0.500 ± 0.047 0.193 ± 0.066 -0.148 ± 0.067 5341.0-5353.0 0.693 ± 0.037 0.667 ± 0.041 0.619 ± 0.042 5407.0-5413.0 1.110 ± 0.042 1.050 ± 0.041 0.950 ± 0.043 5779.0-5793.0 0.781 ± 0.057 0.631 ± 0.049 0.561 ± 0.045 6325.0-6335.0 1.209 ± 0.101 0.938 ± 0.131 0.700 ± 0.126 6973.0-6983.0 1.420 ± 0.052 1.106 ± 0.058 0.967 ± 0.052 [Mn/Fe] 5372.0-5382.0 -0.874 ± 0.209 -0.765 ± 0.181 -0.723 ± 0.171 5390.0-5410.0 -0.124 ± 0.080 -0.167 ± 0.062 -0.159 ± 0.057 5418.0-5434.0 0.395 ± 0.104 0.139 ± 0.104 0.031 ± 0.095 5468.0-5490.0 -0.460 ± 0.095 -0.592 ± 0.070 -0.617 ± 0.063 5511.0-5521.0 0.401 ± 0.150 0.221 ± 0.127 0.145 ± 0.110 6010.0-6030.0 0.298 ± 0.067 0.042 ± 0.065 -0.103 ± 0.061 [Ni/Fe] 4600.0-4610.0 -0.253 ± 0.236 -0.337 ± 0.234 -0.430 ± 0.224 4644.0-4654.0 0.431 ± 0.175 0.423 ± 0.176 0.311 ± 0.163 4681.0-4691.0 -0.548 ± 0.346 -0.343 ± 0.267 -0.277 ± 0.226 4709.0-4719.0 -0.197 ± 0.173 -0.489 ± 0.192 -0.592 ± 0.188 4824.0-4835.0 -1.302 ± 0.247 -1.232 ± 0.197 -1.242 ± 0.179 4899.0-4909.0 -0.588 ± 0.221 -0.647 ± 0.193 -0.643 ± 0.179 4975.0-4985.0 0.470 ± 0.102 0.471 ± 0.097 0.402 ± 0.089 5141.0-5151.0 0.412 ± 0.158 0.109 ± 0.149 0.047 ± 0.154 5472.0-5482.0 0.317 ± 0.037 0.255 ± 0.035 0.128 ± 0.037 5707.0-5717.0 1.215 ± 0.075 0.849 ± 0.088 0.642 ± 0.089 6103.0-6113.0 0.689 ± 0.069 0.521 ± 0.064 0.456 ± 0.061 6172.0-6182.0 0.151 ± 0.055 0.055 ± 0.049 0.011 ± 0.044 [Ba/Fe] 4551.0-4560.0 0.559 ± 0.253 0.615 ± 0.231 0.880 ± 0.216 5849.0-5859.0 1.981 ± 0.115 2.014 ± 0.151 1.772 ± 0.161 6135.0-6145.0 1.175 ± 0.041 1.226 ± 0.040 1.283 ± 0.040 6492.0-6502.0 0.801 ± 0.229 0.843 ± 0.233 0.699 ± 0.228 [Si/Fe] 4420.5-4430.5 0.811 ± 0.115 -0.452 ± 0.494 0.150 ± 0.120 4596.0-4606.0 0.027 ± 0.310 1.975 ± 0.096 1.151 ± 0.095 5767.0-5777.0 0.775 ± 0.227 0.118 ± 0.221 0.413 ± 0.133 5944.0-5954.0 0.277 ± 0.080 0.940 ± 0.231 0.750 ± 0.281 6150.0-6160.0 -0.476 ± 0.073 -0.384 ± 0.069 -0.322 ± 0.065 6233.0-6242.0 -0.373 ± 0.102 -0.270 ± 0.093 -0.227 ± 0.088 7400.0-7427.0 0.078 ± 0.027 0.116 ± 0.028 0.154 ± 0.028 [Cu/Fe] 5101.0-5112.0 0.215 ± 0.172 -0.033 ± 0.189 -0.165 ± 0.179 A159, page 16 of 16
https://openalex.org/W1531652241	https://revistas.marilia.unesp.br/index.php/aurora/article/download/1280/1124	Portuguese	null	Apresentação da Edição Número VIII da Revista Aurora	Revista Aurora	1,969	cc-by	725	UNESP – FFC, Maríla-SP – Ano IV - Número VIII. Agosto/2011. A Revista AURORA vos convida à leitura de seu oitavo número. Nesta apresentação oferecemos uma breve descrição dos autores e dos artigos que compõe a Seção Dossiê, Seção Miscelânea e Seção Especial, respectivamente. Na Seção Dossiê, a Revista contempla periodicamente as temáticas que dão nome às Linhas de Pesquisa do Programa de Pós-Graduação em Ciências Sociais da UNESP, Marília-SP. Assim, nesta edição a temática contemplada é “Pensamento Social e Políticas Públicas”. O artigo inicial, autoria de Maurício Bernardino Gonçalves, doutorando em Ciências Sociais pela UNESP campus de Araraquara-SP, é intitulado “Boaventura de Souza Santos e a ‘pós-modernidade de contestação’: algumas notações marxistas”. Em seguida listamos o artigo “Democracia: tipologia, relações e expressões contemporâneas”, escrito por Carla Salles Rosa e Danuta Cantoia Luiz, mestranda e Professora Doutora, respectivamente, ambas na área de Ciências Sociais Aplicadas da Universidade Estadual de Ponta Grossa. Na seqüencia da leitura, o terceiro artigo da seção versa sobre “Relações entre Estado e Sociedade Civil: reflexões sobre perspectivas democráticas”, autoria de Andressa Kolody, Carla Salles Rosa e Danuta Luiz. O quarto trabalho analisa o “Desenvolvimento social por meio do desenvolvimento tecnológico: um panorama sobre as Políticas Públicas no setor de tecnologia brasileiro no primeiro Governo FHC (1996-1999)”, texto elaborado por Bárbara Regina Vieira Lopes, da graduação em Relações Internacionais pela UNESP, campus de Marília. Adiante temos o artigo “Liderança e motivação profissional: estratégia política e representatividade trabalhista”, de Rodrigo Moreira Vieira, mestrando em Ciências Sociais neste programa. O autor problematiza o uso de estratégias ideológicas e motivacionais como ações empresariais para quebrar a resistência dos trabalhadores. Prosseguindo, o trabalho de Geruza Silva Oliveira, doutoranda em Sociologia pela Universidade Federal de Goiás, nos apresenta resultados de sua pesquisa sobre “Cidade, Espaço Urbano e sua Dinâmica”, atenta a formas de interação e contatos interpessoais no espaço público do centro de Goiânia. Na continuação, Aurora oferece um debate sobre os espaços urbano e rural trazendo o artigo “Sociologia rural e nova ruralidade: alguns entraves teóricos”, redigido por Fernanda Cristina Laubstein, mestranda em Ciências Sociais pela UNESP, campus de Marília. Assim encerramos a Seção Dossiê, na tentativa de colocar em diálogo temas e perspectivas diferentes sobre pensamento social e políticas públicas. Na Seção Miscelânea a Revista Aurora traz artigos de temas variados, por vezes interdisciplinares, buscando contemplar a ampla diversidade das ciências humanas. AURORA ano V número 8 AGOSTO DE 2011 https://doi.org/10.36311/1982-8004.2011.v4n2.1280 AURORA ano V número 8 AGOSTO DE 2011 https://doi.org/10.36311/1982-8004.2011.v4n2.1280 APRESENTAÇÃO UNESP – FFC, Maríla-SP – Ano IV - Número VIII. Agosto/2011. UNESP – FFC, Maríla-SP – Ano IV - Número VIII. Agosto/2011. UNESP – FFC, Maríla-SP – Ano IV - Número VIII. Agosto/2011. O trabalho inicial é de Adriana Marcela Bogado, que realiza uma discussão a respeito dos movimentos sociais como espaços educativos no artigo “A luta também te ensina: processos de ensino-aprendizagem no marco de movimentos sociais argentinos”. O artigo seguinte versa sobre “Ética e Política em Hegel: as formas determinativas do Estado Democrático de Direito”, elaborado por Marcelo Lira Silva, doutorando em Ciências ISSN: 1982-8004 www.marilia.unesp.br/aurora https://doi.org/10.36311/1982-8004.2011.v4n2.1280 https://doi.org/10.36311/1982-8004.2011.v4n2.1280 Sociais pela UNESP, campus de Marília. O próximo trabalho intitula-se “Pré-Sal, Questão Nacional e Pacto Federativo: considerações metodológicas em análises de políticas governamentais”, contribuição de Arthur de Aquino, mestrando em Ciência Política pela Unicamp. O artigo final da seção miscelânea nos foi enviado por Matias Lopez e Mateus de Araújo, mestrados pelo Programa de Pós-Graduação em Sociologia e Antropologia da Universidade Federal do Rio de Janeiro. Com o título “Desenvolvimento e narrativas de modernidade: Costa Pinto e a construção de uma sociologia transnacional para o terceiro mundo”, os autores contribuem para esta edição com o estudo da vida e obra do sociólogo brasileiro Luiz de Aguiar Costa Pinto. Finalmente, na Seção Especial, a Revista Aurora traz nova contribuição do Professor da Universidade de São Paulo, Doutor Osvaldo Coggiola, com o artigo “A Primeira Internacional Operária e a Comuna de Paris”. Adiante, o Professor Doutor Anderson Deo apresenta-nos o trabalho: “Mudar para que tudo continue como está: o modernismo conservador de Fernando Henrique Cardoso”. Encerra-se o qualificado debate desta seção com a contribuição do Professor da UNESP de Marília, Doutor Jair Pinheiro, no artigo “Visões de mundo em luta”. A Revista Aurora agradece gentilmente a colaboração de todos autores, do Conselho Editorial e da UNESP. Boa leitura! Rodolfo Ilário da Silva Conselho Executivo Revista Aurora
https://openalex.org/W3154979067	https://link.springer.com/content/pdf/10.1007/s10980-022-01412-0.pdf	English	null	The influence of landscape context on the production of cultural ecosystem services	Research Square (Research Square)	2,021	cc-by	6,427	Abstract Context Recent efforts to apply sustainability con- cepts to entire landscapes have seen increasing inter- est in approaches that connect socioeconomic and biophysical systems. Evaluating these connections through a cultural ecosystem services lens clarifies how different spatiotemporal scales and levels of organisation influence the production of cultural ben- efits. Currently, however, the effects of multi-level and multi-scale ecological variation on the production of cultural benefits have not yet been disentangled. Conclusions Landscape attributes influence peo- ple’s perceptions of cultural ecosystem service provi- sion by individual species. Recognition of the com- plex, localised and inextricable linkage of cultural ecosystem services to biophysical attributes can improve our understanding of the landscape charac- teristics that affect the supply and demand of cultural ecosystem services. i Objectives To quantify the amount of variation in cultural ecosystem service provision by birds to bird- ers that is due to landscape-level attributes. Methods We used data from 293 birding routes and 101 different birders in South African National Parks to explore the general relationships between birder responses to bird species and environmental conditions, bird-related observations, the biophysical attributes of the landscape and their effect on bird- related cultural benefits. Keywords Landscape variation · Biophysical attributes · Cultural ecosystem services · Birds The influence of landscape context on the production of cultural ecosystem services Kim C. Zoeller · Georgina G. Gurney · Graeme S. Cumming Received: 8 March 2021 / Accepted: 27 January 2022 / Published online: 3 February 2022 © The Author(s) 2022 Results Biophysical attributes (particularly biome, vegetation type, and variance in elevation) signifi- cantly increased the percentage of variance explained in birder benefits from 57 to 65%, demonstrating that birder benefits are derived from multi-level (birds to ecosystems) and multi-scale (site to landscape) social and ecological interactions.l Landsc Ecol (2022) 37:883–894 https://doi.org/10.1007/s10980-022-01412-0 Landsc Ecol (2022) 37:883–894 https://doi.org/10.1007/s10980-022-01412-0 RESEARCH ARTICLE Introduction Recent efforts to apply sustainability concepts to entire landscapes have demonstrated an increasing interest in approaches that connect socioeconomic and biophysical aspects of landscape change (Mao et al. 2020). One widely used approach for think- ing about landscape sustainability is the ecosystem services framework, which focuses on the linkages between people and nature, and specifically, the capacity of ecosystems to deliver benefits essential K. C. Zoeller () · G. G. Gurney · G. S. Cumming Australian Research Council Centre of Excellence for Coral Reef Studies, James Cook University, Townsville, QLD 4811, Australia e-mail: kim.zoeller@my.jcu.edu.au K. C. Zoeller () · G. G. Gurney · G. S. Cumming Australian Research Council Centre of Excellence for Coral Reef Studies, James Cook University, Townsville, QLD 4811, Australia e-mail: kim.zoeller@my.jcu.edu.au K. C. Zoeller · G. S. Cumming Percy FitzPatrick Institute, University of Cape Town, Rondebosch, Cape Town 7701, South Africa ol.: (01 123456789) 3 Landsc Ecol (2022) 37:883–894 884 benefits such as aesthetic values, spiritual fulfilment, tourism and recreation (Chan et al. 2012). They are co-produced through the interactions between people (in social systems) and their environment (ecological systems) (Fish et al. 2016), delivering benefits that have direct contributions to human wellbeing (Fig. 1) (Fischer and Eastwood 2016). Ecological systems comprise multiple levels of ecological organisation. We focused particularly on three levels (and corre- sponding scales) relating to the provision of cultural ecosystem services: species, community, and land- scape (Fig. 1). While the relationship between scales and levels in ecological systems is complex, we use conventional levels of ecological organisation that should exhibit a hierarchical relationship to ecologi- cal processes and associated spatial and temporal scales (Allan 1990). Thus, species and communi- ties are nested within landscapes; landscape-level biophysical attributes support species propagation through the provision of resources like food and habi- tat (Aalders and Stanik 2019). to human wellbeing (MA 2005; Bachi et al. 2020; Bruley et al. 2021). The interaction between ecologi- cal systems and social systems in the production of ecosystem services forms a biocultural feedback loop, where landscape condition is shaped by perception- based preferences for particular ecosystem services that contribute to human wellbeing (Fig. 1) (Maffi and Woodley 2010; Tengberg et al. 2012; Agnoletti and Rotherham 2015). Introduction While the role of biophysical factors in driving ecosystem service production (such as sequestration capacity of a peat bog or timber production in a for- est) has been well established across a range of differ- ent scales, the role of social processes in the receipt of ecosystem benefits at different levels (e.g. organisms to ecosystems) and scales (e.g. site to landscape) has received limited attention (Bruley et al. 2021). Fram- ing ecosystem services through people’s connection to the environment is not a novel concept (Fish et al. 2016; Tew et al. 2019), but the effects of multi-level and multi-scale ecological variation on the production of cultural benefits have not yet been disentangled. It thus remains unclear how people experience ecosys- tem benefits that are produced over multiple scales and levels of organization and which kinds of ben- efit depend primarily on interactions with individual organisms, populations, communities, ecosystems, or landscapes respectively. We used the cultural service of bird-watching as an accessible case study from which to explore how multi-level and multi-scale interactions are related to ecosystem service production. The distributions of birds vary in geographic space, and the benefits associated with birdwatching are well-established and globally prevalent (Sekercioglu 2002; Whelan et al. 2015; Graves et al. 2019). Bird-watching by its nature appears to focus on the level of individual organisms of different species. However, previous research has suggested that there may be a vital link missing in We explore the concept of multi-level and multi- scale organisation in the production of ecosystem services through a cultural ecosystem services lens (Fig. 1). Cultural ecosystem services are non-material Fig. 1 The flow of cultural ecosystem service benefits from ecological systems to social systems using a simplified ecosystem cas- cade model ow of cultural ecosystem service benefits from ecological systems to social systems using a simplified ecosy Fig. 1 The flow of cultural ecosystem service benefits from ecological systems to social systems using a si cade model Fig. 1 The flow of cultural ecosystem service benefits from ecological systems to social systems using a simplified ecosystem cas- cade model 1 Vol:. Landsc Ecol (2022) 37:883–894 885 our understanding of the relationship between land- scape-level processes and the benefits associated with birdwatching (Cumming and Maciejewski 2017). Introduction A recent study found that benefits related to species observations alone accounted for only 27% of vari- ance in birder benefits, while including birder expec- tations and responses to environmental conditions increased the proportion of variance explained to 57% (Cumming and Maciejewski 2017). Some previous research has identified aesthetic benefits associated with birding which are related to certain elements of nature, such as water bodies or complex terrain (Chettri et al. 2005; Andersson et al. 2015). The extent to which variation in landscape-level attrib- utes supports the provision of birder benefits remain unclear, however, and has not been previously quanti- fied relative to the direct benefits derived from see- ing birds. We hypothesized that a significant propor- tion of the remaining 43% of unexplained variation in Cumming and Maciejewski’s (2017) study might be explained by landscape–level characteristics, par- ticularly biophysical attributes such as elevation that might contribute to the benefits associated with bird- ing (Fig. 1). Connecting birder benefits with the bio- physical attributes of landscapes provides important insights into how perceptions of cultural ecosystem services (and thus, benefits experienced) by people are mediated by the multi-level and multi-scale struc- ture of ecological systems (Plieninger et al. 2013). day for at least two hours over a minimum distance of 2 km while wearing a Garmin GPS Forerunner 310XT wristwatch. After completing each route, the track was downloaded from the wristwatch. The ama- teur birders submitted a list of birds they saw and/ or heard, and completed a satisfaction survey (see Sect. Surveys). In total, 101 people participated in the study. Most participants were experienced and well-established birders in South Africa, where the mean number of years of birding experience was 18.6 (± SD 12.3), and the mean number of South African birds seen by participants was 483 (± SD 201) (Cumming and Maciejewski 2017). While there was an even divide of gender (50 female and 51 male), there was lim- ited variability in socio-demographic characteristics of participants (specifically an over-representation of white participants), reflecting broader demographic patterns of National Park visitors in South Africa (Scholtz et al. 2015). Surveys The satisfaction surveys completed by amateur bird- ers comprised a pre-trip and post-trip questionnaire. The pre-trip questionnaire was a short survey on their birding expectations. Longer surveys were conducted for the post-trip survey, in which respondents scored their birding experience using a Likert-type scale from 1 to 10 (i.e., terrible to excellent) to provide a single measurement of overall satisfaction of their birding experience. We term this ‘birder benefit’ (fol- lowing Cumming and Maciejewski 2017), recognis- ing that it is likely to be a relatively coarse correlate of the actual psychological benefit received. Amateur participants also provided detailed explanations for the benefit scores that they assigned, defined as per- ception-based birding experiences. These were coded, using an inductive thematic analytical approach, into five summary categories: (1) subjective impressions of the overall number and nature of birds seen; (2) comfort variables, such as weather, company, and ease of movement along the route; (3) impressions directly related to the particular species seen, such as rare and endemic birds, and specific behavioural interactions (e.g., predation, competition, mating); (4) subjective landscape correlates of the experience, such as the beauty of the surroundings and general visibility; and (5) educational value of the experience, Bird occurrence data To determine the relationships between the subjec- tive experiences of the birders, their bird-related observations and quantifiable biophysical attributes of the landscape, we used the dataset for bird occur- rences and birder experiences described in Cumming and Maciejewski (2017). Data were collected along 293 routes from all 19 of South Africa’s National Parks: Addo, Agulhas, Augrabies, Bontebok, Camde- boo, Garden Route, Golden Gate, Karoo, Kgalagadi, Kruger, Mapungubwe, Marakele, Mokala, Moun- tain Zebra, Namaqua, Richtersveld, Table Mountain, Tankwa-Karoo, and West Coast from 2016 to 2017 (Fig. 2) (Cumming and Maciejewski 2017). To col- lect these data, amateur birders went birding twice a 1 ol.: (01 3 123456789) 3 123456789) 886 Landsc Ecol (2022) 37:883–894 Fig. 2 Map of South African National Parks Fig. 2 Map of South African National Parks species and a good sighting of species; and (4) bor- ing, monotonous landscape and interesting, diverse landscape (see Table 1 for further explanations of these variables). such as new birds learned. To determine which cat- egories contributed to birder benefits, we excluded reasons that explained less than 5% of their variance, as determined by Cumming and Maciejewski (2017). The subsequent reasons included in the final analy- sis under the first four categories were: (1) perceived species richness, low diversity of species, and low abundance of species; (2) bad weather, good weather and unfavourable route; (3) unexpected sighting of a Landscape attribute data The parks in this study include an exceptionally diverse range of habitats, ranging from coastal to 1 Vol:. Landsc Ecol (2022) 37:883–894 887 Table 1 Landscape characteristics, how they were measured and how these characteristics might influence perception of ecosystem services, with examples Landscape characteristics Measurement Mechanism and examples Biome Categorical Biomes are defined by the dominant plant growth form and associated climatic thresholds (Conradi et al. 2020). From an ornithological perspective, biomes create specific conditions for which bird species are adapted (Steven et al. 2017). Specific plant growth forms in biomes may be associated with rare, endangered or common species (Chettri et al. 2005) Elevation Mean Variance Higher elevation has been correlated with low species richness (Graves et al. 2019). In addition, elevation might impede the field of view of birders, nega- tively affecting their birding experience Roads Length Presence/absence Road type The effect of roads on birding include higher rates of disturbance and disruption of bird activity Water body Presence/absence Water body type The importance of water bodies for birdwatching has been well documented in ecosystem service literature (Raudsepp-Hearne et al. 2010). Bodies of water may also contribute positively to the aesthetic experience of birdwatching (Chettri et al. 2005) Vegetation type Categorical Vegetation type is classified according to criteria including physiognomy, structure, plant functional traits and species composition (De Cáceres and Wiser 2012). Local vegetation influences the distribution of bird communities through habitat heterogeneity and resource availability (Belaire et al. 2015) Land cover Categorical Land cover is defined by environmental attributes (including landform, altitude, soil) and specific technical attributes (including cultivated areas) which influ- ences the availability of habitats for birds and therefore the spatial distribution of bird communities (Chettri et al. 2005; Di Gregorio 2005; Kolstoe et al. 2018) Species richness Count Evidence has suggested that species richness, diversity and abundance of bird communities affects perceptions of birding experiences (Booth et al. 2011; Cumming and Macijewski, 2017) Low diversity Count Low abundance Count Unexpected species Perception Unexpected species refers to a bird species that, given the terrain, area or time, was unexpected, but nevertheless a pleasant surprise to the birder. Sightings of unexpected species or a good sighting of species (through e.g. Landscape attribute data clear observa- tions or witnessing particular behaviours) are highly correlated with birder benefits since birders may become conditioned to cultural ecosystem service provision by the same species in different locations (Cumming and Maciejew- ski 2017) Good sighting of species Perception Good weather Perception External variables such as weather and perceptions of landscape has been shown to significantly influence birder benefits. For example, Cumming and Maciejewski (2017) found that incorporating these variables with biodiversity measures increased the percetange of variance explained in birder benefits from 27 to 57% Bad weather Perception Interesting diverse landscape Perception landscape attributes, we extracted data on features that have been shown to influence birder enjoyment: biome, elevation, roads, water bodies, vegetation type and land cover (see Table 1). Each of the variables within each buffer zone was measured for each route. highland and forested to desert. To determine the con- tribution of biophysical attributes to amateur birder benefits, the birding route coordinates were con- verted into a shapefile and analysed in a Geographic Information System (GIS). We added a 5 km buffer around each route to mirror the field of view of stand- ard binoculars and account for biophysical attributes that participants might have encountered while bird- ing, which could have included views across valleys or over the ocean. From existing maps of biophysical Data analysis To reduce the dimensionality of our data, we screened for redundancy in variables with over 40 categories 3 123456789) 888 Landsc Ecol (2022) 37:883–894 Savanna and Succulent Karoo biomes respectively. On average, birders in Succulent Karoo reported lower benefits than all other biomes, although this difference was only significant when compared to routes in Savanna biomes (DF = 6, F-value = 2.161, p = 0.047) (Fig. 3). Differences in species richness according to biome were also significant (DF = 6, F-value = 10.01, p = 5.72e−10), specifically between Grassland and Azonal vegetation and Nama Karoo; Nama Karoo and Savanna; and between Succulent Karoo and Azonal Vegetation, Fynbos, Grassland and Savanna (p < 0.05). On average, species richness was greatest in Grasslands and lowest in Succulent Karoo. In addition to biome and vegetation, variance in elevation had a significant positive effect on route ranking, suggesting that routes with more complex terrain were preferred by birders. Despite the expec- tation that additional biophysical attributes would account for variance in the model, roads, water bodies and land cover types (keeping in mind that all surveys were undertaken in protected areas in ‘natural’ habi- tats) did not have a significant effect on benefits. (i.e., vegetation type and land cover) by separately coding each independent variable as a set of indi- vidual categories and removing non-significant cat- egories from the multivariate model. We reran the analysis three times, removing non-significant vari- ables each time in a stepwise process, to identify the model that best fitted our data based on the lowest AIC value. We tested for a relationship between birder ben- efits and landscape characteristics using multivari- ate mixed-effects linear models to take account of covariance effects within the data. For these models, we used the continuous rating data of satisfaction scores (birder benefits) as our response variable, and perception-based and biophysical landscape attributes as predictors. To account for the nested structure of our data (multiple birders in each National Park), we included location (National Park) as a random effect in the model. We also ran ANOVAs to determine whether there were differences in birder benefits and species richness according to biome, and post-hoc Tukey tests to see where those differences occurred. ifi With the exception of ‘good weather’, responses by participants to observations of bird species and bio- physical attributes were dominant and consistently significant in predicting amateur birder rankings of birding routes. Results The multivariate analysis indicated that 65% of vari- ance in birder benefits was explained by a combina- tion of subjective responses by participants at the species scale (“bird species responses”), perception- based responses at the landscape scale (“environmen- tal responses”) and biophysical attributes, specifi- cally biome, vegetation type and variance in elevation (r2 = 0.65 AIC = 1012, deviance = 933.6, df = 273) (Table 2). Adding landscape variables increased our ability to predict cultural service provision- ing by a significant 38% relative to models that only included bird responses, and 8% relative to models that included bird responses and perception-based responses at the landscape scale. Data analysis Perceptions of the diversity and abun- dance of birds observed had a significant effect on reported benefits. Discussion Our results show that birder benefits were related to biome, vegetation type and perceptions of the bird population observed, the landscape, and the weather. Including biophysical attributes with perception- based birding experiences increased the percentage of variance explained in birder benefits from 57 (Cum- ming and Maciejewski 2017) to 65%, supporting the hypothesis that a small but significant proportion of birder benefit is produced from multi-level and multi- scale social-ecological interactions. We would expect the influence of the surrounding landscape to increase in areas that are more heavily impacted by people (e.g., agricultural landscapes and urban areas) than National Parks. These results provide support for the consideration of landscape-level attributes in addition to species observations, even in cases where cultural The dominant biophysical attribute that explained variance in birder benefits in our model was biome, with all biome types being strong, positive predictors of route ranking (Table 2). Based on birder benefit averages (overall satisfaction), routes in Grassland and Fynbos biomes were favoured by participants. Gabbro Grassy Bushveld and Tankwa Karoo emerged as significant vegetation types in our multivariate model. These vegetation types are characteristic of 1 3 :. (1234567890) 889 Landsc Ecol (2022) 37:883–894 Vol.: (0123456789) Estimate Std. Discussion Error t value Pr( >\|t\|) (Intercept) 2.148926 1.010512 2.127 0.034353* Biome Forest 2.429732 0.748238 3.247 0.001311 Fynbos 3.068522 0.580547 5.286 2.57E-07* Grassland 3.694464 1.047803 3.526 0.000495* Nama-Karoo 3.069363 0.554283 5.538 7.21E-08* Savanna 3.214063 0.553506 5.807 1.77E-08* Succulent Karoo 2.474237 0.536446 4.612 6.13E-06* Elevation Mean −0.067674 0.057398 −1.179 0.239412 Variance 0.323834 0.084162 3.848 0.000148* Roads Road length 0.137437 0.537389 0.256 0.798337 Presence/absence −0.064289 0.84461 −0.076 0.939382 Road type Primary −0.438707 0.429158 −1.022 0.307567 Secondary −0.25979 0.348555 −0.745 0.45671 Service −0.822557 1.394558 −0.59 0.55579 Tertiary 0.334996 0.476005 0.704 0.482179 Track −0.520123 0.689357 −0.755 0.451196 Trunk −0.018427 0.439869 −0.042 0.966615 Unclassified −0.212259 0.333307 −0.637 0.524771 Unsurfaced 0.621175 1.033431 0.601 0.548285 Water bodies Water presence −0.011871 0.220424 −0.054 0.957091 Water body type Dry −0.597705 0.83542 −0.715 0.47494 Non-Perennial −0.16865 0.431912 −0.39 0.696491 Perennial 0.023209 0.493382 0.047 0.962515 Unknown −0.501586 0.522773 −0.959 0.33817 River length −1.367543 4.470527 −0.306 0.759912 River area 12.327655 89.917848 0.137 0.891054 Vegetation type Gabbro Grassy Bushveld 1.993262 0.684651 2.911 0.003896 Kimberley Thornveld 0.905013 0.587533 1.54 0.124631 Tanqua Karoo 1.819932 0.475425 3.828 0.00016* Land cover Low shrubland (Nama Karoo) −0.766333 0.451225 −1.698 0.090583 Bird species responses Richness 0.06887 0.009509 7.243 4.49E-12* Low diversity −0.525371 0.103976 −5.053 7.98E-07* Low abundance −0.321921 0.099448 −3.237 0.001357 Unexpected species 0.350256 0.107758 3.25 0.001297 Good sighting of species 0.33692 0.094402 3.569 0.000423* Environmental responses Good weather 0.210489 0.134004 1.571 0.117394 Bad weather −0.358387 0.090605 −3.955 9.74E-05* Table 2 Summary table of estimates, standard error (SE), t-value and p-value of the multivariate linear model (n = 273) 1 ol.: (01 890 Landsc Ecol (2022) 37:883–894 service provision appears to be highly dependent on l Despite their contribution to variance explained in Table 2 (continued) Estimate Std. Error t value Pr( >\|t\|) Interesting diverse landscape 0.421013 0.103034 4.086 5.77E−05* Predictor variables of birder benefits were assigned significant codes: 0 ‘*’ 0.001 ‘’ 0.01 ‘’ 0.05 ‘.’ 0.1 ‘’ 1 Fig. 3 Comparison by biome of amateur overall satisfaction score with birding routes (top panel) and number of bird species seen (lower panel). Clusters sharing a letter are not statistically different from each other (p < 0.05) 890 Landsc Ecol (2022) 37:883–894 Table 2 (continued) Estimate Std. Error t value Pr( >\|t\|) Interesting diverse landscape 0.421013 0.103034 4.086 5.77E−05 Predictor variables of birder benefits were assigned significant codes: 0 ‘’ 0.001 ‘’ 0.01 ‘’ 0.05 ‘.’ 0.1 ‘’ 1 Table 2 (continued) Fig. Discussion Previous research has shown that perceptions of cultural ecosystem ser- vices associated with birds are likely to vary signifi- cantly across socio-demographic characteristics, such as age, gender, race language and education (Zoeller et al. 2021). For example, in South Africa, Xhosa- speakers were shown to perceive visual traits of birds (including inter alia plumage colour and body size) more frequently than English-speakers (Zoeller et al. 2020, 2021). Avitourism tends to attract an older demographic with high enough income to afford travel and park entry fees (Steven et al. 2017). Indeed, as reflected for our respondents, typical visitors to National Parks in South Africa average 46 years old, speak either English or Afrikaans, are married, and possess higher education qualifications (Scholtz et al. 2015). Understanding how variation in bird- ers’ identity relates to perceptions of birder benefits and their multi-level biophysical drivers provides an important avenue for future research (Tengberg et al. 2012). Many birders fall into a relatively influential and empowered demographic; equitable decisions around biodiversity conservation and landscape pro- tection will ultimately require inclusion of the values and preferences held by the full spectrum of society (Lau et al. 2018).l i Birder benefits in the Succulent Karoo were not significantly different from other biome types. The Succulent Karoo, which features the Tankwa Karoo vegetation type, is located in a biodiversity hotspot (CEPF 2001) that is characterised by fragile drylands that are highly susceptible to disturbance (Ament et al. 2017). Although species diversity was low in the Succulent Karoo, birder benefits did not gener- ally differ compared to more speciose biomes (Cum- ming and Maciejewski 2017). These results suggest that birder benefits were not reduced in low diversity biomes, implying in turn that birders may adjust their expectations to fit specific landscapes (Cumming and Maciejewski 2017). In areas where the environment is harsh and organisms require more specialised adap- tations to survive (e.g., deserts, mountain-tops), cul- tural ecosystem services associated with species and communities may be outweighed by landscape level attributes such as biome and vegetation type (Cum- ming and Maciejewski 2017). Cultural ecosystem services are amongst the most valued products of ecosystems (Orenstein et al. 2015), but are challenging to manage since cultural values are subjective (Tew et al. 2019). Linking quan- tifiable landscape attributes with perception-based measures of the landscape may provide insight into the biophysical drivers of people’s perceptions which can help prioritise landscape management deci- sions. Discussion 3 Comparison by biome of amateur overall satisfaction score with birding routes (top panel) and number of bird species seen (lower panel). Clusters sharing a letter are not statistically different from each other (p < 0.05) Fig. 3 Comparison by biome of amateur overall satisfaction score with birding routes (top panel) and number of bird species seen (lower panel). Clusters sharing a letter are not statistically different from each other (p < 0.05) service provision appears to be highly dependent on individual organisms, to more accurately reflect the processes that result in the co-production of cultural ecosystem service benefits. Despite their contribution to variance explained in birder benefits, only three biophysical attributes added significant explanatory power to the model. The pri- mary explanatory biophysical variables in this model were biome and vegetation type. The importance of 1 3 (1234567890) 1 3 (1234567890) 1 Vol:. Landsc Ecol (2022) 37:883–894 891 biomes in accounting for variance in birder benefits highlights potential connections between individual- level and landscape-level social-ecological interac- tions (typically occurring at fine and broad scales respectively). Biomes are defined by the dominant plant growth form and associated climatic thresholds (Conradi et al. 2020) which create specific conditions to which bird species are adapted (Chettri et al. 2005; Steven et al. 2017; Filloy et al. 2019). In the case of habitat specialists, specialised adaptations enable cer- tain bird species to survive under specific conditions (e.g. cutaneous evaporation in desert birds) (Gerson et al. 2014). Landscape-level processes influencing biome distribution thus also contribute to the receipt of birder benefits at the species level.i significant. Assessing cultural ecosystem services by considering all levels of ecological organization can provide insight into people’s preferences and percep- tions that drive the co-production of ecosystem ser- vices (Katz-Gerro and Orenstein 2015). However, it is important to note that individual perception is not uniform across a given population. For example, amateur birders have been found to be generally more interested in non-birding components of a birding experience than experts (Hvenegaard 2002). (Katz-Gerro and Orenstein 2015). Different social groups may preferentially engage with differ- ent levels of ecological organization to the extent that attributes that contribute to an “interesting, diverse landscape” could differ between ecosystem users (Katz-Gerro and Orenstein 2015). Discussion Recognition of the complex, localised and inextricable linkage of cul- tural ecosystem services to landscape features can also improve our understanding of landscape charac- teristics that affect the supply and demand of cultural ecosystem services (Potschin et al. 2013; Keller and Backhaus 2019). We have provided evidence for the existence of significant, measurable, multi-level spatial influ- ences on cultural ecosystem services associated with birding. An important consideration going forward would be to explicitly account for seasonal shifts in bird assemblages and their impact on cultural bene- fits received from ecosystems, particularly in relation to migratory species. While we conducted sampling evenly throughout summer and winter (Cumming and Maciejewski 2017), we did not measure species-spe- cific responses to seasonal changes and their influence on birder benefits (Graves et al. 2019). Similarly, we did not explore how seasonal shifts may impact ben- efits associated with landscape-level responses. For example, perceptions of birder benefits may be lower during dry periods than flowering seasons, through the formation of concentrations of nectarivorous birds and changes in vegetation-related aesthetics (Chettri et al. 2005). Exploring temporal variation in conjunc- tion with spatial contexts may therefore provide fur- ther insight into birder benefits. Acknowledgements We thank the many amateur birders who participated in birding surveys and enthusiastically volun- teered their time and expertise. We would also like to extend our gratitude to Dominic Henry, Kristine Maciejewski, Robyn Milne and Alice McClure for field assistance and support on sampling protocol. This research was funded by the South Afri- can National Research Foundation (NRF) through a Blue Skies grant to GSC, by the DST/NRF Centre of Excellence at the Percy FitzPatrick Institute, the ARC Centre of Excellence for Coral Reef Studies and James Cook University. Author contributions KCZ and GSC—designed research; KCZ—performed research; KCZ—analysed data; and KCZ, GSC and GGG—wrote the paper. Author contributions KCZ and GSC—designed research; KCZ—performed research; KCZ—analysed data; and KCZ, GSC and GGG—wrote the paper. Funding Open Access funding enabled and organized by CAUL and its Member Institutions. This research was funded by the South African National Research Foundation (NRF) through a Blue Skies grant to GSC, by the DST/NRF Centre of Excellence at the Percy FitzPatrick Institute, the ARC Centre of Excellence for Coral Reef Studies and James Cook University. Data availability (data transparency) Where storage will not compromise the anonymity of research participants, data will be deposited in the Dryad repository. Discussion For example, “interesting, diverse landscape” was a significant explanatory variable in our model. The attributes of a landscape that promote the per- ception of an interesting and diverse landscape can be linked to biome, vegetation type and variation in elevation since these biophysical attributes were also Understanding the influence of landscape charac- teristics on birder benefits requires consideration of the nested relationship between species, communi- ties and landscape. While this study disentangled the individual effects of different levels of ecological organisation to better understand their contribution to birder benefits, components of ecological systems are not independent of each other (Suarez-Rubio and 3 123456789) 1 ol.: (01 Landsc Ecol (2022) 37:883–894 892 Thomlinson 2009; Filloy et al. 2019). For instance, while the results suggested that biome, vegetation type and variance in elevation were significantly related to birder benefits, these biophysical attrib- utes also affect the assemblage of bird communities through hierarchical relationships at different scales and levels (Aalders and Stanik 2019). In addition, social systems exert a critical selective pressure on ecological systems (Tengberg et al. 2012), suggesting that the provision of birder benefits also depends on demand from birders. Consequently, the cultural ben- efits derived from birdwatching are produced from complex social-ecological interactions that occur at multiple levels and scales even when cultural services are ostensibly delivered at the species level. Thomlinson 2009; Filloy et al. 2019). For instance, while the results suggested that biome, vegetation type and variance in elevation were significantly related to birder benefits, these biophysical attrib- utes also affect the assemblage of bird communities through hierarchical relationships at different scales and levels (Aalders and Stanik 2019). In addition, social systems exert a critical selective pressure on ecological systems (Tengberg et al. 2012), suggesting that the provision of birder benefits also depends on demand from birders. Consequently, the cultural ben- efits derived from birdwatching are produced from complex social-ecological interactions that occur at multiple levels and scales even when cultural services are ostensibly delivered at the species level. to individual organisms. Components of landscapes interact with one another, resulting in a landscape mosaic comprising a composite of different attributes (Daniels 1994). Landscapes are often perceived as a whole rather than the sum of individual biophysical attributes (Fagerholm et al. 2019). Safeguarding the provision of birder benefits therefore requires sup- porting variation in spatial contexts and across mul- tiple scales (Graves et al. 2019). Discussion i Understanding cultural ecosystem services at the landscape-level and implementing conservation measures to protect valuable biophysical attributes can mitigate against potential threats to ecosystem service delivery (Schaich et al. 2010). Although eco- system services are generated within the landscape, there is little understanding of landscape-ecosystem service connections (Andersson et al. 2015). 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https://openalex.org/W3124459879	https://hal.archives-ouvertes.fr/hal-01434432/file/422-1-L62.pdf	English	null	Fast evolving size of early-type galaxies at z > 2 and the role of dissipationless (dry) merging	Monthly Notices of the Royal Astronomical Society Letters	2,012	cc-by	6,346	Fast evolving size of early-type galaxies at z >2 and the role of dissipationless (dry) merging Alessandro Cimatti, C. Nipoti, P. Cassata To cite this version: Alessandro Cimatti, C. Nipoti, P. Cassata. Fast evolving size of early-type galaxies at z >2 and the role of dissipationless (dry) merging. Monthly Notices of the Royal Astronomical Society, 2012, 422 (1), pp.L62–L66. 10.1111/j.1745-3933.2012.01237.x. hal-01434432 To cite this version: Alessandro Cimatti, C. Nipoti, P. Cassata. Fast evolving size of early-type galaxies at z >2 and the role of dissipationless (dry) merging. Monthly Notices of the Royal Astronomical Society, 2012, 422 (1), pp.L62–L66. 10.1111/j.1745-3933.2012.01237.x. hal-01434432 Alessandro Cimatti, C. Nipoti, P. Cassata. Fast evolving size of early-type galaxies at z >2 and the role of dissipationless (dry) merging. Monthly Notices of the Royal Astronomical Society, 2012, 422 (1), pp.L62–L66. 10.1111/j.1745-3933.2012.01237.x. hal-01434432 Distributed under a Creative Commons Attribution 4.0 International License ABSTRACT We present the analysis of a large sample of early-type galaxies (ETGs) at 0 < z < 3 aimed at tracing the cosmic evolution of their size and compare it with a model of pure dissipationless (dry) merging in the cold dark matter (CDM) framework. The effective radius Re depends on stellar mass M as Re(M) ∝Mα with α ∼0.5 at all redshifts. The redshift evolution of the mass- or SDSS-normalized size can be reproduced as ∝(1 + z)β with β ∼−1, with the most massive ETGs possibly showing the fastest evolutionary rate (β ∼−1.4). This size evolution slows down signiﬁcantly to β ∼−0.6 if the ETGs at z > 2 are removed from the sample, suggesting an accelerated increase of the typical sizes at z > 2, especially for the ETGs with the largest masses. A pure dry merging CDM model is marginally consistent with the average size evolution at 0 < z < 1.7, but predicts descendants too compact for z > 2 progenitor ETGs. This opens the crucial question on what physical mechanism can explain the accelerated evolution at z > 2, or whether an unclear observational bias is partly responsible for that. Key words: galaxies: elliptical and lenticular, cD – galaxies: evolution – galaxies: formation. Key words: galaxies: elliptical and lenticular, cD – galaxies: evolution – galaxies: formation et al. 2011; Newman et al. 2011 and references therein). It is not clear yet whether the environment plays (e.g. Cooper et al. 2012; Papovich et al. 2011) or not (e.g. Rettura et al. 2010) a role in the ETG size evolution. The few available measurements of stellar ve- locity dispersions are consistent with those expected from the ETG sizes and conﬁrm that these systems are truly massive (Cappellari et al. 2009; Cenarro & Trujillo 2009; van Dokkum, Kriek & Franx 2009; Onodera et al. 2010; van de Sande et al. 2011). Several models have been proposed to explain the size–mass evolution, including dissipationless (dry) major and minor merging, adiabatic expan- sion driven by stellar mass loss and/or strong feedback and smooth stellar accretion (e.g. Nipoti, Londrillo & Ciotti 2003; Khochfar & Silk 2006; Bournaud, Jog & Combes 2007; Fan et al. 2008; Hopkins et al. 2009; Naab, Johansson & Ostriker 2009; Nipoti, Treu & Bolton 2009a; Nipoti et al. 2009b; Graham 2011; Oser et al. 2011). However, the global picture is far from being clear. ABSTRACT In this Letter, we exploit a large sample of ETGs in order to investigate the evolution of their size as a function of redshift and mass, and compare it with the predictions of cosmological models of structure formation. 1 INTRODUCTION Early-type galaxies (ETGs) are important probes of structure for- mation and massive galaxy evolution. At 0 < z < 1, the ETG stellar mass function shows a downsizing evolution apparently difﬁcult to reproduce with the current models of galaxy formation, with the majority of massive ETGs (M > 1011 M⊙) already in place at z ≈ 0.7 (Pozzetti et al. 2010 and references therein). At z > 1, the infor- mation is still incomplete, but bona ﬁde ETGs have been identiﬁed up to z ∼2.5 (e.g. Kriek et al. 2006; Cimatti et al. 2008 and ref- erences therein). These high-z ETGs are characterized by old stars (1–3 Gyr), e-folding decaying star formation time-scales τ ∼0.1– 0.3 Gyr, low speciﬁc star formation rates (SSFR < 10−2 Gyr−1), low dust extinction, large stellar masses (M > 1011 M⊙), spheroidal morphologies (although some of these systems have a disc-like component; van der Wel et al. 2011), and number densities growing rapidly from z > 3 to z ∼1 (e.g. Fontana et al. 2009; Brammer et al. 2011; Dom´ınguez-S´anchez et al. 2011). A puzzling property of ETGs at z > 1 is that they have smaller sizes, down to effective radii Re < 1 kpc, and correspondingly higher internal mass densities than present-day ETGs with the same mass (e.g. Daddi et al. 2005; Trujillo et al. 2006; Buitrago et al. 2008; Cimatti et al. 2008; van der Wel et al. 2008; Saracco, Longhetti & Andreon 2009; Williams et al. 2010; Cassata et al. 2011; Damjanov Accepted 2012 February 13. Received 2012 January 12; in original form 2011 November 25 Accepted 2012 February 13. Received 2012 January 12; in original form 2011 November 25 HAL Id: hal-01434432 https://hal.science/hal-01434432v1 Submitted on 8 Oct 2021 L’archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d’enseignement et de recherche français ou étrangers, des laboratoires publics ou privés. HAL is a multi-disciplinary open access archive for the deposit and dissemination of sci- entific research documents, whether they are pub- lished or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. Distributed under a Creative Commons Attribution 4.0 International License Mon. Not. R. Astron. Soc. 422, L62–L66 (2012) doi:10.1111/j.1745-3933.2012.01237.x doi:10.1111/j.1745-3933.2012.01237.x Mon. Not. R. Astron. Soc. 422, L62–L66 (2012) ⋆E-mail: a.cimatti@unibo.it Fast evolving size of early-type galaxies at z > 2 and the role of dissipationless (dry) merging A. Cimatti,1⋆C. Nipoti1 and P. Cassata2 1Dipartimento di Astronomia, Universit`a di Bologna, Via Ranzani 1, I-40127 Bologna, Italy 2Laboratoire d’Astrophysique de Marseille – LAM, Universit´e d’Aix-Marseille & CNRS, UM 13, France A. Cimatti,1⋆C. Nipoti1 and P. Cassata2 1Dipartimento di Astronomia, Universit`a di Bologna, Via Ranzani 1, I-40127 Bologna, Italy 2Laboratoire d’Astrophysique de Marseille – LAM, Universit´e d’Aix-Marseille & CNRS, UMR 7326, 38 rue Fr´ed´eric Joliot-Curie, F-13388 Marseille Cedex 13, France A. Cimatti,1⋆C. Nipoti1 and P. Cassata2 1Dipartimento di Astronomia, Universit`a di Bologna, Via Ranzani 1, I-40127 Bologna, Italy 2Laboratoire d’Astrophysique de Marseille – LAM, Universit´e d’Aix-Marseille & CNRS, UMR 7326, 38 rue Fr´ed´eric Joliot-Curie, F-13388 Marseille Cedex 13, France A. Cimatti,1⋆C. Nipoti1 and P. Cassata2 1Dipartimento di Astronomia, Universit`a di Bologna, Via Ranzani 1, I-40127 Bologna, Italy 2Laboratoire d’Astrophysique de Marseille – LAM, Universit´e d’Aix-Marseille & CNRS, UMR 7326, 38 rue Fr´ed´eric Joliot-Curie, F-13388 Marseille Cedex 13, France C⃝2012 The Authors Monthly Notices of the Royal Astronomical Society C⃝2012 RAS 2 THE SAMPLE In order to improve statistically on previous studies, we selected a large sample of 1975 ETGs at 0.2 < z < 3 by collecting data from the literature and public data, requiring the availability of spectroscopic redshifts (or high-quality photometric redshifts for z > 1.4), stellar C⃝2012 The Authors Monthly Notices of the Royal Astronomical Society C⃝2012 RAS Fast evolving size of early-type galaxies L63 Figure 1. The size–stellar mass relation for log M/M⊙> 10.5. Black and blue symbols indicate SDSS and non-SDSS ETGs, respectively. Only SDSS ETGs older than 10 Gyr are shown in order to avoid excessive crowding. The black solid line shows the size–mass relation of Shen et al. (2003) and its ±1σ scatter (dashed black lines). Red dashed lines: best-ﬁtting relations using Re ∝Mα. Table 1. ETG subsamples. Sample N Redshift Age Ref. SDSS 59 500 0 < z < 0.4 Yes 1 COSMOS/zCOSMOS 950 0 < z < 1 No 2 GOODS-N+S 469 0 < z∗< 2 Yes 3 Literature 465 0.2 < z < 2.7 No 4 GMASS 45 1.4 < z∗< 3 No 5 COSMOS 12 1.4 < z∗< 1.8 Yes 6 XMMU J2235−2557 11 z = 1.39 Yes 7 K20-0055 9 0.7 < z < 1.2 Yes 8 POWIR 6 1.2 < z∗< 1.8 No 9 K20 4 1.6 < z < 1.9 Yes 10 1255–0 1 z = 2.186 Yes 11 FW-4871 1 z = 1.902 Yes 12 z∗: a fraction of redshifts is photometric; Age: available stellar ages. References: (1) Hyde & Bernardi (2009); (2) http://cosmos. astro.caltech.edu/data/index.html, Scarlata et al. (2007), Moresco et al. (2010); (3) Cassata et al. (2011); (4) Damjanov et al. (2011); (5) Cassata al. (2008); (6) Mancini et al. (2010); (7) Strazzullo et al. (2010); (8) di Serego Alighieri et al. (2005); (9) Carrasco, Conselice & Trujillo (2010, nSersic > 2); (10) Cimatti et al. (2004); (11) van Dokkum et al. (2009); (12) van Dokkum & Brammer (2010). Figure 1. The size–stellar mass relation for log M/M⊙> 10.5. Black and blue symbols indicate SDSS and non-SDSS ETGs, respectively. Only SDSS ETGs older than 10 Gyr are shown in order to avoid excessive crowding. The black solid line shows the size–mass relation of Shen et al. (2003) and its ±1σ scatter (dashed black lines). Red dashed lines: best-ﬁtting relations using Re ∝Mα. masses, sizes (Re) and, when possible, age of the stellar population (see Table 1). 2 THE SAMPLE The ETGs in the different subsamples share the global property to have been originally selected based on the combination of colours, spectra (or sometimes also SSFR) typical of old/passive galaxies with the conﬁrmation of spheroidal (E/S0) morphology, or vice versa. We recall that selection criteria for ETGs are strongly correlated, with up to ∼85 per cent colour-/spectra-selected ETGs being also morphologically E/S0 (e.g. Renzini 2006 and references therein). The ETG sizes were generally measured in the observed- frame red–optical for low-/intermediate-redshift samples and/or in the near-infrared for higher redshifts, i.e. typically sampling the rest-frame optical region at all redshifts. Recently, Damjanov et al. (2011) and Cassata et al. (2011) have shown that the sizes measured in the rest-frame ultraviolet and in the optical correlate very strongly with each other, thus excluding substantial biases dependent on the wavelength at which the size was measured. The Sloan Digital Sky Survey (SDSS) sample of Hyde & Bernardi (2009) was included as the reference sample at z ∼0. high redshift in the three bins of Fig. 1, with α basically independent of redshift. For instance, the ETGs with z > 2 have α = 0.45 ± 0.11. This result is consistent with recent works (Damjanov et al. 2011; Newman et al. 2012) and does not depend signiﬁcantly on the choice of the redshift bin limits or the minimum stellar mass cuts. In comparison, the SDSS ETGs with log M/M⊙> 10.5 have α = 0.58 ± 0.01, consistent with Shen et al. (2003). 4 THE SIZE–REDSHIFT RELATION Fig. 2 shows the redshift evolution of the ETG size in two com- plementary ways: the mass-normalized radius [Re(z)/Mα 11, where M11 = M/1011 M⊙, adopting α = 0.55 as representative value] and radius normalized to the average size of SDSS ETGs [Re(z)/Re(SDSS)] in three mass bins. Both quantities are useful to derive the size evolution independently of the correlation between Re and M. The evolution is parametrized by the usual functional form size ∝(1 + z)β. Clearly, this parametrization does not mean that all high-z ETGs are the direct progenitors of all low-z ETGs be- cause these galaxies evolve in the redshift range 0 < z < 3 through several processes and increase their number density and mass, but it has simply the statistical meaning of indicating how the typical sizes compare at different redshifts. The different subsamples were harmonized to the same cosmol- ogy (H0 = 70 km s−1 Mpc−1, m = 0.3, = 0.7), and the stellar masses and ages rescaled to the Maraston (2005) stellar population synthesis models with the Chabrier initial mass function by using empirical scaling relations of Pforr, Maraston & Tonini (2012). Based on the information available in the literature, the stellar mass completeness of most subsamples is log Mcomp/M⊙= 10.5 at all redshifts. However, a few subsamples have log Mcomp/M⊙∼ 10.8–11: GN/DEIMOS (from Damjanov et al. 2011) and zCOS- MOS at z < 1.3, MUNICS, K20, Mancini et al. (2010) and van Dokkum et al. (2008) at 1.3 < z < 2, Cassata et al. (2011) and van Dokkum et al. (2008) at z > 2. The ﬁnal sample was reduced to 1080 galaxies in order to avoid mass incompleteness effects (see Section 4 for details). In order to mitigate the potential effects of stellar mass incom- pleteness, for each mass bin of Fig. 2 (top three panels), the galaxies with M < Mcomp(z) were removed from each subsample. Thus, each mass bin is always complete down to the minimum mass of the bin. For instance, the ETGs with M < 1011 M⊙at z ≥1 and M < 1010.6 M⊙at z ≥2 have been excluded from the zCOSMOS and the Cassata et al. (2011) sample, respectively. C⃝2012 The Authors, MNRAS 422, L62–L66 Monthly Notices of the Royal Astronomical Society C⃝2012 RAS 3 THE SIZE–MASS RELATION Fig. 1 shows the size–mass relation in three redshift ranges with a comparable number of galaxies in each bin. A power-law ﬁt, Re ∝Mα, applied to non-SDSS ETGs with log M/M⊙> 10.5 provides α = 0.52±0.05, 0.47±0.04 and 0.50±0.04 from low to For the mass-normalized radius (Fig. 2, bottom panel), we derive β = −1.06 ± 0.14 ( −1.24 ± 0.15) for log M/M⊙> 10.5(10.9), in agreement with the literature (Damjanov et al. 2011; Newman L64 A. Cimatti, C. Nipoti and P. Cassata L64 Figure 2. Bottom panel: the mass-normalized radius (Re/M0.55 11 ) of ETGs with log M/M⊙>10.5 as a function of z. Top three panels: the fractional radius [relative to SDSS; ⟨Re(SDSS)⟩= 2.51, 3.10, 5.61 kpc]. In all panels, green and blue small symbols indicate individual SDSS and non-SDSS ETGs, respectively, whereas the large black and red ﬁlled circles are the average values [⟨Re/Re(SDSS)⟩] of SDSS and non-SDSS, respectively, each with the ±1σ scatter. The black solid line is the best-ﬁtting function to the red and black points. The redshift bins adopted for the non-SDSS ETGs in this ﬁgure are 0 < z < 0.5, 0.5 < z < 1, 1 < z < 1.5, 1.5 < z < 2 and 2 < z < 3. The cyan dashed lines show the best ﬁts for the case of ETGs with z < 2 (redshift bins: 0 < z < 0.3, 0.3 < z < 0.6, 0.6 < z < 1, 1 < z < 1.5 and 1.5 < z < 2). The potential role of the so-called progenitor bias (e.g. Saglia et al. 2010 and references therein) has been assessed through an age ﬁltering by comparing the size of ETGs having ages compat- ible with the cosmic time passed from high to low z. For a given redshift range z1 < z < z2 and average redshift ¯z, we estimated β by comparing the average size of the ETGs [having an average age tage(¯z) ± σt(z)] with the size of SDSS ETGs with ages at z0 between [tage(¯z) −σt(z)] + τ(z −z0) and [tage(¯z) + σt(z)] + τ(z −z0), where τ(z −z0) is the cosmic time passed from z to z0. Based on this ap- proach, no signiﬁcant or systematic changes of β have been found for a variety of tested redshift ranges. 5 COMPARISON WITH A CDM MODEL Dissipationless (dry) merging is one of the few mechanisms known to make galaxies less compact (e.g. Nipoti et al. 2003; Naab et al. 2009), so it is often invoked to explain the observed size evolu- tion of ETGs. Here we brieﬂy address the question of whether the observed size evolution is consistent with the merger histories of concordance cold dark matter (CDM) cosmology. For this pur- pose, we use the CDM-based merger models presented in Nipoti et al. (2012, hereafter N12), which are such that the variation in surface-mass density is maximized, because dissipative effects are neglected. In particular, we adopt here model B of N12, which is the most strongly evolving of their models, so the predicted size evolution must be considered an upper limit. Here we brieﬂy de- scribe the main properties of the model, but we refer the reader to N12 for details. For an observed ETG with measured stellar mass M and effective radius Re, the model allows us to calculate the redshift evolution of M and Re via analytic functions calibrated on N-body simulations. The galaxy is ﬁrst assigned a halo mass using the redshift-dependent stellar to halo mass relation of Behroozi, Conroy & Wechsler (2010). The halo growth history is then com- puted using the Fakhouri, Ma & Boylan-Kolchin (2010) ﬁt to halo merger histories in the Millennium I and II Simulations (Springel et al. 2005; Boylan-Kolchin et al. 2009). The associated growth of M is obtained by assigning stellar mass to satellite haloes with the Behroozi et al. (2010) recipe, and considering only mergers with mass ratio >0.03 (to exclude cases with too long merging time). Finally, the corresponding variation in Re is computed using analytic functions veriﬁed with N-body simulations of minor and major dry mergers between spheroids. For observed high-z ETGs, we compute the predicted M(z) and Re(z) up to z = 0.14, which is the average redshift of massive (log M/M⊙> 10.9) SDSS ETGs. The evolution in the M–Re plane is shown in Fig. 3, taking as progenitors the observed ETGs with 2 < z < 3 (⟨z⟩≃2.4) and those with 1.5 < z < 2 (⟨z⟩≃1.7). In both cases the present-day descendants tend to be more compact than real z ∼0 ETGs, but the et al. 2012). 3 THE SIZE–MASS RELATION For example, for ETGs with log M/M⊙> 10.9 at 0.7 < z < 1.3, we derive β = −1.06 ± 0.2 and −0.97 ± 0.2, respectively, with and without applying the above ‘age ﬁltering’. Similarly, if we select the most distant ETGs (1.8 < z < 3), we obtain β = −1.29 ± 0.2 and −1.23 ± 0.2. If we take these results at face value, this implies that most of the Re(z) evo- lution is unlikely to be the result of a progenitor bias due to high-z ETGs being preferentially selected to be redder and more compact than lower z younger and larger ETGs missed at high z. However, we recall that, due to the heterogeneous estimates of the stellar ages in our sample, this result should be conﬁrmed with larger and more homogeneous samples. On the other hand, we note that large ETGs are indeed absent at 1.4 < z < 3 in the GMASS subsample (Fig. 2), which is selected based solely on morphology irrespective of colours (Cassata et al. 2008). Figure 2. Bottom panel: the mass-normalized radius (Re/M0.55 11 ) of ETGs with log M/M⊙>10.5 as a function of z. Top three panels: the fractional radius [relative to SDSS; ⟨Re(SDSS)⟩= 2.51, 3.10, 5.61 kpc]. In all panels, green and blue small symbols indicate individual SDSS and non-SDSS ETGs, respectively, whereas the large black and red ﬁlled circles are the average values [⟨Re/Re(SDSS)⟩] of SDSS and non-SDSS, respectively, each with the ±1σ scatter. The black solid line is the best-ﬁtting function to the red and black points. The redshift bins adopted for the non-SDSS ETGs in this ﬁgure are 0 < z < 0.5, 0.5 < z < 1, 1 < z < 1.5, 1.5 < z < 2 and 2 < z < 3. The cyan dashed lines show the best ﬁts for the case of ETGs with z < 2 (redshift bins: 0 < z < 0.3, 0.3 < z < 0.6, 0.6 < z < 1, 1 < z < 1.5 and 1.5 < z < 2). C⃝2012 The Authors, MNRAS 422, L62–L66 Monthly Notices of the Royal Astronomical Society C⃝2012 RAS 5 COMPARISON WITH A CDM MODEL This result is stable against changing α between 0.4 and 0.7, the boundaries of the redshift bins, and the minimum stellar mass. The consistency of the Re ∝Mα and (Re/Mα 11) ∝(1 + z)β relations with previous results conﬁrms that our sample, despite its somehow heterogeneous composition, can be reliably used to perform further detailed studies. Fig. 2 (top three panels) shows Re normalized to Re(SDSS). For the three bins of increasing mass, we derive β = −1.23 ± 0.15, −0.87 ± 0.14 and −1.39 ± 0.13. This suggests that β does not signiﬁcantly depend on stellar mass, although a steepening is suggested in the most massive bin. These results are stable, within the statistical uncertainties, against changes in the minimum stellar mass in the lowest mass bin, in the boundaries of the mass bins, and in the minimum age of the SDSS ETGs. Fig. 2 also shows that the ETG size growth rate seems to in- crease signiﬁcantly at high redshift, suggesting a slower evolution at z < 2. For the mass-normalized radius (bottom panel), β be- comes −0.57 ± 0.15 if the ETGs at zcut > 2 are excluded. Similarly for Re/Re(SDSS), β becomes −0.73 ± 0.14, −0.76 ± 0.13 and −0.75 ± 0.14 if ETGs at z > 2 are excluded in the three bins of in- creasing mass. We note that the ﬂattening is particularly pronounced and signiﬁcant in the bin of the largest masses. The ﬂattening of β is also present, within the statistical uncertainties, against changing the limits of the redshift bins if we cut ETGs around 1.5 < zcut < 2. For instance, if the ETGs with zcut > 1.5 (1.7) are excluded in the bin with log M/M⊙> 10.9, we derive β = −0.95 ( −0.72) ± 0.15. The overall results presented in this section do not change if median values are used instead of the average ones, or if the SDSS data points are excluded. C⃝2012 The Authors, MNRAS 422, L62–L66 Monthly Notices of the Royal Astronomical Society C⃝2012 RAS Fast evolving size of early-type galaxies L65 Figure 3. Redshift evolution of ETGs in the stellar mass–effective radius plane, as predicted by the dry-merger CDM model described in Section 5. The progenitors (circles) are the ETGs observed at 2 < z < 3 (⟨z⟩≃2.4, upper panel) and those observed at 1.5 < z < 2 (⟨z⟩≃1.7, lower panel). 6 CONCLUSIONS 2010; Shih & Stockton 2011). Do our results necessarily imply that dry merg- ing alone cannot explain the observed size evolution? In principle it could be the case that dry mergers are responsible for the whole size evolution, but the actual rate of mergers is higher than pre- dicted. This hypothesis can be tested by further comparison with observations. A ﬁrst constraint comes from the observed redshift evolution of the ETG stellar mass function. Let us take, for instance, the model describing the evolution of the z ∼1.7 ETGs. At each z ≤1.7 we select only model galaxies with log M/M⊙≥10.9 and ACKNOWLEDGMENTS We thank M. Bernardi, M. Moresco and V. Strazzullo for provid- ing their data, J. Pforr and C. Maraston for providing their scal- ing relations, E. Daddi and A. Renzini for useful discussion, the COSMOS/zCOSMOS teams for making the data available to the community, and the anonymous referee for the constructive com- ments. AC is supported by grants ASI-Uni. Bologna-Astronomy Dept. I/039/10/0 and PRIN MIUR 2008. CN is supported by grant PRIN MIUR 2008. Paolo Cassata acknowledges support from ERC grant ERC-2010-AdG-26107-EARLY. 5 COMPARISON WITH A CDM MODEL the average mass increases by ∼30 per cent (70 per cent) from z = 0.7(1.5) to the present. This is compatible with the observed evolution of the ETG stellar mass function at 0 < z < 1 (e.g. Pozzetti et al. 2010). Another testable feature of the model is the predicted merger rate. Let us de- ﬁne major (minor) mergers those with mass ratio greater than (less than) 1/4. The predicted number of major mergers per unit time dNm/dt decreases for decreasing z (see Fakhouri et al. 2010): for our model ETGs we get, on average, dNm/dt ∼0.13(0.23) Gyr−1 at z ∼0.55(1.15). These rates are higher by a factor of ∼2 than estimated observationally at similar z by Bundy et al. (2009; see also Lotz et al. 2011), indicating that the considered model might be extreme also in this respect. In the model, both major and mi- nor mergers contribute signiﬁcantly to the growth of stellar mass (for instance, ∼50 per cent each between z = 1.5 and 0), so, at least within CDM, massive ETGs do not accrete most of their mass in very minor mergers, which would be more effective in in- creasing the galaxy size. The above arguments suggest that other processes not included in the model should contribute signiﬁcantly to the size evolution (see also Shankar et al. 2011). Unfortunately, at the moment the proposals for additional mechanisms are not very promising: Fan et al. (2008) envisaged that feedback from quasi- stellar objects could play a role, but also this scenario is not without problems (Ragone-Figueroa & Granato 2011). Figure 3. Redshift evolution of ETGs in the stellar mass–effective radius plane, as predicted by the dry-merger CDM model described in Section 5. The progenitors (circles) are the ETGs observed at 2 < z < 3 (⟨z⟩≃2.4, upper panel) and those observed at 1.5 < z < 2 (⟨z⟩≃1.7, lower panel). The predicted descendants at z = 1 and 0.14 are represented, respectively, by triangles and squares. For comparison, we plot SDSS ETGs (green dots) and the local SDSS best ﬁt with its observed scatter (black solid and dashed curves; Shen et al. 2003). The red dashed lines indicate the best ﬁts for ETGs observed at 0.8 < z < 1.2. C⃝2012 The Authors, MNRAS 422, L62–L66 Monthly Notices of the Royal Astronomical Society C⃝2012 RAS 6 CONCLUSIONS The analysis of a large sample of ETGs at 0 < z < 3 shows that their size evolves independently of stellar mass and possibly faster at z > 2 (especially for ETGs with the largest masses). The interpretation of this result is not straightforward as the available information does not allow us to assess if this is an observational bias (e.g. large ETGs with low surface brightness are missed in high-z samples), or it is an intrinsic change in the evolutionary pattern implying a very rapid growth of ETGs from z > 2 to lower redshifts. We explored the possibility of pure dry merging as the dominant growth mecha- nism within the CDM framework, and found that this scenario is marginally consistent with the average size evolution at 0 < z < 1.7, but predicts descendants too compact for z > 2 progenitor ETGs. Further studies and larger samples of ETGs at z > 1.5, which will be obtained with future wide-ﬁeld surveys (e.g. Euclid; Laureijs et al. 2011), will shed light on these open questions. deviation from the SDSS M–Re relation is larger than the observed scatter (∼0.15 log Re at given M) only when z ∼2.4 progenitors are considered: the z ∼0 descendants have median vertical offset from the SDSS best ﬁt log Re ≃−0.3(−0.1) for z ∼2.4 (1.7) progenitors. In the case of z ∼2.4 progenitors, also the z = 1 model descendants are more compact than real z ∼1 ETGs. We conclude that the z > 2 ETGs are so compact that, even according to extreme pure dry-merger models, their low-z descendants are predicted to be signiﬁcantly more compact than present-day ETGs. On the other hand, the milder size evolution observed since z ∼1.7 is marginally consistent with CDM dry-merger models, though the model de- scendants are distributed in the M–Re plane with larger scatter than the observed ETGs (see also N12). An additional problem is the presence, among the predicted z ∼0 descendants, of outliers, i.e. galaxies in regions of the M–Re in which there are no SDSS ETGs: for instance, three model galaxies with log M/M⊙∼12 and Re > 70 kpc, and a model galaxy with log M/M⊙∼11.5 and Re ∼0.3 kpc (Fig. 3). Behroozi P. S., Conroy C., Wechsler R. H., 2010, ApJ, 717, 379 Bournaud F., Jog C. J., Combes F., 2007, A&A, 476, 1179 6 CONCLUSIONS We recall here that the existence of compact low-z ETGs with sizes and masses comparable to those of compact ETGs at z > 2 is somehow unclear, with some results showing an absence of such galaxies (e.g. Taylor et al. 2010) and others ﬁnding a few candidates (e.g. Valentinuzzi et al. 2010; Shih & Stockton 2011). Do our results necessarily imply that dry merg- ing alone cannot explain the observed size evolution? In principle it could be the case that dry mergers are responsible for the whole size evolution, but the actual rate of mergers is higher than pre- dicted. This hypothesis can be tested by further comparison with observations. A ﬁrst constraint comes from the observed redshift evolution of the ETG stellar mass function. Let us take, for instance, the model describing the evolution of the z ∼1.7 ETGs. At each z ≤1.7 we select only model galaxies with log M/M⊙≥10.9 and deviation from the SDSS M–Re relation is larger than the observed scatter (∼0.15 log Re at given M) only when z ∼2.4 progenitors are considered: the z ∼0 descendants have median vertical offset from the SDSS best ﬁt log Re ≃−0.3(−0.1) for z ∼2.4 (1.7) progenitors. In the case of z ∼2.4 progenitors, also the z = 1 model descendants are more compact than real z ∼1 ETGs. We conclude that the z > 2 ETGs are so compact that, even according to extreme pure dry-merger models, their low-z descendants are predicted to be signiﬁcantly more compact than present-day ETGs. On the other hand, the milder size evolution observed since z ∼1.7 is marginally consistent with CDM dry-merger models, though the model de- scendants are distributed in the M–Re plane with larger scatter than the observed ETGs (see also N12). An additional problem is the presence, among the predicted z ∼0 descendants, of outliers, i.e. galaxies in regions of the M–Re in which there are no SDSS ETGs: for instance, three model galaxies with log M/M⊙∼12 and Re > 70 kpc, and a model galaxy with log M/M⊙∼11.5 and Re ∼0.3 kpc (Fig. 3). We recall here that the existence of compact low-z ETGs with sizes and masses comparable to those of compact ETGs at z > 2 is somehow unclear, with some results showing an absence of such galaxies (e.g. Taylor et al. 2010) and others ﬁnding a few candidates (e.g. Valentinuzzi et al. 5 COMPARISON WITH A CDM MODEL The predicted descendants at z = 1 and 0.14 are represented, respectively, by triangles and squares. For comparison, we plot SDSS ETGs (green dots) and the local SDSS best ﬁt with its observed scatter (black solid and dashed curves; Shen et al. 2003). The red dashed lines indicate the best ﬁts for ETGs observed at 0.8 < z < 1.2. for this subsample we measure the average stellar mass ⟨log M⟩. The redshift variation of ⟨log M⟩is found to be well represented by the ﬁt ⟨log M/M⊙⟩(z) = 11.57 −0.15z, i.e. the average mass increases by ∼30 per cent (70 per cent) from z = 0.7(1.5) to the present. This is compatible with the observed evolution of the ETG stellar mass function at 0 < z < 1 (e.g. Pozzetti et al. 2010). Another testable feature of the model is the predicted merger rate. Let us de- ﬁne major (minor) mergers those with mass ratio greater than (less than) 1/4. The predicted number of major mergers per unit time dNm/dt decreases for decreasing z (see Fakhouri et al. 2010): for our model ETGs we get, on average, dNm/dt ∼0.13(0.23) Gyr−1 at z ∼0.55(1.15). These rates are higher by a factor of ∼2 than estimated observationally at similar z by Bundy et al. (2009; see also Lotz et al. 2011), indicating that the considered model might be extreme also in this respect. In the model, both major and mi- nor mergers contribute signiﬁcantly to the growth of stellar mass (for instance, ∼50 per cent each between z = 1.5 and 0), so, at least within CDM, massive ETGs do not accrete most of their mass in very minor mergers, which would be more effective in in- creasing the galaxy size. The above arguments suggest that other processes not included in the model should contribute signiﬁcantly to the size evolution (see also Shankar et al. 2011). Unfortunately, at the moment the proposals for additional mechanisms are not very promising: Fan et al. 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https://openalex.org/W4291814544	https://figshare.com/ndownloader/files/36624132/1	English	null	Standardization on Bias in Artificial Intelligence as Industry Support	null	2,022	cc-by	5,396	Standardization on Bias in Artificial Intelligence as Industry Support This paper was downloaded from TechRxiv (https://www.techrxiv.org). LICENSE CC BY 4.0 SUBMISSION DATE / POSTED DATE 04-08-2022 / 16-08-2022 CITATION Szczekocka, Ewelina; Tarnec, Christele; Pieczerak, Janusz (2022): Standardization on Bias in Artificial Intelligence as Industry Support. TechRxiv. Preprint. https://doi.org/10.36227/techrxiv.20435892.v1 10.36227/techrxiv.20435892.v1 10.36227/techrxiv.20435892.v1 Department: Head Editor: Name, xxxx@email Department Head However, the first significant names for Artificial Intelligence are even earlier, the distinguished mathematician Allan Turing (and his famous test of Artificial Intelligence called "The Imitation Game"), and even before that Rene Descartes, the great French philosopher, and his visions and predictions about thinking and decision-making by machines. intensifying growth of their domestic AI industries, after China published its plan to outdistance United States as the global leader in AI by 2030 [1]. The rapidly growing interest and ever-deepening need to use Artificial Intelligence is one side of the issue. The other key aspect is related to how AI is used and how it protects people affected by its biased results, from which certain actions and consequences for those people may follow. In principle, ensuring the proper operation of AI systems concerns all stakeholders associated with these systems. For example, a bank that rejects a loan application due to a proposed decision of an AI-based banking system may also be de facto harmed. If that decision was based on improper considerations, the bank lost the opportunity to potentially profit from a loan it did not grant. Likewise, if the court makes a judgment based on the wrong decision proposals from the AI system, this can be a detriment not only to the wrongly judged person, but also to the court itself and society as a whole (incurring costs, etc.). One of the better-known examples of harmful bias was seen during the gender bias lawsuit in university admissions against UC Berkeley. After analyzing graduate school admissions data, it seemed like there was bias toward women, a smaller fraction of whom were being admitted to graduated programs compared to their male counterparts. However, when admissions data was separated and analyzed over the departments, women applicants had equality and, in some cases, even a small advantage over men. The paradox happened as women tended to apply to departments with lower admission rates for both genders Artificial Intelligence developed significantly in the 1990s, particularly with the increase in computing power. One of the most interesting moments was the victory of a computer program called Deep Blue over the world chess champion, Garry Kasparov (in 1997). In 2011, IBM's AI-based computer system called Watson took a part in the teleseminar Jeopardy. It answered questions using NLP (Natural Language Processing). It beat the previous champion of the game by a large margin. Title: Standardization on Bias in Artificial Intelligence as Industry Support F. A. Ewelina Szczekocka Orange Innovation Poland B. Christèle Tarnec Orange Innovation C. Janusz Pieczerak Orange Innovation Poland Abstract Industry strives to have trustworthy AI systems, then to recognize and implement Responsible AI principles to achieve that goal. It is important for us to find solutions that will help implement trustworthy AI systems. Standardization activities are an important element for us in this regard, as they provide a platform for discussion for industry towards use and help work out practical rules and requirements. This article first provides an overview of the bias issue in Artificial Intelligence, and presents the concept of Responsible AI. Second, we present examples of interesting ongoing works by international standardization organizations on bias in AI systems. Then we identify a gap between the principles defined by high-level legal studies on responsible AI, including the European AI Act proposal, and practical implementations of these principles. Finally we state how international standardization may fill this gap. And perhaps the travel still to conduct to fill it? First of all, Artificial Intelligence is of a great interest since few years, and it is its great comeback. This is because the data volumes available for training models and extracting valuable information, as well as computing capacities have skyrocketed over the last decade.  THE INTRODUCTION Bias is not a new concept. It has been known in the technical (algorithmic bias) and social fields for a long time. Originally, the concept was not related specifically to Artificial Intelligence systems, but to such branches of science as statistics, mathematics, analytics in general. It acquires particular importance in the face of developing Artificial Intelligence systems. The first intensive works on Artificial Intelligence date back to the 1950s (John McCarthy, Natural Language Processing, the first chatbot ELIZA). Published by the IEEE Computer Society Published by the IEEE Computer Society XXXX-XXXX 2019 IEEE IT Professional IT Professional Department Head BIAS AND FAIRNESS In general, bias known in science has many flavors. By examples, in different disciplines, a bias is a systematic error or simplification (e.g. mathematics, behavioral sciences). Commonly found in statistics or epidemiology, a bias is an approach or procedure that causes errors in the results of a study (overestimation or underestimation of the population parameter that can be measured). As for the above, bias comes from data and algorithms, methods, procedures, or research assumptions. In this, it should be noted that a general limitation of these principles, is that there are no empirically proven and evaluated methods that effectively reflect them in practice [3]. This is a significant hindrance for implementation of AI systems. It means that there is no guarantee of a proper implementation of the responsible AI principles (fairness issues, transparency, explainability, etc.) and efficient evaluation of these aspects allowing for explicit assessment of the correctness of their implementation and further operation. This is therefore a research gap that should be filled. In psychology, there is for instance a cognitive bias which is understood as the tendency to make decisions or take actions in an unknowingly irrational way. It can harm not only decision making, but also a judgment, values, and social interactions. It seems somehow close to ethical aspects of making decisions. However, technically in each case bias manifests as systematic error and oversimplification which may discriminate selections. It can occur intentionally or unintentionally (unwanted bias). The concept of bias is associated with the notion of fairness as it could have positive or negative consequences. A lack of fairness can be described as discrimination if it relates to rights protected by law (such as sex, race, color, ethnic or social origin, genetic features, language, religion or belief, political or any other opinion, membership of a national minority, property, birth, disability, age or sexual orientation as the EU charter of fundamental rights art 21.1 stated). With this in mind, we focus on addressing the gap for trustworthy AI systems. Moreover, we do this based on the example of one of the key concepts related to responsible Artificial Intelligence systems, that is the ethical aspect, and a characteristic related to it, namely fairness (and bias concerned with that), trying to analyze how it may affect AI systems, as well as what can play an important role in identifying and eliminating its negative impact. Department Head Watson has begun to be used to assist in the selection of lung cancer treatment therapies and the device's applicability among law corporations in the US is explored. Another milestone in competition between human and Artificial Intelligence was reached in 2016, when DeepMind's AlphaGo program defeated 18-time world champion Lee Sedol. These and other examples show that recent years have been full of intensive development of technology as well as Artificial Intelligence systems. Speaking the language of numbers, the market research agency IDC investigated that the worldwide market revenue for Artificial Intelligence started to grow significantly in 2018, and this steady growth is forecasted to 2030. It projected that the global AI market will reach a size of over half a trillion U.S. dollars by 2024 and will triple by 2030, growing to over 1.5 trillion U.S. dollars. However, different studies suggest variations in just how much the global market size will increase by. AI is anticipated to become one of the fastest growing industries in the near future. Five industries are expected to spend the most on AI in the coming years: the retail and banking sectors and next: discrete manufacturing, healthcare, and process automation. Other industries that will experience fast spending growth include public safety, emergency response, shopping advisors and recommendations. Increasing interest and adoption of AI technology by SMEs will also fuel this growth for many incoming years. A growing body of research emphasizes that the way to reach trustworthy system is to meet the principles of so-called responsible Artificial Intelligence. Responsible Artificial Intelligence is related to the general question: can AI be trustworthy, or in other words, can we trust Artificial Intelligence. Proposing appropriate principles for responsible Artificial Intelligence addresses this question. Various proposals are emerging about what characterizes responsible AI. Numerous researchers in academia, research centers, standardization organizations, business environment and communities are working on principles for responsible AI, however this list is still open. Speaking of governments, they are supposed to compete by growing their domestic AI industries. Department Head For instance, European Union, United Kingdom, Germany, France and Canada have all committed For instance some researchers propose the following responsible AI themes: ethics, transparency, regulation and control, socioeconomic impact, design, IT professional 2 responsibility [2], while IBM considers principles for AI ethics: explainability, fairness, robustness, transparency, privacy, while Microsoft has formulated its six principles of Responsible AI: fairness, reliability and safety, privacy and security, inclusiveness, transparency, accountability. However these proposals of Responsible AI principles differ to some extent, in each case ethics (including fairness) is enumerated. responsibility [2], while IBM considers principles for AI ethics: explainability, fairness, robustness, transparency, privacy, while Microsoft has formulated its six principles of Responsible AI: fairness, reliability and safety, privacy and security, inclusiveness, transparency, accountability. However these proposals of Responsible AI principles differ to some extent, in each case ethics (including fairness) is enumerated. BIAS AND FAIRNESS BIAS-RELATED PROCESS Ongoing work in IEEE [5] refers to an unequal treatment of certain cases compared to others (it also mentions a statistically significant correlation between certain outcomes and specific input variables). Societal and technical biases are present all along the AI life cycle. Biases existing in the world are included in data, then data are transformed during a process, possibly biased. The data is then used by a biased learning mechanism to produce a model used by biased people that may use an inadequate fairness metric. Moreover, these biases are interconnected due to the existence of the feedback loop phenomenon (i.e. a situation in which the trained machine learning model makes decisions that produce outcomes affecting future data that will be collected for future training rounds) through which stereotypes, discrimination and inequality reinforce each other, thus contributing to perpetuating situations of inequality. Despite the very close definition of bias in AI given by standardization stakeholders and scholars (fairness in machine learning provided by the latter as “absence of any prejudice or favoritism towards an individual or a group based on their intrinsic or acquired traits in the context of decision-making”), there is no consensus of how to precisely measure bias. This also demonstrates the need for a discussion and collaboration that should involve both scholars and stakeholders in standardization, allowing draw on different experiences. All stakeholders should be involved and have a role to play in bias mitigation, thanks to governance process and technical toolkits. In our opinion a process concerned with bias treatment should be seen in a holistic manner (i.e., to include all possible elements identified at each step concerned with bias in AI systems). Department Head In summary, the AI Act proposal states that AI systems should be developed with eliminating mistakes and biases, ensuring they are trustworthy and safe, however without defining what is a bias. existing model (transfer learning) without checking that it is adapted to the new context. We have provided a summary of these bias sources in the tables below. Some definitions are proposed by stakeholders in international standardization bodies. A definition given by ISO/IEC JTC1 SC42 AI (Subcommittee 42 Artificial Intelligence) [4] identifies bias as “systematic difference in treatment of certain object, people or groups in comparison to others”. The ISO intentionally does not provide explicit definition of fairness, pointing out that it is a complex concept, highly contextualized (socially, ethically) and it is difficult to define in a uniform way its impact on AI systems, as it can vary for different applications. This comes from discussions inside this standardization organization and its experts. At the same time, the ISO has identified a number of ways in which AI systems can have negative unfair impact on individuals, groups of people, organizations, and societies (unfair allocation, unfair quality of service, stereotyping, denigration, over- and under-representation). The first table presents sources of bias provided by ISO standardization [4]. The first table presents sources of bias provided by ISO standardization [4]. Table 1. Bias Taxonomy by ISO Table 1. Bias Taxonomy by ISO The second one provides sources of bias collected by scholars [6]. Table 2. Bias Taxonomy by Scholars Table 2. Bias Taxonomy by Scholars We may see that some of the sources are shown in both tables, but there are other sources unique in each table. It shows again that each of the stakeholders (scholars, standardization) is able to extend common knowledge regarding bias. In particular, standardization provides several unique elements from the practitioners (industry experts all over the world, together with national standardization organizations’ representatives, academics, researchers from industrial innovation and research centers). BIAS AND FAIRNESS The EC (European Commission) is addressing ethical principles for Artificial Intelligence in Europe, developing the AI Act. In the United States, there is the National AI Act of 2020 under the National AI Initiatives (NAII), while work on AI is taking place in close cooperation with NIST (National Institute of Standards and Technology) (e.g., NIST Trustworthy AI principles). China is also very active in the field of AI striving to be a global leader, planning to realize trustworthy systems by design (e.g., White Paper on Trustworthy Artificial Intelligence, Ethical Norms for New Generation Artificial Intelligence). When it comes to AI, there is an important need to explicitly work out how bias should be defined and understood. Considering European approach, the purpose of the AI Act, one of the first sets of legal frameworks for AI (next to other efforts by China and Spain) is to frame the legal use of AI in proportion to the risks that AI poses to fundamental human rights (the requirements, mandatory for high-risky AI, will concern data, documentation and traceability, provision of information and transparency, human oversight, robustness and accuracy). For high-risky AI services, the absence of bias in dataset used to train and test AI models is required (art 9.5) and personal data processing is proposed to be allowed in certain circumstances if needed to detect, correct and monitor biases (art 10.5). A legal framework on AI and a Coordinated Plan with European Member States will address the risks of AI systems and new rules on Machinery will ensure the safe integration of the AI system into the overall machinery. The contribution of international standardization in this regard is important to note. In our view, it is capable of contributing to a significant narrowing of the gap between theoretical rules and its practical implementations. This, in our view, will significantly contribute to stimulating further sustainable development of trustworthy AI systems. July/August 2022 3 STANDARDIZATION SPECIFICS The EC intends to have standards that strengthen European competitiveness and benefits for society from AI. Draft AI Act (AIA) under elaboration by the EC sets out a comprehensive framework for AI governance and standards [8]. It also assigns an important role to standards, developed in Europe. In particular, it will require conformance with so called “harmonized standards” that will create a presumption of conformity for high-risk AI applications and services. The AIA Regulation aims to provide a strong incentive for industry to comply with European standards [9]. Creating harmonized standards in the area of AI is a great challenge, especially taking into account having harmonized standards produced and available by the time the AIA regulation is applicable, that is at the end of 2024 or beginning of 2025. For speeding up the process, the EC issued in May 2022 a draft standardization request in support of safe and trustworthy Artificial Intelligence. In general, international standards are aimed to provide a reliable, consensus-based and voluntary basis for industries (no obligation to use) in many aspects (incl. common understanding of technology, achieving interoperability). International standardization is often US based and Chinese are also well represented there. In the same time, in Europe there is a tendency to produce European standards, reflecting European specifics, that may differ from international ones. A further conformance of technical solutions with particular standards is a guarantee of their quality. It also ensures that technical requirements are met enabling that the solutions work in different ecosystems. In general, international standards are being developed within standardization organizations, with active participation of all potential stakeholders like industry (both, SME and In general, international standards are aimed to provide a reliable, consensus-based and voluntary basis for industries (no obligation to use) in many aspects (incl. common understanding of technology, achieving interoperability). Joined Committee of European Standardization, CEN-CENELEC was designated by EC to have a particular role and responsibility in the process of AI standards creation for Europe, and recognition of all stakeholders that should be invited for a cooperation on a development of these standards. For that, it has established a Standardization Request Ad Hoc Group (SRAHG) on AI, for recognizing and cataloguing potential international standards that may help in speeding up the process. SOURCES OF BIAS Numerous studies, conducted by scholars but also standardization organizations have attempted to count and categorize biases that exist in the field of machine learning and there are more than twenty potential sources of bias AI based services. These biases come from existing biases in society and from humans facing cognitive biases, which influence all human decisions whether at the time of data collection or during the construction of the model or even its use, and from technical or statistical biases such as the use of non-representative training data or the use of an [7] provides a proposal of elements that can be a part of bias treatment process. In fact, they propose four major elements of the process: understanding bias (e.g., socio-technical causes of bias, like data generation, bias manifestation in data, like sensitive features and causal inferences), mitigating bias (pre-processing, in-processing, post-processing), IT professional 4 and makes them critical, not only in legal but also in international standardization aspects. accounting for bias (e.g., bias aware data collection, like bias elicitation), legal issues (e.g., regulation provisions, like data accuracy – GDPR). This can be depicted on Diagram 1 below. Diagram 1. Bias Treatment Providing standards for AI is a highly challenging task, as it concerns activities on the borderline between the technical and the non- technical approaches (and stakeholders representing these two kinds of issues). Recent particular concern for different organizations (like e.g., ISO) is also that the technology is changing faster than the regulator is able to take it into account. This results in the situation that the development of rules and legislation to control AI systems is a step behind increasing use of AI in various types of systems and environments [10]. In this situation, standards could play a significant role in identifying the ethical issues, recognizing different data-related biases and providing the necessary framework to address the identified issues. They could serve as guidance to assist regulators in their work, and also increase a possibility of adoption and use of new systems. [10] underpins an importance of achieving a technical interoperability within the Trustworthy AI standards, taking into account that different stakeholders may present varying views of the relative importance of different proposed normative statements within the standardization works. SOURCES OF BIAS It stresses that the standardization of terms and a conceptual framework for Trustworthy AI should therefore enable clear, unambiguous communication between different stakeholders, so that these different viewpoints can be understood, made explicit and shared, enabling elaboration of relevant resolutions. Women and AI Pledge from Cercle InterElles (https://www.interelles.com) or Arborus charter (https://charteia.arborus.org/en/) are good example of the holistic approach to manage bias toward inclusive AI (i.e., AI that is focused on recognizing and eliminating biases, and involves as much diversity as possible, etc.). Department Head standards. This is a set of eleven IEEE P70xx standards (some of them already accomplished). The IEEE P7003 objective is to provide a framework to help developers of algorithmic systems and people responsible for their deployment to identify and mitigate unintended, unjustified and inappropriate biases in the outcomes of the algorithmic systems. The standard will describe specific methodologies that will allow users to assert their way of work on addressing and eliminating issues of above mentioned bias in the creation of their algorithmic system. This will help to design systems auditable by external parties (such as regulatory bodies). large enterprises), individuals, often government, and academics. Standards are important not only from certification perspective but also to give a guideline for companies trying to develop fair AI models [11]. The objectives for standards are concerned with providing a reliable basis for industries, the same understanding of terms concerned with a technology, sharing the same expectations regarding products, services and processes, and to help in facilitating trade, provide a framework for achieving economies, efficiencies and interoperability. This is crucial for a further conformance of technical solutions with particular standards, which guarantees their quality and meeting requirements broadly across economical ecosystems. Consensus- based approach for standards achieved within diverse groups of experts representing countries and industries, is critical to use “standardized” solutions globally. It is important to emphasize that these standards are part of broader ecosystems within their standardization organizations which enables to mutually use achievement of different normalizations and also build on the top of that. Landscape of standards concerned with bias considerations for ISO is shown on Diagram 2. Diagram 2. ISO: AI Bias Standards Map Landscape of standards concerned with bias considerations for IEEE is shown on Diagram 3. STANDARDIZATION AND BIAS Bias management is a subject of work of different international standardization organizations: ISO/IEC, IEEE, NIST. ISO/IEC JTC1 is very active in the field, as three recent major standardization works on ethical aspects, bias in AI systems and its relations with fairness have been launched, articulated with existing relevant standards as it is a factor of success of fair AI in production (ISO/IEC TR 240027 and 24368 - in a form of technical reports - TR, ISO/IEC New Project TS 12791 is a technical specification – TS, close to normative document). Bias is here defined and addressed, especially where AI aids humans in decision making. Diagram 3. IEEE: AI Bias Standards Map Few important elements of the standards achievements are depicted before (especially for ISO, as this standard is already published). ETSI’s work is also worth mentioning here. [13] is White Paper produced by ETSI, exploring key issues of Artificial Intelligence (AI) and presenting both huge potential benefits and risks and new challenges for information. It considers bias from the perspective of interoperability and interchangeability as intrinsic benefits of a standardization process. In this context AI interchangeability in complex systems could be a pragmatic way to (partially) manage the risk of bias. It was also stressed that the ETSI community should identify and analyze the best practices recommended by other standards development organizations (SDOs) to tackle these problems in a complementary and collaborative manner. IEEE, as another international standardization organization, also provides work on bias in AI systems. [12] underpins a role of P7003 activities in recognition of the increasingly pervasive role of algorithmic decision making systems in corporate and government services, and growing public concerns regarding the ‘black box’ nature of AI. It presents a whole ecosystem of ethics standards (P7000 series) aiming to translate the principles in the Ethically Aligned Design document (first edition of IEEE comprehensive report concerned with ethical implementation of autonomous and intelligent systems, A/IS) into actionable guidelines or frameworks to be used as practical industry STANDARDIZATION SPECIFICS SRAHG requested experts within CEN/CENELEC to be nominated for its works and it had its first meeting on 10th June 2022, beginning to collect comments on the AI Act and create a list of standards that are being developed under the AI. One of the malfunctions and unproper results of AI systems can be caused by unconsciously wrong assumptions. This challenges ethical considerations, 5 July/August 2022 CERTIFICATION AND CONFORMANCE This topic is only highlighted in general terms for the sake of completeness of the picture of work on Trustworthy AI. Its integral part is the creation of AI systems free of unwanted bias, which is a goal for industry as fully free of bias may not be feasible. IT professional IT professional 6 At this point, it should be said that standardization concerns compliance issues and conformity assessment of products and services with its several benefits (like providing customers and other stakeholders with added confidence, providing a company with a competitive edge, supporting regulators in ensuring fulfilment of health, safety or environmental conditions).. This approach is closely related to quality as it is concerned with satisfying needs and requirements (e.g. famous ISO 9000 series). It can result in certification of AI systems and assigning possibly a certification label. depicted some universal challenges that are valid in particular for the fairness aspects and the bias issue. Being aware of expectations and requirements from industry, seeing EU perspective expressed in AI Act, we have looked at existing standardization activities. Identified research gap, a discrepancy between theoretical foundations and practical implementations of the Responsible AI notion, would require a necessity to elaborate solutions enabling practical implementations of AI systems together by all stakeholders involved in AI systems considering legal and regulatory aspects, design, development and operationalization. It is crucial to involve academics and regulators, however it is also fundamental to involve stakeholders, representing international practitioners in the business environment. As such, standards are required for checking a compliance of a product or a service (in processes of a conformity assessment showing, that a product, service or system meets the requirements of a standard). Certification is the provision by an independent body of written assurance (a certificate) that the product, service or system in question meets specific requirements. Certification is also known as a third party conformity assessment. As a remedy, we see a close cooperation between European and international standardization as a consensus-based body of international experts. In particular, it is fundamental to the bias in AI systems, which is a complex and multidimensional issue (ethical, legal and technical). A certification label is a label or symbol indicating that compliance with standards has been verified. Use of the label is usually controlled by the standard-setting body. CERTIFICATION AND CONFORMANCE Where certification bodies (validated by authorities and having a legitimacy) certify against their own specific standards, the label can be owned by the certification body. For instance, bias can involve choices that are unfair (ethical issue), but it can also come from an error in data selection and insufficient generalization as its result (rather technical issue but can anyway harm people). At first glance, it can be difficult to distinguish between the causes of bias, especially since the effect can be similar or the same regardless the cause (e.g., unfair decision- making in any case: if bias was discriminatory, whether it was due to faulty assumptions or statistical errors) . While the certificate is a form of communication between seller and buyer, the label is a form of communication with the end customer. An interesting achievement towards AI certification is IEEE CertifAIEd, at this point a high level proposal of a suite of criteria for evaluation, conformity assessment, and certification of properties of products and services based on Autonomous Decision Making and Algorithmic Learning Systems (ADM/ALS). They involve decision-making related to: accountability, transparency, freedom from unacceptable algorithmic bias/fairness, privacy, and responsible governance [14]. Beyond the needed cooperation within standardization bodies, it seems particularly important among various communities, regulatory and legal as well as technical (incidentally, with international standardization as a part), to work together on methods of identifying and preventing bias. Currently, this communication and collaboration looks insufficient to provide coherent solutions to assess the degree of trustworthiness of AI systems, and how to build trustworthy AI systems that will work in practice (taking into account as example the bias issue). This is, based on our observations, a strong rationale for close cooperation between the regulators and standardization organizations (that represent a technical approach and associate experts like analysts, developers, data scientists).  REFERENCES 1. J. Popper, J. Hermann, S. Weyer, et al., “Artificial intelligence across industries - IEC Whitepaper,” IEC, 208. [Online].Available: https://www.researchgate.net/publication/329191549_Artific ial_intelligence_across_industries_-_IEC_Whitepaper (IEC Whitepaper) First A. Ewelina Szczekocka current employment Orange Polska S.A., Orange Innovation Poland, Warsaw, Poland, the M.S. degree in Applied Mathematics at the Warsaw University of Technology. Ms. Szczekocka is a research engineer focused on new technologies in data science, with a specific interest in Responsible AI for Telco, international expert in ISO (SC38, SC42 – Artificial Intelligence), IEEE member (P7003), ENISA (WG on AI Security). Contact her at ewelina.szczekocka@orange.com. 2. “Responsible AI - Key Themes, Concerns and Recommendations for European Research and Innovation, Summary of Consultation with Multidisciplinary Experts,” “A Collaborative Platform to Unlock the Value of Next Generation Internet Experimentation” (HUB4NGI) project under EC grant agreement 732569, 2018. [Online].Available: https://futurium.ec.europa.eu/en/european-ai-alliance/open- library/responsible-ai-key-themes-concerns- recommendations-european-research-and- innovation?language=it/responsible_ai_consultation_- _public_recommendations_v1.0.pdf (report) Second B. Christèle Tarnec, is with Orange S.A., Orange Innovation, France. Ms. Tarnec is a research engineer focused on Ethical AI with a specific interest on fairness issues for Telco. Contact her at christele.tarnec@orange.com 3. C. Sanderson, Q. Lu, D. Douglas, et. al., “Towards Operationalising Responsible AI: An Empirical Study,” extended and revised ver. to: “Software Engineering for Responsible AI: An Empirical Study and Operationalised Patterns,” Proc. International Conference on Software Engineering: The Software Engineering in Practice, ICSE- SEIP, 2022. (conference proceedings) Third C. Janusz Pieczerak, is with Orange Polska S.A., Orange Innovation Poland, Warsaw, Poland. Mr. Pieczerak is a research expert focused on new technologies including network technologies, international expert in ETSI, ITU. Contact him at janusz.pieczerak@orange.com. p g 4. “ISO/IEC TR 24027:2021 - Information Technology - Artificial Intelligence (AI) - Bias in AI systems and AI-aided decision making,” published by ISO, 2021. (published standard document) 5 “IEEE P7003 - Draft Standard for Algorithmic Bias Considerations,” IEEE. (unpublished standard document) ( p ) 6. N. Mehrabi, F. Morstatter, N. Saxena, et al., “A Survey on Bias and Fairness in Machine Learning,” ACM Computing Surveys, Article No.: 115, pp 1–35, 2022. (book) 7. E. Ntoutsi, P. Fafalios, U. Gadiraju et al., “Bias in data - driven artificial intelligence systems - An introductory survey,” WIREs Data Mining and Knowledge Discovery published by Wiley Periodicals, Inc., 2020. (journal) 8. The EU AI Act, [Online].Available: https://artificialintelligenceact.eu/the-act/ (publicly available draft) ) 9. M. McFadden, K. Jones, E. Taylor and G. Department Head Department Head CONCLUSIONS Bias is one of the elements of the complex landscape of Responsible AI. We began with a sum up of the existing considerations of a top level approach, that is responsible AI as a whole (which was a context for further considerations). We 7 7 July/August 2022  REFERENCES Osborn, “Harmonising Artificial Intelligence: The role of standards in the EU AI Regulation,” Oxford Information Labs, 2021. [Online].Available: https://oxil.uk/publications/2021-12-02- oxford-internet-institute-oxil-harmonising-ai/ (report) 10. D. Lewis, L. Hogan, D. Filip and P. J. Wall, “Global Challenges in the Standardization of Ethics for Trustworthy AI,” Journal of ICT, Vol. 8_2, 123–150. River Publishers, 2020. (journal) 11. W. Ziegler, “A Landscape Analysis of Standardisation in the Field of Artificial Intelligence,” Journal of ICT, Vol. 8_2, 151– 184. River Publishers, 2020. (journal) 12. A. Koene, L. Dowthwaite and S. Seth, “IEEE P7003TM Standard for Algorithmic Bias Considerations, work in progress paper,” Proc. ACM/IEEE International Workshop on Software Fairness, FairWare'18, 2018. (conference proceedings) 13. L. Frost, T. B. Meriem, J. M. Bonifacio et al., Artificial Intelligence and future directions for ETSI, ETSI White Paper No. #34, 2020. (white paper) 14. “IEEE CertifAIEd™ – Ontological Specification for Ethical Algorithmic Bias,” IEEE Standards Association. [Online].Available: https://engagestandards.ieee.org/ieeecertifaied.html (standard specification) IT professional IT professional 8
https://openalex.org/W2979212711	https://europepmc.org/articles/pmc6778096?pdf=render	English	null	Understanding the phyllosphere microbiome assemblage in grape species (Vitaceae) with amplicon sequence data structures	Scientific reports	2,019	cc-by	8,366	Prashant Singh , Sylvain Santoni, Audrey Weber, Patrice This & Jean-Pierre Péros Prashant Singh , Sylvain Santoni, Audrey Weber, Patrice This & Jean-Pierre Péros Impacts of plant genotype on microbial assemblage in the phyllosphere (above-ground parts of plants, which predominantly consists of the set of photosynthetic leaves) of Vitis vinifera cultivars have been studied previously but the impact of grape species (under the grape family Vitaceae) was never investigated. Considering the fact, that the phyllosphere microbiome may have profound effects on host plant health and its performance traits, studying the impact of grape species in microbial taxa structuring in the phyllosphere could be of crucial importance. We performed 16S and ITS profiling (for bacteria and fungi respectively) to access genus level characterization of the microflora present in the leaf phyllosphere of five species within this plant family, sampled in two successive years from the repository situated in the Mediterranean. We also performed α and β-diversity analyses with robust statistical estimates to test the impacts of grape species and growing year, over a two-year period. Our results indicated the presence of complex microbial diversity and assemblages in the phyllosphere with a significant effect of both factors (grape species and growing year), the latter effect is being more pronounced. We also compared separate normalization methods for high-throughput microbiome data-sets followed by differential taxa abundance analyses. The results suggested the predominance of a particular normalization method over others. This also indicated the need for more robust normalization methods to study the differential taxa abundance among groups in microbiome research. Plant phyllosphere is the niche of a disparate group of microbial communities of prokaryotes, eukaryotes, and viruses that interact with each other and with their host plant1. Due to the limited nutrient availability and fluc- tuating climatic conditions, phyllosphere is a dynamic and stressful habitat for its microbial colonizers2,3. The knowledge of these colonizers and drivers that might affect their assemblage might explain the mechanisms that control operations at the intersection between plants, microbiome, and the atmosphere. However, phyllosphere has been largely overlooked in most of the grape related microbiome studies and researches were mainly focused on rhizosphere (root and soil colonizers) and endosphere (inside tissue colonizers)4–9. Most of these studies including few in phyllosphere10–12 analyzed the main drivers for microbial assemblage on Vitis vinifera, the most widely cultivated species for wine and raisins. www.nature.com/scientificreports www.nature.com/scientificreports AGAP, University of Montpellier, INRA-SupAgro, CIRAD, Montpellier, France. Correspondence and requests for materials should be addressed to P.S. (email: patrice.this@inra.fr) Received: 10 October 2018 Accepted: 16 September 2019 Published: xx xx xxxx OPEN Received: 10 October 2018 Accepted: 16 September 2019 Published: xx xx xxxx Received: 10 October 2018 Accepted: 16 September 2019 Published: xx xx xxxx Results h ll Phyllosphere exhibits diverse bacterial and fungal communities. Millions of amplicon reads were processed from both data-sets (16S and ITS) and 10825 bacterial and 5252 fungal amplicon sequence variants (or operational taxonomic units-OTUs) were obtained (Table 1). After assigning the OTUs to phylum level more than 73% bacterial OTUs and ~95% of fungal OTUs were assigned to phylum level. Unknown sequences corre- sponded to ~27% and ~5% for bacterial and fungal data respectively, meaning that the taxonomic assignment pro- cedure was not able to assign any microorganism to these sequences. Proteobacteria (relative abundance ~15%) and Cyanobacteria (~14.8%) were the most dominated phyla across the samples followed by Firmicutes (~3%) and Actinobacteria (~1.3%). On the other hand, samples were heavily dominated by fungal phyla of Ascomycota (~91%) followed by Basidiomycota (~9%). After gloming of these OTUs at the genus level, 677 bacterial and 434 fungal gen- era were recovered. Out of these, Sphingomonas, Methylobacterium, Rubelimicrobium, Blastococcus and Alternaria, Aureobasidium, Cladosporium, Lachnum were most abundant bacterial and fungal genera, respectively (Fig. 1). Microbial communities clustered distinctly with year and grape species. Multidimensional scal- ing (or principal coordinate analysis; PCoA) on microbial abundance data showed that the samples from each year clustered together and were distinct from each other (more predominant in ITS data, Fig. 2), confirmed the significant impact of the growing year on microbial community structuring in the phyllosphere. Clustering among grape species was not prominent (Fig. 2) but performing PCoA on the subset of the data (i.e. on separate data for each year) displayed a lower but significant impact of grape species in shaping phyllosphere microbiome, especially the fungal microbiome (Fig. 3). Permutational analysis of variance (PERMANOVA) statistics accord- ing to Year, Species and the interaction term (Year × Species), further confirmed the hypothesis (Table 2) that the synergy between the environment and the plant genotype could be held responsible for microbial community structuring in the phyllosphere. g p y p Furthermore, observed α-diversity estimates of bacterial and fungal OTUs of each grape species (within each growing year, Fig. 4) revealed that the unique OTU-richness in the phyllosphere of each grape species significantly differed between the two years (Table 2). This reconfirmed the major impact of the growing year in shaping phyllo- sphere microbial assemblage. Prashant Singh , Sylvain Santoni, Audrey Weber, Patrice This & Jean-Pierre Péros They suggested that the environmental conditions at different geographic locations (or terroir) and growing seasons are important drivers in the rhizosphere, endosphere or phyllosphere10,11. Cultivars or genotype interaction with the environment also seemed to play a role in this assem- blage10,12. Since most of the current breeding schemes in grapevines involve other Vitis species as pest resistance sources, we wanted to inquire about the effect of the plant species on microbial assemblage. Furthermore, as the selection of microbiome could lead to new plant breeding strategies of next-generation, identifying microbiome differences among grape species could be an interesting opportunity for new grape breeding schemes to develop resistant, healthy and more productive varieties13. Moreover, grape associated epiphytes have been recently estab- lished as promising biocontrol agents (BCA) against fungal pathogens14 of Vitis vinifera, the species level variation could offer us hints of new potential players for BCA.if 15 16i f p p y In this work, we sampled epiphytes from five different species in the Vitaceae15,16 to find major microbial colonizers in their phyllosphere and compared the impact of grape species and growing year on the phyllosphere microbiome assemblage. To mitigate the confounding effect of environmental conditions at different geographic Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 www.nature.com/scientificreports/ Number of samples Reads in Reads out (Filtered) Denoised Chimera removal OTUs 16S Data 30 5,568,565 4,538,503 4,139,738 3,9763,42 10,825 ITS Data 30 2,7429,06 2,674,944 2,411,474 2,407,048 5,252 Table 1. The total number of reads at each step of bacterial microbiome data processing. Number of samples Reads in Reads out (Filtered) Denoised Chimera removal OTUs 16S Data 30 5,568,565 4,538,503 4,139,738 3,9763,42 10,825 ITS Data 30 2,7429,06 2,674,944 2,411,474 2,407,048 5,252 Table 1. The total number of reads at each step of bacterial microbiome data processing. Table 1. The total number of reads at each step of bacterial microbiome data processing. locations (or terroir), we sampled all five grape species (Vitis vinifera cv. Cabernet-Sauvignon, Vitis pentagona, Vitis riparia, Muscadinia rotundifolia, and Parthenocissus quinquefolia) from Montpellier-SupAgro repository of INRA in the Mediterranean. These species were chosen to study the genotype effect at species level within subgenus Vitis, at the subgenus level (subg. Vitis versus subg. Muscadinia) and at the genus level (Vitis versus Parthenocissus). The three species within subg. Vitis are genetically distant15,17 and cover the distribution range of this subgenus in the Northern Hemisphere with the European V. vinifera, the Asian V. Prashant Singh , Sylvain Santoni, Audrey Weber, Patrice This & Jean-Pierre Péros pentagona and the American V. riparia16,18,19. If the genotype is a major driver of the phyllosphere microbiome assemblage, we, therefore, expected increasing differences in microbial assemblages according to the genetic distance between plant species.f p p From a statistical point of view, we compared the differential abundance of microbial genera using three sepa- rate data normalization methods to predict the better normalization approach for grape related or other microbi- ome data. Normalization is the data transformation process enabling a true comparison of statistics from separate measurements by discarding artefactual biases from the original measurements. Most of the microbiome studies including grapevines9,20 still use the most standard statistical methods for differential abundance analysis without testing the data distribution and transformation. In microbial ecology, rarefying samples to even sequencing depth is standard normalization method but is also not an ideal one, as it potentially reduces statistical power relying upon how much data is filtered and does not address the challenge of compositional data21. The log ratio transformation method is also widely accepted by researchers and statisticians and in various high dimensional studies22,23. Here, we used few recently published data transformation methods of cumulative sum scaling (CSS)24, DESeq225 and log ratio to normalize our zero-inflated taxa abundance data and compared estimates of differen- tially abundant genera between two growing years and grape species. Results h ll Although OTU-richness estimates did not vary according to grape species (P~0.05), the interaction term (Year × Species) displayed strong differences in the richness of unique OTUs (Table 2). Comparing normalization methods. Most of the microbiome data doesn’t follow a normal distribution for taxa abundance across the samples9,20,25 and our data-sets were not the exceptions. Using three separate data transformation methods (square root, log-ratio, and CSS) we were unable to achieve proper normalization of our data-sets, and even after transformation, most of the distribution followed negative binomial distribution except CSS which performed better than others (Fig. 5). We used these transformed data for differential abundance anal- ysis of each taxon (at genus level) according to the grape species and growing year (DESeq2 was applied to square root transformed data, to handle negative binomial distribution). Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 www.nature.com/scientificreports/ Figure 1. Mean (a) bacterial and (b) fungal relative abundance of top 25 genus present across samples i.e leaf phyllosphere of five grape species. Figure 1. Mean (a) bacterial and (b) fungal relative abundance of top 25 genus present across samples i.e leaf phyllosphere of five grape species. Figure 1. Mean (a) bacterial and (b) fungal relative abundance of top 25 genus present across samples i.e leaf phyllosphere of five grape species. Figure 2. PCoA ordinations of (a) bacterial and (b) fungal communities derived from leaf phyllosphere at two growing years, using Bray-Curtis distance matrix. Both the axis explains ~20% of variations. The shape represents grape species (N = 30). Figure 2. PCoA ordinations of (a) bacterial and (b) fungal communities derived from leaf phyllosphere at two growing years, using Bray-Curtis distance matrix. Both the axis explains ~20% of variations. The shape represents grape species (N = 30). Performing multiple testing with FDR corrected P-values (adj-P value < 0.05) gave nine bacterial genera for DESeq2 as compared to two and three genera for log and CSS transformed data between the two years. Similarly, 45 fungal genera were obtained for DESeq2 as compared to 11 and 13 genera for other methods between the two years (Figs 6 and 7). The same testing was performed on data-sets of Spring 2017 and Spring 2018 separately Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 www.nature.com/scientificreports/ Figure 3. PCoA ordinations of bacterial (a,b) and fungal (c,d) communities derived from leaf phyllosphere at spring 2017 and spring 2018 separately, using Bray-Curtis distance matrix. Figure 3. Results h ll to identify differential taxa abundance among five grape species and the results were similar (Tables 3 and 4). DESeq2 gave a higher number of genera as compared to other methods (probably an overestimation). Combining normalization performance on taxa abundance across samples and identification of differentially abundant gen- era, indicated that CSS normalization method worked better and was statistically more robust, i.e. fewer false positives and lower false discovery rates, as compared to other methods. to identify differential taxa abundance among five grape species and the results were similar (Tables 3 and 4). DESeq2 gave a higher number of genera as compared to other methods (probably an overestimation). Combining normalization performance on taxa abundance across samples and identification of differentially abundant gen- era, indicated that CSS normalization method worked better and was statistically more robust, i.e. fewer false positives and lower false discovery rates, as compared to other methods. Results h ll PCoA ordinations of bacterial (a,b) and fungal (c,d) communities derived from leaf phyllosphere at spring 2017 and spring 2018 separately, using Bray-Curtis distance matrix. Data ANOVA (on α-diversity measures) PERMANOVA (on PCoA clusters) 16S Year at F = 5.725, P = 0.0076 R2 = 0.269, F = 1.811, P = 0.0001* Year × Grape Species at F = 9.022, P = 0.00138 R2 = 0.154, F = 1.737, P = 0.0001* Grape Species (Spring 2017) at F = 3.752, P = 0.041 R2 = 0.379, F = 1.525, P = 0.0001*** Grape Species (Spring 2018) at F = 1.743, P = 0.217 R2 = 0.304, F = 1.134, P = 0.031* ITS Year at F = 49.261, P = 1.24e-07 R2 = 0.101, F = 3.532, P = 0.0001* Year × Grape Species at F = 57.340, P = 2.71e-07 R2 = 0.112, F = 3.767, P = 0.0001* Grape Species (Spring 2017) at F = 2.843, P = 0.08 R2 = 0.325, F = 1.206, P = 0.0038 Grape Species (Spring 2018) at F = 1.274, P = 0.34 R2 = 0.334, F = 1.257, P = 0.0001* Table 2. Components predicting the impacts of Year and Grape Species on the leaf microbiome. Data ANOVA (on α-diversity measures) PERMANOVA (on PCoA clusters) 16S Year at F = 5.725, P = 0.0076 R2 = 0.269, F = 1.811, P = 0.0001* Year × Grape Species at F = 9.022, P = 0.00138 R2 = 0.154, F = 1.737, P = 0.0001* Grape Species (Spring 2017) at F = 3.752, P = 0.041 R2 = 0.379, F = 1.525, P = 0.0001*** Grape Species (Spring 2018) at F = 1.743, P = 0.217 R2 = 0.304, F = 1.134, P = 0.031* ITS Year at F = 49.261, P = 1.24e-07 R2 = 0.101, F = 3.532, P = 0.0001* Year × Grape Species at F = 57.340, P = 2.71e-07 R2 = 0.112, F = 3.767, P = 0.0001* Grape Species (Spring 2017) at F = 2.843, P = 0.08 R2 = 0.325, F = 1.206, P = 0.0038 Grape Species (Spring 2018) at F = 1.274, P = 0.34 R2 = 0.334, F = 1.257, P = 0.0001* Table 2. Components predicting the impacts of Year and Grape Species on the leaf microbiome. Table 2. Components predicting the impacts of Year and Grape Species on the leaf microbiome. Discussion Microbial colonizers of endosphere and rhizosphere associated with Vitis vinifera cultivars (or grapevines) have been studied before quite extensively4,8,9. Recently, grapevine’s phyllosphere has also been explored by research- ers10–12, but these habitats were not explored in the context of different grape species of Vitaceae prior to this study. At first, we explored the phyllosphere of five different grape species using the culture-independent methods of 16S and ITS profiling. Out of the complex microbial diversity, Sphingomonas and Methylobacterium were the most dominant bacterial genera. The fungal community was dominated by Aureobasidium, Cladosporium and Alternaria. These results are in line with the previous phyllosphere related works26–28, which suggests that the phyllosphere is usually dominated by these genera because of their important functions (e.g- plant growth, plant defense, and biocontrol agent, etc.)11,29. For example, phyllosphere is usually quite rich in Methylobacterium, which can benefit the plant by absorbing the methanol (gaseous) released by the stomata and produces a growth promoting agent for the seedlings of some crop plant29. Biocontrol potential of some of these genera (e.g- Sphingomonas and Aureobasidium) have been reported previously30–34 and should be explored in future studies in the context of grapes and in collaboration with other taxa with major or minor abundances. As the microbial communities in the phyllosphere can modulate leaf susceptibility to infections, it can protect the plant from foliar diseases30,35. Hence, the microflora of the phyllosphere and the local environmental conditions can thus regulate the fitness of their host plant. The current major challenge is to learn the properties of these microbial commu- nities in the phyllosphere (e.g- taxonomic and functional diversity and microbial network structure) that will be beneficial under changing climatic conditions to cultivate properties of biocontrol and robustness in grape plants to sustain the productivity, yield, and resilience of agricultural systems. Among the diverse and complex commu- nities found in the phyllosphere the genus, Massilia is also noteworthy as its presence was quite consistent during the two years. It is a major pollutant of an aerosol with agricultural applications36,37 and could be an indicator of agricultural practices in the Mediterranean. The genus Rubelimicrobium was also one of the major and dominant genera found as a leaf epiphyte. Few species of this genus were isolated from soil38, and this could be a shred of evidence to support the claim that the soil microbiota may influence the epiphyte compositions9. Discussion Microbial colonizers of endosphere and rhizosphere associated with Vitis vinifera cultivars (or grapevines) have been studied before quite extensively4,8,9. Recently, grapevine’s phyllosphere has also been explored by research- ers10–12, but these habitats were not explored in the context of different grape species of Vitaceae prior to this study. At first, we explored the phyllosphere of five different grape species using the culture-independent methods of 16S and ITS profiling. Out of the complex microbial diversity, Sphingomonas and Methylobacterium were the most dominant bacterial genera. The fungal community was dominated by Aureobasidium, Cladosporium and Alternaria. These results are in line with the previous phyllosphere related works26–28, which suggests that the phyllosphere is usually dominated by these genera because of their important functions (e.g- plant growth, plant defense and biocontrol agent etc )11,29 For example phyllosphere is usually quite rich in Methylobacterium in the context of grapes and in collaboration with other taxa with major or minor abundances. As the microbial communities in the phyllosphere can modulate leaf susceptibility to infections, it can protect the plant from foliar diseases30,35. Hence, the microflora of the phyllosphere and the local environmental conditions can thus regulate the fitness of their host plant. The current major challenge is to learn the properties of these microbial commu- nities in the phyllosphere (e.g- taxonomic and functional diversity and microbial network structure) that will be beneficial under changing climatic conditions to cultivate properties of biocontrol and robustness in grape plants to sustain the productivity, yield, and resilience of agricultural systems. Among the diverse and complex commu- nities found in the phyllosphere the genus, Massilia is also noteworthy as its presence was quite consistent during the two years. It is a major pollutant of an aerosol with agricultural applications36,37 and could be an indicator of agricultural practices in the Mediterranean. The genus Rubelimicrobium was also one of the major and dominant genera found as a leaf epiphyte. Few species of this genus were isolated from soil38, and this could be a shred of evidence to support the claim that the soil microbiota may influence the epiphyte compositions9. Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 www.nature.com/scientificreports/ Figure 4. Box plots of mean observed α-diversity measures or unique OTU-richness between Spring of 2017 and 2018 for (a) bacterial and (b) fungal data. Discussion For each box plot, the top point is maximum observation, the lower point is minimum observation, top of the box is the third quartile, the bottom of the box is the first quartile, the middle bar is median values and color represent grape species (N = 30). Figure 4. Box plots of mean observed α-diversity measures or unique OTU-richness between Spring of 2017 and 2018 for (a) bacterial and (b) fungal data. For each box plot, the top point is maximum observation, the lower point is minimum observation, top of the box is the third quartile, the bottom of the box is the first quartile, the middle bar is median values and color represent grape species (N = 30). Secondly, we assessed the relative impacts of grape species and the growing year to shape the assemblage of the microbial communities in the phyllosphere. Morphological structures of leaves, its chemistry and physiology may differ according to the grape species as all these traits can be impacted by plant genetics, and this variation may also lead to different blends of microbial community structures39,40 in the phyllosphere. In previous studies, minor impacts of grapevine genotypes (at cultivar level) have been found10,12 and we expected greater impacts of genotypes once we sample from different species in order to increase genetic distances between them but our analysis indicated that the growing year had much stronger impacts than grape species in microbial com- munity structuring. At each individual growing year, grape species also showed some influence in shaping this assemblage (especially for fungal assemblage) but that is noticeably weaker in comparison with the growing year. Statistical estimates of α and β-diversity suggest that the plausible hypothesis could be the species-climate inter- action that is responsible for recruiting microbes on the leaf surface of different grape species. This interaction could be multilayered as slight changes in meteoclimatic parameters (daylight exposure, increased atmospheric CO2 concentrations, and temperatures) between two growing years may alter certain important soil characteris- tics (moisture volume, amount of root exudates, soil temperature etc.), which in turn may induce major changes in soil microbiome and ultimately in epiphytic communities9,41,42.f y p p y Lastly, we also analyzed the impacts of the data normalization methods to detect the differential taxa abun- dance among different groups. Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 www.nature.com/scientificreports/ www.nature.com/scientificreports/ Figure 7. Separate normalization methods identified different fungal taxa that significantly contributed (adj P < 0.05) to differences between two growing years. Figure 7. Separate normalization methods identified different fungal taxa that significantly contributed (adj P < 0.05) to differences between two growing years. undersampling or from the count distribution (absence of the taxonomic feature in the samples). We evaluated one NB method (DESeq2), CSS method and log transformation of the data to generate normalized counts and performed multiple testing on differential taxa abundance. Our results suggested that the CSS method worked finer than other methods in obtaining the normalized counts and gave statistically more robust estimates of dif- ferential taxa abundance. undersampling or from the count distribution (absence of the taxonomic feature in the samples). We evaluated one NB method (DESeq2), CSS method and log transformation of the data to generate normalized counts and performed multiple testing on differential taxa abundance. Our results suggested that the CSS method worked finer than other methods in obtaining the normalized counts and gave statistically more robust estimates of dif- ferential taxa abundance. Conclusion Our study revealed the existence of heterogeneous microbiome in the leaf phyllosphere of Vitaceae and we spec- ulated that the multilayer species-climate interaction could be the reason for the microbiome assemblage in the phyllosphere. We have also inferred the advantages of CSS normalization over other methods, however, this method needs to be further evaluated with the sufficient amount of other microbiome studies. Discussion Microbiome datasets like taxonomy reads or OTU counts from amplicon sequenc- ing experiments or differential expression (RNA-Seq) data are often scattered and have frequent zeros. In order to fit these overdispersed microbiome datasets, negative binomial (NB) is often applied24,43,44. For example, an NB model was fitted in several microbiome studies related to Parkinson’s disease and to analyze the effect of edible Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 www.nature.com/scientificreports/ Figure 5. Histograms of the distribution of taxa sums across samples using (a) no normalization (b) Square root transformation (c) log transformation and (d) CSS transformations. Figure 5. Histograms of the distribution of taxa sums across samples using (a) no normalization (b) Square root transformation (c) log transformation and (d) CSS transformations. Figure 6. Separate normalization methods identified different bacterial taxa that significantly contributed (adj P < 0.05) to differences between two growing years. Figure 6. Separate normalization methods identified different bacterial taxa that significantly contributed (a P < 0.05) to differences between two growing years. cricket consumption on gut microbiome45–47. Similarly, an NB model was also used for identifying differential sequence tag abundance and for detecting differentially abundant features in clinical metagenomic samples44,48. Zero-inflated Gaussian (ZIG) mixture model was proposed24 in 2013, which uses a new cumulative sum scaling (CSS) normalization technique to correct the bias in measuring the differential abundance introduced by total sum normalization. This model precisely evaluates the probability that an observed zero is generated due to the Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 Material and Methods Sampling, isolation of phyllosphere microbes and DNA extraction. Leaf samples (from each of the 5 grape species) were collected from the repository of the agronomic school SupAgro at Montpellier, France (Mediterranean). 18–20 fully developed asymptomatic leaves were randomly sampled from 3–4 plants of each grape species in the Spring season (mid of May 2017 and 2018, before fungicide spraying) to make three repli- cates. The sample washing procedure was adopted by our previously published protocol12 and was performed with isotonic sodium chloride solution (0.15 M) with 0.01% Tween 20 in 50 ml propylene tubes using a horizontal shaker at 100 RPM for 1hr10. To maximize the microbial recovery from the leaf surface, samples were given an ultrasonic bath for 7–10 minute using Ultrasonic Cleaner (Branson 5510). Afterward, the remaining solution was centrifuged at 4,000 g and microbial pellets were transferred in 2-ml Eppendorf tubes and stored at −20 °C. DNA was extracted from each sample using the ZymoBiomics DNA MicroPrep Kit (Zymo Research, USA). PCR amplification and amplicon sequence library preparation. The 16S ribosomal gene (V4 region) was amplified using 515 F and 806 R primers to characterize bacterial communities. Modified ITS9 and ITS4 primers targeting the ITS2 region were used to access fungal community diversity and abundances. Sequencing Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 www.nature.com/scientificreports/ Method Genus Adj P-value FDR Spring 2017 CSS Cutibacterium 0.033 0.001 Rubelimicrobium 0.0171 0.001 Sphingomonas 0.034 0.018 Log Cutibacterium 0.038 0.017 Rubelimicrobium 0.168 0.001 DESeq2 Cutibacterium 0.038 0.128 Rubelimicrobium 0.0192 0.212 Sphingomonas 0.042 0.201 Microvirga 0.022 0.113 Rhodococcus 0.022 0.113 Spring 2018 CSS Hymenobacter 0.036 0.061 Rubelimicrobium 0.036 0.061 Log Hymenobacter 0.034 0.045 Rubelimicrobium 0.034 0.045 Methylobacterium 0.039 0.045 DESeq2 Hymenobacter 0.027 0.118 Rubelimicrobium 0.027 0.118 Paracoccus 0.027 0.118 Methylobacterium 0.038 0.221 Pedobacter 0.038 0.221 Kineococcus 0.038 0.221 Spirosoma 0.043 0.312 Blastococcus 0.043 0.312 Table 3. Differential taxa abundance (bacterial taxa, genus level) among Grape Species at each year. libraries were prepared using two-step PCR reactions. Amplification of the target regions and the addition of Illumina Nextera transposase sequence to the amplicons was performed in step one PCR (or PCR1). Both PCR1 primers (forward and reverse) were amended with frameshift (FS) sequences in their 5′ overhang to improve Table 4. Differential fungal taxa abundance (fungal taxa, genus level) among Grape Species at each year. Material and Methods Method Genus Adj P-value FDR Spring 2017 CSS Cutibacterium 0.033 0.001 Rubelimicrobium 0.0171 0.001 Sphingomonas 0.034 0.018 Log Cutibacterium 0.038 0.017 Rubelimicrobium 0.168 0.001 DESeq2 Cutibacterium 0.038 0.128 Rubelimicrobium 0.0192 0.212 Sphingomonas 0.042 0.201 Microvirga 0.022 0.113 Rhodococcus 0.022 0.113 Spring 2018 CSS Hymenobacter 0.036 0.061 Rubelimicrobium 0.036 0.061 Log Hymenobacter 0.034 0.045 Rubelimicrobium 0.034 0.045 Methylobacterium 0.039 0.045 DESeq2 Hymenobacter 0.027 0.118 Rubelimicrobium 0.027 0.118 Paracoccus 0.027 0.118 Methylobacterium 0.038 0.221 Pedobacter 0.038 0.221 Kineococcus 0.038 0.221 Spirosoma 0.043 0.312 Blastococcus 0.043 0.312 Table 3. Differential taxa abundance (bacterial taxa, genus level) among Grape Species at each year. Method Genus Adj P-value FDR Spring 2017 CSS Aspergillus 0.0011 0.022 Alternaria 0.0171 0.033 Log Aspergillus 0.0012 0.017 Alternaria 0.0012 0.017 Botrytis 0.0131 0.112 DESeq2 Hyphodontia 0.006 0.081 Aspergillus 0.026 0.119 Alternaria 0.026 0.119 Botrytis 0.026 0.119 Spring 2018 CSS Alternaria 0.024 0.038 Sclerostagonospora 0.024 0.038 Truncatella 0.032 0.048 Log Alternaria 0.027 0.0199 Sclerostagonospora 0.027 0.0199 Truncatella 0.034 0.0231 DESeq2 Knulfa 0.021 0.132 Alternaria 0.021 0.132 Sclerostagonospora 0.021 0.132 Truncatella 0.037 0.172 Botrytis 0.037 0.172 Table 4. Differential fungal taxa abundance (fungal taxa, genus level) among Grape Species at each year. Table 4. Differential fungal taxa abundance (fungal taxa, genus level) among Grape Species at each year. libraries were prepared using two-step PCR reactions. Amplification of the target regions and the addition of Illumina Nextera transposase sequence to the amplicons was performed in step one PCR (or PCR1). Both PCR1 primers (forward and reverse) were amended with frameshift (FS) sequences in their 5′ overhang to improve Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 www.nature.com/scientificreports/ overall read quality and sequence diversity49. 25 μL reactions (with 30 ng of sample DNA) using the KAPA HiFi HotStart (KAPA Biosystems, USA) PCR mix (initial denaturing at 95 °C followed by 30 cycles of denaturing at 95 °C for 30 s, primer annealing at 57 °C for 60 s and primer extension at 68 °C for 60 s) were used to perform PCR1. Purification of amplicons was achieved using Agencourt AMPure XP beads (Beckman Coulter, USA) at a bead-to-DNA ratio of 0.7:1. Amplicons were then resuspended in 30 μL MilliQ water and evaluated in aga- rose gels. In PCR2 (Illumina dual indexing PCR), each cleaned PCR1 product within the same sample received a unique combination of forward and reverse primers (respectively, N7 and S5 Illumina dual index oligos). Material and Methods To assess the statistical significance of PCoA clusters according to the sample categories, strati- fied permutational multivariate analysis of variance (PERMANOVA) with 9999 permutations was conducted (at α = 0.05) on all principal coordinates obtained during PCoA ordinations with the adonis command (with appropriate model matrix) of the vegan package57. Data transformations and statistical analysis. Square root transformation of the data was performed on taxa counts using sqrt(1 + x) function. Log transformation was done using log(1 + x) function on taxa counts. DESeq2 normalization was performed using the phyloseq_to_deseq2 function of the DESeq2 package25. CSS nor- malization was done using the metagenomeSeq package24. Multiple testing was performed using the mt function of the phyloseq package after each data transformations to identify differentially abundant taxa between groups. All computational analyses were performed in R-environment v3.3.4 (R Core Team, 2017) and the statistical significance was assessed at P < 0.05 throughout, and we adjusted P-values for multiple comparisons (when- ever necessary) according to the Benjamini and Hochberg method to control False Discovery Rate (FDR)55. We performed ANOVA (analysis of variance)56 among sample categories while measuring the observed estimates i Data transformations and statistical analysis. Square root transformation of the data was performed on taxa counts using sqrt(1 + x) function. Log transformation was done using log(1 + x) function on taxa counts. DESeq2 normalization was performed using the phyloseq_to_deseq2 function of the DESeq2 package25. CSS nor- malization was done using the metagenomeSeq package24. Multiple testing was performed using the mt function of the phyloseq package after each data transformations to identify differentially abundant taxa between groups. p y q p gt yf y g p All computational analyses were performed in R-environment v3.3.4 (R Core Team, 2017) and the statistical significance was assessed at P < 0.05 throughout, and we adjusted P-values for multiple comparisons (when- ever necessary) according to the Benjamini and Hochberg method to control False Discovery Rate (FDR)55. We performed ANOVA (analysis of variance)56 among sample categories while measuring the observed estimates of α-diversity. To assess the statistical significance of PCoA clusters according to the sample categories, strati- fied permutational multivariate analysis of variance (PERMANOVA) with 9999 permutations was conducted (at α = 0.05) on all principal coordinates obtained during PCoA ordinations with the adonis command (with appropriate model matrix) of the vegan package57. Data Availability y Data is provided fully in the result section of this paper and the sequence data is uploaded at the institutional server of INRA and can be obtained upon reasonable request to authors. Scientific Reports \| (2019) 9:14294 \| https://doi.org/10.1038/s41598-019-50839-0 Material and Methods Samples were again cleaned afterward, using AmPure XP magnetic beads, pooled in equimolar concentrations and sequenced using 2 × 250 bp MiSeq v2 sequencing (Illumina Inc., San Diego, CA, USA). ZymoBIOMICS microbial community standard and DNA extraction buffer were used for this library preparation as a positive and negative control respectively following the manufacturer’s instructions. Data analysis. Paired-end sequence reads from 16S and ITS sequences were filtered, trimmed and processed with the dada2 v1.8 (R Bioconductor package)50. The fastqPairedFilter function of the dada2 was used to trim primers and discard bases with low-quality scores (q < 11). A core Divisive Amplicon Denoising Algorithm (DADA) was performed on these filtered files and amplicon sequence variants (or OTUs) were inferred10,50. Chimeras were removed afterward using the removeBimeraDenovo function of the same dada2 package (Table 1 represents the total number of reads retained after performing each of these steps). Taxonomy was assigned to bacterial and fungal OTU sequences using the RDP classifier51 and UNITE data base52 respectively with k-mer size 8 and 100 bootstrap replicates.h p p Later, the phyloseq package53 was used to get the α and β-diversity estimates. The estimate_richness function of the phyloseq gave observed α-diversity measures within sample categories. Relative abundances of microbial genera were plotted using the ggplot2 package54 after gloming the data at the genus level (using the tax_glom function of the phyloseq) and transforming genus abundance data into relative counts. PCoA ordination was performed on variance stabilized log-transformed data using the Bray-Curtis dissimilarity matrix and visualized by using their base functions in the phyloseq package. Data transformations and statistical analysis. Square root transformation of the data was performed on taxa counts using sqrt(1 + x) function. Log transformation was done using log(1 + x) function on taxa counts. DESeq2 normalization was performed using the phyloseq_to_deseq2 function of the DESeq2 package25. CSS nor- malization was done using the metagenomeSeq package24. Multiple testing was performed using the mt function of the phyloseq package after each data transformations to identify differentially abundant taxa between groups. 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https://openalex.org/W3034308358	https://scholarcommons.sc.edu/cgi/viewcontent.cgi?article=1026&context=nurs_facpub	English	null	Improving Adherence to Adjuvant Hormonal Therapy Among Disadvantaged Women Diagnosed with Breast Cancer in South Carolina: Proposal for a Multimethod Study	JMIR research protocols	2,020	cc-by	7,554	University of South Carolina University of South Carolina Scholar Commons Scholar Commons Faculty Publications Nursing, College o 9-1-2020 Improving Adherence to Adjuvant Hormonal Therapy Among Improving Adherence to Adjuvant Hormonal Therapy Among Disadvantaged Women Diagnosed With Breast Cancer in South Disadvantaged Women Diagnosed With Breast Cancer in South Carolina: Proposal for a Multimethod Study Carolina: Proposal for a Multimethod Study Tisha M. Felder University of South Carolina, feldert@mailbox.sc.edu Sue Heiney University of South Carolina, heineys@mailbox.sc.edu James R. Hébert University of South Carolina, jhebert@mailbox.sc.edu Daniela B. Friedman University of South Carolina, dfriedma@mailbox.sc.edu Ronit Elk The University of Alabama at Birmingham See next page for additional authors Follow this and additional works at: https://scholarcommons.sc.edu/nurs_facpub Part of the Nursing Commons Publication Info Publication Info Published in JMIR Research Protocols, Volume 9, Issue 9, 2020. This Article is brought to you by the Nursing, College of at Scholar Commons. It has been accepted for inclusion in Faculty Publications by an authorized administrator of Scholar Commons. For more information, please contact di @ ilb d University of South Carolina University of South Carolina Scholar Commons Scholar Commons Nursing, College of See next page for additional authors Author(s) Author(s) Tisha M. Felder, Sue Heiney, James R. Hébert, Daniela B. Friedman, Ronit Elk, Regina Franco, Lucy Gansauer, Barbara Christensen, and Marvella E. Ford Publication Info Publication Info Published in JMIR Research Protocols, Volume 9, Issue 9, 2020. This Article is brought to you by the Nursing, College of at Scholar Commons. It has been accepted for inclusion in Faculty Publications by an authorized administrator of Scholar Commons. For more information, please contact digres@mailbox.sc.edu. This article is available at Scholar Commons: https://scholarcommons.sc.edu/nurs_facpub/26 Corresponding Author: Tisha M Felder, MSW, PhD College of Nursing University of South Carolina 1601 Greene Street Room 620 Columbia, SC, 29208 United States Phone: 1 8037779830 Email: feldert@mailbox.sc.edu Author(s) Author(s) This article is available at Scholar Commons: https://scholarcommons.sc.edu/nurs_facpub/26 JMIR RESEARCH PROTOCOLS Felder et al Improving Adherence to Adjuvant Hormonal Therapy Among Disadvantaged Women Diagnosed with Breast Cancer in South Carolina: Proposal for a Multimethod Study Tisha M Felder1,2, MSW, PhD; Sue P Heiney1, RN, PhD; James R Hebert2,3, MSPH, ScD; Daniela B Friedman4,5, PhD; Ronit Elk6, PhD; Regina Franco7, MSN, ANP-C; Lucy Gansauer8, CCRP, OCN, RN, MSN; Barbara Christensen8, CCRP; Marvella E Ford9,10,11,12, PhD 1College of Nursing, University of South Carolina, Columbia, SC, United States Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States 4Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States ffice for the Study of Aging, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States 5Office for the Study of Aging, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States 6Center for Palliative and Supportive Care, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama-Birmingham School of Medicine, Birmingham, AL, United States 7 5Office for the Study of Aging, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States 6Center for Palliative and Supportive Care, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama-Birmingham School of Medicine, Birmingham, AL, United States 7Center for Integrative Oncology & Survivorship, Cancer Institute, Prisma Health, Greenville, SC, United States 8Gibbs Cancer Center & Research Institute, Spartanburg Regional Healthcare System, Spartanburg, SC, United States 9Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States 10Population Sciences and Cancer Disparities, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States 11Office of Community Outreach and Engagement, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States 12SmartState Endowed Chair, Cancer Disparities Research, Medical University of South Carolina and South Carolina State University, Charleston, SC, United States 7Center for Integrative Oncology & Survivorship, Cancer Institute, Prisma Health, Greenville, SC, United States 8Gibbs Cancer Center & Research Institute, Spartanburg Regional Healthcare System, Spartanburg, SC, United States 9Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States 10Population Sciences and Cancer Disparities, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States 11Office of Community Outreach and Engagement, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States 12SmartState Endowed Chair, Cancer Disparities Research, Medical University of South Carolina and South Carolina State University, Charleston, SC, United States https://www.researchprotocols.org/2020/9/e17742 Project Goal and Innovation The overall goal of this study is to improve adherence to AHT among breast cancer survivors from racially and socioeconomically disadvantaged backgrounds. The specific aims of this study are as follows: (1) explore patient, health care system, and structural factors that may influence adherence to AHT; (2) develop a theory-based, multilevel intervention program to improve adherence to AHT; and (3) pilot and evaluate the intervention program designed in Aim 2. Systematic reviews show that sociodemographic factors, such as race and age, are associated with treatment adherence. In contrast, there is limited evidence about psychosocial or behavioral factors that could be targeted with interventions [4,6,7]. Additionally, previous studies that have examined modifiable factors suggest that negative beliefs about AHT, limited social support, low decisional balance scores and poor patient-provider communication are all negatively associated with therapy adherence [8-12]. Early discontinuation of and poor adherence to AHT have been significantly associated with disease progression and increased morality rates [5,13]. This project will incorporate principles of health communication theory into the development and testing of the proposed multilevel intervention program. The field of health communication has been nationally prioritized as a strategy to improve individual and population health [23]. Health communications reflect an ecological perspective which posits that individual health beliefs and behaviors are influenced by the broader social environment. Thus, effective public health communication can improve health behaviors by using strategies that consider multiple levels of influence (eg, intrapersonal, interpersonal, community) [24]. The use of health communication theory in this study represents a novel approach to fill a gap in the literature on how to apply theory in multilevel interventions. Furthermore, the application of theory will yield a practical framework for how to use health communication theoretical constructs to determine appropriate communication strategies (eg, knowledge, attitudes) that will target factors at multiple levels known to influence AHT adherence, and how to test them in a multilevel intervention. The problem of suboptimal adherence to AHT is important for three key reasons. First, roughly 75% of diagnosed breast cancers are HR+ [14], meaning that adherence to AHT is critical for extending the survival of the majority of breast cancer survivors. Second, studies show that differences in treatment, including AHT use, significantly contribute to persistent racial disparities observed in breast cancer mortality rates between Black and White women [15,16]. This disparity increases for women who are socioeconomically disadvantaged [17,18]. Abstract Background: Current clinical guidelines recommend that hormone receptor–positive breast cancer survivors take adjuvant hormonal therapy (AHT) for 5 to 10 years, following the end of definitive treatment. However, fewer than half of patients adhere to the guidelines, and suboptimal adherence to AHT is associated with an increased risk of breast cancer mortality. Research has extensively documented sociodemographic and disease-specific factors associated with adherence to AHT, but very little evidence exists on behavioral factors (eg, knowledge, patient-provider communication) that can be modified and targeted by interventions. Objective: The goal of this study is to develop and test a theory-based, multilevel intervention to improve adherence to AHT among breast cancer survivors from racially and socioeconomically disadvantaged backgrounds (eg, Medicaid-insured). The specific aims are to (1) explore multilevel (eg, patient, health care system) factors that influence adherence to AHT; (2) develop a theory-based, multilevel intervention to improve adherence to AHT; and (3) pilot test and evaluate the intervention developed in Aim 2. Methods: For Aim 1, we will recruit breast cancer survivors and health care professionals to participate in semistructured interviews to gain their perspectives about barriers and facilitators to AHT use. We will conduct a directed content analysis of the Aim 1 qualitative interview data. For Aim 2, we will integrate Aim 1 findings and current literature into the design of a JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 1 (page number not for citation purposes) XSL•FO RenderX JMIR RESEARCH PROTOCOLS Felder et al multilevel intervention using an Intervention Mapping approach. For Aim 3, we will recruit Medicaid-insured breast cancer survivors to assess the feasibility of the pilot intervention. multilevel intervention using an Intervention Mapping approach. For Aim 3, we will recruit Medicaid-insured breast cancer survivors to assess the feasibility of the pilot intervention. Results: From May 2016 to July 2018, we completed interviews with 19 breast cancer survivors and 23 health care professionals in South Carolina. We will conduct a directed content analysis of the qualitative interview data. Results from this analysis will be used, in combination with current literature, to design (Aim 2) and pilot test a theory-based multilevel intervention (Aim 3) in Summer 2021. Results of the pilot are expected for Fall 2021. KEYWORDS breast neoplasms; medicaid; medication adherence; vulnerable populations; hormonal therapy; endocrine therapy; qualitative methods breast neoplasms; medicaid; medication adherence; vulnerable populations; hormonal therapy; endocrine therapy; qualitative methods AHT compared to White women. Therefore, the improvement of adherence to AHT among socioeconomically disadvantaged Black women with breast cancer is critical to increase their survival rate as well as to close the gap on racial disparities in breast cancer treatment. AHT compared to White women. Therefore, the improvement of adherence to AHT among socioeconomically disadvantaged Black women with breast cancer is critical to increase their survival rate as well as to close the gap on racial disparities in breast cancer treatment. Background Adjuvant hormonal therapy (AHT) has been shown to significantly reduce recurrence and mortality rates among women diagnosed with hormone receptor–positive (HR+) breast cancer [1]. Current clinical guidelines for women diagnosed with early stage (stages I-III) HR+ breast cancer recommend up to 10 years of AHT with tamoxifen or an aromatase inhibitor (AI), following surgery, chemotherapy and/or radiation, as indicated. [2,3]. However, although AHT is considered the standard of care for breast cancer, reports show that only about 50% of women complete treatment as recommended [4,5]. Project Goal and Innovation Third, rates of adherence to AHT are lowest among financially disadvantaged populations versus other population–based groups. For example, only 58% of Medicaid-insured women adhered to AHT in the first year [19], compared to 80%-85% in privately insured populations [20,21]. Hershman et al [22] recently found that low annual household income (<US $40,000) significantly decreased the odds of Black women adhering to Abstract Conclusions: This study will provide a deeper understanding of how to improve adherence to AHT, using a novel and multilevel approach, among socioeconomically disadvantaged breast cancer survivors who often experience disproportionate breast cancer mortality. https://www.researchprotocols.org/2020/9/e17742 International Registered Report Identifier (IRRID): DERR1-10.2196/17742 International Registered Report Identifier (IRRID): DERR1-10.2196/1774 JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 2 (page number not for citation purposes) Study Overview The PI will schedule an interview at a time and location convenient to the potential participants to determine their eligibility for the study. Eligibility requirements will include (1) being employed as a health care professional (ie, physicians, nurses, pharmacists, social workers, patient navigators); (2) currently working with breast cancer patients, for example in an oncology setting, such as a cancer center or hospital; and (3) age ≥ 21 years. the study’s principal investigator (PI).The invitation letter will describe the study aims, study procedures, funding source, and institutional review board approval protocol information. Interested health care professionals will be able to contact the study PI directly by telephone or email. The PI will schedule an interview at a time and location convenient to the potential participants to determine their eligibility for the study. Eligibility requirements will include (1) being employed as a health care professional (ie, physicians, nurses, pharmacists, social workers, patient navigators); (2) currently working with breast cancer patients, for example in an oncology setting, such as a cancer center or hospital; and (3) age ≥ 21 years. Study Design Study Aim 1 will explore patient, health care system, and structural factors that influence adherence to AHT (Years 1-2). To achieve this aim, in-depth, semistructured qualitative interviews will be conducted with health care professionals who work in oncology settings and with breast cancer survivors. For purposes of this research, we define a “breast cancer survivor” as anyone who has been diagnosed with invasive breast cancer. https://www.researchprotocols.org/2020/9/e17742 JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 3 (page number not for citation purposes) Study Overview This project received funding from the National Cancer Institute of the National Institutes of Health (2015-2020). The proposed research will address concepts proposed by the World Health JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 2 (page number not for citation purposes) XSL•FO RenderX JMIR RESEARCH PROTOCOLS Felder et al Felder et al Organization’s (WHO) Multidimensional Adherence Model Framework [25] and the Multi-level Context of Cancer Care Model [26] (Table 1). This adapted framework shows how factors are nested within multiple levels to influence AHT adherence and can be useful for designing and targeting multilevel interventions. The formative, in-depth, semistructured interviews (Aim 1, Years 1-2) will constitute the basis for the development of culturally appropriate messaging and content of the multilevel intervention (Aim 2; Year 2) to be pilot-tested and evaluated in Year 3 (Aim 3). multilevel interventions. The formative, in-depth, semistructured interviews (Aim 1, Years 1-2) will constitute the basis for the development of culturally appropriate messaging and content of the multilevel intervention (Aim 2; Year 2) to be pilot-tested and evaluated in Year 3 (Aim 3). Table 1. Modifiable factors at multiple levels that influence adherence to adjuvant hormonal therapy [27-29]. Potential interventions Related factors Level and factors Patient • • Education + behavioral support Psychosocial factors • • Case management Knowledge, beliefs, attitudes • • Pharmacist-led, multicompo- nent intervention Illness perceptions Family/social support • • Family/dyadic education Family dynamics • Friends, network support • • Enhance skill mix/competen- cies of care team AHT recommendations Health care system/health care team • • Reminders AHT fill interval • • Education on effective patient- centered communication + be- havior management Communication prefer- ences/styles • Perceptions/bias • • Reduced out-of-pocket expens- es Cost of AHT Policy/structural/cultural • • Public health insurance cover- age National/state/local policy • Distance to health/pharmacy services e factors at multiple levels that influence adherence to adjuvant hormonal therapy [27-29]. Patient Family/social support Health care system/health care team • • Reduced out-of-pocket expens- es Cost of AHT • • Public health insurance cover- age National/state/local policy Policy/structural/cultural Policy/structural/cultural • Distance to health/pharmacy services the study’s principal investigator (PI).The invitation letter will describe the study aims, study procedures, funding source, and institutional review board approval protocol information. Interested health care professionals will be able to contact the study PI directly by telephone or email. Breast Cancer Survivor Recruitment and Eligibility Breast cancer survivors will be recruited from the South Carolina Oncology Associates (SCOA) and the Gibbs Cancer Center and Research Institute (GCCRI). Eligibility requirements include: (1) age≥21 years; (2) diagnosed with HR+, invasive breast cancer; (3) having medical records that confirm the prescription of any hormonal treatment (anastrozole, exemestane, letrozole, tamoxifen) at any point after diagnosis; (4) eligible for or enrolled in South Carolina Medicaid program; and (5) being able to speak and read in English. Following consent, participants will be asked to complete a brief information form about their personal information (eg, age, race, marital status), hormonal therapy (eg, type of drug, daily use), and type of AHT resources used and preferred. The research team will conduct all interviews using a semistructured interview guide. Breast cancer survivors will be asked to describe their experiences with AHT, including experiences communicating with health care professionals about AHT, and strategies used for addressing AHT nonadherence. All participants will be given a US $50 cash stipend for their time and effort. At the end of the interview, participants will be asked if they are willing to participate in the intervention development phase of this study (Aim 2). To recruit participants, we will apply a recruitment model developed by Heiney and colleagues [30], which combine social marketing with relationship building. The PI and a research assistant will work with SCOA and GCCRI staff to identify participants who meet the study eligibility criteria using electronic medical records. SCOA patients will be mailed a personal invitation letter from the PI explaining the goals of the study, including a Frequently Asked Questions document that addresses potential concerns of research participants. The letter will include a phone number to call if the participant prefers not to be contacted. Within 3-5 days after the recruitment letter is mailed, the PI or research assistant will contact the participant by phone to provide them with an overview of the study. If the participant expresses interest in the study, the PI or research assistant will verify the participant’s study eligibility. If eligibility is met, an interview appointment will be scheduled at a time and location convenient to the participant. If a participant is not eligible, the PI or research assistant will let the participant know that they did not meet the study criteria and will thank them for their interest in participating. https://www.researchprotocols.org/2020/9/e17742 Data Analysis of Interviews All interviews will be recorded and transcribed verbatim by a professional transcription service. Each participant’s audio file and transcript will be assigned the same unique identifier as their corresponding brief questionnaire. Quality control checks will be conducted while reviewing the transcripts to ensure that no personal identifiers are used. Audiotaped transcripts and field notes will be used for data analyses. Transcripts will be independently read and reviewed to check for accuracy and authenticity. To identify potential modifiable factors and future intervention targets for Aim 2, Assarroudi et al’s [31] qualitative content analysis approach will be used to analyze interview transcripts. The PI will develop a preliminary codebook of main categories and subcategories derived from the WHO Multidimensional Adherence Model Framework [25] and Multilevel Context of Cancer Care [26]. The PI will work with other team members to discuss the codebook as well as the final main categories and subcategories and their related meanings. The PI and two other research team members will independently read and code a selection of transcripts using the preliminary codebook. Following this initial coding, all team members will meet, compare coding results, and discuss differences in coding interpretations and concerns with the preliminary codebook. The PI will revise the codebook as needed. Once the codebook is finalized, a research assistant who is knowledgeable in the study topic area will, independently, code all the transcripts, and the PI will code a random sample of the transcripts. The PI and research assistant will then meet and discuss coded At GCCRI, designated staff will contact potentially eligible breast cancer survivors by phone and provide them with an overview of the study. If the participant shows interest in the study, GCCRI staff will then ensure the participant meets study eligibility. If eligibility is met, GCCRI staff will request verbal consent by phone and set up an interview appointment at GCCRI. Interested and eligible participants will be mailed an “Appointment Form” confirming the date, time, and location of the interview; a copy of the informed consent; and the Frequently Asked Questions document. JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 4 (page number not for citation purposes) Health Care Professional Recruitment and Eligibility Before the interview, health care professionals will be asked to complete a brief questionnaire about their personal (eg, gender, age) and professional (eg, current job title, type of health care professional, health care setting) information. The PI will conduct all interviews using a guide developed by the study team. Key topics include: (1) major barriers to AHT adherence; (2) organizational resources to support posttreatment (eg, surgery, chemotherapy) of breast cancer survivors; (3) Health care professionals will be recruited to participate in qualitative interviews. The study will target health professionals from key networks and organizations in South Carolina, including professional organizations (eg, oncology nursing, oncology social work), cancer centers and South Carolina’s cancer coalition and department of health. The primary method of recruitment will be through email invitation letters sent by JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 3 (page number not for citation purposes) XSL•FO RenderX JMIR RESEARCH PROTOCOLS Felder et al will be conducted: a research team member (PI or research assistant) will read aloud a consent form that will inform the participant about the following components of the study: title of the research project, the identity of the project PIs and their respective contact information, an introduction about the study, the aims of the study, reason for the project, a summary of why the individual has been asked to participate, a description of the study procedures (ie, audiotaping of interviews), an outline of any risks and/or benefits, an overview of how confidentiality will be maintained, a discussion of any benefits, and a method of securing additional information or asking questions. After the consent form is read aloud and the participant agrees to participate in the study, the research team member and participant will sign and date the form. Participants will be given a copy of the form for their records. communication among health care team members; (4) communication with patients and their families; and (5) organizational strategies for addressing problems with AHT adherence. Participants will receive a US $50 cash stipend for their time and effort. At the end of the interview, participants will be asked for their contact information if they are willing to participate in a follow-up feedback session, which will serve to inform the development of a subsequent intervention. All interviews will be digitally recorded and field notes will be taken. Validation of Formative Data and Intervention Design Through Participant Feedback Session From the group of participants that agreed to participate in a follow-up feedback session, we will select a purposive sample of breast cancer survivors (n=5; and their designated family member/friend, n=5) and health care professionals (n=5), based on their brief questionnaire and interview responses. We will host two, 1 to 2 hours feedback sessions: one for breast cancer survivors and their family member/social support, and another one for health care professionals. The feedback sessions will provide participants with the opportunity to judge the accuracy and credibility of the qualitative research findings, as well as to provide alternative interpretations and explanations when necessary [38]. We will also discuss any differences of opinion that may appear between the survivor and health care professional interviews to reach a resolution. Participants will receive US $50 and a light meal for their time and effort upon In conclusion, achieving the proposed aims will contribute to the scientific community’s growing interest in multilevel intervention design and analyses; describe relationships between modifiable patient, family/social support, and health care system/team factors and adherence to AHT; and identify feasible intervention strategies for improving adherence to AHT among breast cancer survivors from racially and socioeconomically disadvantaged backgrounds. Discussion Findings from this research will help fill a gap in our current understanding of underlying modifiable factors that influence adherence to AHT, particularly among understudied disparate populations [4]. To our knowledge, no previous study has applied a multi-level intervention approach to improve adherence to AHT [39]. Applying this approach to the cancer treatment and survivorship phases of the cancer control continuum is novel because most multi-level research in this area focuses on prevention and screening [26,40]. There is a similar pattern within the field of breast cancer research, where there are fewer intervention studies that focus on improving breast cancer treatment outcomes, compared to screening [41,42]. Among the studies that focus on improving adherence to AHT, few have found significant intervention effects [39,43-45] or are currently analyzing data [46]. Validation of Formative Data and Intervention Design Through Participant Feedback Session Aim 2. Develop a Theory-based, Multi-level Intervention Program to Improve Adherence to AHT Aim 2. Develop a Theory-based, Multi-level Intervention Program to Improve Adherence to AHT Overview of Intervention Development Via Data Integration/synthesis and Intervention Mapping The institutional review boards of the University of South Carolina, Prisma Health (formerly Greenville Health System) and Spartanburg Regional Hospital System reviewed the study protocols for Aim 1 and determined that they were exempt from human research subject regulations. Qualitative data collection for Aim 1 began in May 2016 and has been completed as of July 2018. A total of 19 breast cancer survivors and 23 health care professionals have been interviewed. Qualitative data analysis will be completed by December 2020. Results from this analysis will be used, in addition to current literature, to design (Aim 2) and pilot test a theory-based multilevel intervention (Aim 3) by Summer 2021. Multiple sources will be used for the development of a theory-based, multilevel intervention, including findings from Aim 1, current scientific literature, insights from participant feedback sessions (Aim 2), expertise of the research team, and trainings from the Multilevel Intervention Training Institute at the National Cancer Institute. Multiple sources will be used for the development of a theory-based, multilevel intervention program, including findings from Aim 1, current scientific literature, insights from participant feedback sessions (described below), and expertise of the project mentoring team. After analyzing the qualitative data from the breast cancer survivor and health care professional interviews, we will develop a modified, data-informed logic model of potential interventions aimed at health care professionals and their organizations, and survivors and their family/social support. Logic models, representing an outcomes hierarchy, will assist with a broad understanding of the components of each potential intervention [33]. Potential intervention strategies are shown in Table 1 [27-29]. The research team will systematically review and compare findings from the survivor and health care professional qualitative interviews and quantitative questionnaire data. Of interest is not only the variation within the survivor and health care professional groups, but also the variation between the survivor and health care professional reports. We will, therefore, identify themes that occur within and across groups. We will employ a logic model based on the PRECEDE approach [34] to illustrate survivors’ experiences with AHT and how knowledge, perceptions and attitudes at different levels impact their ability to adhere to AHT. We will apply appropriate multi-level theories to refine the intervention strategies and messages [35-37]. JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 5 (page number not for citation purposes) Breast Cancer Survivor Data Collection Interviews with participants recruited from SCOA will be scheduled and conducted at a location (eg, home, library) and time convenient to the participant, while GCCRI participant interviews will be scheduled in person and onsite at GCCRI. Before the interviews, the following informed consent process XSL•FO RenderX JMIR RESEARCH PROTOCOLS Felder et al completion of the session. The project mentoring team will provide guidance on how to refine the intervention design based on the data from the feedback sessions and resolve any data discrepancies. completion of the session. The project mentoring team will provide guidance on how to refine the intervention design based on the data from the feedback sessions and resolve any data discrepancies. transcripts, reach a consensus among any discrepancies and calculate intercoder agreement [32]. Acknowledgments TMF was funded by an NCI Mentored Research Scientist Development Award to Promote Diversity (K01CA193667). All opinions expressed herein are the sole responsibility of the authors and do not reflect the views of the National Institutes of Health. TMF was funded by an NCI Mentored Research Scientist Development Award to Promote Diversity (K01CA193667). All opinions expressed herein are the sole responsibility of the authors and do not reflect the views of the National Institutes of Health. Conflicts of Interest None declared. https://www.researchprotocols.org/2020/9/e17742 XSL•FO RenderX JMIR RESEARCH PROTOCOLS Felder et al References Breast Cancer Res Treat 2013 Feb;137(3):829-836 [FREE Full text] [doi: 10.1007/s10549-012-2387-8] [Medline: 23263740] 12. Liu Y, Malin JL, Diamant AL, Thind A, Maly RC. Adherence to adjuvant hormone therapy in low-income women with breast cancer: the role of provider-patient communication. 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The Patient's Anastrozole Compliance to Therapy (PACT) Program: a randomized, in-practice study on the impact of a standardized information program on JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 7 (page number not for citation purposes) https://www.researchprotocols.org/2020/9/e17742 JMIR RESEARCH PROTOCOLS Felder et al persistence and compliance to adjuvant endocrine therapy in postmenopausal women with early breast cancer. Ann Oncol 2013 Jun;24(6):1505-1512 [FREE Full text] [doi: 10.1093/annonc/mds653] [Medline: 23378537] persistence and compliance to adjuvant endocrine therapy in postmenopausal women with early breast cancer. Ann Oncol 2013 Jun;24(6):1505-1512 [FREE Full text] [doi: 10.1093/annonc/mds653] [Medline: 23378537] 45. Yu K, Zhou Y, Liu G, Li B, He P, Zhang H, et al. A prospective, multicenter, controlled, observational study to evaluate the efficacy of a patient support program in improving patients' persistence to adjuvant aromatase inhibitor medication for postmenopausal, early stage breast cancer. Breast Cancer Res Treat 2012 Jul;134(1):307-313. [doi: 10.1007/s10549-012-2059-8] [Medline: 22527106] 46. He Y, Tan EH, Wong ALA, Tan CC, Wong P, Lee SC, et al. Improving medication adherence with adjuvant aromatase inhibitor in women with breast cancer: study protocol of a randomised controlled trial to evaluate the effect of short message service (SMS) reminder. BMC Cancer 2018 Jul 09;18(1):727 [FREE Full text] [doi: 10.1186/s12885-018-4660-7] [Medline: 29986672] JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 8 (page number not for citation purposes) Abbreviations Edited by G Eysenbach; submitted 17.02.20; peer-reviewed by A Sutton, R Wassersug; accepted 15.06.20; published 03.09.20 Please cite as: Felder TM, Heiney SP, Hebert JR, Friedman DB, Elk R, Franco R, Gansauer L, Christensen B, Ford ME Improving Adherence to Adjuvant Hormonal Therapy Among Disadvantaged Women Diagnosed with Breast Cancer in South Carolina: Proposal for a Multimethod Study JMIR Res Protoc 2020;9(9):e17742 URL: https://www.researchprotocols.org/2020/9/e17742 doi: 10.2196/17742 PMID: 32880374 ©Tisha M Felder, Sue P Heiney, James R Hebert, Daniela B Friedman, Ronit Elk, Regina Franco, Lucy Gansauer, Barbara Christensen, Marvella E Ford. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 03.09.2020. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included. https://www.researchprotocols.org/2020/9/e17742 JMIR Res Protoc 2020 \| vol. 9 \| iss. 9 \| e17742 \| p. 8 (page number not for citation purposes) XSL•FO RenderX
https://openalex.org/W1506520913	https://library.oapen.org/bitstream/20.500.12657/33526/1/459998.pdf	English	null	The ADB’s Story	null	2,013	cc-by	184,419	Published by ANU E Press The Australian National University Canberra ACT 0200, Australia Email: anuepress@anu.edu.au This title is also available online at http://epress.anu.edu.au Published by ANU E Press The Australian National University Canberra ACT 0200, Australia Email: anuepress@anu.edu.au This title is also available online at http Contents A Dictionary of Public Figures. . . . . . . . . . . . . . . . . . . . . . . . . . ix Geoff Page Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Tom Griffiths Obligations and Debts in Writing the ADB’s Story. . . . . . . . . . . . . 1 Melanie Nolan and Christine Fernon 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Melanie Nolan Document: ‘The Australian Dictionary of Biography’, paper presented to ANU Council, 10 May 1960. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Document: ‘The Australian Dictionary of Biography’, paper presented to ANU Council, 12 April 1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Document: Keith Hancock launches Volume 10 of the ADB, 1986. . . . . . . . 42 Editors and their Eras 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 . . . . . 49 Ann Moyal Document: Report of My Journey to Perth, Adelaide, Melbourne and Hobart, August–Sept. 1959, by Ann Moyal. . . . . . . . . . 78 Profile: Ann Moyal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Profile: Keith Hancock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Profile: Malcolm Ellis . . . . . . . Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 The Wild Colonial Bore by O. K. H. Spate. . . . . . . . . . . . . . . . . . . . . . . . . 92 Profiles: Geoffrey Sawer and Ross Hohnen. . . . . . . . . . . . . . . . . . . . . . . . 93 Profile: Norman Cowper. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Profile: Gwyn James. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Profile: A. G. L. Shaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 John D. Calvert Profile: Nan Phillips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Profile: Jim Gibbney. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Profile: Sally and Bob O’Neill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Profile: Ruth Frappell. . National Library of Australia Cataloguing-in-Publication entry National Library of Australia Cataloguing-in-Publication entry Other Authors/Contributors:  Nolan, Melanie, editor. Fernon, Christine, editor. Dewey Number: 920.094 Dewey Number: 920.094 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise, without the prior permission of the publisher. Cover illustration: Keith Hancock planting an English oak tree on the southern lawn of University House in 1984 to celebrate the house’s thirtieth anniversary. The ‘Hancock oak’, grown from an acorn he brought from Cambridge, commemorates the association between The Australian National University and Cambridge, England. The ADB was another of Hancock’s ‘oaks’. ANUA225-511 The ANU Lives Series in Biography is an initiative of the National Centre for Biography in the History Program in the Research School of Social Sciences at The Australian National University. The National Centre was established in 2008 to extend the work of the Australian Dictionary of Biography and to serve as a focus for the study of life writing in Australia, supporting innovative research and writing to the highest standards in the field, nationally and internationally. Books that appear in the ANU Lives series will be lively, engaging and provocative, intended to appeal to the current popular and scholarly interest in biography, memoir and autobiography. They will recount interesting and telling life stories and engage critically with issues and problems in historiography and life writing. Cover design and layout by ANU E Press Printed by Griffin Press This edition © 2013 ANU E Press Editors and their Eras Editors and their Eras 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 . . . . . 49 Ann Moyal Document: Report of My Journey to Perth, Adelaide, Melbourne and Hobart, August–Sept. 1959, by Ann Moyal. . . . . . . . . . 78 Profile: Ann Moyal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Profile: Keith Hancock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Profile: Malcolm Ellis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 The Wild Colonial Bore by O. K. H. Spate. . . . . . . . . . . . . . . . . . . . . . . . . 92 Profiles: Geoffrey Sawer and Ross Hohnen. . . . . . . . . . . . . . . . . . . . . . . . 93 Profile: Norman Cowper. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Profile: Gwyn James. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Profile: A. G. L. Shaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 . . . . . . . . . . . . . . . . . . . . . . . . Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 A Dictionary of Public Figures. . . . . . . . . . . . . . . . . . . . . . . . . . ix Geoff Page Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Tom Griffiths Obligations and Debts in Writing the ADB’s Story. . . . . . . . . . . . . 1 Melanie Nolan and Christine Fernon 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Melanie Nolan Document: ‘The Australian Dictionary of Biography’, paper presented to ANU Council, 10 May 1960. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Document: ‘The Australian Dictionary of Biography’, paper presented to ANU Council, 12 April 1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Document: Keith Hancock launches Volume 10 of the ADB, 1986. . . . . . . . 42 Editors and their Eras . . . . . . . . . . 101 John D. Calvert Profile: Nan Phillips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Profile: Jim Gibbney. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Profile: Sally and Bob O’Neill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Profile: Ruth Frappell. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Christopher Cunneen Profile: Chris Cunneen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Profile: Bryan Gandevia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Profiles: Margaret Steven and Heather Radi. . . . . . . . . . . . . . . . . . . . . . . 150 5. John Ritchie: Consolidating a Tradition, 1987–2002. . . . . . . 153 Geoffrey Bolton Document: Phar Lap: an ADB entry by B. G. Andrews. . . . . . . . . . . . . . . 172 Profiles: Richard Tolhurst, Gough Whitlam and Barry Jones. . . . . . . . . . . . 174 Profiles: Barry and Ann Smith. Editors and their Eras . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Profiles: John La Nauze and Ken Inglis. . . . . . . . . . . . . . . . . . . . . . . . . . 178 6. The Di Langmore Era, and Going Online, 2002–2008. . . . . . . 181 Darryl Bennet Profile: Darryl Bennet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Profile: Gavan McCarthy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Profile: John Molony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Profiles: Ivy Meere, Edna Kauffman and Karen Ciuffetelli . . . . . . . . . . . . . 207 The ADB’s Workflow Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 ADB Files. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 The ADB’s Corrigenda Ruler. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 National Collaboration 7. Working Parties: Recollections of the South Australian Working Party. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Editors and their Eras 213 John Tregenza The New South Wales Working Party. . . . . . . . . . . . . . . . . 218 Beverley Kingston Recollections of the New South Wales Working Party. . . . . . 227 Russell Doust The Queensland Working Party. . . . . . . . . . . . . . . . . . . . . 229 Spencer Routh Profile: Spencer Routh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Profile: Michael Roe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Profile: Wendy Birman. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Profile: Cameron Hazlehurst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Profiles: Maurice (Bunny) Austin, Alec Hill and Frank Brown. . . . . . . . . . . 242 Profiles: Gordon Briscoe and Frances Peters-Little. . . . . . . . . . . . . . . . . . 244 Profile: John Poynter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 8. From the First Fleet to ‘Underbelly’: Writing for the ADB . . . . 249 Gerald Walsh Profile: Gerry Walsh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Profile: Ann Hone . . . . . . . . . . . . . . . . . . . . . . Editors and their Eras . . . . . . . . . . . . . . . . . . 263 Profile: Ken Cable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Profiles: Martha Campbell and Suzanne Edgar. . . . . . . . . . . . . . . . . . . . . 266 A King’s Remains by Suzanne Edgar . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 The ADB—My Best Friend by P. A. Selth. . . . . . . . . . . . . . . . . . . . . . . . 271 9. National Collaboration: The ADB Editorial Board and the Working Parties. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Jill Roe Profile: Jill Roe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Profile: Geoffrey Bolton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 10. Assessing the ADB: A Review of the Reviews. . . . . . . . . . . 299 Mark McGinness Review of ADB, Volumes 1 and 2 (1967) by Geoffrey Blainey. . . . . . . . . . 322 Review of ADB, Volume 9 (1983) by Stuart Macintyre. . . . . . . . . . . . . . . 329 Review of ADB, Volume 18 (2012) by Mark McGinness. . . . . . . . . . . . . . 332 Pasts and Futures ADB Volumes. . . . . . . . . . . . . . . . . . . Editors and their Eras . . . . . . . . . . . . . . . . . 337 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012. . . . . . . . . . . 345 Philip Carter 12. From Book to Digital Culture: Redesigning the ADB. . . . . . . 373 Melanie Nolan Appendices Appendix 1: Time Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Appendix 2: ADB Staff List, 1958–2013. . . . . . . . . . . . . . . . . 403 Appendix 3: National Committee, Editorial Board and Working Parties by Volume. . . . . . . . . . . . . . . . . . . . . . . . 411 Appendix 4: ADB Medal Recipients. . . . . . . . . . . . . . . . . . . . . 443 Appendix 5: ADB Bibliography . . . . . . . . . . . . . . . . . . . . . . . . 447 Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469 Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471 Tom Griffiths Tom Griffiths When an organisation begins to imagine the next phase of its future, it generally composes a strategic plan. The Australian Dictionary of Biography (ADB), however, writes a history—and one spiced with biographical portraits. Of course, the ADB has done the strategic plans too—more than should have been demanded of such an unimpeachable and impressive national enterprise. But the reality of daily life in the ADB is that, even after 50 years, it continually has to fight for its future, especially against those within its own university who are driven by corporate competition rather than national collaboration. The ADB’s Story reminds us of the foundation vision of cooperative scholarship that brought the ADB to life, a vision that the dictionary has realised so superbly and that continues to inspire all who work for it. This book is about a half- century of dedicated work across the nation by good and generous people who are also brilliant scholars. It is about the organic, federal design of the ADB and how those structures have coped with and invented change. Knowing this history—in all its biographical and contextual richness—is the best strategic plan an institution could possibly generate. We learn from this history that when Keith Hancock was establishing the Australian Dictionary of Biography in 1959, he assured the ANU vice-chancellor that he thought it ‘unlikely’ that he would ‘need to look for a millionaire’. As Hancock’s current successor as chair of the Editorial Board of the ADB, I recently sought help from the ANU vice-chancellor in finding that millionaire. The ADB Endowment Fund, wisely established by Professor John Ritchie, has become more important with the years and has been vital to maintaining core functions in straitened times. The Australian National University remains firmly committed to the ADB, but its ability to fund this prestigious collaboration is being steadily eroded. Yet, as Keith Hancock foresaw, the ADB—more than any other single enterprise— realises the national mission that is literally at the heart of The Australian National University. In the recent words of the Chancellor of the ANU, Professor the Hon. Gareth Evans AC QC, ‘The Australian Dictionary of Biography captures the life and times and culture of this country in an absolutely distinctive and irreplaceable way … I could not be prouder of the ANU’s continuing role as custodian of this crucial part of our national legacy’. A Dictionary of Public Figures Geoff Page Buried now a second time by alphabet and golden year (floreat circa 1880) the outlines of their lives are fleshed again from paper; their myths persist rs. by committee requirement— gate of three to the text. s, colonial mayors, es or morning papers re shown and kept ans vate um of all these shelve e us be, cophagus or crypt— wearing already mell of yellow. Will vanish also into the text. Clergymen, graziers, colonial mayors, owners of goldmines or morning papers … wince and flinch as year by year the sweaty thumbs turn through them. Geoff Page is a Canberra poet. His wife, Carolyn, worked for the ADB in 1982–84. This poem is reprinted from Collected Lives (Angus & Robertson, 1986) with the author’s permission. ix ix Tom Griffiths FAHA Chair, Editorial Board, Australian Dictionary of Biography W. K. Hancock Professor of History, The Australian National University The ADB’s Story Yet to work with the ADB is immediately to become keenly aware of how much it draws on a truly devolved, federal synergy. One is quickly humbled by the range and generosity of its expert volunteer labour, the brilliance and originality of its thousands of unpaid and willing contributors, the enthusiastic support of universities, libraries and museums right around the country, the dedication of its vital working parties and members of the Editorial Board, the skill and devotion of its staff, and the daily dependence on ADB entries by scholars and readers, businesspeople and politicians, lawyers, teachers, journalists, nurses, farmers, cooks, possibly shearers and hopefully millionaires. We now know more than ever before the extraordinary extent of that readership because of the launch of ADB online in 2006 and the 70 million hits the site receives each year. I am proud not only of the ADB and its vast, dispersed team but also of the fact that The ADB’s Story is a product of the intelligent historical insight that detailed knowledge of the past does indeed enable us to plan wisely for the future. I congratulate the General Editor, Professor Melanie Nolan, and Online Manager, Christine Fernon, for recognising the need for this book and for all their work in bringing it into being, and I thank all the authors for combining scholarship and experience in a perceptive and inspiring portrait of a truly great national institution. Tom Griffiths FAHA Chair, Editorial Board, Australian Dictionary of Biography W. K. Hancock Professor of History, The Australian National University Tom Griffiths FAHA Chair, Editorial Board, Australian Dictionary of Biography W. K. Hancock Professor of History, The Australian National University Tom Griffiths The ADB—as the largest and most successful cooperative research enterprise in the humanities and social sciences in Australia—is indeed inscribed into the very fabric, identity and rationale of our national university. xi The ADB’s Story Tom Griffiths FAHA xii xii 1 Michael Piggott, ‘ADB Files as a Historical Source’, Biography Footnotes, no. 2 (March–May 2009), p. 5. Obligations and Debts in Writing the ADB’s Story Melanie Nolan and Christine Fernon At the beginning of 2009 we decided to write an account of the Australian Dictionary of Biography (ADB). Melanie Nolan took up her position as general editor of the ADB in June 2008. While she had been involved in the Dictionary of New Zealand Biography as a working party member and author, she was the first general editor of the ADB not to have had experience with the institution. She was, moreover, heading a unit in a state of change: many staff were retiring and there was a pressing need to develop the online version of the ADB further. Nolan believed that an account of the ADB’s past was overdue, not only to preserve institutional memory and to understand why decisions had been made, but also to help locate a path into the future. Meanwhile Christine Fernon, the ADB’s bibliographer and, from 2009, online manager, was busily arranging, cataloguing and boxing up more than 11 000 of the ADB’s working files for transfer to the ANU Archives. Previous general editors John Ritchie and Di Langmore had sent some ADB administrative records to the archives. All of the working files on subjects in the dictionary, and the unit’s more recent organisational files, however, were held in 44 metal filing cabinets spread throughout the ADB’s offices. Working through the files, Fernon realised that they were rich in information about the ADB’s administrative and editorial processes. She began to use some of the material she was finding for items in our Biography Footnotes newsletter, which she edits. As Michael Piggott has noted elsewhere, the ‘distributed “ADB family” (the thousands of authors that have written for the ADB, and the distinguished members of the Editorial and Working Parties) probably did not realise they were doubly making history as they researched, wrote, argued over inclusions, edited, checked the facts, and conducted correspondence’.1 While the files were important to preserve for posterity, Fernon also believed that a ‘full’ history, based on the files, should be compiled as the broadest and best kind of guide to the records that was possible. 1 The ADB’s Story The ADB’s Story Presenters at the ADB’s fiftieth birthday seminar, December 2009. From left: John Calvert, Geoffrey Bolton, Wendy Birman, Sue Edgar, Chris Cunneen, Ann Moyal, John Poynter, Jim Davidson and Gerry Walsh Presenters at the ADB’s fiftieth birthday seminar, December 2009. Obligations and Debts in Writing the ADB’s Story From left: John Calvert, Geoffrey Bolton, Wendy Birman, Sue Edgar, Chris Cunneen, Ann Moyal, John Poynter, Jim Davidson and Gerry Walsh Photographer: Peter Fitzpatrick, ADB archives Our common ambition to write a history of the ADB was timely. In 2009 the dictionary celebrated its first half-century. Fiftieth birthdays are a cause also for reflection. Thus, in December 2009 we held a one-day conference on the ADB’s history. Many of those who have been involved with the ADB over the years, including Ann Moyal and Geoffrey Bolton, who were present at its birth, attended the conference. The following day we held a closed workshop on the dictionary’s future directions. Conferences often lead to edited collections. In the absence of any other contenders, the ADB took it upon itself to coordinate the writing of its own history. It proved more difficult than we expected. Many of the leading figures in the ADB’s history—Keith Hancock, Laurie Fitzhardinge, Douglas Pike, John La Nauze and Geoffrey Serle—are now, themselves, subjects of ADB entries, and full biographies of Hancock, Pike and Serle have been written. These studies, however, have included little on their contributions to the ADB and its development. Indeed those involved in the ADB have shown a marked reluctance to write memoirs. 2 Obligations and Debts in Writing the ADB’s Story Historians have traditionally rejected first-person accounts, especially their own memoirs, as subjective and, therefore, unreliable. This is changing. There is increasing interest in historians’ own pasts, their life stories and the institutions with which they were associated as things that help us understand the stories they have written.2 Accounts of Australian historical enterprises are, as a consequence, appearing.3 This collection, then, is a companion to understanding the content, character and form of the 18 volumes (plus the supplement volume) of the ADB, so far published. This collection has taken time to assemble and finalise. Presentations to the 2009 conference, which provided the foundation, needed augmentation. New work was commissioned. In the end we had too much and had to omit some material in the interest of space and the demands of the narrative. There are, for instance, 47 short profiles of significant ‘ADB personalities’ in this book. What appear here are summaries of longer accounts that will be published on the National Centre of Biography’s web site. Like the ADB itself, this project has been a national collaboration and we have incurred many debts. ( ) pp 3 Fay Anderson and Stuart Macintyre (eds), The Life of the Past: The Discipline of History at the University of Melbourne (Melbourne: Department of History, University of Melbourne, 2006). Rob Pascoe, The Manufacture of Australian History (Melbourne: Oxford University Press, 1979). 2 Jeremy Popkin, History, Historians, and Autobiography (Chicago: University of Chicago Press, 2005). Jeremy Popkin, ‘Ego-histoire Down Under. Australian Historian-Biographies’, Australian Historical Studies, 38, no. 121 (2007), pp. 806–23. James M. Banner, jr, and John R. Gillis (eds), Becoming Historians (Chicago and London: University of Chicago Press, 2009). Doug Munro, ‘Biographies of Historians—Or the Choreographers’ Craft’, Australian Historical Studies, 43, no. 1 (2012), pp. 11–27. 2 Jeremy Popkin, History, Historians, and Autobiography (Chicago: University of Chicago Press, 2005). Jeremy Popkin, ‘Ego-histoire Down Under. Australian Historian-Biographies’, Australian Historical Studies, 38, no. 121 (2007), pp. 806–23. James M. Banner, jr, and John R. Gillis (eds), Becoming Historians (Chicago and London: University of Chicago Press, 2009). Doug Munro, ‘Biographies of Historians—Or the Choreographers’ Craft’, Australian Historical Studies, 43, no. 1 (2012), pp. 11–27. 3 Fay Anderson and Stuart Macintyre (eds), The Life of the Past: The Discipline of History at the University of Melbourne (Melbourne: Department of History, University of Melbourne, 2006). Rob Pascoe, The Manufacture of Australian History (Melbourne: Oxford University Press, 1979). Photographer: Peter Fitzpatrick, ADB archives We wish to thank, above all, the contributors: Darryl Bennet, Geoffrey Bolton, John Calvert, Philip Carter, Chris Cunneen, Russell Doust, Beverley Kingston, Mark McGinness, Ann Moyal, Philip Selth, Jill Roe and Gerry Walsh. Retired ADB senior staff—Bennet, Gail Clements and Cunneen; past staff—Paul Arthur, Pam Crichton, Barbara Dawson and Janet Doust; and present staff—Niki Francis, Sam Furphy and Rani Kerin, read and checked particular sections of the text. Of these, Clements’ and Francis’s contributions were substantial. We thank The Australian National University, especially former vice-chancellor, Ian Chubb, and the present one, Ian Young, for their support of the ADB. The ANU Archives’ staff—in particular, Maggie Shapley, University Archivist, and Sarah Leithbridge, Senior Archivist—were especially helpful. David Carment, Tom Griffiths, John Nethercote and Philip Selth read the entire manuscript and saved us from making some simple errors. Selth epitomises the nature of the ADB family: he was a member of the ANU’s executive, he is an author and he is a second-generation ADB supporter. Geoff Page and Suzanne (Sue) Edgar wrote poems about the ADB, which are reproduced with their kind permission. Sue Edgar, a long-serving ADB staff member, also contributed photographs. 3 The ADB’s Story The ADB’s Story Staff at ANU E Press, especially Lorena Kanellopoulos and Duncan Beard, and copyeditor Jan Borrie, helped with the publication of the manuscript. The press is, of course, the appropriate host for this publication, which appears digitally and, for those who wish it, in hardcopy. Every attempt has been made to locate the copyright holders for material quoted in this book. Any person or organisation that may have been overlooked or misattributed may contact the publisher. 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? Melanie Nolan 2 Hancock Notes, box 69, Q31, ADB archives [hereinafter ADBA], ANUA. Hancock’s prehistory paper has not survived but his speaking notes were comprehensive. The ADB’s provisional Editorial Board met for the first time on 19 June 1959; the first ADB Editorial Board meeting was held, jointly with the National Advisory Panel meeting, on 23 April 1960. 1 W. K. Hancock, ‘The Australian Dictionary of Biography’ (12 April 1962), Minutes, ANU Council meeting (11 May 1962), 567/1962, box 1, series 245, ANU Archives [hereinafter ANUA], p. 3 [reprinted here as Document 1]. Separately, Hancock also had to request the council to make Pike’s a professorial appointment, which then had to be subject to an electoral committee process: Minutes, ANU Council meeting (30 April 1962), 639/1962, box 1, series 245, ANUA. The Australian Dictionary of Biography’s genealogy In May 1962 Sir Keith Hancock, Professor of History and Director of the Research School of Social Sciences (RSSS), appeared before the ANU Council to put the case for funding the Australian Dictionary of Biography (ADB). The ADB Editorial Board had appointed Douglas Pike as general editor of the dictionary in January 1962 but there was no provision in Hancock’s budget for the position. Boldly, Hancock went to the council to convince it to cover Pike’s appointment. He hoped to also convince council members to release funds for the appointment of research staff.1 Hancock began by discussing the ADB’s ‘prehistory’: how the idea for an Australian dictionary had ‘been in the minds of historians in various parts of Australia for ten years or more’; how Laurie Fitzhardinge had started a National Register (later called the Biographical Register) in the history department in 1954; how a conference of Australian historians, held at The Australian National University (ANU) in 1957, gave their general support for the dictionary project and how, after wide consultation, an editorial board, headed by Hancock, had met for the first time in 1960.2 5 5 The ADB’s Story 7 Lawrence Goldman, ‘A Monument to the Victorian Age? Continuity and Discontinuity in the Dictionaries of National Biography 1882–2004’, Journal of Victorian Culture, 11, no. 1 (2006), pp. 111–32. 3 ‘Notes on Dictionaries of National Biography’, Memo, Ann Mozley to Professor Hancock (13 March 1962), and material in box 73, Q31 ADBA, ANUA; and W. K. Hancock, ‘The Family Experience’, in ‘The Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA. 6 Iain McCalman, with Jodi Parvey and Misty Cork (eds), National Biographies and National Identity (Canberra: Humanities Research Centre, 1996), p. iv. 3 ‘Notes on Dictionaries of National Biography’, Memo, Ann Mozley to Professor Hancock (13 March 1962), and material in box 73, Q31 ADBA, ANUA; and W. K. Hancock, ‘The Family Experience’, in ‘The Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA. 4 Thomas Carlyle, ‘On History’ (1830), republished in G. B. Tennyson (ed.), A Carlyle Reader (Cambridge: Cambridge University Press, 1984), p. 57. Thomas Carlyle, On Heroes, Hero-Worship, and the Heroic in History. Six Lectures (London: James Fraser, 1841), p. 47. 5 Stefan Collini, ‘Our Island Story’, London Review of Books, 27, no. 2 (20 January 2005), pp. 3–8. 6 Iain McCalman, with Jodi Parvey and Misty Cork (eds), National Biographies and National Identity (Canberra: Humanities Research Centre, 1996), p. iv. 7 Lawrence Goldman, ‘A Monument to the Victorian Age? Continuity and Discontinuity in the Dictionaries of National Biography 1882–2004’, Journal of Victorian Culture, 11, no. 1 (2006), pp. 111–32. ( ) 5 Stefan Collini, ‘Our Island Story’, London Review of Books, 27, no. 2 (20 January 2005), pp. 3–8. y g p y 4 Thomas Carlyle, ‘On History’ (1830), republished in G. B. Tennyson (ed.), A Carlyle Reader (Cambridge: Cambridge University Press, 1984), p. 57. Thomas Carlyle, On Heroes, Hero-Worship, and the Heroic in History. Six Lectures (London: James Fraser, 1841), p. 47. ADB promotional poster, produced by Melbourne University Press, about 1992 ADB promotional poster, produced by Melbourne University Press, about 1992 Source: ADB archives 6 6 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? Hancock was also keen for the ANU Council to be aware that the idea of a national biographical dictionary had ‘deep roots’ in the Western world. A few months earlier he had had a background paper prepared on other national dictionary projects. He also scattered around the council table copies of the British Dictionary of National Biography (DNB), which he referred to as the ‘senior member of the family’.3 He argued that the genesis for national biographical dictionaries was often associated with the massive wave of biographical writing that occurred in Victorian Britain. The role of the individual in history was emphasised by the great historian and essayist Thomas Carlyle, who, following Georg Hegel’s lead, declared that ‘no great man lives in vain. The history of the world is but the biography of great men’, and that ‘history is the essence of innumerable biographies’.4 The nineteenth-century era of nationalism witnessed the great national dictionary of biography projects throughout Europe, including the French Biographie Universelle (1811–62) and the German Allgemeine Deutsche Biographie (1875–1912). These were massive collaborations that produced series of volumes of concise, alphabetically ordered entries. In their wake, the DNB published 63 volumes between 1885 and 1900 and then decadal supplements.5 Some have characterised these dictionaries as triumphant ships sailing ‘through the second half of the nineteenth century unshakably confident’ of their ‘values and virtues’, ‘legitimizing unified national identity’.6 Hancock prosaically employed the language of usefulness: an Australian dictionary of biography would be a useful record for research and a good vehicle for ANU university politics.7 Hancock was also keen for the ANU Council to be aware that the idea of a national biographical dictionary had ‘deep roots’ in the Western world. A few months earlier he had had a background paper prepared on other national dictionary projects. He also scattered around the council table copies of the British Dictionary of National Biography (DNB), which he referred to as the ‘senior member of the family’.3 He argued that the genesis for national biographical dictionaries was often associated with the massive wave of biographical writing that occurred in Victorian Britain. The role of the individual in history was emphasised by the great historian and essayist Thomas Carlyle, who, following Georg Hegel’s lead, declared that ‘no great man lives in vain. The history of the world is but the biography of great men’, and that ‘history is the essence of innumerable biographies’.4 The nineteenth-century era of nationalism witnessed the great national dictionary of biography projects throughout Europe, including the French Biographie Universelle (1811–62) and the German Allgemeine Deutsche Biographie (1875–1912). These were massive collaborations that produced series of volumes of concise, alphabetically ordered entries. In their wake, the DNB published 63 volumes between 1885 and 1900 and then decadal supplements.5 Some have characterised these dictionaries as triumphant ships sailing ‘through the second half of the nineteenth century unshakably confident’ of their ‘values and virtues’, ‘legitimizing unified national identity’.6 Hancock prosaically employed the language of usefulness: an Australian dictionary of biography would be a useful record for research and a good vehicle for ANU university politics.7 The impulse to create a multi-volume collaborative dictionary of biography came later in Australia than in Britain and Europe and made a dictionary project in the 1960s all the more timely. Early Australian dictionaries of biography were neither comprehensive—many required that subjects pay a fee to be included—nor did they involve systematic research: fee-paying subjects tended to write their own biographies. J. Henniker Heaton’s Australian Dictionary of Dates and Men of the Time (1879) set the tone, recording the lives of 550 men and eight women. David Blair’s Cyclopaedia of Australasia (1881), Everard Digby’s Australian Men of Mark (1889) and Philip Mennell’s The Dictionary of Australasian Biography 7 The ADB’s Story from the Inauguration of Responsible Government (1892) followed. The last, while largely reliable, did not include Arthur Phillip, Lachlan Macquarie or John Macarthur. from the Inauguration of Responsible Government (1892) followed. The last, while largely reliable, did not include Arthur Phillip, Lachlan Macquarie or John Macarthur. Fred Johns began his series of volumes—Johns’s Notable Australians—in 1906, and in 1934 he published An Australian Biographical Dictionary containing about 3000 biographies. The average length of each entry was 90 words. The Australian Encyclopaedia, published in 1925–26, focused on prominent achievers. Percival Serle was the next to take up the challenge, publishing 1030 biographies in his two-volume Dictionary of Australian Biography in 1949. It was a mammoth task. 8 Percival Serle, Dictionary of Australian Biography (Sydney: Angus & Robertson, 1949), Preface. 9 Laurie Fitzhardinge, Interview by Barbara Ross, 4–26 March 1987, TRC 2159, transcript, National Library of Australia [hereinafter NLA], Canberra. See also J. A. La Nauze, Review of P. Serle, Historical Studies, Australia and New Zealand, 4, no. 16 (1951). It should be noted that, while the DNB was a team effort, just 100 individuals wrote three-quarters, with Stephen Lee writing 820 articles and Leslie Stephen 378. 10 Keith Hancock, ‘Formation of the Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA. 11 Fitzhardinge interviewed by Ross (1987). 8 Percival Serle, Dictionary of Australian Biography (Sydney: Angus & Robertson, 1949), Preface. y f g p y ( y y g ) 9 Laurie Fitzhardinge, Interview by Barbara Ross, 4–26 March 1987, TRC 2159, transcript, National Library of Australia [hereinafter NLA], Canberra. See also J. A. La Nauze, Review of P. Serle, Historical Studies, Australia and New Zealand, 4, no. 16 (1951). It should be noted that, while the DNB was a team effort, just 100 individuals wrote three-quarters, with Stephen Lee writing 820 articles and Leslie Stephen 378. 10 K ith H k ‘F ti f th A t li Di ti f Bi h ’ b 69 Q31 ADBA ANUA An accountant by profession, Serle began collecting biographical information about Australians in 1929. Ten years later, and by then in his mid seventies, he decided to compile a dictionary, and during the next five years set himself the task of writing four lives a week; the average article length was 640 words.8 It was a marvellous accomplishment, though it also showed, as Laurie Fitzhardinge later commented, that ‘[t]his is the best that can be done by one man. It’s better than anything that went before. It makes it clear that this is no longer a one-man job. It’s got to be a team job on the model of the DNB’.9 The idea of a collaborative national dictionary of Australia had been taking shape in the minds of a number of prominent Australian historians, Hancock told the ANU Council: ‘Frank Crowley in Western Australia … [Manning] Clark in Canberra and Laurie Fitzhardinge who, although “the last person to claim proprietorship”’, was first on Hancock’s list of the dictionary’s direct forebears to be commended.10 Fitzhardinge’s love affair with dictionaries of biography was rooted in his schooldays at a boarding school, in the aftermath of World War I, where, on wet Sunday afternoons, students were permitted to read reference books from the school library. Fitzhardinge chose the DNB: ‘I devised games, dodging about in it, opening a volume at random and then following all the cross references and following up the cross references to that and so on’.11 His love affair continued while working as a reference officer at the Commonwealth National Library (1934–46), where he found himself using Australian dictionaries constantly in his work. At the same time, he was writing a biography of Littleton Groom, the son of a convict who went on to become a long-serving federal politician, and found that, ‘with one or two exceptions, it was very difficult to get even the most elementary background information’ on subjects in Australian history. 8 8 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? 12 Fitzhardinge interviewed by Ross (1987). 13 Fitzhardinge interviewed by Ross (1987). 14 W. K. H. [Hancock], ‘The ADB’ (12 April 1962), box 69, Q31, ADBA, ANUA. In the late 1940s, when Fitzhardinge was in charge of setting up a press at the University of Sydney, he thought that an Australian biographical dictionary project, based on the DNB, should head its list: ‘I remember discussing it with Syd Butlin for instance, and there was general agreement in principle that this would be a good project for Sydney University Press’.12 Sent on an apprenticeship to Oxford University Press in 1947, he spent an ‘afternoon with the then editor of the current supplement to the DNB [talking] about methods of compiling and problems’.13 Following his appointment as reader in sources of Australian history in the RSSS, in 1951, Fitzhardinge convened a small committee to consider the possibility and desirability of an ANU press, again hoping to make a dictionary of Australian biography a flagship publication. The scientists, however, ‘wouldn’t have a bar of it’: Ernest Titterton declared that scientists had no interest in contributing resources to a press, for they published in journals. Fitzhardinge then discussed the possibility of commissioning authors to write DNB-style articles, which might be circulated ‘in monograph form, like the Law Book publications, in a loose-leaf thing which eventually would be the ADB and would then be made up and printed as volumes’. In the meantime, he employed a series of research assistants to work on a card index. The card index later became the Biographical Register, ‘building up material’ for a biographical dictionary. And he talked enthusiastically about a dictionary to anyone who would listen. In his turn, Fitzhardinge was clear that the ADB project, as it developed, was without doubt, ‘Hancock’s baby’ and that he (Fitzhardinge) could never have assembled the widespread academic support necessary to launch the project. From time to time, Hancock discussed how the idea for a biographical dictionary grew on him from his involvement with the DNB in wartime Britain and, in particular, when he started to work on a biography of the prominent South African and British Commonwealth statesman Jan Smuts, and ‘found good cause to curse the lack of a South African DNB’. The four volumes of Smuts’ papers involved hundreds of references to individuals; Hancock found himself duty- bound as a good editor ‘to track down these individuals and write brief notes about them’. 13 Fitzhardinge interviewed by Ross (1987). 14 W. K. H. [Hancock], ‘The ADB’ (12 April 1962), box 69, Q31, ADBA, ANUA. ‘If a Dictionary had existed’, he noted, ‘I should have been saved two years more of finicky work’.14 In his turn, Fitzhardinge was clear that the ADB project, as it developed, was without doubt, ‘Hancock’s baby’ and that he (Fitzhardinge) could never have assembled the widespread academic support necessary to launch the project. In October 1947 Max Crawford had suggested to Hancock that the ANU produce an ‘Australian Dictionary of National Biography’. As part of the planning of the ANU in the immediate postwar period, Hancock, who had been invited by the ANU Council to advise it about the establishment of a school of social sciences, invited leading economist Syd Butlin, political scientist Perc Partridge, 9 The ADB’s Story legal academic George Paton, psychologist Bill O’Neill, social studies researcher James Cardno and historian Crawford to prepare overview papers on their respective disciplines and their prospects at the ANU. He asked them to consider ‘[w]hat facilities are necessary for the encouragement of research in your field in Australia’. Presciently, Crawford suggested: There is I believe more work being done now on Australian biography, a field in which we have in the past done relatively little. I do not need to labour the point that biographical studies will teach us about much more than the persons studied. This is work for individual scholars. The role of the National University might be the eventual production of an Australian Dictionary of National Biography.15 Whatever its genesis, by the late 1950s, the dictionary idea was being publicly attributed to Hancock. When he took up his position as professor of history and director of RSSS in 1957, he also took up the dictionary as an important flagship of his professional leadership. Without any major source of funding, but with the cooperation of historians from all the universities and a belief that authors would willingly write entries, based on original research and without payment, the provisional editorial committee, of what was then called the Dictionary of Australian Biography, met for the first time in Hancock’s office in the old Canberra Community Hospital in June 1959. 15 Professor R. M. Crawford, ‘History’ (10 October 1947), in W. K. Hancock (ed.), Research in the Social Sciences in Australia. Reports Prepared at the Request of Professor Keith Hancock, January 1948 (Canberra: Australian National University, 1948), p. 3. 16 Ann Mozley, ‘Report on My Journey to Perth, Adelaide, Melbourne and Hobart, August–Sept 1959’, box 69, Q31, ADBA, ANUA [reprinted here]. 15 Professor R. M. Crawford, ‘History’ (10 October 1947), in W. K. Hancock (ed.), Research in the Social Sciences in Australia. Reports Prepared at the Request of Professor Keith Hancock, January 1948 (Canberra: Australian National University, 1948), p. 3. 16 Ann Mozley, ‘Report on My Journey to Perth, Adelaide, Melbourne and Hobart, August–Sept 1959’, box 69, Q31, ADBA, ANUA [reprinted here]. The committee consisted of Hancock (as chair), Manning Clark, Professor of History in the neighbouring Canberra University College; Jim Davidson, Professor of Pacific History in the Research School of Pacific Studies (RSPS); Robin Gollan, Research Fellow in RSSS; Laurie Fitzhardinge; and Ann Mozley, who had been employed by Hancock in 1958 specifically to work on the dictionary. They defined their objective as the publication of a multi-volume dictionary within 10 years, and set up two working parties to act as pilots for the organisation of the first two volumes on the period of the naval governors, 1788–1809, and a Pacific history group. Hancock had written to leading historians in Australian universities and outside, inviting them to be involved in the project. He had brought them together to confer and then to join a national committee. Hancock then sent Mozley around the country to proselytise the idea and to encourage the formation of working parties in the States. Travelling to Perth, Adelaide, Melbourne and Hobart in August and September 1959, she reported that there was general agreement ‘that now was the time to begin’.16 10 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? ANU historian Robin Gollan was a member of the ADB’s Editorial Board from 1960 until 1981, and was acting chairman in 1973 ANU historian Robin Gollan was a member of the ADB’s Editorial Board from 1960 until 1981, and was acting chairman in 1973 ANU Archives, 225-459, 1975 ANU Archives, 225-459, 1975 Hancock emphasised to the ANU Council members in 1962 that, while the Australian dictionary was part of a world family of such projects, and that a dictionary project in Australia was overdue, the ADB was developing in exceptional ways too. It was different from other dictionary projects in the way it was to be funded, designed, operated and managed. The DNB, the Dictionary 11 The ADB’s Story of American Biography (DAB) and the Canadian Dictionary of Biography (CDB) were the direct results of substantial private endowments. 17 The New Zealand Cabinet decided in late 1959 to produce an encyclopedia of New Zealand, which included 900 biographies of up to 3000 words. A publication committee was set up, with the parliamentary historian as editor; two editorial staff were appointed; two preliminary advisory committees, one of which was concerned with biography, were established and contributors engaged. It resulted in A. H. McLintock (ed.), An Encyclopedia of New Zealand, 3 vols (Wellington: Government Printer, 1966), box 73, Q31, ADBA, ANUA. 18 W. K. Hancock to Sir Leslie Melville (22 July 1959), box 70, Q31, ADBA, ANUA. 20 Hon. J. J. Dedman MP, Minister for Post-War Reconstruction, ‘Second Reading Speech—Australian National University Bill 1946’, Hansard (19 June 1946). ( y ), , Q , , 19 W. K. Hancock to Sir Leslie Melville (22 July 1959), box 70, Q31, ADBA, ANUA. in this significant national historical enterprise should feel that they were not merely instruments of ANU policies and ambitions but that ‘their partnership with us, in this national enterprise, is a real one’.21 Hancock won the council’s approval, and recurrent funding was made available for the ADB.22 Research staff were appointed, lists of subjects were completed, authors commissioned and a schedule for publication drawn up. It was a significant turning point in the project’s history. In 1959 the New Zealand Government had directly funded an encyclopedia project—which had a Biography Advisory Committee and would contain a large number of biographies.17 Hancock regarded the comparison between the CDB and the ADB to be the closest: ‘Our definitions of the objective and the method of achieving it are, in many respects, very similar’. They were both twentieth-century endeavours, founded in 1959, and situated in universities. But, while the CDB was developed out of the Canadian Biographical Centre at the University of Toronto, the Canadians also ‘took the precaution of discovering a benevolent millionaire’, who died and left a large legacy to establish their project. Hancock assured the ANU vice-chancellor that ‘I think it unlikely that I shall need to look for a millionaire. I believe that we can do this work at least as well as the Canadians and far more economically’.18 Making a virtue out of necessity, the ADB had been launched in the belief that cooperative scholarship and interest could compensate for the lack of large- scale funds if financial responsibility for editing the publication was accepted by the ANU; Melbourne University Press (MUP) agreed to bear the burden of publication. Hancock noted that the ADB was ahead of the Canadians in the race to produce a dictionary because it had access to Fitzhardinge’s Biographical Register. Australia was following ‘British precedents fairly closely but, of course, after the lapse of more than half a century, we should be able to do better than the British did. I have no doubt’, he told the council, ‘we shall do’.19 Finally, Hancock reminded the 1962 gathering that the ANU was founded in 1946 with a specific nation-building charter to encourage, and provide facilities for, research and postgraduate study, both generally and in relation to subjects of national importance to Australia.20 He saw an ANU-led national history project as an important realisation of the ANU’s charter. He also repeated to the council the remark of Queensland colleague Gordon Greenwood that ‘[w]e will do nothing for the ANU; but with the ANU there are no limits to what we are willing to do’. Hancock emphasised the absolute necessity that the partners 12 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? 26 W. K. Hancock, Professing History (Sydney: Sydney University Press, 1976). Ann Moyal, Breakfast with Beaverbrook. Memoirs of an Independent Woman (Sydney: Hale & Iremonger, 1995), p. 137. 23 Noel Annan, Leslie Stephen. The Godless Victorian (London: Weidenfeld & Nicolson, 1984). H. G. C. Matthew, Leslie Stephen and the New Dictionary of National Biography (Cambridge: Cambridge University Press, 1997). Brian Harrison, ‘A Slice of Their Lives. Editing the DNB, 1882–1999’, English Historical Review, 119, no. 484 (2004), pp. 1179–201. 22 Minutes, ADB Editorial Board meeting (7–8 June 1963). While the salaries of all full-time staff at the ADB were being paid by the history department, Hancock made provision for the dictionary’s autonomy and ‘symbolise[d] it by giving the Dictionary a budget of its own’ within his history department budget when Pike shifted to Canberra. ) ( ) 25 Keith Thomas, Changing Conceptions of National Biography. The Oxford DNB in Historical Perspective, The Leslie Stephen Special Lecture, 2004 (Cambridge: Cambridge University Press, 2005); see footnotes for references to a wide literature. 21 W. K. Hancock, ‘The Australian Dictionary of Biography’, presentation to the ANU Council on 12 April 1962, box 69, Q31, ADBA, ANUA, p. 6.f 24 Leslie Stephen, ‘National Biography’, in Sir Leslie Stephen, Studies of a Biographer, vol. 1 (London: Duckworth, 1929) (FP 1898), pp. 1–36. Sidney Lee, Principles of Biography (Cambridge: Cambridge University Press, 1911). Allen Johnson, The Historian and Historical Evidence (New York: C. Scribner’s Sons, 1926). 21 W. K. Hancock, ‘The Australian Dictionary of Biography’, presentation to the ANU Council on 12 April 1962, box 69, Q31, ADBA, ANUA, p. 6. 22 Minutes, ADB Editorial Board meeting (7–8 June 1963). While the salaries of all full-time staff at the ADB were being paid by the history department, Hancock made provision for the dictionary’s autonomy and ‘symbolise[d] it by giving the Dictionary a budget of its own’ within his history department budget when Pike shifted to Canberra. 23 Noel Annan, Leslie Stephen. The Godless Victorian (London: Weidenfeld & Nicolson, 1984). H. G. C. Matthew, Leslie Stephen and the New Dictionary of National Biography (Cambridge: Cambridge University Press, 1997). Brian Harrison, ‘A Slice of Their Lives. Editing the DNB, 1882–1999’, English Historical Review, 119, no. 484 (2004), pp. 1179–201. 24 Leslie Stephen, ‘National Biography’, in Sir Leslie Stephen, Studies of a Biographer, vol. 1 (London: Duckworth, 1929) (FP 1898), pp. 1–36. Sidney Lee, Principles of Biography (Cambridge: Cambridge University Press, 1911). Allen Johnson, The Historian and Historical Evidence (New York: C. Scribner’s Sons, 1926). 25 Keith Thomas, Changing Conceptions of National Biography. The Oxford DNB in Historical Perspective, The Leslie Stephen Special Lecture, 2004 (Cambridge: Cambridge University Press, 2005); see footnotes for references to a wide literature. 26 W. K. Hancock, Professing History (Sydney: Sydney University Press, 1976). Ann Moyal, Breakfast with Beaverbrook. Memoirs of an Independent Woman (Sydney: Hale & Iremonger, 1995), p. 137. g y g 30 John Thompson, ‘Geoffrey Serle and His World: The Making of an Australian Historian’ (PhD thesis, The Australian National University, 2004); and The Patrician and the Bloke: Geoffrey Serle and the Making of Australian History (Canberra: Pandanus Books, 2006). John David Calvert, ‘Douglas Pike (1908–1974): South Australian and Australian Historian’ (MA thesis University of Adelaide 2008) 27 Ann Mozley, ‘The Australian Dictionary of Biography’, Historical Studies: Australia and New Zealand, 9, no. 35 (1960), pp. 313–14. 33 Peter Ryan, Final Proof: Memoirs of a Publisher (Melbourne: Melbourne University Press, 2010), pp. 43–50. Earlier, he also published ‘The ADB’, Quadrant (June 2000), pp. 87–8. y ( ) g Australian and Australian Historian’ (MA thesis, University of Adelaide, 2008). 27 Ann Mozley, ‘The Australian Dictionary of Biography’, Historical Studies: Australia and New Zealand, 9, no. 35 (1960), pp. 313–14. 28 Pike published a few ephemeral pieces: Douglas Pike, ‘Historical Biography and Australian Libraries’, Papers Library Association of Australia, 13th Biennial Conference, 2 (1965), pp. 489–92; ‘The Commemorative Business’, Scholarly Publishing, 1, no. 4 (1970), pp. 331–4; ‘The Making of a Biographical Dictionary’, Papers and Proceedings [Tasmanian Historical Research Association], 19, no. 4 (1972), pp. 139–46; ‘Making a Biographical Dictionary’, in David Dufty, Grant Harman and Keith Swan (eds), Historians at Work: Investigating and Recreating the Past (Sydney: Hicks Smith & Sons, 1973), pp. 103–9. 29 Jim Davidson, A Three-Cornered Life: The Historian W. K. Hancock (Sydney: UNSW Press, 2010). Stephen Holt, A Short History of Manning Clark (St Leonards, NSW: Allen & Unwin, 1999). Brian Matthews, Manning Clark: A Life (Crow’s Nest, NSW: Allen & Unwin, 2008). Mark McKenna, An Eye for Eternity: The Life of Manning Clark (Carlton, Vic.: Melbourne University Publishing, 2011). 30 John Thompson, ‘Geoffrey Serle and His World: The Making of an Australian Historian’ (PhD thesis, The Australian National University, 2004); and The Patrician and the Bloke: Geoffrey Serle and the Making of Australian History (Canberra: Pandanus Books, 2006). John David Calvert, ‘Douglas Pike (1908–1974): South Australian and Australian Historian’ (MA thesis, University of Adelaide, 2008). 31 ‘National Biographies and National Identity: A Critical Approach to Theory and Editorial Practice’, an International Conference sponsored by the Humanities Research Centre, the Australian Dictionary of Biography (Australian National University), and the National Library of Australia, 1–3 February 1995, National Library of Australia, Canberra. Iain McCalman (ed.), National Biographies and National Identity. A Critical Approach to Theory and Editorial Practice (Canberra: Australian National University Press, 1996). 32 See Gerald Walsh, ‘Recording “the Australian Experience”: Hancock and the Australian Dictionary of Biography’, in D. A. Low (ed.), Keith Hancock: The Legacies of an Historian (Melbourne: Melbourne University Press, 2001), pp. 249–68. 33 Peter Ryan, Final Proof: Memoirs of a Publisher (Melbourne: Melbourne University Press, 2010), pp. 43–50. Earlier, he also published ‘The ADB’, Quadrant (June 2000), pp. 87–8. 34 Jeremy D. Popkin, History, Historians, and Autobiography (Chicago: University of Chicago Press, 2005). 35 G. Davison, J. Hirst and S. Macintyre (eds), The Oxford Companion to Australian History (Melbourne: Oxford University Press, 1998). This includes a number of entries on the ADB and its staff. 34 Jeremy D. Popkin, History, Historians, and Autobiography (Chicago: University of Chicago Press, 2005). 35 G. Davison, J. Hirst and S. Macintyre (eds), The Oxford Companion to Australian History (Melbourne: Oxford University Press, 1998). This includes a number of entries on the ADB and its staff. 31 ‘National Biographies and National Identity: A Critical Approach to Theory and Editorial Practice’, an International Conference sponsored by the Humanities Research Centre, the Australian Dictionary of Biography (Australian National University), and the National Library of Australia, 1–3 February 1995, National Library of Australia, Canberra. Iain McCalman (ed.), National Biographies and National Identity. A Critical Approach to Theory and Editorial Practice (Canberra: Australian National University Press, 1996). 32 See Gerald Walsh, ‘Recording “the Australian Experience”: Hancock and the Australian Dictionary of Biography’, in D. A. Low (ed.), Keith Hancock: The Legacies of an Historian (Melbourne: Melbourne University 29 Jim Davidson, A Three-Cornered Life: The Historian W. K. Hancock (Sydney: UNSW Press, 2010). Stephen Holt, A Short History of Manning Clark (St Leonards, NSW: Allen & Unwin, 1999). Brian Matthews, Manning Clark: A Life (Crow’s Nest NSW: Allen & Unwin 2008) Mark McKenna An Eye for Eternity: The Life of ( ) pp 28 Pike published a few ephemeral pieces: Douglas Pike, ‘Historical Biography and Australian Libraries’, Papers Library Association of Australia, 13th Biennial Conference, 2 (1965), pp. 489–92; ‘The Commemorative Business’, Scholarly Publishing, 1, no. 4 (1970), pp. 331–4; ‘The Making of a Biographical Dictionary’, Papers and Proceedings [Tasmanian Historical Research Association], 19, no. 4 (1972), pp. 139–46; ‘Making a Biographical Dictionary’, in David Dufty, Grant Harman and Keith Swan (eds), Historians at Work: Investigating and Recreating the Past (Sydney: Hicks Smith & Sons, 1973), pp. 103–9. 29 Jim Davidson, A Three-Cornered Life: The Historian W. K. Hancock (Sydney: UNSW Press, 2010). Stephen Holt, A Short History of Manning Clark (St Leonards, NSW: Allen & Unwin, 1999). Brian Matthews, Manning Clark: A Life (Crow’s Nest, NSW: Allen & Unwin, 2008). Mark McKenna, An Eye for Eternity: The Life of Manning Clark (Carlton, Vic.: Melbourne University Publishing, 2011). 32 See Gerald Walsh, ‘Recording “the Australian Experience”: Hancock and the Australian Dictionary of Biography’, in D. A. Low (ed.), Keith Hancock: The Legacies of an Historian (Melbourne: Melbourne University Press, 2001), pp. 249–68. Manning Clark (Carlton, Vic.: Melbourne University Publishing, 2011). 30 John Thompson, ‘Geoffrey Serle and His World: The Making of an Australian Historian’ (PhD thesis, The Australian National University, 2004); and The Patrician and the Bloke: Geoffrey Serle and the Making of Australian History (Canberra: Pandanus Books, 2006). John David Calvert, ‘Douglas Pike (1908–1974): South Australian and Australian Historian’ (MA thesis, University of Adelaide, 2008). 31 ‘National Biographies and National Identity: A Critical Approach to Theory and Editorial Practice’, an International Conference sponsored by the Humanities Research Centre, the Australian Dictionary of Biography (Australian National University), and the National Library of Australia, 1–3 February 1995, N i l Lib f A li C b I i M C l ( d ) N i l Bi hi d N i l Id i Holt, A Short History of Manning Clark (St Leonards, NSW: Allen & Unwin, 1999). Brian Matthews, Manning Clark: A Life (Crow’s Nest, NSW: Allen & Unwin, 2008). Mark McKenna, An Eye for Eternity: The Life of Manning Clark (Carlton, Vic.: Melbourne University Publishing, 2011). 28 Pike published a few ephemeral pieces: Douglas Pike, ‘Historical Biography and Australian Libraries’, Papers Library Association of Australia, 13th Biennial Conference, 2 (1965), pp. 489–92; ‘The Commemorative Business’, Scholarly Publishing, 1, no. 4 (1970), pp. 331–4; ‘The Making of a Biographical Dictionary’, Papers and Proceedings [Tasmanian Historical Research Association], 19, no. 4 (1972), pp. 139–46; ‘Making a Biographical Dictionary’, in David Dufty, Grant Harman and Keith Swan (eds), Historians at Work: Investigating and Recreating the Past (Sydney: Hicks Smith & Sons, 1973), pp. 103–9. 29 Jim Davidson, A Three-Cornered Life: The Historian W. K. Hancock (Sydney: UNSW Press, 2010). Stephen Holt, A Short History of Manning Clark (St Leonards, NSW: Allen & Unwin, 1999). Brian Matthews, Manning Clark: A Life (Crow’s Nest, NSW: Allen & Unwin, 2008). Mark McKenna, An Eye for Eternity: The Life of 34 Jeremy D. Popkin, History, Historians, and Autobiography (Chicago: University of Chicago Press, 2005). 35 G D i J Hi t d S M i t ( d ) Th O f d C i A li Hi (M lb ( y ) 31 ‘National Biographies and National Identity: A Critical Approach to Theory and Editorial Practice’, an International Conference sponsored by the Humanities Research Centre, the Australian Dictionary 35 G. Davison, J. Hirst and S. Macintyre (eds), The Oxford Companion to Australian Histo Oxford University Press, 1998). This includes a number of entries on the ADB and its staff. an International Conference sponsored by the Humanities Research Centre, the Australian Dictionary of Biography (Australian National University), and the National Library of Australia, 1–3 February 1995, National Library of Australia, Canberra. Iain McCalman (ed.), National Biographies and National Identity. A Critical Approach to Theory and Editorial Practice (Canberra: Australian National University Press, 1996). 32 See Gerald Walsh, ‘Recording “the Australian Experience”: Hancock and the Australian Dictionary of Biography’, in D. A. Low (ed.), Keith Hancock: The Legacies of an Historian (Melbourne: Melbourne University Press, 2001), pp. 249–68. an International Conference sponsored by the Humanities Research Centre, the Australian Dictionary of Biography (Australian National University), and the National Library of Australia, 1–3 February 1995, National Library of Australia, Canberra. Iain McCalman (ed.), National Biographies and National Identity. A C i i l A h h d di i l i (C b A li i l i i 1996) A decentralised collaborative design: The ADB’s exceptionalism This collection is the first sustained account of the history of the ADB. The prefatory pages of the ADB’s published volumes, unlike other national biographical dictionary projects, say little about its own history. Those who founded other major national dictionary projects wrote memoirs and/or were themselves the subjects of biographies;23 in some cases they wrote about their philosophy of biography.24 The histories of a number of dictionary projects have been analysed,25 with debates over their design and legacies. Ann Moyal has observed that the lack of a historical account is an interesting and telling omission; the ADB ‘appears to be “a Dictionary without a history”’, and ‘stands out as one of the few great biographical ventures that offers no introductory account of the founding impulse, or of those who set it on its route’.26 Only a couple of the historians involved in the ADB have written memoirs: Hancock, 13 The ADB’s Story the first chair of the Editorial Board (1959–66); and Mozley (later Moyal), the ADB’s first staff member (1958–62).27 Both passed over the history of the ADB ‘lightly’ because it was really a minor event in their long careers. Nevertheless, there are some early accounts of the ADB’s history.28 A biography of Hancock, two full biographies of Manning Clark, one of the two inaugural volume editors, and a number of reconsiderations of Clark’s life and work have recently been published.29 And there have been accounts of those who had long careers with the ADB: a thesis on Douglas Pike, the first general editor, and another on Geoffrey Serle, the third general editor, subsequently published as a book.30 A conference on ‘National Biographies and National Identities’, which showcased the ADB, was held in Canberra in 1995.31 A number of papers considering the dictionary’s history have also begun to appear.32 Peter Ryan, the director of the ADB’s publisher, Melbourne University Press, from 1962 to 1988, has written fondly of the ADB in his memoirs.33 This story of the ADB is in keeping with a more general historiographical tendency by, and of, historians.34 Australian historians have become more self-reflective and interested in the sociology of knowledge.35 There has been a wave of interest in historians and editors as authors and ‘makers’ of history, whose backgrounds and ideas are integral to understanding the history that was 14 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? written. 41 Letter, Ann Moyal to John La Nauze (28 May 1968); Letter, Hancock to La Nauze (11 December 1967), box 65, Q31, ADBA, ANUA. 37 Stephen Foster and Margaret Varghese, The Making of the Australian National University 1946–1996 (Canberra: ANU, 1996). 36 Tom Wengraf, Prue Chamberlayne and Joanna Bornat (eds), The Turn to Biographical Methods in Social Science: Comparative Issues and Examples (London: Routledge, 2002). ( ) pp g p y p ( ) p 39 Minutes, ADB Editorial Board meeting (6 February 1962), box 64, Q31, ADBA, ANUA. ( ) 38 M. H. Ellis, ‘Why I Have Resigned’, Bulletin (15 June 1963), pp. 25–31; ‘Disaster in Australian Research’, ll i ( h ) d ‘ i h ’ ll i ( ) g ( y ) 40 Sir Keith Hancock to Malcolm Ellis (June 1962), box 68, Q31, ADBA, ANUA. 43 Hancock, ‘Formation of the Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA A decentralised collaborative design: The ADB’s exceptionalism More widely, biography has been resurrected in academic history, after social and Marxist history initially downplayed individuals, with some positing a ‘biographical turn’.36 The ‘biography’ of Australian historical institutions is also gaining attention.37 There is, however, a degree of difficulty involved in writing the ADB’s story because its beginnings were not happy. Moyal has argued that those involved in the early years wished to ‘draw a veil’ over the arguments between Hancock, Clark, John Ward, the chair of the NSW Working Party, and Malcolm Ellis in the early years—to the point of destroying records. Ellis, who, with Clark, was chosen to edit the ADB’s first two volumes, had attacked Clark publicly as a ‘crypto-communist’ and promoter of biographies ‘without facts’.38 By all other accounts, Ellis, who was difficult to work with, nearly brought down the infant dictionary project. Certainly Hancock destroyed at least one of Ellis’s infamous resignation letters and expunged the minutes of a small episode of the dispute.39 But he recorded the missing incidences in other documents. While aspects of the formation of the ADB were a painful personal memory for Hancock, who wrote in 1962, ‘for the present I have no interest in the historical record’, he also noted that the ‘documents have been kept, and some historian 30 years from now may have a go at them. Good luck to him’.40 When, in 1968, Mozley complained to John La Nauze, then chair of the Editorial Board, that in the preface to Volume 1 her contribution to the ADB was not properly recognised (which he conceded) and did not include a history of the ADB’s birth, La Nauze checked with Hancock, who responded that, while he had Ellis in mind and did not wish to antagonise him with his version of events, he also thought not enough time had passed to look at the origins of the ADB and its role dispassionately.41 For its part, the Editorial Board noted that the history of the project ‘was planned for inclusion in a later Index Volume’, although that never eventuated.42 There is, however, a degree of difficulty involved in writing the ADB’s story because its beginnings were not happy. 42 Minutes, ADB Editorial Board meeting (4 April 1968), box 64, Q31, ADBA, ANUA. 36 Tom Wengraf, Prue Chamberlayne and Joanna Bornat (eds), The Turn to Biographical Methods in Social Science: Comparative Issues and Examples (London: Routledge, 2002). 37 Stephen Foster and Margaret Varghese, The Making of the Australian National University 1946–1996 (Canberra: ANU, 1996). 38 M. H. Ellis, ‘Why I Have Resigned’, Bulletin (15 June 1963), pp. 25–31; ‘Disaster in Australian Research’, Bulletin (26 March 1966), pp. 48–9; and ‘Biography Soup’, Bulletin (10 June 1967), p. 82. 39 Minutes, ADB Editorial Board meeting (6 February 1962), box 64, Q31, ADBA, ANUA. 40 Sir Keith Hancock to Malcolm Ellis (June 1962), box 68, Q31, ADBA, ANUA. 41 Letter, Ann Moyal to John La Nauze (28 May 1968); Letter, Hancock to La Nauze (11 December 1967), box 65, Q31, ADBA, ANUA. 42 Minutes, ADB Editorial Board meeting (4 April 1968), box 64, Q31, ADBA, ANUA. 43 Hancock, ‘Formation of the Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA. 41 Letter, Ann Moyal to John La Nauze (28 May 1968); Letter, Hancock to La Nauze (11 December 1967), box 65, Q31, ADBA, ANUA. 42 Mi t ADB Edit i l B d ti (4 A il 1968) b 64 Q31 ADBA ANUA 36 Tom Wengraf, Prue Chamberlayne and Joanna Bornat (eds), The Turn to Biographical Methods in Social 42 Minutes, ADB Editorial Board meeting (4 April 1968), box 64, Q31, ADBA, ANUA. 43 H k ‘F i f h A li Di i f Bi h ’ b 69 Q31 ADBA AN 38 M. H. Ellis, ‘Why I Have Resigned’, Bulletin (15 June 1963), pp. 25–31; ‘Disaster in Australian Bulletin (26 March 1966), pp. 48–9; and ‘Biography Soup’, Bulletin (10 June 1967), p. 82. 44 Keith Hancock, ‘Speech Notes for the Launch of Volume 10 of the ADB’ (1986), box 116, Q31, ADBA, ANUA. [reprinted here as Document 3] 44 Keith Hancock, ‘Speech Notes for the Launch of Volume 10 of the ADB’ (1986), box 116, Q31, ADBA, ANUA. [reprinted here as Document 3] 45 Walsh, ‘Recording “the Australian Experience”’, pp. 249–68. 46 Andrew Moore, ‘“History without facts”: M. H. Ellis, Manning Clark and the Origins of the Australian Dictionary of Biography’, Journal of the Royal Australian Historical Society, 85, no. 2 (1999), pp. 71–84; ‘“The Historical Expert”: M. H. Ellis and the History of the Cold War’, Australian Historical Studies, 31, no. 114 (2000), pp. 91–109; ‘The “Great-Literary Witch Hunt” Revisited: Politics, Personality and Pique at the CLF, 1952’, Labour History (May 2002); ‘From the Strand to Boorooloola: M. H. Ellis as Pioneer Motorist’, Journal of Australian Studies, 81 (2004), pp. 83–92. 47 Robin Gollan, ‘Canberra History Conference’, Historical Studies: Australia and New Zealand, 8, no. 29 (1957), p. 81. 48 M. Ellis, ‘The Writing of Australian Biographies’, Historical Studies, 6, no. 24 (1955), based on his Australia and New Zealand Association for the Advancement of Science (ANZAAS) paper, Canberra, 1954, p. 432. A decentralised collaborative design: The ADB’s exceptionalism Moyal has argued that those involved in the early years wished to ‘draw a veil’ over the arguments between Hancock, Clark, John Ward, the chair of the NSW Working Party, and Malcolm Ellis in the early years—to the point of destroying records. Ellis, who, with Clark, was chosen to edit the ADB’s first two volumes, had attacked Clark publicly as a ‘crypto-communist’ and promoter of biographies ‘without facts’.38 By all other accounts, Ellis, who was difficult to work with, nearly brought down the infant dictionary project. Certainly Hancock destroyed at least one of Ellis’s infamous resignation letters and expunged the minutes of a small episode of the dispute.39 Rather than any orchestrated decision, then, writing the ADB’s history just has not been a priority over the years. The archives, as Hancock indicated, are there.43 Jim Davidson makes clear, too, in his biography of Hancock, that 15 The ADB’s Story Hancock finally ‘accepted paternity’ in 1986 when he launched Volume 10.44 Nonetheless, the ‘foundational dispute’ has cast a long shadow over the project, not only on its participants. Most publications about the ADB’s early history, such as Gerry Walsh’s account, concentrate upon the disagreements between Hancock, Ellis and Clark.45 Andrew Moore has written four articles on aspects of the dispute and Ellis’s pioneering role in modern Australian history, arguing that his anticommunism contributed to an early Australian ‘history war’.46 As is so often the case, dramatic conflicts overshadow more significant and long- lasting developments. The ‘Ellis affair’ needs to be considered but it also needs to be put in its place. Other questions need to be asked of Hancock, Ellis and Clark, and all those associated with the ADB. What, for instance, was the foundational culture they collectively established? Hancock finally ‘accepted paternity’ in 1986 when he launched Volume 10.44 Nonetheless, the ‘foundational dispute’ has cast a long shadow over the project, not only on its participants. Most publications about the ADB’s early history, such as Gerry Walsh’s account, concentrate upon the disagreements between Hancock, Ellis and Clark.45 Andrew Moore has written four articles on aspects of the dispute and Ellis’s pioneering role in modern Australian history, arguing that his anticommunism contributed to an early Australian ‘history war’.46 As is so often the case, dramatic conflicts overshadow more significant and long- lasting developments. The ‘Ellis affair’ needs to be considered but it also needs to be put in its place. f ( ) pp 47 Robin Gollan, ‘Canberra History Conference’, Historical Studies: Australia and New Zealand, 8, no. 29 (1957), p. 81. [ p ] 45 Walsh, ‘Recording “the Australian Experience”’, pp. 249–68. ( ) p 48 M. Ellis, ‘The Writing of Australian Biographies’, Historical Studies, 6, no. 24 (1955), based on his Australia and New Zealand Association for the Advancement of Science (ANZAAS) paper, Canberra, 1954, p. 432. 46 Andrew Moore, ‘“History without facts”: M. H. Ellis, Manning Clark and the Origins of the Australian Dictionary of Biography’, Journal of the Royal Australian Historical Society, 85, no. 2 (1999), pp. 71–84; ‘“The Historical Expert”: M. H. Ellis and the History of the Cold War’, Australian Historical Studies, 31, no. 114 (2000), pp. 91–109; ‘The “Great-Literary Witch Hunt” Revisited: Politics, Personality and Pique at the CLF, 1952’, Labour History (May 2002); ‘From the Strand to Boorooloola: M. H. Ellis as Pioneer Motorist’, Journal of Australian Studies, 81 (2004), pp. 83–92. A decentralised collaborative design: The ADB’s exceptionalism Other questions need to be asked of Hancock, Ellis and Clark, and all those associated with the ADB. What, for instance, was the foundational culture they collectively established? Moyal records in Chapter 2 that Hancock had called a national conference in August 1957 to gauge the state of Australian history and to begin a conversation among Australian historians. Calling, and partly funding, this four-day conference of university historians (and others involved in researching Australian history) from across the nation was one of Hancock’s first acts when he returned from England to take up the inaugural chair of history and directorship of RSSS. As a distinguished Australian historian and biographer, Ellis was invited, along with other non-university historians Brian Fitzpatrick, Archbishop Eris O’Brien and Gavin Long, to discuss how to ‘advance the study of Australian history’.47 Ellis was one of the few historians of any hue who had published several well- received biographies: on John Macarthur, Lachlan Macquarie and Francis Greenway. He was one of the few historians who thought about biography. Most Australian biographies, Ellis wrote in 1955, were like ‘licking the cold outside of a champagne bottle on a thirsty day’.48 Hancock was attracted to someone who stressed the facts of a life but also insisted on ‘familiarity with the age in which 16 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? your victim lived; with its conventions, with its mode of thinking, with the limitations of its thought, with the stage of its civilisation with its sumptuary conditions and with its social climate’.49 At this landmark conference, Australian historians took stock of their profession, assessing its state and plumbing the depths (or shallows) of the ‘soul of Australian history’. They concentrated on four fields: biography, church history, labour history and economic history; there were also sessions on the teaching of Australian history and the state of archives. This last session was characteristic of Hancock, especially influenced by his experience with archives when writing the biography of Smuts. The conference unanimously agreed that ‘one of the badly needed aids to historical research … [was] a Concise Dictionary of Australian Biography’, and acknowledged the start that had been made towards this goal with Fitzhardinge’s Biographical Register.50 It was also agreed that any dictionary project would be a long-term one needing the cooperation of the ANU, State universities and the general public. 49 Ellis, ‘The Writing of Australian Biographies’, pp. 432–46. James J. Auchmuty, ‘The Background of Australian History’, Journal of the Royal Australian Historical Society, 41, no. 3 (1955), p. 139; see also ‘The Biographical Approach to History’, Journal of the Royal Australian Historical Society, 46, no. 2 (1960), pp. 97–111. 50 ‘Excerpt from Statement prepared by Professor Hancock. Formation of the Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA. Biography , box 69, Q31, ADBA, ANUA. 51 Robin Gollan, ‘Canberra History Conference’, Historical Studies: Australia and New Zealand, 8, no. 29 (1957), pp. 80–92. 50 ‘Excerpt from Statement prepared by Professor Hancock. Formation of the Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA. 51 Robin Gollan, ‘Canberra History Conference’, Historical Studies: Australia and New Zealand, 8, no. 29 (1957), pp. 80–92. 52 Walsh makes this point, too, quoting from Hancock’s view on design from Hancock’s ‘The Dictionary; Retrospect and Prospect’ (18 June 1963), box 68, Q31, ADBA, ANUA. 53 Walsh, ‘Recording “the Australian Experience”’, pp. 249–68. 54 Hancock, ‘The Dictionary; Retrospect and Prospect’ (18 June 1963), box 68, Q31, ADBA, ANUA. 55 Hancock, ‘The Australian Dictionary of Biography’; Hancock, ‘Speech Notes for the Launch of Volume 10 of the ADB’ (1986), box 116, Q31, ADBA, ANUA. 56 G. Bolton to J. Calvert (11 May 2002), privately held, cited by Calvert, ‘Douglas Pike (1908–1974)’. Walsh makes this point, too, quoting from Hancock’s view on design from Hancock’s ‘The Dictionary; trospect and Prospect’ (18 June 1963), box 68, Q31, ADBA, ANUA. A decentralised collaborative design: The ADB’s exceptionalism Gollan, who wrote an account of the conference, regarded the meeting ‘as an index of the growing maturity of Australian history studies’, but also observed that ‘very few decisions were reached’ about actually starting a biographical dictionary.51 It was left to Hancock and Ellis to take up the mantle. While Hancock continued to correspond with historians about the shape and governance of the project, Ellis, with characteristic energy, drew up an organisational plan involving the establishment of a unit based at the ANU to which a managing editor and some research editors would be appointed. There would also be 1. an inclusive ‘National Committee’ (National Advisory Panel) consisting of representatives from every university 1. an inclusive ‘National Committee’ (National Advisory Panel) consisting of representatives from every university 2. a small executive Editorial Board to determine the broad lines of strategy and procedural, budget, staffing and publication matters 2. a small executive Editorial Board to determine the broad lines of strategy and procedural, budget, staffing and publication matters 3. a working party system established through the States and Territories, which would draw up lists of subjects for inclusion and suggest authors for the articles. 17 The ADB’s Story Malcolm Ellis’s suggested organisational plan for the ADB, 1959. He proposed an Australasian Dictionary of Biography that would include New Zealand and Pacific working parties ADB archives Malcolm Ellis’s suggested organisational plan for the ADB, 1959. He proposed an Australasian Dictionary of Biography that would include New Zealand and Pacific working parties ADB archives 18 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? While this part of Ellis’s structure was almost completely realised, a major difference erupted between Ellis and Hancock on the question of centralisation. Hancock distinguished between two approaches to a big academic venture: the i ti l th d ith t t l itt (Elli ’ f ) d While this part of Ellis’s structure was almost completely realised, a major difference erupted between Ellis and Hancock on the question of centralisation. f Hancock distinguished between two approaches to a big academic venture: the organisational method, with a strong central committee (Ellis’s preference); and the growth method (Hancock’s preference).52 Ellis’s proposal was first to 1. set up a directorate of ‘tycoons’ (political, commercial, industrial, academic leaders) under the chairmanship of the chief justice or someone similar to guide and promote the project 2. 52 Walsh makes this point, too, quoting from Hancock’s view on design from Hancock’s ‘The Dictionary; p p ( ) 53 Walsh, ‘Recording “the Australian Experience”’, pp. 249–68. A decentralised collaborative design: The ADB’s exceptionalism obtain money from the government and private benefactors to finance the project 2. obtain money from the government and private benefactors to finance the project 3. establish an office under a managing director, editor or administrator, with ample academic, administrative, secretarial and typing assistance 4. publicise the enterprise 5. draw up lists of subjects 6. commission authors and pay them well 7. and then, expeditiously, send the dictionary to press.53 7. and then, expeditiously, send the dictionary to press.53 Provided there is plenty of money, Hancock said, ‘the organisational method … excludes any possibility of failure’. On the other hand, success may come too easily because there had been ‘so little struggle’ and, in the long run, little collaboration. Hancock’s major objection was that ‘the danger of the organisational method is—to use old fashioned language—that it may give you “a body without a soul”’.54 There were also differences over principle. Hancock’s growth model had, as its features, decentralisation and national cooperation. He took care to avoid ‘a Canberra stamp or even the appearance of one; the Dictionary had to avoid being “a Canberra racket with an all-Australian façade”’. From the outset, he ‘sought advice and approval from colleagues in the state universities’ and beyond for a ‘consultative constitution’, which he later referred to as a ‘co- operative federalism’.55 Hancock’s strategy was both practical and political. As Geoffrey Bolton has suggested, until relatively recently, Australian history was best comprehended as six regional histories rather than a simply national one.56 Hancock’s model 19 The ADB’s Story ensured that committees consisted of, as well as academics, librarians, archivists and members of historical societies, among others. A complex system of State and thematic working parties spoke not only to the federal nature of Australian historiography, but also to the logic of doing research in the 1960s. Hancock’s view prevailed and the ADB evolved under a model of decentralisation and national cooperation. State-based working parties assumed the critical task of choosing subjects and authors for entries. While it was agreed that the ‘final decision on all lists will rest with the Editors’, in fact the general editor has rarely vetoed or changed lists. The decision about working party autonomy was made at a meeting of the Editorial Board in April 1960. 57 A. Mozley, ‘The Australian Dictionary of Biography’, Historical Studies: Australia and New Zealand, 9, no. 35 (1960), pp. 313–14. 58 Minutes, ADB Editorial Board meeting (18 August 1988), box 125, Q31, ADBA, ANUA. 59 ‘Personal Notes for Concluding Speech by W. K. H. (December 1961)’, box 69, Q31, ADBA, ANUA. 59 ‘Personal Notes for Concluding Speech by W. K. H. (December 1961)’, box 69, Q31, ADBA, ANUA. 57 A. Mozley, ‘The Australian Dictionary of Biography’, Historical Studies: Australia and New Zealand, 9, no. 35 (1960), pp. 313–14. 58 Minutes, ADB Editorial Board meeting (18 August 1988), box 125, Q31, ADBA, ANUA. 59 ‘Personal Notes for Concluding Speech by W. K. H. (December 1961)’, box 69, Q31, ADBA, ANUA. Minutes, ADB Editorial Board meeting (18 August 1988), box 125, Q31, ADBA, ANUA. ‘Personal Notes for Concluding Speech by W. K. H. (December 1961)’, box 69, Q31, ADBA, ANUA. A decentralised collaborative design: The ADB’s exceptionalism Gollan suggested that, in retrospect, Hancock thought ‘probably correctly, that he had started too small’;60 but he never regretted that the ADB was, as he described it to Mozley in a letter in 1964, ‘insufficiently engineered’.61 We will return to this point—that the ADB is less directed in its shape than other dictionary projects. Its position in a national university, its national collaborative structure and its recurrent university funding continue to distinguish the ADB from other national dictionary projects. A decentralised collaborative design: The ADB’s exceptionalism It was agreed that the dictionary should reflect the federal and national character in its presentation, and ‘give a representative picture of all strands of Australian life, observing the varying interests from state to state’.57 The meeting also accepted that ‘there can be no blueprint for Working Party organisation; each state will face different problems and will seek individual solutions’. Working parties were established in each State (in the early stages New South Wales had three working parties, based in Sydney, Newcastle and Armidale). An armed services working group developed into a working party in 1974, a Commonwealth working group became a working party in 1989 and the Indigenous Working Party was formed in 2005. From the 1970s, working party quotas were based on demographic proportions. Hancock was aware that this decentralised ‘ad-hoc’ or ‘growth’ method had some dangers. One was that funding of the project was dependent upon continuing university support. While other national dictionary projects, based in universities, have received substantial endowments and grants, the ADB has relied almost solely on funding from the ANU, facilitated by block grants from the Commonwealth Government. The project has been sustained over the past 50 years but it has not had the infusion of large grants that have enabled other dictionary projects to revise their earliest entries or add new features. And it has never had the funding to pay authors.58 The second hazard was that Hancock’s method required ‘lots of discussion’—a ‘universal law of editorship in the academic world’. Bill Williams, a friend of Hancock, had indulged in the ‘time-consuming but rewarding processes of academic consultation, which are required in any great venture of co-operative scholarship’, when he edited the decadal volumes (1951–60) of the DNB.59 20 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? Hancock, as editor of the 28 volumes of the British Civil Histories of the War and member of the Editorial Board of the Economic History Review, swore by this method too. Ellis, however, had not been inducted into this academic culture. He was also adamant that the project needed powerful backers and a large injection of capital. 60 Robin Gollan, ‘Sir (William) Keith Hancock 1898–1988’, Proceedings of the Australian Academy of Humanities, 14 (Canberra: Australian Academy of the Humanities, 1990), p. 63. ( y ) p 61 Moyal, Breakfast with Beaverbrook, p. 148, citing Hancock to Moyal (June 1964). y f g y ( ) 62 ‘Draft Directions for Working Parties, Working Party Procedures’ (n.d., c. 1960), box 64, Q31, ADBA, ANUA. 63 ‘Notes for Seminar’ (n.d. [1975]), ‘Geoff Serle Correspondence’, box 132, Q31, ADBA, ANUA. 60 Robin Gollan, ‘Sir (William) Keith Hancock 1898–1988’, Proceedings of the Australian Academy of Humanities, 14 (Canberra: Australian Academy of the Humanities, 1990), p. 63. 61 Moyal, Breakfast with Beaverbrook, p. 148, citing Hancock to Moyal (June 1964). 62 ‘Draft Directions for Working Parties, Working Party Procedures’ (n.d., c. 1960), box 64, Q31, ADBA, ANUA. 63 ‘Notes for Seminar’ (n.d. [1975]), ‘Geoff Serle Correspondence’, box 132, Q31, ADBA, ANUA. 60 Robin Gollan, ‘Sir (William) Keith Hancock 1898–1988’, Proceedings of the Australian Academy of Humanities, 14 (Canberra: Australian Academy of the Humanities, 1990), p. 63. 61 Moyal, Breakfast with Beaverbrook, p. 148, citing Hancock to Moyal (June 1964). 62 ‘Draft Directions for Working Parties Working Party Procedures’ (n d c 1960) box 64 Q31 ADBA Is insufficient design ideal? The ADB has been based on autonomous working parties that have never had precise criteria for selecting the people to be included. The ADB avoided the subject of national identity directly, deciding in 1960 that it was not possible to lay down rigid categories for inclusion and selection. It was expected that the criteria would evolve organically. ‘Some offices and ranks may qualify for automatic inclusion e.g. Governors (up to responsible government), Governors- General, Colonial Secretaries, Federal and State Cabinet Ministers, Chief Justices, Archbishops and their nonconformist equivalents, Generals, Admirals, etc’. Working parties were also told to provide a ‘representative picture of all strands of Australian life, politics, religion, the professions, business, commerce, the arts, the services, sport, science, education, entertainment, and, on the precedent of the D.N.B., the historic villain will not be neglected’.62 There was also a discussion about what constitutes an Australian: birth, education, residence of five years, impact on society? This has never been resolved.63 Subjects in the ADB have not been selected on any criteria to do with Australian character. Richard White, in Inventing Australia, critically deconstructs attempts to capture Australia’s ‘essence’ or national identity. He looks at all the attempts, beginning before settlement (when Europeans ‘dreamed’ of terra incognita), and argues that it and all subsequent images are inventions. White describes Russel Ward’s The Australian Legend (1958) as the ‘last great re-statement of 21 The ADB’s Story the character of Australian type’ or identity.64 Ward was a section editor, from the mid 1960s to 1976, for Volumes 3–6 of the ADB but did not impose radical national criteria for subject selection. the character of Australian type’ or identity.64 Ward was a section editor, from the mid 1960s to 1976, for Volumes 3–6 of the ADB but did not impose radical national criteria for subject selection. Nor did other authors of ‘radical nationalism histories’, such as Gollan and Bede Nairn, who have also been involved in the ADB (Nairn as the ADB’s second general editor).65 None of them imposed their view of Australian identity on the selection of articles for the ADB nor did they manage to manipulate working party subject proportions. As a consequence, the dictionary has survived the test of time, providing material for others to construct their own images of the ‘real’ Australia or the ‘typical Australian’ that have, inevitably, become dated and have been disputed over time. 67 Douglas Pike, ‘Preface’, Australian Dictionary of Biography, vol. 1 (Carlton, Vic.: Melbourne University Press, 1966), p. v. 65 Melanie Nolan, ‘Entwined Associations: Labour History and its People in Canberra’, in Melanie Nolan (ed.), Labour History and its People, Twelfth Biennial National Labour History Conference (Canberra: Canberra Region Branch of the Australian Society for the Study of Labour History [hereinafter ASSLH] and the National Centre of Biography [hereinafter NCB], ANU, 2011), pp. 1–15. 64 Richard White, Inventing Australia (St Leonards, NSW: Allen & Unwin, 1981). 65 Melanie Nolan, ‘Entwined Associations: Labour History and its People in Canberra’, in Melanie Nolan (ed.), Labour History and its People, Twelfth Biennial National Labour History Conference (Canberra: Canberra Region Branch of the Australian Society for the Study of Labour History [hereinafter ASSLH] and the National Centre of Biography [hereinafter NCB], ANU, 2011), pp. 1–15. 66 Peter Read, Quadrant (June 1980), p. 88. 67 Douglas Pike, ‘Preface’, Australian Dictionary of Biography, vol. 1 (Carlton, Vic.: Melbourne University Press, 1966), p. v. 68 ‘Preface’, Australian Dictionary of Biography, vol. 10 (Carlton, Vic.: Melbourne University Press, 1983). 69 Chris Cunneen, ‘The Australian Dictionary of Biography: Creating History (or No Room for “Rosebuds”?)’, a paper to the Documenting A Life Seminar, 26 October 1996, National Library of Australia, Canberra. 64 Richard White, Inventing Australia (St Leonards, NSW: Allen & Unwin, 1981). ) p 68 ‘Preface’, Australian Dictionary of Biography, vol. 10 (Carlton, Vic.: Melbourne University Press, 1983). 69 Chris Cunneen, ‘The Australian Dictionary of Biography: Creating History (or No Room for “Rosebuds”?)’, a paper to the Documenting A Life Seminar, 26 October 1996, National Library of Australia, Canberra. Is insufficient design ideal? Mark McGinness shows in his review of the reviews of the ADB in Chapter 10 that there has been bias in the selections but the range of subjects has been sufficiently broad to support the fracturing, questioning and redefining of any dominant story. Until recently, most ADB reviewers have praised its very lack of design, the ‘thousands of little biographies [that] are undefiled by dogmas, theory or interpretation’.66 The ADB has prided itself on the inclusion of representative people: since 1966, prefaces to volumes have noted that ‘many of the names were obviously significant and worthy of inclusion. Others, less notable, were chosen simply as samples of the “Australian experience”’.67 Representatives ‘of ethnic and social minorities and of a wider range of occupations, or as innovators, notorieties or eccentrics’ have been included.68 Thus, earlier volumes contain, for instance, a representative shearer, a drover, a rabbiter, a barmaid and a landlady. In 1996, Chris Cunneen, the ADB’s deputy general editor, observed that consideration in selecting entries had been given to subjects most likely to be looked for in the future … despite this concentration on the famous, a great number of those who would not normally be considered as belonging to the elite are also included. State committees are constantly searching not only for important figures to include but also for representative, ordinary people.69 22 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? Hancock, launching Volume 10 of the ADB in 1986, judged that the ADB was an improvement over the DNB because of its more adventurous inclusion of people ‘widely representative of endeavour and achievement on every front of our experience as an emergent nation’. Where else could one find between one set of covers a scholarly essay on Sir John Monash and a rollicking account of the adventures of Herbert Dyce Murphy, who travelled the French railways as a spy in the guise of a woman?70 The most common criticism of the ADB has nevertheless been about representation. There are any number of questions to be asked of biography— about the role of the individual in history and individual human agency as opposed to social structure. What details are appropriate to be included? Is it possible to know the inner life of another? Should that be the goal of concise biography? Is biography an art? 70 Research School of Social Sciences (RSSS), Annual Report (2007). See also Diane Langmore to Sydney Institute (13 November 2007), published as ‘The Australian Dictionary of Biography: A National Asset’, Sydney Papers, 20, no. 1 (Summer 2008), pp. 22–30. Herbert Dyce Murphy was also a member of Mawson’s Australasian Antarctic Expedition, a fact that makes his appearance in the volume seem less eccentric perhaps. 71 Ray Monk, ‘Life without Theory: Biography as Exemplar of Philosophical Understanding’, Poetics Today, 28, no. 3 (2007), pp. 259–60. 73 Australian Bureau of Statistics, Australian Historical Population Statistics: Deaths (Canberra: Australian Bureau of Statistics, 2008). Wray Vamplew (ed.), Australians, Historical Statistics (Broadway, NSW: Fairfax, Syme & Weldon Associates, 1987), p. 59. 72 Tim O’Leary, ‘Daniel Mannix; The Dictionary of Biography’s Hatchet Job’, AD2000: A Journal of Religious Opinion (April 1989). James Griffin, ‘Reality or Revisionism: Daniel Mannix and the Australian Dictionary of Biography’, Tirra Lira, 6, no. 1 (1995), pp. 18–23. ( ) pp 72 Tim O’Leary, ‘Daniel Mannix; The Dictionary of Biography’s Hatchet Job’, AD2000: A Journal of Religious Opinion (April 1989). James Griffin, ‘Reality or Revisionism: Daniel Mannix and the Australian Dictionary of Biography’, Tirra Lira, 6, no. 1 (1995), pp. 18–23. 73 Australian Bureau of Statistics, Australian Historical Population Statistics: Deaths (Canberra: Australian Bureau of Statistics, 2008). Wray Vamplew (ed.), Australians, Historical Statistics (Broadway, NSW: Fairfax, y y ( ) y y Australasian Antarctic Expedition, a fact that makes his appearance in the volume seem less eccentric perhaps. 71 Ray Monk, ‘Life without Theory: Biography as Exemplar of Philosophical Understanding’, Poetics Today, 28, no. 3 (2007), pp. 259–60. 72 Tim O’Leary, ‘Daniel Mannix; The Dictionary of Biography’s Hatchet Job’, AD2000: A Journal of Religious Opinion (April 1989). James Griffin, ‘Reality or Revisionism: Daniel Mannix and the Australian Dictionary of Biography’, Tirra Lira, 6, no. 1 (1995), pp. 18–23. 73 Australian Bureau of Statistics, Australian Historical Population Statistics: Deaths (Canberra: Australian Bureau of Statistics, 2008). Wray Vamplew (ed.), Australians, Historical Statistics (Broadway, NSW: Fairfax, Syme & Weldon Associates, 1987), p. 59. Is insufficient design ideal? These are questions that Samuel Johnson asked, in the eighteenth century, in his two essays on biography.71 Some of these questions have been broached in discussions about particular ADB articles. Should there have been a biography of Azaria Chamberlain, a baby who lived only for a few weeks? Should the ADB have more explicitly discussed Dame Nellie Melba’s facelift as the cause of her death from septicemia? Was James Griffin’s entry on Daniel Mannix fair in describing the archbishop as politically naive, intellectually shallow, hardly an educationalist and not well versed in socioeconomic matters?72 These particular ‘controversies’ pale into insignificance, however, in the face of the main question: ‘Who deserves to have a biography written of them?’ The ADB is hardly representative. It has been estimated that nine million Australians died between 1788 and 1990.73 Given that 12 500 dictionary entries cover this period, any single person has 0.1 per cent chance of ‘getting into’ the ADB. Since the mid 1970s, with the growth in popularity of women’s history and social history, there has been increasing criticism of ‘group omissions’: women, Aborigines, and the working class. There have also been criticisms that certain groups are ‘over-represented’: the elite, the military and people from New South Wales. At the Editorial Board meeting in 1975, as quotas were being decided for volumes covering the period 1891–1939, there was extended debate 23 The ADB’s Story about representation. It was decided that weighted population figures obtained from the Australian Bureau of Statistics Census were to be regarded as ‘a guide’. The main criterion was to be ‘the importance of the name in Australian history’, while also taking into account the ‘relative development of each State’.74 There was much discussion when the relative proportions were tabled (Table 1.1). Table 1.1 Number and Proportion of Entries in Period 3 (1891–1939) Allocated to Each Working Party State or theme Quota of articles Proportion of total New South Wales 1060 27 Victoria 960 24 Queensland 360 9 South Australia 330 8 Western Australia 210 5 Tasmania 125 3 New Guinea 40 1 Commonwealth 320 8 Armed Services 560 14 Miscellaneous 40 1 Source: Minutes, ADB Editorial Board meeting (29 October 1975), box 66, Q31, ADBA, ANUA. 74 Paul Brunton, ‘Mysterious Quotas’, Australian Book Review (February 2006), pp. 19–20; and response by Di Langmore, Australian Book Review (May 2006), p. 4. 75 Minutes, ADB Editorial Board meeting (29 October 1975). 76 Ann Curthoys, Submission to the 1986 Review of the ADB, box 125, Q31, ADBA, ANUA. 77 Marilyn Lake and Henry Reynolds, with Mark McKenna and Joy Damousi, What’s Wrong with Anzac? The Militarisation of Australian History (Sydney: UNSW Press, 2010). 74 Paul Brunton, ‘Mysterious Quotas’, Australian Book Review (February 2006), pp. 19–20; and response by Di Langmore, Australian Book Review (May 2006), p. 4. g ( ) 76 Ann Curthoys, Submission to the 1986 Review of the ADB, box 125, Q31, ADBA, ANUA. Is insufficient design ideal? Table 1.1 Number and Proportion of Entries in Period 3 (1891–1939) Allocated to Each Working Party State or theme Quota of articles Proportion of total New South Wales 1060 27 Victoria 960 24 Queensland 360 9 South Australia 330 8 Western Australia 210 5 Tasmania 125 3 New Guinea 40 1 Commonwealth 320 8 Armed Services 560 14 Miscellaneous 40 1 Source: Minutes, ADB Editorial Board meeting (29 October 1975), box 66, Q31, ADBA, ANUA. Table 1.1 Number and Proportion of Entries in Period 3 (1891–1939) Allocated to Each Working Party Table 1.1 Number and Proportion of Entries in Period 3 (1891–1939) Allocated to Each Working Party Source: Minutes, ADB Editorial Board meeting (29 October 1975), box 66, Q31, ADBA, ANUA. Above all, the proportion of armed services entries was questioned. Bob O’Neill, convenor of the Armed Services Working Party, justified the 560 entries allotted to his working party on the basis of the importance of World War I. The involvement of 300 000 Australians in the services in that war was nationally significant. He noted that the armed services subjects came from all States and the intention was to include a good sample of the experience arising from war, in various ranks and occupations.75 In 1986, Editorial Board member Ann Curthoys more explicitly criticised the extent of military articles in the ADB.76 Marilyn Lake, Henry Reynolds and others have developed this criticism more expansively.77 Most criticism has concerned the lack of inclusion of Aborigines and women, and the overprovision of the ‘successful’. Reviewing Volume 1, Allan Martin praised the ADB but also referred to omissions, remarking that ‘only fifteen of the entries refer to individuals born locally and five of these are aborigines’, and 24 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? signalled that although women hover in the background, ‘barely half a dozen rate a mention in their own right’.78 A decade later, Peter Ryan noted that the ‘blurbs of the earliest volumes (despite the presence of articles about women) speak only of “he” and “him”. Soon we find the awkward replacement of “he/ she” and “him/her”’.79 In 1975 the general editor of the ADB, Geoff Serle, contacted the feminist collective Refractory Girl and leading women historians for advice about women who could be included in the dictionary. 78 A. W. Martin, Historical Studies: Australia & New Zealand, 12, no. 48 (1967), pp. 584–6. 79 Peter Ryan, ‘The ADB’, p. 88. 80 Minutes, ADB Editorial Board meeting (23 May 1985), box 125, Q31, ADBA, ANUA. 81 Heather Radi to Geoffrey Serle (20 May 1987), box 142, Q31, ADBA, ANUA. 82 Pat Grimshaw, ‘Female Lives and the Tradition of Nation-Making’, in McCalman (ed.), National Biographies and National Identities, pp. 35–53. f y ( y ) 82 Pat Grimshaw, ‘Female Lives and the Tradition of Nation-Making’, in McCalman (ed.), National Biographies and National Identities, pp. 35–53. Is insufficient design ideal? He noted that, despite the best intentions, the proportion of entries on women was still ‘rather disappointing’.80 When Editorial Board member Heather Radi set out to compile a list of 200 Australian women for a bicentennial project—in a critical commentary on the paucity of women in the ADB, as well as in the bicentennial projects more generally—she found to her surprise that her first cut included 104 women who were in the ADB. She explained that was because ‘achievement’ had been part of the definition.81 Radi drew up a list of possible female inclusions for the volumes covering the period 1940–80, which John Ritchie, the fourth general editor, circulated to all working parties in 1989. Even though the proportion of women had reached a record 20 per cent in Volume 14, the historian Pat Grimshaw was impatient for more progress. She noted in a paper in 1996 on ‘Female Lives and the Tradition of Nation- Building’ the centrality of the ADB in the Australian history profession and the ‘production of a national history’. The project involved ‘eminent historians … while innumerable other respected scholars have contributed the biographical entries’. Despite this, she argued, a ‘new Australian Dictionary of Biography was needed’ that ‘would have inclusiveness important for all Australians, rather than serving as a narrative of success and achievements for the victors’.82 In 2004 Gordon Briscoe criticised the ADB for the paucity of entries on Aboriginal people and the limitations on contemporary biography imposed by the dictionary’s periodisation by date of death. Subsequently, an Indigenous working party was established to promote their better representation. It was not a success and, like attempts to establish specialist medical and legal working parties, was soon abandoned. 83 Christopher Cunneen with Jill Roe, Beverley Kingston and Stephen Garton (eds), Australian Dictionary of Biography, Supplement 1580–1980 (Carlton, Vic.: Melbourne University Press, 2005). 84 P. A. Pickering, ‘Review of D. Langmore (ed.), Australian Dictionary of Biography, Volume 17, 1981–1990, A–K’, Labour History, no. 95 (November 2008), pp. 271–3. g p y pp ( y ) 84 P. A. Pickering, ‘Review of D. Langmore (ed.), Australian Dictionary of Biography, Volume 17, 1981–1990, A–K’, Labour History, no. 95 (November 2008), pp. 271–3. 83 Christopher Cunneen with Jill Roe, Beverley Kingston and Stephen Garton (eds), Australian Dictionary of Biography, Supplement 1580–1980 (Carlton, Vic.: Melbourne University Press, 2005). Is insufficient design ideal? 25 The ADB’s Story Table 1.2 Representation of Women and Aboriginal Subjects in the ADB Volume/period Publication date Total Women Percentage Indigenous Percentage 1 (1788–1850) 1966 575 10 1.74 4 0.7 2 (1788–1850) 1967 607 11 1.80 4 0.7 3 (1850–1890) 1969 526 14 2.66 1 0.2 4 (1850–1890) 1972 614 13 2.12 0 ---- 5 (1850–1890) 1974 533 12 2.25 2 0.4 6 (1850–1890) 1976 543 12 2.20 2 0.4 7 (1891–1939) 1979 723 81 11.20 0 ---- 8 (1891–1939) 1981 737 69 9.36 2 0.3 9 (1891–1939) 1983 742 73 9.84 5 0.7 10 (1891–1939) 1986 737 95 12.89 3 0.4 11 (1891–1939) 1988 759 94 12.38 5 0.7 12 (1891–1939) 1990 755 95 12.60 4 0.5 13 (1940–1980) 1993 721 138 19.14 14 1.9 14 (1940–1980) 1996 703 141 20.10 18 2.6 15 (1940–1980) 2000 714 129 18.07 19 2.7 16 (1940–1980) 2002 694 112 16.14 15 2.2 17 (1981–1990) 2007 670 115 17.16 15 2.2 18 (1981–1990) 2012 669 132 20.00 26 3.8 Av. proportion 10.65 1.13 Supplement 2005 565 167 29.56 50 8.9 Proportion including supplement volume 11.64 1.54 Defenders of the ADB rightly note that it is becoming more representative. In 2005 four members of the current Editorial Board, Chris Cunneen, Jill Roe, Stephen Garton and Beverley Kingston, edited a special supplementary volume of ‘missing persons’, covering the period 1580 to 1980. This included nearly 30 per cent women and 9 per cent Aborigines. There was a feeling that, for the process to be sustained, the decisions had to be ‘mainstreamed’ rather than imposed from above.83 Even then, in 2008, Paul Pickering, in a review of Volume 17, highlighted that ‘labour historians can but lament the silences and omissions in what is still basically an elite enterprise’.84 There were many more knights than commoners in the ADB. One of the inadequacies—not picked up 26 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? by most of the reviewers—is that the Irish are under-represented in the ADB. The Scottish were prudent and valued education and it is not surprising that they are over-represented.85 Those working closely with the ADB have accepted its organic development. In Chapter 9 Jill Roe points to an intriguing dilemma in the ADB’s design. 85 Melanie Nolan, ‘Scots in the Australian Dictionary of Biography’, History Scotland, 9, no. 4 (July–August 2009), pp. 49–53. 86 Jill Roe, ‘Biography Today: A Commentary’, Australian Historical Studies, 43, no. 1 (April 2012), pp. 107–18. 87 ADB Style Manual. For earlier versions, see boxes 44 and 138, Q31, ADBA, ANUA. Is insufficient design ideal? She points to the relationship between the ADB and Australian historiography, the gradually widening range of subjects, but also the subtly changing treatment ‘in accordance with changing mores’.86 New impetuses and research have permitted the ADB to uncover a wider range of lives, in association with wider historiographical developments. Most importantly, Roe emphasises that data and information need to be available to the working parties during the selection process. Because the ADB has never adopted explicit selection criteria, it has been able to adapt to change without ideological dilemmas. Which historians are involved in the ADB working parties and in making the decisions about selection is therefore critical; but the question remains: should a dictionary of national biography represent the general population or should it represent the movers and shakers? 88 Geoffrey Bolton, ‘The Art of Australian Political Biography’, in Tracey Arklay, John Nethercote and John Wanna (eds), Australian Political Lives. Chronicling Political Careers and Administrative Histories (Canberra: ANU E Press, 2006), p. 5. Bolton also discusses this in Chapter 5, in this volume. 89 Geoffrey Serle, ‘General Editor’s Workload’, Submission to the ADB Review Committee (1986), box 125, Q31, ADBA, ANUA. 90 C. Kerr, Archie: The Biography of Sir Archibald Grenfell Price (Melbourne: Macmillan, 1983). 91 Davidson, A Three-Cornered Life, p. 501. Ken Inglis, ‘Obituary of Hancock’, Canberra Times and Age [Melbourne] (15 August 1988). 92 1986 Review quoting Sir Sidney Lee of the Dictionary of National Biography, box 125, Q31, ADBA, ANUA. The ADB system: Structure and agency A further question in relation to the history of the ADB is begged by the way in which this volume is organised. In the first part it is organised around the ‘eras’ of the general editors. Pike edited the first five volumes; Nairn edited Volume 6 as sole editor and, with Serle, co-edited volumes 7–10; Serle was sole editor for Volume 11; Ritchie edited volumes 12–15 and co-edited Volume 16 with Di Langmore, who then edited Volume 17 and part of Volume 18. If, however, as it has been argued, the working parties have been largely autonomous, with minimal interference over who is to be included and who is to write the entries, have the general editors made any impact? Can one tell the difference between their eras? As Chris Cunneen muses in Chapter 4, ‘now that all the entries are wonderfully available in one alphabetical sequence online’ the volumes seem superfluous. Given this digital soup, how important are the general editors in the scheme of things? The ADB has progressively developed a style manual, a tight template, and a rigorous editing process for entries.87 The various section editors are the first to 27 The ADB’s Story review the entries, which are then handed to desk editors who check them for factual accuracy (where possible) and edit the entry to conform with the ‘ADB style’. The managing, or deputy, editor then reviews their work. The general editor reviews this process overall. The entries are also refereed by one or more of the ADB’s external editorial fellows. Finally, authors consider and approve the edited piece. At their best, these articles attain the simple perfection of, as Bolton says, ‘a haiku or a sonnet’.88 Despite the many hands through which entries pass, most articles still require editorial work and styling from the general editor. According to Serle: ‘The General Editor cannot delegate much. His final editing must be comprehensive. 91 Davidson, A Three-Cornered Life, p. 501. Ken Inglis, ‘Obituary of Hancock’, Canberra Times and Age [Melbourne] (15 August 1988). The ADB system: Structure and agency Apart from any special knowledge he may have, he has primary and ultimate responsibility for overall wordage, relative lengths of entries, quality of writing, style-consistency, negotiation with contributors over their entries, etc’.89 And there have been complaints about editorial interference, most famously by Archibald Grenfell Price, who complained in correspondence with Pike in July 1964 that over many years of publishing in Australia, Britain and America I have had dealings with a number of editors, including the editor of the British Dictionary of Biography but never before with one who completely rewrote a contribution, without any preliminary conversations, and then suggested that the unfortunate author should put his signature to other people’s work.90 Is the ‘ADB style’ larger than the general editors appointed to enforce it? Strategy, procedures, budgeting, staffing and publication decisions have been ways by which successive general editors have left their mark on the project. Ken Inglis, a former chair of the Editorial Board, observed that it was Hancock, the de facto first executive, who turned it from a ‘set of cards and hopes into a great national achievement of collaborative scholarship’.91 We learn in Chapter 3 that it was Pike, whose hobby was to construct concrete and stone walls, who instituted the ‘Spartan methods, heartlessly enforced’ on ADB entries.92 Bede Nairn and Geoff Serle did not simply ‘inherit the editorship’ and house-sit it, as Fitzhardinge suggested: ‘Pike had got the whole thing on wheels and running Is the ‘ADB style’ larger than the general editors appointed to enforce it? Strategy, procedures, budgeting, staffing and publication decisions have been ways by which successive general editors have left their mark on the project. Ken Inglis, a former chair of the Editorial Board, observed that it was Hancock, the de facto first executive, who turned it from a ‘set of cards and hopes into a great national achievement of collaborative scholarship’.91 We learn in Chapter 3 that it was Pike, whose hobby was to construct concrete and stone walls, who instituted the ‘Spartan methods, heartlessly enforced’ on ADB entries.92 Bede Nairn and Geoff Serle did not simply ‘inherit the editorship’ and house-sit it, as Fitzhardinge suggested: ‘Pike had got the whole thing on wheels and running 28 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? The ADB system: Structure and agency and it didn’t take all that much—I mean it didn’t take an organisational creative genius to keep it running’.93 They were, as Serle would have it, ‘managers of a huge cooperative’.94 It was Nairn and Serle who oversaw the development of the ADB editorial team, instigated the system for obtaining birth, death and marriage records, and added cause of death for those under seventy years old as a feature of ADB entries. These were important developments, as was doubling of staff numbers. More resources meant more could be done and the whole scale of the ADB was increased: Volume 7 contained one-third more pages and one- quarter more entries than Volumes 3 to 6.95 Ritchie had more resources than any other general editor for the first part of his editorship. In the late 1980s he oversaw the reinvigoration of the working parties and the Editorial Board as members of the foundation generation retired. During his reign the floruit principle was dropped. Until Volume 13 subjects were included in the period in which they had made their most important contribution to Australian affairs—floruit, not death, being the guide to their location. The criterion for inclusion in a particular period, under Ritchie, was date of death. This brought the ADB into line with most other dictionaries of biography, including the DNB, but it brought us perilously close to the present as his efficient work system churned out volumes every few years. Ritchie also started the ADB Endowment Fund (and managed to persuade the university to match any funds raised), oversaw the creation of the index of the ADB and the production of the ADB CD-ROM. He had little interest in what was then called the World Wide Web, however, and in 1992, when renewing the contract with MUP, gave them all publishing rights in this new media. In 2006, under Di Langmore’s editorship, the ADB went online, a development assisted by three Australian Research Council grants, and following protracted negotiations with MUP. The move not only greatly increased the ADB’s readership—the online version attracts more than 70 million hits a year—it also offered possibilities for presenting the entries in exciting new ways.96 Instead of a seamless history, watersheds can be marked by general editors’ ‘eras’. A biographical approach is taken here and one might think it is appropriate, certainly understandable, that the ADB writes its own history in this way. 93 Fitzhardinge interviewed by Ross (1987). 94 Thompson, The Patrician and the Bloke, p. 249. 95 Serle, ‘General Editor’s Workload’. 96 Brendan O’Keefe, ‘11,000 Great Australian Lives Available at a Keystroke’, Australian (12 July 2006), p. 32. 96 Brendan O’Keefe, ‘11,000 Great Australian Lives Available at a Keystroke’, Australian (12 July 2006), p. 32. The ADB system: Structure and agency We are all too aware in historiography that the writers are as important as the history that occurs, so it is in one sense fitting that in the first part these articles concentrate biographically upon the ADB general editors and the people involved in the institution. It is a convenient way of breaking up the 50 years and the individuals who have taken critical roles. 29 The ADB’s Story 97 1986 Review, box 125, Q31, ADBA, ANUA, p. 4. 98 1986 Review, box 125, Q31, ADBA, ANUA. 99 John Ritchie, ‘Strategic Plan’ (1994), box 149, Q31, ADBA, ANUA; see earlier ‘Strategic Planning’, box 126, Q31, ADBA, ANUA. 100 H. J. Gibbney and Ann G. Smith (eds), A Biographical Register 1788–1939: Notes from the Name Index of the Australian Dictionary of Biography (Canberra: Australian Dictionary of Biography, 1987). 101 A. W. Martin and P. Wardle, Members of the Legislative Assembly of New South Wales, 1856–1901, Forward by L. Fitzhardinge (Canberra: Australian National University Social Science Monograph No. 16, 1959). G. C. Bolton and Ann Mozley, The Western Australian Legislature, 1870–1930 (Canberra: Australian National University Press, 1961), with Bolton’s biography of Alexander Forrest being a major source. D. B. 97 1986 Review, box 125, Q31, ADBA, ANUA, p. 4. p 98 1986 Review, box 125, Q31, ADBA, ANUA. The ADB’s sustained achievement and continuing legacy The ADB’s achievement has grown over half a century. Its impact was particularly important in the early period when there were few sources on Australian history. It has, indeed, been at the centre of the development of Australian history, as suggested by the circumstances surrounding the 1957 conference. The ADB has acted as a ‘stimulus and support in the remarkable wave of research and writing’ on Australian history that has occurred since the 1950s.97 Subsequently, it has attracted most of Australia’s leading historians to its ranks as authors and as members of the Editorial Board and working parties. This book’s Appendix 3 records the names of members of the Editorial Board and the working parties, demonstrating the ADB’s pervasive reach. The ADB has, moreover, been widely consulted. The report of the 1986 review of the ADB included anecdotal evidence of professional historians, declaring that ‘hardly a day goes by when I do not reach for it [the ADB]’.98 In 1994, the then general editor, Ritchie, remarked that ‘in terms of visibility, we have been reliably informed by librarians in major international institutions that the A.D.B. is their most frequently consulted source for information on Australians’.99 The Australian Encyclopedia was the only other reference as frequently used. The ADB has inspired work in a number of directions. The Biographical Register is perhaps the most significant. Begun by Fitzhardinge in 1954, it was maintained by the ADB until 2009 and consisted of biographical citations gleaned from newspapers, parliamentary debates, magazines and newsletters. The first—and eagerly anticipated—copy of the register, a 108-page roneoed booklet, was published in 1959. Updates were subsequently produced and, in 1987, a two-volume copy of the register was published.100 By then the register had grown to include more than 300 000 index cards housed in 180 catalogue- card drawers. A few years earlier, staff had started entering new citations into an in-house database. The biographical registers of members of the various parliaments were an offshoot of the Biographical Register.101 Allan Martin and Patience Wardle 30 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? published the first, a register of members of the NSW Legislative Assembly, in 1959. By 1961 it had been decided to produce a continuing series of registers for each State and for the federal legislatures, entitled ‘Australian Parliaments: Biographical Notes’. Waterson, A Biographical Register of the Queensland Parliament: 1860–1929 (Canberra: Australian National University Press, 1972). Kathleen Thomson and Geoffrey Serle, A Biographical Register of the Victorian Legislature 1859–1900 (Canberra: Australian National University Press, 1972). Joan Rydon, A Biographical Register of the Commonwealth Parliament, 1901–1972 (Canberra: Australian National University Press, 1975). Heather Radi, Peter Spearritt and Elizabeth Hinton, A Biographical Register of the NSW Parliament, 1901– 1970 (Canberra: Australian National University Press, 1979). Scott Bennett and Barbara Bennett, Biographical Register of the Tasmanian Parliament 1851–1960 (Canberra: Australian National University Press, 1980). D. B. Waterson and John Arnold, Biographical Register of the Queensland Parliament 1930–1980 with an Outline Atlas of Queensland Electorates 1859–1980 (Canberra: Australian National University Press, 1982). 106 In 1993 MUP planned a series of spin-offs. Two appeared: Chris Coulthard-Clark (sel. and ed.), The Diggers: Makers of the Australian Military Tradition—Lives from the Australian Dictionary of Biography (Carlton, Vic.: Melbourne University Press, 1993); and Michael McKernan (sel. and ed.), The Makers of Australia’s Sporting Traditions: Lives from the Australian Dictionary of Biography (Carlton, Vic.: Melbourne University Press, 1993). A third, ‘Colonial Australians’, edited by Deirdre Morris and Geoff Browne, did not 103 Material relating from certificates requested by Waterson, Rubenstein, Browne, Connolly, Langmore, Bolton, Radi, box 63, Q31, ADBA, ANUA. y g g 105 Radi, Spearritt and Hinton, A Biographical Register of the NSW Parliament, 1901–1970, p. ix.f 102 C. N. Connolly, Biographical Register, NSW Parliament 1850–1901 (Canberra: Australian National University Press, 1983).i 104 Connolly, Biographical Register, p. ix. The ADB’s sustained achievement and continuing legacy Chris Connolly’s Biographical Register, NSW Parliament 1850–1901 (1983) was effectively the ninth and last in the series. It was a revised compilation of the first by Martin and Wardle and contained information on all the members of the Legislative Council. Like Martin’s register, it had its genesis in the author’s PhD thesis at the ANU.102 Connolly dedicated it to ADB staff whose scholarship he had ‘come to admire’, and who had provided certificates and other vital information.103 The series of alphabetically arranged biographies, with collective biographical introductions, relating to the members of the Australian legislatures became, at the time, ‘essential for research in Australian political history’.104 Radi, Spearritt and Hinton wrote in their Biographical Register of the NSW Parliament, 1901–1970: Reference aids in Australia are notoriously inadequate. Our libraries struggle to keep up with day-to-day demands on minuscule budgets and rarely get a chance to do anything else. Sustained biographical research has been left to the small but dedicated bands at the Australian Dictionary of Biography at ANU and to a handful of other scholars.105 Since then there has been a trickle of collective accounts of ADB articles. Bernard Smith and others at the Power Institute undertook a Biographical Dictionary of Artists and Architects with which the ADB was involved. More directly, The Makers of Australian Sporting Traditions (1993, edited by Michael McKernan) and The Diggers (1993, edited by Chris Coulthard-Clark [now Clark]) were special editions of selected entries from the ADB.106 They were envisaged 104 Connolly, Biographical Register, p. ix. 31 The ADB’s Story as the first of a ‘proposed series of illustrated compilations from the A.D.B. on specialist subject areas designed to reach new readers and expose the A.D.B. to a wider audience’, but the series never eventuated.107 Historians have used the ADB systematically for research; for example, R. S. Neale attempted to measure whether social mobility in the colonies was responsible for taking some of the ‘sting out of the nineteenth-century radical movement’ by analysing the social origins and characteristics of executive and administrative leaders in Australia from 1788 to 1856 who had entries in the first three volumes of the ADB.108 Gauging the importance of the ADB in Australian historiography more widely is difficult. appear. Later and separately came G. P. Gilbert (ed.), Australian Naval Personalities: Lives from the Australian Dictionary of Biography, Papers in Australian Maritime Affairs No. 17 (Canberra: Sea Power Centre—Australia, 2006). 107 RSSS, Annual Report (1993), box 137, Q31, ADBA, ANUA, p. 68. 108 ‘The Colonies and Social Mobility: Governors and Executive Councilors in Australia, 1788–1856’, in R. S. Neale, Class and Ideology in the Nineteenth Century (London: Routledge & Kegan Paul, 1972), pp. 97–120. 109 John Ritchie, RSSS Annual Report (1996), NCB/ADB files, pp. 79–80. 110 Jill Roe, Stella Miles Franklin. A Life (Pymble, NSW: Fourth Estate, 2008). appear. Later and separately came G. P. Gilbert (ed.), Australian Naval Personalities: Lives from the Australian Dictionary of Biography, Papers in Australian Maritime Affairs No. 17 (Canberra: Sea Power Centre—Australia, 2006). 2006). 107 RSSS, Annual Report (1993), box 137, Q31, ADBA, ANUA, p. 68. 108 ‘The Colonies and Social Mobility: Governors and Executive Councilors in Australia, 1788–1856’, in R. S. Neale, Class and Ideology in the Nineteenth Century (London: Routledge & Kegan Paul, 1972), pp. 97–120. 109 John Ritchie, RSSS Annual Report (1996), NCB/ADB files, pp. 79–80. 110 Jill Roe, Stella Miles Franklin. A Life (Pymble, NSW: Fourth Estate, 2008). Professor Melanie Nolan is the General Editor of the ADB and Director of the National Centre of Biography. The ADB’s sustained achievement and continuing legacy In 1996, Ritchie claimed that the ADB had ‘consolidated knowledge of the most important figures in Australian history and sharply etched in many who were shadowy or unknown’.109 Certainly some historians have been inspired by writing an ADB entry to go on and write a great deal more. Jill Roe, an eminent historian and former chair of the ADB Editorial Board, has published two books that had their genesis as ADB entries. Her entry on theosophist George Arundel culminated in the publication of Beyond Belief: Theosophy in Australia 1879–1939 in 1986, while her Miles Franklin entry led to a number of edited books of Franklin’s work as well as her award-winning full-scale biography of Franklin.110 The ADB is at a watershed as it moves from a book to a digital culture. Its future promises the possibilities of advanced indexing, network analysis, visualisations, inclusion of supporting resources and e-research. The ADB served a particularly important role when there was little in the way of authoritative published Australian history in the 1950s and 1960s. It is important again, in the twenty-first century, when there is so much information on the Internet. The ADB attracts attention due to its conciseness and the discipline of well- referenced, well-researched, concise biography that can lend itself to addressing big questions in Australian history such as the significance of kinship and family relations, and the associational life of Australians since 1788. It is timely to record the history of the ADB. In 2008 the unit was amalgamated into the National Centre of Biography (NCB) at the ANU and in 2010 was integrated into the School of History. There has been a significant turnover of staff in the unit, and new directions, which take advantage of opportunities offered by the Internet, are being instigated. As already mentioned, the ADB’s 32 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? long-established Biographical Register has been abandoned. In its place has emerged Obituaries Australia, an online, full-text database that is linked to relevant ADB entries. Further enhancements, and other databases, are being developed. The ADB remains, however, at their core. This account of the ADB is built around the general editors; but in conclusion we return to Hancock’s emphasis, with two other sections on the ADB’s perennial concerns: national collaboration and its relative and comparative position in the wider dictionary world. Document 1 Keith Hancock kept ANU vice-chancellor, Sir Leslie Melville, appraised of dictionary plans from the outset. This report was presented to the ANU Council following the joint meeting of the ADB Editorial Committee and National Advisory Panel on 23-24 April 1960, which had made important decisions about organisational structure. The ADB’s sustained achievement and continuing legacy Professor Melanie Nolan is the General Editor of the ADB and Director of the National Centre of Biography. 33 33 The ADB’s Story Documents Keith Hancock was the pivotal personality in the ADB’s early history. His biographer, Jim Davidson (p. 393) observes that his ‘self-effacement” over his role in the dictionary in the early years was “persistent”. We have included these three documents to highlight his role. The Australian Dictionary of Biography The idea of an Australian Dictionary of Biography has been entertained for some years; historians indicated approval at the Conference of Australian historians held in Canberra in 1957, and the work of building up a National Register has been carried on in the History Department of the A.N.U. since 1954. In 1959, the Dictionary plan gathered momentum and a permanent member was appointed to the History Department to organise the project. At the same time, the support and interest of the State Universities and Libraries was sought for the plan, and a very real measure of co-operation obtained. It was widely felt that this was a national task of great importance and that the Australian National University was the proper body to direct and organise it. It was also realised that much of the work would be produced in the State Universities and that it was essential for them to play a part in the making of policies and procedures. An organisation for the Dictionary has now evolved which reflects the national character of the enterprise. The Dictionary is governed by a National Committee made up of representatives from each of the State Universities and the Editorial Board, and is under the chairmanship of Professor Sir Keith Hancock. The Editorial Board itself is the executive of the National Committee, composed predominantly of members of the Australian National University, and centered in Canberra. All editors are members of the Board. Considerable progress has already been made through the Commonwealth, and Dictionary Working Parties have been organised in each State. These consist of specialists and experts in different fields giving their time voluntarily, proposing lists of names for inclusion in the Dictionary and lists of possible contributors, 34 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? and, in many cases, writing Dictionary articles. It is anticipated that the greater part of the work will be done on an unpaid basis, bringing in the knowledge of scholars, scientists, professional men, antiquaries, to make it a work of national scholarship. Present plans for the Dictionary envisage that approximately 9–10 volumes will be published in the next decade. The Dictionary will be published in chronological volumes, the first covering the period 1788–1825; the second 1825–56, and so on. Professor Manning Clark and Mr. M. H. Ellis have been appointed joint editors of the first two volumes. W. K. Hancock, ‘The Australian Dictionary of Biography’ (10 May 1960), Minutes, ANU Council meeting (13 May 1960), 483/1960, box 1, series 245, ANUA. The Australian Dictionary of Biography It is expected that work will be started concurrently on the post 1850 volumes, and editors appointed in the near future. Publishing arrangements will be undertaken by the Melbourne University Press who have expressed their confidence in offering to publish without a subsidy. It is Professor Hancock’s belief that the Dictionary will be produced without substantial endowments, unlike the Canadian counterpart now being started on a bequest of one million dollars. The History Department of the Australian National University has nonetheless committed itself to an organisational task of considerable magnitude. Document 2 In May 1962, having already appointed Douglas Pike as general editor of the ADB, Keith Hancock appeared before the ANU Council to secure funding for the appointment and for the employment of editorial staff. He prepared this background paper to explain the genesis of the ADB and why the ANU should lead the project. 10 May 1960 W. K. Hancock, ‘The Australian Dictionary of Biography’ (10 May 1960), Minutes, ANU Council meeting (13 May 1960), 483/1960, box 1, series 245, ANUA. 35 35 The ADB’s Story The ADB’s Story The Family Experience The Family Experience Great Britain’s Dictionary of National Biography originated in the private enterprise of a patriotic publisher, George M. Smith, who, having amassed in this business a large fortune, was eager to employ it in ‘a munificent contribution to the literary world’. In 1882 he launched the Dictionary with Sir Sidney Lee as editor. Lee was succeeded by a man of still greater distinction, Sir Leslie Stephen. Both editors showed persistence and drive and won wide support throughout the community of learning. By 1901 the Dictionary was complete from A. to Z. in sixty-eight volumes. In this century it has come under the management of the Delegates of the Clarendon Press (in effect the University of Oxford), which publishes supplementary volumes covering ten-year periods. The Dictionary of National Biography is widely recognised as an important British institution, an embodiment in published print of the national inheritance, a roll of honour, in Church and State, peace and war, science, industry, the arts, literature—from the beginning of British history up to recent times. Its patriotic value, if the phrase may be permitted, is rooted in its scholarly value. To every student of British history in any of its aspects—political or economic, literary or scientific—it is an indispensable work of reference. The Americans were the first English-speaking nation of the New World to follow the British example. In 1922 the American Council of Learned Societies inaugurated a Dictionary of American Biography, which at once received moral and material help from many sources; for example, Yale University provided its editorial headquarters; the Library of Congress provided a staff for checking contributions; the New York Times opened the financial endowment fund with a gift of $250,000. The work proceeded at high speed. In 1928, twenty-two volumes and an index were published. Two supplementary volumes have been published since then. 36 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? Since the Second World War, moves have been made in each of the ‘Old Dominions’ of the Commonwealth to launch their own Dictionaries. From my vantage point at the Institute of Commonwealth Studies in London, I witnessed and supported the opening moves of the South Africans and Canadians. The former have not as yet got far, but the latter are well under way. The Family Experience The Dictionary of Canadian Biography was fortunate in starting with an endowment of $350,000 from the estate of a Canadian millionaire. Its headquarters are in the University of Toronto where a Biographical Centre with a large staff has been established under the editor, Professor George Brown. Publicity has been organised rather lavishly; at the same time, solid foundations have been laid for scholarly effort on a Dominion-wide basis. The proposed lists of inclusions and authors, English and French, are published regularly in the Canadian Historical Review. Presumably, contributions are now coming in well. In contrast with the Canadian effort, New Zealand’s is poorly endowed and advertised, but the task of producing a national Dictionary has been entrusted to the Parliamentary historian, Dr. A. H. McClintock, in co-operation with the New Zealand libraries. The Australian Venture I shall interpolate here a note about my personal concern with Dictionaries of National Biography. In the 1940’s I served for five years on a central committee of the British D.N.B. In the 1950’s, when I started work on Smuts, I found good cause to curse the lack of a South African D.N.B. At present I have in the press four volumes of Smuts papers (1887–1919), which contain many hundreds of references to individuals. The rules of good editing have compelled me to track down these individuals and write brief notes about them. If a Dictionary had existed, I should have been saved a year or more of finicky work. Consequently, I was anxious, when I returned to Australia in 1957, to find out what the prospects were for launching an Australian Dictionary. I was aware, of course, of the valuable pioneering work which had been done by the late Mr. Serle and was being continued by the Australian Encyclopedia; but I knew that much more than this was needed. I soon discovered that my colleague, Mr. Fitzhardinge, had the need very much in mind and had taken some important steps to meet it. In 1947 he had spent six months in the Clarendon Press, where he had made it his particular business to master the publishing problems of the D.N.B. In 1951, at the A.N.Z.A.A.S. [Australian and New Zealand Association for the Advancement of Science] conference in Brisbane, he had made himself the advocate of an Australian D.N.B. He then proceeded from advocacy to action. 37 37 The ADB’s Story Soon after his joining the staff of the A.N.U., he started work on a collection of biographical information which has come to be called the National Register [later Biographical Register]. This compilation of basic biographical and bibliographical information, has, up to the present, dealt with over 6,000 persons of significance in Australian history and it continues to grow from month to month as new knowledge is gathered in. It has already proved itself to be an indispensable tool of research into—for example—the history of Australian legislatures, which are the subject matter of a useful series of A.N.U. monographs. But this is by the way. The chief value of the Register (as Mr. Fitzhardinge always foresaw) is as a foundation and buttress of the Australian Dictionary of Biography. The Australian Venture We are responsible for the Register; we are providing the administrative and editorial headquarters of the Dictionary. I have to confess that I personally made the mistake (and have suffered from it) of accepting these large responsibilities with too few resources for fulfilling them. At the Conference of May 1960 it was suggested that we ought to appoint a General Editor; but there was no provision on the budget of my department for such an appointment. As chairman of the Editorial Board, I have had the assistance of a secretary/assistant-editor with the status in this University of Research Fellow. With her support, I have tried to cope, in the midst of other heavy commitments, with a rapidly increasing stream of business coming in from volume editors, State, Regional and Functional Working Parties (whose task it is to compile draft lists of inclusions and authors) and, during the past twelve months, contributors. All this demands continuous and extensive correspondence and a heavy administrative burden. It will soon call for continuous and meticulous editorial work. At this point it needs to be explained that the Dictionary will not, at least in its first edition, run from A. to Z. over the whole period (1789 to 1919, or whatever terminal date we choose); but will be published in successive chronological volumes: e.g. Volume 1, 1789–1825; Volume 2, 1826–1850, and so on. A great deal of work has already been done on these first two volumes and important progress has been made in opening up the period 1851–1890, which will call for a number of volumes. For each successive period a Volume Editor is appointed by the Editorial Board; but experience has shown that we must also have a General Editor, to ensure co-ordination between volumes, to maintain uniformity of standards, to provide facilities for checking and similar editorial tasks, to supervise the Register, to run the headquarters machine and—not least—to keep alive the enthusiasm of the scores, nay, the hundreds of workers throughout Australia who, in various capacities, are sustaining the Dictionary. The all-Australian character of our enterprise has been recognised by the three learned societies—Academy of Science, Humanities Research Council, Social Sciences Research Council—each of which has passed a resolution in support of the Dictionary. The Australian Venture In August 1957, a conference of historians working in the field of Australian history, and representative of every Australian university, met in Canberra. The members of the conference were asked to examine the Register carefully and critically and then answer two questions: Should we continue the Register? Should we go further and launch a Dictionary? The answer to the first question was an emphatic ‘Yes’; together with a request to us in Canberra to make the register available in the States and a promise of help from them to us in continuing the work. In fulfillment of these mutual undertakings, we are receiving from the States a steady stream of new material for entry on our cards, and we distribute the Register in mimeograph form to all State Libraries and University History Departments and to many Historical Societies throughout Australia. The answer to the second question was also an emphatic ‘Yes’; but the conference did not last long enough for any progress to be made in planning the Dictionary and the ways and means of achieving it. This responsibility was put upon us at Canberra. We realised, however, that the Dictionary was a national enterprise which needed a firm base of national support. Consequently, we maintained continuous consultation with our colleagues in the States and in every step which we took forward we had the assurance of their support. By the beginning of 1960 two institutions had taken shape; a provisional Editorial Committee and a National Advisory Panel: the former was based at the A.N.U., the latter represented all the Australian Universities. At a conference held in Canberra in May 1960, these two bodies were fused into a National Committee, whose duty it is broadly to define policy. At the same time, the provisional editorial committee was constituted as an Editorial Board, under the chairmanship of the Professor of History in the Research School of Social 38 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? Sciences. The Vice-Chancellor of the A.N.U., who had been kept informed at every important stage of planning and action, approved these decisions insofar as the A.N.U. was concerned. The A.N.U. is, of course, deeply concerned. As the proceeding story has shown, the Dictionary has its tap root here. The Editorial Board is constituted exclusively (except for the addition of Volume Editors ex officio) by the members of this University. The Australian Venture It may become appropriate later on to seek more tangible support from these bodies in the form of grants in aid of publication, so that the published price of successive volumes may be kept reasonably low. Meanwhile, 39 The ADB’s Story it is the National Committee which continuously embodies the all-Australian element. Its partnership with the Editorial Board, and therefore with the A.N.U., rests upon a body of case law which is now being codified. The partnership has been tested and its strength proved. Its spirit may be expressed in some words used recently by the chairman of the Queensland Working Party—‘We will do nothing for the A.N.U.; but with the A.N.U. there are no limits to what we are willing to do’. In practice, we are operating a consultative constitution. The Editorial Board conducts the affairs of the Dictionary within a framework of policy nationally approved. The Board has responsibilities to the University, which provides the main financial support (although there have also been two generous private benefactions) for the headquarters establishment. The Board, however, also thinks itself bound to keep members of the national Committee continuously informed of its proceedings. In major matters of policy it would feel unable to proceed unless it had an explicit assurance that this support was forthcoming. These rules of consultation are well exemplified by the appointment of a General Editor. Strictly within the terms of the Dictionary’s constitution, the power of appointment lies with the Editorial Board. In fact, however, the Editorial Board has had to accept two practical limitations upon its power: first it had to satisfy itself that the man of its choice would be acceptable in all the Australian universities: secondly, it had to make the appointment in such a manner as would leave the A.N.U. uncommitted, unless and until Council had decided that the proposed commitment was one which it was willing to accept. As to the second point, the National Committee expressed the wish in 1961 that the General Editor, when appointed, should join the academic staff of the A.N.U. if he were not already on it. From the description which has now been given of the Dictionary’s organisation, it will be apparent that any other arrangement would create great difficulties. It might not, however, create impossibilities—at least, not so long as the inflow of contributions falls some distance short of its predicable peak. The Australian Venture For a few years, at any rate, a General Editor enjoying rude health and able to make fairly frequent visits to Canberra might have his home base in Sydney or—let us say—in Hobart. The National Committee was anxious that the Editorial Board, in looking for a General Editor, should not confine its inquiries to historians already resident in Canberra, but that it should survey the whole field of Australian historians. The Board, on its side, was anxious to appoint a man who could count in advance upon the support of every Australian university. At the meeting of the National Committee in May 1961, a sub-committee was appointed to make recommendations to the Editorial Board. This committee represented fifty/fifty the A.N.U. and the State Universities. After long and careful explorations, it 40 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? unanimously recommended Professor Pike. The Editorial Board, at a meeting last December, appointed him General Editor. This appointment has been received with great satisfaction by the National Committee and by historians both throughout Australia and overseas. Professor Pike retains his Chair in Hobart. The University of Tasmania has been most co-operative in permitting and encouraging him so to organise his work that he is able to make fairly frequent journeys to Canberra. This arrangement is now working well and will continue to work well so long as the progress of the Dictionary is confined mainly to the early volumes. But when contributions over the whole period begin to flood in a ‘visiting’ General Editor would need to be a superman to avoid breaking down. The National Committee and the Editorial Board are convinced of this. I personally am convinced of it from the experience I gained in trying to run the U.K. war histories from Oxford. In the end, after suffering severe damage and inflicting it upon others, I had to make the move to London. Theoretically, the problem could be solved another way, by uprooting the National Register and the headquarters of the Dictionary from the A.N.U. and planting them in another University. Practically, this would prove an impossible task. The National Committee has expressed the wish that the General Editor, when he joins the A.N.U. should have appropriate academic status. W. K. Hancock, ‘The Australian Dictionary of Biography’ (12 April 1962), Minutes, ANU Council meeting (11 May 1962), 567/1962, box 1, series 245, ANUA. The Australian Venture Since Professor Pike is Professor and Head of the Department of History in another Australian University, it is my own view and the view of my colleagues in the Research School of Social Sciences that the appropriate status in his case is that of Professor. If the Board of the Institute or the Council cannot see their way clear to offer Professor Pike such an appointment, the Editorial Board and the National Committee will have to think again. On behalf of my own Department I shall say only this: that, after investing so much thought and effort in the Dictionary, we will not allow it to collapse. With the aid of our colleagues in the States we shall manage somehow. I need hardly add that at every stage in these transactions I have kept in the closest possible touch with the Director of my School, the Registrar and the Vice-Chancellor. W. K. Hancock 12 April 1962 W. K. Hancock, ‘The Australian Dictionary of Biography’ (12 April 1962), Minutes, ANU Council meeting (11 May 1962), 567/1962, box 1, series 245, ANUA. 41 The ADB’s Story The ADB’s Story Document 3 Keith Hancock said little publicly about the ADB following his resignation as chairman of the Editorial Board and National Committee in 1965. In 1986 he was invited to launch volume 10 of the ADB and took the opportunity to reflect on the dictionary's creation and development. Keith Hancock launches Volume 10 of the ADB 1986 It is my privilege and my pleasure to launch Volume 10 of the Australian Dictionary of Biography. This volume, like all its predecessors, is an achievement of co-operative federalism on the front of scholarly endeavour. The initiative belongs to working parties in each of the Commonwealth’s six States. They make proposals for inclusions—lists of the men and women whose services to Australia merit commemoration. They also nominate authors for the proposed biographical articles and suggest some at least of the evidence—in print, in manuscript and in oral tradition—which the authors will need to study. The proposals of the Working Parties are addressed to the editor of the Dictionary. He is a senior member of the Research School of Social Sciences in the Australian National University. He is ultimately responsible to the Vice-Chancellor and is immediately supported by an Editorial Board—of which you my dear Ken [Inglis], are now the Chairman. Moreover, he takes counsel with a small but highly competent group of research editors. Consequently, it may happen that he will propose to working parties sources of information more ample and precise than those they have cited, and propose authors better qualified than those they have recommended. Thus the dialogue continues between the Editor and each of the six Working Parties … Cooperative Federalism at its best. Now let us remember famous men. Now let us remember famous men. First, Percival Serle. Sixty-eight years ago, when I began my undergraduate studies at Melbourne University, he helped me to take my compass bearings. He was then a senior Administrative Officer of the University. He was also giving voluntary service as a Guide-Lecturer in Victoria’s Art Gallery. In 1920 he resigned from his post at the university in order to give all his time and energy to literary and bibliographical study. For many years he remained hard at work on a self-imposed bibliographical task, a Dictionary of Australian Biography. In 1949 that pioneering work was published in two volumes. His son, Geoffrey, is editor of the volume which I am now launching. Viewed in historical perspective, The Australian Dictionary of Biography has run a straight course from Serle to Serle. 42 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? Let us also remember Laurie Fitzhardinge. He is still with us, although he no longer rides to work on his horse, ‘Red Brick’. Throughout the past half-century he has achieved excellence on three separate fronts of historical endeavour: Let us also remember Laurie Fitzhardinge. He is still with us, although he no longer rides to work on his horse, ‘Red Brick’. Throughout the past half-century he has achieved excellence on three separate fronts of historical endeavour: 1. Classical History. Only a few years ago his book, The Spartans, was acclaimed by scholarly reviewers throughout and beyond the English-speaking world. 1. Classical History. Only a few years ago his book, The Spartans, was acclaimed by scholarly reviewers throughout and beyond the English-speaking world. 2. Parochial history. He grew up and still lives in the Limestone Plains, the region now known as the Australian Capital Territory. He was the first scholar to produce learned and elegant articles on the history of this delectable parish. He was also a founding father of the Canberra and District Historical Society. 3. National History. He produced what I call his Billy Book—a two-volume biography of Prime Minister W. M. Hughes. More to the present point, from the early 1950s onwards he worked steadily to produce a National Register of representative Australians—a tool of research which today renders indispensable service to the editor of the Australian Dictionary of Biography. And not only to him. Now let us remember famous men. Thereafter he brought to birth two of the four volumes which cover the period 1851 to 1890. The third volume for this period was already in galley proof when Douglas Pike died on 19 May 1974. Death of a hero. Bede Nairn succeeded Douglas Pike as Editor of the Dictionary. His immediate task was to work on those galley proofs and send to the printer the third volume of that period 1851–1890. He then brought to birth the concluding volume of that period. Thereafter, in combination with Geoffrey Serle, he has produced the three opening volumes of the period 1891–1939. Where do we go from here? That question must very soon be asked and answered. However, there is another question that can be asked and answered now. The founding fathers of the Australian Dictionary of Biography set themselves the task of producing scholarly work comparable in quality with that of Britain’s Dictionary of National Biography. Has this ambition been made good? The answer to this question is plain. Our performance not only equals, it excels the British performance. It has been more scholarly. It has been more adventurous. More scholarly? Yes! Whereas contributors to the D.N.B. have relied for the most part on sources of information familiar to historians, more often than not in published print, contributors to our A.D.B., from start to finish, have delved deep into the primary sources. More adventurous? Yes! Almost always the persons included in the D.N.B. have already been well known for their services to the nation in church and state, or in science and literature and art, or in commerce and industry. By contrast, the persons included in our A.D.B. have been widely representative of endeavour and achievement on every front of our experience as an emergent nation. To prove this point I shall cite an entry from Volume 9 of our Dictionary. Edward Gilbert was an Aboriginal Australian. His birth was not recorded and his parents are unknown, but in 1905 or 1906 he began to cry and crawl in the children’s dormitory of Queensland’s Durundur Aboriginal Reserve. Some years later Durundur was abolished and Eddie was shifted to the Barambah Reserve. The blacks of Barambah played cricket. Richard Crawford, a wise and humane schoolmaster, saw great promise in Eddie Gilbert’s bowling. Despite his low stature and short run Eddie’s whiplike wrist action released the ball like a stone from a catapult. Now let us remember famous men. Today, the Register brings grist to the mills of many and various men and women in many and various walks of life. Fitzhardinge saw the National Register as a stepping-stone towards a Dictionary of Australian Biography which would be comparable in quality with Britain’s Dictionary of National Biography. In August 1957 this proposal was approved by a Conference which met in Canberra. Every Australian University was represented at that Conference. There were also present some eminent ‘freelance’ historians. The ‘all clear’ for an immediate start of work on the Dictionary was contained in two decisions: Fitzhardinge saw the National Register as a stepping-stone towards a Dictionary of Australian Biography which would be comparable in quality with Britain’s Dictionary of National Biography. In August 1957 this proposal was approved by a Conference which met in Canberra. Every Australian University was represented at that Conference. There were also present some eminent ‘freelance’ historians. The ‘all clear’ for an immediate start of work on the Dictionary was contained in two decisions: 1. To establish a Working Party in every State of the Commonwealth 1. To establish a Working Party in every State of the Commonwealth. 2. To establish a National Committee representative of every Australian University. 2. To establish a National Committee representative of every Australian University. The sequel was spotty. In the states the working parties lived up to their names. They did real work, proposing inclusions and nominating authors. From that day to this, all the authors, with very rare exceptions—I think there is only one exception—have given unpaid service to the Dictionary. In Canberra, by contrast, the National Committee did no real work. It was a talking shop. The talk grew acrimonious. The good ship ADB nearly became a wreck in Sydney Harbour. Salvage was now the immediate task. I was chairman of that damnable national committee. In 1961 I did what I should have done in 1957. I had a talk with my vice-chancellor and, with his support, appealed to the Council of the Australian National University for funds to establish an editor of the Dictionary with an expert supporting staff. In 1962 a distinguished historian, Professor Douglas Pike, started work as editor. He salvaged the sinking ship and set it on course. In 1966 and 1967 he brought 43 The ADB’s Story to birth the first two volumes which covered the Dictionary’s first period, 1788 to 1850. W. K. Hancock, speech notes, launch of vol 10, ADB. Box 116, Q31, ADBA, ANUA. I now launch Volume 10 of the Australian Dictionary of Biography. W. K. Hancock, speech notes, launch of vol 10, ADB. Box 116, Q31, ADBA, ANUA. Now let us remember famous men. He was chosen to play for Queensland. In 1931 he bowled to Bradman. His first ball knocked the bat from Bradman’s hand; his second left Bradman sprawling on the ground; his third got Bradman ‘caught behind’. The crowd on the hill booed Eddie Gilbert. Umpires in the southern states began to ‘no-ball’ him for throwing. He was twice 44 1. ‘Insufficiently Engineered’: A Dictionary Designed to Stand the Test of Time? filmed by slow-action cameras which revealed no fault in his action; but the ‘no-balling’ continued. Was Eddie Gilbert the victim of White Australian prejudice? Perhaps he was; but when Eddie died Bradman attended his funeral. You must wait just a little longer for this evening’s celebration. Here and now, let us remember famous women. Establishing the Biographical Register was a combined operation by Mr Laurie Fitzhardinge and Mrs Pat Wardle. Mrs Nan Phillips rendered indispensable service to three editors of the Dictionary. Today, all the Dictionary’s research editors are women. Looking to the future, I can see—someday—a woman working at the editorial desk. But now at last we come to Volume Ten. I have not yet had time to read it from cover to cover and shall confine myself, now, to a few entries under the letter ‘M’. For example—Douglas Mawson, geologist and Antarctic explorer; Max Meldrum, painter and ardent advocate of tonal values in the painter’s art; Nellie Melba, singer. As I read this entry, I felt no doubt at all that it is the best ‘brief life’ of a prima donna that anybody has ever written, or ever will write. I now launch Volume 10 of the Australian Dictionary of Biography. W. K. Hancock, speech notes, launch of vol 10, ADB. Box 116, Q31, ADBA, ANUA. 45 45 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Ann Moyal 1 Robin Gollan, ‘Laurence Fitzhardinge 1908–1993’, Proceedings, vol. 18, 1993 (Canberra: Australian Academy of the Humanities, 1994), pp. 52–4. 2 Percival Serle, Dictionary of Australian Biography (Sydney: Angus & Robertson, 1949). 2 Percival Serle, Dictionary of Australian Biography (Sydney: Angus & Robertson, 1949). 1 Robin Gollan, ‘Laurence Fitzhardinge 1908–1993’, Proceedings, vol. 18, 1993 (Canberra: Australian Academy of the Humanities, 1994), pp. 52–4. Genesis The genesis of the idea for a biographical dictionary of Australia lay with the librarian, classicist and scholar of Australian history Laurence (Laurie) Frederic Fitzhardinge (1908–93). A graduate of the universities of Sydney and Oxford, he was, from 1934, a research officer in the Commonwealth National Library, where he immersed himself in the documents of Australia’s history. In 1943 he began teaching Australian history at the newly established School of Diplomatic Studies within Canberra University College. Taking up an appointment in 1951 as reader in the sources of Australian history at the young Australian National University, he headed the then small history department in the Institute of Advanced Studies and initiated the training of the first intake of postgraduate students to do their PhDs in Australia.1 Previously, the ANU Overseas Scholarships scheme had provided funds for ANU people, including Bob Gollan and Ken Inglis, to do their PhDs elsewhere. The ANU intake was a talented coterie, as it proved, of young Australian historians destined for prominent academic careers, including Allan Martin, Eric Fry, Russel Ward, John Tregenza and Michael Roe. As his original ANU title (later converted to reader in Australian history, in the Research School of Social Sciences) suggested, Fitzhardinge was widely read in the Australian historical sources and was aware that, if the study of Australian history was to make headway, there was a clear need to build the sources of biographical knowledge. Fitzhardinge had first advanced the idea of an Australian dictionary of national biography in 1947, as a team project for the planned Sydney University Press, but no press eventuated. On study leave in Britain later that year, he spent time with the Clarendon Press in Oxford, studying the procedures of the Dictionary of National Biography (DNB). 3 ‘BR/ADB—Organisation and Development, 1957/8/-59’, box 67, Q31, ADBA, ANUA. 4 ‘BR/ADB—Organisation and Development, 1957/8/-59’, box 67, Q31, ADBA, ANUA. 5 K. S. Inglis, ‘The Foundation Chairman’, Australian Dictionary of Biography, vol. 12 (Carlton, Vic.: Melbourne University Press, 1990), pp. xi–xii. Genesis Two years later, publication of Percival Serle’s two-volume Dictionary of Australian Biography (1949) gave zest to his concept and pointed the way to the possibility of a cooperative project.2 49 The ADB’s Story The ADB’s Story The ADB’s Story Laurie Fitzhardinge at his home, 1981 Photographer: Alec Bolton, National Library of Australia, an14465757-1 At the Australian and New Zealand Association for the Advancement of Science (ANZAAS) Congress, held in Brisbane in 1951, Fitzhardinge publicly canvassed the id f ti l bi hi l di ti R di t i t t f b f Laurie Fitzhardinge at his home, 1981 Photographer: Alec Bolton, National Library of Australia, an14465757-1 Photographer: Alec Bolton, National Library of Australia, an14465757-1 At the Australian and New Zealand Association for the Advancement of Science (ANZAAS) Congress, held in Brisbane in 1951, Fitzhardinge publicly canvassed the idea of a national biographical dictionary. Responding to interest from a number of historians who were becoming alert to its need, he began to develop an embryonic national ‘index’ of names and, in 1954, employed Patience (Pat) Tillyard (later Mrs Wardle) as an assistant in the history department to work on it.3 50 3 ‘BR/ADB—Organisation and Development, 1957/8/-59’, box 67, Q31, ADBA, ANUA. 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Sir Keith Hancock arrives at Canberra airport in 1957 to take up his appointment as director of RSSS. Left to right: Laurie Fitzhardinge, Mark Oliphant, Keith Hancock and Leslie Melville; Ross Hohnen is in the background Sir Keith Hancock arrives at Canberra airport in 1957 to take up his appointment as director of RSSS. Left to right: Laurie Fitzhardinge, Mark Oliphant, Keith Hancock and Leslie Melville; Ross Hohnen is in the background 4 BR/ADB Organisation and Development, 1957/8/ 59 , box 67, Q31, ADBA, ANUA. 5 K. S. Inglis, ‘The Foundation Chairman’, Australian Dictionary of Biography, vol. 12 (Carlton, Vic.: Melbourne University Press, 1990), pp. xi–xii. 4 ‘BR/ADB—Organisation and Development, 1957/8/-59’, box 67, Q31, ADBA, ANUA. ANU Archives, ANUA225-511-6 Hancock’s return to Australia from Britain in 1957, as founding director of the RSSS and professor of history, gave new impetus to Fitzhardinge’s idea. The question of an Australian dictionary was raised as a departmental project before Fitzhardinge departed on sabbatical leave that year. The dictionary project now fell into Hancock’s lively grasp. As a former member of the central committee of Britain’s DNB, he was experienced in national dictionary matters and saw Fitzhardinge’s biographical initiative as ‘a work of fundamental importance to the future history of the Dictionary’.4 In 1957, shortly after his arrival, and acting, in Ken Inglis’s view, as the archbishop of Australian historians, he called a conference in Canberra at which he raised the biographical concept.5 51 The ADB’s Story Fitzhardinge’s ‘Paper Prepared for the Conference of Historians 24–27 August 1957’, setting down his ‘sources of information for methods of inclusion’ and adding a description of the project to be built from his existing ‘index’, further shaped the idea of a central source for the sharing of biographical information, to be located in Canberra.6 It attracted considerable support from State university historians, among them John La Nauze and Geoffrey Serle from the University of Melbourne, who made subsequent inputs.7 It also fired the enthusiasm of the independent Sydney historian and biographer Malcolm Ellis, who was invited to attend. In April 1958 Fitzhardinge responded to the enthusiasm with a two- part document outlining the plans emerging from the conference suggestions and putting the ‘register’ on a more systematic footing.8 Central to this were the questions: was the register method satisfactory; was the venture worth continuing; and should a national dictionary of biography—or, alternatively, a concise dictionary of biography—be undertaken? Fitzhardinge saw the index’s 4500 cards as essentially a basic tool available for reference in Canberra directly or through postal inquiry, and ‘in occasional monograph publication’. On the second point, he wrote: On the question of the ‘D.N.B.’, I myself think that the long-range objective should be the organization, with the co-operation of the other universities and of other specialists, but under the auspices of the A.N.U., of a full scale Dictionary, on the lines of the D.N.B., the Dictionary of American Biography, and the projected Dictionary of Canadian Biography. 6 ‘Paper Prepared for the Conference of Historians’, in folder ‘BR/ADB—Organisation and Development, 1957/8/-59’, box 67, Q31, ADBA, ANUA. Robin Gollan, ‘Canberra History Conference’, Historical Studies: Australia and New Zealand, 8, no. 29 (1957). 7 ‘Report on ANU Biographical Card Index and the Possibility of a Concise DNB’ (n.d., c. October 1957), box 57, Q31, ADBA, ANUA. 8 ‘Biographical Project’ (19 February 1958), box 57, Q31, ADBA, ANUA. 9 ‘BR/ADB—Organisation and Development, 1957/8/-59’, box 67, Q31, ADBA, ANUA. 10 Laurie Fitzhardinge, Interview by Barbara Ross, 4–26 March 1987, TRC 2159, transcript, NLA. 10 Laurie Fitzhardinge, Interview by Barbara Ross, 4–26 March 1987, TRC 2159, transcript, NLA. g p j ( y ) 9 ‘BR/ADB—Organisation and Development, 1957/8/-59’, box 67, Q31, ADBA, ANUA. 8 ‘Biographical Project’ (19 February 1958), box 57, Q31, ADBA, ANUA. 9 ‘BR/ADB—Organisation and Development, 1957/8/-59’, box 67, Q31, ADBA, ANUA. 10 Laurie Fitzhardinge, Interview by Barbara Ross, 4–26 March 1987, TRC 2159, transcript, NLA ANU Archives, ANUA225-511-6 This would be a big undertaking, in which perhaps the Social Sciences Research Council and other bodies might assist financially, but I think we should be prepared to take responsibility for its planning and organization.9 Envisaging that such a work would cover the period up to 1939 and be completed in 10 years, Fitzhardinge had early mooted the idea of an ‘ultimate’ dictionary of national biography for Australia; however, as an old man, he acknowledged that Hancock ‘had a dynamism and energy, and immense reputation and great charisma. He was able to get it off the ground on a scale and in a way which I could never have been able to do’.10 52 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Ann Moyal, 1960s By courtesy of Ann Moyal Ann Moyal, 1960s By courtesy of Ann Moyal By courtesy of Ann Moyal What emerges from the documentary evidence is the gradual nature of the evolution of the biographical enterprise in a busy research department that consisted of Hancock, Fitzhardinge and the labour historian Robin Gollan. All were deeply engaged in their own research projects and in the supervision of an expanding corps of postgraduate students. It was into this environment that, from Europe, as Mrs Ann Mozley, I sent my overture to Hancock inquiring about a possible position in his department. 53 The ADB’s Story A first-class honours graduate in history from Sydney University, I had been working for the previous four years as personal research assistant for Lord Beaverbrook, the Canadian-born newspaper proprietor and politician.11 But after nine years in Britain, I determined that it was time for me to return to Australia and dispatched inquiries to both Hancock and Jim Davidson, director of the Research School of Pacific Studies, asking about possible openings at the ANU. Two letters arrived simultaneously from the ANU, one from Davidson offering me a postgraduate scholarship in Pacific history and the other from Hancock inviting me to join him to work on a proposed national dictionary of biography. I had met Hancock in England early in 1949 when I visited him at the British cabinet office in London where he was editing the British official World War II histories. I was hoping that he might offer me some work. This small, inquiring man was to have a singular influence on my life. 11 Described in Ann Moyal, Breakfast with Beaverbrook. Memoirs of an Independent Woman (Sydney: Hale & Iremonger, 1995). 12 Mozley was appointed a research assistant in November 1958 with ‘main responsibility’ for ‘the organization of the Register of Australia Biography and preliminary work towards a Dictionary of Australian Biography’: ANU News, 11, no. 1 (August 1959), p. 27. g ) 12 Mozley was appointed a research assistant in November 1958 with ‘main responsibility’ for ‘the organization of the Register of Australia Biography and preliminary work towards a Dictionary of Australian Biography’: ANU News, 11, no. 1 (August 1959), p. 27. 13 W. K. Hancock to Sir Leslie Melville (22 July 1959), box 70, Q31, ADBA, ANUA. 14 ‘W. K. Hancock Files—Organization’, box 70, Q31, ADBA, ANUA. ANU Archives, ANUA225-511-6 While unable to offer me a temporary research position, he helped to secure me a post with Nicholas Mansergh, working on the British Survey of Commonwealth Affairs at Chatham House. He also put my name on his list of possible researchers where, four years later, Beaverbrook’s archivist, who was looking for someone for Beaverbrook to employ, picked it out. Thus, in 1958, I was known to Hancock. Attracted by his reputation and the pioneering nature of the biography project, I declined the scholarship and chose the dictionary. Arriving in Canberra in November, I was met at the train by a ragged Fitzhardinge, his toes poking through his shoes. Talking volubly, he whisked me away to his farm at Narrabundah and on to University House. On my first morning at the history department, then lodged in the old Canberra Community Hospital building, Pat Wardle sat me down and asked me to fill in a card for the Biographical Register to see if I could manage it. I wondered mildly if it might be ‘downhill all the way’.12 In the event, the creative ‘founding days’ of the ADB would prove a dynamic and constructive episode in my career. 54 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Keith Hancock, 1948 ANU Archives, ANUA225-511-4 Keith Hancock, 1948 ANU Archives, ANUA225-511-4 55 The ADB’s Story The ADB’s first offices were in the old Canberra Community Hospital, which became part of the ANU. Keith Hancock had the room on the left of the front entrance and Douglas Pike had the room on the right of the entrance The ADB’s Story The ADB’s first offices were in the old Canberra Community Hospital, which became part of the ANU. Keith Hancock had the room on the left of the front entrance and Douglas Pike had the room on the right of the entrance Photographer: Brian Wimborne, ADB archives 15 ‘Biographical Register and Australian Dictionary of Biography Development and Procedures’, and also W. K Hancock to L. F. Fitzhardinge, Dr R. Gollan and Mrs A. Mozley, requesting such an overview (18 December 1958), box 67, Q31, ADBA, ANUA. 16 W. K. H., L. F. F. and A. M., ‘Memorandum on a Dictionary of National Biography’ (February 1959), box 67, Q31, ADBA, ANUA. A doodle, thought to be by ADB staffer Jim Gibbney, of a possible coat of arms for the ADB ADB archives 15 ‘Biographical Register and Australian Dictionary of Biography Development and Procedures’, and also W. K Hancock to L. F. Fitzhardinge, Dr R. Gollan and Mrs A. Mozley, requesting such an overview (18 December 1958), box 67, Q31, ADBA, ANUA. 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 ) 16 W. K. H., L. F. F. and A. M., ‘Memorandum on a Dictionary of National Biography’ (February 1959), box 67, Q31, ADBA, ANUA. Foundations Sir Keith Hancock’s letter inviting me to join the dictionary project has not survived, but writing later to the vice-chancellor, he recommended that I be promoted to a research fellow dedicated to the dictionary project: ‘I have chosen her specifically for this job … I should want to keep her until the complete Dictionary is published, say, ten years from now’.13 Certainly my appointment at the ANU as a research assistant proved a trigger to action. Defined as ‘partly academic and partly administrative’ and designed both for work on the Biographical Register and for developing initiatives for the dictionary, it inaugurated a series of developments that required Fitzhardinge, Gollan and myself to implement some early structures and processes. Malcolm Ellis, enthused by the historians’ conference, had called on Hancock in Canberra in mid 1958 with the proposal that work on an Australian dictionary might ‘be done in chronological sections rather than as a whole’—a suggestion that was put fruitfully on hold. In December 1958, with personnel now to hand, Hancock, for his part, started to consult with members of all the history departments in the Australian universities with the aim of linking them cooperatively to the venture.14 56 2. Sir Keith Hancock: Laying the Foundations, 1959 1962 A doodle, thought to be by ADB staffer Jim Gibbney, of a possible coat of arms for the ADB A doodle, thought to be by ADB staffer Jim Gibbney, of a possible coat of arms for the ADB ADB archives ADB archives His judgment was shrewd. Tensions had grown since the national university’s creation between its well-funded RSSS and the impecunious State teaching departments. Hancock considered that, as we could now implement the plan, ‘we should so far as possible, give the impression of going ahead with work that other people want us to do, and not merely pushing ahead on our own’.15 Accordingly, as a first step, a ‘Memorandum of a Dictionary of National Biography’, initialled by ‘W. K. H.’, ‘L. F. F.’ and ‘A. M.’ (Hancock, Fitzhardinge and myself) was sent out in February 1959 under Hancock’s covering hand, giving details of the contents of a ‘National Register’ (later called the Biographical Register), which was already in use. The first specialist monograph of biographical notes, by A. W. Martin and P. Wardle, Members of the Legislative Assembly of New South Wales, 1856–1901, developed as a pilot study, was with the ANU Press. As the memorandum indicated, while the question and problem of the dictionary were long term, the ANU department of history would accept responsibility for the register and the monograph pilot scheme, pending the time when ‘more formal machinery for collaboration will probably become necessary’. Meanwhile, it was thought that, for a time, conference by correspondence would prove a fruitful source of criticism, and State colleagues were urged ‘to advise, exhort and warn us’.16 They did. James Auchmuty, representing Newcastle University College and the University of New South Wales, accepted the present plans as ‘of great historical importance from the point of view of preservation of significant historical 57 The ADB’s Story data and as a sound interim measure’. He looked forward to the ‘unlikely day when some organization or editorial board would empower them to undertake the organization of a dictionary which will become the work of a great mass of historical scholars in this country’.17 John La Nauze at Melbourne also temporised about the foreseeable future of a dictionary but made suggestions on register items, as did Geoffrey Serle.18 Other history professors also recorded their willingness to share information and to encourage their postgraduate students to supply biographical data from their theses.19 Initially, Hancock had conceded much to Fitzhardinge’s register concerns. Reflecting later on the early history of the dictionary project in ‘Retrospect and Prospect’, he recalled, ‘[w]ith me this phase lasted one year. 17 ‘Organization and Development’, box 67, Q31, ADBA, ANUA. 18 Geoffrey Serle, ‘Report on ANU Biographical Card Index and the Possibility of a Concise DNB’ (n.d., before 4 November 1957), ‘Suggested projects’ file, box 57, Q31, ADBA, ANUA. 19 W. K. Hancock to all professors of history in Australia (7 October 1959); see, for example, John McManners to W. K. Hancock (14 October 1959), box 67, Q31, ADBA, ANUA. 20 Keith Hancock, ‘ADB: Retrospect and Prospect’ (18 June 1963), box 69, Q31, ADBA, ANUA. 21 A. Mozley, ‘The Project of a National Register and a Dictionary of Australian Biography’, a work-in- progress seminar to the Department of History, RSSS, ANU (23 April 1959), box 67, Q31, ADBA, ANUA. 22 Minutes, Provisional ADB Editorial Committee meeting (19 June 1959), box 64, Q31, ADBA, ANUA. p p ( ) 21 A. Mozley, ‘The Project of a National Register and a Dictionary of Australian Biography’, a work-in- progress seminar to the Department of History, RSSS, ANU (23 April 1959), box 67, Q31, ADBA, ANUA. 22 Minutes, Provisional ADB Editorial Committee meeting (19 June 1959), box 64, Q31, ADBA, ANUA. ) gg p ji W. K. Hancock to all professors of history in Australia (7 October 1959); see, for example, John McManners ( ) 20 Keith Hancock, ‘ADB: Retrospect and Prospect’ (18 June 1963), box 69, Q31, ADBA, ANUA. ADB archives It was not until late 1958 or early 1959 that we really got going’.20 He now seized on the cooperative responses from the universities as a go-ahead for formulating definite plans for moving the dictionary project forward. In response to the university departments’ and public libraries’ ‘criticisms and comments’, I presented a seminar to the Department of History in April 1959 considering the difficulties and outlining a plan ‘for moving ahead with the long term project— the production of a Dictionary of Australian Biography’, to elicit colleagues’ comments on organisation, finance and editorial policy.21 Hancock began to settle his plans on a small central steering committee within the history department to consider organisation and finance, and a committee of the State universities, drawn in the first instance from members of the history departments, to be responsible for advising on the selection of subjects and contributors. He envisaged a ‘biographical centre’ with a research fellow and assistants. The provisional editorial committee of the dictionary, comprising Hancock, Davidson, Manning Clark, Fitzhardinge, Gollan and myself, first met, under Hancock’s chairmanship, on 19 June 1959.22 It defined its objectives as ‘the publication of the Dictionary within ten years’ and discussed three different methods of approach 1. publication of the work in strictly alphabetical arrangement on the model of the Dictionary of National Biography 1. publication of the work in strictly alphabetical arrangement on the model of the Dictionary of National Biography 2. publication in chronological order, the method adopted by the Canadian Dictionary of Biography 2. publication in chronological order, the method adopted by the Canadian Dictionary of Biography 3. arrangement by subject headings. 3. arrangement by subject headings. 58 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 While no decision was reached, the Canadian ‘chronological’ model was recommended. To make a start, two working parties were appointed as pilot schemes, one on the period of the naval governors (1788–1809), and the second relating to the Pacific region. ( g ), , Q , , 25 Minutes, ADB Editorial Committee meeting (1 October 1959), box 64, Q31, ADBA, ANUA. g p M. H. E. [Malcolm Ellis] to W. K. Hancock, ‘Notes on the Suggested Design of Organisation’ (n.d.), and lcolm Ellis to W. K. Hancock (25 August 1959), box 68, Q31, ADBA, ANUA. 26 W. K. Hancock to M. H. Ellis (13 October 1959), box 68, Q31, ADBA, ANUA. 27 W. K. H. to Mrs Mozley (n.d.), and, in reply, Mozley to Hancock (30 August 1959), box 69, Q31, ADBA, ANUA. g ( ) 26 W. K. Hancock to M. H. Ellis (13 October 1959), box 68, Q31, ADBA, ANUA. 23 ‘ADB Editorial Board, Agenda, Report and Minutes, 1959–61’, box 64, Q31, ADBA, ANUA. g p M. H. E. [Malcolm Ellis] to W. K. Hancock, ‘Notes on the Suggested Design of Organisation’ (n.d.), and l l Elli t W K H k (25 A t 1959) b 68 Q31 ADBA ANUA 24 M. H. E. [Malcolm Ellis] to W. K. Hancock, ‘Notes on the Suggested Design of Organisation’ Malcolm Ellis to W. K. Hancock (25 August 1959), box 68, Q31, ADBA, ANUA. E. [Malcolm Ellis] to W. K. Hancock, Notes on the Suggested Design of Organisation (n.d.), and llis to W. K. Hancock (25 August 1959), box 68, Q31, ADBA, ANUA. 23 ‘ADB Editorial Board, Agenda, Report and Minutes, 1959–61’, box 64, Q31, ADBA, ANUA. 24 M. H. E. [Malcolm Ellis] to W. K. Hancock, ‘Notes on the Suggested Design of Organisation’ (n.d.), and Malcolm Ellis to W. K. Hancock (25 August 1959), box 68, Q31, ADBA, ANUA. 25 Minutes, ADB Editorial Committee meeting (1 October 1959), box 64, Q31, ADBA, ANUA. 26 W. K. Hancock to M. H. Ellis (13 October 1959), box 68, Q31, ADBA, ANUA. 27 W. K. H. to Mrs Mozley (n.d.), and, in reply, Mozley to Hancock (30 August 1959), box 69, Q31, ADBA, ANUA. ADB archives The history department, the meeting agreed, would carry the financial burden of the dictionary for some time.23 The provisional editorial committee held its second meeting on 1 October 1959 to discuss the organisational plan that Ellis had devised and presented to Hancock in August.24 Topped by a designated ‘Board of Control’ of four prominent men drawn from commerce, finance and the professions, and headed by a distinguished citizen, such as chief justice Sir Owen Dixon, it prescribed substantial money from government and private sources, an administrative office with a director, an administrative editor, the establishment of State working parties, a national advisory panel of State representatives, and the commissioning and payment of authors. At this meeting, it was agreed that the provisional editorial committee should be formally constituted as the Editorial Board, which would be the central body of the dictionary, located at the ANU, and ‘available for meetings at short notice’.25 Ellis’s ‘tycoons’ (as Hancock called them) were set aside, and academics, Hancock, Clark, Davidson, Fitzhardinge and Gollan, and also Mozley, were named as permanent members of the board. Members of a national committee would be included on a geographical basis. Editors of successive volumes would be invited to join the board for the currency of their volumes. Hancock wrote enthusiastically to Ellis: ‘I think that the proposed scheme, if it wins a majority approval, will work. Something like it worked very well in my thirty-volume series of War Histories’.26 Ellis’s suggestion of one of his younger friends as a possible editor was tactfully declined. The concept of a chronological basis for dictionary entries was endorsed. At the time, Hancock attributed ‘breakneck speed’ on organisation, content and publication plans to ‘the zeal of Malcolm Ellis’; while I, too, found ‘Ellis’s zeal … compelling’, we discussed the ‘overcomplicated’ plans and ‘difficulties’.27 Meanwhile, Hancock dispatched letters to the key representatives of university history departments—John Ward and A. G. L. (Alan) Shaw at Sydney University, Gordon Greenwood at Queensland, Frank Crowley at Western Australia, Douglas Pike at Adelaide, Auchmuty at Newcastle and Malcolm McCrae at Hobart—inviting them to come to Canberra to discuss the formation of the National Advisory Committee. ADB archives Simultaneously, he sought the formalisation of 59 The ADB’s Story The ADB’s Story the Editorial Board as an ‘instrument of the university’, authorised to make agreements with editors and contributors in the university’s name from the ANU vice-chancellor.28 Early in 1959, I had made an exploratory trip to Adelaide and Perth, where the ANZAAS conference was in session, to, as Hancock put it, ‘make my face known’. I did. Involved in a car over-spin on the road at Tailem Bend, near Adelaide, I arrived with my face littered with cuts. In both capitals, I met with the professors of history, specialists in Australian history and interested members from other institutions, including the State archives and libraries. It proved a most lively time. As the prospective dictionary’s administrator, I made direct connections with likely key participants and found a remarkable sense of commitment to the dictionary idea. I noted on my return to Canberra that ‘the overall response was one of wide and genuine approval of the plan’. Amid expressions of surprise that we had progressed so far, academics and librarians endorsed the need for a ‘full scale Dictionary of Australian Biography’, and judged it as ‘the rightful task’ of a national university.29 The outcome was immediate action. In Adelaide I met with a provisional State working party, instantly convened under Douglas Pike as chair and including Ken Inglis and Harold Finnis. Hugh Stretton offered a strong commitment of help. This group at once drew up an initial list of inclusions for the period 1851–1900, and recommended that articles be ‘candid and unbiased’ and drawn widely from contributors to offset any ‘progenitor’ emphasis in that State’s selection. In Perth, equally positive, Frank Crowley called together a provisional WA working party, consisting of the government archivist, Mollie Lukis, Geoffrey Bolton (a recent research fellow from the ANU, who was attending the ANZAAS conference) and myself to discuss the State’s situation. Crowley intended to add Alexandra Hasluck to the group immediately. A plan also shaped there for a second Biographical Register monograph; G. C. Bolton and Ann Mozley, The Western Australia Legislature 1870–1930, was published in 1961.30 On the way back to Canberra, I visited Hobart and invited a working party to meet under McCrae’s chairmanship at the University of Tasmania. 28 ‘Organization and Development’ file, box 67, Q31, ADBA, ANUA. 29 Ann Mozley, ‘Report of My Journey to Perth, Adelaide, Melbourne and Hobart, August–Sept 1959’, box 69, Q31, ADBA, ANUA. 30 G. C. Bolton and Ann Mozley, The Western Australian Legislature, 1870–1930 (Canberra: Australian National University, 1961). 28 ‘Organization and Development’ file, box 67, Q31, ADBA, ANUA. ADB archives Members included the State archivist, Robert Sharman, the journalist and former clerk of the House of Representatives Frank Green, Janet MacCrae (research assistant in the history department) and the president of the Tasmanian Historical Research Association, Robert Garvie. The Tasmanian situation was unusual. While its members had a declared interest in the period 1788–1850, none had specialist 60 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 knowledge and would rely on suggestions for inclusion from New South Wales and Victoria. It was anticipated that a different membership would deal with the next period (1851–1900). knowledge and would rely on suggestions for inclusion from New South Wales and Victoria. It was anticipated that a different membership would deal with the next period (1851–1900). In Melbourne, Serle made thoughtful criticisms and suggestions for membership of a Victorian working party to work on the first volume. He urged, in these early days of Australian historical research, ‘flinging the net wide in order to bring in good people’ to write articles, including members of historical societies and ‘first class schoolmasters’.31 The formation of working parties was fundamental to the dictionary’s advance. In a period when Australian historiography was only slowly beginning to gather depth and range, the working parties were conceived as the essential mechanism for an Australia-wide participation in the dictionary’s growth. The first working party on the period of the early governors had begun its meetings in early August 1959. Attended by Hancock, Fitzhardinge, Gollan, Clark, Ellis and myself, it laid down some specific policies. On Ellis’s suggestion, it agreed to extend the scope of the first volume from 1788–1809 to 1788–1825 (eventually two volumes would cover the period 1788–1850). It recommended that experts should be set up in specific fields wherever they might be conveniently located (arts, science, military and the Pacific were cases in point) to draw up lists of names for inclusion, which would be referred in the future to the State working parties to circulate for criticism and advice. Also at this meeting (although this concept does not appear to have been formally recorded) the notion of including people in the dictionary in a chronological period on the basis of their floruit—the period of their main contribution to Australian life—was set in train. y y y 32 Ann Mozley, ‘The Australian Dictionary of Biography’, Historical Studies: Australia and New Zealand, 9, no. 35 (1960), pp. 313–14. 31 Mozley, ‘Report of My Journey to Perth, Adelaide, Melbourne and Hobart’. 31 M l ‘R t f M J t P th Ad l id M lb d H b t’ y 9, no. 35 (1960), pp. 313–14. ADB archives It was then, too, in my recollection, that we accepted the distinctive view that Hancock’s favoured principle of ‘span’ should be our guideline in the selection of names for inclusion and that, while we should cover all strands of Australian life from governors, chief justices, politicians, administrators and bureaucrats through to industrialists, artists, clergymen, scientists, writers, surveyors and engineers, we should also include some scoundrels and colourful vagabonds. Inclusions should also embrace those who, like Charles Darwin, Thomas Huxley, Anthony Trollope and Mark Twain, had visited Australia and contributed knowledge about the country.32 My reconnaissance around the States had yielded a consensus on working party approaches and methodologies, which I would later carry to the universities of New England and Queensland. These were incorporated into ‘A Manual of Instructions for Working Parties’, setting length, style and content of dictionary 61 The ADB’s Story entries. Articles were to have a minimum of 500 words and a maximum of 6000, while major articles would fall between 2000 and 4000 words. They were to be ‘factual, precise and unbiased’ but with critical appraisal and evocation of character and atmosphere. It was agreed that contributors should be unpaid according to the practice of Australian scholarly journals. The dictionary of biography, as a national enterprise, belonged to that class.33 The contacts I made personally with librarians and archivists in the States also fertilised work and the planning of shared resources for the Biographical Register. Hancock, with his rare skill for building bridges between colleagues, had received positive responses from the history professors for his plan of a national advisory panel or committee within the dictionary structure and their agreement to be the representatives of their State. The one exception was Gordon Greenwood. Replying from the University of Queensland in December 1959, he expressed the view that in his department the younger staff members had their own careers to make rather than turning to this new venture and that ‘the structure of the organization should give them more regional credit for their work than would appear likely under the proposed scheme of organization’. He felt that the national advisory committee was ‘a somewhat functionless body with little real influence’ and should either change places with the Editorial Board or be merged with it. 33 ADB, Working Party Procedures (3 November 1959), boxes 31 and 67, Q31, ADBA, ANUA. 34 Gordon Greenwood reply to Sir Keith Hancock (17 December 1959), box 67, Q31, ADBA, ANUA. 35 W. K. Hancock, ‘The Australian Dictionary of Biography’, presentation to the ANU Council (12 April 1962), box 69, Q31, ADBA, ANUA, p. 6. 3 Go do G ee wood ep y to S e t a coc ( ece be 959), bo 6 , Q3 , , NU . 35 W. K. Hancock, ‘The Australian Dictionary of Biography’, presentation to the ANU Council (12 April 1962), box 69, Q31, ADBA, ANUA, p. 6. 33 ADB, Working Party Procedures (3 November 1959), boxes 31 and 67, Q31, ADBA, ANUA. 36 M. H. Ellis, Lachlan Macquarie: Some Aspects of His Life (Brisbane: University of Queensland, 1942); M. H. Ellis, Lachlan Macquarie: His Life, Adventures and Times, with Reference Notes and Bibliography (Sydney: Dymocks, 1947); M. H. Ellis, Francis Greenway: His Life and Times (Sydney: Shepherd Press, 1949); M. H. Ellis, John Macarthur (Sydney: Angus & Robertson, 1955). ADB archives While he considered that the executive function should belong to the smaller group, for example, the Editorial Board, where the primacy of the ANU would be recognised, he felt strongly that ‘the formulation of general lines of policy … should be a function of a nationally constituted group’. Greenwood knew from my visit that the general proposals had received ‘enthusiastic endorsement’ elsewhere but he argued that Queensland was ‘perhaps the most difficult state’ owing to its size, dispersion of population and because ‘there had been so little serious historical published work’.34 Later, he warned Hancock, ‘[w]e will do nothing for the ANU. But there is nothing we will not do with the ANU’.35 He agreed, however, to serve on the National Committee and his intervention proved crucial. The far-flung National Committee, as it now became known, was to meet annually but conduct its business otherwise by correspondence. This arena fell to me. As the assistant editor, I was from the outset a member of the National Committee and the Editorial Board. 62 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 University of Newcastle Library, P041 37 F. Alexander, A. B. Gibson, M. Gowing and R. Gollan, ‘Hancock. Some Reminiscences’, Historical Studies, 13, no. 51 (1968), pp. 229–306. National collaboration and the Ellis interlude Throughout these events, Malcolm Ellis was assuming a growing presence in dictionary affairs. Born in Queensland in 1890, the son of a storekeeper and itinerant fettler, Ellis had won a scholarship to Brisbane Grammar School. He had risen through journalism in Brisbane, Sydney and London to become, in 1933, a special feature writer and columnist (‘Ek Dum’) for the Bulletin. The author of biographies of Lachlan Macquarie, Francis Greenway and John Macarthur,36 Ellis was a respected writer and historian, president of the Australasian Pioneers Club and of the Royal Australian Historical Society, and a man of wide and active contacts. From the outset Hancock saw Ellis’s independent involvement from outside academia as an imaginative addition to the dictionary’s evolution. This brought Ellis frequently to Canberra, where he stayed at University House, enjoying the Oxbridge rituals of ‘high table’, and where, as a resident, I saw much of him. His round, currant-bun face glowed with contentment. Early in November 1959, with Manning Clark, he was formally endorsed by the provisional Editorial Board as a joint editor of Volume 1 and as such became a member of the board. Yet, as we were soon to learn, he had a volatile temperament and, holding no degree, was touchily suspicious of academe. 63 The ADB’s Story Malcolm Ellis was one of the first recipients of an honorary doctorate conferred by the University of Newcastle, in 1966 University of Newcastle Library P041 Malcolm Ellis was one of the first recipients of an honorary doctorate conferred by the University of Newcastle, in 1966 University of Newcastle Library, P041 University of Newcastle Library, P041 University of Newcastle Library, P041 64 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 The Australian dictionary project had been launched in the belief that cooperative national scholarship and interest could compensate for the lack of external funding. Certainly we looked with some envy at other national dictionaries— Britain’s DNB, funded by Oxford University Press; The Dictionary of American Biography, brought out under the auspices of the American Council of Learned Societies; and the recently established Dictionary of Canadian Biography, about to be launched with a handsome bequest of $1 million. 40 Minutes, ADB Editorial Board meeting (1 October 1959), box 64, Q31, ADBA, ANUA. W. K. Hancock to John Ward (5 November 1959), discussing his memo to Sir Leslie Melville, box 66, Q31, ADBA, ANUA. ( ) pp 38 Mozley, ‘The Project of a National Register and a Dictionary of Australian Biography’, p. 8. y j g y g p y p 39 M. H. Ellis to A. Mozley (19 November 1959), on details of proposal with Angus & Robertson and arranging for Mozley to visit the press in Sydney; Mozley to Ellis (8 December 1959), box 68, Q31, ADBA, ANUA. 37 F. Alexander, A. B. Gibson, M. Gowing and R. Gollan, ‘Hancock. Some Reminiscences’, Historical Studies, 13, no. 51 (1968), pp. 229–306. 38 Mozley, ‘The Project of a National Register and a Dictionary of Australian Biography’, p. 8. 39 M. H. Ellis to A. Mozley (19 November 1959), on details of proposal with Angus & Robertson and arranging for Mozley to visit the press in Sydney; Mozley to Ellis (8 December 1959), box 68, Q31, ADBA, ANUA. 40 Minutes, ADB Editorial Board meeting (1 October 1959), box 64, Q31, ADBA, ANUA. W. K. Hancock to John Ward (5 November 1959), discussing his memo to Sir Leslie Melville, box 66, Q31, ADBA, ANUA. 41 Ann Mozley to Malcolm Ellis (16 December 1959), about MUP’s proposal; see also (25 January, 2 February 1960), box 68, Q31, ADBA, ANUA. 42 Minutes, ADB Editorial Board meeting (28 January 1960), box 64, Q31, ADBA, ANUA. 43 Chairman’s Notes for ADB Editorial Board meeting (9 November 1961), ‘Personal Notes, W. K. H. 5/12/61’, box 68, Q31, ADBA, ANUA. 44 Ann Mozley to W. K. Hancock, ‘Chronology of Publishing Arrangements’ (22 June 1960), box 66, Q31, ADBA, ANUA. National collaboration and the Ellis interlude But, as Hancock later summed up: ‘With a skeleton staff, limited funds and the enthusiastic co- operation of people all over Australia, the work began’.37 The Australian dictionary project had been launched in the belief that cooperative national scholarship and interest could compensate for the lack of external funding. Certainly we looked with some envy at other national dictionaries— Britain’s DNB, funded by Oxford University Press; The Dictionary of American Biography, brought out under the auspices of the American Council of Learned Societies; and the recently established Dictionary of Canadian Biography, about to be launched with a handsome bequest of $1 million. But, as Hancock later summed up: ‘With a skeleton staff, limited funds and the enthusiastic co- operation of people all over Australia, the work began’.37 Plans for publication had occupied our discussions as early as April 1959, when a kite was flown to the Oxford Clarendon Press and the virtues of the major Australian presses were examined.38 On 29 October 1959, a special meeting of the provisional Editorial Board was called to meet George Ferguson of the Sydney publisher Angus & Robertson, which had recently completed publication of the Australian Encyclopedia. Encouraged by Ellis, Angus & Robertson had offered an expression of interest. The meeting, which Hancock, Fitzhardinge, Clark, Gollan, Ellis and I attended, concluded with a decision to accept the Angus & Robertson offer if, as anticipated, it was formally made with sample pages and dummies.39 I visited the press in Sydney. At the same time, Hancock wrote to the vice-chancellor, suggesting that the Editorial Board be set up on a basis whereby it would make agreements with editors, contributors and voluntary consultants in the name of the ANU. The copyright of the work, he assumed, would be vested in the university and ‘whoever may publish’.40 65 The ADB’s Story Jim Davidson, professor of Pacific history, ANU, was a founding member of the ADB Editorial Board ANU archives, ANUA225-297, 1973 Jim Davidson, professor of Pacific history, ANU, was a founding member of the ADB Editorial Board ANU archives, ANUA225-297, 1973 66 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 While we awaited a specific follow-up from Angus & Robertson, Melbourne University Press (MUP) indicated their keen interest in the project and, in December 1959, sought informal discussions. National collaboration and the Ellis interlude Their proposal, outlined by the publisher, Gwyn James, gave more detailed provisions than any yet received from Angus & Robertson.41 Accordingly, the provisional Editorial Board, to which the ANU registrar, Ross Hohnen, and Leicester Webb, chair of the university’s publication committee, had been added, met on 28 January 1960 to discuss the position. Ellis did not attend. While the board noted that MUP’s overture had created a situation ‘not anticipated by the Board in October’ and that Angus & Robertson ‘were entitled to very real consideration’, no conclusion was reached and the matter was referred to the publication committee to report back. Ellis’s absence was particularly regretted.42 In February 1960 Hancock received Ellis’s first threat of resignation, over the decision to open negotiations with MUP, but, by swift action, he dissuaded him from doing so. Both Hancock and I were soon enmeshed in problems that loomed from Ellis’s ingrained disposition to dominate and a temperament entirely unsympathetic to the maxim ‘never resign; wait until you’re sacked’. During his three years with the dictionary, he resigned no less than six times before the seventh throw brought him down.43 In the event, on 8 April 1960, the provisional Editorial Board accepted the recommendation of the ANU publication committee to publish with MUP. Thereafter Webb, as chairman of the publication committee, became a member of the dictionary’s central board, which was entrusted with dealing directly on all publishing matters with the publisher.44 In February 1960 Hancock received Ellis’s first threat of resignation, over the decision to open negotiations with MUP, but, by swift action, he dissuaded him from doing so. Both Hancock and I were soon enmeshed in problems that loomed from Ellis’s ingrained disposition to dominate and a temperament entirely unsympathetic to the maxim ‘never resign; wait until you’re sacked’. During his three years with the dictionary, he resigned no less than six times before the seventh throw brought him down.43 In the event, on 8 April 1960, the provisional Editorial Board accepted the recommendation of the ANU In February 1960 Hancock received Ellis’s first threat of resignation, over the decision to open negotiations with MUP, but, by swift action, he dissuaded him from doing so. Both Hancock and I were soon enmeshed in problems that loomed from Ellis’s ingrained disposition to dominate and a temperament entirely unsympathetic to the maxim ‘never resign; wait until you’re sacked’. 45 Minutes, Conference of National Advisory Panel and ADB Editorial Board (23–24 April 1960), box 64, Q31, ADBA, ANUA. 46 W. K. Hancock, ‘Retrospect and Prospect’, box 68, Q31, ADBA, ANUA. 47 Minutes, Conference of National Advisory Panel and ADB Editorial Board (23–24 April 1960), box 64, Q31, ADBA, ANUA. 48 ‘Theaden: Portrait of a Marriage’, in Jim Davidson, A Three-Cornered Life: The Historian W. K. Hancock (Sydney: UNSW Press, 2010), pp. 421–56. National collaboration and the Ellis interlude During his three years with the dictionary, he resigned no less than six times before the seventh throw brought him down.43 In the event, on 8 April 1960, the provisional Editorial Board accepted the recommendation of the ANU publication committee to publish with MUP. Thereafter Webb, as chairman of the publication committee, became a member of the dictionary’s central board, which was entrusted with dealing directly on all publishing matters with the publisher.44 Undoubtedly the critical highlight of dictionary development was the conference of the National Committee and the Editorial Board held in Canberra on 23–24 April 1960, which marked a crowning national consolidation of dictionary affairs. Under Hancock’s chairmanship, it fused the Editorial Board with its permanent membership of Hancock, Clark, Davidson, Fitzhardinge, Gollan, Hohnen, Webb, Ellis and myself, with the State representatives John Ward, Greenwood, Auchmuty, Crowley, Pike and Russel Ward (representing the University of New England), La Nauze representing Serle, and A. G. L. Shaw, who was visiting Canberra from the University of Sydney. La Nauze and Shaw were promptly appointed members of the National Committee. The minutes 67 The ADB’s Story affirmed that the conference marked ‘a rearrangement and renaming of the existing constitutional framework … [that it] might more accurately reflect the national character of the work of the Dictionary’.45 The function of the newly arranged joint organisation was to deal with all matters of broad policy and procedure, including working parties, volume priorities, criteria for inclusion and instructions to contributors. The Editorial Board, made up predominantly of representatives of the ANU, retained its power to appoint editors, approve all financial proposals and make decisions on matters of publication. It would also carry out the executive tasks of the National Committee, which conducted its consultations by correspondence apart from its yearly meeting. Greenwood’s firm representations for a national body with full decision-making powers had triumphed. As Hancock later acknowledged, ‘we all owe him a great debt’.46 The April meeting of the National Committee was ready for action. Formally endorsing the decision to publish the dictionary in chronological slabs, it recommended that work on the second period (1851–90) should begin at once and that the question of appointing editors for these and later volumes covering 1891–1920 should be settled in the immediate future. National collaboration and the Ellis interlude The meeting also agreed, ‘with reluctance’, to abandon the title ‘Dictionary of Australian Biography’, already pre-empted by Percival Serle’s two volumes, and to accept the alternative title Australian Dictionary of Biography.47 The ADB was officially established! We entered into a new epoch in ADB affairs. Hancock’s wife, Theadon, died in March 1960 and he left Canberra for eight months at the end of July to take up a position as fellow of All Souls, Oxford.48 Geoffrey Sawer of the RSSS law department succeeded him as the ADB’s interim chairman. The ADB archives attest to the constantly expanding web of correspondence and consultation that formed the basis of this Australia-wide enterprise. These processes of communication fell to me, as its assistant editor, and, working through the records to write this chapter, I was startled by its size and range and the myriad typescripts of those formative days that reflect my self-taught, far from perfect typing skills! According to Hancock: We went ahead with determination but also with patience. The responsibility for planning has been put upon us, but we realised that in this national enterprise our plans for it would come to nothing unless 68 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 they were firmly grounded upon national support. Consultation and discussion were fundamental. At every stage, we submitted our plans to our colleagues in the Australian Universities.49 During his absence, Hancock remained connected to ADB affairs through a problem that continued as a dominant feature of these establishment days and made serious calls on patience and time. Central to the problem was Ellis’s refusal to work within the cooperative processes established between editors, working parties and the Editorial Board. In June 1960, alert to Ellis’s political antipathy to Manning Clark—Ellis, in a resignation letter to Hancock in June 1960, had described Clark as a ‘crypto- communist’—the board had accepted the proposal to separate their joint editorship and to give Ellis Volume 1 and Clarke Volume 2.50 Early that year the chairman of the NSW Working Party, John Ward, notified Hancock that ‘there seems no prospect whatever that he [Ellis] will work with us in what I am sure was originally intended as a partnership of editors and Working Parties’.51 Passing through Sydney, Hancock met Ward and sent me word that ‘we both believe our gains are likely to outweigh our anxieties. M.E. 50 W. K. Hancock to M. Ellis (27 June 1960), box 68, Q31, ADBA, ANUA. For a broader consideration of Ellis’s views about Clark, see Andrew Moore, ‘“History without facts”: M. H. Ellis, Manning Clark and the Origins of the Australian Dictionary of Biography’, Journal of the Royal Australian Historical Society, 85, no. 2 (1999), pp. 71–84. 49 Hancock, ‘Formation of the Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA. ( ) 51 See Malcolm Ellis to A. Mozley (18 September 1961); Note from Professor John Ward attached to NSW Working Party List (18 September 1961), box 69, Q31, ADBA, ANUA. 53 W. K. Hancock to Malcolm Ellis (3 October 1961); Chairman’s Notes for ADB Editorial Board meeting (9 November 1961), ‘Personal Notes, W. K. H. 5/12/61’, box 68, Q31, ADBA, ANUA. ) / / 54 Hancock to Mozley (November 1960), Moyal private collection, cited in Moyal, Breakfast with Beaverbrook, p. 142. 49 Hancock, ‘Formation of the Australian Dictionary of Biography’, box 69, Q31, ADBA, ANUA. 50 W. K. Hancock to M. Ellis (27 June 1960), box 68, Q31, ADBA, ANUA. For a broader consideration of Ellis’s views about Clark, see Andrew Moore, ‘“History without facts”: M. H. Ellis, Manning Clark and the Origins of the Australian Dictionary of Biography’, Journal of the Royal Australian Historical Society, 85, no. 2 (1999), pp. 71–84. 51 See Malcolm Ellis to A. Mozley (18 September 1961); Note from Professor John Ward attached to NSW Working Party List (18 September 1961), box 69, Q31, ADBA, ANUA. 52 W. K. Hancock to A. Mozley (Private collection). 53 W. K. Hancock to Malcolm Ellis (3 October 1961); Chairman’s Notes for ADB Editorial Board meeting (9 November 1961), ‘Personal Notes, W. K. H. 5/12/61’, box 68, Q31, ADBA, ANUA. 54 Hancock to Mozley (November 1960), Moyal private collection, cited in Moyal, Breakfast with Beaverbrook, p. 142. ANU archives, ANUA 225-222, 1977 National collaboration and the Ellis interlude is still the best editor for Vol 1, as far at least as knowledge is the qualification’.52 From the outset, Hancock had set himself the task of maintaining harmonious relations with this informed but quarrelsome member of the team. He hoped that Ellis ‘would gradually get used to academic habits of discussion and decision. But he didn’t’.53 As time went on and tensions continued to disturb working party progress in Sydney, the blue air letters that fluttered to my box from Hancock at Oxford reflected his attempt to grapple with the problem at a distance. In November 1960, he wrote me: I think it very desirable if possible to retain Mr Ellis, but not at any price. The Board may fairly ask the Editor to spread the work within reason. I think it should be prepared to raise matters such as this courteously and firmly in my absence. We can concede a good deal to an original personality.54 I think it very desirable if possible to retain Mr Ellis, but not at any price. The Board may fairly ask the Editor to spread the work within reason. I think it should be prepared to raise matters such as this courteously and firmly in my absence. We can concede a good deal to an original personality.54 69 The ADB’s Story Manning Clark jointly edited Volume 2 of the ADB and was a member of the Editorial Board until 1990 ANU hi ANUA 225 222 1977 Manning Clark jointly edited Volume 2 of the ADB and was a member of the Editorial Board until 1990 ANU archives, ANUA 225-222, 1977 70 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 I had some sympathy with Hancock’s desire to retain the independent historian on a long and encouraging lead; academic historians could be given to loftiness. But at the centre of affairs at headquarters, attitudes hardened, and, as a member of the NSW Working Party, I wrote to Hancock in November: Everything really depends on a decision that would ultimately be yours, whether Mr Ellis’s knowledge, zeal and speed, and the quality of the volume he might produce (of which he himself would probably write 70 per cent) outweigh all the hazards and disadvantages of trying to work with him along normal lines.55 In correspondence with Ward, Hancock agreed that he had misgivings over Volume 1 being ‘the collected papers of Malcolm Ellis’. y ( ) y p 56 A. Mozley to John Ward (6 September 1960), box 27, Q31, ADBA, ANUA. 55 Moyal to Hancock (November 1960), Moyal private collection. y ( ) y 58 Moyal, ‘Chronology of Progress’, box 66, Q31, ADBA, ANUA. y ( p ) to Hancock (November 1960), Moyal private collection National collaboration and the Ellis interlude Ellis would give the dictionary ‘a better start if he would spread the authorship more widely’.56 Later that month, in a further letter, I put on record: The salient thing that emerges from going through the Dictionary correspondence since the beginning of this year is the number of conciliatory letters that we have all written to Ellis, and the pains we have taken to go along with him. One might, with a detached eye, see him as a bully; it is hardly as deliberate as that; he is thoroughly disorganized, and, of course, with academics, insecure.57 A different picture of achievement with Period 2 began to emerge. We had moved ahead in laying the ground plan for the volumes covering the period 1851–90 with the appointment of three ‘provisional editors’—Greenwood, Ken Cable of the University of Sydney history department and Geoffrey Serle—with Gollan as convenor. I wrote to Hancock: The Dictionary has gathered pace. The New South Wales Working Party have picked out the major articles for the volume and offered contributors, and these lists are now circulating and drawing some very interesting and frank criticism which recommends the adoption of our democratic principles. The South and Western Australians are already writing their articles for this volume, both large and small. The Victorian picture will be clear within a few weeks. The Editor will then be able to embark on the assessment between states, and the whole pattern of the volume will be complete … So very real progress has been made.58 I urged Hancock to communicate the success of Volume 2’s constitutional processes to Ellis as an encouraging exemplar. He did, and in doing so, he set 71 The ADB’s Story down an illuminating picture of how he saw his chairman’s role, which, in all its unanticipated density and commitment, had come to him as the busy director of the RSSS as somewhat of a surprise. He told Ellis that one of his motives in returning to Canberra, having shed the office of director, was to leave himself more time for the dictionary.59 His letter to Ellis, written with an ameliorating tone, reflected a belief that ran strong in Hancock, that he could extract the best. 59 W. K. Hancock to M. H. Ellis (3 October 1961), box 68, Q31, ADBA, ANUA. 60 See Malcolm Ellis, ‘Dispute Between the Editor of Volume 1 and the Editorial Board’ (15 January 1962), box 68, Q31, ADBA, ANUA. 61 National Register Short List (Canberra: History Department, Australian National University, 1959). Biographical Register Short List. Supplement (Canberra: History Department, Australian National University, 1961). Biographical Register Short List (Canberra: Department of History, Australian National University, 1963). H. J. Gibbney and Ann G. Smith (eds), A Biographical Register 1788–1939: Notes from the Name Index of the Australian Dictionary of Biography (Canberra: Australian Dictionary of Biography, 1987). 62 Mozley, ‘The Australian Dictionary of Biography’. 63 Bolton and Mozley, The Western Australian Legislature. 59 W. K. Hancock to M. H. Ellis (3 October 1961), box 68, Q31, ADBA, ANUA. ( ) 60 See Malcolm Ellis, ‘Dispute Between the Editor of Volume 1 and the Editorial Board’ (15 January 1962), box 68, Q31, ADBA, ANUA. National collaboration and the Ellis interlude In a progress report for the period April 1960 to August 1961, Hancock concluded: ‘By any fair standard of comparison … a great deal has been achieved during the past sixteen months. We have solid grounds for satisfaction and confidence’.64 g ( g ) 65 Minutes, National Committee meeting (12–13 August 1961), box 64, Q31, ADBA, ANUA, p. 3. National collaboration and the Ellis interlude In May 1961 Ellis again threatened resignation unless arrangements were made to let him carry out his work ‘expeditiously and efficiently’, and twice more in September and November 1961 over relations with the NSW Working Party.60 Other ADB affairs moved forward. Judy Robinson and I produced the Biographical Register Short List to which she had been substantially adding information. Made available to working party chairs, it formed the basis of later editions and of Jim Gibbney and Ann Smith’s A Biographical Register 1788–1939 (1987).61 At the same time, I had written an article on the ADB, making public for the first time its development, methods and purposes.62 Bolton and Mozley’s The Western Australian Legislature 1870–1930 was moving towards completion.63 A provisional style manual was developed and copies sent to MUP and the editors. Communication with a number of key consultants abroad, whom we called informal correspondents, was set in train and, aided by Hancock’s presence in England, included Taylor Milne at the Institute of Historical Research, London, Phyllis Mander-Jones, the first Australian Joint Copying Project officer, who was based at the Australian High Commission, and the American historian Hartley Grattan. With Hancock’s return, a meeting of the National Committee was convened on 12–13 August 1961. The committee, as well as its core members, Hancock (chairman), Clark, Sawer, John Ward, Crowley, Auchmuty, Pike, Gollan, Shaw, McCrae, Hohnen, Ellis and myself, now included La Nauze, Serle and John Salmon. Allan Morrison stood in for Greenwood. Hancock categorised progress to date: the existence of working parties in each State plus two regional subcommittees of the NSW Working Party at Newcastle and New England; the Armed Services working group led by Gavin Long; and an informal subcommittee on foreign immigrant groups convened by Charles 72 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Price. Decisions on procedures for working parties were carefully stressed. A subcommittee on criteria consisting of Pike, Serle, Crowley, Gollan and myself was appointed; SA and WA entries had been commissioned; Queensland and Tasmanian lists had been finalised and major entries commissioned; plans for the period 1851–90 were in progress; and arrangements had been set in place for Serle’s provisional editorship and responsibility for Victoria and Tasmania, Pike’s for South Australia and Western Australia and Morrison’s for Queensland, with Gollan again acting as convenor. 64 W. K. Hancock, ‘The Need for a General Editor’ (July 1961), Agenda and papers, National Committee meeting (12–13 August 1961), box 64, Q31, ADBA, ANUA. 64 W. K. Hancock, ‘The Need for a General Editor’ (July 1961), Agenda and papers, National Committee meeting (12–13 August 1961), box 64, Q31, ADBA, ANUA. 65 Minutes, National Committee meeting (12–13 August 1961), box 64, Q31, ADBA, ANUA, p. 3. The need for a general editor On the meeting’s second day, Hancock, having experienced an evident sea change about his role as a de facto editor, presented a paper on ‘The Need for a General Editor’. He drew attention to the ‘rapidly accumulating’ business involving ‘Working Parties, Volume-Editors and contributors’, and foresaw the ‘heavy and meticulous editorial work’ that lay ahead. After paying tribute to me and my work, he also noted that ‘Mrs Mozley now wished to resign her position as Assistant Editor to enable her to accept an opportunity for individual research and writing’.65 He went on to say that the chairman and the assistant editor together could not provide the leadership required at the centre because they were not experts in Australian history able to deal with the detailed problems of scholarship. The assistant editor’s position, moreover, lacked ‘status and authority requisite for leadership’. Therefore a new position, that of general editor, was required. Hancock’s broad definition of the functions of a general editor were: to serve as the chief administrative officer of the dictionary, taking over (with as much assistance as necessary) all the secretarial and administrative channels of communication and functions now performed by the assistant editor; to act as secretary to the National Committee and as executive officer to the Editorial Board; as the chief academic officer of the dictionary, responsible for the coordination of policies, procedures and standards between volumes; and to visit the working parties once a year. He wrote with clarity: There emerges a fairly clear picture of the type of man required [women did not feature here]. He must have a knowledge of Australian society in historical breadth and depth, an awareness of conflicting historical interpretations where they exist and a sensitiveness to the trends of 73 The ADB’s Story scholarship, so as to ensure, so far as possible, that the Dictionary will neither be constricted by past-preoccupations, nor become the victim of ephemeral fashions, but will satisfy the needs of scholars for many generations to come.66 At the same time, Hancock notified that he had received a letter from Greenwood paying tribute to Mozley and putting his preference for a ‘team of four’ rather than a general editor. The National Committee, however, endorsed the proposal for a general editor ‘at the centre’ and a subcommittee of Hancock, Clark, John Ward, Serle, Pike and Gollan; Hohnen and Morrison (representing Greenwood) were appointed to pursue it. 66 Hancock, ‘The Need for a General Editor’ (July 1961), box 64, Q31, ADBA, ANUA, pp. 4–5. 67 Minutes, National Committee meeting (12–13 August 1961), box 64, Q31, ADBA, ANUA, p. 4. 68 See, for instance, W. K. Hancock to John La Nauze (27 October 1961); La Nauze to Hancock (12 November 1961), box 69, Q31, ADBA, ANUA. 69 For a discussion of the candidates, see, for instance, W. K. Hancock to John Ward (27 November 1961); G. Greenwood to W. K. Hancock (1 December 1961); G. Serle to W. K. Hancock (6 December 1961); G. Serle to Hancock (8 December 1961); J. Ward to W. K. Hancock (30 November 1961); Syd Butlin to W. K. Hancock (6 December 1961), box 69, Q31, ADBA, ANUA. Hancock, ‘The Need for a General Editor’ (July 1961), box 64, Q31, ADBA, ANUA, pp. 4–5. The need for a general editor A major function of the general editor would be to give guidance to the working parties—notably, on the work of other working party lists. And, in the fluidity of the moment, it was thought that the appointment should be ‘a young man … able to organize and edit and check articles and provide leadership’.67 Although the position of general editor was not advertised, word circulated in the ivory towers. Between October 1961 and February 1962, the National Committee subcommittee dealt with a veritable rollcall of possible candidates. It gave ‘unanimous and ardent’ support to La Nauze, then at Cambridge, who was tempted but declined on the grounds of his commitment to the history department at Melbourne.68 Most of the historical fraternity was sounded. Sydney Butlin at the University of Sydney was expressly invited but declined. Others, including Hugh Stretton, Ken Inglis and Allan Martin, were approached but did not want their names to go forward. An abundant short list—Crowley, Fitzhardinge, Serle, Shaw, Russel Ward, Gwyn James (from MUP), Don Baker (School of General Studies, ANU) and Adelaide historian John Tregenza— confronted the subcommittee. Hancock ruled Fitzhardinge out, believing he should not interrupt his work on the biography of Billy Hughes on which he had been long engaged. Baker, an exceptional teacher in his forties, yet to make his reputation in research and publication, was a popular candidate.69 The last man standing was Pike. A member of the subcommittee, he had twice declined attempts to interest him in the post as he had recently taken up a chair of history at the University of Tasmania; but with his deep interest in the ADB, he was prevailed upon to take the general editorship. Hancock wrote him winningly in December 1961: ‘I can imagine no greater service that any 74 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 historian could render just now to academic standards in Australia’.70 Even the vice-chancellor of the University of Tasmania, about to lose his professor of history, thought that Hancock was right to think Pike was ideal for the job.71 There was one obstacle arising from his recent move to Tasmania and his appointment was proposed on a part-time basis for two years until his permanent physical transfer could be made. Pike’s acceptance was reported to the Editorial Board meeting of 6 February 1962. A new era in the ADB’s affairs was about to begin. g y ( p ) 73 Minutes, ADB Editorial Board meeting (13 December 1961), box 64, Q31, ADBA, ANUA. 72 See Malcolm Ellis to Ann Mozley (18 September 1961); Note from Professor John Ward attached to NSW Working Party List (18 September 1961), box 69, Q31, ADBA, ANUA. g ( ) 74 W. K. Hancock to M. Ellis (20 December 1961), box 68, Q31, ADBA, ANUA. ( ) ( y ) 71 Keith S. Isles, Vice-Chancellor of University of Tasmania, to W. K. Hancock (21 March 1962), box 69, Q31, ADBA, ANUA. ( ) 75 Minutes of an Extraordinary ADB Editorial Board meeting (2 February 1962); M. H. Ellis to W. K Hancock (1 February 1962); Hancock to Ellis (2 February 1962), box 64, Q31, ADBA, ANUA. 70 W. K. Hancock to D. Pike (8 December 1961); see also Pike to Hancock (7 December 1961); Hancock to Pike (12 December 1961); Hancock to Pike (4 January 1962), box 69, Q31, ADBA, ANUA. ( ) ( ) Pike (12 December 1961); Hancock to Pike (4 January 1962), box 69, Q31, ADBA, ANUA. 71 Keith S. Isles, Vice-Chancellor of University of Tasmania, to W. K. Hancock (21 March 1962), box 69, Q31, ADBA, ANUA. 75 Minutes of an Extraordinary ADB Editorial Board meeting (2 February 1962); M. H. Ellis to Hancock (1 February 1962); Hancock to Ellis (2 February 1962), box 64, Q31, ADBA, ANUA. y g ( y ) Hancock (1 February 1962); Hancock to Ellis (2 February 1962), box 64, Q31, ADBA, ANUA. 70 W. K. Hancock to D. Pike (8 December 1961); see also Pike to Hancock (7 December 1961); Hancock to Pike (12 December 1961); Hancock to Pike (4 January 1962), box 69, Q31, ADBA, ANUA. 71 Keith S. Isles, Vice-Chancellor of University of Tasmania, to W. K. Hancock (21 March 1962), box 69, Q31, ADBA, ANUA. The need for a general editor Other events had also introduced change. There was continuing dissent and disagreement within the NSW Working Party over who should write the contributions on the major governors. Ellis had signalled to Hancock in Oxford: ‘I am setting myself to do all the Governors, all of their periods except Phillip, of whom I have a reasonable knowledge, are at my fingertips’; Ward had indicated that the ‘Working Party is strongly of the opinion that no one author should write the biographies of more than two governors’ on grounds of principle.72 Ellis offered his sixth and, as it proved, fatal threat of resignation, as editor of Volume 1, to the chairman early in December 1961. An Editorial Board meeting on 13 December resolved that, as confidence no longer existed on either side, between Ellis and the board, the chairman request him to submit his resignation no later than 10 days from the date of the chairman’s letter.73 Hancock’s letter of 20 December thanked Ellis for his valuable assistance to the dictionary and expressed the hope that he would continue to contribute his knowledge to it.74 At its meeting in February 1962, the board accepted Ellis’s written letter of resignation and appointed Alan Shaw as editor of Volume 1.75 At his own request, Ellis remained a member of the National Committee to lend his knowledge and scholarship to the work but, in one of those swift changes of mind that marked his volatile personality, he asked that all reference to ‘conflicts’ with the Editorial Board and the National Committee be removed from the records. They were. His intemperate words were destroyed. Other events had also introduced change. There was continuing dissent and disagreement within the NSW Working Party over who should write the contributions on the major governors. Photographer: Peter Fitzgerald, ADB archives The need for a general editor Ellis had signalled to Hancock in Oxford: ‘I am setting myself to do all the Governors, all of their periods except Phillip, of whom I have a reasonable knowledge, are at my fingertips’; Ward had indicated that the ‘Working Party is strongly of the opinion that no one author should write the biographies of more than two governors’ on grounds of principle.72 75 The ADB’s Story ANU vice-chancellor Ian Chubb and the ADB’s first member of staff, Ann Moyal, cut the ADB’s fiftieth birthday cake, December 2009 Photographer: Peter Fitzgerald, ADB archives The ADB’s Story ANU vice-chancellor Ian Chubb and the ADB’s first member of staff, Ann Moyal, cut the ADB’s fiftieth birthday cake, December 2009 Photographer: Peter Fitzgerald, ADB archives 76 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Ellis, however, had not finished with the dictionary.76 Frustrated and unforgiving, he resigned from the National Committee and, cutting all links and contributing not one word, he published his detailed assault upon the ADB, its organisation and his own dealings with it in a long article in the Bulletin on 15 June 1963, entitled ‘Why I Have Resigned: The Australian Dictionary of Biography—Intrigues, inefficiency, incompetence’. He demanded that the vice- chancellor set up a public inquiry into the conduct of the ADB’s administration. The registrar wisely counselled Hancock against attempting to answer. Hancock came to believe that Ellis was indeed a ‘peacock among parrots’ (as Ellis had described himself on one occasion). For his part, Hancock thought, in retrospect, that he had underestimated the vast differences in the ‘intellectual and practical experience between Ellis and “university people”’.77 The experience had been, as Fitzhardinge shrewdly put it, ‘very much like building your home on the top of a volcano’.78 76 M. H. Ellis to W. K. Hancock (6 and 7 June 1963), box 65, Q31, ADBA, ANUA. 77 ‘Notes for Concluding Speech by W. K. H. (to be departed from or elaborated according to circumstances): [L. F.—please advise me what to cut out]’, 8 pp. (n.d., c. June 1963), box 68, Q31, ADBA, ANUA. 78 Fitzhardinge interviewed by Ross (1987). 79 Ann Mozley’s Letter of Resignation (8 March 1962), box 66, Q31, ADBA, ANUA. 80 Moyal, Breakfast with Beaverbrook, p. 149. Dr Ann Moyal is a historian with a special interest in Australian science and technology. 80 Moyal, Breakfast with Beaverbrook, p. 149. Document In 1959 Ann Moyal (then Ann Mozley) set off on a trip around Australia to set up working parties for the fledgling dictionary project and to source material for the National Register. Report of My Journey to Perth, Adelaide, Melbourne and Hobart, August–Sept. 1959 I shall submit the report in two parts; (1) steps taken in connection with the Dictionary of Australian Biography, and (2) discussion and proposals on the work of the National Register. Conclusion For my part, I agreed with Hancock’s reasoning about the need for a general editor and I looked forward to returning to historical research. I would stay with the ADB for a seven-month interim period as Pike made a transition into the work.79 My own conclusion on the establishment era, despite the high demands of the task, was that it had been a period of formidable achievement from which we were handing a solid legacy to the first general editor of the ADB. For me, it had been a particularly rewarding experience, working closely with Hancock on so important and pioneering a national venture. I enjoyed the title bestowed on me subsequently by a deputy editor, Chris Cunneen, of ‘Founding Mother’!80 77 77 The ADB’s Story Plans for Volume 1 In Hobart, after talking with Professor McManners81 and Mr McRae, and independently with Mr. Sharman (the State Archivist) I invited a Working Party to meet and advise on the existing list of inclusions for the period 1788– 1825 and to make suggestions. Its members are Mr. McRae, Chairman, Miss Janet McRae (Research Assistant in the History Department responsible for the collection of Tasmanian Historical Documents), Mr. Sharman (who will be replaced by Mr. P. Eldershaw, member of the Archives staff when Sharman leaves in October), Mr. Frank Green (journalist and ex-Clerk of the House) and Mr. Garvie (President of the Tasmanian Historical Research Association and founder member of Tasmanian Historical Records Society). It has been suggested that the Chairmanship should pass to Miss McRae when her brother goes on study leave in November. This is a rather unusual Working Party; none of its members have a specialist knowledge of the period though all have a real interest in it. Their contribution will therefore be more of an industrious researching into claims for inclusion than the decisions from experience made by Malcolm Ellis. For this reason they proposed that we should use the help and advice of members of the Tasmanian Historical Research Association for expert opinion on particular small aspects of the early period and I have a list of interested members for this purpose. The Working Party also acknowledged that they would have some difficulty in nominating contributors for Volume 1 as there is a dearth in Tasmania of persons qualified to write on the first 25 years. Suggestions, they felt, would have to come in the main from N.S.W. and Victoria. The military and naval people, for example, would certainly be better dealt with from N.S.W. A second meeting of the Working Party was called for September 16 and I now expect their amended list for Volume 1 together with a short Appendix list to supplement Professor Manning Clark’s. As there was a meeting of the Tasmanian Historical Research Association while I was in Hobart, I was able to talk with many of the people to whom we will circulate the proposed list of inclusions. This is a most robust and lively association and their co-operation and interest in the Dictionary seems assured. I have, in addition, made arrangements with the editor of their journal to publish the list of Tasmanian inclusions in Vol. 1 (and any N.S.W. 81 John McManners (1916–2006) was a cleric and historian of British religion and the Ancien Régime. 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Plans for Volume 1 Dictionary of Australian Biography My journey has been a most profitable one. I have now had the opportunity of discussion and conversation with members of the History Departments of the four Universities, and in particular with the specialist Australian history staffs; with interested members of other Departments whom we might later want to co-opt to the Dictionary work; with the Archivists and Libraries of each centre; and, particularly in Tasmania, with the members of the Historical associations whose help with the early volumes of the Dictionary will be important. The overall response in all these discussions has been one of wide and genuine approval of the plan and a readiness to carry enthusiasm into action as soon as invited to do so. There was considerable surprise that we had progressed so far, though the view was general in academic and library circles that there was a need for a fullscale Dictionary of Australian Biography, and that now was the time to begin. Everyone agreed that this was the rightful task of a National University. In view of this most positive reaction, it seemed appropriate to accept suggestions for provisional Working Parties and to arrange exploratory meetings. I did this in Adelaide, Perth and Hobart. With Professor La Nauze’s coming visit to Canberra, there were no round table discussions in Melbourne, but I found my talk with Dr. Serle particularly profitable and encouraging. 78 82 In 1959 and 1960, Period 1 was planned to be up to 1825; and Period 2 1826–50. It was decided to amalgamate the first two periods at the National Committee meeting of 13–14 August 1964. Plans for Volume 1 figures with Tasmanian connections) in this year’s last issue. This will give the list the widest possible circulation. Outside the Working Party, Professor McManners gives his blessing to the plan though he contemplates no active part in it himself. He has a proprietary interest 79 The ADB’s Story in the collection of Historical Documents by the History Department and feels that the gradual discovery of this material may provide good reason for a later reprinting of the Dictionary in straightforward alphabetical arrangements, when new light has been thrown on the earlier periods,82 but this he feels is no argument for holding up the work now. Plans for Volume 2 In each of the Universities I discussed our ideas for producing a second volume of the Dictionary, possibly in 1963. The concept of two chronological volumes covering the entire early period of the Australian Colonies, and produced almost simultaneously, was a popular one, and there seems no good reason against embarking on the early work of the second volume right away. In each State I formed the impression that while the History Departments are quite hard pressed on their own projects, they were genuinely disposed towards being identified with the Dictionary and making a start on it now. South Australia In Adelaide, Dr. Douglas Pike is a strong advocate of the Dictionary plan and supports our ideas of centralisation in Canberra and an Advisory Committee consisting of one representative from each University to act in a consultative capacity. He would be the obvious choice for this and has expressed his readiness to take charge of the South Australian Working Party on the 1825–50 period. Dr. Grenfell Price was proposed as the second member of the team, and Mr. Finnis (local historian on the early period). Another candidate would be Mr. Pitt, former Principal Librarian who began the Archives’ biographical index. At a provisional meeting of the Working Party, Dr. Pike presented a preliminary list of S.A. names for inclusion in Volume 2, which discussion reduced to 52. The amended list is attached. The intention was to have a further meeting with Dr. Grenfell Price (who was unable to join us in Adelaide) and to consider lengths for the proposed biographies. Dr. Pike thinks that the minimum length for a biography should not be more than 400 words; he contends that the articles should be candid and unbiased, maintaining that the Dictionary will afford an opportunity of reducing some historical figures to size. His chairmanship should, I feel, offset the danger of the ‘progenitor’ emphasis in the S. Australian selection. He thinks we should consider extending the date of Volume 2 to 1856. The position in South Australia is therefore that a Provisional Working Party has been nominated, and we have a preliminary list for circulation. Dr. Price 80 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 (who seems to have some reservations in view of his other commitments) is visiting Canberra in November and will talk with us then. If expansion of the Working Party seems desirable, Mr. Pitt might be invited to join it. Professor Stretton endorsed the project and has offered to appoint a Research Assistant in the Department to help in the basic work for the S.A. contributions, a certain amount of which is likely to devolve on Dr. Pike. Among other members of the History staff there seems to be a very real interest in the Dictionary and, in particular, Dr. Inglis should be helpful when we reach the later period. The Archives people have also promised their support. Western Australia In Perth, Dr. Crowley’s reaction was most enthusiastic and positive, and he at once offered to draw up a tentative list of inclusions for Western Australia up to 1850. I took the opportunity therefore, as G. Bolton was also in Perth, to organise a provisional Working Party of Dr. Crowley, Miss Mollie Lukis (Government Archivist), Mr. Bolton and myself to discuss the W.A. position. Mrs Alexandra Hasluck has been nominated as a fourth member of this Working Party, and she has the advantage of links in both Perth and Canberra. The Western Australian contribution to Volume 2 will, of course, be comparatively small. The list which the Working Party considered when it met, contains 25 names of which a number have been marked for review against the other lists in order to determine relative importance. It was agreed that this method of comparative assessment would be the most satisfactory way of determining final allocation between the States. The W.A. list is hence essentially provisional; it does provide some estimate of lengths of proposed biographies. In the case of the West it was suggested that the practice of the D.N.B. in amalgamating the lives of father and son when one is of lesser distinction, could usefully be applied. This Working Party shared the view that we have set our minimum wordage too high. Dr. Crowley and Miss Lukis will certainly form a competent and hard working nucleus of the W.A. Working party, and Mrs. Hasluck would give it another dimension if she can be persuaded to join. The question of contributors is not likely to present many difficulties here; there are several obvious choices of authors, and Dr. Crowley will undertake two or three major ones, although there is a prospect of his absence in Malaya for two years. Miss Lukis has offered to do any research in the archives on the minor characters. The Working Party has supplied me with the names of persons among whom the list of inclusions should be circulated. 81 81 The ADB’s Story Victoria In Melbourne, Dr. Serle gave me much of his time and many thoughtful criticisms and suggestions. He expressed the keenest interest in our proposals, and despite his own present undertakings, I am sure we can anticipate some very constructive help from him. He recommends the following members for a Working Party on the 1825–50 period. Mrs. June Philips (Department of History), Philip Brown, Ian McLaren (Chairman of Historical Society) and himself. He would be willing to chair this group. One of the members of the Melbourne Library should, with the advice of the Librarian, be added to it. Dr Serle has also given me names of a number of people who will be useful for consultation on the lists of inclusions. He is also ready to make Historical Studies available to publicise the Dictionary project and for the publication of proposed lists of inclusions. The list for Volume 1 should, desirably, be printed in the March number. He advises that we should bring in the Historical Societies to help us as consultants, and that we should aim to associate some first class schoolmasters with the writing of Dictionary articles, flinging the net wide in order to bring in good people. Importantly, he proposed that we should also be considering constituting a Working Party for the post 1850 period, as from the Victorian viewpoint, this will be when the strain will be felt, and that we should begin now accumulating material on these more difficult years. This view is endorsed by Professor La Nauze who would, I gather, be prepared to take on the chairmanship (possibly with Professor Crawford or with Dr. Serle) of a later Working Party. Geoffrey Blainey is recommended as someone who would be a particularly useful member. Professor La Nauze feels that this long term group should at least make an early start drawing up names and estimating the problems. He has offered that a Department Research Assistant could be made available to help in the work. The first step in Victoria is to assemble the 1825–50 Working Party (Mrs. Philips has indicated her willingness to join) to draw up a list; with this in progress we will be in a position to think in terms of the post 1850 Party. Tasmania The problem of two concurrent Working Parties arose in Tasmania. The view of the History Department was that the Working Party for Volume 2 should be drawn from completely different personnel than those engaged on the early period in order to ensure speed of production. Two names have been agreed upon, and others have been put up for consideration. 82 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Mr. John Reynolds (who recalls your first advocacy of a Dictionary in the late 1920s) has offered his help. His own researches now lie in the field of Victorian mining and company history post 1850 and in later political biography and he has undertaken to give us consultative assistance there. At the same time he has agreed to work on the Tasmanian Working Party 1825–1850, and would be willing to take the chair. Mr. K. Dallas of the Economics Department has also consented to join. Mr. John Reynolds (who recalls your first advocacy of a Dictionary in the late 1920s) has offered his help. His own researches now lie in the field of Victorian mining and company history post 1850 and in later political biography and he has undertaken to give us consultative assistance there. At the same time he has agreed to work on the Tasmanian Working Party 1825–1850, and would be willing to take the chair. Mr. K. Dallas of the Economics Department has also consented to join. Of the other names advanced, no real agreement existed in Hobart. Mr. von Steigletz, a Launceston local historian strongly recommended by Mr. Reynolds, was not supported by the academics; Mr. Stancombe of Launceston would make a sensible contribution but his specialist interests are surveyors and highways; Professor Townley, Department of Political Science, though he contends that he has moved away from historical interests of the last century into the post 1930s, would, I imagine, respond with the right approach. My own feeling is that we should, in part, resist the opinion of the History Department and induce Miss McRae to sit in on the second Working Party as the documents she is investigating relate particularly to this period; and that we should also have an Archives representative, either Mr. Stilwell or Mr. Eldershaw, on this committee. We could continue to circularise the Historical Association and Royal Society members for this later period. Mr. Tasmania Reynolds, who showed a lively interest in our plans, underlines that we should be thinking about building up personal recollections of important recent figures from competent living contemporaries—if necessary by a process of interviewing and recording first hand impressions. The ADB’s Story I gathered some opinions from people like Dr. Serle, Professors McManners and Stretton, Dr. Pike and Dr. Crowley on general questions of editorship. The proposal for separate editorship of each volume was a popular one among them. Finally the question of paying contributors seems to be clearly settled. There is certainly no question of it among academics, and in each Working Party the view was held that contributors would be found outside the range of freelance journalists and writers who would expect remuneration. Members of historical associations are most willing to give their help and their time and the Serle suggestion of using competent schoolmasters has much to recommend it. National Register Work Conclusions All these steps taken so far will need consolidating, and it seems desirable to constitute the Working Parties—which have in most cases already acted—by formal invitation as soon as possible. I have indicated that we hope to clarify problems of organization and procedure after October, but I think my discussions and provisional arrangements should be underwritten from here before this. On organizational questions, there is no doubt that we will have support for centralization in Canberra, this is accepted everywhere as the obvious course. The University people felt that the proposed Advisory Committee of one of their members from each State, and acting in an advisory role would be adequate machinery for identifying them with the project. It would be helpful to devise a manual or procedure and policy for the Working Parties. 83 The ADB’s Story National Register Work The Archivist in Melbourne recommends a similar approach to the Trustees of the Public Library, and I think the process might be profitably applied to the S.A. Archives, the Mitchell and the Oxley Library. From the point of view of general Library resources, I have been able to acquire a first hand picture of the biographical indexes of each Library and they vary considerably. At this stage it is quite beyond the range of possibility to consider incorporating this mass of material into the National Register, but with a knowledge of their range and contents, it will be possible to act as an informed channel of reference to them. These are, after all, the working tools of the individual State libraries and for the present we will benefit from the research they are carrying out through them. The process of systemization can be extended to the Universities. Opinion in the History Departments points to the fact that they feel some responsibility in making a specific contribution to the Register work, and Melbourne and Hobart have offered to put a Research Assistant on the work of going through their theses abstracting biographical information. It is suggested that we invite each University to do this. Dr. Serle was also of the opinion that the Working Parties might be asked to draw up lists of names for the Register in addition to the Dictionary. This seems a heavy demand but in the normal way names discarded from preliminary Dictionary lists will be picked up for the Register. The most important contribution the Universities could make, this is again Dr. Serle’s suggestion, would be the collection of basic material for political monographs, on the lines of Martin and Wardle. Dr. Serle feels that the Melbourne History Department could organize such a one, with the help of Allan Martin and the research assistant Professor La Nauze has offered. This is a most constructive offer and sustains our plan to produce these specialized monographs at regular intervals. My present intention is to make the first step towards remedying the Western Australian gap in our biographical work by organizing material for a monograph on members of the W.A. Legislative Assembly and Council 1870–1930. G. Bolton already has the basic framework for this and has offered to fill it out. I also discussed the idea in Perth with Dr. National Register Work Part of my time in each of the capitals was spent in investigating Library resources and in gathering opinions from the Librarians and the Archivists, as well as from the Australian historians, on how we could most effectively build up our Register material, and become in time the centre of biographical information. There was general support for this plan and concurrence that the A.N.U. was the legitimate place for developing such a centre. Some idea of our present achievement was revealed in the Register Short List which has been distributed among the Libraries and History departments. There was comment and criticism on the selection reflected in the Register, and on the choice of sources, but there was also the view that we had progressed a long way in a useful direction. This criticism was helpful as it brought with it recommendations from each State of printed biographical sources which we should consider incorporating in the Register. It also exposed the immediate deficiencies that might be remedied, the most singular being the comparative neglect in our records of Western Australian, and to a lesser extent, of Tasmanian personalities. The discussions convinced me of one thing: that to make the Register effective and representative, it would be necessary to ensure that material will flow in systematically from the States, both from the Libraries and Universities. From the Library point of view I have gone some way to organize this. In Tasmania, the States Archives conduct research, often of a prolonged and serious kind, for enquiries. Much of this is biographical and I have worked through their files making lists of those from which useful material for the Register could be drawn. At some time, it would seem desirable to employ a researcher for a couple of weeks going through these files from my instructions to extract the material, I am sure the University could suggest someone. The Librarian and Archivist have promised henceforth to send me an extra copy of each piece of biographical research that is done. This will greatly strengthen our Tasmanian entries, particularly on the early period. 84 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 In Perth I collected material from their research files myself, and Miss Lukis the Archivist, is prepared to send copies of additions they make. National Register Work Crowley and Miss Lukis and they will give us local help in checking and adding to the material. It is also my plan to arrange that material will flow in from the Historical Associations. Source: Box 69, Q31, ADBA, ANUA. Source: Box 69, Q31, ADBA, ANUA. 85 The ADB’s Story Source: Ann Moyal, Breakfast with Beaverbrook. Memoirs of an Independent Woman (Sydney: Hale & Iremonger, 1995). Source: Ann Moyal, Breakfast with Beaverbrook. Memoirs of an Independent Woman (Sydney: Hale & Iremonger, 1995). Source: Jim Davidson, A Three-Cornered Life: The Historian W. K. Hancock (Sydney: UNSW Press, 2010). Ann Moyal (b. 1926) A graduate of the University of Sydney (BA Hons, 1947), Ann Hurley (later Cousins and Mozley) worked in Britain for nine years, four of them as Lord Beaverbrook’s research assistant. She has written about that period of her life in Breakfast with Beaverbrook (1995). In November 1958, on Mozley’s return to Australia, Sir Keith Hancock employed her as a research assistant responsible for the ‘organization of the Register of Australian Biography and preliminary work towards a Dictionary of Australian Biography’. In October 1959 she became a research fellow and assistant editor of the ADB. She has recounted her experiences as the ADB’s first, and only, employee for nearly four years, in Chapter 2. In 1962 Mozley took up a position at the Basser Library, Australian Academy of Science, where she began work on establishing a historical archive of Australian scientists. In 1963 she married the mathematician Joe Moyal. She worked in publishing in Chicago, returning to Australia to teaching positions at the NSW Institute of Technology (1972–76) and at Griffith University, where she was director of the Science Policy Research Centre (1977–79). Over the years she has published widely on the social history of nineteenth and twentieth-century Australian science. In 1995 she founded the Independent Scholars Association of Australia. Appointed AM in 1993, she was awarded an honorary D.Litt by the ANU in 1995 and by the University of Sydney in 2007. 86 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Ann Moyal, 2009 Ann Moyal, 2009 Photographer: Peter Fitzgerald, ADB archives Photographer: Peter Fitzgerald, ADB archives 87 87 The ADB’s Story Malcolm Ellis (1890–1969) Malcolm Ellis is one of the most vilified characters in the ADB story, accused of almost wrecking the project in its infancy; however, he also deserves a place as one of the founders of the great enterprise alongside Sir Keith Hancock, Ann Mozley (Moyal) and Laurie Fitzhardinge. A Queenslander by birth, Ellis began his working life as a cadet reporter on the Brisbane Daily Mail. In 1933, he joined the staff of the Bulletin, where he remained until his retirement in 1965. Passionate about early Australian colonial history and biography—he published biographies of Lachlan Macquarie (1942), Francis Greenway (1949) and John Macarthur (1955)—Ellis was one of the few non-academics invited to the conference convened by Hancock in Canberra in October 1957 at which the concept of a dictionary of Australian biography was discussed. He showed intense interest in the project and, in 1959, was appointed to the provisional Editorial Board. Ellis was the sole non-academic on the board. In August that year he submitted a detailed organisational plan, which, with some amendments by Hancock, forms the basis of the ADB’s organisation to this day. Ellis’s drive and commitment saw him writing the draft constitution and pressuring Hancock and the Editorial Board to begin the search for a publisher. In October 1959, Ellis and Manning Clark were appointed joint editors of Volumes 1 and 2. Hancock later wrote that ‘Ellis then was our devoted comrade. His ardour sustained our faith … he helped us, more than anybody else did, to get the Dictionary off the ground’. Hancock made that file note in December 1961, in the midst of a dispute between Ellis and the NSW Working Party over the selection of authors and the length of articles. This was just one of several disputes that took on seismic proportions and included the way in which Melbourne University Press was appointed publisher instead of Angus & Robertson, Ellis’s preferred option. The rows were exacerbated by Ellis’s vituperative personality and his outspoken anticommunism, which, at one point, led to a confrontation with Manning Clark. Finally, Ellis resigned from all his ADB positions. His dissatisfaction was well documented in his July 1963 Bulletin article, ‘Why I Have Resigned’. While the Ellis controversy continues to loom large in the ADB’s early history, the danger is that the positive aspects of the story are forgotten. Keith Hancock (1898–1988) Although the ADB was a minor episode in Sir Keith Hancock’s illustrious career, he looms large in its history. As director of the Research School of Social Sciences (1957–61) and head of the history department (1957–65) at the ANU, Hancock in the late 1950s advocated the establishment of the ADB, believing the dictionary to be an important means of promoting both Australian history and the university whose charter was to encourage and provide facilities for research of national importance. Hancock, a graduate of the University of Melbourne (BA Hons, 1920), won a Rhodes Scholarship that he took up at Balliol College, Oxford (BA, 1923; MA, 1930). Professor of history at the universities of Adelaide (1926–34), Birmingham (1934–44) and Oxford (1944–49), and founding director of the Institute of Commonwealth Studies, London (1949–56), before his return to Australia, he was the author of 20 books, including a two-volume biography of the South African statesman Jan Smuts (1962–68). Jim Davidson in his biography of Hancock noted that his ‘once immense reputation is now hard for Australians to grasp: most of it was earned outside Australia, and the Commonwealth context which gave it coherence has virtually collapsed’. In Britain Hancock had been involved in large collaborative projects, mainly as the supervisor for 12 years of 27 of the 28-volume civil series of the official history of Britain in World War II. He was also associated with the British Dictionary of National Biography. Once at the ANU, he called a meeting of Australian historians and raised the idea of a national biographical dictionary. Support for the proposal was forthcoming and in 1959 Hancock formed a provisional Editorial Board that met in his office. Appointed chairman, he provided seed funding for the project from his departmental budget and personally visited archivists to win their support. For Hancock, consultative relationships, genuine partnerships and collaboration were essential to the success of the project. He retired from the Editorial Board in November 1965. 88 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Keith Hancock, 1965 Keith Hancock, 1965 ANU Archives, ANUA225-511 89 The ADB’s Story Malcolm Ellis (1890–1969) Despite his prickly temperament, Ellis made significant contributions both to the establishment of the ADB and to early colonial Australian history and biography. 90 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Sources: B. H. Fletcher, ‘Ellis, Malcolm Henry (1890–1969)’, Australian Dictionary of Biography, vol. 14 (Melbourne: Melbourne University Press, 1996), pp. 95–7; W. K. Hancock’s files, ‘Correspondence with Ellis, 1958–1963’, box 70, Q31, ADBA, ANUA. Q31, ADBA, ANUA. Malcolm Ellis, 1950s ADB archives Malcolm Ellis, 1950s ADB archives ADB archives 91 91 The ADB’s Story Oskar Spate (1911–2000), Professor of Geography, ANU, and ADB author, wrote this poem in 1963 following the publication of Malcolm Ellis’s article ‘Why I Have Resigned’ in the Bulletin. The poem was privately circulated. The Wild Colonial Bore by O. K. H. Spate ’Tis of a Wild Colonial Bore, Malcolm Ellis is his name. And he has a Bigge monopoly, and one in Macquarie’s fame; His native heath was Botany Bay, he messed with the Rum Corps, And dearly did he love them both, the Wild Colonial Bore. ’Tis of a Wild Colonial Bore, Malcolm Ellis is his name. And he has a Bigge monopoly, and one in Macquarie’s fame; His native heath was Botany Bay, he messed with the Rum Corps, And dearly did he love them both, the Wild Colonial Bore. He is the boldest bushranger that never ranged the bush, In Sydney Town he’s captain of a literary push, He fills the Forum many a time with most uncivil war, A terror to Australia is the Wild Colonial Bore. He is the boldest bushranger that never ranged the bush, In Sydney Town he’s captain of a literary push, He fills the Forum many a time with most uncivil war, A terror to Australia is the Wild Colonial Bore. He is a stout Exclusivist, as everybody may see, And no man but an Ellis fan need write our history; Emancipists and Hawkesbury men are rudely shown the door, He has Squatter’s Rights to our convict past, has the Wild Colonial Bore There’s none like Malcolm Ellis to write biography, To review with old-world courtesy, and shun all pedantry; He tried his hand with Greenway and got in on the ground floor, But the Hospital rum went to the head of the Wild Colonial Bore. He bailed up Justice Evatt, Mike Roe, and Manning Clark, He hinted that the ANU gave doctorates in the dark, He slaughtered reputations and all dons he did deplore And they none of them got quarter from the Wild Colonial Bore. The Wild Colonial Bore And when he isn’t flaying Profs, he’s ferretting out the Reds, He finds them Up the Garden Path and under all the beds, Their corpses lie about his track, his rushes drip with gore, A Prof or a Red, ’tis all the same to the Wild Colonial Bore, And when he isn’t flaying Profs, he’s ferretting out the Reds, He finds them Up the Garden Path and under all the beds, Their corpses lie about his track, his rushes drip with gore, A Prof or a Red, ’tis all the same to the Wild Colonial Bore, ’Tis in the Sydney Bulletin he pursues his wild career With letters and columns every week of colonial small beer, And each new Bulletin we read, we’ve read it all before— He’s flaming repetitious, is the Wild Colonial Bore. ’Tis in the Sydney Bulletin he pursues his wild career With letters and columns every week of colonial small beer, And each new Bulletin we read, we’ve read it all before— He’s flaming repetitious, is the Wild Colonial Bore. But cheer up all, my hearties, all things must have an end; ’Tis like that Malcolm’s meanderings will take him round the bend; He’s bound to be Transported, of that you may be sure, To a warmer place than Botany Bay, this Wild Colonial Bore. 92 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Geoffrey Sawer (1910–1996) and Ross Hohnen (1917–2003) From the outset, the ANU supported Sir Keith Hancock’s initiative to launch a dictionary of biography and provided significant recurrent funding. After forming a provisional Editorial Board in 1959, Hancock sought university approval for its permanent establishment. The vice-chancellor, Leslie Melville, endorsed the proposal, subject to the addition of two ANU staff members, the chairman of the publication committee, Professor Geoffrey Sawer, and the university registrar, Ross Hohnen, to the Editorial Board. A graduate of the University of Melbourne (LLB, 1933) in 1934, Sawer was admitted as a solicitor and in 1938 as a barrister. He was the foundation professor of law at ANU (1950–74) and dean of the Research School of Social Sciences (1951–56). In 1955, when Hancock was director of the Institute of Commonwealth Studies, University of London, Sawer, who was on sabbatical at the London School of Economics and Political Science, participated in Hancock’s seminars. They became good friends. A couple of years later Sawer was involved in the selection and appointment of Hancock as professor of history at the ANU. Sawer served on the ADB’s Editorial Board and its National Committee for more than two decades, until 1984. He played a vital role, giving advice on legal matters, particularly regarding copyright, drafting the ADB’s constitution, and drawing up the contract with Melbourne University Press. At times he was acting chairman of the Editorial Board. He chaired the committee searching for Douglas Pike’s successor as general editor and negotiated directly with Monash University in 1975 to enable Geoffrey Serle’s appointment as joint general editor. Reminiscing in 1987 about the ADB, Laurie Fitzhardinge noted that a critical factor in Hancock’s success in obtaining money from the ANU was the ‘enthusiastic support’ provided by Ross Hohnen, the university registrar (1949–75). Hohnen, an active member of the Editorial Board until 1975, advocated both the payment of an establishment grant for the dictionary and the appointment, in 1962, of the first general editor, with the status and title of professor. He also provided practical assistance in seeking endowments and donations. With his support, the ADB’s staff increased from one in 1960 to more than four by 1964 and seven by 1969. He also encouraged Douglas Pike to take up an ANU travel grant in 1969 to visit dictionary projects in the United States, Canada and France. Sources: Laurie Fitzhardinge to Professor Hancock (3 February 1960), Q31, ADBA, ANUA. Sources: Laurie Fitzhardinge to Professor Hancock (3 February 1960), Q31, ADBA, ANUA. Biographical cuttings on Ross A. Hohnen, NLA. Geoffrey Sawer interviewed by Mel Pratt, five sessions (November 1971 – May 1972), NLA. Source: Martha Rutledge, ‘Cowper, Sir Norman Lethbridge (1896–1987)’, Australian Dictionary of Biography, vol. 17 (Carlton, Vic.: Melbourne University Press, 2007), pp. 258–60. Geoffrey Sawer (1910–1996) and Ross Hohnen (1917–2003) Biographical cuttings on Ross A. Hohnen, NLA. Geoffrey Sawer interviewed by Mel Pratt, five sessions (November 1971 – May 1972), NLA. 93 The ADB’s Story Geoffrey Sawer, 1953 ANU archives, ANUA225-1102 Ross Hohnen, 1974 ANU archives, ANUA225-564 The ADB’s Story The ADB’s Story Geoffrey Sawer, 1953 Geoffrey Sawer, 1953 ANU archives, ANUA225-1102 ANU archives, ANUA225-1102 Ross Hohnen, 1974 ANU archives ANUA225 564 Ross Hohnen, 1974 ANU archives, ANUA225-564 ANU archives, ANUA225-564 94 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Norman Cowper (1896–1987) An eminent commercial lawyer, company director and businessman, Norman Cowper was an experienced committee man. As a member (1955–74) of the ANU Council, he was a supporter of the ADB. He was responsible for securing the ADB’s first endowment: an ‘anonymous benefactor’ (later revealed as the Bushell Trust), who the Editorial Board acknowledged was gained only ‘through the auspices of Mr Norman Cowper’, gifted £1500 per annum for a period of three years in 1960. This was a vital gift to the fledging project. As chairman (1960– 70) of the board of Angus & Robertson, Cowper became involved in settling the dispute between the ADB Editorial Board and Malcolm Ellis. Largely because of his ability to resolve conflicts, he was recruited to the Editorial Board and to the National Committee in 1961. Not only did he help the academics to work out their policy differences, but he also brought a great deal of financial expertise to the management of the ADB. He contributed articles on George Allen and his son Sir George Wigram Allen (the founders of the law firm, Allen, Allen and Hemsley, of which Cowper was a senior partner from 1951 to 1975) and on Georgiana and her son George Gordon McCrae, who were relations of his wife. After vice-chancellor Anthony Low made comments about the ‘advancing years’ of many associated with the ADB, Cowper resigned from the Editorial Board in November 1979. He was himself the subject of an entry in the ADB. 95 95 The ADB’s Story Norman Cowper, 1977 Photographer: Anton Cermak, by courtesy of Fairfax Media Norman Cowper, 1977 Photographer: Anton Cermak, by courtesy of Fairfax Media Photographer: Anton Cermak, by courtesy of Fairfax Media 96 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Sources: Peter Ryan, ‘The ADB’, Quadrant (June 2000), pp. 87–8. ‘Chronology of Publishing Arrangements’, Ann Mozley to Keith Hancock (22 June 1960), box 68, Q31, ADBA, ANUA. Gwyn James (1900–1978) Over the past 50 years, ADB staff have worked with six directors of Melbourne University Press: Gwyn James (1943–62); Peter Ryan (1962–88); Brian Wilder (1989); John Iremonger (1990–93); Brian Wilder (1993–96); John Meckan (1997–2002); and from 2003, Louise Adler. Gwyn James was pivotal in that he committed the MUP to publishing the ADB and was responsible for the high- quality design of its volumes. James, an Englishman by birth, and Keith Hancock first met at the University of Birmingham. James was a student (MA, 1937) working on the British Admiralty in the seventeenth-century; Hancock was a professor of history (1934–44). In 1938 James moved to Australia and two years later took up a lectureship at the University of Melbourne and became foundation editor (1940–46) of Historical Studies: Australia and New Zealand. He was also well known to Laurie Fitzhardinge, who had helped to establish Historical Studies. Director of MUP from 1943, James learnt about the dictionary project in a rather circuitous way—during a discussion in Canada with those working on the new Canadian dictionary project. When he returned to Australia in November 1959, he approached the ADB Editorial Board with a proposal that MUP publish the dictionary. At that stage the board was on the verge of signing with Angus & Roberston but was swayed by James’s academic background and his enthusiasm for the project. Such were James’s academic credentials that the ADB Editorial Board considered him as a possible general editor of the dictionary before appointing Douglas Pike in 1962. His publishing credentials were also impeccable. As Peter Ryan, James’s successor at MUP, described it: ‘Gwyn James, besides his scholarship, had deep feeling for typography, quality book production, and the sacred (yes, sacred) role of rigorous editorial integrity’. James pursued publishing perfection and was innocent of the costs it imposed on MUP, such as when he chose the dictionary’s nine-point Juliana typeface: It was perfect for such a work of reference: cram as you would the narrow columns with text, the pages were never a pain in the eye, never hard to read. Juliana was unknown then in Australia, and James could import it only in ‘English depth’, where the type surface of the characters stand high and clear above the body. Alan George Lewers (‘Agl’, pronounced ‘aggle’) Shaw (1916–2012) Keith Hancock originally wanted A. G. L. Shaw, senior lecturer in history at the University of Sydney, as one of several editors of the first two volumes of the ADB. His candidature, however, was caught up in the ‘Ellis dispute’. Ellis was critical of what he described as the domination by John Ward and Shaw of the ADB’s NSW Working Party. Ellis wanted the working party to have wider representation: ‘New South Wales University, the Historical and Pioneers Societies, the Genealogical Society, the Public Librarian and Government Archivist, with representative attendant sub-committees from the law, medicine and architecture. And it needs some young men’. Ellis and the working party also disagreed about the lists of subjects and authors. When the working party proposed that Shaw write the entry on Lachlan Macquarie, Ellis responded by saying that he wanted to write that one, and suggested Shaw for Thomas Makdougall Brisbane. At its meeting of 6 February 1962, the ADB Editorial Board, advised of Douglas Pike’s acceptance of the position of general editor, resolved to appoint Shaw joint editor of Volume 1 following the resignation of Malcolm Ellis. It was held that special knowledge of the colonial period was essential and that Shaw had that expertise. As section editor for Volumes 1 and 2, he was de facto in charge of ‘period one’. He reported to National Committee members on progress until Pike took over. Born in Melbourne, Shaw was educated at Melbourne Grammar School, the University of Melbourne (BA Hons, 1938), where he studied history and political science, and Christ Church, Oxford (MA, 1940). Back in Australia, he worked first in the Commonwealth Public Service, before taking up a lectureship at the University of Melbourne. He was associate editor (1949–51) of Historical Studies and a member of its editorial board. In 1950, he was awarded a Nuffield dominion travelling scholarship and spent a year in England undertaking research into Australia’s convict period. In 1952 he was appointed senior lecturer in history at the University of Sydney. During the 1950s and 1960s he published widely on the early history of Australia. A stalwart of the ADB, Shaw was a member of the National Committee and of the Editorial Board (1960–99); he contributed 10 articles. He also produced biographies of Ralph Darling (1971) and George Arthur (1980). Gwyn James (1900–1978) The result was that MUP’s linos were 97 The ADB’s Story incompatible with the linotype equipment of the whole of the rest of the Australian printing industry—a considerable technical and financial sacrifice by the Press in the service of perfection for the Dictionary. Then there was the paper—no reach-me-down rubbish from some paper merchant’s shelf for the ADB. James cajoled a local manufacturer of fine papers to agree to make a special quality for the ADB; A cream ‘laid’ writing paper in an unconventional sheet size, to accommodate the grandeur of the Dictionary’s ‘full royal’ dimensions … As the papers makers could only occasionally interrupt the ordinary run of their production for the special ADB make, MUP itself had to warehouse very considerable reserves of it, at great expense. As well as being its publisher, James wrote four entries for the ADB. g p Gwyn James, n.d. Photographer: Squire Photographics, University of Melbourne Archives Sources: Peter Ryan, ‘The ADB’, Quadrant (June 2000), pp. 87–8. ‘Chronology of Publishing Arrangements’, Ann Mozley to Keith Hancock (22 June 1960), box 68, Q31, ADBA, ANUA. Gwyn James, n.d. Photographer: Squire Photographics, University of Melbourne Archives Gwyn James, n.d. Gwyn James, n.d. Photographer: Squire Photographics, University of Melbourne Archives Photographer: Squire Photographics, University of Melbourne Archives Sources: Peter Ryan, ‘The ADB’, Quadrant (June 2000), pp. 87–8. ‘Chronology of Publishing Arrangements’, Ann Mozley to Keith Hancock (22 June 1960), box 68, Q31, ADBA, ANUA. Sources: Peter Ryan, ‘The ADB’, Quadrant (June 2000), pp. 87–8. ‘Chronology of Publishing Arrangements’, Ann Mozley to Keith Hancock (22 June 1960), box 68, Q31, ADBA, ANUA. 98 2. Sir Keith Hancock: Laying the Foundations, 1959–1962 Sources: The ‘Ellis Dispute’ files (1959–63), box 68, Q31, ADBA, ANUA. Peter Yule and Will Kimpton, ‘Alan George Lewers Shaw’, Age [Melbourne], 15 May 2012. A. Atkinson, ‘Shaw, A. G. L’, in G. Davison, J. Hirst and S. Macintyre (eds), The Oxford Companion to Australian History, rev. edn (Melbourne: Oxford University Press, 2001), p. 588. Alan George Lewers (‘Agl’, pronounced ‘aggle’) Shaw (1916–2012) For 10 years from 1994, he was associate editor (Australia) of the Oxford Dictionary of National Biography. He was awarded an ADB Medal in 2002. 99 The ADB’s Story A. G. L. Shaw, about 1964 A. G. L. Shaw, about 1964 Monash University Archives, 42 Monash University Archives, 42 100 1 This chapter is drawn from my master’s thesis: John David Calvert, ‘Douglas Pike (1908–1974): South Australian and Australian Historian’ (MA thesis, University of Adelaide, 2008). 2 Staff file 1272, ANUA. 3 Ann Mozley, ‘Report on My Journey to Perth, Adelaide, Melbourne and Hobart, August–Sept. 1959’, box 69, Q31, ADBA, ANUA. 4 Professor Keith Isles, Vice-Chancellor, University of Tasmania, to Sir Keith Hancock (21 March 1962), box 69, Q31, ADBA, ANUA. 5 Calvert, ‘Douglas Pike (1908–1974), p. 137, citing W. K. Hancock, Professing History (Sydney: Sydney University Press, 1976), pp. 38 and 39. 1 This chapter is drawn from my master’s thesis: John David Calvert, ‘Douglas Pike (1908–1974): South Australian and Australian Historian’ (MA thesis, University of Adelaide, 2008). 2 S ff fil 1272 ANUA ADB archives 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 John D. Calvert1 His great work as General Editor of the Dictionary of National Biography, organised in its working aspects as a unit in this Research School, will ensure that Professor Pike is remembered as long as there are Australians interested in the history of their country and in particular of its great men. D. H. Pike obituary, Minutes of the Faculty of the Research School of Social Sciences, 12 June 19742 Douglas Pike was an enthusiast for the Australian Dictionary of Biography project from the outset. At the conference on Australian history, held at the ANU in 1957, he supported the call for a biographical dictionary. When Ann Mozley travelled to Adelaide to gauge support for the dictionary project in August 1959, she reported that ‘Dr Douglas Pike is a strong advocate of the Dictionary plan and supports our ideas of centralization in Canberra and an Advisory Committee consisting of one representative from each University to act in a consultative capacity’, and he was the ‘obvious choice’ to chair the SA Working Party.3 Three years later, Pike was appointed the dictionary’s first general editor. The vice-chancellor of the University of Tasmania, who was about to lose the newly appointed professor of history at his university to the ADB, assured Sir Keith Hancock, the chair of the Editorial Board, that he had made the right decision, for the ‘whole project is very dear to his heart, and if there is anyone able to cajole a group of individualist contributors to work together in harmony as a team, I think that it is he’.4 Indeed, Hancock came to think of Pike in terms of a saviour, commenting that ‘only just in time, Douglas Pike came to the rescue’.5 101 The ADB’s Story Douglas Pike, 1960s Douglas Pike, 1960s Douglas Pike, 1960s ADB archives 102 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Like a number of others, such as Hancock and Manning Clark, associated with the early years of the ADB, Pike was the son of a parson. Born on 3 November 1908, at Tuhshan, China, he was the second of five children of Douglas Fowler Pike and his wife, Louisa, née Boulter, Australian-born Methodist missionaries with the China Inland Mission. 6 Andrew Pike to John La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. Bede Nairn, ‘Pike, Douglas Henry (1908–1974)’, Australian Dictionary of Biography, vol. 16 (Carlton, Vic.: Melbourne University Press, 2002), pp. 1–2. 11 Pike achieved 88.1 per cent in first year, 88.5 per cent the next year, and 87.4 per cent in his final year. Enrolment Card, Douglas H. Pike, College of the Bible Archives, 1939–41. 10 Student Record, College of the Bible, Melbourne, no. 464. A. Titter, Archives Centre, College of the Bible, Melbourne, to John Calvert (6 March 2002).ii 8 Hugh Stretton, interviewed by John Calvert (18 March 1999), John Calvert. Research papers on Douglas Pike, MSS 0160, University of Adelaide Library. Peter Ryan, ‘The ADB’, Quadrant (June 2000), p. 88. 9 A. Butler to Olive Pike (15 January 1980), Calvert papers, University of Adelaide Library. ‘D. F. Pike Believed Killed’, China’s Millions (November 1929), ‘Missionary News’, p. 5. ‘Missionary Murdered’, Sydney Morning Herald (13 December 1929), p. 3. g g 12 J. Wright interviewed by John Calvert (23 April 1999), Calvert papers, University of Adelaide Library. 13 Pike to La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. ) pp 7 Pike to La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. 12 J. Wright interviewed by John Calvert (23 April 1999), Calvert papers, University of Adelaide Library. 13 Pike to La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. 6 Andrew Pike to John La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. Bede Nairn, ‘Pike, Douglas Henry (1908–1974)’, Australian Dictionary of Biography, vol. 16 (Carlton, Vic.: Melbourne University Press, 2002), pp. 1–2. 7 Pike to La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. 8 Hugh Stretton, interviewed by John Calvert (18 March 1999), John Calvert. Research papers on Douglas Pike, MSS 0160, University of Adelaide Library. Peter Ryan, ‘The ADB’, Quadrant (June 2000), p. 88. 9 A. Butler to Olive Pike (15 January 1980), Calvert papers, University of Adelaide Library. ‘D. F. Pike Believed Killed’, China’s Millions (November 1929), ‘Missionary News’, p. 5. ‘Missionary Murdered’, Sydney Morning Herald (13 December 1929), p. 3. 10 Student Record, College of the Bible, Melbourne, no. 464. A. Titter, Archives Centre, College of the Bible, Melbourne, to John Calvert (6 March 2002). 11 Pike achieved 88.1 per cent in first year, 88.5 per cent the next year, and 87.4 per cent in his final year. Enrolment Card, Douglas H. Pike, College of the Bible Archives, 1939–41. 12 J. Wright interviewed by John Calvert (23 April 1999), Calvert papers, University of Adelaide Library. 13 Pike to La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. 14 G. V. Portus, Happy Highways (Carlton, Vic.: Melbourne University Press, 1953), p. 281. 15 G. Stirling to J. Calvert (27 September 2004), Calvert papers, University of Adelaide Library. Alf Pike, interviewed by John Calvert (21 June 2002), privately held. 16 N. Meaney to John Calvert (21 February 2002), Calvert papers, University of Adelaide Library. 17 Geoffrey Blainey to J. Calvert (10 April 2002), Calvert papers, University of Adelaide Library. 18 Pike to La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. 19 D. H. Pike, Australia: The Quiet Continent (Cambridge: Cambridge University Press, 1962). 20 A. Mozley, ‘The Australian Dictionary of Biography’, Historical Studies: Australia and New Zealand, 9, no. 35 (1960), pp. 313–14. Ann Mozley’s article was written before Pike’s appointment and is most pertinent regarding the early history of the ADB. 21 Douglas Pike to Keith Hancock (23 February 1959), box 67, Q31, ADBA, ANUA. 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 At the age of six, Doug was sent to an English- style mission boarding school at Chefoo, in northern China, hundreds of miles and three months’ journey from Tuhshan. The school had Spartan, puritan and evangelical values; it was four years before the young boy saw his parents again. In 1924 he passed the Oxford senior examination and the next year studied English and Latin at the University of Melbourne as a part-time student. He supported himself financially by teaching at Spring Road State School.6 Lonely, suffering culture shock and grieving for his sister who had died of tuberculosis in China during the year, Pike failed his first-year exams. Rather than sit for the supplementary exams, he ‘went bush’. For the next 12 years, he worked on remote properties in New South Wales.7 He later remarked that he could ‘kill, skin and dress a lamb in a minute forty seconds’, and that he ‘had once held the Australian speed record for skinning a sheep’.8 In 1929, brigands killed his father in China.9 The unhappy episodes of his youth were to have a lasting impact on Pike, and perhaps accounted for his emotionally reserved character. In 1938, at the age of thirty, Pike applied to study theology at the Churches of Christ College of the Bible in Melbourne.10 His academic marks, this time around, were consistently high.11 Fellow students remember him as very intelligent, exhibiting a strong social conscience and possessing firm ideas, but noted that he was not always easy to get on with.12 In November 1941, he married Olive Hagger, the daughter of his mentor, Reverend Thomas Hagger, and his senior by five years. Two days after their wedding, he was ordained a Churches of Christ minister.13 g g 12 J. Wright interviewed by John Calvert (23 April 1999), Calvert papers, University of Adelaide Library. 13 Pike to La Nauze (20 September 1974), box 70, Q31, ADBA, ANUA. 103 The ADB’s Story The Adelaide years Pike continued with his studies part-time at the University of Adelaide (BA Hons, 1947; MA, 1951) while ministering to parishes at Colonel Light Gardens and Glenelg in South Australia. G. V. Portus, professor of history and political science, regarded him as ‘the most mature student I had ever taught’.14 In 1948, frustrated with church politics and unsure of his own vocation—he acknowledged that the Scriptures contained much wisdom but came to discount ‘the idea of an entity called God, who could be experienced’—he resigned his ministry.15 Those close to him have suggested that Pike ‘had lost his faith and had nothing to put in its place. He had struggled with this personal crisis but had not been able to resolve it’.16 The historian Geoffrey Blainey observed that Pike was ‘not sure till the end of his life (without telling anyone) whether he should be in the church or the university’.17 Talented and conscientious, he was also shy, with a complicated and independent personality. The day after resigning his ministry, Pike accepted a part-time lecturing position in the Department of History and Political Science at the University of Adelaide.18 He then taught at the University of Western Australia (1949–50) for two years before returning to Adelaide as a reader (1950–60). In 1953–54 he was commissioned by Cambridge University Press to write a history of Australia for their Commonwealth Series. This was eventually published in 1962 as Australia: The Quiet Continent.19 His doctoral thesis, completed in 1956 (Keith Hancock, at the University of London, was one of his examiners), was published as Paradise of Dissent: South Australia 1829–1857 in 1957. In 1961 he was appointed to the chair of history at the University of Tasmania. 22 Mozley, ‘The Australian Dictionary of Biography’. 23 W. K. Hancock, ‘The Need for a General Editor’ (July 1961), Agenda and Papers, National Committee meeting (12–13 August 1961), box 64, Q31, ADBA, ANUA. 24 W. K. Hancock, ‘ADB: Retrospect and Prospect’ (18 June 1963), box 69, Q31, ADBA, ANUA, p. 3. Gerald Walsh, ‘“Recording the Australian Experience”: Hancock and the Australian Dictionary of Biography’, in D. A. Low (ed.), Keith Hancock: The Legacies of an Historian (Carlton, Vic.: Melbourne University Press, 2001), p. 257. 25 K. Hancock to J. La Nauze (27 October 1961); J. La Nauze to K. Hancock (12 November 1961), box 69, Q31, ADBA, ANU. 26 W. K. Hancock to J. M. Ward (27 November 1961), box 69, Q31, ADBA, ANUA. 27 Douglas Pike to W. K. Hancock (7 December 1961), box 69, Q31, ADBA, ANUA. 28 W. K. Hancock to Douglas Pike (8 December 1961), box 69, Q31, ADBA, ANUA. Pike joins the ADB The development of an Australian dictionary of biography had been discussed for more than a decade before a general editor was appointed.20 Correspondence with Hancock in early 1959 showed Pike’s enthusiasm for the dictionary: ‘I like the project and your plans for tackling it. So does [Ken] Inglis. We are each willing to keep a candle alight in our own small corners’.21 104 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 At a conference of the ADB’s National Advisory Panel and Editorial Board, held in Canberra in April 1960, the question of appointing a general editor was raised and, while agreed as desirable, ‘there were real difficulties in the way of achieving it’.22 Put baldly, there was no money to fund a general editor. The plan was to make do with administrative staff and have special editors for each volume. It was not until after the hiatus with Malcolm Ellis that there was real pressure for the appointment of a general editor. In July 1961 Hancock, as chairman of the Editorial Board, produced a five-page report for the National Committee on ‘The Need for a General Editor’. He visualised a general editor taking on three responsibilities: chief administrative officer of the dictionary; secretary to the National Committee; and executive officer to the Editorial Board.23 Hancock also set down what he considered to be the type of man required for the position: an Australian historian at the forefront of scholarly developments prepared to navigate sensitively a way between traditional and nonconforming trends whose work would ‘stand the test of time’.24 In October 1961 Hancock invited John La Nauze of the University of Melbourne to consider becoming general editor. La Nauze declined, saying that he did not have the right temperament for the job and did not wish to uproot his sons, who were in their final years of schooling.25 Pike, his next choice, also proved reluctant, saying that he had only just taken a new appointment at the University of Tasmania.26 Hancock discussed other candidates with a number of people, including with Pike, who helped to ‘beat the bush … to ensure that no names have been missed’. Other candidates, however, either were thought to be too junior or also declined the job. 22 Mozley, ‘The Australian Dictionary of Biography’. p ( ) p 30 G. Bolton to J. Calvert (11 May 2002), Calvert papers, University of Adelaide Library. 29 ‘Capital Letter’, Canberra Times (1969), p. 3. 31 W. K. Hancock to Pike (26 January 1962); Pike to Hancock (31 January 1962), box 66, Q31, ADBA, ANUA. 32 ‘General Editor’ File (4 October 1962), box 71, Q31, ADBA, ANUA. 29 ‘Capital Letter’, Canberra Times (1969), p. 3. 29 ‘Capital Letter’, Canberra Times (1969), p. 3. 30 G. Bolton to J. Calvert (11 May 2002), Calvert papers, University of Adelaide Library. 31 W. K. Hancock to Pike (26 January 1962); Pike to Hancock (31 January 1962), box 66, Q31, ADBA, ANUA. 32 ‘General Editor’ File (4 October 1962), box 71, Q31, ADBA, ANUA. ( y ) ( 32 ‘General Editor’ File (4 October 1962), box 71, Q31, ADBA, ANUA. 32 ‘General Editor’ File (4 October 1962), box 71, Q31, ADBA, ANUA. ( y ), p p , y y 31 W. K. Hancock to Pike (26 January 1962); Pike to Hancock (31 January 1962), box 66, Q31, ADBA, ANUA. 32 ‘General Editor’ File (4 October 1962), box 71, Q31, ADBA, ANUA. Pike joins the ADB Pike informed Hancock, for instance, that Ken Inglis had declined the offer, ‘saying, “Nature made me a contributor rather than an editor, I fear”’.27 In December 1961 Hancock reminded Pike that he possessed the very qualities sought in a candidate and asked him, for the third time, to take the position.28 Hancock appealed to Pike’s sense of duty and obligation to take this important position to help raise historical standards in Australia. He had pursued Pike for a variety of reasons: his academic seniority, his reputation as a fine editor, his specialty in nineteenth-century history and his breadth of knowledge about Australia’s past. There were few colonial historians 105 The ADB’s Story in Australia at that time; moreover, Pike saw himself as living in the nineteenth century: ‘I prefer it to the 20th century’, he told Hancock.29 Pike’s peripatetic academic career also suggested an aptitude to negotiate the provincialism of Australian history: he had studied in Melbourne, taught briefly in Western Australia and spent a decade in Adelaide before moving to Tasmania. Geoffrey Bolton has observed that Pike’s Paradise of Dissent taught him that ‘Australian history is best understood as a mosaic of regions rather than as a “monstrous tribe”’.30 Douglas Pike, 1973 Photographer: G Carpay ANUA225-981 Douglas Pike, 1973 Douglas Pike, 1973 Photographer: G. Carpay, ANUA225-981 Photographer: G. Carpay, ANUA225-981 Pike finally accepted the general editor’s position at the end of January 1962.31 He was granted the status and title of professor within the ANU, at a salary of £4250 per annum.32 For both ethical and financial reasons, however, he delayed his move to the national capital. His terms of appointment in Hobart included 106 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 a proviso: ‘If the Professor resigns within two years of taking up his duties, he will be required to refund the allowances in full, and if he resigns after two years but within three years, he will be required to refund half the allowances’. It was agreed, then, that he would take up the position part-time and remain in Tasmania until 1964.33 He would then move to Canberra to work on the project full-time. 33 Hancock sent Pike a telegram reassuring him that his acceptance of appointment would be compatible with postponement for up to two years of his ‘physical transfer’ to Canberra: W. K. Hancock to Douglas Pike (12 December 1961), box 66, Q31, ADBA, ANUA. 34 G. Walsh to J. Calvert (12 April 2002), Calvert papers, University of Adelaide Library. 35 D. Pike, ‘The Australian Dictionary of Biography’, Business Archives and History, 7, no. 2 (1962), p. 185. 36 Douglas Pike, ‘The Commemorative Business’, Scholarly Publishing, 1, no. 4 (1970), pp. 331–46. Pike joins the ADB Pike began juggling his responsibilities as professor of history in Hobart and general editor in Canberra with frequent travel to the nation’s capital, where he would work in his office in the old hospital building.34 In August 1962, he published an article on the ADB project. It shed light on the project’s embryonic development and his own increasing involvement in it. His choice of language was succinct: ‘Whether men make history or history makes men is a question for argument, but there can be no debate that biography is a proper study’.35 Establishing dictionary systems Pike did not table a plan at the outset, so his priorities as the inaugural general editor can only be discerned from other evidence. The main problem, as he came to see it, was that many systems had already been put in place by the time he took up his position. In 1970 the Canadian journal Scholarly Publishing included an article by Pike tracing the development of other national dictionaries, in which he contextualised ADB methods and reflected upon dictionary practices.36 Pike advocated that ‘the first desirable step is to appoint an editor’, an agreed choice of both the ‘sponsor and the management committee, and elected in time to have some share in determining the size of the enterprise, its purposes, and its methods’. He then elaborated his ideas in two sentences that read somewhat ‘tongue-in-cheek’ but were revealing, perhaps, of the challenges he faced: The ideal editor should be young and healthy enough to survive the whole distance, and endowed with prophetic vision, wide experience, omniscience, infallible memory, the resolution of an autocrat tempered by consideration and apparent reasonableness, skill in mesmerism, the irresistibility of Satan, the patience of Job, wisdom beyond Solomon, legible handwriting, and mastery of detail; he should also be so great a celebrator of life that he blesses even drudgery. Since no such prodigy 107 The ADB’s Story exists in male form (except in distorted biography), wise electors would do well to turn to the other sex for its renowned grace, sagacity, and happy devotion to little things.37 exists in male form (except in distorted biography), wise electors would do well to turn to the other sex for its renowned grace, sagacity, and happy devotion to little things.37 The first desirable step for a general editor, in turn, according to Pike, was ‘to start looking and praying for that rara avis, a good sub-editor’.38 Pike spoke from experience here, too; he was without a deputy until the appointment of Bede Nairn to the staff in 1966.39 Pike noted that all dictionary projects were in the same ‘commemorative business’ and shared similar basic systems. Subject lists were compiled and circulated widely, authors commissioned and their work edited. Pike was very aware that the ‘last word in biography, as in history, can never be written, and dictionary space prevents fully exhaustive work’.40 The ‘scholarly performance of contributors’ and the nature of sources were limiting. 37 Pike, ‘The Commemorative Business’, p. 340. 38 Pike, ‘The Commemorative Business’, p. 341. 39 The first discussions about editors and lists for Volumes 3–6 (Period 2) were held in May 1961; in May 1962, the ADB Editorial Board elected Laurie Fitzhardinge, Geoffrey Serle and John Ward as co-editors for Period 3 (1850–90): Minutes, ADB Editorial Board meeting (11 May 1962); Fitzhardinge resigned early in 1965 and Nairn replaced him: Minutes, ADB Editorial Board meeting (4 March 1966), box 64, Q31, ADBA, ANUA. 40 Pike, ‘The Commemorative Business’, p. 338. 41 Pike, ‘The Commemorative Business’, p. 335. 42 Pike, ‘The Commemorative Business’, p. 341. 43 Pike, ‘The Commemorative Business’, p. 336. 44 Pike, ‘The Commemorative Business’, p. 343. 37 Pike, ‘The Commemorative Business’, p. 340. Establishing dictionary systems Nevertheless, good dictionary methods were also critical. Pike’s more specific editorial methods were developed ‘from intercommunication between editors of the postwar dictionaries’.41 He noted that the ADB was ‘the smallest project’ internationally and it was heavily indebted to models and methods of the National Dictionary of Biography and the Dictionary of American Biography but, nevertheless, it had developed some of its own ways in terms of scope and quality, despite its size. A key feature of the ADB was its own ‘information bank’, begun in 1954 as a biographical list, which had developed into a large Biographical Register. On that basis, the ADB compiled working lists, which it sent to its working parties to develop and, ‘with faith in provincial rivalry’, produce good lists of subjects for inclusion.42 Chronological rather than a ‘totally alphabetical system’ of work was best and, on this basis, rather than organising subjects by death dates, the ADB had developed a floruit system that enabled close attention to one particular slab of history at a time.43 A third particular feature of the ADB was that it had volunteer section editors ‘renowned for scholarship in the historical slab under review’.44 Pike inherited a number of particular challenges as a result of how the ADB was set up from 1958 to 1962 and the fallout from the Ellis dispute; other hurdles 108 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 were common to all dictionary projects. The ADB solved some of the issues it confronted in a unique way. In his 1970 article, Pike also signalled three issues that were simply intractable: the selection of subjects; editing style; and dictionary resources. A central and continuing issue for Pike was justification of the selection of names for inclusion in the ADB. A recurring explanation appeared in every ADB preface written by Pike and continued in Volume 6, under Nairn’s editorship: ‘Many of the names were obviously significant and worthy of inclusion. Others, less notable, were chosen simply as samples of the Australian experience’.45 This explanation echoes the themes of Pike’s earlier writing, in which he gave prominence not only to convicts, colonial identities and notable personalities, but also to the ‘smallholders’ of the land. 45 D. H. Pike, ‘Preface’ [January 1966], ADB, vol. 1, p. v. 46 D. Pike, ‘Making a Biographic Dictionary’, in David Dufty, Grant Harman and Keith Swan (eds), Historians at Work: Investigating & Recreating the Past (Sydney: Hicks Smith & Sons, 1973), pp. 139–46. This was first delivered as the Eldershaw Memorial Lecture (3 August 1972), RSSS, ANU. 47 Pike, ‘Making a Biographic Dictionary’, p. 144. Establishing dictionary systems In ‘Making a Biographic Dictionary’ (1973), Pike surveyed the earlier dictionary editors and observed that they had not evolved definite selection principles apart from the exclusion of living subjects.46 Leslie Stephen, editor of the Dictionary of National Biography, for example, regarded worthy subjects as those whose literary works were catalogued in the British Museum. The Dictionary of American Biography sought to ‘re-create the makers of American life and culture’. James Nicholson prescribed that the Dictionary of Canadian Biography should include ‘all noteworthy inhabitants’. W. J. de Kock aimed for those who made a positive contribution to South African events and also ‘minor personalities who through the vicissitudes of chance have remained obscure’. Despite all this, Pike was inclined to prick the bubble of innovation, pointing out that prosaic constraints lie in limited space and the search for appropriate authors: In practice these prescriptions had little relevance. First of all a biographical dictionary must be a work of reference and, however bigger or better, capable of achievement. Readers will expect many categories to be represented and conventional leaders in government, church, law, education, business, medicine, literature, science, sport and exploration must therefore be included. Little space is left for worthy but lesser known samples of the Australian experience.47 The publisher placed restrictions on the size of the manuscript but an efficient and concise writing style in ADB entries suited Pike’s temperament exactly. According to Nairn, Pike ‘more than once claimed that when a minister he could always reduce his sermons to one sentence as he ascended the pulpit’. 48 B. Nairn, ‘The Foundation General Editor’, Australian Dictionary of Biography, vol. 6 (Carlton, Vic.: Melbourne University Press, 1976), p. xii. 49 Martha Campbell interviewed by John Calvert (14 July 2004); and Gerald Walsh to John Calvert (26 June 2002), Calvert papers, University of Adelaide Library. 50 ‘Pike’s Own Time’, Canberra Times (20 March 1969), p. 3. 51 Pike, ‘The Commemorative Business’, p. 344. 52 J. Cross, ‘Historiography—D. H. Pike’s Advice in 1958’, Historical Facts & Events: Mainly South Australian, 8, no. 3 (April 1994), pp. 43–4. 53 Pike, ‘The Commemorative Business’, p. 344. 54 W. K. Hancock to Douglas Pike (29 September 1964), box 71, Q31, ADBA, ANUA. 55 Douglas Pike to W. K. Hancock, undated reply to Hancock’s letter (18 March 1965), box 71, Q31, ADBA, ANUA. Establishing dictionary systems Although he did not expect his authors to do likewise, he ‘often gave the impression 109 The ADB’s Story that he wanted something like it’.48 Claiming that there were no adjectives or adverbs in the Old Testament book of Psalms, Pike advocated their non-use in ADB contributions, and instead advised a stronger use of ‘verbs’.49 In the Canberra Times in 1969, Pike was described as ‘a small, slow and quietly spoken man, whose pencil is forever poised to strike out unnecessary adjectives in the biographies of Australia’s famous and infamous sons’.50 He believed that condensation was a ‘cardinal virtue’ above all others.51 In 1958 Pike had given Jack Cross, a postgraduate student at the University of Adelaide, some guidance on writing, which Cross later published.52 The advice suggested that students ought to cover all possible sources, try to develop an individualistic approach, write for publication, a book, not a thesis, write as if an observer, keep a close contact with ordinary people and work full-time because ‘part-time research and writing is the bane of Australian historiography’. He also stressed: ‘Put a lot of thought into the actual writing. Each part should be re-written at least ten or twelve times over’. He believed the hardest test of prose was to read it aloud to an ‘informed critic’.53 As general editor, Pike followed his own advice. 55 Douglas Pike to W. K. Hancock, undated reply to Hancock’s letter (18 March 1965), box 71, Q31, ADBA, ANUA. p 54 W. K. Hancock to Douglas Pike (29 September 1964), box 71, Q31, ADBA, ANUA. Editorial burden Following Pike’s move to Canberra in 1964 as full-time general editor, momentum built for the publication of the first ADB volume and exposed the lack of resources at the ADB. News of hectic schedules reached Hancock, who wrote to Pike from Cambridge, where he was on leave: ‘Fitz [L. F. Fitzhardinge] tells me that you have been getting disappointing support … we must try and improve the situation’.54 Hancock also wrote to Fitzhardinge so that he and Pike could discuss changes to procedures and the employment of extra staff. A few months later Pike wrote to Hancock that ‘the interminable details of production, endless checking, explaining, encouraging, planning and writing of unwanted articles—makes me feel sometimes like the lonely Elijah or the spectre ridden Ezekiel, when there is any time to feel at all’.55 110 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Besides the heavy editorial burden Pike was still a relative newcomer at the ANU and may have experienced a sense of isolation in Canberra. His letters to Hancock illustrate the continuing tension he was internalising. In July 1965 Hancock recorded his concern about Pike’s intense concentration on his work and the strain he was imposing on himself, suggesting ‘he would be wise to give himself some let-up’.56 A trip to New Zealand for both a holiday and to discuss dictionary matters with that country’s contributors was organised. Besides the heavy editorial burden Pike was still a relative newcomer at the ANU and may have experienced a sense of isolation in Canberra. His letters to Hancock illustrate the continuing tension he was internalising. In July 1965 Hancock recorded his concern about Pike’s intense concentration on his work and the strain he was imposing on himself, suggesting ‘he would be wise to give himself some let-up’.56 A trip to New Zealand for both a holiday and to discuss dictionary matters with that country’s contributors was organised. As already observed, Pike had inherited the fallout from the conflict involved in the early planning of the infant ADB, in particular, that caused by the Sydney journalist Malcolm Ellis—‘a wrecker from outside the academy’—plus the (unspecified) medical concerns that affected the involvement of Manning Clark (a section editor with A. G. L. Editorial burden Shaw for Volume 1).57 There is no doubt that Hancock fully supported Pike, for they were good friends, but Pike had entered from outside into an entrenched ‘small world of god-professors’. There were times when he was ‘very disheartened’. An ‘orderly, probing editor’, he worked long hours and focused on his editorial tasks, setting high standards and persevering despite some personal criticism and jealousy.58 56 Chairman’s Note, Minutes, ADB Editorial Board meeting (16 July 1965), box 64, Q31, ADBA, ANUA. 57 Douglas Pike to A. G. L. Shaw and Nan Phillips (23 March 1962), box 71, Q31, ADBA, ANUA. 58 Geoffrey Bolton to J. Calvert (11 May 2002); Wendy Birman to J. Calvert (30 October 2002), Calvert papers, University of Adelaide Library. 59 D. Pike (ed.), ADB, vol. 1, inside cover. g p ( ) 58 Geoffrey Bolton to J. Calvert (11 May 2002); Wendy Birman to J. Calvert (30 October 2002), Calvert papers University of Adelaide Library 56 Chairman’s Note, Minutes, ADB Editorial Board meeting (16 July 1965), box 64, Q31, ADBA, ANUA. l k h d h ll ( h ) b 59 D. Pike (ed.), ADB, vol. 1, inside cover. 56 Chairman’s Note, Minutes, ADB Editorial Board meeting (16 July 1965), box 64, Q31, ADBA, ANUA. 57 Douglas Pike to A. G. L. Shaw and Nan Phillips (23 March 1962), box 71, Q31, ADBA, ANUA. ‘Bowing the knee to Baal’ Members of the National Committee, Editorial Board and working parties performed their tasks on a voluntary basis, as did most authors. A key word here was ‘national’, for the ADB was an Australia-wide project. It also involved various overseas links, with inevitable delays in communication in an era before fax machines, computers and email. The blurb on the dust jacket of Volume 1 gives an idea of the human involvement and the extent of administrative contact that was crucial in meeting publishing deadlines: ‘In this volume, the 535 entries have been written by some 250 authors’. Apart from Australia, contributors came from Britain, the Netherlands and the United States, and included a wide range of backgrounds and writing abilities.59 111 The ADB’s Story The ADB’s Story ADB author Archibald Grenfell Price refused to ‘bow the knee to Baal’ in 1964 N ti l Lib f A t li 1940 23355934 ADB author Archibald Grenfell Price refused to ‘bow the knee to Baal’ in 1964 National Library of Australia, 1940s, an23355934 National Library of Australia, 1940s, an23355934 112 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Pike established a routine for editing entries, setting aside Friday afternoons for rewriting unsuitable articles, which were then returned to their original author with an invitation to append their name.60 Authors’ responses to his editoral ‘improvements’ varied. One appreciative author commented when returning his proofs: ‘Dear Professor Pike, not a word of this is mine, and I am proud to put my name to it’. Another commented that Pike’s spare style made ‘history dull.’ Pike remained firm in his approach to editing, occasionally at the cost of friendships. His confrontation with the historical geographer Sir Archibald Grenfell Price, was particularly difficult for Pike as they had been friends in Adelaide. Price had launched Pike’s Paradise of Dissent at the University of Adelaide in 1957 and was a member of the SA Working Party. Within three years of Pike’s appointment however, ‘an acrimonious correspondence’ had developed between the two men over Price’s ADB entries on George Fife Angas, Charles Sturt and John Hindmarsh. Price’s articles, despite attempts at revision, were regarded by Pike as not meeting ‘ADB style’ and were considered unsuitable for inclusion. A heated exchange of letters fuelled the dispute and Price resigned from the working party. The Editorial Board supported Pike but hoped that Price would withdraw his resignation. ( p ) p p y y 61 Colin Kerr and A. Price, Archie: The Biography of Sir Archibald Grenfell Price (Melbourne: Macmillan, 1983), pp. 239–41. Minutes, ADB Editorial Board meeting (21 January and 12 February 1965), box 70, Q31, ADBA, ANUA. p 63 Price was a devout Anglican, had studied at St Peter’s College and became a Synod member of the Adelaide Diocese. G. Walsh, Australia: History & Historians (Canberra: Australian Defence Force Academy, 1997), p. 122. 60 Smith to Calvert (8 April 2002), Calvert papers, University of Adelaide Library. 61 Colin Kerr and A. Price, Archie: The Biography of Sir Archibald Grenfell Price (Melbourne: Macmillan, 1983), pp. 239–41. Minutes, ADB Editorial Board meeting (21 January and 12 February 1965), box 70, Q31, ADBA, ANUA. 62 Kerr and Price, Archie, p. 240. 63 Price was a devout Anglican, had studied at St Peter’s College and became a Synod member of the Adelaide Diocese. G. Walsh, Australia: History & Historians (Canberra: Australian Defence Force Academy, 1997), p. 122. 64 Kerr, Archie, pp. 240–1. ( p ) p p y y 61 Colin Kerr and A. Price, Archie: The Biography of Sir Archibald Grenfell Price (Melbourne: Macmillan, 1983), pp. 239–41. Minutes, ADB Editorial Board meeting (21 January and 12 February 1965), box 70, Q31, ADBA, ANUA. 62 Kerr and Price, Archie, p. 240. 63 Price was a devout Anglican, had studied at St Peter’s College and became a Synod member of the Ad l id Di G W l h A li Hi & Hi i (C b A t li D f F A d 60 Smith to Calvert (8 April 2002), Calvert papers, University of Adelaide Library. 62 Kerr and Price, Archie, p. 240. 63 Price was a devout Anglican, had studied at St Peter’s College and became a Synod member of the Adelaide Diocese. G. Walsh, Australia: History & Historians (Canberra: Australian Defence Force Academy, 1997), p. 122. 64 Kerr, Archie, pp. 240–1. 65 General Editor, ‘Australian Dictionary of Biography’ (13 July 1973), box 70, Q31, ADBA, ANUA. ‘Bowing the knee to Baal’ He did, and his name was included in Volume 1 as a member of the SA Working Party, but he had no further involvement with the ADB.61 Price was not the only rejected author, as extracts from Pike’s ‘conciliatory letter’ to Price, reveal. ‘Yours is by no means an isolated case, but out of some 200 authors who have already “bowed the knee to Baal”, you are the first to protest and decline authorship’.62 It was a biblical expression from the Old Testament account of Elijah, which Price would have understood both from his schooldays and other religious connections—hence his reply, denying that he would ‘bow the knee to Baal’ even if he were ‘the only Elijah against 450 prophets’.63 Price offered to ‘clean up Angas’ and to submit the article anonymously, handing Pike an olive branch. According to Colin Kerr, who wrote a biography of Price, Pike accepted the redrafted article on Angas, invited Price to lunch at his Canberra home, then wrote formally to Price in January 1965 advising that both the Angas and Hindmarsh articles were ‘out of harmony in general style’ with ADB requirements.64 In the end, the entries were published in Volume 1 unsigned. The entry on Charles Sturt, in Volume 2, was written by Jim Gibbney, an ADB staffer. The drawn-out saga between the two men demonstrates two aspects of an 113 The ADB’s Story The ADB’s Story The ADB’s Story ADB editor’s responsibilities. From one perspective, it depicted Pike’s personal involvement with contributors, many of whom he knew, and the emotional strain it generated. Parallel with this was his responsibility in establishing and maintaining an ADB style and standard that would guarantee the first volume’s acceptance with a critical readership. If for Hancock the ‘cross’ to bear was Ellis, for Pike it was Sir Archibald Grenfell Price. ADB staff, 1971. Left to right: Margaret Crago, Sue Edgar, Sally O’Neill, Martha Campbell, Nan Phillips, Dorothy Smith ADB staff, 1971. Left to right: Margaret Crago, Sue Edgar, Sally O’Neill, Martha Campbell, Nan Phillips, Dorothy Smith ADB archives ADB archives By the early 1970s Pike had assembled an impressive editorial team that included Bede Nairn (senior fellow), Jim Gibbney (research officer), research assistants Martha Campbell, Suzanne Edgar and Sally O’Neill, the war historians Gavin Long and Arthur Bazley, and Nan Phillips, the ‘super-efficient’ secretary and office manager. Outside Canberra there were part-time research assistants in each capital city and in Wellington and London.65 According to Campbell, Pike could be ruthless with authors who did not meet his strict standards or ignored his demands to adhere to strict word limits. In the 1960s Campbell, Edgar and O’Neill 65 General Editor, ‘Australian Dictionary of Biography’ (13 July 1973), box 70, Q31, ADBA, ANUA. 114 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 were frequently given an article and told to rewrite it, which meant beginning again from scratch, researching it and then rewriting it. If an author who had submitted a shoddy article objected to this draconian editing they were given very short shrift. If they accepted or thanked him for improving it, they signed it.66 Edgar recollected: ‘As an editor he put the style and content of the ADB ahead of contributor’s/author’s delicate feelings’.67 O’Neill, who confirmed these opinions, regarded Pike as a brilliant editor, who ‘established the ADB as a first- class resource for both academics and amateurs. As editor rather than prolific author he is undeservedly unrecognised—a shadowy figure in Australian historiography’.68 These comments reveal the high regard in which Pike was held by his staff, and show a different side to the writing standard required by the ADB. In each of the five volumes that Pike edited, the preface contained the sentence: ‘Most of the unsigned entries were prepared in the Dictionary office’.69 Any attempt to be more specific in discovering particular authors is virtually impossible.70 72 Walsh, ‘“Recording the Australian Experience’”, p. 250. Pike, ADB, vol. 1, p. v. 68 Sally O’Neill to John Calvert (11 October 2002), Calvert papers, University of Adelaide Library. O’Neill (née Burnard), a former student of Pike’s in Adelaide, was employed by Pike as a research assistant in the ADB office in the 1960s. 66 Campbell, interviewed by Calvert (14 July 2004). 66 Campbell, interviewed by Calvert (14 July 2004). 67 Suzanne Edgar to John Calvert (10 October 2002), Calvert papers, University of Adelaide Library. 68 Sally O’Neill to John Calvert (11 October 2002), Calvert papers, University of Adelaide Library. O’Neill (née Burnard), a former student of Pike’s in Adelaide, was employed by Pike as a research assistant in the ADB office in the 1960s. 69 Pike, ‘Preface’, p. v. See also ADB, vols 3, 4 and 5. 70 A detailed scan of the files and card system of the ADB held at the ANU Archives would reveal the names of authors but I have not undertaken this task. 71 G. Fischer to J. Calvert (14 April 2002); B. Nairn to J. Calvert (10 September 2002), Calvert papers, University of Adelaide Library. The invitation prescribed ‘dinner jacket’ but not all guests were so attired: see P. Ryan, ‘Manning Clark’, Quadrant, 37, no. 9 (1993), p 18. See also Sydney Morning Herald (2 March 1966), p. 14, and (3 March 1966), p. 2. 72 Walsh, ‘“Recording the Australian Experience’”, p. 250. Pike, ADB, vol. 1, p. v. fi 69 Pike, ‘Preface’, p. v. See also ADB, vols 3, 4 and 5. p y ( y ) 67 Suzanne Edgar to John Calvert (10 October 2002), Calvert papers, University of Adelaide Library. 71 G. Fischer to J. Calvert (14 April 2002); B. Nairn to J. Calvert (10 September 2002), Calvert papers, University of Adelaide Library. The invitation prescribed ‘dinner jacket’ but not all guests were so attired: see P. Ryan, ‘Manning Clark’, Quadrant, 37, no. 9 (1993), p 18. See also Sydney Morning Herald (2 March 1966), p. 14, and (3 March 1966), p. 2. 66 Campbell, interviewed by Calvert (14 July 2004). 67 S Ed t J h C l t (10 O t b 2002) p 70 A detailed scan of the files and card system of the ADB held at the ANU Archives would reveal the names of authors but I have not undertaken this task. 73 D. H. Pike (gen. ed.), Australian Dictionary of Biography, vol. 2 (Carlton, Vic.: Melbourne University Press, 1967). 74 Minutes, ADB Editorial Board meeting (28 February 1967), box 64, Q31, ADBA, ANUA. 75 D. Pike, Charles Hawker (Melbourne: Oxford University Press, 1968), p. 30. Pike received a congratulatory letter from Australia’s governor-general, Lord Casey, who had served with Hawker in Federal Parliament during the 1930s: dated 20 May 1968, NLA 6869, box 7/2. 76 ‘A Memory for “Only 500”’, ANU Reporter (25 August 1972), p. 3. 77 J. La Nauze to R. Hohnen (7 December 1968), box 70, Q31, ADBA, ANUA. 78 R. Hohnen to S. Stackpole, Carnegie Corporation (18 December 1968), box 70, Q31, ADBA, ANUA. 79 R. Hohnen to ANU Vice-Chancellor (10 March 1969), box 70, Q31, ADBA, ANUA. The ADB in print, and travel abroad On 4 March 1966, a formal dinner to launch Volume 1 of the ADB was held at the ANU, presided over by the recently retired prime minister, Sir Robert Menzies.71 The event was a pinnacle in Australian historical scholarship and the culmination of long periods of organisation, writing, meetings and hard work. The ADB was described as ‘the basic reference for research into Australia’s past’, and ‘the largest project in the Social Sciences ever undertaken in Australia’.72 The ‘Acknowledgments’ page recognised the financial backing of the Bushell Trust and the Myer Foundation and the privileges extended by Australian universities, followed by a series of people, local and overseas. 115 The ADB’s Story Volume 2 was published in 1967. It contained 581 entries and completed the years up to 1850.73 Pike’s staff continued to compile contributions for Volume 3 (the authors’ deadline for submissions for Volume 3 was 1 June 1967, Easter 1968 for Volume 4, Easter 1969 for Volume 5 and Easter 1970 for Volume 6).74 Meanwhile, Pike combined his own editorial tasks with a title in the Oxford University Press series ‘Great Australians’, a 30-page work on the South Australian soldier, politician and pastoralist Charles Hawker, published in 1968. Pike’s concluding sentences, describing Hawker, show his concise expertise with descriptive expressions: Deeply religious, he never allowed church-going to become a habit that might blunt his sense of God. He won trust and affection by his high ideals of ‘living right’. He loved fun and wit but found his best satisfaction in serving his country as soldier and citizen, statesman and patriot.75 Pike’s working practice was that once he had checked page proofs for publication, he diverted his mind from the published volume to concentrate on the next production. He was known to possess a ‘remarkable memory’ that enabled him ‘to recall surprising details about the hundreds of personalities being recorded’, but claimed with mock modesty that he could ‘only keep the details of five hundred personalities’ in his head at one time.76 Pike’s working practice was that once he had checked page proofs for publication, he diverted his mind from the published volume to concentrate on the next production. 73 D. H. Pike (gen. ed.), Australian Dictionary of Biography, vol. 2 (Carlton, Vic.: Melbourne University Press, 1967). g ( y ) Q 75 D. Pike, Charles Hawker (Melbourne: Oxford University Press, 1968), p. 30. Pike received a congratulatory letter from Australia’s governor-general, Lord Casey, who had served with Hawker in Federal Parliament during the 1930s: dated 20 May 1968, NLA 6869, box 7/2. ( ) R. Hohnen to S. Stackpole, Carnegie Corporation (18 December 1968), box 70, Q31, ADBA, ANUA. 79 R. Hohnen to ANU Vice-Chancellor (10 March 1969), box 70, Q31, ADBA, ANUA. 80 D. Pike, ‘Review: The Collected Works of Edward Gibbon Wakefield’, in M. F. Lloyd Prichard (ed.), Historical Studies, 14, no. 53 (1969), pp. 109–10. 81 D. Pike (ed.), Australian Dictionary of Biography, vol. 3 (Carlton, Vic.: Melbourne University Press, 1969), p. v. 82 H. G. Helms, University of Melbourne, to D. Pike (24 November 1969), box 1, MS 6869, Douglas Pike Papers, NLA. The Canberra Times (6 December 1969), p. 10. The award recognised the most distinguished work on Australian or New Zealand history published in the period by a resident in either country, and was individual not collective. 83 The Master, St John’s College, Cambridge, to D. Pike (16 May 1969), box 7, MS 6869, Douglas Pike Papers, NLA. F. Colbert, Archivist, St John’s College, Cambridge, to J. Calvert (12 September 2003), Calvert papers, University of Adelaide Library. The ADB in print, and travel abroad He was known to possess a ‘remarkable memory’ that enabled him ‘to recall surprising details about the hundreds of personalities being recorded’, but claimed with mock modesty that he could ‘only keep the details of five hundred personalities’ in his head at one time.76 As work began on Volume 3, it was suggested that Pike should combine study leave with a holiday abroad. The Pikes had been overseas separately but never together. Hancock sought to arrange a visiting fellowship at Cambridge University or on the campus of an American university. The chair of the ADB’s Editorial Board, John La Nauze, estimated that the costs to the university of the trip would be about $1000, which he estimated as ‘chicken feed compared with our regular sending of a scholar to India to write a thesis which will be forgotten’.77 Ross Hohnen, the ANU registrar and ADB Editorial Board member, writing to the Carnegie Corporation of New York regarding the possibility of a grant to supplement the ANU’s travel contribution, also mentioned Pike’s ‘gentle nature’.78 In the end, invitations from various dictionary projects in Canada, the United States and France resulted in arrangements for research, combining study leave and dictionary business, with a grant of $2750 to meet all costs.79 116 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Before setting off, Pike completed two more tasks. First, he wrote a two-page review of the ‘collected works’ of E. G. Wakefield, advocate of systematic colonisation, with an introduction designed to facilitate ‘a fuller assessment of his worth’.80 His other responsibility was the editorial oversight of Volume 3, published in 1969.81 A few weeks after he and his wife set out in October 1969 it was announced that he had been awarded the biannual $500 Ernest Scott Prize by the University of Melbourne for his general editorship of Volumes 1 and 2.82 Apart from three weeks in Canada and the United States, Pike was based in Cambridge, where he was elected Commonwealth Fellow for 1969–70 by St John’s College, entitling him to furnished rooms and dining rights in the college occupancy at Merton House.83 Returning home in July 1970, Pike resumed his ADB duties and continued the task of preparing Volume 4 for publication. Volumes 1–12 originally had plain, cream dust jackets. 83 The Master, St John’s College, Cambridge, to D. Pike (16 May 1969), box 7, MS 6869, Douglas Pike Papers, NLA. F. Colbert, Archivist, St John’s College, Cambridge, to J. Calvert (12 September 2003), Calvert papers, University of Adelaide Library. 84 J. A. La Nauze, ‘Obituary: Douglas Henry Pike’, Historical Studies, 16, no. 64 (1975), pp. 498–502. 85 Stretton, interviewed by Calvert (18 March 1999), John Calvert. 86 Robin Gollan to J. Calvert (10 May 2002), Calvert papers, University of Adelaide Library. See also ‘Capital Letter’, Canberra Times (20 March 1969). 87 Minutes, ADB Editorial Board meeting (26 October 1972), box 64, Q31, ADBA, ANUA. 88 ‘Negotiations Over the Retirement of Professor Pike’, box 70, Q31, ADBA, ANUA. 89 Letter to D. Pike from D. K. R. Hodgkin, Registrar, ANU (15 November 1973), box 6, MS 6869, Douglas Pike Papers, NLA. 90 Nairn, ‘The Foundation General Editor’, p. xii. 91 La Nauze, ‘Obituary’. 92 R. Reid to J. Calvert (2 August 2002), Calvert papers, University of Adelaide Library. B. Nairn, ‘D. H. Pike’, in ADB, vol. 16, p. 2. The ADB in print, and travel abroad In 1993 John Ritchie suggested to MUP that they be replaced with the more colourful gold and blue covers 117 The ADB’s Story y 92 R. Reid to J. Calvert (2 August 2002), Calvert papers, University of Adelaide Library. B. Nairn, ‘D. H. Pike’, in ADB, vol. 16, p. 2. g 89 Letter to D. Pike from D. K. R. Hodgkin, Registrar, ANU (15 November 1973), box 6, MS 6869, Douglas Pike Papers, NLA. 93 ADB confidential report under names of R. Gollan and J. La Nauze to members of the Editorial Board, box 70, Q31, ADBA, ANUA. ANU Vice-Chancellor to O. Pike, signed by D. K. R. Hodgkin, Registrar (24 January 1974), folder 1272, ANUA. 94 Jacqueline Rees, ‘Editor of “Dictionary of Biography” Dies’, Canberra Times (21 May 1974), p. 3. La Nauze, ‘Obituary’. 95 Nairn, ‘D. H. Pike’, p. 2. A. Pike, interviewed by J. Calvert (25 June 2002); D. Pike, jr, interviewed by J. Calvert (10 April 2007), Calvert papers, University of Adelaide Library. 96 D. H. Pike (ed.), Australian Dictionary of Biography, vol. 5 (Carlton, Vic.: Melbourne University Press, 1974), pp. v and vii. Nairn, ‘The Foundation General Editor’, p. xii. 97 ‘Capital Letter’ (1969), p. 3. Birman to Calvert (30 October 2002), Calvert papers, University of Adelaide Library. Bowing out Throughout his time with the ADB, Pike showed little concern for his own wellbeing. His hard-work ethic, in which he pushed himself mentally and physically for years, was combined with internalising personal doubts. For him the biggest sin was ‘scamped work or failure to fulfil obligations voluntarily undertaken’.84 After suffering two heart attacks late in 1954 in Adelaide, he had been off work for three months. Hugh Stretton remembered that Pike ‘recovered from [the heart attacks] with a reckless determination to get fit or die, running well ahead of his doctors’ schedules of exercise and return to work’;85 but he did not stop smoking. Robin Gollan recollected Pike wandering into his (Gollan’s) study in the 1960s, ‘puffing his pipe and starting in the middle of a sentence— the first part of which I had not heard’.86 In 1972, while Pike was involved with his staff in preparing material for Volumes 5 and 6, the Editorial Board prepared for his retirement at the end of 1973, after a last period of leave, by appointing a committee to search for his replacement.87 In August 1973, the acting chairman of the Editorial Board, Robin Gollan, forwarded a memorandum to the acting director of the RSSS outlining his preferred option to retain Pike’s services for some additional years. He referred to a meeting 10 months previously when he and three others had agreed ‘that after retirement from the university, Professor Pike should be given a contract at a suitable fee to enable him to complete to publication, Volume 6 of the Dictionary, the fee to be underwritten by the University’. The figure suggested was $10 000.88 Less than two weeks after Pike’s birthday, a letter from the ANU registrar offered him an appointment as visiting fellow in the Department of History (ADB) from 1 January 1974 in order to work towards completing the fifth and sixth volumes.89 Having worked in close association with Pike for the past several years, Nairn had noticed that Pike’s health was ‘suffering, at least partly from his intense editorial efforts’.90 La Nauze, chairman of the Editorial Board, was also aware that Pike worked too hard and ‘never relaxed’.91 Within days of his birthday, while mowing his lawn, Pike suffered a cerebral thrombosis, and was taken to Canberra Hospital.92 By the end of November it 118 3. John Calvert, a postgraduate of the University of Adelaide, lectures in church history at the Bible College of South Australia. y 99 W. K. Hancock to K. S. Isles (27 February 1962), box 69, Q31, ADBA, ANUA, cited by Davidson, A Three- Cornered Life, p. 400. 98 La Nauze, ‘Obituary’. Bowing out ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 was obvious that he would not recover sufficiently to return to his desk. Nairn was appointed acting general editor until the end of 1973, but, in the light of Pike’s medical condition, he continued in the post while steps were taken to appoint a new general editor.93 In March 1974, the ANU honoured Pike by conferring the title emeritus professor on him. Pike died in hospital on 19 May 1974.94 A private, non-religious funeral service, followed by cremation, was conducted at the Canberra cemetery two days later. The ADB entry on Pike stated that the service was conducted with ‘Presbyterian forms’, but Pike had not professed religion following his resignation from the ministry. Rather he had embraced humanist ideas, believing that all religions should be grouped together, not separated into denominations.95 Volume 5 of the ADB, including Pike’s preface, was published the year he died. The final paragraph of ‘Acknowledgments’ mentioned his illness, adding that a tribute to his service would be included in the following volume.96 Paving courtyards and building stone walls had been Pike’s relaxation from his time in Western Australia in the late 1940s; during his first five years in Canberra, ‘he used about ten tons of stone’, creating a stone wall at his house.97 La Nauze noted in his obituary that ‘he built them soundly and expertly so that they would stand for a hundred years, like the volumes of the Dictionary he edited’.98 Appointed as general editor by Hancock, who had declared that ‘he was born to do this work’,99 Pike had gathered together an editorial team and established the systems that set the style and tone for the ADB, and yet, reluctant to delegate, he did much of the editing himself. His meticulous concern to eliminate scholarly error left minimal time for writing, beyond talks and a few journal articles that originated from his own research. He effectively wrote the job specification for the post later filled by Nairn, Serle, John Ritchie and Diane Langmore. John Calvert, a postgraduate of the University of Adelaide, lectures in church history at the Bible College of South Australia. 119 The ADB’s Story Nan Phillips (1911–1984) Nan Phillips joined the ANU as a departmental assistant in the history department in 1961. She began working on the ADB after Douglas Pike’s appointment as general editor in 1962. During the next two years, Pike worked part-time while fulfilling obligations to the University of Tasmania. Phillips’ letters kept him up to date on gossip and doings: in July 1962, for example, she told him that ‘Professor Hancock is in Brisbane’, flooded in, and Mr Fitzhardinge was ‘a little off colour’. She observed when she sent him the minutes of a meeting that, in her ‘sad experience’, it was ‘unwise to issue a draft too far in advance of the next performance; with all due respect to academics, they have a wonderful habit of forgetting where things are and then there is a frantic rush to produce more copies’, adding ‘(Present copy excepted, of course!)’. The ADB and writing history became ‘the vocation of her maturity’. As the office administrator, she was responsible for writing the ADB’s first style manual. Geoffrey Serle (general editor, 1975–87) described her as the ADB’s ‘heart and soul’; Ken Inglis (chair of the Editorial Board) said, ‘[a]part from the editors … nobody has contributed so richly to the achievement of the dictionary as Nan Phillips’; while a research editor, Sue Edgar, said that she was reassured by having Nan as a role model. Like many ADB staff, Phillips contributed entries to the dictionary. She was also one of the few women who regularly worked in the Petherick Reading Room at the National Library of Australia, where she checked the accuracy of the items in the bibliographies of ADB entries. Edgar and Martha Campbell have noted that with ‘her patience and persistent care in compiling bibliographies she developed a masterly system of abbreviations and thereby helped to build the Dictionary’s high reputation for accuracy’. She also helped to build up the ADB’s library by her personal and avid collecting. Keith Phillips donated 830 books to the ADB in memory of his wife in 1984, a gift estimated to be worth more than $4000. Phillips retired from the ADB in 1980. In the following year, the ANU recognised her ‘outstanding achievements’ by conferring upon her the degree of Master of Arts, honoris causa, for ‘outstanding service to scholarship’—which Phillips cherished because she had not had the opportunity to pursue tertiary study. 120 3. Sources: Chris Cunneen, ‘Obituary Jim Gibbney’, Canberra Times (26 August 1984), p. 6. Graeme Powell, ‘The Readers of “68”’, National Library of Australia News, 12, no. 2 (November 2001), pp. 14–17. Nan Phillips (1911–1984) ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Sources: Ken Inglis, Citation for Honorary Degree for Nan Phillips (23 August 1981), box 59, Q31, ADBA, ANUA. Chris Cunneen, ‘Obituary: Mrs Nan Phillips, Historian’, Canberra Times (28 April 1984), p. 4. Suzanne Edgar and Martha Campbell, ‘Dictionary was Vocation of Nan Phillips’, Obituary, ANU Reporter (May 1984), p. 6. Sources: Ken Inglis, Citation for Honorary Degree for Nan Phillips (23 August 1981), box 59, Q31, ADBA, ANUA. Chris Cunneen, ‘Obituary: Mrs Nan Phillips, Historian’, Canberra Times (28 April 1984), p. 4. Suzanne Edgar and Martha Campbell, ‘Dictionary was Vocation of Nan Phillips’, Obituary, ANU Reporter (May 1984), p. 6. (May 1984), p. 6. Nan Phillips, n.d. By courtesy of the Canberra and District Historical Society Nan Phillips, n.d. By courtesy of the Canberra and District Historical Society 121 The ADB’s Story Jim Gibbney (1922–1989) Jim Gibbney was a research officer and editor with the ADB from 1965 to 1983. After war service, he graduated from the University of Western Australia (BA Hons, 1949) and trained as a librarian at the Commonwealth National Library in Canberra. He then transferred to the library’s archives division before taking up his appointment at the ADB. Like other early members of the ADB’s staff, he had been known to key ADB personnel before his appointment: Douglas Pike had taught him at the University of Western Australia. Gibbney wrote 81 entries for the ADB and worked on countless others as research editor of the Queensland desk. With Ann Smith, he also prepared 10 000 short biographical records, with citations, for the two-volume A Biographical Register, 1788–1939 (1987). While working at the ADB, Gibbney completed an MA thesis (ANU, 1969): a biography of the journalist and Labor politician Hugh Mahon. His independent research centred on Canberra. He was chosen to write one of three volumes on the history of Canberra, Canberra 1913–1953 (1988), for the Australian Bicentenary. The book was submitted as a PhD thesis that was awarded in 1988. In 1968 Gibbney, a frequent user of the National Library’s collections, was given ticket no. 1 for readers in the library’s Advanced Studies Reading Room (later Petherick Room). This room was reserved for highly qualified researchers who were given privileges and were helped in their work by a small group of reference librarians. Manning Clark once said that Jim Gibbney ‘standing on the steps of the Library in the early morning was like a man anxiously waiting to meet his lover’. Sources: Chris Cunneen, ‘Obituary Jim Gibbney’, Canberra Times (26 August 1984), p. 6. Graeme Powell, ‘The Readers of “68”’, National Library of Australia News, 12, no. 2 (November 2001), pp. 14–17. 122 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 3. Born to do this work : Do Jim Gibbney, 1983 Jim Gibbney, 1983 Jim Gibbney, 1983 By courtesy of Sue Edgar By courtesy of Sue Edgar 123 The ADB’s Story Jim Gibbney, like many ADB staff, liked to write ditties. He sent this one to ADB staff after his retirement in 1984. Jim Gibbney (1922–1989) His sentiments about the writing, editing and research skills learnt at the ADB would be echoed by all former and present ADB staff. Jim Gibbney, like many ADB staff, liked to write ditties. He sent this one to ADB staff after his retirement in 1984. His sentiments about the writing, editing and research skills learnt at the ADB would be echoed by all former and present ADB staff. Jim Gibbney, like many ADB staff, liked to write ditties. He sent this one to ADB staff after his retirement in 1984. His sentiments about the writing, editing and research skills learnt at the ADB would be echoed by all former and present ADB staff. Jim Gibbney, like many ADB staff, liked to write ditties. He sent this one to ADB staff after his retirement in 1984. His sentiments about the writing, editing and research skills learnt at the ADB would be echoed by all former and present ADB staff. Box 58, Q31, ADBA, ANUA Box 58, Q31, ADBA, ANUA 124 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Sally (b. 1940) and Bob (b. 1936) O’Neill When Douglas Pike set out in 1964 to build up a staff, he turned to people he knew and trusted. He had taught Sally Burnard at the University of Adelaide in the late 1950s (Ken Inglis supervised her honours thesis in 1961) and, when she came to Canberra in 1967 with her husband, Robert O’Neill, he appointed her as a part-time research assistant. In 1969 he made her full-time, responsible for the Victorian desk. A graduate of the Royal Military College, Duntroon, Bob O’Neill had been a Rhodes Scholar at the University of Oxford (DPhil, 1965) before serving in Vietnam as an infantry captain (1966–67); he had then taken up a teaching post at Duntroon. He left the Army in 1968, and in 1969 was appointed a senior fellow in international relations at the ANU. In 1971 he was appointed head of the Strategic and Defence Studies Centre at the ANU. Pike sought his help in creating an armed services group list and appointed him section editor of armed services entries and a member of the Editorial Board. The O’Neills moved to Britain in 1982 when Bob became director of the International Institute for Strategic Studies, based in London. From 1987 to 2001, he was Chichele Professor of the History of War at Oxford. For 18 years from 1983, until their return to Australia, Sally worked for the ADB, gathering English certificates, probate records and dealing with research queries. In addition, she has written 49 entries for the ADB. Bob continued seamlessly as section editor of armed forces entries from 1971 to 2001. Sources: Sally O’Neill to Chris Cunneen (14 September 1983), box 112; and General Editor’s Report, Minutes ADB Editorial Board meeting (23 May 1985), box 125, Q31, ADBA, ANUA. Desmond Ball, ‘Robert O’Neill: A Strategic Career’, Australian Journal of International Affairs, 60, no. 1 (March 2006) pp. 7–11. 125 The ADB’s Story Sally O’Neill, 2013 Sally O’Neill, 2013 ADB archives ADB archives 126 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Bob O’Neill, 2013 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Bob O’Neill, 2013 ADB archives ADB archives 127 The ADB’s Story 1 J. A. La Nauze, Chairman, to Members of the ADB Editorial Board (11 September 1975), box 70, Q31, ANUA, ADBA. 2 For biographical details, see Chris Cunneen, ‘The ADB’s Second General Editor’, in Australian Dictionary of Biography, vol. 17 (Carlton, Vic.: Melbourne University Press, 2007), pp. xiii–xiv. ‘A Big Fella in His Field’, Sydney Morning Herald (5 May 2006). Geoff Serle, ‘Bede Nairn: His Life and Work’, in Bede Nairn and Labor History (Sydney: Pluto Press, 1991), pp. 3–10. I am grateful for the help of Martha Campbell, Sally O’Neill, Suzanne Edgar, Helga Griffin and John Thompson in writing this account. Ruth Frappell (née Teale) (1942–2011) Ruth Teale graduated with honours in history from the University of Sydney in 1963. She began her ADB career while working as a research assistant to Norman Cowper, helping him to compile an article (on Sir George Wigram Allen) that became a joint entry. Recruited then as an author in her own right, she contributed eight articles to Volume 3. In 1970 she was offered a PhD scholarship at the ANU but chose instead to marry a fellow historian, Leighton Frappell. An expert in the resources of the Mitchell Library, the State Archives and the NSW Probate Office, she was employed as the dictionary’s Sydney research assistant from 1977 to 1984. In 1978 she published, as Ruth Teale, the groundbreaking Colonial Eve: Sources on Women in Australia, 1788–1914. Over the years, under both her maiden and her married names, she wrote 56 articles for the ADB. Active in the Anglican Church, Ruth Frappell extensively researched its history in Australia, collaborated on Anglicans in the Antipodes: An Indexed Calendar of the Archbishops of Canterbury, 1788–1961, Relating to Australia, New Zealand and the Pacific (1999), wrote a parish history and contributed many articles and book chapters. In 1992 the University of Sydney awarded her a PhD for a thesis on rural Anglicism in which she compared the work of Bush Church Aid with that of the Bush Brotherhood. President (1998–2002) of the Royal Australian Historical Society, she was involved in many historical and academic associations as well as church organisations and groups. Sources: Leighton Frappell, ‘Family Tribute to Ruth Frappell’, read by the Right Reverend Richard Hurford, Bishop of Bathurst, St Alban’s Anglican Church, Epping, NSW (8 August 2011), private collection. Leighton Frappell, ‘Biographer Captured Diversity of Life. Ruth Frappell, 1942–2011’, Obituary, Sydney Morning Herald (18 October 2011). 128 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Ruth Frappell, n.d. By courtesy of Leighton Frappell 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 3. ‘Born to do this work’: Douglas Pike and the ADB, 1962–1973 Ruth Frappell, n.d. Ruth Frappell, n.d. By courtesy of Leighton Frappell By courtesy of Leighton Frappell 129 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 Christopher Cunneen When the Australian Dictionary of Biography’s general editor, Douglas Pike, was felled by a devastating stroke on Remembrance Day 1973, the ADB team was fortunate to have, at ‘first drop’ (to use a cricketing analogy that Bede Nairn might have appreciated), a veritable Victor Trumper of a historian, able to continue the strong innings that the openers had established.1 Nairn: Consolidating the innings Noel Bede Nairn (1917–2006) was born on 6 August 1917 at Turill, near Mudgee, NSW, youngest of six children of Robert John (Jack) Nairn and his wife, Rose Ann, née Hopkins.2 When the boy was six, the family moved to inner Sydney, where Jack worked as a council watchman and cleaner. Though the Nairns were close to poverty, Bede’s mother, Rose, bought a piano and he took music lessons, financed by taking in boarders. He was educated at St John’s Poor School, in Kent Street, and then by the Christian Brothers at St Mary’s Cathedral School, where he completed the Intermediate Certificate. On leaving school, he worked for the NSW Electoral Office. While studying for matriculation part-time, he worked as a clerk at Sydney Technical College; later he was an evening student at the University of Sydney (BA Hons, 1945; MA, 1955). He married Jean Hayward on 26 January 1943. In 1948 he taught at Sydney Technical College, Ultimo, and the following year lectured in history at the newly founded NSW University of Technology (now University of New South Wales); in 1956 he became senior lecturer and head of the school of history at the university and, in 1961, associate professor of history. In 1957, on a Rockefeller grant, he and his family went to Balliol College, Oxford, where he researched trade unions in Britain. 131 The ADB’s Story The ADB’s Story Bede Nairn, 1985 By courtesy of Sue Edgar Bede Nairn, 1985 Bede Nairn, 1985 By courtesy of Sue Edgar 132 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 ADB staff, Chris Cunneen, Marion Consandine and Bede Nairn, 1983 ADB staff, Chris Cunneen, Marion Consandine and Bede Nairn, 1983 ANU Archives, ANUA226-689 ANU Archives, ANUA226-689 Nairn became chairman of the ADB’s NSW Working Party in 1962, and guided the committee through the latter part of the ructions caused by Malcolm Ellis. He quickly became an essential element in the team of volunteers supporting the work of Pike in the early volumes of the dictionary. Nairn was not, however, an early member of the National Committee that established the ADB, though in 1965 he did act on that committee as a replacement for the departed John Salmon. Nor was he a member of the Editorial Board that governed the project prior to the publication of Volumes 1 and 2 in 1966–67. Indeed, he did not contribute any entries to Volume 1 and only two to Volume 2; it is significant that those two were on the pastoralist/politician Hannibal Macarthur, and the Catholic Archbishop John Bede Polding. (It is possible that Nairn was actually named after Bede Polding, though not by his parents. His son John has told me that the parents had wanted to baptise him Lloyd George Nairn, but that the officiating priest had refused to allow it.) 133 The ADB’s Story After a sabbatical year at the ANU in Canberra in 1965, the Nairn family moved there permanently in 1966. On the ANU staff, Nairn became deputy to Pike and he now joined the National Committee and the Editorial Board. With Geoffrey Serle and Russel Ward, he was a section editor for Volumes 3–4, covering people who flourished in 1851–90. He continued his membership of the NSW Working Party, but handed the chairmanship to Gordon Richardson, the State librarian of New South Wales, who was in turn succeeded by Russell Doust. In addition to his work on the ADB, Nairn took a prominent role in the Australian Society for the Study of Labour History, serving as vice-president and a member of the editorial board of Labour History, and completed his groundbreaking book Civilising Capitalism: The Labor Movement in New South Wales 1870–1900 (1973).3 So he was ready, when Pike fell ill, to step in and complete the final stages of work on Volume 5. At the urging of the then chairman of the Editorial Board, John La Nauze, Nairn agreed to act as general editor for Volume 6. He accomplished this at a difficult time, when the publisher of Melbourne University Press, Peter Ryan, was having one of his obstreperous periods. 3 Bede Nairn, Civilising Capitalism: The Beginnings of the Australian Labor Party (Carlton, Vic.: Melbourne University Press, 1989). Frank Bongiorno, ‘Nairn (N) B’, in G. Davison, J. Hirst and S. Macintyre (eds), The Oxford Companion to Australian History, rev. edn (Oxford: Oxford University Press, 2001), p. 455. ANU Archives, ANUA226-689 In response to a demand from MUP that the length of the volume be reduced, Nairn was forced to delete a large number of articles—30 were removed from the NSW list alone—some of which had already been commissioned and, indeed, written. Still, Volume 6, though slimmer than the others in the series, was a notable continuation of the form and style set by Pike. Nairn was enormously assisted in his task by the remarkable team of research assistants Pike had assembled. The administrative role of Nan Phillips was notable, and the skilled editing of Martha Campbell, Sally O’Neill, Suzanne Edgar and the late Deirdre Morris was clear to me when I joined the team in 1974. Nairn retained the spare style—notoriously devoid of adjectives—that Pike had established. Indeed, his enthusiasm for abbreviation was even more zealous, perhaps because of the limitations in length of the volume imposed by MUP. Nairn insisted on the use of short verbs, such as ‘quit’, and he was responsible for persuading Pike to allow staff to be credited for the entries they had written. Staff have described Nairn as ‘full of humour, warmth and kindness’, which he ‘let … shine out’. Under him, research assistants had much more responsibility for preliminary editing. With support from other research assistants, Edgar drafted a proposal for them to be designated internally as research editors. Nairn supported that change successfully. He was an excellent and involving manager of his team, and his many staff meetings, at which everyone happily discussed at length such weighty issues as whether to hyphenate or not, are well remembered. 134 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 Jim Gibbney was another memorable team member inherited by Nairn. He had taken over the role of ‘biographical registrar’, or gatherer of biographical data. This task has always been a crucial aspect of the ADB work and Gibbney, an amiable and much-loved figure in Canberra, and a habitué of the National Library’s Petherick Room ‘Club’,4 helped to gather the thousands of little white cards filled with biographical data. Authors have been grateful to Gibbney’s Biographical Register for its help in the writing of ADB entries. 4 Gibbney had the number one Petherick ticket: see Graeme Powell, ‘The Readers of “68”’, National Library of Australia News, 12, no. 2 (November 2001), pp. 14–16. 5 H. J. Gibbney and Ann G. Smith (comps and eds), A Biographical Register 1788–1939: Notes from the Name Index of the Australian Dictionary of Biography, 2 vols (Canberra: Australian Dictionary of Biography, 1987). ANU Archives, ANUA226-689 At Nairn’s urging, Gibbney began, and Ann Smith completed, the useful two-volume Biographical Register, 1788–1939 (1987).5 Joyce Gibberd was the ADB’s South Australian research assistant in 1974–2005, a member of that State’s working party in 1990–2005 and wrote 21 ADB entries. She was awarded an ADB Medal in 2002 Joyce Gibberd was the ADB’s South Australian research assistant in 1974–2005, a member of that State’s working party in 1990–2005 and wrote 21 ADB entries. She was awarded an ADB Medal in 2002 4 Gibbney had the number one Petherick ticket: see Graeme Powell, ‘The Readers of “68”’, National Library of Australia News, 12, no. 2 (November 2001), pp. 14–16. f ( ) pp 5 H. J. Gibbney and Ann G. Smith (comps and eds), A Biographical Register 1788–1939: Notes from the Name Index of the Australian Dictionary of Biography, 2 vols (Canberra: Australian Dictionary of Biography, 1987). ADB archives Nairn brought his innate administrative efficiency to the business of gathering certificates of birth, death and marriage (BDM). He and I travelled around Australia, spoke to registrars-general in each State and secured special concessions that enabled the ADB to obtain such information centrally and efficiently. The system of BDM data collection varied from State to State. In 135 The ADB’s Story some States, the registrar’s office provided the information as uncertified copies. In the case of Queensland, one registrar-general transcribed by hand the details from the registers. In Sydney, Nairn was given privileged access to the files and he himself transcribed the BDM details. He soon handed that task to me and I continued to do the transcribing of NSW certificates until new privacy and security measures were introduced some 20 years later. The gathering of BDM material in a period of increasing concerns about privacy continues to cause anxiety. Another task carried out successfully by Nairn, while he worked on Volume 6, was the reinvigoration of the working parties. On our tours to the various State capitals, Nairn and I met with key historians for advice on the best way to proceed. In some cases the working parties had more or less withered and Nairn started over from scratch. In particular, I remember with affection the support and friendship of Denis Murphy in Queensland, assisted by Paul Wilson and the splendid Spencer Routh. In South Australia, John Playford assembled a new team, assisted by Harold Finnis, John Love, Peter Howell and others. In other States we met stalwarts such as Geoffrey Bolton (in Perth) and Michael Roe (in Hobart), both of whom set up committees crucial in the whole ADB enterprise, which continue to be so. The Armed Services Working Party, steered by Bob O’Neill, had been established under Pike, and was from the start a splendid and efficient committee, full of engaging and memorable characters such as Alec Hill, Colonel Frank Brown and the inimitable Brigadier ‘Bunny’ Austin. Nairn also formalised the previously informal system of interstate research assistance. When Pike had wanted a reference checked in Perth, Adelaide or Hobart, he would write to his friends, and ask them to help! Two of these were Wendy Birman, in Perth, and Joyce Gibberd, in Adelaide. On our travels, Nairn and I met these friends, and they agreed to continue as interstate research assistants. A fine partnership Nairn was the sole general editor for Volume 6. When the position of general editor was eventually advertised, the Editorial Board was unable to find a suitable candidate. Neither Nairn nor Serle had applied, knowing that the position was an all-absorbing job.6 Then Serle had the idea that he and Nairn should apply jointly. Nairn agreed, as did the board (though La Nauze needed to be persuaded by Serle),7 and in 1975 the two were appointed as joint general editors.8 The arrangement agreed upon was that Serle would visit Canberra for only two or three days a fortnight. Serle later joked that ‘[i]t wasn’t a bad idea to appoint a Sydney Catholic and a Melbourne Protestant: it surely would have been much worse the other way around’.9 Nairn did not commit his assessment of Geoff Serle to paper, but in a rare interview granted to John Thompson, he was at pains to draw out the differences between the two collaborators—the differences that came from their almost diametrically opposed intellectual and cultural backgrounds (Melbourne versus Sydney; Catholic versus Protestant; [Serle’s] privilege [but not of money] as opposed to Nairn’s simpler, working-class origins; Nairn’s love of the turf against [Serle’s] complete indifference/antipathy—Nairn was puzzled by this).10 differences between the two collaborators—the differences that came from their almost diametrically opposed intellectual and cultural backgrounds (Melbourne versus Sydney; Catholic versus Protestant; [Serle’s] privilege [but not of money] as opposed to Nairn’s simpler, working-class origins; Nairn’s love of the turf against [Serle’s] complete indifference/antipathy—Nairn was puzzled by this).10 Although Nairn stressed the differences between the two editors, there were notable similarities. Both were softly spoken family men; both were influenced by, and supporters of, Manning Clark; both were staunch Labor supporters, though neither was particularly radical, and each was criticised by the ‘New Left’ historians of the 1970s; both were what might now be described as ‘blokey’, sporty men who enjoyed a beer in mostly male company after work on Tuesday afternoon. ADB archives Both are worthy recipients of the ADB Medal, initiated by John Ritchie. Among the several Sydney researchers who helped me in the time of Nairn and Serle were Ruth Frappell and Mike Bosworth. Interstate and overseas research assistants who gave generously of their time and commitment during the Nairn–Serle era included Jennifer Harrison and Anne Rand (both recipients of ADB Medals), Barbara Dale, Naomi Turner, Susan Hogan, Noeline Hall, Betty Crouchley, Mimi Colligan, Geoff Browne, Beth McLeod, Gillian Winter and Leonie Glen. The ADB owes them a great debt of gratitude. 136 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 Bede Nairn, Nan Phillips and Geoffrey Serle in the ADB’s library ANU Archives, ANUA226-680 Bede Nairn, Nan Phillips and Geoffrey Serle in the ADB’s library Bede Nairn, Nan Phillips and Geoffrey Serle in the ADB’s library ANU Archives, ANUA226-680 ANU Archives, ANUA226-680 137 The ADB’s Story 6 Minutes, ADB Editorial Board meeting (22 February 1974), box 64, Q31, ADBA, ANUA. 7 Bede Nairn and Geoffrey Serle to John La Nauze (19 August 1974), box 70, Q31, ADBA, ANUA. 8 See Serle, ‘Bede Nairn’. 10 John Thompson to Chris Cunneen, email (24 November 2009). 9 Serle, ‘Bede Nairn’, p. 6. 6 Minutes, ADB Editorial Board meeting (22 February 1974), box 64, Q31, ADBA, ANUA. 7 Bede Nairn and Geoffrey Serle to John La Nauze (19 August 1974), box 70, Q31, ADBA, ANUA. 8 See Serle, ‘Bede Nairn’. 9 Serle, ‘Bede Nairn’, p. 6. 10 John Thompson to Chris Cunneen, email (24 November 2009). 8 See Serle, ‘Bede Nairn’. Serle: The stylist We are fortunate to have in John Thompson’s masterly biography The Patrician and the Bloke (2006) a comprehensive account of Serle’s role as a teacher, historian and biographer. Alan Geoffrey Serle (1922–98) was born on 11 March 1922 at Hawthorn, Melbourne, third and last child of Percival Serle, accountant and p 10 John Thompson to Chris Cunneen, email (24 November 2009). 138 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 scholar, and his wife, Dora, née Hake, a skilled artist. Educated at Scotch College and the University of Melbourne, the youngster had some of his middle-class, scholarly smoothness roughened by war service in the ranks in New Guinea where he was seriously wounded. He recovered in Queensland, before resuming his university studies (BA Hons, 1946). Winning a Rhodes Scholarship, he entered University College, Oxford. He graduated DPhil in 1950. He returned to Melbourne University, where he taught Australian history, and then moved to Monash University. In 1955 he married Jessie McDonald. Geoff Serle, 1980s By courtesy of Sue Edgar Geoff Serle, 1980s Geoff Serle, 1980s By courtesy of Sue Edgar 139 The ADB’s Story Serle’s two important histories of colonial Victoria, The Golden Age (1963) and The Rush to be Rich (1971), and the pioneering history of Australian culture From Deserts the Prophets Come (1973)11 had shown him to be a leading exponent of what Thompson calls a ‘new nationalistic approach to the teaching and writing of Australian history’.12 Moreover, his father’s long and fruitful engagement with Australian biography—notably, as author of the two-volume Dictionary of Australian Biography (1949)—had instilled in him a lifelong interest in biographical research. He was a founding member of the ADB National Committee, and of the Editorial Board. Like Nairn, he was a section editor for Volumes 3–6 (those who flourished in 1851–90). As joint general editors, Nairn and Serle produced the bulk of Volumes 7–10 that included the men and women who flourished in the half-century from 1891 to 1939 and that covered the period of the depression of the 1890s, the Federation movement, the Boer War, the early years of the Commonwealth, World War I and the Great Depression—in ADB ‘lingo’ this was Period 3, or P3. The decision to continue to use the floruit principle and devote six volumes to this period and to stop before World War II dated from Pike’s general editorship. 11 Geoffrey Serle, The Golden Age: A History of the Colony of Victoria, 1851–1861 (Melbourne: Melbourne University Press, 1963); The Rush to be Rich: A History of the Colony of Victoria, 1883–1889 (Melbourne: Melbourne University Press, 1971); and From Deserts the Prophets Come: The Creative Spirit in Australia 1788–1972 (Melbourne: Heinemann, 1973). 12 J. R. Thompson, The Patrician and the Bloke (Canberra: Pandanus Books, 2006), p. xxiii. ( ) 12 J. R. Thompson, The Patrician and the Bloke (Canberra: Pandanus Books, 2006), p. xxiii. Serle: The stylist Nairn, Serle and the Editorial Board confirmed this plan. After Nairn’s serious illness in 1982, and retirement in 1984, Serle became the sole general editor for Volume 11. To allow for preparations of lists and authors for a new period, and for Nairn to take overdue sabbatical leave in 1977, there was a delay of three years between publication of Nairn’s Volume 6 in 1976 and Volume 7—the first of the jointly edited volumes—in 1979; however, through a sustained period of activity, the following four volumes were published in 1981, 1983, 1986 and 1988. In March 1988 Serle retired. Neither Serle nor Nairn wrote much in the way of a reflective account of what we might think of as their ‘editorial philosophy’ for the ADB. The prefaces in their volumes were bare, formulaic, half-page explanations of the form and structure of the work. When Serle was forced to produce an information sheet for a Research School of Social Sciences open day in 1981, he sighed, took some paper (and a bottle of red wine) back to the college in the evening and returned next day with his summary, which was incorporated into a blue brochure. Some of his modus operandi might be gleaned from this unlikely source: ‘Following the precedents of the British Dictionary of National Biography and the Dictionary of American Biography, nearly twenty countries are engaged in building similar memorials to their “mighty dead”’. 140 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 ADB staff, Helen Bankowski, Nan Phillips and Helga Griffin, 1983 ADB staff, Helen Bankowski, Nan Phillips and Helga Griffin, 1983 By courtesy of Sue Edgar By courtesy of Sue Edgar By courtesy of Sue Edgar So, Geoff Serle, at least, saw the ADB as a ‘memorial to the mighty dead’. He went on to stress the utilitarian nature of the project: The ADB is a standard work of reference and a research tool consulted by hundreds of scholars, students and the general public. It has to be as accurate as possible, given the complexity of biographical research; it also has to be readable. It has consolidated knowledge of the most important figures in Australian history and sharply etched in many who previously were shadowy or unknown. Its accumulation of information has, moreover, stimulated research in many areas of Australian history where access was difficult. Above all, the ADB is a national, co-operative enterprise. 141 The ADB’s Story And he showed a pragmatic realisation of the limitations of the exercise: And he showed a pragmatic realisation of the limitations of the exercise: Yet the ADB does not pretend to be setting up a pantheon of immortals. The most important will be obvious, but the choice of the remainder can only reflect the present state of historians’ knowledge. The editorial team claims only to have taken the best advice available and reached the greatest possible measure of agreement; subsequent generations may have other standards of judgment. So much for any reflection on the theory of prosopography! He did, however, finish his survey with a bit of a boast: ‘The ADB prides itself on its blend of elitism and democracy’. Nairn would not have disagreed with Serle’s ruminations on the ADB’s role and purpose. Indeed, I never had any evidence that they differed on anything substantial. The two men certainly got along with each other remarkably amicably. Serle also acknowledged that he and Nairn had ‘inherited a senior editorial staff … with whom we adopted the most informal, unauthoritarian, collaborative relationship, which increased the very high staff morale and pride in the enterprise. This was primarily Bede’s achievement—he was on the spot’.13 With Serle sojourning in Canberra for only a few days a fortnight, Nairn carried the full administrative load of the project. As Serle’s appointment was half-time, he could escape to his ‘cave’ in Hawthorn and work on his biography of the World War I general Sir John Monash; however, Serle may have understated his role. 13 Bob Carr (ed.), Bede Nairn and Labor History (Leichhardt, NSW: Pluto Press in association with the NSW Branch of the Australian Labor Party, 1991), p. 6. By courtesy of Sue Edgar 14 Minutes, ADB Editorial Board meeting (16 May 1977 and 8 November 1979), box 64, ADBA, ANUA. By courtesy of Sue Edgar First, it was a relief to Nairn to be able to consult Serle on the important issues, and he could leave the whole of the Victorian editing and some of the Commonwealth entries in Serle’s expert hands, ably assisted by Sally O’Neill and, later, by the accomplished new editorial appointees Di Langmore and Ann Smith. But the constant commuting between Melbourne and Canberra, and residence in a university college, was in itself stressful for Serle. In setting up and producing most of the volumes covering the floruit period 1891–1939, Nairn and Serle consciously aimed at continuing the style and format established by Douglas Pike. There was some regularisation of practices. For example, the systematic collection of BDM certificates, begun by Nairn, provided access to a certified medical cause of death that had previously not been available. Their friend the medical historian Bryan Gandevia had given occasional advice to Pike for some years. Because the death certificates now provided a cause of death, Gandevia urged that those details should be included in all entries. Serle was concerned that the artistic flow of an article might be affected by this invariable inclusion of technical medical terms. The issue was 142 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 discussed with section editors, and by the Editorial Board.14 A compromise was reached whereby, where a death certificate was available, a brief cause of death would be provided for people who had died by the age of seventy, but not for those who survived beyond that age. From that time onwards, copies of death certificates for the ‘under-seventies’ were forwarded to Gandevia, who would then scrawl on the copy a brief interpretation of the chief cause of death. This was edited into the entries. It was a labour of love for Gandevia, and an example of the generous support unobtrusively given to the project by many supporters. g y g j y ADB administrative officer Alison Manners, 1980s ADB administrative officer Alison Manners, 1980s ADB administrative officer Alison Manners, 1980s 143 The ADB’s Story Of the volumes Serle edited, he considered Volume 10 to be the most interesting. It included such articles as Stuart Macintyre’s on Sir John Latham, Jim Griffin’s on Archbishop Daniel Mannix, Jim Davidson’s on Dame Nellie Melba and Serle’s own masterly assessments of Monash and Sir Keith Murdoch. 15 Geoffrey Serle, John Monash: A Biography (Melbourne: Melbourne University Press in association with Monash University, 1982). 16 Geoffrey Serle, Sir John Medley: A Memoir (Carlton, Vic.: Melbourne University Press, 1993); and Robin Boyd: A Life (Carlton South, Vic.: Miegunyah Press, 1995). 17 Bede Nairn, The Big Fella: Jack Lang and the Australian Labor Party 1891–1949 (Carlton, Vic.: Melbourne University Press, 1995); and ‘The Governor, the Bushranger and the Premier’, Journal of the Royal Australian Historical Society, 86, part 2 (December 2000), p. 114. By courtesy of Sue Edgar There were also memorable articles by Nairn on the politician Jim McGowen, and the jockey David ‘Darby’ Munro. Geoffrey Blainey and Ann Smith co-authored the entry on Essington Lewis, Peter Burgis wrote on Gladys Moncrieff, Tony Cahill on Cardinal P. F. Moran, and Philip Hart and Clem Lloyd on Joseph Lyons. The volume also included what is probably the most notable ‘family entry’ in the whole ADB—that is, the one on the Lindsays by Bernard Smith. Now that all the entries are wonderfully available in one alphabetical sequence online, and the entries have changed from the floruit to the date of death principle, the flavour of a remarkable cohort of individuals flourishing in a single period is perhaps no longer necessarily possible. Sally O’Neill has described Serle as ‘a wonderful editor, with an elegant but spare style and a real feel for biography and for revealing the subject as a person and not just a list of achievements’. Sue Edgar appreciated his being so well read in literature, as well as in history. Martha Campbell enjoyed his ‘surer sense of language’, despite the fact that he ‘conversed frequently in grunts’. During his time as general editor, Serle researched and wrote his major biography John Monash (1982).15 After their stint as general editors, both Nairn and Serle remained active historians. Serle worked on a study of the Melbourne University vice-chancellor, Sir John Medley (1993), and published a biography of the architect Robin Boyd in 1995.16 He died in Melbourne on 27 April 1998, to the last a vital member of the Victorian Working Party. In all, he had written 49 During his time as general editor, Serle researched and wrote his major biography John Monash (1982).15 After their stint as general editors, both Nairn and Serle remained active historians. Serle worked on a study of the Melbourne University vice-chancellor, Sir John Medley (1993), and published a biography of the architect Robin Boyd in 1995.16 He died in Melbourne on 27 April 1998, to the last a vital member of the Victorian Working Party. In all, he had written 49 articles for the dictionary, beginning with Charles Ebden in Volume 2 (1967) and ending with Sir John Medley in Volume 15 (2000). 15 Geoffrey Serle, John Monash: A Biography (Melbourne: Melbourne University Press in association with Monash University, 1982). ff l h dl ( l lb ) d b By courtesy of Sue Edgar, 1980s By courtesy of Sue Edgar Among the most memorable, for me, are those on John Curtin, prime minister, Brian Fitzpatrick, historian, Vance Palmer, writer, Jack Murray, grazier and premier, James Service, businessman and politician, and Bob Croll, author and public servant. the last a vital member of the Victorian Working Party. In all, he had written 49 articles for the dictionary, beginning with Charles Ebden in Volume 2 (1967) and ending with Sir John Medley in Volume 15 (2000). Among the most memorable, for me, are those on John Curtin, prime minister, Brian Fitzpatrick, historian, Vance Palmer, writer, Jack Murray, grazier and premier, James Service, businessman and politician, and Bob Croll, author and public servant. Nairn published his biography of Jack Lang, The ‘Big Fella’, in 1986 and his last scholarly article in the Journal of the Royal Australian Historical Society in December 2000.17 To my horror, he destroyed his personal papers in the 1980s. He died in Canberra on 21 April 2006. Like Serle, he remained active in his working party until the end; although unable to attend meetings, he remained 144 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 in close contact with its deliberations through correspondence. Among the most notable of his 80 ADB entries, apart from those I have already mentioned, are those on politicians Sir John Robertson, Jack Lang, Jack Beasley and Chris Watson; on the trade unionist Frank Dickson; and on the cricketers Archie Jackson and Victor Trumper. His article on Clive Churchill, footballer, was his last: it appeared in Volume 17, after his death. Helga Griffin was the ADB’s bibliographer, 1979–98. She also edited hundreds of ADB entries Helga Griffin was the ADB’s bibliographer, 1979–98. She also edited hundreds of ADB entries By courtesy of Sue Edgar, 1980s 145 The ADB’s Story Dr Christopher Cunneen was a Research Fellow (1974–82) and deputy general editor (1982–96) of the ADB. He has been a member of the NSW Working Party since 1975 and of the Editorial Board since 2011. ‘[Their] glory was [they] had such friends’ This chapter has emphasised the individual achievements of the second and third general editors. The essential point in their leadership of the ADB was, however, that they were team men. In this they were supported by outstanding Editorial Board chairmen Ken Inglis and acting chair Alan Barnard. A crucial element in the organisation for Volumes 7–11 was the continuous consultation between the general editors and the five section editors: Geoff Bolton, Ken Cable, Bob O’Neill, John Poynter and Heather Radi. Nairn and Serle relied heavily on the enthusiasm, expertise and wisdom of these historians, who gave their time generously, as did the dozens of members of the working parties and their chairmen, such as Russell Doust, Denis Murphy, Ross Johnston, John Playford, Michael Roe, Alec Hill and Wendy Birman. In addition, both Nairn and Serle had strong connections with their extraordinary team of contributors—thousands of men and women who might sometimes protest about too vigorous editing but retained a remarkable affection for and loyalty to the ADB. In achieving their punishing schedule—five volumes published within 12 years—Nairn and Serle were supported by their dedicated staff at HQ. Apart from those already mentioned there were the expert researchers, such as Merrilyn Lincoln, Hilary Kent, Margaret Steven, Helga Griffin, Gillian Fulloon, Jean Fielding, Sheila Tilse and Alan Fewster, each of whom deserves much more recognition than I have time to give them here. The same goes for the stalwart administrative assistance provided to Nairn and Serle by Dorothy Smith, Norma Gregson, Marion Consandine, Frances Dinnerville, Edna Kauffman, Ivy Meere and too many others to mention by name. The truth is that the finest achievement of Bede Nairn and Geoff Serle was that they nurtured and expanded the ADB’s relationship with the thousands of individuals involved in the enterprise. General editors are indeed important in the ADB story, but the essence of the project is that it is a mighty collaborative effort. Dr Christopher Cunneen was a Research Fellow (1974–82) and deputy general editor (1982–96) of the ADB. He has been a member of the NSW Working Party since 1975 and of the Editorial Board since 2011. 146 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 Sources: Christopher Cunneen, personal file, NCB/ADB files. Chris Cunneen, Suzanne Edgar and Darryl Bennet, ‘“Solers and heelers of paragraphs”: Editing the Australian Dictionary of Biography’, in Iain McCalman, with Jodi Parvey and Misty Cork (eds), National Biographies and National Identity (Canberra: Humanities Research Centre, 1996), pp. 149–61. Chris Cunneen (b. 1940) Impressed by Christopher Cunneen’s PhD thesis on the role of the governor- general in Australia (ANU, 1973), Bede Nairn recruited him to the ADB as a research fellow. In 1982 Cunneen was appointed deputy general editor. Under Nairn and Geoffrey Serle’s joint editorship, he increasingly performed most of the day-to-day management of the project, including allocation of duties to research staff, liaison with working parties and supervision of the office. He also assisted the general editor in editing entries and in preparing the manuscript for publication. As Serle noted, ‘sticking to the editorial grind’ meant that there was little time for Cunneen to pursue his own research interests and he was overlooked for the position of general editor when it became vacant in 1987. He then served as a loyal deputy to the successful applicant, John Ritchie. In 1996 he took a voluntary redundancy and moved to Sydney where he became an honorary research fellow at Macquarie University. His involvement in the ADB continued: he had been a key member of the NSW Working Party since 1975 and remains so to this day. He led the team that produced the supplement volume in 2005 and joined the Editorial Board in 2011. He has written 77 ADB entries. Sources: Christopher Cunneen, personal file, NCB/ADB files. Chris Cunneen, Suzanne Edgar and Darryl Bennet, ‘“Solers and heelers of paragraphs”: Editing the Australian Dictionary of Biography’, in Iain McCalman, with Jodi Parvey and Misty Cork (eds), National Biographies and National Identity (Canberra: Humanities Research Centre, 1996), pp. 149–61. 147 147 The ADB’s Story The ADB’s Story Chris Cunneen, 2012 Photographer: Brian Wimborne, ADB archives Chris Cunneen, 2012 Chris Cunneen, 2012 Photographer: Brian Wimborne, ADB archives Photographer: Brian Wimborne, ADB archives 148 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 Sources: Brian Gandevia, correspondence, 1960–92, including Bryan Gandevia to A. G. Serle (13 June 1986), box 136, Q31, ADBA, ANUA. Geoffrey Field, ‘Bryan H. Gandevia Obituary’, Thoracic Society News, 16, no. 4 (December 2006), p. 81. Brenda Heagney, ‘Bryan Gandevia Obituary’, Health and History, 8, no. 2 (2006), pp. 186–91. Sources: Margaret J. E. Steven, personal file, NCB/ADB files. ANU Reporter (28 October 1988), p. 5. Heather Radi to Geoffrey Serle (20 May 1987), box 142, Q31, ADBA, ANUA. Heather Radi (ed.), 200 Australian Women: A Redress Anthology (Sydney: Women’s Redress Press, 1988). Bryan Gandevia (1925–2006) Bryan Gandevia, a respiratory medicine specialist and medical historian, was an ADB author. In 1977 the Editorial Board decided to include cause of death for those subjects who had died under the age of seventy. When research editors found it difficult to interpret the information provided on death certificates, Gandevia’s advice was sought. He proposed that the ADB send him copies of the death certificates as they came to hand and he would ‘summarise them and develop a classification’. This involved him in a 20-year project with the ADB, in which he wrote down the major cause of death on each certificate and returned them to the office. One of the ‘unsung heroes’ of the ADB, Gandevia considered it a ‘privilege to be able to assist in such a magnificent national project’. He wrote widely on the history and bibliography of Australian health and welfare measures and helped to found in 1986 the Australian Society of the History of Medicine. He also served on the Australian War Memorial (AWM) Board of Trustees and subsequently as a member of the AWM Council (1967–88). 149 The ADB’s Story 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 Margaret Steven (b. 1933) and Heather Radi (b. 1929) Margaret Steven, who graduated with a PhD in history from ANU in 1963 and had written a number of books on colonial and imperial history, joined the ADB in 1978 as a research editor, responsible for the Commonwealth desk. She remained until 1996. Heather Radi, a lecturer in history at the University of Sydney, was appointed in 1975 to both the NSW Working Party and the Editorial Board. A feminist with an interest in women’s biography, she was the first woman member of the board and strongly supportive of its aim to increase the proportion of entries on women ‘to 10 per cent or more’. Both Steven and Radi were heavily involved in bicentennial history projects: Steven advised on and researched a special exhibition in London on the British role in the ‘discovery’ of Australia based on the collections of the British Museum of Natural History; Radi edited 200 Australian Women: A Redress Anthology (1988). She retired from the Editorial Board in 1994 but remained on the NSW Working Party until 2005. Steven has contributed 24 articles and Radi 37, on a wide range of subjects, to the ADB. 150 4. Bede Nairn and Geoffrey Serle: A Fine Partnership, 1973–1987 4. Bede Nairn and Ge Margaret Steven, 1988 ANU Archives, ANUA225-1184 Heather Radi, 1980s By courtesy of Heather Radi Margaret Steven, 1988 Margaret Steven, 1988 ANU Archives, ANUA225-1184 Heather Radi, 1980s By courtesy of Heather Radi ANU Archives, ANUA225-1184 Heather Radi, 1980s By courtesy of Heather Radi ANU Archives, ANUA225-1184 Heather Radi, 1980s By courtesy of Heather Radi By courtesy of Heather Radi By courtesy of Heather Radi 151 1 John Ritchie, ‘Talk to the New Dictionary of National Biography, 9 October 1999’, Ritchie MSS, box 2, Acc 06/191, NLA. I draw on memory for Ritchie’s reactions to his appointment. 5. John Ritchie: Consolidating a Tradition, 1987–2002 Geoffrey Bolton In 1987, when John Ritchie was appointed general editor of the Australian Dictionary of Biography, he must have believed that he was being entrusted with one of Australia’s most respected and securely established academic enterprises. Ritchie himself was given to quoting commentators who described the ADB as ‘the largest work of collaborative scholarship in the arts or social sciences in Australia’, and ‘arguably the nation’s most substantial and significant publishing venture, and amongst the greatest of its kind in the world’.1 Few would have forecast that the ensuing 20 years, under the general editorship of Ritchie and his successor, Diane Langmore, would see the ADB struggling strenuously to preserve not merely its standards but, at times, its very existence. Ritchie, who was forty-six when he was offered the general editorship in 1987, was seen as representing generational and cultural change. Unlike his predecessors, he had spent his entire academic life with the ADB as part of his professional and cultural landscape. He was a product of one of the vintage years of the Department of History at the University of Melbourne. At that time it was Australia’s leading nursery of historians, and Melbourne’s influence spread to many schools of history throughout Australia, not least to both sectors of The Australian National University. His contemporaries included Graeme Davison, Cameron Hazlehurst, Bill Kent and Gary Trompf. The last two names remind us that, although Melbourne led the way in the establishment of Australian history at the university level, it was also a nursery of European historians, and the Australianists were expected to retain awareness of the European roots of Australian culture. In this respect, as in many others, Ritchie was shaped by his University of Melbourne upbringing. Like many of its graduates, he emerged with a sense of social responsibility and a tendency to fanaticism about Australian Rules Football. It also counted that he was a history student in the early 1960s, the last years of the god-professors Max Crawford and John La Nauze. Dressed in suit and tie, they presided over departmental afternoon teas attended by deferential staff and graduate students, their authority as yet unchallenged. Feminist history had yet to make its appearance—it was in some ways a rather blokeish 153 The ADB’s Story department despite the presence of the impressive Kathleen Fitzpatrick—and the Vietnam War had yet to stimulate a generation of protest. 2 Ian Hancock, ‘John Ritchie, 1941–2006’, History Australia, 3, no. 2 (2006), pp. 52.1–52.3. By courtesy of Sue Edgar 5. John Ritchie: Consolidating a Tradition, 1987–2002 Ritchie’s role- models at Melbourne taught him the meticulous use of source materials, as well as the value of lucidity and elegance in historical writing, but they also introduced him to a somewhat hierarchical concept of the exercise of authority. Throughout his career his instincts were to lean towards the traditional. John Ritchie, 1980s John Ritchie, 1980s ADB archives 154 5. John Ritchie: Consolidating a Tradition, 1987–2002 Di Langmore, Darryl Bennet and Edna Kauffman relax after one of their regular Thursday afternoon games of tennis, 1980s Di Langmore, Darryl Bennet and Edna Kauffman relax after one of their regular Thursday afternoon games of tennis, 1980s By courtesy of Sue Edgar 3 John Ritchie, Punishment and Profit: The Reports of Commissioner John Bigge on the Colonies of New South Wales and Van Diemen’s Land (Melbourne: Heinemann, 1970); The Evidence of the Bigge Reports: New South Wales under Governor Macquarie (Melbourne: Heinemann, 1971); A Charge of Mutiny: The Court Martial of Lieutenant Colonel George Johnston for Deposing Governor William Bligh in the Rebellion of 26 January 1808 (Canberra: National Library of Australia, 1988). 4 John Ritchie, Australia as Once We Were (Melbourne: Heinemann, 1975). By courtesy of Sue Edgar, 1985 5 Ritchie, Australia as Once We Were, p. 259. By courtesy of Sue Edgar Ritchie, after tutoring at Monash University, was appointed to a lectureship in Manning Clark’s Department of History at the School of General Studies at the ANU. He gained experience as a student mentor through his appointment, from 1972 to 1976, as deputy warden and sometimes acting warden of a hall of residence, Burton Hall. He was one of the first university teachers of history to take his students on fieldtrips and, in 1980, established an advanced undergraduate course on ‘biography and history’, which was a model of its kind. His obituaries were to stress his excellence as a teacher.2 Departmental folklore remembers him as something of a traditionalist, vigilant to resist any development that he saw as eroding high standards. He found himself much in the minority when his colleagues, mindful of an uneven gender balance among their number, resolved that if the next staff vacancy attracted two candidates of comparable merit, preference should be given to a woman. Ritchie criticised the decision; he feared that this might be the thin end of a wedge advancing sectional favouritism. In this, as in several less contentious respects, he retained into the 1980s and 1990s the traditionalist attitudes instilled in his students by Crawford at Melbourne in the early 1960s. 155 The ADB’s Story Research editor Merrilyn Lincoln, 1980s The ADB’s Story The ADB’s Story Research editor Merrilyn Lincoln, 1980s By courtesy of Sue Edgar By courtesy of Sue Edgar Ritchie soon established himself as a productive researcher, specialising in the early colonial period of New South Wales. Two of his publications established his credentials as an editor: the first scholarly edition of the report of the Bigge commission of inquiry into New South Wales, and an account of the trial of Major George Johnston for his role in the overthrow of Governor William Bligh.3 More ambitiously, he published a general history of Australia, Australia: As 156 5. John Ritchie: Consolidating a Tradition, 1987–2002 Once We Were, in 1975.4 It was remarkable both for its felicitous choice of photographic illustrations and for its clear perception that history is a branch of literature, to be written with grace and accessibility. In his introduction, Ritchie credited his ANU colleagues Bill Mandle and John Molony for fostering his love of the language, but an even stronger influence could be discerned in Manning Clark. ( ) 5 Ritchie, Australia as Once We Were, p. 259. By courtesy of Sue Edgar Like Clark, his writing was enriched by echoes from the great works of English literature, though Ritchie largely managed to avoid Clark’s trick of overworking a phrase. Nor could he match Clark’s penchant for the role of prophet. He confessed: ‘I have found it a riddle to read man’s past, difficult to diagnose his present condition, and perilous to predict what is to come’.5 Once We Were, in 1975.4 It was remarkable both for its felicitous choice of photographic illustrations and for its clear perception that history is a branch of literature, to be written with grace and accessibility. In his introduction, Ritchie credited his ANU colleagues Bill Mandle and John Molony for fostering his love of the language, but an even stronger influence could be discerned in Manning Clark. Like Clark, his writing was enriched by echoes from the great works of English literature, though Ritchie largely managed to avoid Clark’s trick of overworking a phrase. Nor could he match Clark’s penchant for the role of prophet. He confessed: ‘I have found it a riddle to read man’s past, difficult to diagnose his present condition, and perilous to predict what is to come’.5 Emma Grahame worked on the Biographical Register, 1985–86, and was the ADB’s NSW research assistant in 1991–92 Emma Grahame worked on the Biographical Register, 1985–86, and was the ADB’s NSW research assistant in 1991–92 157 The ADB’s Story Although Ritchie showed a perceptive interest in periods such as the 1930s Depression, and themes such as sport, he continued to concentrate on the first decades of settlement in New South Wales. He consolidated his credentials as a scholarly biographer with his life of Lachlan Macquarie.6 This was a project which inevitably invited comparison with its major predecessor, the learned, elegant and cantankerous life of Macquarie published 40 years earlier by Malcolm Ellis.7 Ritchie was generally seen as showing a deeper understanding of Macquarie’s Scottish background and a greater objectivity in judging Macquarie and his critics. Perhaps also his empathy with his subject was subtler; where Ellis, as he always did in his biographies, became Macquarie’s partisan and fought his battles, Ritchie showed an appreciation of the pressures on Macquarie, the outsider from the Highland fringes grateful for the approval of his seniors and zealous to prove his worth as a benevolent autocrat. 6 John Ritchie, Lachlan Macquarie: A Biography (Carlton, Vic.: Melbourne University Press, 1986). 7 M. H. Ellis, Lachlan Macquarie, His Life, Adventures and Times 4th rev. edn (Sydney: Angus & Robertson, 1965) [1st edn Sydney: Dymocks, 1947]. 8 Jim Davidson, A Three-Cornered Life: The Historian W. K. Hancock (Sydney: UNSW Press, 2010), p. 493. 9 Christopher Cunneen, King’s Men: Australia’s Governors-General from Hopetoun to Isaacs (Sydney: George Allen & Unwin, 1983). 6 John Ritchie, Lachlan Macquarie: A Biography (Carlton, Vic.: Melbourne University Press, 1986). 10 Christopher Cunneen, William John McKell: Boilermaker, Premier, Governor-General (Sydney: UNSW Press, 2000). By courtesy of Sue Edgar Piquantly, it was a scholar with whom Ellis had memorably crossed swords, the aged but still influential Sir Keith Hancock, who first suggested to Ritchie that he should consider applying for the general editorship of the ADB.8 Others added their encouragement. By now Ritchie had matured into a judicious biographer with form as a meticulous editor of texts, but in some respects he was not the most obvious candidate for a general editorship overseeing the ADB’s volumes covering the mid twentieth century. He had contributed six articles to the first 11 volumes of the ADB, neatly observed and engagingly written. With one exception, all dealt with characters connected with the turf, among them the late-nineteenth-century jockey Tommy Corrigan and the restauranteur Azzalin Romano, owner of the legendary Bernborough, whose feats dominated the racing game just after World War II. Unlike previous general editors, Bede Nairn and Geoffrey Serle, Ritchie had not served an apprenticeship by chairing or even belonging to a working party of the ADB. His main competitor, the incumbent deputy general editor, Chris Cunneen, had credentials in twentieth-century Australian political history, but at that time his record of publication, despite a study of the early governors-general of the Australian Commonwealth, was somewhat less substantial than Ritchie’s.9 Of necessity senior staff at the ADB have been given to subordinating their own research to the demands of their job. Conjecture about the processes of past selection committees can never be satisfactory, but in this case it would appear that Ritchie’s stronger record of productivity turned the decision in his favour. Perhaps he presented more confidently in interview; perhaps the selectors 158 5. John Ritchie: Consolidating a Tradition, 1987–2002 thought it was time for an outside appointment. Cunneen accepted the outcome and settled down to provide Ritchie with loyal and effective support. After retirement, he completed a well-regarded biography of Sir William McKell, the Sydney boilermaker who became a successful premier of New South Wales and governor-general.10 ADB staff: Ivy Meeres, Margaret Steven, Martha Campbell, Ann Smith and John Ritchie, 1988 ADB staff: Ivy Meeres, Margaret Steven, Martha Campbell, Ann Smith and John Ritchie, 1988 Photographer: Stuart Hay, ANUA226-689 Photographer: Stuart Hay, ANUA226-689 Ritchie inherited an experienced team. In addition to his very competent deputy general editors—Cunneen until 1996 and subsequently Diane Langmore—the research editors included figures such as Martha Campbell, who served the ADB for 35 years, Helga Griffin, Sue Edgar and Margaret Steven. There were six research officers, two part-time research assistants, and four clerical staff. As the newcomer, Ritchie had to establish a managerial style appropriate to this seasoned group of professionals with much accumulated experience between them. Where his predecessor, Serle, although no less hardworking than Ritchie, had managed his team with the relaxed touch of an old professional who made sure that his weekends were spent in Melbourne, Ritchie prided himself on 159 The ADB’s Story being a 16-hours-a-day, seven-days-a-week practitioner who took no holidays apart from the Christmas–New Year break. ‘Our project’, he remarked, ‘resembles a funnel, with the general editor being the spout; if the spout blocks, the flow will be dammed’.11 He lived and worked at a pitch of intensity that revealed itself even in the way he smoked his cigarettes. After five years, his wife, Joan, persuaded him at least to relax at the weekends, but he continued to put all his stamina into the job, priding himself that in his first decade he was absent only three days through illness. This intensity was natural to the man, but it was strengthened by an awareness that he was filling the shoes of distinguished older predecessors who had established a great tradition. He had still to learn that it is not enough for a leader to be a perfectionist; there must also be an ability to delegate. Anxious to demonstrate his mastery of every aspect of the ADB process, he overdid micro-management at times, probing into unnecessary detail and unsettling members of staff by persistent questioning and comment. He refused to allow staff to work on projects outside the ADB and begrudged allowing them time to attend seminars away from the ADB’s editorial work. At times, when the velvet glove would have served him better, he used a bluntness that bruised. Many of the older hands were eventually provoked into resignation, as were those who followed. Yet Ritchie also knew that he was well served by his hardworking colleagues. y g p y 12 See, for example, Geoffery Serle to John Ritchie (28 October 1988), letter box 43, Papers of John Ritchie, 1954–2005, Acc 04/18, NLA. 11 Ritchie, ‘Talk to the New Dictionary of National Biography’. 12 See, for example, Geoffery Serle to John Ritchie (28 October 1988), letter box 43, Papers of John Ritchie, 1954–2005, Acc 04/18, NLA. 11 Ritchie, ‘Talk to the New Dictionary of National Biography’. Photographer: Stuart Hay, ANUA226-689 He acknowledged his debt, and sought to encourage them by holding weekend conferences and celebratory dinners, and by monitoring their workloads more carefully than he monitored his own. It was Ritchie’s initiative, as Jill Roe relates in her chapter, that led to the institution of the ADB Medal for members of working parties and other volunteers who made exceptional contributions to the ADB. He also relied on Serle, who had taught him at Melbourne, and who stayed on as consultant for the first few months after Ritchie’s appointment. Until his death in 1998, Serle corresponded frequently with Ritchie, offering advice about possible entries, drawing attention to new publications, soothing Ritchie’s moments of testiness and generally playing the role of a mentor.12 160 5. John Ritchie: Consolidating a Tradition, 1987–2002 5. John Ritchie: Consolidating a Tradition, 1987–2002 Research assistant Gillian Fulloon, 1980s Research assistant Gillian Fulloon, 1980s By courtesy of Sue Edgar Research assistant Gillian Fulloon, 1980s By courtesy of Sue Edgar By courtesy of Sue Edgar 161 The ADB’s Story With Melbourne University Press, publishers of the ADB, his relations were more chequered. It happened that shortly after Ritchie’s appointment, the veteran director, Peter Ryan, retired. During the next 10 years five successors came and went. Consequently, Ritchie complained: ‘It is difficult from volume to volume to deal with someone who carries over no previous experience. It may sound harsh, but it is perfectly honest to report that a number of the younger staff of this particular publishing firm have been (and are) both illiterate and ignorant’.13 Despite this level of dissatisfaction, Ritchie entered into an agreement in 1992 giving MUP all rights of publication over all materials produced by the ADB. This decision was puzzling, as Ritchie at other times blamed MUP for a want of energy in marketing, pointing out that whereas Volume 1 had sold more than 10 000 copies, the number had fallen by more than half when it came to Volume 14. Institutional demand remained steady, but private purchasers fell off. 13 Ritchie, ‘Talk to the New Dictionary of National Biography’. 14 This observation is based on several cases in the author’s personal experience. 15 Ritchie, ‘Talk to the New Dictionary of National Biography’. 13 Ritchie, ‘Talk to the New Dictionary of National Biography’. 15 Ritchie, ‘Talk to the New Dictionary of National Biography’. Photographer: Branko Ivanovic, ANUA225-719 Photographer: Stuart Hay, ANUA226-689 Some at least seem to have considered that with Volume 12 concluding the pre-1939 period they had sufficiently filled their bookshelves.14 Volume 12 also marked a caesura in that it was the last volume whose entries recorded the lives of individuals chosen on the basis of their floruit, the period in which they were deemed to have made their major impact on Australian history (in this case 1891–1939). Volumes 13 to 16 would consist of men and women who died between 1940 and 1980, whether they were sporting identities whose feats lay well back in the past or creative artists continuing into vigorous old age. From Volume 13 a change was made from the sober dustcover that had uniformly served previous volumes to a more brightly coloured cover featuring appropriate contemporary works of art, but the decline in sales continued. In 1996 Ritchie persuaded MUP to release the entire series at half price on time payment, but the public response was disappointing. Ritchie thought it had been inadequately advertised. The press, he commented, ‘doesn’t seem to appreciate that in publishing you have to spend a penny to make a pound’.15 In the same year, MUP issued Volumes 1–12 in CD-ROM form, but Ritchie himself was disinclined to venture into the opportunities arising from the evolution of electronic technology. His entrenched preference for the handwritten, although vindicated by his unfailingly neat calligraphy, left him slow to grasp the potential of online publication. He would have argued that if the ADB’s production methods might be called conservative, they were also a model of scholarly thoroughness. 162 5. John Ritchie: Consolidating a Tradition, 1987–2002 Anne-Marie Gaudry, office administrator, John Ritchie, general editor, and Di Langmore, research editor, 1990 Anne-Marie Gaudry, office administrator, John Ritchie, general editor, and Di Langmore, research editor, 1990 Photographer: Branko Ivanovic, ANUA225-719 Photographer: Branko Ivanovic, ANUA225-719 163 The ADB’s Story In his early years, nevertheless, Ritchie oversaw a number of innovations. To cope with the increasing number of inquiries from members of the public wanting to use the ADB’s files and card indexes, a position of ‘biographical register officer’ was created in May 1989. Hilary Kent’s appointment came just in time, as the number of inquiries increased from 251 in 1989 to 478 in 1990, stabilising a little below that number. 16 Hilary Kent, Australian Dictionary of Biography: Index. Volumes 1 to 12 (1788–1939) (Melbourne: Melbourne University Press, 1991). Others indexes had been prepared: Julie G. Marshall and Richard C. S. Trahair, Occupational Index to the Australian Dictionary of Biography (1788–1890), Volumes 1–6 (Bundoora, Vic.: Department of Sociology, School of Social Sciences, La Trobe University, 1979); Malcolm R. Sainty and Michael C. Flynn (eds), Index to the Australian Dictionary of Biography, Volumes 1 & 2 (A to Z, 1788–1850) (Sydney: Library of Australian History, 1991). 17 Chris Coulthard-Clark (sel. & cond.), The Diggers: Makers of the Australian Military Tradition—Lives from the Australian Dictionary of Biography (Carlton, Vic.: Melbourne University Press, 1993). 18 Ritchie, ‘Talk to the New Dictionary of National Biography’. 19 Ritchie, ‘Talk to the New Dictionary of National Biography’. 17 Chris Coulthard-Clark (sel. & cond.), The Diggers: Makers of the Australian Military Tradition—Lives from the Australian Dictionary of Biography (Carlton, Vic.: Melbourne University Press, 1993). 16 Hilary Kent, Australian Dictionary of Biography: Index. Volumes 1 to 12 (1788–1939) (Melbourne: Melbourne University Press, 1991). Others indexes had been prepared: Julie G. Marshall and Richard C. S. Trahair, Occupational Index to the Australian Dictionary of Biography (1788–1890), Volumes 1–6 (Bundoora, Vic.: Department of Sociology, School of Social Sciences, La Trobe University, 1979); Malcolm R. Sainty and Michael C. Flynn (eds), Index to the Australian Dictionary of Biography, Volumes 1 & 2 (A to Z, 1788–1850) (Sydney: Library of Australian History, 1991). y g p y 19 Ritchie, ‘Talk to the New Dictionary of National Biography’. By courtesy of Sue Edgar, 1980s Photographer: Stuart Hay, ANUA226-689 Evatt.20 There was a reminder that my article was overdue—I was somewhat cheered to find that nearly two-thirds of authors failed to meet their original deadlines—and the submitted article went to Cameron Hazlehurst, at that time chair of the Commonwealth Working Party. On the ‘bluey’—the famous cover sheet accompanying all ADB articles—he wrote: ‘I enjoyed this, but would have preferred to see more of Evatt’s own words and less attention to what other historians have said. ADB should not be a forum for historiographical debate’. (I disagreed, especially where a character as contentious as Evatt was involved, and in the published article a little historiography survives.) Ritchie then annotated the file, generally approving of the article but observing that ‘there were too many participle phrases’. In correspondence, he questioned my dating of Evatt’s first membership of the Australian Labor Party at 12 November 1918, as other authorities suggested 1920 or 1924. I gave him as my source the notes that I had taken from the Evatt papers in the library of Flinders University; he accepted this, but quite properly got the ADB’s SA stringer to check. I would have concurred with Reece Jennings, a SA contributor who wrote that ‘anyone who took exception to the way in which the Dictionary rewrites articles must surely have an ego of such colossal proportions that it must be something of a handicap to them’.21 It was hard to resist an editor who was apt to conclude his letters of advice or admonishment with: ‘Yours with abiding affection’. Delinquents were discarded. The author chosen to write about the author Ernestine Hill failed to deliver despite repeated reminders. The convener of the Queensland Working Party, Ross Johnston, found a replacement, Nancy Bonnin, who wrote the article promptly but commented: ‘It turns out that Ernestine was great on poetic licence with regard to her personal life’. This created a problem about when Hill first met Daisy Bates, as Bonnin preferred 1932 to 1920, the date given in the article about Bates in Volume 7 of the ADB. Ritchie wrote: ‘Given that the Bates article has so many flaws I think we should go for 1932. I’ll ask Chris C[unneen] about a possible corrigendum’. With eminent authors he could be diplomatic. Photographer: Stuart Hay, ANUA226-689 Her first responsibility was preparation of an index to the first 12 volumes of the ADB, embracing the names, occupations and birthplaces of nearly 10 000 individuals. This was published by MUP in 1991.16 A concise one-volume condensation of Volumes 1–12 was planned but abandoned; however, 1993 saw the publication of an illustrated volume entitled The Diggers: Makers of the Australian Military Tradition.17 It comprised 207 lives from Volumes 1–12 of the ADB. It was the first of a series of anthologies of ADB articles targeting specialised readerships which might not be interested in acquiring all the volumes. Ritchie estimated that the editorial process involved 20 different stages, from submission of a draft article to its emergence in its final form. Like his predecessors, he insisted on reading every article when the first draft arrived, and again before the revised version was sent to the author, comparing the subedited text with the original. He believed that only about 10 per cent of the ADB’s contributors could be relied on to produce excellent biographical writing. They showed appreciation that ‘the central task of the biographer is … to understand what made the subject tick, to explain why he was as he was’. Another 25 per cent wrote ‘well enough’; the rest were pedestrian and in need of more or less radical revision. ‘As a general rule’, Ritchie asserted, ‘the worse the writer the louder his howls of protest’.18 Four out of five articles when first submitted were too long. Academics were not necessarily the best performers. Some professors produced perfunctory and superficial work; but he reckoned that the best article ever submitted to the ADB was written by the journalist- historian Gavin Souter, about Lex Banning, a poet suffering from cerebral palsy who nevertheless was a thoroughgoing member of the Sydney ‘push’.19 164 5. John Ritchie: Consolidating a Tradition, 1987–2002 During her four years with the ADB (1988–92), Hilary Kent was a biographical register officer, research editor and worked on the Australian Bicentennial project ‘Heritage 200’ During her four years with the ADB (1988–92), Hilary Kent was a biographical register officer, research editor and worked on the Australian Bicentennial project ‘Heritage 200’ By courtesy of Sue Edgar, 1980s 165 The ADB’s Story Curiosity led me to examine half-a-dozen ADB files from Ritchie’s period, starting with my own article on H. V. i 21 Dr Reece Jennings to John Ritchie (28 March 1990), letter box 46, Papers of John Ritchie, 1954–2005, Acc 04/18, NLA. 20 These files are held at the ANU Archives. Photographer: Stuart Hay, ANUA226-689 I do not know if it was Ritchie or Serle who recruited Sir Donald Bradman to write the article about a predecessor as test cricket captain, W. M. Woodfull. Bradman produced an excellent entry requiring only slight editing: ‘It is as revealing of Bradman as it is of his subject’, Ritchie wrote. When the author returned the proof, however, he pointed out that his name was given simply as ‘Donald Bradman’, but he was a knight and also a Companion of the Order of Australia, a distinction ranking 166 5. John Ritchie: Consolidating a Tradition, 1987–2002 six degrees higher in the table of precedence than a knighthood. Considerations of space preclude reproducing Ritchie’s reply in full, but he explained that he had inherited from previous editors the practice of signatures without titles or honours, and went on: ‘I trust that you will appreciate that for consistency I am obliged to follow my predecessors’ precedent in this respect. I do so without in any way diminishing the respect in which I hold both your title and honour’.22 The Don was mollified. ADB staff, 1999. Back row: John Molony, Martha Campbell, Rosemary Jennings, Chris Clark, Anthea Bundock, Di Langmore, Darryl Bennet. Front row: Brian Wimborne, Karen Ciuffetelli, Christine Fernon, John Ritchie, Barbara Dawson, Edna Kauffman, Gillian O’Loghlin ADB staff, 1999. Back row: John Molony, Martha Campbell, Rosemary Jennings, Chris Clark, Anthea Bundock, Di Langmore, Darryl Bennet. Front row: Brian Wimborne, Karen Ciuffetelli, Christine Fernon, John Ritchie, Barbara Dawson, Edna Kauffman, Gillian O’Loghlin 22 Ritchie was a strong supporter of a proposal that the ANU should offer Bradman an honorary doctorate, but Bradman modestly declined. ADB archives Ritchie’s diplomatic skills were tested more protractedly when it came to upholding the interests of the ADB from pressures within the ANU itself. Between 1991 and 1996 the three senior Australian historians in the Research School of Social Sciences, Ken Inglis, Barry Smith and Allan Martin, all retired, as did Oliver MacDonagh, who strongly supported the ADB. Although Inglis continued as a visiting fellow and mentor attached to the ADB, it meant that Paul Bourke (who had been director of the RSSS from 1985 to 1992 and became chair of the board of the Institute of Advanced Studies in 1997) was the only 167 The ADB’s Story senior academic remaining among the powerbrokers of the RSSS who could be expected to fight the ADB’s battles. His untimely death in 2000 robbed the ADB of an influential ally. After Inglis retired in 1996, the chair of the ADB Editorial Board went for the first, and so far the only, time to an appointee from outside the ANU, Jill Roe, a professor at Macquarie University. Although she was energetic, decisive and knowledgeable, and enjoyed the staunch support of seniors such as Inglis, some wondered if her outsider status would be a disadvantage in dealing with the ANU hierarchy. The vice-chancellor at that time, Deane Terrell, was not thought to be excessive in his support of the ADB, but Roe proved to be an effective negotiator. It soon came to be acknowledged that she played a valuable role in providing support and complementarity to the general editor. Ritchie’s regime as general editor saw the consolidation of the ADB’s traditions. The writing of entries for the ADB had been evolving into a peculiarly specialised mode of discourse that has been compared with the composition of sonnets or haiku, allowing infinite variation within a strictly formal pattern. This mode of discourse perhaps reached its zenith under Ritchie’s editorial practice. Standardisation of form was fostered by other pressures as the ADB’s content advanced into the late twentieth century. The entries for the nineteenth-century volumes had been chosen from an Australian population of not more than four million in 1900; there were more than four times as many Australians competing for inclusion in the volumes dedicated to those who died in the 1980s. More could be accommodated if contributors wrote tersely. 23 Ritchie, ‘Talk to the New Dictionary of National Biography’. 24 Ritchie, ‘Talk to the New Dictionary of National Biography’. 25 Statistics provided by the ADB; however, the entries in the supplement edited by Cunneen, Garton, Kingston and Roe included nearly 30 per cent of women. 26 John Ritchie, The Wentworths: Father and Son (Carlton, Vic.: Melbourne University Press, 1997). 27 John Ritchie, ‘Macquarie, Lachlan (1761–1824)’, Oxford Dictionary of National Biography, vol. 36 (Oxford: Oxford University Press, 2004 [online edn, January 2008]). He was also part-author with Michael Collins Persse of ‘Wentworth, William Charles (1790–1872)’, Oxford Dictionary of National Biography, vol. 58 (Oxford: Oxford University Press, 2004 [online edn, January 2008]), p. 160. He was invited to write an article on Lord Gowrie, governor-general 1936–44, but refused, suggesting Chris Cunneen instead. Ritchie to Editor, Oxford Dictionary of National Biography (21 July 1997), box 2, Papers of John Ritchie, 1954–2005, Acc 06/191, NLA. 28 For these developments, see Stuart Macintyre, The Poor Relation (Carlton, Vic.: Melbourne University Publishing, 2010), esp. pp. 249–53. ADB archives Ritchie was also careful to proclaim the democratic bias of the ADB and, possibly more than any other comparable works in the English language, the ADB found room for the eccentric and the disreputable as well as the great and the powerful. As Ritchie told an English audience: ‘If the Australian Dictionary of Biography can be accused of being less discriminating than the Dictionary of National Biography, it can also be said to be more democratic’.23 Some observers thought that the volumes of the ADB published on Ritchie’s watch included fewer ratbags and eccentrics than those covering earlier periods, but perhaps authors were more cautious in dealing with recently deceased subjects with surviving spouses and children. Making much of the demographic factor, Ritchie reminded his hearers that the population of Australia, particularly in the 1788–1850 period, was much smaller than that of the United Kingdom, so that room could be found for a wider cross-section of society. While most entries in the ADB were included for some quality of historical significance, he estimated that between 5 and 10 per cent 168 5. John Ritchie: Consolidating a Tradition, 1987–2002 were included as representative samples of their era.24 To some extent, however, it was left to the working parties to decide whether the high proportion of white males in earlier volumes should be leavened by more entries from other categories. Whereas women were represented by little more than 2 per cent of the entries in Volumes 1–6, covering the period 1788 to 1890, and by about 11.4 per cent of the entries for 1891–1939, Volumes 13 and 14 touched 20 per cent, but the proportion fell away in subsequent volumes.25 Respect for scholarly quality was still paramount. Ritchie himself maintained an example of productivity by producing the first of a projected two volumes on D’Arcy Wentworth and his son William, a publication that consolidated his reputation as a major historian of Australia’s colonial period.26 It pleased him when he was asked to contribute an entry on Macquarie to the Oxford Dictionary of National Biography; it became the first entry in Volume 36 of the printed version of that publication.27 It was nevertheless uncertain whether the traditions of scholarship could be preserved in an age of increasing managerialism in the universities, a process the ANU could not escape and which bore hardest on the humanities and the social sciences. ADB archives From 1989 the Commonwealth Government adopted research funding criteria that favoured the physical and medical sciences and their practices of publication and citation.28 A particular injustice (which successive governments failed to correct) ruled that articles contributed to the ADB were not eligible for counting as evidence of academic research productivity. No explanation was offered. The pressures on Ritchie grew. Around this time an opinion was becoming prevalent that the ANU should concentrate on distinguishing itself in fields of research commanding international recognition. Economics, philosophy and politics might serve this aim more readily than subject matter limited to Australian history. It happened that the directors of the RSSS from 1991 to 2008 were all drawn from these disciplines, whereas the focus of research productivity in the history program tended to be concentrating on Australian subject matter to the exclusion of other fields that might have secured greater international resonance. It was in vain to argue that the ADB’s achievements were receiving recognition abroad as a model of collective national biography. 169 The ADB’s Story At the ANU in the late 1990s the ADB seemed to be losing ground against other scholarly priorities. It did not help that the advent of the Howard Government in 1996 ushered in a period of greater financial stringency for universities. Ritchie responded by endeavouring, during a visit to the United Kingdom, to stimulate reviews in journals such as the Times Literary Supplement, but the response was tardy. More successfully the ADB managed to establish an endowment fund. This was a cause that engrossed Ritchie’s energies, and his commitment produced results. Encouraged by Martha Campbell, Caroline Simpson, an ADB author and member of the Fairfax family, made a major donation. The Myer Foundation provided a substantial sum. MUP was persuaded of its duty to make a contribution in recognition of the fact that it had never been required to pay royalties to the ADB. These gifts were subsequently matched on a dollar-for-dollar basis by the ANU administration. Ritchie did not take to the role of fundraiser with any enthusiasm, but he proved himself a persistent and tactful negotiator, especially in dealing with the ANU. The endowment fund was of lasting service in ensuring the survival of the ADB and stands as Ritchie’s monument; but it was not enough to avert some attrition of resources. 29 Christopher Cunneen with Jill Roe, Beverley Kingston and Stephen Garton (eds), Australian Dictionary of Biography, Supplement 1580–1980 (Carlton, Vic.: Melbourne University Press, 2005). ADB archives By 2001 the number of research editors had fallen from six to four and the administrative staff from four to two. These numbers were barely enough to cope with any major episodes of illness among staff. The ADB responded in 1999 by moving from a two-year publishing cycle to a three-year cycle. This change was made manageable by a decision to produce volumes covering a span narrower than the 40 years traversed in Volumes 13 to 16. Instead there would be two volumes for each decade after 1980, so that Volumes 17 and 18 would cover persons who died in 1981–90. Meanwhile members of the Editorial Board promoted the concept of a ‘missing persons’ volume that would supplement Volumes 1–16 by providing biographies of individuals who had been overlooked. There was a precedent for a work of this kind in the British Dictionary of National Biography. In Australia changing fashions in historical writing since Volume 1 appeared in 1966 suggested that greater attention should be given to women, Aborigines and representatives of minority groups, especially in the period before 1890, covered by the earlier volumes. An Australian Research Council (ARC) grant was secured enabling the work to take place at Macquarie University, and Chris Cunneen was on hand to serve as its editor in association with Stephen Garton, Beverley Kingston and Jill Roe.29 Plans were also in hand for the publication of Volumes 17 and 18; but, for the first time, doubts were beginning to surface about the long-term viability of the ADB. 170 5. John Ritchie: Consolidating a Tradition, 1987–2002 Might not the series be drawn to a close at the year 2000? Was it the role of the ANU to continue shouldering sole responsibility for the project, or might it be shared with other Australian universities? (There were even a few voices who questioned whether the ADB, with its contributors a mixture of university academics and writers drawn from a wide cross-section outside the universities, could be considered a kosher scholarly exercise; fortunately they proved a minority.) And what about the challenge of going online? The massive Oxford Dictionary of National Biography was planned to appear in both print and electronic media. The New Zealand Dictionary of Biography was already advancing vigorously and successfully into the new technology. 30 Heather Radi to John Ritchie (14 October 1987), cited by Peter Howell, ‘100 Years After: Reassessing Lives for the ADB’ [Adelaide, 1998]. 31 I am grateful to Darryl Bennet and Jill Roe for their comments on a draft of this chapter; also to Joan Ritchie for her advice and permission to consult the Ritchie MSS in the National Library of Australia. ADB archives Roe and one or two colleagues on the NSW Working Party made it their business to keep abreast of the New Zealand developments. It seemed probable that when the ADB’s Editorial Board met in June 2002 these issues would have to be canvassed, although Ritchie’s instincts seemed to favour hastening slowly. At this juncture, in August 2001, Ritchie suffered a serious stroke. Although he made a partial recovery and survived another five years, it became clear that he would not be able to resume the duties that he had pursued at an all too demanding pace. He retained a room in the ANU’s Coombs Building, where he attempted to struggle on with the second volume of the Wentworth biography, but although he bore his affliction bravely, in the end he was overcome. He died on 10 May 2006. He was the longest serving of the ADB’s general editors, and his performance was recognised by appointment as an Officer of the Order of Australia in 2002. When John Ritchie was appointed to the general editorship in 1987 the Sydney historian Heather Radi wrote to him: I think it was Bruce Mitchell who said once that all we who write for the ADB love and hate it. We feel that a little bit of it belongs to each of us and we would defend it to the death, even after the shrieks of protest about what they do to our articles.30 Conscious of his responsibilities in inheriting and consolidating a great tradition, and confronted by pressures that his predecessors could never have anticipated, John Ritchie had indeed defended the Australian Dictionary of Biography to the death.31 Geoffrey Bolton’s relationship with the ADB spans his working life. At different times a member of three ADB working parties, he chaired the WA Working Party (1967–82, 1996–2011), and was a member of the National Committee and Editorial Board (1963–2011). 171 The ADB’s Story Phar Lap: An ADB entry Barry Andrews, who contributed 27 articles to the ADB, also wrote one fictitious entry, in immaculate ADB house style, on the champion racehorse Phar Lap. Barry delivered his article as an after-dinner speech at the first ‘Making of Sporting Traditions’ conference in 1977. Says Michael McKernan (a fellow ADB author): ‘We laughed until we could bear no more; the timing of the performer and the occasion was perfect. It was a privilege to have been there’. Phar Lap, c. 1930 State Library of Victoria, H91.160/287 Phar Lap, c. 1930 State Library of Victoria, H91.160/287 State Library of Victoria, H91.160/287 LAP, PHAR (1926–32), sporting personality, business associate of modest speculators and national hero, was born on 4 October 1926 at Timaru, New Zealand, the second of eight children of Night Raid and his wife Entreaty, nee 172 5. John Ritchie: Consolidating a Tradition, 1987–2002 Prayer Wheel. The family had military connections, including Carbine and Musket (q.q.v.) although Raid himself had emigrated to Australia during the first World War. Prayer Wheel. The family had military connections, including Carbine and Musket (q.q.v.) although Raid himself had emigrated to Australia during the first World War. A spindly, unattractive youth with chestnut hair, Lap was educated privately at Timaru until January, 1928, when he formed a liaison with the Sydney entertainment entrepreneur Harold Telford. With Telford, Lap moved to Sydney and established premises in the suburb of Randwick, a number of short term (distance) ventures were unsuccessful, although after James E. Pike (q.v.) commenced employment and Telford became a silent partner, the business flourished. A small, dapper man who dressed flamboyantly in multi-coloured coats and hats, Pike’s nervousness caused him to lose weight before each speculation with Lap; yet their affiliation lasted for over two years and proved beneficial to hundreds of Australian investors. The most successful years were between 1930 and 1932, when the business expanded into Victoria, South Australia and Mexico. Pike and Lap received numerous awards for services to the entertainment industry, including an MC in 1930; they shared with Telford a gross taxable income of over 50,000 pounds. This income was substantially increased, however, by generous donations from several Sydney publishers, including Ken Ranger and Jack Waterhouse (q.q.v.). Early in 1930 Lap journeyed to North America to strengthen his interest there; Telford, who disliked travelling, and Pike, who had weighty problems to contend with, stayed behind. Barry’s article was published in Sporting Traditions: The Journal of the Australian Society for Sports History, 5, no. 1 (November 1988), pp. 7–8. Sources: ADB Newsletter, no. 1 (December 1980), and no. 7 (September 1990). ‘Barry Jones Launches the ADB Endowment Fund Campaign’, Biography Footnotes, no. 4 (2009). Christine Fernon, ‘Dear ADB’, Biography Footnotes, no. 5 (2010). Barry Jones, The Thinking Reed (Crows Nest, NSW: Allen & Unwin, 2006). Phar Lap: An ADB entry Tall and rangy, known affectionately as ‘Bobby’, ‘The Red Terror’ and occasionally as ‘you mongrel’, Lap died in mysterious circumstances in Atherton, California, on 5 April, 1932, and was buried in California, Melbourne, Canberra and Wellington. A linguist as well as a businessman, he popularised the phrase ‘get stuffed!’ although owing to an unfortunate accident in his youth he left no children. I. Carter, Phar Lap (Melbourne, 1971), and for bibliog; information from J. O’Hara and T. H. Mouth; inspiration from anon. ADB contributors. * Barry’s article was published in Sporting Traditions: The Journal of the Australian Society for Sports History, 5, no. 1 (November 1988), pp. 7–8. Barry’s article was published in Sporting Traditions: The Journal of the Australian Society for Sports History, 5, no. 1 (November 1988), pp. 7–8. 173 The ADB’s Story Profiles Richard Tolhurst (1930–1999), Gough Whitlam (b. 1916) and Barry Jones (b. 1932) As ‘each volume comes out, we fear revelation of some ludicrous botch’, general editors Serle and Nairn wrote in an ADB newsletter in 1980. They had cause to worry, for volumes were subjected to close scrutiny by a group of avid readers, including Richard Tolhurst, Gough Whitlam and Barry Jones. Tolhurst, a former barrister and solicitor who worked in the Commonwealth Public Service until his retirement and move to England in 1973, wrote almost monthly to John Ritchie from 1989 to 1999 with lists of errors that he had detected in ADB entries. He wrote so many letters that a special folder was created in which to store them, along with Ritchie’s replies. It became almost a sport among staff to prove ‘Mr Tolhurst’ wrong, but he never was; his depth of knowledge of Australian history and dates and quirky facts was phenomenal. Gough Whitlam, prime minister (1972–75) and the author of two entries, on Sir George Knowles in 1983 and Hubert Lazzarini in 2000, also frequently sent in lists of errors, mainly to do with titles and honorifics. Barry Jones, former schoolteacher, quiz- show champion and politician, has had a long association with the dictionary, both as an author of a dozen articles and as a reviewer and avid reader. He regards the ADB as ‘a work of endless fascination and inexhaustible richness’, but contends that the inevitable errors must be corrected. One issue that Jones involved himself with, for instance, concerned whether Alfred Deakin was born in the Melbourne suburbs of Collingwood or Fitzroy. There is no doubt that despite the best efforts of staff to check facts, mistakes do occur and the ADB appreciates readers such as Tolhurst, Whitlam and Jones for reporting them. 174 5. John Ritchie: Consolidating a Tradition, 1987–2002 5. John Ritchie: Consolidating a Tradition, 1987–2002 Barry Jones, 2009 Photographer: Peter Fitzpatrick, ADB archives Barry Jones, 2009 Photographer: Peter Fitzpatrick, ADB archives Barry Jones, 2009 Barry Jones, 2009 Photographer: Peter Fitzpatrick, ADB archives Photographer: Peter Fitzpatrick, ADB archives Gough Whitlam with John Ritchie at the launch of Volume 13 of the ADB, 1993 Gough Whitlam with John Ritchie at the launch of Volume 13 of the ADB, 1993 ADB archives 175 The ADB’s Story Sources: ANU Reporter (8 April 1988), p. 4. Graeme Davison, Pat Jalland and Wilfrid Prest (eds), Body and Mind. Historical Essays in Honour of F. B. Smith (Melbourne: Melbourne University Press, 2010). Sally Wilde, ‘In Celebration of F. B. Smith’, Medical Journal of Australia, 191, no. 11 (December 2009), p. 631. Barry (b. 1932) and Ann (b. 1943) Smith When John La Nauze was appointed to Sir Keith Hancock’s chair in the Research School of Social Sciences at the ANU in 1966 he appointed Barry Smith, a graduate of the University of Melbourne and Trinity College, London, to a senior fellowship in the history department. Smith was appointed professorial fellow in 1974 and professor in 1991. During these years and, especially after his retirement, Smith became closely involved in the ADB. He had been a member of the Victorian Working Party from 1962 and was its adviser on entries for Volumes 7–12, which included people who had flourished in the period 1891–1939. When he retired, in 1997, becoming an emeritus professor and visiting fellow, Smith simply moved around the corridor to take up an office amongst ADB staff. He was a great sounding board for staff and a knowledgeable source on medical history. He was also intimately involved with the ADB through his wife, Ann Smith, a research officer there for more than a decade (1977–89). Ann Stokes had met Barry at the University of Melbourne when she was a student (BA Hons, 1965; MA, 1969). When they shifted to Canberra, Ann was employed in library and archival work (1965–76) and undertook a Diploma of Librarianship at the Canberra College of Advanced Education (DipLib, 1974). She joined the ADB in 1977 in a part-time position and was promoted to Victorian desk editor in July 1982. By that stage, Jim Gibbney had been working on the 8100 entries for the Biographical Register for nearly 10 years. When he retired in 1984, Ann Smith took over the project, seeing it to its publication in 1987. She resigned from the ADB in early 1989 to work in computing and information technology and, then, she became an artist. Altogether, Barry wrote eight ADB entries and Ann wrote 25 entries. Barry relinquished his visiting fellowship in the ADB in 2010. Sources: ANU Reporter (8 April 1988), p. 4. Graeme Davison, Pat Jalland and Wilfrid Prest (eds), Body and Mind. Historical Essays in Honour of F. B. Smith (Melbourne: Melbourne University Press, 2010). Sally Wilde, ‘In Celebration of F. B. Smith’, Medical Journal of Australia, 191, no. 11 (December 2009), p. 631. Sources: ANU Reporter (8 April 1988), p. 4. Graeme Davison, Pat Jalland and Wilfrid Prest (eds), Body and Mind. Historical Essays in Honour of F. B. Smith (Melbourne: Melbourne University Press, 2010). Barry (b. 1932) and Ann (b. 1943) Smith Sally Wilde, ‘In Celebration of F. B. Smith’, Medical Journal of Australia, 191, no. 11 (December 2009), p. 631. 176 5. John Ritchie: Consolidating a Tradition, 1987–2002 5. John Ritchie: C Barry Smith, 2009 5. John Ritchie: Consolidating a Tradition, 1987 2002 Barry Smith, 2009 ADB archives Ann Smith, 1980s By courtesy of Sue Edgar Barry Smith, 2009 Barry Smith, 2009 ADB archives ADB archives Ann Smith, 1980s By courtesy of Sue Edgar Ann Smith, 1980s Ann Smith, 1980s By courtesy of Sue Edgar 177 The ADB’s Story John La Nauze (1911–1989) and Ken Inglis (b. 1929) Barry Smith noted in his obituary of John La Nauze that in 1974–75 he had ‘spent much time and emotional energy safeguarding the Australian Dictionary of Biography during a difficult transitional period’. The same could be said of Ken Inglis, who chaired the Editorial Board from 1977 to 1996. A graduate of the University of Western Australia (BA, 1932) and Oxford (BA, 1934; MA, 1938), La Nauze held the Ernest Scott Chair of History at the University of Melbourne in 1961 when Keith Hancock asked him to consider accepting the position of general editor of the ADB. La Nauze was about to publish his two- volume life of Alfred Deakin, and did not wish to uproot his children, who were in their final years of school. He declined Hancock’s invitation in a six-page handwritten letter. Ironically, under very different circumstances, in 1966 he succeeded Hancock to all his positions. He became professor and head of history at the Research School of Social Sciences, ANU (1966–76), and was the obvious successor to Hancock as chairman of the ADB Editorial Board (1966–77). The ADB was in the sphere of interest of La Nauze, as head of history. During the prolonged crisis of Pike’s illness and death, and the appointment of new general editors, La Nauze was determined to preserve the dictionary on sound foundations. When he resigned from the Editorial Board in 1977, it placed on record both its appreciation of its second chairman’s ‘unobtrusive but firm leadership in its affairs over more than a decade’ and its respect and affection for him. Ken Inglis succeeded La Nauze as head of history in RSSS and chairman of the ADB Editorial Board in 1977, a position he held for almost two decades. A graduate of both the University of Melbourne (MA, 1954) and Oxford University (DPhil, 1956), and an eminent scholar, Inglis had lectured in history at the University of Adelaide and was vice-chancellor of the University of Papua New Guinea (1972–75). As chair of the ADB Editorial Board, Inglis shepherded the ADB through a number of significant changes. He led the change from the floruit period to the date-of-death principle in line with the practice of the Dictionary of National Biography and Dictionary of American Biography. He undertook a review of the ADB’s constitution (Rules and Procedures) in 1981–83 and formally abolished 178 5. Sources: Stuart Macintyre, ‘La Nauze, Andrew John (1911–1990)’, Australian Dictionary of Biography, vol. 18 (Carlton, Vic.: Melbourne University Press, 2012), pp. 3–5. Ken Inglis, interviewed by Neville Meaney (13 November 1986), Neville Meaney collection, Oral History and Folklore collection, 2053-0011, National Library of Australia. 1 q y pp g editor in 1988. John La Nauze, 1965 ANU Archives, ANUA225-708 Sources: Stuart Macintyre, ‘La Nauze, Andrew John (1911–1990)’, Australian Dictionary of Biography, vol. 18 (Carlton, Vic.: Melbourne University Press, 2012), pp. 3–5. Ken Inglis, interviewed by Neville Meaney (13 November 1986), Neville Meaney collection, Oral History and Folklore collection, 2053-0011, National Library of Australia. John La Nauze, 1965 John La Nauze (1911–1989) and Ken Inglis (b. 1929) John Ritchie: Consolidating a Tradition, 1987–2002 the National Committee, while at the same time strengthening the role of the Editorial Board. He also oversaw a generational change, with many original board members resigning to allow for the appointment of younger members. In 1986 he instituted a review of the ADB, which determined that the ADB would continue after the original 12 volumes first envisaged were published. Subsequently, he headed the committee that appointed John Ritchie general editor in 1988. ANU Archives, ANUA225-708 179 The ADB’s Story The ADB’s Story Ken Inglis, n.d. ADB archives 180 6. The Di Langmore Era, and Going Online, 2002–2008 It was fortunate for the ADB that the deputy general editor, and the person who would have to carry the load in the meantime, was a leader of great capability. Di Langmore had been educated at Firbank Church of England Girls’ School, Brighton, Melbourne (General Exhibition on Matriculation, 1958), the University of Melbourne (BA Hons, 1963; DipEd, 1964), the University of Papua New Guinea (MA, 1973) and the ANU (PhD, 1982). After employment as a tutor and research assistant (1969–75) in the history department of the University of Papua New Guinea and as a part-time tutor in history in the Faculties at ANU (1982–83), she joined the ADB’s staff in 1982 and worked for 15 years as the research editor responsible for articles on subjects from Victoria. She was herself the author, by 2001, of 41 ADB articles. In addition, while at the ADB, she published three books: Missionary Lives: Papua, 1874–1914 (1989); Prime Ministers’ Wives: The Public and Private Lives of Ten Australian Women (1992); and Glittering Surfaces: A Life of Maie Casey (1997).1 As deputy general editor from 1997, she revealed herself to be an able manager and had reached out to the community with engaging public addresses and a series of radio talks. The position of general editor was finally advertised late in 2003. Langmore was the successful candidate in the competitive selection process and in May 2004 she received her substantive appointment.2 She was unique among the general editors in having risen from the ranks. I was appointed to the vacant post of deputy general editor. The first challenge for Langmore, as acting general editor, had been to complete Volume 16 for publication. This volume was the last in a series of four on individuals who died in the period 1940–80. It was about 60 per cent finished when Ritchie was incapacitated. Langmore threw herself into the work. Maintaining the ADB’s high standards of checking and editing, she kept to the schedule, and the volume was finished on time and launched in Adelaide in 2002. Production of Volume 17, the first of two volumes covering the period 1981–90, began immediately. 6. The Di Langmore Era, and Going Online, 2002–2008 Darryl Bennet The stroke suffered in August 2001 by the general editor, John Ritchie, marked the beginning of a time of turbulence and transformation for the Australian Dictionary of Biography. There had been pressure to trim the budget in the 1990s and, as recounted in the previous chapter, the first signs were appearing that the ADB might be called upon to justify its existence in the new century. Nevertheless, in 2001 the organisation that had evolved over four decades was intact and apparently under no immediate threat. Three factors foreshadowed a dramatic change in the ADB’s fortunes. First, the sudden incapacity of its head created an opportunity for some people in the Research School of Social Sciences to question openly the cost and relevance to the school of a project with a large establishment of general staff. Second, the dictionary would experience its share of scrutiny as the ANU responded to reductions in government funding and embarked on a major reorganisation. Third, the ADB’s sole venture in the new electronic media had been the publication in 1996 by Melbourne University Press of Volumes 1–12 on CD- ROM; this situation was soon to change. In 2001 the ADB was staffed at the minimum level to meet its needs. Only the general editor held an academic post. The positions of the deputy general editor, four research editors, two full-time-equivalent research assistants, a biographical register officer, part-time bibliographer and two administrators in Canberra, and seven part-time research assistants in the State capitals and in England were all general staff. The Canberra office was the hub of a national network of people who contributed to the dictionary on a voluntary basis: some 4000 authors had written for it; eight external section editors peer-reviewed draft articles within their spheres of interest; the same number of regional and specialist working parties, with a total membership of about 100 historians and experts in various fields, nominated subjects and authors for each new period of the ADB; the policymaking Editorial Board comprised 15 senior academics and managers from the ANU and universities throughout the country. 181 The ADB’s Story The ADB’s Story The ADB’s Story Di Langmore, 2009 Di Langmore, 2009 Di Langmore, 2009 Photographer: Darren Boyd, ADB archives Photographer: Darren Boyd, ADB archives 182 6. The Di Langmore Era, and Going Online, 2002–2008 A permanent successor to John Ritchie would not be appointed for almost three years. 3 John Ritchie and Diane Langmore (gen. eds), ADB, vol. 16. Diane Langmore (gen. ed.), ADB, vol. 17. Personal knowledge. 1 Diane Langmore, Missionary Lives: Papua, 1874–1914 (Honolulu: University of Hawai’i Press, 1989); Prime Ministers’ Wives: The Public and Private Lives of Ten Australian Women (Ringwood, Vic.: McPhee Gribble, 1992); Glittering Surfaces: A Life of Maie Casey (Ringwood, Vic.: McPhee Gribble, 1997). 2 This paragraph paraphrases the citation for the award of the ADB Medal to Dr Di Langmore AM, presented in March 2009. 3 John Ritchie and Diane Langmore (gen. eds), ADB, vol. 16. Diane Langmore (gen. ed.), ADB, vol. 17. Personal knowledge. ) g f f f y ( g ) 2 This paragraph paraphrases the citation for the award of the ADB Medal to Dr Di Langmore AM, presented in March 2009. 1 Diane Langmore, Missionary Lives: Papua, 1874–1914 (Honolulu: University of Hawai’i Press, 1989); Prime Ministers’ Wives: The Public and Private Lives of Ten Australian Women (Ringwood, Vic.: McPhee Gribble, 1992); Glittering Surfaces: A Life of Maie Casey (Ringwood, Vic.: McPhee Gribble, 1997). 4 Christopher Cunneen with Jill Roe, Beverley Kingston and Stephen Garton (eds), Australian Dictionary of Biography, Supplement 1580–1980 (Carlton, Vic.: Melbourne University Press, 2005). 6. The Di Langmore Era, and Going Online, 2002–2008 Volume 17, alone, contains more than 600 articles chronicling and evaluating the lives of important and representative figures in the nation’s history, such as Dame Kate Campbell, a pioneering medical specialist in neonatal intensive care, who saw ‘pre-term babies as fascinating fellow human beings’;5 Sir Reginald Ansett, who did not ‘think that private enterprise should be allowed to go mad—some government control is necessary’;6 and the ‘will-o’-the-wisp with a sting’, the diminutive but tough and elusive rugby league footballer Clive Churchill.7 There is, in addition, an article on George Abdullah, an Indigenous community leader from Western Australia who exhorted his people, ‘don’t be ashamed. Be proud of being an Aboriginal’.8 During Langmore’s term as acting and substantive head of the ADB, approximately 1000 concise biographies of past Australians, from all walks of life, were added to the inventory of the dictionary’s principal series. Volume 17, alone, contains more than 600 articles chronicling and evaluating the lives of important and representative figures in the nation’s history, such as Dame Kate Campbell, a pioneering medical specialist in neonatal intensive care, who saw ‘pre-term babies as fascinating fellow human beings’;5 Sir Reginald Ansett, who did not ‘think that private enterprise should be allowed to go mad—some government control is necessary’;6 and the ‘will-o’-the-wisp with a sting’, the diminutive but tough and elusive rugby league footballer Clive Churchill.7 There is, in addition, an article on George Abdullah, an Indigenous community leader from Western Australia who exhorted his people, ‘don’t be ashamed. Be proud of being an Aboriginal’.8 Firm in her conviction that the core function of the ADB is the creation of accurate, authoritative, enlightening and interesting knowledge about individuals in Australian history, Langmore ensured that the dictionary remained an exemplar of the best biographical research and writing. Under her, as under her predecessors, the ADB fulfilled the vision of historical biography that prime minister Kevin Rudd articulated at the launch in 2009 of Tom Keneally’s book, Australians: Origins to Eureka, a work that drew extensively on the ADB: Biography is the fulfilment of a duty owed by every generation to those who have gone before us, and able to be claimed against those yet to be born. A duty to capture, to preserve and to transmit the stories— the legacy of each generation. Because a human voice—a human life— retains its validity, its power and its relevance beyond its physical demise. y g y ( ) pp 7 B. Nairn, ‘Churchill, Clive Bernard (1927–1985)’, in ADB, vol. 17, pp. 213–14. 5 J. McCalman, ‘Campbell, Dame Kate Isabel (1899–1986)’, in ADB, vol. 17, pp. 185–6. 6. The Di Langmore Era, and Going Online, 2002–2008 As a result of progressive reductions in staff and the necessity of diverting resources to the ADB online project (of which more later), there was no possibility of completing this volume in the normal time of two or three years, without compromising the quality of the editing or the effort needed to check articles for factual accuracy and historical judgment. The volume was launched in Melbourne in 2007. Langmore then edited about one-quarter of Volume 18 before she retired in May 2008.3 183 The ADB’s Story The ADB’s Story Di Langmore, 1985 By courtesy of Sue Edgar Di Langmore, 1985 By courtesy of Sue Edgar 184 6. The Di Langmore Era, and Going Online, 2002–2008 6. The Di Langmore Era, and Going Online, 2002–2008 6. The Di Langmore Era, and Going Online, 2002–20 Rosemary Jennings was a research assistant, based in Canberra, from 1999 to 2007 Rosemary Jennings was a research assistant, based in Can 1999 to 2007 Rosemary Jennings was a research assistant, based in Canberra, from 1999 to 2007 Photographer: Natalie Azzapardi, 2012, ADB archives Photographer: Natalie Azzapardi, 2012, ADB archives Readers of the ADB did not experience a gap between Volumes 16 and 17, as the supplementary volume, edited by Chris Cunneen in association with Jill Roe, Stephen Garton and Beverley Kingston, was published in 2005.4 The genesis of this work, funded by an ARC grant, and its production in Sydney are described in the previous chapter. Work on it continued during Langmore’s general editorship and involved support from her and other members of the Canberra staff. Later, its biographical-subject files were integrated with the ADB’s records in Canberra. 185 The ADB’s Story During Langmore’s term as acting and substantive head of the ADB, approximately 1000 concise biographies of past Australians, from all walks of life, were added to the inventory of the dictionary’s principal series. g y ( ) 9 Speech by Kevin Rudd at the launch of T. Keneally, Australians: Origins to Eureka, National Library of Australia, Canberra (27 August 2009), <http://www.pm.gov.au/node/6152> (accessed 21 December 2009). ( ) pp 8 Y. J. Abdullah, ‘Abdullah, George Cyril (1919–1984)’, in ADB, vol. 17, p. 1. 6 C. Fahey, ‘Ansett, Sir Reginald Myles (1909–1981)’, in ADB, vol. 17, pp. 25–7. 6. The Di Langmore Era, and Going Online, 2002–2008 As we build on the work done in our name and on our behalf by our forebears, we honour them best by listening to their voices from the past.9 186 6. The Di Langmore Era, and Going Online, 2002–2008 Challenging times, calls for structural change Challenging times, calls for structural change ADB staff, 2006. Left to right: Barbara Dawson, Rosemary Jennings, Gail Clements, Brian Wimborne, Jolyon Horner (seated), Anthea Bundock, Darryl Bennet, Di Langmore (seated), Pam Crichton, Nick Brown, Christine Fernon, Edna Kauffman, Karen Ciuffetelli ADB staff, 2006. Left to right: Barbara Dawson, Rosemary Jennings, Gail Clements, Brian Wimborne, Jolyon Horner (seated), Anthea Bundock, Darryl Bennet, Di Langmore (seated), Pam Crichton, Nick Brown, Christine Fernon, Edna Kauffman, Karen Ciuffetelli Photographer: Darren Boyd, ADB archives Photographer: Darren Boyd, ADB archives While managing the affairs of the ADB, Langmore had to cope with the distraction of no fewer than three organisational reviews in five years. The director of RSSS, Ian McAllister, had commissioned the first of these in 2002, immediately it became known that John Ritchie would be unable to resume his post as general editor. It was probably at this point that the continued existence of the ADB was most in doubt. Fortunately, it was blessed with the backing of a wise and understanding Editorial Board. The successive chairs, Jill Roe (to 2006) and Tom Griffiths, were forceful and effective fighters for the dictionary. At McAllister’s request in 2002, Roe (as chair), Geoffrey Bolton and Stephen Garton formed an ad-hoc subcommittee of the board to report on the long-term future of the ADB. They submitted their report in November that year. The reviewers recognised that, in a research environment increasingly reliant on external sources of funds, the relevance of the ADB ‘to the changing mission of RSSS’ had to be considered. Their report argued that ‘to survive in the long run’, the ADB ‘must embrace both continuity and change’, through commitments to the production of new volumes, the publication of an online 187 The ADB’s Story edition and ‘participation in the modern research culture’. Having selected the five-year period 2003–07 as ‘an appropriate and manageable time frame’, the subcommittee examined four options for the future of the ADB.10 Three of the four alternative approaches arose from ill-disposed or ill-informed suggestions to the subcommittee. Option one was for the ANU to wind down the ADB after the publication of Volume 18. Roe, Bolton and Garton noted that, if the ANU vacated the field, other institutions could confidently be expected to take it up and gain the associated credit. If they did not, important figures in twentieth-century Australian history who had died in the 1990s would ‘lack a definitive account’ of their contributions. Ending the production of volumes of the ADB ‘would also mean the enforced loss of highly skilled staff, not to mention the loss of research capability and reputation to the ANU’. Option two was for an immediate merger of the ADB with the History Program in RSSS. The subcommittee advised that this approach was unwanted by both parties and would benefit neither. 10 Jill Roe, Geoffrey Bolton and Stephen Garton, ‘Long Term Futures for the Australian Dictionary of Biography 2003–2007. A report with recommendations from an ad hoc sub-committee of the Editorial Board to Professor Ian McAllister’ (21 November 2002), ADB file, ADB, pp. 2, 3. ( )i pp 11 Roe, Bolton and Garton, ‘Long Term Futures for the Australian Dictionary of Biography 2003–2007’, pp. 3, 4, 6. 10 Jill Roe, Geoffrey Bolton and Stephen Garton, ‘Long Term Futures for the Australian Dictionary of Biography 2003–2007. A report with recommendations from an ad hoc sub-committee of the Editorial Board to Professor Ian McAllister’ (21 November 2002), ADB file, ADB, pp. 2, 3. 11 Roe, Bolton and Garton, ‘Long Term Futures for the Australian Dictionary of Biography 2003–2007’, pp. Photographer: Darren Boyd, ADB archives There would be insurmountable difficulties in integrating the ADB’s general staff into the ‘current formulation of general staff entitlements’ for research assistance to academics within RSSS. Option three was to redefine the ADB as a ‘data-collecting’ project and to transfer it to the university library. Describing this proposal as ‘a fundamental misconception’ of the nature of the ADB, the subcommittee explained that its business was ‘not to be understood as data collection and dissemination, but rather as involving detailed research into the location and value of discrete evidence and its possible utilisation’ in the production of historical biography. Strong academic leadership was required.11 Option four, the subcommittee’s preferred approach, envisaged ‘a closer alignment with the History Program’ and the ADB’s later designation as ‘a special research area’ that would be a component of a National Life History Project within the program. The subcommittee proposed a two-stage process. In the first stage (2003–04), it recommended that three joint ADB/History Program positions be created and filled: general editor/professor of Australian history; deputy general editor, as an academic appointment; and an information technology (IT) officer to support the planned ADB online project and other future electronic research. It further recommended that the ADB’s general staff, required for the timely completion of Volumes 17 and 18, should be ‘quarantined from current RSSS quotas’. In the second stage (2005–07), the subcommittee recommended that work begin on two new volumes, 19 and 20, covering the period 1991–2000. It 188 6. The Di Langmore Era, and Going Online, 2002–2008 considered that a slower rate of production was feasible and desirable for these volumes, the implication being that general staff numbers would decline over time. To implement the suggested closer association between the ADB and the History Program, the subcommittee recommended that the proposed National Life History Project be implemented and that the parties negotiate a formal collaborative agreement.12 Roe, Bolton and Garton affirmed the national importance of the ADB. They proposed a future course that they believed would preserve as much as possible of its traditional structure, while adapting it to survive in a changing research environment. Their recommendations were only partially implemented but their strong and persuasive support for the ADB ended 15 months of uncertainty. In October 2003 the ANU’s vice-chancellor, Ian Chubb, approved the appointment of a new general editor and, as noted earlier, Langmore assumed the role substantively in May 2004. 12 Roe, Bolton and Garton, ‘Long Term Futures for the Australian Dictionary of Biography 2003–2007’, pp. 4–5. 13 Personal knowledge and views. 14 Colin Lucas, Margaret Levi, Gilles Paquet and Derek Volker, ‘The Research School of Social Sciences, Report of 2006 Review to Ian Chubb and Frank Jackson’ (Canberra: ANU, September 2006), pp. 9, 16–17, 21, 23. 15 Lucas et al., ‘The Research School of Social Sciences’, pp. 9, 16–17. 12 Roe, Bolton and Garton, ‘Long Term Futures for the Australian Dictionary of Biography 2003–2007’, pp. 4–5. 14 Colin Lucas, Margaret Levi, Gilles Paquet and Derek Volker, ‘The Research School of Social Sciences, Report of 2006 Review to Ian Chubb and Frank Jackson’ (Canberra: ANU, September 2006), pp. 9, 16–17, 21, 23. Photographer: Darren Boyd, ADB archives Her appointment was duly made in both the ADB and the History Program. The deputy general editor remained a general staff position; when I filled it, the research editor post I had occupied was left vacant. A new joint ADB/History Program academic position, established later that year, was filled by Nicholas Brown, who also became chair of the Commonwealth Working Party. He was required to perform in an academic role for half of the time and as an ADB research editor for the other half. An IT officer position was not created, although the ADB online project had been funded from 2004. By 2007 two full-time members of the staff (a research editor and an administrator) and one half-time research assistant had retired and not been replaced. Budgetary constraints were at the heart of these cutbacks in the ADB’s staffing requirements. As the Federal Government continued its practice of not fully indexing the funds it provided to universities, RSSS had to make savings to cover salary and general cost increases.13 In 2006 RSSS was itself subjected to a major review. The report was brief in its treatment of the ADB.14 It rejected suggestions that the dictionary might be more conveniently located outside the school. More controversially, it reached the remarkable conclusion that the ADB ‘should be financially self-sufficient within five years’. The reviewers offered no argument to support this contention (no major dictionary project has been funded this way), merely observing that ‘it is clear to us that revenue can be generated by the on-line ADB in ways that do not diminish its character as free at point of delivery’.15 Although there may 189 The ADB’s Story be methods by which a modest income could be obtained from the ADB online, the suggestion that the total operations of the ADB should cease to be a charge to RSSS’s budget in five years was impracticable. The ADB responded to the report with efforts to solicit additional donations to its endowment fund but to no avail.16 Following a major restructure of the ANU, the College of Arts and Social Sciences was established in 2007. This change in the organisation of the university led to widespread discussions about the ADB’s future relationships with RSSS, the History Program, and a projected research school of the humanities. 16 ‘External sources of funds’, NCB/ADB files. 17 R. G. Gregory, Tom Griffiths, Ann Curthoys, Linda Boterill and Daniel Stoljar, ‘Australian Dictionary of Biography Working Party Report to the Director, Research School of Social Sciences Review’ [hereinafter ‘Gregory Report’] (2007), NCB/ADB files, p. 1. 16 ‘External sources of funds’, NCB/ADB files. Photographer: Darren Boyd, ADB archives The Di Langmore Era, and Going Online, 2002–2008 generation of biographers through postgraduate and summer school programs; to produce new volumes of the ADB up to Volume 20; to continue to develop the ADB online; and to work more closely with, and conduct joint research and exhibitions with, the national cultural institutions.18 On the subject of staffing, the working party recommended that the position of head of the new organisation be redesignated as director of the National Centre for Biography and general editor of the ADB with responsibility for the aims outlined above. Oversight of the ADB and editing functions should take no more than 20 per cent of the director’s time. A new general staff position of managing editor would take over the functions of the deputy general editor, including supervision of the ADB online, and assume the responsibilities no longer discharged by the general editor. A new academic post of deputy director would be created, the occupant of which would have no specific editorial role in relation to the ADB. The existing research editor, research assistant and administrative positions would be ‘maintained at the level possible within the funding allocated’. As with Roe, Bolton and Garton, the working party seemed to assume that the number of these positions would be fewer in future. Noting that ‘in the medium and longer term, there will be a reduced school funded resource base’, the working party suggested that the production time for each volume could be increased to five years.19 As might be expected, financial issues dominated the working party’s deliberations. Its members considered that the recommendation of the 2006 review of RSSS that the ADB become self-supporting was unrealistic in any time frame, let alone five years. Moreover, it was no less reasonable for RSSS to continue supporting the ADB than it was for the school to fund its other respected ‘departmental groups’. Yet the working party thought it inevitable that RSSS would scale down its funding for the dictionary in the future. The ADB would have to devote more effort to raising money from endowments, ARC grants, commercial activities in collaboration with Melbourne University Publishing and direct Commonwealth Government funding. Photographer: Darren Boyd, ADB archives At the end of Langmore’s editorship, the ADB was still part of RSSS and linked to the History Program while retaining its own budget. A consensus about the most appropriate arrangements in the future had not been achieved, however, and the debate would continue in later years. Meanwhile, the annual reductions in RSSS’s real funding and the recommendations of the 2006 review prompted the director, Rod Rhodes, to commission another review of the ADB, in 2007. A working party, chaired by Bob Gregory, was appointed to ‘investigate the priorities, current staffing level and funding of the ADB and advise on future strategy, staffing and sources of finance’. In the introduction to its report, the working party gave a firm endorsement of the ADB: ‘In our conversations with individuals, from our reading of the submissions, and from past reviews of the ADB a clear and uniform picture emerges—the ADB is widely regarded as a considerable asset for the ANU and people think highly of it’. The report went on to pay generous tributes to the general editor, her staff and the people throughout the country whose voluntary contributions were vital to the success of the ADB.17 In considering the question of future strategy, the working party held the strong view that the ADB must build on its past achievements and adapt to a rapidly changing environment. It should integrate more with biographical scholarship in other parts of the university and with national institutions that have a direct interest in its work. To this end, the working party proposed the establishment of a National Centre for Biography in RSSS. The working party listed a number of aims for the centre, both within and outside the ANU. In summary, these were for it to act as a focus for, and to develop proficiency in, the study and writing of biography in Australia; to coordinate the activities of biographers throughout the ANU; to conduct public lectures, seminars, symposia and other forms of academic and scholarly exchange in the field; to attract outstanding scholars on visiting scholarships and short-term appointments; to train the next 190 6. 18 ‘Gregory Report’, pp. 3–4. 19 ‘Gregory Report’, pp. 5–6, 8. 20 ‘Gregory Report’, pp. 2, 6–8. Photographer: Darren Boyd, ADB archives Seeking money ‘on a wide range of fronts’ was a crucial role that must absorb much of the energy of the new director/general editor.20 The Gregory review’s broad approach was approved and the National Centre of Biography, headed by Melanie Nolan, was established in June 2008, following Di Langmore’s retirement. The old structure of the ADB had served it well for half a century. Its strength was the stability of the research, editing and administrative workforce. The research editors and research assistants tended to remain in their posts for 191 The ADB’s Story many years, building up large funds of knowledge. For example, Martha Campbell, the doyen of research editors, served the ADB for 35 years, until 2002; she was also the author of 161 articles. Biographical research is complex and painstaking. Sources for the lives of individuals in Australian history are scattered throughout the country and the world—in the collections of libraries, government archives, museums and other institutions; in the records of societies and professional bodies; and in documents held privately. Editing the ADB to achieve an even style, tone and standard is skilled work. The knowledge of sources, style conventions and historical context required of an ADB research editor is not acquired quickly, although research is becoming easier with the expansion of the Internet and the development of digital technology generally. It is relevant that the ADB had relied on the labours of people—mainly women—few of whom had the prospect of further promotion. The new structure reflected the realities of the research environment in the twenty-first century and provided opportunities for research and editing personnel to advance their careers. Its challenge would be to preserve the level of corporate knowledge that sustained the dictionary in its first 50 years. 21 ‘Options for the Future of the Australian Dictionary of Biography, 2000’, email, Alan Ventress to Darryl Bennet (21 December 2009). 22 See Note 21. ( 22 See Note 21. The online project The impetus for a project to publish an online edition of the ADB began in the NSW Working Party. As early as 2000, on the initiative of Alan Ventress, the working party had discussed the desirability of publishing the ADB on the Internet. In a paper prepared for the working party, Ventress noted that the British ‘Dictionary of National Biography has moved away from print to electronic access’.21 Oxford University Press had published the American National Biography online and the forthcoming Oxford Dictionary of National Biography would also have an online edition. Ventress recommended that the ADB and MUP collaborate with the Australian Science and Technology Heritage Centre (Austehc; later the eScholarship Research Centre) at the University of Melbourne with a view to making the complete text of the ADB available on the web.22 Roe, a member of the working party as well as chair of the ADB’s Editorial Board, attended the launch of the Dictionary of New Zealand Biography (DNZB) online in Christchurch in December 2001. Impressed by what she saw, 192 6. The Di Langmore Era, and Going Online, 2002–2008 she arranged for the general editor of the DNZB, Claudia Orange, and key staff members to travel to Australia in 2002 and give a series of presentations on their work.23 she arranged for the general editor of the DNZB, Claudia Orange, and key staff members to travel to Australia in 2002 and give a series of presentations on their work.23 At its biennial meeting on 7 June 2002, the Editorial Board unanimously approved preparation of an ARC Linkage—Infrastructure, Equipment and Facilities (LIEF)—grant application, as soon as possible, ‘with a view to ensuring that the ADB is available online to schools and to communities nationwide by 2005’.24 Without ever losing her preference for the feel of a book in her hands, Langmore embraced the potential of information technology to communicate and educate, and set about implementing the board’s decision. A member of the board, Janet McCalman, recommended Austehc, a leader in the new field of informatics, as an ideal partner in the project, adding weight to Ventress’s earlier suggestion. ADB staff judged that a LIEF application that could demonstrate a major collaboration between universities—principally ANU and Melbourne at the working level—and national cultural institutions should meet the ARC’s criteria for funding. Negotiations with potential partners and the drafting of the application began without delay. 23 Jill Roe to Darryl Bennet, email (21 December 2009). Seminar on Dictionary of New Zealand Biography, Coombs Building, ANU (6 June 2002). 24 Minutes, ADB Editorial Board meeting (7 June 2002), NCB/ADB files. 25 Personal knowledge. 23 Jill Roe to Darryl Bennet, email (21 December 2009). Seminar on Dictionary of New Zealand Biography, Coombs Building, ANU (6 June 2002).i 24 Minutes, ADB Editorial Board meeting (7 June 2002), NCB/ADB files. 25 Personal knowledge. The online project Because of the ARC’s schedule, the earliest that an application could be submitted was at the beginning of 2003, for funding in 2004. It soon emerged that a three-year project would be required. Although the project team hoped to meet the Editorial Board’s goal of having an online edition of the ADB publicly available in 2005, the actual launch took place in 2006.25 It was apparent from the outset that implementation of the ADB online would require a virtually full-time project manager. While the general editor retained responsibility for the project’s higher direction, involving meetings, consultations and decision making, I became project manager, responsible for its organisation, planning and day-to-day running. My key duties included liaising with partners and other external authorities, writing the three grant applications and their associated reports, recruiting and supervising the Canberra-based project staff, controlling the budget, and leading the discussions that determined the final design and functionality of the web site. There were two difficulties with obtaining funds through the LIEF scheme, especially for a multi-year project. The first was that an application had to be submitted every year and each application had to be prepared nearly 12 months in advance. Thus the application for funding in 2004 was begun in late 2002 and completed early in 2003. Immediately the project staff learned in late 2003 that funding was approved for 2004, work had to start on the application for funding in 2005. An interval of the same length would occur between the 193 The ADB’s Story application and the funding for 2006. Writing the application for 2005 involved dealing with a particularly thorny problem, because the 2004 project had scarcely commenced before the 2005 application was due at the ARC. The results of almost a whole year of technical development and data analysis and entry had to be anticipated, based on minimal experience. 26 Personal knowledge. The online project It was possible to report that a working web site would be established, however, because a pilot site—set up with ‘seeding’ money supportively provided by the director of RSSS—had existed from 2003 and its transformation into the first version of a restricted- access web site, for use by the project staff and the chief investigators, would be complete before the end of 2004.26 Governor-General Major General Michael Jeffery launched the online version of the ADB in the Great Hall, University House, ANU, in July 2006 Governor-General Major General Michael Jeffery launched the online version of the ADB in the Great Hall, University House, ANU, in July 2006 27 The project cost a total of $1 569 000. For the 2004 project $217 000 was raised from the participants, $450 965 was sought from the ARC and $376 000 was granted: Australian Research Council, Linkage— Infrastructure Equipment & Facilities—Application for Funding in 2004, Project LE0452798, ‘The Australian Dictionary of Biography Online: A Database of National Biography Facilitating Research into Australian History’. For the 2005 project, $198 500 was raised from the participants, $407 599 was sought from the ARC and $260 000 was granted: Australian Research Council, Linkage—Infrastructure Equipment & Facilities— Application for Funding in 2005, Project LE0560774, ‘The Australian Dictionary of Biography Online Enhancement Project’. For the 2006 project, $167 500 was raised from the participants, $402 845 was sought from the ARC and $350 000 was granted: Australian Research Council, Linkage—Infrastructure Equipment & Facilities—Application for Funding in 2006, Project LE0668026, ‘The Australian Dictionary of Biography Online and Emerging National Information Systems: Networking Research Capability’. The ARC contributed $986 000 of $1 569 000, being 63 per cent of total funds. ADB archives The second difficulty was that the participating institutions had to provide at least 25 per cent of the cash required for the project. At a time of financial stringency, there were limits to how much money the participants could make available. Moreover, even if they contributed more than 25 per cent of the cost, records showed that the ARC normally did not give all the money that applicants sought. The project, therefore, was never likely to have enough money to meet all of its objectives. 194 6. The Di Langmore Era, and Going Online, 2002–2008 It was a measure of the ADB’s standing among historians that six members of the Editorial Board and six additional senior historians supported the initiative, agreeing to be the chief investigators for the 2004 project and to seek the backing of their universities. The chief investigators for the first year were Tom Griffiths, David Horner and Patricia Jalland, all from ANU; Stuart Macintyre and Janet McCalman, both from the University of Melbourne; David Carment from the Northern Territory (later Charles Darwin) University; Stephen Garton from the University of Sydney; Patrick Buckridge from Griffith University; Jill Roe from Macquarie University; Alison Mackinnon from the University of South Australia; Graeme Davison from Monash University; and Tom Stannage from Curtin University of Technology. As was to be expected, the ANU and the University of Melbourne provided most of the cash and in-kind support, but the other seven universities contributed significantly. The National Library of Australia provided both cash and in-kind support. For the 2005 project, the chief investigators and participating institutions were the same. Two universities—Curtin University of Technology and Charles Darwin University—were unable to commit money for 2006 and the chief investigators from the two institutions were replaced with Langmore and Nicholas Brown from the ANU and Gavan McCarthy from the University of Melbourne. Two additional cultural institutions joined the project in its last year: the National Museum of Australia, which contributed cash, and the National Archives of Australia, which gave in-kind support in the form of free digitisation of biographical sources in its collection. Over the three years of the project’s duration, $583 000 was raised by the project’s participants, $1 261 409 was sought from the ARC and $986 000 was granted, leaving a shortfall of $275 409.27 This shortfall was to be a significant obstacle, preventing the project from achieving its full aims. ADB archives It was fundamental to the project’s vision that the ADB online should be an open resource, available without cost to every person and institution with a computer connected to the Internet. The online editions of the New Zealand and Canadian dictionaries of national biography were established on this principle. Conversely, those of the United Kingdom and the United States charged 195 The ADB’s Story subscriptions for access to them. The ADB online project considered that, in Australia’s relatively small market—more akin to the markets of Canada and New Zealand than those of the more populous countries—revenue gained from charging for access was likely to be small compared with the cost of creating and maintaining the resource. The project also believed that the web site having been produced with taxpayers’ money, it should be made freely available to all Australians. In this way, it could be used by people living in remote areas who lacked the amenity of public libraries—an important consideration in a country as large as Australia. More broadly, teachers and pupils in schools, researchers and students in tertiary institutions, librarians, journalists, genealogists, the general public and the citizens of other countries would have, literally at their fingertips, knowledge about individuals in Australian history previously found only in public and private libraries. Before the project could publish the ADB online, it was necessary to clarify the ANU’s relationship with Melbourne University Publishing (now hosting MUP), which had been producing handsome volumes of the ADB since 1966. An amendment to the longstanding contract between the two institutions— signed in the 1990s before MUP published the edition on CD-ROM mentioned earlier—had vested in MUP the rights to all forms of electronic publication. The parties negotiated a new contract that gave the electronic rights to the ANU and created opportunities for MUP to publish and sell new print-based products derived from the ANU’s online edition. As with the traditional print volumes, MUP would pay an advance to the ADB for each volume and, for the first time, royalties as a percentage of sales based on the publisher’s net receipts.28 The sales have never generated sufficient income, however, to pay royalties. 28 ‘Publishing Agreement between MUP and ANU’ (3 August 2005), NCB/ADB files, section 7, p. 8. 29 ‘Publishing Agreement between MUP and ANU’. ‘Gregory Report’, p. 8. 30 Personal knowledge. 31 This paragraph and those that follow about the ADB Online Project are based primarily on personal knowledge. See also ARC Final Report—Linkage—Infrastructure, Project LE0668026, ‘The Australian Dictionary of Biography Online and Emerging National Information Systems: Networking Research Capability’ (2006). ADB archives Later, the publisher expressed dissatisfaction with the lack of progress in the commercial exploitation of the ADB online.29 The first priority, however, was to establish the online database and to resolve the problems that the project encountered in the process, including a major one inherited from MUP. Before the project began, MUP had obligingly handed over the only electronic version in existence of the volumes produced before computerisation. This text had been scanned by the publisher from the pages of the print volumes for the CD- ROM edition. In 2005 the project discovered that the scanned text contained hundreds of errors. Cleansing these data became a lengthy and expensive operation, involving the whole ADB staff and a team of casual researchers, working in pairs, one person reading from the page and the other from the screen, and recording discrepancies for investigation and correction of the electronic text.30 196 6. The Di Langmore Era, and Going Online, 2002–2008 6. The Di Langmore Era, and Going Online, 2002–2008 Vijoleta Braach-Maksvytis, deputy vice-chancellor, Innovation and Development, University of Melbourne; Jill Roe, chair, ADB Editorial Board; Di Langmore, ADB general editor; Michael Jeffery, governor- general; and Ian Chubb, ANU vice-chancellor, at the launch of the online version of the ADB, July 2006 Vijoleta Braach-Maksvytis, deputy vice-chancellor, Innovation and Development, University of Melbourne; Jill Roe, chair, ADB Editorial Board; Di Langmore, ADB general editor; Michael Jeffery, governor- general; and Ian Chubb, ANU vice-chancellor, at the launch of the online version of the ADB, July 2006 ADB archives At the University of Melbourne, Austehc provided the technical management of the project. Gavan McCarthy, Joanne Evans, Helen Morgan, Rachel Tropea, Alan van den Bosch, Peter Neish, James Williams, Rosemary Francis, Davis McCarthy, Fabian Parker, Annette Alafaci and Ailie Smith contributed their knowledge and skills. Bruce Smith gave advice. Russ Weakley (design) and Jonathan O’Donnell (testing) were contracted for specialist assistance. At the ANU in Canberra the ADB staff collaborated with Austehc in determining the design and functionality of the web site. Christine Fernon was the assistant project manager. Four part-time researchers—Margaret Park, Ruth McConnell, Andrew Newman-Martin and Barry McGowan—and a volunteer, Margaret Lee, read each article, analysed the text and entered details in the data fields to facilitate searches by name, gender, lifespan, date and place of birth and death, cultural heritage, religious influence, occupation, place of occupation, and year or range of years of occupation.31 197 The ADB’s Story Future users of the ADB online would be able to search the database using each of the fielded categories or a combination of them to identify the biographical subjects relevant to a research project. Moreover, it would be possible to explore the interactions and relationships between factors such as class, ethnicity, religion, region and period in Australian history. The word and phrase search function would enable a researcher to investigate historical events, developments and issues through the lives of people involved in them. It would be possible to find articles on individuals associated with major historical themes. Future users of the ADB online would be able to search the database using each of the fielded categories or a combination of them to identify the biographical subjects relevant to a research project. Moreover, it would be possible to explore the interactions and relationships between factors such as class, ethnicity, religion, region and period in Australian history. The word and phrase search function would enable a researcher to investigate historical events, developments and issues through the lives of people involved in them. It would be possible to find articles on individuals associated with major historical themes. y 33 The NLA later abandoned the People Australia project. In 2012 the NCB decided to create its own version of the service. 32 Picture Australia was subsumed into the NLA’s Trove search facility in 2012. ADB archives An essential feature of the ADB online—as conceived by the director of Austehc and enthusiastically endorsed by ADB staff—was that it would not duplicate existing library and information infrastructure but would be capable of being linked with other web sites, thus contributing to the formation of a network of resources for research in the humanities and social sciences. An early application of this principle was the project’s association with the National Library’s image search facility, Picture Australia, which provided a single access point to the pictorial collections of the nation’s major cultural institutions.32 Staff spent two years searching Picture Australia for images of the ADB’s 11 000 subjects. The project obtained permission from the holders of the images and the owners of copyright in them to utilise them to illustrate the ADB online. All waived their fees on condition that users would have cost-free access to the ADB online. The images were then linked back to Picture Australia, using a permanent identifier created by the National Library, enabling researchers to read the associated catalogue record. The ADB online was the first project to make use of this new technology offered by the library. The benefit was mutual. The ADB avoided the cost of acquiring and curating its own collection of images, and the publicly funded web sites of Picture Australia participants gained greater exposure of their holdings. Within the constraints of its budget, the project forged additional links with resources in the collections of its partner cultural institutions. Chief among these was the National Library, the support of which was of immeasurable importance to the project. The library’s executive officers were unfailingly encouraging, none more so than the assistant director-general, Australian collections and reader services, Margy Burn, who had been a member of the ADB’s NSW Working Party in the late 1990s. Regular discussions were held with library staff to formulate a plan for collaboration in its proposed People Australia project.33 Meanwhile, links were created from articles in the ADB online to relevant digital sources in the library’s collection. In 2006 the ADB online became one of the first internet-based scholarly works to register the new persistent 198 6. The Di Langmore Era, and Going Online, 2002–2008 identifiers of library catalogue items in the Australian National Bibliographic Database (ANBD), thus linking published sources in the bibliographies of ADB articles directly to the Libraries Australia service. ADB archives A number of links were also established with digitised records held by the National Archives of Australia. The ADB online was awarded the Manning Clark House National Cultural Award (Group Category) for 2006. Di Langmore and Darryl Bennet accepted the award The ADB online was awarded the Manning Clark House National Cultural Award (Group Category) for 2006. Di Langmore and Darryl Bennet accepted the award ADB archives For the ADB online articles to function as nodes in a network, it was essential that linking to them from other online resources would also be possible. This was facilitated by providing each article with its own web page and persistent identifier. Thus, for example, the Libraries Australia service could create sustainable back-links to ADB articles from materials in its database, permitting a person viewing an item in the ANBD to see its prior use as a source for an ADB article. There was potential for future interconnections and interoperability between the ADB online and other systems, such as Trove. 199 The ADB’s Story The ADB online project was the crowning achievement of the Langmore years. Its launch on 6 July 2006 at University House by the governor-general, Major General Michael Jeffery AC CVO MC (Rtd), was a grand occasion, timed to coincide with that year’s conference of the Australian Historical Association, held at the ANU. The event generated considerable media interest, with outlets as far away as Darwin seeking interviews and publishing reports and reviews. Within 16 months of going ‘live’, the site was receiving 40 million ‘hits’ a year,34 which rose to a phenomenal 70 million annual ‘hits’ by 2009.35 Members of the general public find it accessible and usable. Researchers have mentioned the gains in productivity that the resource has brought to their work. Others have reported being able to undertake studies that previously were not feasible. It is not surprising that the site won the Manning Clark House National Cultural Award (Group Category) for 2006. 34 Diane Langmore talk to the Sydney Institute (13 November 2007), published as ‘The Australian Dictionary of Biography: A National Asset’, The Sydney Papers, 20, no. 1 (Summer 2008), pp. 22–30. g p y y y p ( ) pp 35 Ian Chubb, ‘The ADB: Honouring its Foundational Culture’, Biography Footnotes, no. 4 (December 2009). 34 Diane Langmore talk to the Sydney Institute (13 November 2007), published as ‘The Australian Dictionary of Biography: A National Asset’, The Sydney Papers, 20, no. 1 (Summer 2008), pp. 22–30. 35 Ian Chubb, ‘The ADB: Honouring its Foundational Culture’, Biography Footnotes, no. 4 (December 2009). Conclusion The ADB was a productive and cohesive organisation in the Langmore era. At various times in 2001–08, Wendy Birman, Nicholas Brown, Anthea Bundock, Martha Campbell, Karen Ciuffetelli, Gail Clements, Pam Crichton, Barbara Dawson, Christine Fernon, Joyce Gibberd, Rachel Grahame, Jennifer Harrison, Jolyon Horner, Rosemary Jennings, Edna Kauffman, Judith Nissen, Charlene Ogilvie, Anne Rand, Margaret Robertson, Patricia Stretton, Kim Torney and Brian Wimborne were members of the staff; and Ken Inglis, Ian Hancock and John Molony were visiting fellows. Ensuring the ADB’s efficiency and internal tranquillity, while it was being buffeted from without and experiencing significant change within, was the personality of the general editor, Di Langmore. She was thoroughly professional in her relations with staff and external authorities, and she set a compelling example of hard work and selfless commitment to the ADB. Her achievements received public recognition through the award of an ANU Council Medal for General Staff Excellence in 2002 and her appointment as a Member of the Order of Australia in 2008. Darryl Bennet was the deputy general editor of the ADB from 2001 to 2008. He has been a member of the Queensland Working Party since 2008 and a member of the Editorial Board since 2011. 200 6. The Di Langmore Era, and Going Online, 2002–2008 Darryl Bennet (b. 1948) Darryl Bennet began his career with the ADB in 1989 as a casual research assistant helping Chris Cunneen to compile the NSW list of possible inclusions in volumes covering the period 1940–80. A former naval officer, he had undertaken a degree in arts at the ANU (BA, 1987), winning the history medal in the same year, and a diploma of education in 1988. His knowledge of the military and his familiarity with computer technology characterised his contribution to the ADB during the next two decades. He ‘rose through the ranks’: during the 1990s his employment became permanent and he worked as research editor on the Commonwealth, armed forces and Victorian desks. John Ritchie described him as ‘diligent, conscientious, highly intelligent, a gifted editor and a superb colleague’. In 2001 he became deputy general editor; Di Langmore reckons that it was ‘impossible to imagine a more perfect deputy’. When in 2002 the Editorial Board decided that the ADB should go online, Bennet was given the responsibility for making it happen. He planned the project and defined its goals, wrote three successful submissions for LIEF (infrastructure) grants to the ARC, established and maintained close collaboration with IT experts at the Australian Science and Technology Heritage Centre at the University of Melbourne and established partnerships with national cultural institutions with a shared interest in enhancing the application of IT to their services. For his efforts, in 2006, he won an ANU staff award for innovative IT application. Although he worked with new technology, Bennet was always most comfortable as a ‘soler and heeler of paragraphs’. His knowledge of Australian history and his ability to write clear English were highly regarded in the ADB. He was the author of 20 entries before his retirement in 2008. Having moved to Brisbane, he is now a key member of the Queensland Working Party and also an editorial fellow, checking all completed entries before publication to ensure that they conform with ADB ‘style’. Sources: Darryl Bennet, personal file, NCB/ADB files. Chris Cunneen, Suzanne Edgar and Darryl Bennet, ‘“Solers and heelers of paragraphs”: Editing the Australian Dictionary of Biography’, in Iain McCalman, with Jodi Parvey and Misty Cork (eds), National Biographies and National Identity (Canberra: Humanities Research Centre, 1996), pp. 149–61. Darryl Bennet (b. 1948) 201 The ADB’s Story The ADB’s Story Darryl Bennet, 2012 Photographer: Brian Wimborne, ADB archives Darryl Bennet, 2012 Photographer: Brian Wimborne, ADB archives Darryl Bennet, 2012 Photographer: Brian Wimborne, ADB archives Photographer: Brian Wimborne, ADB archives 202 6. The Di Langmore Era, and Going Online, 2002–2008 Sources: Darryl Bennet, Tom Griffiths and Gavan McCarthy. Sources: John Molony, interviewed by Peter Stewart (3 and 9 April and 20 May 2008), Emeritus Faculty Oral History Project, <http://www.anu.edu.au/ emeritus/ohp/interviews/john_molony.html> Series 7, ‘Australian National University, 1964–90’, Papers of John Molony, MS 6634, NLA. Gavan McCarthy (b. 1956) Gavan McCarthy, as a part-time archivist (1978–85) at the University of Melbourne, first began to consider the use of computerised databases for archives in the early 1980s. In 1985 he became inaugural archivist-in-charge, later director, of the Australian Science Archives Project and pioneered the development of national information services and infrastructure to support the history of Australian science, technology, medicine and engineering through the utilisation of the emerging digital technologies. This resulted, in 1993, in the creation of the Bright Sparcs web site, with its customised underpinning technology that later was transformed into the generalised software system known as the Online Heritage Resource Manager (OHRM). Appointed, in 1999, director of the Australian Science and Technology Heritage Centre (Austehc), at the University of Melbourne, he continued to develop the OHRM in association with a number of historical projects and became well known internationally for his innovative approach to archival information and digital information management. In 2003 Austehc was engaged to look after the technological aspects of the ADB online project. McCarthy and Darryl Bennet formed a formidable partnership, working closely together and managing, at the project’s peak, a team of some 20 people devoting at least some of their time to the undertaking. The online version of the ADB was launched on 6 July 2006. From 2007 McCarthy has run the University of Melbourne’s eScholarship Research Centre. He has been working with other groups and individuals, including the former deputy director of the National Centre of Biography, Paul Arthur, on building new digital networks and paradigms, including the Humanities Networked Infrastructure (HuNI), which will be the first national, cross-disciplinary, virtual laboratory for the humanities to be established anywhere in the world. 203 The ADB’s Story Gavan McCarthy and Darryl Bennet check out the ADB online, July 2006 Photographer: Richard Briggs, by courtesy of The Canberra Times The ADB’s Story The ADB’s Story Gavan McCarthy and Darryl Bennet check out the ADB online, July 2006 Photographer: Richard Briggs, by courtesy of The Canberra Times Photographer: Richard Briggs, by courtesy of The Canberra Times 204 6. The Di Langmore Era, and Going Online, 2002–2008 John Molony (b. 1927) John Molony studied theology and canon law at the Pontifical Urban College of Propaganda Fide in Rome. Ordained a priest in 1950, he served in Rome, Boston (USA) and Ballarat. Leaving the priesthood in 1963, he applied for a position in the Research School of Social Sciences, ANU, as a translator of medieval Latin texts. Encouraged by Bede Nairn, Laurie Fitzhardinge and Manning Clark, he enrolled as a graduate student (MA, 1967; PhD, 1971). A two-month job as a research assistant at the ADB developed into a strong association with the dictionary for more than half a century. First employed as a tutor in 1966, he was appointed a lecturer in the Department of History, School of General Studies, in 1968, senior lecturer in 1974 and was promoted to professor in 1975. Two years later he became Manning Clark professor and head of department. Author of a number of scholarly works on Australian history, he is considered an expert on Ned Kelly. He became the ‘safe hands’ which the ADB called upon to sit on its selection and review committees; and he was on the team for the important 1986 review that recommended continuation of the ADB following completion of Volumes 1–12. Molony resigned from his position at the ANU in 1990 to take up a three-year appointment as Professor of Australian Studies at University College, Dublin. On his return to Canberra, he became a visiting fellow in the ADB and later an editorial fellow; his encyclopedic knowledge of the Catholic Church and of the Australian and Democratic Labor parties has been of great help to research editors. In 1999, with Barry Ninham, he founded the ANU Emeritus Faculty; chairman until 2012, he took responsibility for having the life stories of its members recorded and for developing an oral history program. 205 The ADB’s Story John Molony, 1985 ANU Archives, ANUA225-868 John Molony, 1985 ANU Archives, ANUA225-868 ANU Archives, ANUA225-868 206 6. The Di Langmore Era, and Going Online, 2002–2008 Ivy Meere (1927–2005), Edna Kauffman (b. 1948) and Karen Ciuffetelli (b. 1968) John Ritchie liked to describe the ADB’s administrators’ office as its ‘engine- room’. Two administrators overlapped and managed the office for more than 30 years: Ivy Meere (1975–92) and Edna Kauffman (1985–2007). They were responsible for ensuring that the ‘production line’ involved in creating ADB volumes ran smoothly. They prepared files for the subject of each entry, in manila folders—about 700 for each volume—and handed them to the research editors; they sent reminders to tardy authors; they liaised with section editors. In pre-computer days, they typed and retyped articles several times before the final edits were dispatched as proofs to the publisher. Editing is now undertaken electronically and very little typing of entries is required. Karen Manning, now Karen Ciuffetelli, joined the ADB as Kauffman’s assistant in 1992 and is now the sole office administrator. She has taken on other duties, including management of the budget. 20 Ivy Meere, 1980s By courtesy of Sue Edgar Sources: Edna Kaufmann, interviewed by Niki Francis (20 June 2012), NCB/ADB files. ‘A Job Whose Future Depends on the Past’, Canberra Times (22 December 1971). ADB Newsletter, no. 3 (August 1983), p. 2. ANU Reporter (8 April 1988), p. 4. Biography Footnotes, no. 7 (2010), p. 7. Ivy Meere, 1980s Ivy Meere, 1980s By courtesy of Sue Edgar Sources: Edna Kaufmann, interviewed by Niki Francis (20 June 2012), NCB/ADB files. ‘A Job Whose Future Depends on the Past’, Canberra Times (22 December 1971). ADB Newsletter, no. 3 (August 1983), p. 2. ANU Reporter (8 April 1988), p. 4. Biography Footnotes, no. 7 (2010), p. 7. 207 The ADB’s Story The ADB’s Workflow Board In the days before computers, the ADB’s office administrators used a whiteboard and magnetic tiles to chart the various stages of the editing cycle. At the beginning of each volume the names of all entries—about 700 in total— were written on individual tiles and placed in the first column of the whiteboard. When an entry came in from an author, its marker moved to the next column, then on to the next one when it was edited, to the next one when it came back from its author and so on until it reached the final column—when the entry was ready to send to MUP for publication. Different background colours were used to distinguish entries. Armed services entries had a pink background, Commonwealth entries were purple, SA green, WA yellow, Tasmanian blue; Victorian entries had a white background and were written in black texta, while Queensland entries had a white background and were written using a brown texta. Undoubtedly labour-intensive, the old system nevertheless allowed staff to quickly gauge a volume’s progress. The board remained in use until 2008. The board remained in use until 2008. The ADB’s workflow board The board remained in use until 2008. The ADB’s workflow board The ADB’s workflow board ADB archives 208 6. The Di Langmore Era, and Going Online, 2002–2008 ADB Files Every entry in the ADB has its own file. It contains the subject’s birth, death and marriage certificates, photocopies of biographical material such as academic records, personal files, army records, obituaries and items about the person found in newspapers, magazines and journals, as well as correspondence with the author and others about the subject. The file also contains multiple copies of the subject’s ADB entry, starting with the original version submitted by the author, all the edited versions and the final version sent to MUP for publication. On the front cover of the file is a worksheet, developed by Nan Phillips in the early 1960s, to monitor the editing cycle. It shows the many stages involved in the editing process. The files are, themselves, a valuable reference source and are held in the ANU Archives. ADB files ADB files ADB archives 209 The ADB’s Story ADB archives The ADB’s Corrigenda Ruler The ADB prides itself on correcting factual errors. Prior to 2012, new volumes of the ADB included a ‘Corrigenda’ insert, listing mistakes (and their corrections) that had been discovered in earlier volumes since the publication of the last volume. The page, column and line numbers of corrigenda were given to assist those who wanted to handwrite the corrections into their volumes. A ‘corrigenda ruler’, which gave the line numbers of entries in the ADB, was created in the 1960s to assist ADB staff in calculating line numbers. Corrigenda are now corrected online. Footnotes are used to indicate where text has been changed. The ADB’s corrigenda ruler ADB archives The ADB’s corrigenda ruler ADB archives 210 7. Working Parties: Recollections of the South Australian Working Party John Tregenza At the very beginning, 1960 to 1961, before I came back to Adelaide, Douglas Pike himself seems to have played an important role in the establishment of the SA Working Party and was probably responsible for the appointment of his good friend Harold Finnis as chairman—a position Finnis held through the first 14 years or so of the working party’s life. Finnis much admired Paradise of Dissent and would have almost unquestioningly supported Pike’s suggestions for the first two volumes. Gerald Fischer says that he remembers Douglas coming in to the South Australian Archives (he is not sure whether this was before or after he became general editor) and going through every card in the distinctive Biographical Index, which had been compiled by George Pitt and then John McLellan. He also remembers Douglas saying that it was unequalled in Australia as a resource of its kind and regretting that it did not have counterparts elsewhere. For the period up to 1850, we were, therefore, rather unexercised as a working party because Douglas had thoroughly prepared the ground, and because Sir Grenfell Price, who might have contested Pike’s and Finnis’s views, never (at least after I joined the working party in 1963) attended meetings, although year after year he was sent agendas and minutes and continued to be listed as a member in the first three published volumes. John Playford, who succeeded Finnis as chairman in 1975, has just drawn my attention to the pages in Colin Kerr’s biography of Grenfell Price, which describe the towering row that Price and Pike had over the former’s article on George Fife Angas, which led to Price abandoning any claim to the article he had revised, and also articles submitted on Charles Sturt and Governor Hindmarsh, and withdrawing his offer to write on John Howard Angus. Evidently, Price resigned from the working party, but his resignation was not accepted—hence the anomaly. The published articles on George Fife Angas and John Hindmarsh are unsigned and cite books by both Price and Pike. 213 The ADB’s Story The ADB’s Story John Tregenza (1931–99) was a member of the SA Working Party from 1963 to 1990 and wrote four ADB entries John Tregenza (1931–99) was a member of the SA Working Party from 1963 to 1990 and wrote four ADB entries State Library of South Australia, 1980, B63412 214 7. 7. Working Parties: Recollections of the South Australian Working Party Working Parties: Recollections of the South Australian Working Party Harold Finnis was a public service administrator and chair of the SA Working Party, 1959–75 S Lib f S h A li d Harold Finnis was a public service administrator and chair of the SA Working Party, 1959–75 State Library of South Australia, n.d. 215 The ADB’s Story In Grenfell Price’s absence it was very much a Finnis working party at the time I joined it in 1963. Finnis was well over six feet tall, a hale and authoritative seventy-four, with a deep, carrying voice and the aura of a decided member of the Adelaide establishment for several decades past, president of the Pioneers’ Association, president of the Historical Division of the Royal Geographical Society of Australasia (SA branch), chairman of the Botanic Gardens Board, member of the Board of the Public Library and member of the Adelaide Club. He was a courtly man. Pat Stretton, who stood in for Ken Inglis for a couple of meetings in 1961, when she was still Pat Gibson and a tutor in the history department, vividly remembers him asking her permission to remove his coat when the temperature was about 40ºC. His most memorable and often used phrase as chairman was ‘But does he measure up?’ When he decided that the explorer Horricks did not measure up that was fatal to Horricks’ chances of inclusion. As I recollect, we selected names by a series of stages. The editorial office in Canberra drew up a basic list of names for consideration with the barest of biographical details, drawing on the valuable Biographical Register that Laurie Fitzhardinge had been building up at the ANU, supplemented in South Australia’s case at least by, I imagine, Douglas Pike’s own additions, including names selected from the Biographical Index in the South Australian Archives. The working party would go through this list and make amendments. It would then be circulated (via the editorial office probably) to individuals and societies and institutions for further suggestions. These would then be considered and the Working Party would reduce the number of names to the quota allowed for South Australia according to the size of the population in the relevant era. We would also recommend lengths of articles and names of authors. 7. Working Parties: Recollections of the South Australian Working Party As time passed, and I became involved in supervising honours and postgraduate theses in the history department at Adelaide, I was able to make a more positive contribution in recommending names of people whose importance had only recently been revealed by the new research of students and also authors. When Jim Main (senior lecturer, 1966, and reader, 1967–84, in history at Flinders University) joined the working party, he was able to tap the research at Flinders in the same way. In the Finnis era we all agreed that we should value originality and innovation as distinct from wealth and established position in the community as criteria for determining inclusion and length of articles. A significant change in the working party took place when Finnis retired in 1975. He was replaced as chairman with John Playford. Several new members joined the working party—including Ron Gibbs, a teacher, author of a good one-volume history of South Australia for schools, and first president of the new Historical Society of South Australia (then in his thirties); and Helen Jones, who was beginning a PhD thesis on the emancipation of women in South Australia. 216 7. Working Parties: Recollections of the South Australian Working Party This reconstituted working party went through the preliminary lists prepared by the Finnis working party for the 1891–1939 period and made some substantial changes. Ironically, one of the major changes was to reduce the numbers of Labor politicians and union leaders. The Finnis list had incorporated many Labor names suggested years before by John Playford himself in a letter he had written in response to a circulated preliminary list. South Australian Working Party, 2013. Left to right: Prue McDonald, Paul Sendziuk, Roger André, Bernard Whimpress, Peter Howell (chair), David Hilliard, Catherine Kevin, Bernard O’Neil, Peter Donovan, Judith Raftery Photographer: Chris Thomson, ADB archives. South Australian Working Party, 2013. Left to right: Prue McDonald, Paul Sendziuk, Roger André, Bernard Whimpress, Peter Howell (chair), David Hilliard, Catherine Kevin, Bernard O’Neil, Peter Donovan, Judith Raftery h h h i h hi Photographer: Chris Thomson, ADB archives. Photographer: Chris Thomson, ADB archives. At that time Playford was positively to the left in his politics. When he became chairman of the working party he had moved to the ‘right of centre’ and now persuasively argued against many of the names he had formerly recommended. John Tregenza to Keith Hancock (29 June 1986), box 69, Q31, ADBA, ANUA. 7. Working Parties: Recollections of the South Australian Working Party (He has just reminded me of this in a telephone call.) Finnis, although by no means a Labor man, had made a point of trying to be even-handed with political inclusions. The new working party also disagreed with the Finnis working party’s weighting on clergy—especially Lutheran clergy—Finnis holding a strong conviction that the Lutherans’ significance in South Australia was out of all proportion to their numbers. These perceptions and weightings changed with time, new research, and a new and younger membership. John Tregenza was a member of the SA Working Party between 1963 and 1986 and was a ‘living witness’ with Harold Finnis (chair of the SA Working Party, 1959–75) to the National Committee meetings of 1960. John Tregenza to Keith Hancock (29 June 1986), box 69, Q31, ADBA, ANUA. 217 By courtesy of Jill Roe The ADB’s Story The New South Wales Working Party The ADB’s Story Beverley Kingston When Frank Crowley sent me to deputise for him at a meeting of the NSW Working Party of the ADB sometime in 1970, I was quite familiar with the project. There was a lot of ADB talk and work in the history department at Monash, where I had been a postgraduate student during the 1960s. From behind his pipe, Geoff Serle oversaw the Victorian entries, and Duncan Waterson was busy with what became his Biographical Register of the Queensland Parliament, 1860–1929 (1972). I happily contributed information to Waterson’s database as I worked through the 1860s Queensland newspapers for my PhD thesis on Queensland land legislation and politics. And I had already prepared a couple of entries on obscure Queensland pastoralists for Volume 4 of the ADB, published in 1972. The NSW Working Party, 2009. Left to right: Barrie Dyster, Ross Curnow, Andrew Moore, Stephen Garton, Chris Cunneen, Jill Roe, Murray Goot, Nancy Cushing, Bridget Griffen-Foley, Jack Carmody The NSW Working Party, 2009. Left to right: Barrie Dyster, Ross Curnow, Andrew Moore, Stephen Garton, Chris Cunneen, Jill Roe, Murray Goot, Nancy Cushing, Bridget Griffen-Foley, Jack Carmody 218 7. Working Parties: Recollections of the South Australian Working Party In 1970 the NSW Working Party met in the office of the state librarian, Gordon Richardson, with its marvellous stained-glass windows and its view across the Botanic Gardens to Sydney Harbour. Over the years we have met in other rooms in the library depending on availability, and until recently were back in that handsome old room, no longer the state librarian’s office, but a meeting room named in honour of Jean Garling, a major benefactor of the library. As I recall, there were no formalities at my first meeting. I introduced myself, said I had been sent by Crowley, and spent the next few meetings quietly listening and learning as fast as I could. At the midpoint of the afternoon, tea and coffee and a plate of Arnotts mixed creams were carried in by Richardson’s secretary and placed in front of us on the long table. I was greatly in awe of Richardson, a craggy, grizzled Scot, and the group of professors and senior historians like Bede Nairn and Ken Cable who made up the working party. I was probably about half the age of most of them. The ADB’s Story The New South Wales Working Party At first the only other woman was Hazel King, who rarely came because we had moved out of her period. Soon the average age went down somewhat with the arrival of Heather Radi from the University of Sydney, Gerry Walsh from the Australian Defence Force Academy, and the deputy general editor, Chris Cunneen, who began coming with Bede from Canberra to help with the rather complex business of keeping track of the long NSW list. We were working our way through a thick, stencilled and stapled list of names for possible inclusion in Volumes 3–6 (those who flourished in 1851–90) and were more than halfway through the alphabet. The list, as I recall, was heavy on politicians whose names were mostly unfamiliar to me, though there was a fair selection of writers, artists and other cultural figures about whom I felt more confident. Sportsmen seemed to feature prominently, although this may have been mainly because Nairn and Cable discussed them so enthusiastically. Ken’s views on churchmen, of whom there also seemed to be a great many, were rarely questioned. My arrival was fortuitous, not only because I was a late-nineteenth-century historian, unlike some of the earlier colonial history specialists who no longer had a great deal to contribute, but also because I was, by then, already working seriously on women in Australian history and Volumes 7–12 (those who flourished in 1891–1939), on which we soon began work, covered the early feminist movement. It was at about this stage that the NSW section of the ADB began to move from the fairly well-known and well-researched colonial period into the relatively under-researched early twentieth century in New South Wales. Nairn, of course, had the 1890s and the early labour movement thoroughly covered—too thoroughly it seemed sometimes. Heather Radi and I took up the challenge of adding more women to the list; we were excited by the possibilities of the new social history for broadening the ADB’s scope. As well, Heather began to remedy 219 The ADB’s Story the lack of systematic biographical material on NSW politicians, especially the non-labour ones, for the period after 1900, and recruited Peter Spearritt and Elizabeth Hinton to help her compile the Biographical Register of the New South Wales Parliament, 1901–1970 (1979). State Library of New South Wales, n.d. The ADB’s Story The New South Wales Working Party With her help we were able to make better decisions about which of the dozens of minor politicians we could cross out and replace with interesting and significant characters from other walks of life. NSW State Librarian, Gordon Richardson, was a founding member of the NSW Working Party and its chair in 1968-73 State Library of New South Wales, n.d. NSW State Librarian, Gordon Richardson, was a founding member of the NSW Working Party and its chair in 1968-73 220 7. Working Parties: Recollections of the South Australian Working Party Gordon Richardson retired not long after I joined the working party and was succeeded by Russell Doust both as state librarian and as chair of the working party, so the library continued to host our meetings. Russell saw us through Volumes 6–10. By Volume 11 he had retired and was followed by Alison Crook, who assiduously attended meetings though she sometimes left Nairn to chair them. Her successor, Dagmar Schmidmaier, decided she would prefer Alan Ventress, then Mitchell librarian, to deputise for her at meetings, and somehow in 1996 I found myself in the chair. This would not have worked except that Chris Cunneen, who had retired from his position as deputy general editor in Canberra, moved to Sydney and became our record-keeper, chief research organiser and go-between with Canberra. All I had to do was to keep the business moving at a good pace, make sure all issues were canvassed and points of view aired, and sometimes push for a decision. Gordon Richardson retired not long after I joined the working party and was succeeded by Russell Doust both as state librarian and as chair of the working party, so the library continued to host our meetings. Russell saw us through Volumes 6–10. By Volume 11 he had retired and was followed by Alison Crook, who assiduously attended meetings though she sometimes left Nairn to chair them. Her successor, Dagmar Schmidmaier, decided she would prefer Alan Ventress, then Mitchell librarian, to deputise for her at meetings, and somehow in 1996 I found myself in the chair. This would not have worked except that Chris Cunneen, who had retired from his position as deputy general editor in Canberra, moved to Sydney and became our record-keeper, chief research organiser and go-between with Canberra. The ADB’s Story The New South Wales Working Party All I had to do was to keep the business moving at a good pace, make sure all issues were canvassed and points of view aired, and sometimes push for a decision. All these years we have continued to benefit from the hospitality of the State library. This means that we are alerted to the arrival of significant new collections at the library, also to significant research being done by other scholars, many of whom may be potential authors. We hope that the library itself gains something from its links with the research enterprise that the ADB represents. Meetings in the library—long ago seen as neutral ground in the battle between Malcolm Ellis and academe—now mean that working party members can organise precious research time for themselves in the Mitchell Library in conjunction with meetings if they so wish. We have also had substantial and much appreciated assistance from library staff members appointed to deputise for the state librarian, first Margy Burn, who would come to meetings pushing a trolley of reference works when we were drawing up lists for the period 1940–80, then Warwick Hirst, and now Linda West, who books the room, emails the agenda to members and organises the much appreciated afternoon tea. With the various restructurings of the Editorial Board, there were fewer nominal members of the working party; at its largest in 1988 there were 22 names on the list. For some years now there have been 15 or 16 members, most attending regularly, all hardworking. Meetings have become more frequent in recent years. There used to be months, occasionally a whole year, when nothing needed to be done, but these days more of the work that was once done in the central office in Canberra falls to the working parties. Besides, it seems as if members of the working party appreciate an excuse to escape to the Mitchell Library from time to time. 221 The ADB’s Story Margy Burn in her office at the State Library of New South Wales, 1993. Margy has continued to promote the ADB in her role as assistant director- general of Australian Collections & Reader Services at the National Library of Australia The ADB’s Story The ADB’s Story Margy Burn in her office at the State Library of New South Wales, 1993. The ADB’s Story The New South Wales Working Party Margy has continued to promote the ADB in her role as assistant director- general of Australian Collections & Reader Services at the National Library of Australia By courtesy of Margy Burn By courtesy of Margy Burn By courtesy of Margy Burn Our meetings have always been enjoyable, though the reasons for this may have changed over time. For all of us they are a continuing learning experience. A huge amount of information and a great many stories pass over the table. Once almost entirely made up of academic historians and heavily weighted towards the professoriate, the working party has become more diverse in the past decade or so and the informal exchange of gossip between disciplines and institutions can be fascinating. We now have specialists in political science, industrial relations, public administration, law, and Jack Carmody, who covers both medicine and music. Gavin Souter, our expert since the late 1980s on Sydney newspapers and journalists, and memorably, the history of Mosman, retired, and was replaced with media historian Bridget Griffen-Foley, whose internet skills and address book became invaluable. Where once Bruce Mitchell and Greg McMinn came 222 7. Working Parties: Recollections of the South Australian Working Party from Armidale and Newcastle respectively to broaden our outlook, Nancy Cushing now keeps a close eye on Newcastle and the north and does her best to prevent us from becoming complacent about the kind of women we include, while Glenn Mitchell constantly amazes us with his knowledge of Wollongong people and popular culture. Not everyone enjoys biography, though for those who have stayed with the ADB it has often proved a useful adjunct to their professional research. Since we completed Volumes 7–12 (1891–1939), something of a pattern has developed for the work on each new period. First it is essential to draw up an initial list of necessary, likely and possible inclusions. This begins with a careful combing of Who’s Who in Australia for NSW names, then the ADB’s Biographical Register, other dictionaries, companions, encyclopedias and lists of obituaries. We also ask for advice from professional groups, industry representatives and experts in fields in which we think we need help. The preliminary list is sometimes twice as long as, or even longer than, the number of names we have been allocated. This list is then sifted, applying an unofficial series of criteria. The ADB’s Story The New South Wales Working Party Sometimes it is that little extra interesting detail—a noteworthy marriage or a twist in an earlier career. Sometimes it is because better sources exist, or because there is an author known to us who is also willing and able: having a suitable and reliable author to hand can make an immense difference. Occasionally the choice is invidious or seems random or unfair, but there is not enough space to include everyone. Other State working parties may think New South Wales is being precious about this. Most of them do not have the luxury of this kind of choice. When we were compiling the lists for the supplement volume it became clear that by the time the small States had covered their core list of premiers, chief justices, church leaders and major community figures, they did not have many more spaces to play with. Our core list is not so different in size from Tasmania’s or South Australia’s, but it constitutes a much smaller proportion of our allocation. New South Wales can afford more variety than other States because we have a larger population and therefore a longer list. Once we have covered the essential and the obvious, we have more space for quirky or unusual people. People who become significant in the arts and cultural life especially have tended to gravitate to Sydney, so there may be a need for some negotiation about whether we include these names or send them back to their State or Territory of origin, and then over the choice of author. All this will undoubtedly change as the online version of the ADB becomes more significant and allocation of space less of a consideration. One of the most debated questions is the number of words to allocate to any particular person. The assumption is that word length is a measure of worth or significance; however, it is also the case that a person with a complicated story, many changes of occupation or country, a war record, or a complex set of ideas to expound, requires more words than an arguably more significant or influential character who has had an otherwise straightforward life. A morally upright teacher who has never married, or a dedicated scientist who has had an admirable career with a single big discovery, rarely requires more than 500 words. The ADB’s Story The New South Wales Working Party I think of the sifting as applying a series of different grids, a bit like the coin-sorting machine I knew from my childhood in the bank where my father worked. Other members of the working party have different views of the sifting process. Some are articulated, some instinctive. We have had substantial discussions from time to time on, for example, the desirability of including famous criminals or celebrities who are household names but significant for no other reason. People who have died young often spark discussion. Is their achievement really significant, how will it compare with their peers who live a longer life, or has it been inflated by the manner or time of their death? The different screening criteria applied by the different members of the working party mean, however, that those who are placed on the list are usually considered from a number of different points of view. Most members of the working party now have an automatic reaction to an unfamiliar name encountered in their daily lives and these names are raised subsequently. Have we considered this person? Should we be considering this person? So we do. We are no longer worried about finding suitable women for inclusion. They are much more visible these days, though they do tend to live longer and may be forgotten by the time they actually die. But we do keep a close eye on people whose lives have been significant but markedly less flamboyant than the new media celebrities, in business and banking, for example, and have been greatly helped by Barrie Dyster’s devotion to entrepreneurs and industrialists. From time to time, we pause to ponder the main developments 223 The ADB’s Story in the demography of the period on which we are working to ask if we are reflecting the patterns of immigration, changing employment, cultural shifts and so on. As the list is reduced to something like the number allocated, there are further levels of refinement. It has been most interesting to sit down with a list of a dozen or 20 artists, writers, solicitors, politicians, even historians, and try to rank them in order of significance for inclusion. There are often several versions of the same occupational story—the careers of minor politicians or headmistresses, for example, can be fairly repetitive and they cannot all be included. A choice has to be made. The ADB’s Story The New South Wales Working Party A villain with many aliases, complex personal arrangements and a sticky end needs many more words to set out the facts. 224 7. Working Parties: Recollections of the South Australian Working Party 7. Working Parties: Recollections of the South Australian Working Party First meeting of ADB Supplement steering committee, 2000. From left: Beverley Kingston, Chris Cunneen (editor), Jill Roe, Stephen Garton B t f Ch i C First meeting of ADB Supplement steering committee, 2000. From left: Beverley Kingston, Chris Cunneen (editor), Jill Roe, Stephen Garton By courtesy of Chris Cunneen When I first joined the working party in 1970, a majority of the authors were academic historians or postgraduate research students who could be found through the universities. Leonie Kramer, then Professor of Australian Literature at the University of Sydney, was frequently sent a list of literary figures and asked to suggest authors. We still call on the expertise of people who are supervising research to suggest authors. We also have a ‘stable’ of skilled biographers with expertise in different fields who can be relied on to research and write an entry within their field, but fewer of the authors are now academic historians. The working party has become more sensitive to developments in the research and publishing that now occur outside an academic framework. Sometimes it can be a case of finding a trusted author to counteract what has been judged to be a bad popular biography. Sometimes we find that there is a biography but it is obscure or specialised. Then it seems a good idea to encourage the author to produce a succinct piece that may reach a different or wider readership. Occasionally authors have found themselves with a subject that develops into a larger project. Sometimes the work involved in researching and writing an entry seems a lot to ask of an author, but the level of commitment and professionalism demonstrated by authors is a constant source of admiration and gratitude (and for asking them to undertake yet another entry). In addition to its official business of drawing up lists of names and suggesting authors, the NSW Working Party takes a keen interest in all matters affecting the ADB. Editorial policy, administrative developments in the central office at the ANU, the treatment of the ADB in reviews, and feedback from the public generally are often discussed informally at meetings. Recollections of the New South Wales Working Party Russell Doust When I became State Librarian of New South Wales in early 1973, I ‘inherited’ from my predecessor, Gordon Richardson, the chairmanship of the ADB’s NSW Working Party. This was not prescribed in any book of rules (unlike, for instance, membership of the NSW Geographic Names Board or the NSW Council of the National Trust of Australia, both of which named the state librarian or his nominee in the enabling legislation). Richardson had been chair of the working party almost from the beginning, as far as I can infer from the list of members in Volume 7, taking over after a year or two from the first chairman, Bede Nairn. Neither Richardson nor I were professional historians, although Richardson had written a well-regarded MA thesis (University of Sydney) on the records of the NSW colonial secretary, while I had (in about 1969) submitted my thesis for the degree of master of librarianship to the University of New South Wales on ‘The Administration of Official Archives in New South Wales 1870–1960’. I do not know where the working party first met, but I suspect that it had always been in the State library (formerly the Public Library of New South Wales). Apart from any other considerations, this might well have been a reason for the choice of Richardson as chairman in place of Nairn. Perhaps the only comment I should make about my own chairmanship of the working party is that I seemed to be accepted for what I was—landlord, whose institution provided space and tea and coffee for meetings. My knowledge of Australian history was not great because it was not taught in my University of Sydney undergraduate days, but I did know about controlling and guiding a committee and, for the whole of my chairmanship, I was guided by Chris Cunneen, who was both a member of the working party and the close link with the ADB office in Canberra. I never proposed a possible ‘biographee’ to the working party, nor did I ever contribute an entry. Richardson, on the other hand, wrote six entries for the ADB. Perhaps he had more time to write, whereas I was committed to a program of pulling the library a little further into the later 1900s in a period when, to say the least, the then heavy hand of the Public Service Board was not always on my side! The ADB’s Story The New South Wales Working Party There are some vocal advocates of the ADB among the members. Those of us who have closer links with Canberra and the ANU are frequently quizzed and occasionally asked to raise matters at Editorial Board meetings. 225 The ADB’s Story The NSW Working Party enthusiastically urged adoption of the latest technology when it was first proposed to issue the ADB as a CD-ROM. A little later, as has been told elsewhere, Alan Ventress, who, as Mitchell librarian was keenly aware of the way in which information technology was transforming the library, initiated a discussion at a working party meeting that led, eventually, to putting the ADB online. And the supplement volume was driven from within the NSW Working Party. There is a sense in which the (relatively) selfless commitment of the NSW Working Party (though I am sure this is true of all working parties) to the highest values of scholarship and collaborative research has helped to sustain the ADB, especially through its more trying times. Beverley Kingston taught history at the University of New South Wales for 30 years and is currently an honorary research fellow in the School of History at the UNSW. She has been a member of the NSW Working Party since 1974, its chair since July 1994 and has served on the Editorial Board since August 1996. 226 7. Working Parties: Recollections of the South Australian Working Party Russell Doust was the NSW State librarian and chair of the NSW Working Party from 1973 until 1987. from 1973 until 1987. Recollections of the New South Wales Working Party What I gained, personally, from the NSW Working Party was an acquaintance with real historians, whose friendship and cooperation in general were to stand me in good stead. Who were these people? In no particular order, I see these 227 The ADB’s Story names: J. M. Bennett; Ken Cable; Frank Crowley; Chris Cunneen; Rae (Justice) Else-Mitchell (later president of the Library Council of New South Wales, and a good if formidable friend to a new State librarian); Frank Farrell; Brian Fletcher; Hazel King; Beverley Kingston; W. G. Minn; Bruce Mansfield; Bruce Mitchell; Heather Radi; John Ryan; Gerry Walsh; John Manning Ward (later vice- chancellor of the University of Sydney); Baiba Irving (later Mitchell librarian); Barry Andrews. names: J. M. Bennett; Ken Cable; Frank Crowley; Chris Cunneen; Rae (Justice) Else-Mitchell (later president of the Library Council of New South Wales, and a good if formidable friend to a new State librarian); Frank Farrell; Brian Fletcher; Hazel King; Beverley Kingston; W. G. Minn; Bruce Mansfield; Bruce Mitchell; Heather Radi; John Ryan; Gerry Walsh; John Manning Ward (later vice- chancellor of the University of Sydney); Baiba Irving (later Mitchell librarian); Barry Andrews. There was remarkably little change in the membership of the working party from 1973 until my retirement in 1987. My two immediate successors as State librarian, Alison Crook and Dagmar Schmidmaier, also chaired the working party. I believe that if the NSW Working Party gains something from the State library, it is equally true that the library gains, too; it is a good deal more, on both sides, than just tea and biscuits. Russell Doust, n.d. State Library of New South Wales Russell Doust was the NSW State librarian and chair of the NSW Working Party from 1973 until 1987. Russell Doust, n.d. State Library of New South Wales Russell Doust was the NSW State librarian and chair of the NSW Working Party from 1973 until 1987. Russell Doust was the NSW State librarian and chair of the NSW Working Party from 1973 until 1987. 228 7. Working Parties: Recollections of the South Australian Working Party Speech notes for presentation of ADB Medal, 11 December 2003 I remember very well how much had to be done when the Queensland Working Party was re-formed in 1975; there were lots of late-night meetings, and lots of speed-reading in between. It is sad that neither of our two fine leaders is here now: Denis Murphy, labor politician, historian and biographer, and Paul Wilson, State archivist, both died from cancer. I have a tiny story about each. Denis was the chairman of the working party. He proposed that we include a political cartoonist in the ADB. None of us had heard of this person; discussion was sceptical. ‘OK’ said Denis, ‘Seeing there’s not a consensus, we’ll have a vote. Those in favour say Aye’. ‘Aye’, said Denis, I think alone. ‘Those against?’ ‘No’, we chorused. ‘The Ayes have it: I’ve learnt a lot from Jack Egerton’.1 As we held him in such admiration and affection, we let him get away with it. I wrote my first ADB entry on the Queensland jockey and horse trainer Walter Blacklock. It was full of the names of horses and horseraces. Jim Gibbney, the Queensland desk editor in Canberra, was a lovely bloke, but he had no interest whatever in horseracing. After editing the entry, Jim sent me a message: ‘Spencer, you must get your man out of the stables for at least a couple of sentences’. I was shattered, particularly as I was about to get on a plane to go on long leave overseas. I shoved the whole mess into the hands of Paul Wilson, who was then the secretary of the Queensland Working Party. I will read you the couple of sentences that conclude my article on Blacklock: ‘Small, sturdy and jovial, with a sweeping white moustache, he remained always the quintessential horseman. He failed to learn to drive a motor car, purchased in 1923, which he would try to stop by pulling on the steering wheel and shouting “Whoa”’. It is still the best conclusion to any of my articles, but I wrote not a word. Paul found someone who had known Blacklock 50 years before, interviewed him, and wrote those sentences. It is a good example of the friendly cooperation that helps hold the ADB project together. 1 Jack Egerton (1918–98) was a trade union organiser and member of the Australian Labor Party. The Queensland Working Party Spencer Routh Speech notes for presentation of ADB Medal, 11 December 2003 I have been lucky that the conveners of the working party since Denis—Ross Johnston and Pat Buckridge—have not been running personal agendas: they have just wanted to get out a good dictionary of biography. 229 The ADB’s Story The ADB’s Story The ADB s Story The Queensland Working Party, 2012. Left to right: Darryl Bennet, Brian Stevenson, Libby Connors (front), Jennifer Harrison, Pat Buckridge (chair), Spencer Routh and Geoff Ginn The Queensland Working Party, 2012. Left to right: Darryl Bennet, Brian Stevenson, Libby Connors (front), Jennifer Harrison, Pat Buckridge (chair), Spencer Routh and Geoff Ginn By courtesy of Cathy Jenkins By courtesy of Cathy Jenkins I owe debts to many more people. Jennifer Harrison was a paid research assistant for the ADB for many years. She also gave many more hours of unpaid service to the project each year. She was my constant educator and sounding board: ‘Jenny, Canberra says the date of this Irish immigrant ship is wrong, and yet to me the source seems so reliable’, I would say to her. ‘Don’t worry, Spencer, you’re right. For a while archives had a couple of lists mislabelled. I’ll show you how to explain it’, she would reply. ‘Jenny, this tombstone could be magic for me if only it weren’t so weathered. I just can’t read it’. ‘Don’t worry, Spencer, you can trust the published transcription. Those people checked them by X-ray crystallography’. I might have exaggerated that last bit a little, but you get the general theme. She was a great workmate for years. I will leave anonymous a great crowd of Queensland librarians and archivists who have contributed to the ADB: they could fill this room. I use mention of librarians to lead on to the three parts of my life with the ADB: helping select subjects; helping select authors; writing articles. Denis Murphy 230 7. Working Parties: Recollections of the South Australian Working Party encouraged us to range across all fields, but he also gave us a portfolio. Mine was primary production and sport. My present colleagues might say firmly, ‘And how faithful he has been’. But I have taken these fields very broadly. Many years before the ‘smart State’ was invented, we were going through the accomplishments of the Department of Primary Industries, checking entomology newsletters for obituaries and the like, to find the scientists who had helped lead Queensland primary production—not always successfully. We included the scientists who introduced the cane toad. At times you look out for representatives—such as the best shearer: Jackie Howe. Often the search is led by events. You look for a couple of people most influential in the switch from British breeds of beef cattle in northern Australia to tropical breeds; a key figure in the transformation of the port of Gladstone; and so on. We also get suggestions from various sources, with the most fragmentary information attached. For example, for the supplement volume, Abdul Wade, Afghan camel driver, was on a list of potential inclusions. By courtesy of Cathy Jenkins If I’m not confident that a potential author is as well informed as that scientist, I often send them a little starter kit, containing a few sample articles, obituaries and the like. And I have a deep confession about some authors who have received overwhelmingly useful starter kits. They might have thought ‘How generous!’; but I was thinking, ‘This subject must be included. I can’t for the life of me think of anyone else to write this article; if I don’t recruit this person, I’m going to have to write the article myself’. So, some of the generosity has been pretty calculated. My third work theme: my own ADB entries. For most people here I do not have to describe the long slog of research work, and the contrasting joy of ingenious hypothesis that turns out right. But a couple of comments. I am usually writing up people in fields not dealt with in history honours courses. So I try hard to help the desk editors in Canberra with references for the sources for each statement, and why I have included some sentences. For example, when I say in my text that a Scottish migrant stud breeder imported shorthorn bulls from Scotland, I need to let the desk editor know that in about 1910 there was a great controversy between devotees of a traditional style of beast, and those favouring a new style being developed in Scotland. You could caricature it as basically a contest between cattle that could walk a long way to water, and beef you could actually eat. So I have to educate the editor about the importance of this development so that they will leave it in the entry. More recently, Chris Cunneen asked me to write up an Illawarra dairy-cattle breeder for the supplement volume. I tactfully asked Chris whether he had a primary industry background—even perhaps a family background in dairying. Chris didn’t literally reply that he knew milk had its origin in plastic containers in Woolworths, but I knew the sort of notes I had to write to accompany the article. My final story about writing for the ADB concerns the buck-jump rider and tent showman Lance Skuthorp. I volunteered for this article because I thought it was going to be easy. By courtesy of Cathy Jenkins All we had for him were a few sentences from Geoffrey Bolton’s book on north Queensland. So you ask yourself, ‘But is he the best Afghan camel driver?’ So you speed-read books on Afghans in Australia, and books on camels in Australia, and discover that you do, indeed, have the ‘Lindsay Fox’ of camel transport in Australia—and it is going to be a beaut article. So you are involved in a mad career of preparation that includes Afghan camel drivers and Aboriginal boxers and State auditors and archbishops and businessmen and so on. A supervisor in the John Oxley Library is entitled to ask, ‘What is this surprising bump for a week’s stack retrieval figures?’ And get the answer, ‘Spencer Routh, preparing for an ADB working party meeting’. Some of the people here tonight are here partly because they have helped me— and others—as consultants. It is sad John Kerr isn’t here. His books on the sugar industry helped me so much. The specialists we consult about inclusions are always extraordinarily helpful. You go to them at times with some names and notes and they say: ‘Doubtful about him. The action came mainly from the minister, or from people lower in the organisation’. Next name: ‘Thank goodness you’ve got her’. Next: ‘It’s a good one but put this extra theme into your notes for him.’ They are part of the friendly network that upholds the ADB. The second theme about my work is helping to recruit authors. A lot of what I have already said applies here also. At times the author is really obvious. But at other times you do bibliographical work, follow some other leads, write a letter with some photocopies of biographical information included, and wait, while saying a little prayer. At times, there are failures. At others times there are great successes. I remember, for example, a phone call in answer to my letter from 231 The ADB’s Story a senior (in age as well as status) scientist. For between five and 10 minutes, I listened to the essence of an authoritative article. When the old scientist drew breath, I could only say, ‘If we’d invited anyone else, you’d have sued’. I have a confession at this point. NB: ADB editors have greatly appreciated Spencer’s extensively footnoted entrie Source: ‘Our Man in the Library: Spencer Routh: Library Legend’, UQL News (22 December 2005), pp. 1–2. By courtesy of Cathy Jenkins There were a couple of editions of a book about him, there was a chapter in another book, and a number of feature articles in popular magazines. The more research I did, though, the more detailed corrections I had to make and big myths dispel. Eventually the article appeared. I waited and watched. Some more of the standard rehashes about Skuthorp appeared. But in 1993 a good coffee-table book about stockmen, including pages on the Skuthorp family, and a detailed page on Lance, were published. It was—I was about to say ‘extensively plagiarised’—let us just say, it was written with ‘sustained close 232 7. Working Parties: Recollections of the South Australian Working Party 7. Working Parties: Recollections of the South Australian Working Party attention’ to the ADB article. And no acknowledgment! Was I angry? No. I was delighted. Because in the end we are not in this for the pleasures of cooperation, or the joys of detective work, but to make good introductions to some of the people who have made Australia. attention’ to the ADB article. And no acknowledgment! Was I angry? No. I was delighted. Because in the end we are not in this for the pleasures of cooperation, or the joys of detective work, but to make good introductions to some of the people who have made Australia. NB: ADB editors have greatly appreciated Spencer’s extensively footnoted entries. 233 The ADB’s Story Spencer Routh (b. 1935) Spencer Routh has been a stalwart of the ADB’s Queensland Working Party since he joined it in 1975. He has consistently worked to ensure that representation of Queenslanders—in particular, cattlemen and other primary producers, horseracing identities and sportspeople—is balanced yet comprehensive. This is no accident: Denis Murphy as chairman of the working party (1974–84) allocated ‘portfolios’ to individual members, a system that his successors have continued; Routh, assigned these particular occupations, has been doing justice to them ever since. Routh’s knowledge of his subjects is legendary. Over the years many Queensland authors have received copious bibliographies, elusive references and treasured snippets in the mail; Routh calls them ‘starter kits’. A graduate of the University of Queensland (BA Hons, 1958), Routh was appointed the university library’s first reference librarian in 1959, a position he held until his retirement in 1997. He played a major role in developing the library’s research collections; in 2005, the university conferred on him an honorary DLitt. His wide knowledge of Queensland university students and their academic interests meant that he could quickly identify appropriate authors for ADB entries. His enthusiasm and helpfulness invariably prompted a positive response from his nominees. Awarded an ADB Medal in 2003, Routh resigned from the Queensland Working Party in 2013. 234 7. Working Parties: Recollections of the South Australian Working Party 7. Working Parties: Recollections of the South Australian Working Party Spencer Routh, 1986 ADB archives Spencer Routh, 1986 Spencer Routh, 1986 ADB archives 235 The ADB’s Story Sources: Interview with Professor Michael Roe, Limina: A Journal of Historical and Cultural Studies 2 (1996) pp. 86-91. David Walker and Michael Bennett (eds.), Intellect and Emotion: Perspectives on Australian History: Essays in Honour of Michael Roe (1998). Michael Roe (b. 1931) After gaining a PhD from the ANU in 1960, Michael Roe took up a post in the history department at the University of Tasmania. In 1965 he published Quest for Authority in Eastern Australia 1835–1851. Appointed professor of history in 1975, he was a stalwart of the Tasmanian Historical Research Association and much of his work reflects his interest in Tasmanian history and personalities. Other significant books included Nine Australian Progressives: Vitalism in Bourgeois Social Thought, 1890–1960 (1984) and Australia, Britain and Migration, 1915–1940: A Study of Desperate Hopes (1995). In 1960, immediately after his arrival in Tasmania, Roe joined the ADB’s Tasmanian Working Party. From the outset, he carried the administrative burden. Chairman throughout the preparation of Volumes 11–18 (and the supplement volume), he served as section editor for Volumes 13–18 and as a member of the Editorial Board for Volumes 8–18. He resigned in 2012, for health reasons. Roe has written 33 entries for the ADB, on individuals as diverse as doctors, photographers, clergymen, educationists, thinkers, journalists, writers, rebels, Aboriginal leaders, and his beloved eccentrics. Sources: Interview with Professor Michael Roe, Limina: A Journal of Historical and Cultural Studies 2 (1996) pp. 86-91. David Walker and Michael Bennett (eds.), Intellect and Emotion: Perspectives on Australian History: Essays in Honour of Michael Roe (1998). 236 7. Working Parties: Recollections of the South Australian Working Party 7. Working Parties: Recollections of the South Australian Working Party Michael Roe, 2012 Michael Roe, 2012 Photographer: Brian Wimborne, ADB archives Michael Roe, 2012 Photographer: Brian Wimborne, ADB archives Photographer: Brian Wimborne, ADB archives 237 The ADB’s Story Wendy Birman (b. 1926) A graduate of the University of Western Australia (BA, 1947), Wendy Birman became a qualified librarian. In 1968 she joined the ADB’s WA Working Party, serving as chairman in 1982–96. She gave up library work in 1973 to pursue historical research and, as the ADB’s local research assistant from 1977 to 1996, she built up an unrivalled knowledge of source materials. Interested in the history of exploration in northern Australia, she co-authored, with Geoffrey Bolton, a biography of the explorer Augustus Gregory in 1972 and wrote herself Gregory of Rainworth: A Man in His Time (1979). With Michael White, she wrote The Apprenticeship Training System in Western Australia (1981), a history of the teacher-training system in that State. She has written 57 entries for the ADB. One other important association in Birman’s life was the Library Board of Western Australia, of which she was a member for a decade from 1982, and chairman, 1988–92. In that role she did much to promote the development of Western Australia’s major archival repositories: the State Records Office of Western Australia and the J. S. Battye Library. She championed the State library’s use of emerging electronic technologies and encouraged full engagement with the online world. A prominent member of Perth PEN Centre since its formation in 1984, she has served as State president and delegate to international conferences. Sources: John Ritchie to Wendy Birman, 22 November 1996 in response to her letter of resignation, 14 November 1996. University of West Australian Graduates Association, 50th Reunion of the Graduates of 1947 (Perth: UWA Graduates Association, 1997). 238 7. Working Parties: Recollections of the South Australian Working Party Wendy Birman, 2009 Wendy Birman, 2009 Photographer: Peter Fitzpatrick, ADB archives Photographer: Peter Fitzpatrick, ADB archives 239 The ADB’s Story Sources: ‘Commonwealth Working Party Correspondence’, including K. S. Inglis to Cameron Hazlehurst (20 January 1989), and E. G. Whitlam to Cameron Hazlehurst (2 January 1990), box 135, Q31, ADBA, ANUA. By courtesy of Cameron Hazlehurst Cameron Hazlehurst (b. 1941) Cameron Hazlehurst’s background as a historian and biographer, combined with experience as a senior Commonwealth public servant, were good attributes for a chair of the ADB’s Commonwealth Working Party. Prior to 1989, Donald McDonald (1923–90) was largely responsible for compiling the Commonwealth list; he contributed 27 entries himself. That year, Hazlehurst, then a senior fellow in the Research School of Social Sciences, ANU, brought together a group of Canberrans to form the working party. He served as chairman (and as a member of the Editorial Board) until 1999. The first issue he had to deal with was the title: Gough Whitlam wrote to him in January 1990 arguing that the word ‘Commonwealth’ should never be used except in ‘the Commonwealth of Australia’ and that the working party should have been called the ‘federal working party’ to prevent confusion with the (British) Commonwealth. As chairman, Hazlehurst continually asked for a larger quota and a higher average word allocation, in order to do justice to Members of Parliament and public servants. He also advocated that all cabinet ministers and heads of government departments should be included in the ADB, thereby enabling prosopographical work on cabinet and the public service. He wrote 11 entries on a range of subjects, including Whitlam’s father, H. F. (Fred) Whitlam, Gilbert Bogle and Margaret Chandler (more famous in death than in life), and cycling champion Russell Mockridge, plus a film director, deep-sea diver, governor and politician, soldier, aviator and statistician. Sources: ‘Commonwealth Working Party Correspondence’, including K. S. Inglis to Cameron Hazlehurst (20 January 1989), and E. G. Whitlam to Cameron Hazlehurst (2 January 1990), box 135, Q31, ADBA, ANUA. 240 7. Working Parties: Recollections of the South Australian Working Party Cameron Hazlehurst in his office in the Coombs Building at the ANU, 1980s Cameron Hazlehurst in his office in the Coombs Building at the ANU, 1980s 241 The ADB’s Story Source: A. J. Sweeting, ‘Long, Gavin Merrick (1901–1968)’, Australian Dictionary of Biography, vol. 15 (Melbourne: Melbourne University Press, 2000), pp. 43–4. A. J. Hill, ‘Austin, Maurice (Bunny) (1916–1985)’, ADB, vol. 17, pp. 119–21. Maurice (Bunny) Austin (1916–1985), Alec Hill (1916–2008) and Frank Brown (1906–2000) In 1963–65, when he was a research fellow at the ADB, the military historian Gavin Long convened an active ADB armed services ‘working group’. The Armed Services Working Party, formed in 1974, was responsible for preparing lists for volumes covering the period 1891–1939. Because of the impact of World War I on Australian history, 560 entries, or 14 per cent of the total, had been allocated to the lives of servicemen. On completing the task in 1976, the section editor, Bob O’Neill, wrote that it was a ‘major effort’ that ‘fatigued everyone along the way’. For the list to be realised as entries, an indispensable source were the individual service records, held by the services themselves in repositories such as the Central Army Records Office. The ADB was greatly assisted by a group of retired army officers and historians, including Brigadier Maurice Austin, Captain Alec Hill and Lieutenant Colonel Frank Brown, in gathering this material. ‘Bunny’ Austin DSO OBE was an army officer (1938–71), who worked from 1971 to 1982 as army historian, researching and publishing works on Australian military history from 1788 to Federation. A consultant to the ADB and a founding member of the Armed Services Working Party, he transcribed—by hand—armed services personal files; after 1982 he had permission to continue accessing the records on behalf of the ADB. Alec Hill AM MBE ED, educated at Sydney Grammar School, University of Sydney (BA, 1938) and Balliol College, Oxford (BA 1948; MA, 1952), taught at Sydney Grammar from 1938 to 1966, interrupted by World War II, in which he saw service in the Middle East and New Guinea. In 1966 he was appointed a lecturer in history at the Royal Military College, Duntroon, where he influenced a new generation of soldiers and military historians, including David Horner (chairman of the working party since 1994), Peter Pederson and Chris Clark, all of whom later wrote for the ADB. Associated with the ADB for more than 30 years, Hill was a founding member of the Armed Services Working Party and chairman in 1982–94. He wrote 38 entries, many on prominent generals. His biography of General Sir Harry Chauvel, the commander of the Desert Mounted Corps in World War I, published in 1978, emphasised the role of leadership. 242 7. Maurice (Bunny) Austin (1916–1985), Alec Hill (1916–2008) and Frank Brown (1906–2000) Working Parties: Recollections of the South Australian Working Party Frank Brown, a former lieutenant colonel in the Corps of Royal Engineers, was employed by the ADB as a research assistant from 1971 to 2000. His work, often involving time voluntarily spent far in excess of his reimbursement, was undertaken chiefly at the Australian War Memorial, where he was given special access to service records and war diaries. Brown’s careful, well-organised notes were of immense benefit to ADB editors for more than 25 years, until he resigned from the working party at the age of eighty-seven. Bob O’Neill noted in 1974 that his notes were valuable, going ‘further than the subjects’ military records in many cases’. One opens any armed service subject’s file compiled before the late 1990s and sees Brown’s handwritten notes adorning the pages. Frank Brown, a former lieutenant colonel in the Corps of Royal Engineers, was employed by the ADB as a research assistant from 1971 to 2000. His work, often involving time voluntarily spent far in excess of his reimbursement, was undertaken chiefly at the Australian War Memorial, where he was given special access to service records and war diaries. Brown’s careful, well-organised notes were of immense benefit to ADB editors for more than 25 years, until he resigned from the working party at the age of eighty-seven. Bob O’Neill noted in 1974 that his notes were valuable, going ‘further than the subjects’ military records in many cases’. One opens any armed service subject’s file compiled before the late 1990s and sees Brown’s handwritten notes adorning the pages. 243 The ADB’s Story Gordon Briscoe (b. 1938) and Frances Peters- Little (b. 1958) Gordon Briscoe and Frances Peters-Little are two Aboriginal historians who have been critical of the ADB not only for failing to identify and include enough Indigenous subjects, but also for not extending its editorial practices to take into account Indigenous conventions of narration and remembrance. Briscoe is descended from the Mardudjara and Pitjantjatjara peoples of Central Australia. From the 1960s he has been active in Aboriginal affairs, helping to establish, in 1971, the Aboriginal legal and medical services in Redfern, Sydney. At ANU (BA Hons, 1986; MA, 1991; PhD, 1996), he was the first Indigenous scholar to be awarded a PhD in history. Peters-Little is the daughter of singers Jimmy Little and Marjorie Rose Peters. A documentary filmmaker, she attended the University of Technology, Sydney (BA, Communications, 1991), and ANU (MPhil, 2002) and is currently a PhD candidate at the University of Sydney, working on a biography of her father. In an attempt to address the criticisms, an Indigenous Working Party (IWP) was formed in 2004, with Peters-Little as chairwoman and including members Nick Brown, Dawn Casey, Ann Curthoys, Ann McGrath, Margo Neale, Kaye Price, Peter Read and Tim Rowse. Early in 2006 McGrath and Neale resigned and Robin McNamee and Aileen Blackburn were invited to join in their stead. The working party was initially asked to review the lists of Indigenous Australians, already prepared for Volumes 16 and 17 by the State working parties, and to nominate authors. It was also asked to begin collecting names for subjects who died between 1991 and 2000 for inclusion in Volumes 19 and 20. The general editor, Di Langmore, suggested that they decide on 40 names. It soon became obvious that research assistance was needed because everyone was ‘over- committed’. To that end, in 2006, the working party decided to seek a grant from the Australian Institute of Aboriginal and Torres Strait Islander Studies. More generally, the IWP was meant to advise the general editor on means of ensuring that editorial policy and practice respected the sensitivities of Indigenous families whose deceased kin were included in the ADB. In relation to conventions regarding authorship, it took the view that there was no point in laying down general prescriptions about the ADB’s editorial policies because Indigenous Australians were not homogeneous in their views on such matters. 244 7. Gordon Briscoe (b. 1938) and Frances Peters- Little (b. 1958) Working Parties: Recollections of the South Australian Working Party At the end of 2008, Peters-Little, Rowse, Curthoys and Casey resigned for various reasons, mostly to do with relocation. Owing to the loss of key personnel and also as a protest at not having the same functionality as other working parties, the IWP, now chaired by Samantha Faulkner, decided to disband and to recommend to the Editorial Board that an Indigenous advisory board be established with new terms of reference and governance. In 2013 the ADB began to develop a relationship with Yuraki, the History, Politics and Culture node of the National Indigenous Research and Knowledges Network (NIRAKN) of more than 40 members who are all Indigenous academics from across Australia. The node was led by Aboriginal historians Professor John Maynard and Dr Jaky Troy. At the end of 2008, Peters-Little, Rowse, Curthoys and Casey resigned for various reasons, mostly to do with relocation. Owing to the loss of key personnel and also as a protest at not having the same functionality as other working parties, the IWP, now chaired by Samantha Faulkner, decided to disband and to recommend to the Editorial Board that an Indigenous advisory board be established with new terms of reference and governance. In 2013 the ADB began to develop a relationship with Yuraki, the History, Politics and Culture node of the National Indigenous Research and Knowledges Network (NIRAKN) of more than 40 members who are all Indigenous academics from across Australia. The node was led by Aboriginal historians Professor John Maynard and Dr Jaky Troy. 24 members who are all Indigenous academics from across Australia. The node was led by Aboriginal historians Professor John Maynard and Dr Jaky Troy. Gordon Briscoe By courtesy of Ann McGrath Source: ADB Indigenous Working Party, NCB/ADB files. Gordon Briscoe, Racial Folly: A Twentieth-Century Aboriginal Family (Canberra: ANU E Press, 2010). 245 members who are all Indigenous academics from across Australia. The node was led by Aboriginal historians Professor John Maynard and Dr Jaky Troy. Gordon Briscoe By courtesy of Ann McGrath Source: ADB Indigenous Working Party, NCB/ADB files. Gordon Briscoe, Racial Folly: A Twentieth-Century Aboriginal Family (Canberra: ANU E Press, 2010). Gordon Briscoe By courtesy of Ann McGrath Gordon Briscoe Gordon Briscoe By courtesy of Ann McGrath By courtesy of Ann McGrath Source: ADB Indigenous Working Party, NCB/ADB files. Gordon Briscoe, Racial Folly: A Twentieth-Century Aboriginal Family (Canberra: ANU E Press, 2010). Source: ADB Indigenous Working Party, NCB/ADB files. Gordon Briscoe, Racial Folly: A Twentieth-Century Aboriginal Family (Canberra: ANU E Press, 2010). 245 The ADB’s Story Source: John Poynter, interviewed by Ann Turner (22–23 July 1999 and 28 February 2002), NLA. 1 For some of the results of my research into manufacturing, see G. P. Walsh, ‘The English Colony in New South Wales: A. D. 1803’, New Zealand Geographer, 18, no. 2 (1962), pp. 149–69; ‘The Geography of Manufacturing in Sydney, 1788–1851’, Business Archives and History, 3, no. 1 (1963), pp. 20–52; and Chapter 13, ‘Manufacturing’, in G. J. Abbott and N. B. Nairn (eds), Economic Growth of Australia 1788–1821 (Melbourne: Melbourne University Press, 1969). John Poynter (b. 1929) A graduate of the University of Melbourne (BA, 1951; PhD, 1961), John Poynter won a Rhodes Scholarship, which took him to Magdalen College, Oxford (MA, 1953). Returning to the University of Melbourne, he was dean of Trinity College before becoming Ernest Scott professor of history (1966–75) and deputy vice- chancellor (1975–90). He was a member of the ADB’s National Committee and of the Editorial Board (1974–98) and chairman of the Victorian Working Party and section editor (1978–90). For a dozen years, he read all the Victorian entries, writing erudite comments on the ‘blues’ that were returned to Canberra. As an ADB author, he has maintained an association that extends back to the 1960s: the first of his 17 entries, on Alfred Felton, was published in Volume 4 in 1972. Many of his subsequent articles, including a 5000-word entry on the Baillieu family and long entries on other significant figures such as the Grimwades, Alexander Leeper, Sir Ronald Munro Ferguson, Dame Mabel Brookes and Sir Charles Lowe, were major contributions. Most are Victorian subjects; all are characterised by solid research and elegant prose. Poynter developed his article on Leeper into a full biography, Doubts and Certainties: A Life of Alexander Leeper (1997). His shorter entries, such as on Helena Rubinstein and Sir Kenneth Wheare, involved insight leavened by dry humour and sometimes firsthand knowledge of a subject. For instance, he used to tell the story that the girl who assisted Miss Crouch at the Coleraine school was my step- grandmother … She said that Helena [Rubinstein] suggested that she go to Melbourne with her and start a beauty salon. My step-grandmother turned the offer down. She didn’t think there was any money to be made in face cream. From 1976 to 1987, Poynter was chairman of the ADB’s publisher, Melbourne University Press. Since 1995 he has been a professorial fellow at the Australian Centre, University of Melbourne. He was awarded an ADB Medal in 2004. 246 7. Working Parties: Recollections of the South Australian Working Party John Poynter, 2009 Photographer: Peter Fitzpatrick, ADB archives John Poynter, 2009 Photographer: Peter Fitzpatrick, ADB archives John Poynter, 2009 Photographer: Peter Fitzpatrick, ADB archives Photographer: Peter Fitzpatrick, ADB archives 247 247 8. From the First Fleet to ‘Underbelly’: Writing for the ADB Gerald Walsh I became acquainted with the Australian Dictionary of Biography half a century ago, in February 1961, when I was appointed a research scholar in historical geography in the Research School of Pacific Studies (RSPS) at the ANU. My task was to research the origins and development of manufacturing, or secondary industry, in Sydney, from its foundation to 1900. This involved identifying the manufacturers and industrialists—the flour millers, brewers, tanners, engineers, ironworkers, soap and candle makers, and textile manufacturers, for example— and gathering information on the locations of their factories, the processes employed, the power used, and the duration of their establishments and the place of manufacturing in the emerging colonial economy.1 Anyone doing research in Australian history at that time was always sent along to have a yarn with L. F. Fitzhardinge, who had the somewhat grand title of ‘reader in sources of Australian history’. My meeting with Laurie was most helpful. In conversations with him and other staff and students, I learnt about the existence of the Biographical Register that he had instituted in 1954 and about the two volumes then being prepared to cover the first period of the ADB project, which would include, on the floruit principle, people who contributed to the Australian experience in the early colonial years, 1788–1850. Some of these people were my manufacturers and I soon realised that many manufacturers were also farmers, graziers, merchants and traders, which is not surprising considering that the emerging economy was very small and could not support much specialisation of economic activity. Early days In 1961 RSPS and the Research School of Social Sciences (RSSS), together with the library of the Institute of Advanced Studies (IAS), were housed in the wooden buildings of the old Canberra Community Hospital. These buildings are largely still there, on either side of Mills Road, except that what was then 249 The ADB’s Story the library and the western wing of the main hospital building has given way to new buildings of the Research School of Earth Sciences. If you stand in front of the elegant portico (now heritage listed) of the old hospital, at the southern end of Mills Road, you can see where Douglas Pike, the first general editor, had his office, on the right-hand side next to the road, and Sir Keith Hancock, director of the RSSS, was on the left or Black Mountain side of the entrance. The main part of the hospital consisted largely of three wings parallel with the road, and the wing, verandah and lawn nearest to Black Mountain were where staff and postgraduate students met for morning and afternoon tea. In those pioneering days the relatively small academic body was a close community of scholars. In addition to Hancock, Pike and Fitzhardinge, and sometimes Manning Clark from the School of General Studies, there were, among others, Sir John Crawford (economics), Jim Davidson (Pacific history), Oskar Spate (geography), Mick Borrie (demography), Noel Butlin (economic history), Patrick Fitzgerald (oriental history), Pat Moran (statistics) and Geoff Sawer (law). It was at a morning tea that Nan Phillips, the energetic and efficient secretary who organised the ADB office, introduced me to Douglas Pike, who was then still professor of history at the University of Tasmania and on one of his regular visits from Hobart. At the time the ADB was still in its planning stages and the list of persons to be included in the first few volumes was far from complete. Pike and the State working parties had little difficulty in getting established historians and specialist workers to write the articles on prominent figures, such as the early governors, explorers, politicians, judges, clergy and prominent settlers, but they often had trouble attracting authors for the less-prominent people: traders, merchants, farmers, minor civil and military officials and manufacturers. Pike expressed interest in my work and, always on the lookout for potential authors, asked me to contribute some entries. 2 Pat Croft was a respected editor of ANU publications and, later, of ANU Press. See Shirley Purchase, ‘Croft, Patricia (Pat) (?–1995)’, ANU Reporter (16 August 1995), p. 11. Early days I started my 48-year association with the ADB by writing 19 articles (13 in Volume 1 and six in Volume 2), which were published in 1966 and 1967 respectively. Among the people I wrote about were the First Fleeters James Squire, convict, farmer and Australia’s first commercial brewer, and Henry Hacking, quartermaster of HMS Sirius and explorer. Others were Benjamin Boyd, the flamboyant entrepreneur and pioneer of Twofold Bay, the Monaro and the Riverina; John Busby, engineer of Sydney’s first regular water supply; John Dickson, who introduced steam power to Australia when he erected his steam mill on Darling Harbour in 1815; Sir John Jamison, physician, landowner and politician; David Jones, founder of the well-known retail firm; Mary Reibey, Australia’s first businesswoman, whose portrait is on the $20 note; and James Wilshire, commissary department official and tanner. Wilshire had the largest tannery in the colony, which operated from 1803 to 1860 on the site of the now Central Local Court and Brickfield Place in Liverpool Street, Sydney. 250 8. From the First Fleet to ‘Underbelly’: Writing for the ADB 8. From the First Fleet to ‘Underbelly’: Writing for the ADB The first article I completed and felt confident to submit was on Wilshire, the tanner. Pike commented on my first effort in the following letter: THE UNIVERSITY OF TASMANIA HOBART 19-2-63 Dear Mr Walsh, Dear Mr Walsh, Mrs Phillips has sent a copy of your article on James Wilshire with a request for comments. You have done a fine job on the man—his enterprise and energy come out clearly, in contrast to many articles where the man is lost behind a great mass of factual data. I think the prime question is—what will users look for in the Dictionary? Most will want specific information on dates and places, and a few will want a more general summary. If I’m right, then information becomes more important than interpretation, and that in turn raises the problem of word length. Your article could be edited down a little without sacrificing any substance at all, but even then would exceed the approximate span. I’m inclined to suggest, therefore, the deletion of such phrases of fact, on the grounds of relevance, as Page 1. line 5 ‘under the recommendation of John Palmer’. Page 1. line 5 ‘under the recommendation of J line 10 ‘in place of William Neate Chapman’ 12. Historical research in the 1960s Doing historical research 50 years ago was very different from today. There was no quick, relatively cheap means of photocopying, and there were no computers, search engines or word processors. Note-taking was usually by hand on paper or cards and writing required a typewriter with carbon paper and correcting fluid. Library facilities were somewhat limited in Canberra, but were rapidly improving. The libraries of the IAS and the School of General Studies moved into their present buildings in 1963, but it was not until 1968 that the National Library of Australia (NLA) occupied its present handsome building on the shore of Lake Burley Griffin. Before this the NLA collections were dispersed at several locations: in Nissen huts at Scott’s Crossing of the Molonglo River, at the western end of what is now King’s Avenue Bridge; at Hume Circle in the suburb of Griffith; in the basement of the old Administration Building (now the Sir John Gorton Building) in Parkes Place; and even in (Old) Parliament House. The Mitchell Library in Sydney, with which I was already very familiar, was, however, and still is, the great repository of early Australian history; it contained most of the vital sources for the majority of people included in the first six volumes of the ADB, covering the years 1788 to 1890. Located in the original wing of the Public Library of New South Wales on the Macquarie Street side, it was also the then shopfront for the Archives Office of New South Wales. Although the Mitchell was small, with space for only about 30 readers at a time, its catalogue of printed books and manuscripts was excellent and crucial to the realisation of the ADB project. This is evident in the source identification ‘MS cat under [name] (ML)’ that occurs in numerous early ADB bibliographies. Another indispensable biographical source in the Mitchell was the ‘Mutch Index’, a comprehensive card index of the early settlers of New South Wales and Van Diemen’s Land, compiled from convict indents, musters, land records and parish registers by the politician, historian and genealogist T. D. Mutch. There were some advantages to the researcher working in libraries and archives before modern technology made photocopying cheaper and before an increasing number of universities and students resulted in a greater demand for, and stress on, original source materials. Early days ‘during the … Williamson’ 18 ‘upon … relieved’. 18 ‘upon … relieved’. These names have some importance but do not directly bear on Wilshire’s own personal story, in quite the same way as the reference to Nelson and Miss Pitt (p.2.l.2). By editing, I mean nothing more than say—p.2. line 4—to reread—‘By the bankruptcy of his English agent in 1811, he lost three years’ salary and had to sell some land and cattle’. The picking up of 10 words or so here and there, without losing the point, make quite a difference. With articles that have no substance, the problem is frightening, but your work is a delight. I suggest that you have a chat with Pat Croft2—she’s very good and merciless on style. I hope this has helped. You leave me grateful. With my best wishes, Sincerely, Douglas Pike. Pike’s reference to style was no doubt justified, but finding his comments both useful and encouraging, I continued to finish the other 18 articles for 251 The ADB’s Story the first two volumes and to suggest more manufacturers and other interesting characters I came across in the course of my research. And, of course, it was almost inevitable that if you found someone worthy who had been overlooked for inclusion, you were asked to write the entry. Historical research in the 1960s You could peruse the early printed books and manuscripts (letters, diaries and private papers) in the original without 252 8. From the First Fleet to ‘Underbelly’: Writing for the ADB using those never-fitting, cumbersome white gloves, and you could read all the newspapers in hardcopy, which is easier and quicker than viewing them on microfilm—though copying was not at the push of a button. Certain sources, however, were only available abroad, as many of my biographical subjects had substantial links with the United Kingdom. When based in London during two long study-leave periods in the 1970s, I was able to research these connections using, among other collections, the marvellous resources of the British Museum (Library), the General Register Office (Somerset House), the Society of Genealogists (Kensington), the Public Record Office (then in Chancery Lane), the Institute of Historical Research, University of London, and the National Army Museum (Chelsea). Fieldwork, visiting cemeteries and such places as Cranbrook in Kent for the Tooth family, Sizergh Castle in the Lake District for the Stricklands, and East Grinstead, Surrey, for the financier Donald Larnach, was especially rewarding, as were visits to county and town archives, regimental museums, and Coalbrookdale in Shropshire, the cradle of the Industrial Revolution. Cemeteries as historical sources Most of the men and women included in the ADB come from the lists compiled by the various working parties. Inevitably some worthy people have been missed from time to time, only to be suggested later by relatives or someone with special knowledge of a particular profession, trade or occupation. Interestingly, some who were overlooked originally were picked up from claims made on their headstones. This was especially the case with the people I was interested in and with minor figures. Cemeteries, with their tombstone epigraphy, especially in the eighteenth and nineteenth centuries, are veritable ‘documents’ in stone. Some monuments not only state name, dates of birth and death, occupation and names of family members, but also give a résumé of the deceased’s life and a supposed claim to fame or remembrance. The older headstones—much larger than modern ones—sometimes reveal the date of marriage, the country, county or town the person was ‘native of’, date of arrival in Australia, the person’s educational qualifications, and the cause of death. The last mentioned was often recorded if it was the result of an accident, and especially if the person fell victim to one of the new means of transport, such as a train, steamboat, tram or motorcar accident. In these cases the name, number and a relief representation of the fatal vehicle were sometimes engraved on the stone—a vestige, perhaps, of the ancient law of deodand. Old cemeteries in general are landscapes of the past, survivals of a bygone age. They tell us much about the social history of their time—the mortality rate, the aspirations 253 The ADB’s Story and achievements of the pioneers, artistic taste, and the strength of religious feeling. They provide evidence for the biographical historian otherwise not readily available. Cemetery epigraphy is a reminder that the art of biography, the history of the lives of individual men and women as a branch of literature, has its origins in the commemorative instinct, the impulse to defy annihilation. Because I had long been addicted to ‘reading’ these landscapes of the past, I was able to make a somewhat singular contribution to the ADB project. As a boy in Sydney, I lived not far from Rookwood Cemetery, the largest Victorian- age cemetery in the world.3 Opened in 1868 and still in use, Rookwood was a product of the railway age. 3 For a history of Rookwood Cemetery, see D. A. Weston (ed.), The Sleeping City: The Story of Rookwood Necropolis (Sydney: Society of Australian Genealogists/Hale & Iremonger, 1989). 4 The Devonshire Street monuments at Bunnerong were removed to make way for an extension of Botany Cemetery in the 1970s. Squire’s beautifully cut ledger stone has since disappeared. ( ) pp 6 R. W. Chapman (ed.) and Pat Rogers (intro.), James Boswell, Life of Dr. Johnson, London, 1791, Oxford World Classics (Oxford: Oxford University Press, 2008), p. 662. 5 For an anecdote regarding Fiaschi, see my contribution, ‘Grave History’, in Peter Donovan (comp.), Adventures with Clio (Blackwood, SA: Donovan & Associates, 1994), pp. 48–9. 6 R. W. Chapman (ed.) and Pat Rogers (intro.), James Boswell, Life of Dr. Johnson, London, 1791, Oxford World Classics (Oxford: Oxford University Press, 2008), p. 662. 5 For an anecdote regarding Fiaschi, see my contribution, ‘Grave History’, in Peter Donovan (comp.), Adventures with Clio (Blackwood, SA: Donovan & Associates, 1994), pp. 48–9. 6 R W Chapman (ed ) and Pat Rogers (intro ) James Boswell Life of Dr Johnson London 1791 O ford Cemeteries as historical sources The bodies for burial, accompanied by mourners, were brought by train from Sydney and other stations along the western line to four mortuary stations within the cemetery, until 1948, when motor-vehicle funerals completely took over. My friends and I would ride our bicycles through the cemetery and through the most elaborate of these stations: Mortuary No. 1, which in the 1950s was sold, dismantled and reassembled as All Saints Anglican Church in the Canberra suburb of Ainslie. Eventually, in connection with my own research and biographical commitments for the ADB, I ‘read’ most of the old burial grounds in the Sydney metropolitan area. This was well before interested groups such as the ‘friends of’ various cemeteries began to take an interest, make systematic transcriptions of their epigraphy, clean them up, and conduct tours to the last resting places of the famous. I will give two examples of informative tombstone inscriptions, one from 1822 and the other from 1927. The first is from the table-tomb of James Squire, the brewer, already mentioned. Originally in the old Devonshire Street (The Sandhills) Cemetery in Sydney, it was removed, like many of the graves, vaults and monuments, in 1901 to Bunnerong Cemetery, La Perouse, next to Botany Cemetery, to make way for Central Railway Station.4 I read and photographed it there more than 50 years ago. The inscription reads: In Sacred Respect to the Remains of MR. JAMES SQUIRE, late of Kissing Point, who departed this life May 16th, 1822, Age 67 Years. He arrived in this Colony in the First Fleet, and by Integrity and Industry acquired and maintained an unsullied Reputation. 254 8. From the First Fleet to ‘Underbelly’: Writing for the ADB Under his Care the HOP PLANT was first Cultivated in this Settlement, and the first BREWERY was Erected, which progressively matured to Perfection. As a Father, a Husband, a Friend, and a Christian He lived Respected and died Lamented. Also JAMES SQUIRE, Son of the above, who Died MARCH 5th, 1826, Aged, 28 years. Under his Care the HOP PLANT was first Cultivated in this Settlement, and the first BREWERY was Erected, which progressively matured to Perfection. As a Father, a Husband, a Friend, and a Christian He lived Respected and died Lamented. Also JAMES SQUIRE, Son of the above, who Died MARCH 5th, 1826, Aged, 28 years. Cemeteries as historical sources Henry Carter Perdriau (1817–92), ‘One of the Leading Pioneers of Steam Ferry Transport on Sydney Harbour’; Bernard Bede Kieran (1886–1905), ‘Late Champion Swimmer of the World’; James Thomas Allan (1831–1912), ‘The Barcoo Pioneer and owner of Mount Enniskillen for 47 years’; and John Paton VC (1834–1914), ‘93 Sutherland Highlanders, Hero of Lucknow’. All the statements on their monuments proved to be true. Bradley was one of the wealthiest landholders in New South Wales, a promoter of railways and a member of the Legislative Council. Strickland was a commissary officer who retired from the British army to live in Sydney. Author and promoter of geographical research, he was the one who suggested the sending of a contingent to the Sudan War in 1885. He was the uncle of Sir Gerald Strickland, first and last Baron Strickland of Sizergh Castle, Kendal, Westmorland, who, between 1904 and 1917 was successively governor of Tasmania, Western Australia and New South Wales. Perdriau, founder of the Balmain Steam Ferry Company Limited, was a member of a family prominent in the business life of Sydney. His eldest son, Henry, set up the Perdriau Rubber Company, later the Dunlop-Perdriau Rubber Company. Kieran, the greatest swimmer the world had seen, held every world record from 200 yards (183 m) to one mile (1.6 km), and many of his phenomenal times were not approached until many years after his death at the age of nineteen. Allan was a notable Queensland explorer and pastoralist based at Mount Enniskillen, near Tambo. At one stage his stations on the Barcoo River covered 4700 sq km. Known as ‘Black Allan’, he was a ‘terror to cattle thieves and trade unionists’. Paton won his Victoria Cross during the Indian Mutiny in 1857. Soon after, he migrated to New South Wales and joined the prison service, finishing his career as governor of Goulburn Gaol.7 Among the many names and claims I investigated that were not included in the ADB for reasons ranging from the insubstantial nature of their claims to the lack of any further supporting evidence, were: James Bryan (d. 7 The Perdriau, Allan and Paton graves are in Rookwood Cemetery; Strickland and Kieran in Gore Hill, St Leonards; and Bradley is in St Stephen’s Churchyard, Newtown. Cemeteries as historical sources Son of the above, who Died MARCH 5th, 1826, Aged, 28 years. Squire had his brewery, tavern and 400 ha farm at Kissing Point, near Ryde, on the left bank of the Parramatta River, halfway between Sydney and Parramatta. Some might recall that Squire’s reputation, name and rustic signature were resurrected in 1998 and given to a number of very good boutique-style ales, pilsener, porter and beer, produced in Sydney by the Malt Shovel Brewery Proprietary Limited at Camperdown. The second is the substantial monument in Waverley Cemetery to the surgeon Thomas Henry Fiaschi, who died in 1927.5 It gives his degrees and decorations, stating that he was a doctor of both medicine and surgery from the universities of Pisa and Florence and that he was a brigadier general in the Australian Army Medical Corps, a companion of the Distinguished Service Order and a recipient of the Volunteer Decoration. It gives the dates and places of his birth and death, and lists other honours: Knight of St Maurice and St Lazarus, Italy, and Commendotore of the Crown of Italy. It also records that he was honorary surgeon of the Hawkesbury Hospital (1879–83), worked at the Sydney Hospital (1889–1912), and was honorary consulting surgeon at the latter from 1912 to 1927. Lastly, it tells us that he was president of the NSW Wine Association, 1902–27. Both these inscriptions, especially Squire’s, are fairly representative of a type and their eras and yet, as Dr Samuel Johnson reminds us, ‘in lapidary inscriptions a man is not upon oath’. The information had to be checked and tested.6 In addition to Squire and Fiaschi, among my many cemetery ‘discoveries’ whose entries I wrote for the ADB were the following: William Bradley (1800–68) ‘of Lansdowne Park, Goulburn and Bibbenluke, Monaro’; Sir Edward Strickland (1821–89) ‘K.C.B., F.R.G.S. of the Noble Knightly Family of Sizergh Castle’; 255 The ADB’s Story Henry Carter Perdriau (1817–92), ‘One of the Leading Pioneers of Steam Ferry Transport on Sydney Harbour’; Bernard Bede Kieran (1886–1905), ‘Late Champion Swimmer of the World’; James Thomas Allan (1831–1912), ‘The Barcoo Pioneer and owner of Mount Enniskillen for 47 years’; and John Paton VC (1834–1914), ‘93 Sutherland Highlanders, Hero of Lucknow’. All the statements on their monuments proved to be true. Cemeteries as historical sources 1845), ‘the first to introduce gas light into this part of the world’; Richard Murray, ‘Cricketer of this City’ (1861); William Vial, ‘Who Saved the Life of the Duke of Edinburgh at Clontarf, March 12, 1868’; ‘Professor’ Charles Owen Peart, ‘Champion high diver of the world’ (1896); Sir John Cecil Read, ‘Baronet’ (1899); and Ernest James Card, ‘Founder and Life Patron of the Society of Bricks’ (1925). One tall, granite centennial family monument (1800–1900) in Rookwood Cemetery with an inscription beginning ‘Robbery and Revolution Ruined Their Irish and French Estates Which were the operating causes of Their leaving England’ looked promising but, on investigation, proved unrewarding. 256 8. From the First Fleet to ‘Underbelly’: Writing for the ADB Having espoused the value of cemeteries and gravestones as a possible source for ADB aspirants, it is, to say the least, rather paradoxical that the occupant of what is perhaps the largest grave and monument in Sydney, and very likely in New South Wales, was overlooked. This was Michael Dwyer (1772–1825), the Irish revolutionary and political exile, ‘The Wicklow Chief’ of the 1798 Rebellion, who was reinterred with his wife in Waverley Cemetery from Devonshire Street in 1898. I, like many others, was very familiar with the beautiful, large marble monument with its tall Celtic cross, bas-reliefs, mosaics and metalwork, but not unnaturally assumed that Dwyer would be on the list for the first period. This was not so and the error was rectified in the ADB’s supplement volume, edited by Chris Cunneen (with Jill Roe, Beverley Kingston and Stephen Garton) and published in 2005.8 8 Ruan O’Donnell, ‘Dwyer, Michael (1772–1825)’, in ADB, Supplement 1580–1980, p. 110. 9 P. Cunningham, Two Years in New South Wales: Comprising Sketches of the Actual State of Society in that Colony, of its Peculiar Advantages to Emigrants, of its Topography, Natural History, & c., vol. 1 (London: Henry Colburn, 1827), pp. 91–2. 10 J. Lycett, Views in Australia, or, New South Wales & Van Diemen’s Land Delineated: In Fifty Views with Descriptive Letter Press (London: J. Souter, 1825), Letterpress accompanying Plate no. 8, ‘Kissing Point, New South Wales’, which shows Squire’s brewery and farm. 11 The account of my researches, ‘The Preparation of a Dictionary Entry: The Case of Colonel Kempt’, was originally published in RMC Historical Journal, 2 (1973), pp. 25–30; it is substantially reproduced in Chapter 9 of Iain McCalman, with Jodi Parvey and Misty Cork (eds), National Biographies and National Identity (Canberra: Humanities Research Centre, 1996), pp. 123–33. Writing ADB entries As I see it, the task of the biographer or mini-biographer is first to ascertain the relevant facts about the person’s life and then by critical selection, imagination and, perhaps, artistry tell their story. But a full account can only be written if, according to the classical formula, you know a good deal about three things: what the person did; what the person thought and said; and what other people said about the person. For a full or ‘three-dimensional’ biography there must be adequate material from each of the three requisites. Many people I wrote about for the ADB, especially in the early volumes, were what I call ‘one or two-dimensional’ characters. Very often you only knew what the person did, little or nothing about what they thought or said, and were short on contemporary assessments of their life to add colour to the biography. The First Fleeters Henry Hacking and James Squire are cases in point. Generally, with minor figures, the evidence supplied by contemporaries was rather terse. For example, Governor Philip King wrote of Hacking, who had been twice sentenced to death and reprieved: ‘He is still a good Man and I am inclined to believe the last Crime was Committed to Obtain Spirits’, and ‘I am glad you have kept Hacking, he is a good man but was lost here by the Arts of a Woman’. In Squire’s case, while much was known about his career, the only bit of colour was provided by a contemporary author and a fellow ex-convict. Peter Cunningham tells us that the ‘jocose’ brewer and proprietor of the celebrated halfway tavern at Kissing Point on the Parramatta River ‘took pleasure in quoting’ the epitaph in Parramatta churchyard of one of Squire’s patrons: 257 The ADB’s Story Ye who wish to lie here, Drink Squire’s beer!9 And Joseph Lycett, the forger, ex-convict and artist, wrote: And Joseph Lycett, the forger, ex-convict and artist, wrote: He was universally … respected and beloved for his amiable and useful qualities as a member of society, and more especially as the friend and protector of the lower class of settlers. 9 P. Cunningham, Two Years in New South Wales: Comprising Sketches of the Actual State of Society in that Colony, of its Peculiar Advantages to Emigrants, of its Topography, Natural History, & c., vol. 1 (London: Henry Colburn, 1827), pp. 91–2. Writing ADB entries I will not go into details here, but it turned out that Kempt could only have been completed using sources in London, and my account fairly well illustrates some of the difficulties in tracking down minor characters. Among the entries on manufacturers, merchants and businessmen I wrote for the first 16 volumes of the ADB were many on people who were household names over much of Australia, including Bushell, Farmer, Fowler, Foy, Hudson, Lysaght, Penfold, Peters, Playfair, Resch, Sands, Soul, Taubman, Toohey, Tooth, Vicars, Wormald and Wunderlicht. My research interests in Australian history widened when I began to teach a course on the history of science and technology in Australia. This led to invitations to write articles on natural scientists, inventors and people connected with agriculture and the pastoral industry. Sportsmen and women, especially swimmers and cricketers, have been another of my interests. 12 George Freeman, George Freeman: An Autobiography (Miranda, NSW: G. Freeman, 1988). Writing ADB entries Had he been less liberal, he might have died more wealthy; but his assistance always accompanied his advice to the poor and unfortunate, and his name will long be pronounced with veneration by the grateful objects of his liberality.10 Such a tribute had to be used as it was all I could find. It was sometimes easier to add colour to an entry if the subject was a politician. You could gauge from what they said as reported in parliamentary debates or Hansard something about their character and political stance: whether, for example, they were liberal or conservative, free trade or protectionist. In the days before modern political parties the test was what they said and how they voted on such key questions as electoral reform, industrial relations and the payment of Members of Parliament, but sometimes a search through parliamentary debates revealed nothing that could be used. Indeed, some politicians never spoke or asked a question in their whole parliamentary career. I remember the case of one pastoralist who uttered only 81 words in 12 years— all on the one day. Not surprisingly, he asked what the government was doing about the rabbit problem! Writing a 500-word entry on a minor figure is very often more difficult and time-consuming than preparing an article on a fully rounded, more important, ‘three-dimensional’ character. Usually, with the more important people, where sources abound, the problem is one of interpretation, condensation and deciding what details to omit. For the ‘one and two-dimensional’ figures the problem is finding enough material to build up a meaningful sketch of a person’s life and work. In London I once kept a record of my research work and published an account of how I put together a 500-word article.11 All I had to start with were 17 words: ‘John Francis Kempt, soldier, administrator of the government of New 258 8. From the First Fleet to ‘Underbelly’: Writing for the ADB South Wales, 22 January – 22 March 1861’. No dates of birth or death. I will not go into details here, but it turned out that Kempt could only have been completed using sources in London, and my account fairly well illustrates some of the difficulties in tracking down minor characters. South Wales, 22 January – 22 March 1861’. No dates of birth or death. Conclusion Forty-odd years after writing about James Squire, convict and First Fleeter, I was asked to write about another convict, George David Freeman (1935–90), ‘criminal, gambler and racing commission agent’, who appears in Volume 17. His story, along with others, was featured in 2009 in the first instalment of the popular and controversial television series ‘Underbelly, a Tale of Two Cities’, which dealt with organised crime in Sydney and Melbourne in the 1970s and 1980s. Freeman was one of the most talked about alleged leaders of organised crime in New South Wales during a time of corrupt police and politicians. Accused of murder, assault, fixing horseraces, running illegal casinos and consorting with American crime figures, he was named in Parliament and royal commissions into organised crime, but his only convictions in the last 20 years of his life were two fines for illegal betting operations. According to one of his friends, the only thing he was never blamed for was the Newcastle earthquake. A colourful character, described by police as ‘hard, smart and charming’, Freeman had a degree of social acceptability despite his reputation. In 1988 he took the unusual step of publishing his autobiography in which he relates frankly and movingly his drift into juvenile crime, but is somewhat less satisfying on his later life.12 The worlds of the ex-convicts Squire and Freeman, born 180 years apart, were vastly different; nevertheless their stories are representative, part of the Australian experience, and so rightly have their place in the ADB. 259 The ADB’s Story Writing for the ADB has helped me to realise how much I did not know about Australia, and recognising how much you do not know is an essential part of any education. From the professional point of view as a university teacher of Australian history, it has been a preparation and enrichment that could not have been bettered. The ADB is the great repository of the Australian identity. The value of accessible, definitive biographies of the major figures in our history needs hardly be stressed, but they are only part of the picture. The lesser known, often only ‘one or two-dimensional’ figures also have their place, and because they are included we have a fuller, truer picture of Australia’s past. In most histories the common persons’ achievements, while omnipresent and undisputable, are muted and obscured in a collective anonymity. 13 The gold-seeker was H. B. Lasseter, the outlaw was Jimmy Governor and ‘The Flying Pieman’ was William Francis King. F. Y. Wolseley was the inventor of the shearing machine, and the most famous Anzac of all is John Simpson Kirkpatrick, ‘The Man with the Donkey’. Conclusion The ADB represents that essential corrective in Australian historiography. While I have written about the lives of important figures who could be the subjects of full biographies—and some have been—I have concentrated mainly on the lesser known, knockabout and shadowy minor characters. I have been pleased to suggest and to write the biographies of a swagman, a rabbiter, a shearer, a whip-maker, horse-breakers, sheep-classers, sheepdog breeders, a rugby union coach, a singer, a gold-seeker, an outlaw, ‘The Flying Pieman’, the inventor of the shearing machine, Australian VC winners, and the most famous Anzac of all!13 It has been a fascinating and most interesting experience. I have enjoyed the journey immensely. Dr Gerry Walsh is preparing for publication the third volume of his series beginning with The Bush and the Never Never (2004), dealing with significant but neglected aspects of Australian rural history and technology. 260 8. From the First Fleet to ‘Underbelly’: Writing for the ADB Source: Citation for ADB Medal for Gerry Walsh (11 October 2002), NCB/ADB files. Gerry Walsh (b. 1934) Gerry Walsh is the ADB’s most prolific author, having written, up to 2013, 195 entries (and a chapter for this book). A former cricket coach, administrator and umpire, he has been fittingly described as the ‘Don Bradman’ of the ADB. He is a graduate of the University of Sydney (BA, 1956; DipEd, 1957; MA, 1960) and ANU (MA, 1970), and was a lecturer/senior lecturer in history (1966–2001) in turn at the Royal Military College of Australia (Duntroon), the Faculty of Military Studies, University of New South Wales at Duntroon, and, from 1986, at the Australian Defence Force Academy, University College, UNSW, Canberra. He has been associated with the ADB for more than 50 years, first as a research assistant for six months in 1964, then as a member of the NSW Working Party for 20 years—his knowledge of manufacturing in nineteenth-century Sydney was very much appreciated—and as an author. His books, which reflect his work for the ADB, include Pioneering Days: People and Innovations in Australia’s Rural Past (1993), Australia: History and Historians (1997), The Bush and the Never Never (2004), Born of the Sun: Seven Young Australian Lives (2005) and On the Wallaby (2005). He also introduced and taught a course at ADFA on the history of science and technology in Australia. Source: Citation for ADB Medal for Gerry Walsh (11 October 2002), NCB/ADB files. 261 The ADB’s Story Gerry Walsh, 2009 Photographer: Peter Fitzpatrick, ADB archives The ADB’s Story Gerry Walsh, 2009 Photographer: Peter Fitzpatrick, ADB archives Photographer: Peter Fitzpatrick, ADB archives 262 8. From the First Fleet to ‘Underbelly’: Writing for the ADB Ann Hone (b. 1939) Ann Hone, after graduating from the University of Melbourne (BA Hons, 1961), undertook graduate study at Monash University (MA, 1965) with Geoffrey Serle as her supervisor. In 1975 the University of Oxford awarded her a DPhil for a thesis on London radicalism, 1796–1821, which was later published by Oxford University Press as For the Cause of Truth: Radicalism in London, 1796–1821 (1982). From 1973 to 1996, she lectured in the faculty of education, University of Canberra, and from 1996 to 1999 she was dean of students at Ormond College, University of Melbourne. Hone’s association with the ADB began with a 10-month stint (including three months in Canberra) as a research assistant in 1965. During the next few years she wrote 65 entries, all 500-worders. Later she reconnected with the ADB: as a member of the Commonwealth Working Party, she particularly enjoyed her special brief to search the Commonwealth Scientific and Industrial Research Organisation (CSIRO) records for possible subjects. Interestingly, both her father, Sir Brian Hone, and her grandfather, Frank Sandland Hone, have entries in the ADB. Source: Ann Hone to the ADB (31 July 2012), NCB/ADB files. Source: Ann Hone to the ADB (31 July 2012), NCB/ADB files. 263 Source: Ann Hone to the ADB (31 July 2012), NCB/ADB files. Ann Hone, n.d. By courtesy of Ann Hone Ann Hone, n.d. Ann Hone, n.d. By courtesy of Ann Hone By courtesy of Ann Hone By courtesy of Ann Hone 263 The ADB’s Story Source: Brian Fletcher, ‘Dr Ken Cable AM, 1929–2003: A Memoir’, Journal of the Royal Australian Historical Society, 89, no. 2 (December 2003), pp. 103–6. Ken Cable (1929–2003) Ken Cable’s work for the ADB spanned its first 50 years, from 1960 when he was selected as a provisional section editor. He was drawn into the ADB at the outset because of his expertise in the history of church and state, his professional standing, and his enthusiasm for biography. He had graduated with first-class honours and the university medal in history from the University of Sydney (BA, 1949; MA, 1954) and had travelled to Britain, where he took a degree at King’s College, Cambridge (BA, 1954). Appointed first as a history lecturer at the University of New South Wales, he transferred to the University of Sydney in 1958. He served as head of department (1986–89) before retiring in 1989. Cable, who joined the NSW Working Party in mid 1962, was a member during the preparation of Volumes 1–13. He was on the National Committee for Volumes 6–9, on the Editorial Board for Volumes 6–12, and was NSW section editor for Volumes 7–12. His wide-ranging interests were very useful to the working party: he spoke authoritatively on national, state, church and university politics, education at all levels, the arts, the legal profession, architecture, railways and cricket. Fellow members remember him for his geniality and wit. He wrote 74 ADB entries on bishops, clergy and prominent laymen of the Church of England, on significant figures of the University of Sydney (Professors John Woolley and Mungo MacCallum) and on cricketers such as Stan McCabe. ADB staff appreciated his readiness to provide elusive ordination dates and other details from his meticulously kept card index of Anglican clergy, which he prepared with his wife, Leonie; the Cable Clerical Index is now online. 264 8. From the First Fleet to ‘Underbelly’: Writing for the ADB Ken Cable, 1985 University of Sydney Archives, G77_1_1069 Ken Cable, 1985 Ken Cable, 1985 University of Sydney Archives, G77_1_1069 University of Sydney Archives, G77_1_1069 265 The ADB’s Story Martha Campbell (b. 1936) and Suzanne Edgar (b. 1939) Between them, Martha Campbell and Suzanne Edgar worked for the ADB for nearly 65 years—Campbell from 1967 to 2002 and Edgar from 1969 to 1998. Their working lives spanned many of the changes that have occurred at the ADB. Campbell, a graduate of the University of Sydney (BA, 1959) and ANU (MA, 1966), observed that her job had evolved ‘like Topsy’. Under Douglas Pike, she wrote entries; under later general editors, she ‘subedited and checked’. When the editing was delegated under Nairn and Serle, she took charge of the NSW desk, the largest of the State desks. As the 1986 review noted, ‘editing’ is a modest term for procedures that at times prompt considerable new research and in all cases involve careful checking back to original source materials. Described as the ‘doyen of research editors’, Campbell mentored a succession of new staff members. She remained at the NSW desk until her retirement. Under the name Martha Rutledge, she wrote a total of 172 entries. Edgar was a graduate of the University of Adelaide (BA Hons, 1962), where she was a student of Pike’s. Like Campbell, she started at the ADB as a ‘traditional fact-finding research assistant’ until taking on the SA desk and also, at various times, some of the smaller State desks. She has written 53 entries. She resigned in 1998 and is now well known in Canberra as a full-time writer and poet. Sources: ‘Editorial Staff—The Research Assistants—At the ADB. To be Presented to the Committee of Review, February 1985’, signed by Suzanne Edgar, Helga Griffin, Dr Di Langmore, Merrilyn Lincoln and Dr Margaret Steven, box 125, Q31, ADBA, ANUA. Suzanne Edgar, interviewed by Niki Francis and Melanie Nolan (22 June 2012), NCB/ADB files. 266 8. From the First Fleet to ‘Underbelly’: Writing for the ADB 8. From the First Fleet to ‘Underbelly’: Writing for the ADB Martha Campbell, 1985 Martha Campbell, 1985 By courtesy of Sue Edgar Martha Campbell, 1985 By courtesy of Sue Edgar By courtesy of Sue Edgar 267 The ADB’s Story Sue Edgar, 2009 Photographer: Peter Fitzpatrick, ADB archives The ADB’s Story The ADB’s Story Sue Edgar, 2009 Sue Edgar, 2009 Photographer: Peter Fitzpatrick, ADB archives Photographer: Peter Fitzpatrick, ADB archives 268 8. From the First Fleet to ‘Underbelly’: Writing for the ADB The poem is reprinted from Quadrant, 55, no. 11 (November 2011). It was also selected by Les Murray (ed.) for inclusion in his best of the crop from the past 10 years: The Quadrant Book of Poetry (Quadrant, 2012). A King’s Remains by Suzanne Edgar Sue wrote the ADB entry on Albert Augustine Edwards, (1888-1963), hotelier, philanthropist and politician and later wrote this poem about him. Every little while, In tracking past obsessions, I sift through dusty files and find in my possession a story in the archive of characters long dead; like bees in summer hives, they once flew round my head. It’s how I read today of Bert, a Labor ‘pollie’ who honed his willful ways to the point of shameless folly. Though the newspaper has yellowed and its print is not as black this maverick hasn’t mellowed, his ploys come rushing back. As King of the wild West End he fiddled ballot books, said rules were made to bend and went to bed with crooks. He made a heap of dough and ran a shelter for the poor while never slow to show the rent-boys through his door. When the King came to die he had himself embalmed: you have to wonder why there was no one to be charmed. 269 The ADB’s Story The subtle old knave was in a copper-lined box when lowered to his grave— one lad threw down some rocks Last year they disinterred him to take samples of his tissues the need was dark and grim to settle several issues, like who was this man’s father, the premier or a pimp? Bert claimed it was the former though his case is looking limp. like who was this man’s father, the premier or a pimp? Bert claimed it was the former though his case is looking limp. Members of the press and historians gathered round the controversial mess In the grave-site’s opened ground. That’s why I love my files— old stories will revive and villains with their wiles rise up and come alive. The poem is reprinted from Quadrant, 55, no. 11 (November 2011). It was also selected by Les Murray (ed.) for inclusion in his best of the crop from the past 10 years: The Quadrant Book of Poetry (Quadrant, 2012). 270 8. From the First Fleet to ‘Underbelly’: Writing for the ADB y ( ) pp 16 Gwenda M. Webb and Peter G. Webb, ‘Skemp, John Rowland (1900–1966)’, ADB, vol. 16, pp. 253–4. p ( ) pp 18 L. L. Robson, ‘Brady (Bready), Matthew (1799–1826)’, ADB, vol. 1, pp. 147–8. p ( ) pp 17 G. T. Stilwell, ‘Archer, Joseph (1795–1853)’, ADB, vol. 1, pp. 24–5. g y ( g) ( ) p 15 John Reynolds, ‘West, John (1809–1873)’, ADB, vol. 2, pp. 590–92. 14 Bede Nairn, ‘Pike, Douglas Henry (Doug) (1908–1974)’, ADB, vol. 16, pp. 1–2. The ADB—My Best Friend P. A. Selth Earlier this year I casually remarked to an ADB staff member that the Australian Dictionary of Biography was ‘my best friend’, and in various ways had been part of my life for longer than I cared to remember. I was promptly asked to put this in writing. My father, Don, had a history degree from the University of Adelaide. There were four students in his honours year; one of them was Douglas Pike. In 1959 our family moved from Adelaide to Launceston when Dad became headmaster of the Launceston Church of England Grammar School. Dad wanted to increase the amount of attention given in the school curriculum to Australian history, in particular the history of Tasmania. The main problem was the curriculum set by external examination bodies. He set about having it changed. He had an ally: Doug Pike was appointed to the chair of history at the University of Tasmania in 1960, and became foundation general editor of the ADB on 31 January 1962.14 There were then few books about Tasmania’s history. Dad had a copy of John West’s The History of Tasmania (1852), and he arranged for a copy of the Libraries Board of South Australia’s 1966 facsimile edition to be placed in the school library.15 (Multiple copies of A. G. L. Shaw’s wonderful 1971 edition were also to be added to the library’s growing collection of books on Australian history.) Dad taught a Tasmanian history class. Our textbook was J. R. Skemp’s dark-green, limp-cloth-covered Tasmania Yesterday and Today, published in 1958.16 It was all fairly rudimentary; there was not much readily available for the teaching of secondary school students (or anyone else), despite our teacher’s passion for the subject. Things changed in 1966. Volume 1 (1788–1850, A–H) of the ADB appeared in the shops. Dad soon brought home the beautifully produced red-cover, cream-dust jacket volume—and we discussed who got to read it first. I lost, but we jointly looked for entries of men and women who had a connection with Tasmania (and South Australia). The ADB—My Best Friend I remember our finding the entry for Joseph Archer, the Tasmanian landowner, some of whose descendants were at the school.17 And there was the bushranger Matthew Brady, whose alleged hide-out near Launceston we had been shown on a school excursion.18 271 The ADB’s Story The ADB’s Story Philip Selth with his beloved editions of the ADB, 2012 By courtesy of Philip Selth Philip Selth with his beloved editions of the ADB, 2012 Philip Selth with his beloved editions of the ADB, 2012 272 8. From the First Fleet to ‘Underbelly’: Writing for the ADB The advent of the ADB did not help me in my study of history at school, for by now I was required to learn about the kings and queens of England, but I had the ADB at home and read it avidly. In the end Dad gave up, and bought me my own copy of Volume 1 (and Volume 2 in 1967). The advent of the ADB did not help me in my study of history at school, for by now I was required to learn about the kings and queens of England, but I had the ADB at home and read it avidly. In the end Dad gave up, and bought me my own copy of Volume 1 (and Volume 2 in 1967). I went to the ANU in 1968 to study Australian history and political science. A few years earlier Dad had given me a copy of Fin Crisp’s Ben Chifley: A Biography (1961)19 and Manning Clark’s A History of Australia. Volume 1: From the Earliest Times to the Age of Macquarie (1962). Now I had access to wonderful libraries on the campus and across the lake where the National Library of Australia was opened later that year. Like many students then, I had a Commonwealth Scholarship—and little money. But I was at the Co-Op Bookshop on the day Volume 3 of the ADB was available—and I bought Dad a copy. I was to give Dad a copy of each volume as it came out. He was reading the Supplement 1580–1980, published in 2005, when he became too ill to continue to read. His set of the ADB went to a grateful grandson. 19 Scott Bennett, ‘Crisp, Leslie Finlay (1917–1984)’, ADB, vol. 17, pp. 269–70. 20 Suzanne Edgar and Martha Campbell, ‘Phillips, Nan (1911–1984)’, Obituaries Australia, National Centre of Biography, The Australian National University, Canberra, <http://oa.anu.edu.au/obituary/phillips- nan-814/text815> (accessed 26 June 2012) (f.p. ANU Reporter [May 1984], p. 6). 21 George Temperly, ‘Patience (Pat) Australie Wardle, nee Tillyard (20 June 1910 – 22 April 1992): ‘A Lover of Nature, a Ministering Angel and a Friend to All’, Canberra Historical Journal, [NS] no. 30 (1992), pp. 5–7. 22 P. A. Selth, ‘Donald Ian McDonald 1923–1990: “A scholar and a gentleman”: A Memoir’, Canberra Historical Journal, [NS] no. 27 (1991), pp. 12–20. 19 Scott Bennett, ‘Crisp, Leslie Finlay (1917–1984)’, ADB, vol. 17, pp. 269–70. The ADB—My Best Friend The ANU’s history and political science departments at that time were filled with lecturers such as Manning Clark, Don Baker, Eric Fry, Barbara Penny, Dorothy Shineberg and Fin Crisp, who inspired their students and made frequent references to the ADB. Not surprisingly, most had written entries for the dictionary. John Ritchie, whom I still remember giving a wonderful oration in the Tank lecture theatre on Governor Macquarie, his black academic gown astray, was to become general editor of the ADB in 1988. We lived near each other, and on occasion met at the Belconnen Trash and Treasure Market where, among other matters, we would talk about the forthcoming volume of the ADB or the book on which he was working, The Wentworths: Father and Son (1997). John would invariably have to counsel me to wait patiently for the next volume—it would not be published until he was satisfied it was in the best possible form. While at the ANU I joined the Canberra and District Historical Society and met three of the ADB’s greatest supporters: Nan Phillips,20 Pat Wardle21 and Don McDonald.22 Nan was the society’s long-serving secretary, Pat the editor of its Newsletter, while Don edited its Journal. Nan was personal assistant to the ADB’s general editor; Pat had assisted in the early work of the Biographical Register, the forerunner to the ADB; all three were contributors. All three deserve entries 273 The ADB’s Story in the ADB; both of Pat’s parents, and her husband, are already there.23 I also remember, with fondness, Jim Gibbney, both in his room in the ADB offices, squinting over his collection of file cards of biographical references, which so many of us regarded as an Aladdin’s cave of delights, and at his kitchen table with a glass of whisky, arguing over my suggestions for his PhD thesis that was to be published as one of a three-volume history of the Australian Capital Territory.24 Jim also deserves an entry in the ADB or, as he used to call it, ‘the Dic’. Don McDonald was succeeded as the Journal’s editor in December 1971 by John Iremonger; I became editor in March 1976. From 1990 to 1993, John was the ADB’s publisher at Melbourne University Press. I remember discussing with him what I thought to be a dreadful decision—the replacing of the lovely cream dust jacket with the current glary blue jacket. 23 K. R. Norris and D. F. Waterhouse, ‘Tillyard, Robin John (1881–1937)’, ADB, vol. 12, pp. 232–3. Patricia Clark, ‘Tillyard, Pattie (1880–1971)’, ADB, vol. 12, p. 232. Barbara Dawson, ‘Wardle, Robert Norman (1895–1979)’, ADB, vol. 16, p. 491. An entry for ‘Wardle, Patience Australie (Pat), née Tillyard (1910–1992), Community Member/Worker’, is scheduled for publication in the 1991–95 volume. 24 Jim’s cards formed the basis of H. J. Gibbney and Ann G. Smith (eds), A Biographical Register 1788–1939: Notes from the Name Index of the Australian Dictionary of Biography (Canberra: Australian Dictionary of Biography, 1987). H. J. Gibbney, Canberra 1913–1953 (Canberra: Australian Government Publishing Service, 1988). Obituaries for Jim include Chris Cunneen, ‘Obituary Jim Gibbney’, The Canberra Times (26 August 1989), p. 6; ‘Obituary, Dr H. J. Gibbney, 1922–1989’, Historical Records of the Australian Capital Territory (Canberra: Canberra District Historical Society, 1990), pp. 4–5. See also, posthumously, ‘Launching of Jim Gibbney’s Historical Records of the Australian Capital Territory. A Guide’, Canberra Historical Journal, [NS] no. 27 (1991), pp. 48–9. 25 P. A. Selth, ‘Pottinger, Sir Frederick William (1831–1865)’, ADB, vol. 5, pp. 451–2; ‘Piper, Harold Bayard (1894–1953)’, ADB, vol. 16, p. 6; ‘Miller, Eric Stanislaus Joseph (1903–1986)’, ADB, vol. 18, p. 161. ‘Kevin Ross Murray (1931–1991), barrister and army officer’, ‘Daniel Leahy (1912–1991), explorer and pioneer’ and ‘W. J. Read (1904–1992), Coastwatcher and government officer’ are scheduled for publication in the volume covering the period 1991–95. 26 As happened with so many other contributors, I was encouraged by Don McDonald and Nan Phillips to expand my entry on Sir Frederick William Pottinger into an article: ‘“A splendid type of the genuine English gentleman”: Sir Frederick William Pottinger, Bart. (1831–1865)’, Canberra Historical Journal (March 1974), pp. 20–53. 25 P. A. Selth, ‘Pottinger, Sir Frederick William (1831–1865)’, ADB, vol. 5, pp. 451–2; ‘Piper, Harold Bayard (1894–1953)’, ADB, vol. 16, p. 6; ‘Miller, Eric Stanislaus Joseph (1903–1986)’, ADB, vol. 18, p. 161. ‘Kevin Ross Murray (1931–1991), barrister and army officer’, ‘Daniel Leahy (1912–1991), explorer and pioneer’ and ‘W. J. Read (1904–1992), Coastwatcher and government officer’ are scheduled for publication in the volume covering the period 1991–95. 26 As happened with so many other contributors, I was encouraged by Don McDonald and Nan Phillips to expand my entry on Sir Frederick William Pottinger into an article: ‘“A splendid type of the genuine English gentleman”: Sir Frederick William Pottinger, Bart. (1831–1865)’, Canberra Historical Journal (March 1974), pp. 20–53. 23 K. R. Norris and D. F. Waterhouse, ‘Tillyard, Robin John (1881–1937)’, ADB, vol. 12, pp. 232–3. Patricia Clark, ‘Tillyard, Pattie (1880–1971)’, ADB, vol. 12, p. 232. Barbara Dawson, ‘Wardle, Robert Norman (1895–1979)’, ADB, vol. 16, p. 491. An entry for ‘Wardle, Patience Australie (Pat), née Tillyard (1910–1992), Community Member/Worker’, is scheduled for publication in the 1991–95 volume. 24 Jim’s cards formed the basis of H. J. Gibbney and Ann G. Smith (eds), A Biographical Register 1788–1939: Notes from the Name Index of the Australian Dictionary of Biography (Canberra: Australian Dictionary of Biography, 1987). H. J. Gibbney, Canberra 1913–1953 (Canberra: Australian Government Publishing Service, 1988). Obituaries for Jim include Chris Cunneen, ‘Obituary Jim Gibbney’, The Canberra Times (26 August 1989), p. 6; ‘Obituary, Dr H. J. Gibbney, 1922–1989’, Historical Records of the Australian Capital Territory (Canberra: Canberra District Historical Society, 1990), pp. 4–5. See also, posthumously, ‘Launching of Jim Gibbney’s Historical Records of the Australian Capital Territory. A Guide’, Canberra Historical Journal, [NS] no. 27 (1991), pp. 48–9. 25 P. A. Selth, ‘Pottinger, Sir Frederick William (1831–1865)’, ADB, vol. 5, pp. 451–2; ‘Piper, Harold Bayard (1894–1953)’, ADB, vol. 16, p. 6; ‘Miller, Eric Stanislaus Joseph (1903–1986)’, ADB, vol. 18, p. 161. ‘Kevin cove g t e pe od 99 95. 26 As happened with so many other contributors, I was encouraged by Don McDonald and Nan Phillips to expand my entry on Sir Frederick William Pottinger into an article: ‘“A splendid type of the genuine English gentleman”: Sir Frederick William Pottinger, Bart. (1831–1865)’, Canberra Historical Journal (March 1974), pp. 20–53. 23 K. R. Norris and D. F. Waterhouse, ‘Tillyard, Robin John (1881–1937)’, ADB, vol. 12, pp. 232–3. Patricia Clark, ‘Tillyard, Pattie (1880–1971)’, ADB, vol. 12, p. 232. Barbara Dawson, ‘Wardle, Robert Norman (1895–1979)’, ADB, vol. 16, p. 491. An entry for ‘Wardle, Patience Australie (Pat), née Tillyard (1910–1992), Community Member/Worker’, is scheduled for publication in the 1991–95 volume. The ADB—My Best Friend ‘Comrade’, he said, ‘it gets the customer’s eye’. He wanted to introduce the ADB to a wider readership; I just wanted to read it. He gave me a full set of the blue jackets and instructed me to put them on my volumes of the ADB; I did—over the cream jacket. I have three entries in the ADB, and am trying to draft three more.25 I cannot remember who asked me to draft the first two (probably John Ritchie). Chris Cunneen asked me to write the next two. I volunteered myself for the two that will follow. The entry on the barrister Eric Miller inspired me to begin work on two full-length biographies, of Eric Miller QC and of his cousin John Joseph Murphy (1914–97), New Guinea patrol officer, Coastwatcher, POW and PNG district officer. The ADB has been the genesis of literally hundreds of articles and books, and is cited in any scholarly work on Australian history.26 It has also been the ‘cause’ of many of its readers, not least me, spending more than we perhaps should to purchase books cited in entries or written by contributors. 274 8. From the First Fleet to ‘Underbelly’: Writing for the ADB I returned to the ANU in January 1992 as pro vice-chancellor (planning and administration). It was not long before I was wandering lost about the Coombs Building looking for the ADB offices. (I had been there dozens of times, but the catacombs-like Coombs Building is not exactly visitor-friendly.) I was greeted like a long-lost friend (as I would like to be regarded) of the ADB—and promptly asked if I could help solve a problem. It was thought I may have some influence. The request was reasonable and the ADB did indeed have a friend in the Chancellery Building. More importantly, it had many across the campus, throughout Australia, and abroad. I returned to the ANU in January 1992 as pro vice-chancellor (planning and administration). It was not long before I was wandering lost about the Coombs Building looking for the ADB offices. (I had been there dozens of times, but the catacombs-like Coombs Building is not exactly visitor-friendly.) I was greeted like a long-lost friend (as I would like to be regarded) of the ADB—and promptly asked if I could help solve a problem. It was thought I may have some influence. The ADB—My Best Friend The request was reasonable and the ADB did indeed have a friend in the Chancellery Building. More importantly, it had many across the campus, throughout Australia, and abroad. As I try to write the two biographies for which I ‘blame’ (thank) the ADB, I refer daily to the ADB online; but only to find the references—I then prefer to sit in a chair in a quiet place reading the bound volume. My son, however, probably has not picked up a bound volume. Like many of his generation, he reads the ADB on a hand-held device. But that does not matter. What matters is the existence of the ADB and the scholarship, and pleasure, it has brought so many people. I am glad that the ADB is my best friend. Philip Selth OAM is executive director of the New South Wales Bar Association. His ADB entry on the Sydney silk Eric Miller QC (1903-86) has led him to work on two full length biographies, one on Miller and the other on his cousin, John Joseph Murphy (1914-97), a coastwatcher charged with treachery after being released from a Japanese prison camp. Philip is also writing the ADB entry on Murphy. 275 1 Jill Roe, personal files. See also ‘GS to KI [Geoff Serle to Ken Inglis], ‘Membership of the Editorial Board’ (26 May 1984), box 132, Q31, ADBA, ANUA. Board members had been circularised to propose ‘(1) contemporary historians/political scientists; (ii) women (iii) re Cunneen ex officio; (iv) non-academics’. 2 Jill Roe, personal files. 9. National Collaboration: The ADB Editorial Board and the Working Parties Jill Roe On 6 February 1985, Geoffrey Serle wrote to me inquiring if I would be willing to join the Editorial Board of the Australian Dictionary of Biography. At that stage I had contributed no more than half a dozen entries to the ADB, though, like most contributors, I was familiar with its work and aspirations. Naturally, I hastened to say I would be happy to accept.1 ADB Editorial Board, 2011. Left to right: Darryl Bennet, Chris Cunneen, John Lack, Paul Pickering, Pat Buckridge, Stephen Garton, Jill Roe, Nick Brown, Tom Griffiths (chair), Michael Roe, Melanie Nolan, Geoffrey Bolton, Peter Howell, David Dunstan, David Horner ADB Editorial Board, 2011. Left to right: Darryl Bennet, Chris Cunneen, John Lack, Paul Pickering, Pat Buckridge, Stephen Garton, Jill Roe, Nick Brown, Tom Griffiths (chair), Michael Roe, Melanie Nolan, Geoffrey Bolton, Peter Howell, David Dunstan, David Horner Photographer: Max Korolev, ADB archives A month or so later, a formal letter arrived from Alan Barnard, acting chair of the Editorial Board, informing me that the vice-chancellor of the ANU, Peter Karmel, had confirmed my appointment to the Editorial Board. On the same day came a notice of the board’s next meeting, to be held at the ANU on Thursday, 25 May; soon after, I received an agenda paper.2 So it was really happening. You might even say it was a turning point in my life. As historians are well aware, turning points have wide ramifications. So it was with my appointment to the Editorial Board. Apart from anything else, I was not the only new appointment. The others were Don Aitkin, a political scientist, and the historian Ann Curthoys, all of us working mainly on twentieth-century 277 The ADB’s Story history. General editor Serle’s note to me had made that dimension clear: ‘We are in the process of enlarging the Board in order to meet a need for younger members, more women members, and people with twentieth-century interests’. history. General editor Serle’s note to me had made that dimension clear: ‘We are in the process of enlarging the Board in order to meet a need for younger members, more women members, and people with twentieth-century interests’. Serle’s phrase ‘enlarging the Board’ encapsulated an even more significant aspect of the change. With the volumes of nineteenth-century lives (Volumes 1–6) long since completed, three of the projected six volumes on the period 1891–1939 already published and a fourth in press (Volume 10 appeared in 1986), work for the remaining two volumes of early twentieth-century lives was well under way. The possibility—and the challenge—of volumes encompassing the later twentieth century beckoned. There had been considerable discussion at the outset as to when the series should conclude. A meeting at the ANU in October 1959 had left the matter up in the air, suggesting 1920 or 1930. When Volume 1 appeared, a very spare preface announced that there would be 12 volumes and that the series would probably conclude with those who had flourished in 1938. By 1973, when Volume 5 appeared, the ADB was committed to 1939 as the concluding date for its third section, but no overall terminating date was given, nor does it ever seem to have been thereafter. 3 Minutes, Conference of National Advisory Panel and ADB Editorial Board (23–24 April 1960), box 64, Q31, ADBA, ANUA. I thank Christine Fernon for assistance in accessing early ADB records. Photographer: Max Korolev, ADB archives From left, clockwise: Brian Wimborne, Barbara Dawson, Peter Howell, Gail Clements, Michael Roe, John Lack, Ben Evans, Rick van Haeften, Anthea Bundock, John Nethercote, Karen Ciuffetelli, Christine Fernon, Tom Griffiths, Kent Fitch, Ross Coleman, Basil Dewhurst, Chris Cunneen, Geoffrey Bolton, Jim Davidson, David Dunstan, Janet Doust, Darryl Bennet, Nick Brown, Melanie Nolan ADB staff, Editorial Board members and a few invited guests attended a workshop on the future of the ADB in December 2009. From left, clockwise: Brian Wimborne, Barbara Dawson, Peter Howell, Gail Clements, Michael Roe, John Lack, Ben Evans, Rick van Haeften, Anthea Bundock, John Nethercote, Karen Ciuffetelli, Christine Fernon, Tom Griffiths, Kent Fitch, Ross Coleman, Basil Dewhurst, Chris Cunneen, Geoffrey Bolton, Jim Davidson, David Dunstan, Janet Doust, Darryl Bennet, Nick Brown, Melanie Nolan Photographer: Max Korolev, ADB archives The initial uncertainty is understandable, and the early proposals to end prior to the onset of World War II made sense in the late 1950s when the ADB began; but by the early 1980s the project had been so successful that no-one thought it should stop there. Likewise, by the mid 1980s, it was apparent that a new general editor would have to be appointed soon. Of the two men who had served the ADB so well in that role since the untimely death of Douglas Pike in 1974, Bede Nairn had retired in 1984 owing to ill health and the retirement of Geoffrey Serle was imminent in 1987.3 In his 1985 note to me, Serle summed up the overall situation with characteristic precision. The Editorial Board might need to meet more frequently than in times past, he wrote, ‘in view of the need to appoint a new General Editor and of moving into the post-1940 period’. Structural change is seldom speedy or drastic in academe. Certainly a modest generational shift was under way, and given that the new appointees were all from New South Wales or the Australian Capital Territory, a new dynamic was implicit in the enlargement of the Editorial Board. On the other hand, there were significant continuities. The ANU, in particular, was always well represented on the board, as was only right and proper, given that the history discipline had a continuing role and the Research School of Social Sciences (RSSS) provided all the funding. 278 9. National Collaboration: The ADB Editorial Board and the Working Parties ADB staff, Editorial Board members and a few invited guests attended a workshop on the future of the ADB in December 2009. From left, clockwise: Brian Wimborne, Barbara Dawson, Peter Howell, Gail Clements, Michael Roe, John Lack, Ben Evans, Rick van Haeften, Anthea Bundock, John Nethercote, Karen Ciuffetelli, Christine Fernon, Tom Griffiths, Kent Fitch, Ross Coleman, Basil Dewhurst, Chris Cunneen, Geoffrey Bolton, Jim Davidson, David Dunstan, Janet Doust, Darryl Bennet, Nick Brown, Melanie Nolan ADB staff, Editorial Board members and a few invited guests attended a workshop on the future of the ADB in December 2009. Photographer: Darren Boyd, ADB archives History, as we know from writings about Sir Keith Hancock, was about ‘chaps’. Evidently, it was taken for granted at the outset that historical biography in Australia was to be sustained by ‘chaps’. Not until 1977, almost two decades after the project began, did the situation change, and even then not by much. Apart from Canberra-based Ann Mozley (later Moyal), an ex-officio member of the first Editorial Board, Heather Radi was the only female appointment to the inner counsels of the ADB until 1985. Radi had been a member of the NSW Working Party since the early 1970s, and by 1977 was serving as a member of the Editorial Board and as a section co-editor. The main point here, however, is that the Editorial Board to which she first belonged was in theory rather different from the one to which she transferred in 1985, when it was restructured. I say in theory because, by the 1980s, the administrative arrangements put in place at the beginning to ensure national collaboration were not functioning very well. 279 The ADB’s Story Photographer: Darren Boyd, ADB archives 4 Minutes, National Committee and ADB Editorial Board meetings (1959–61), box 64, Q31, ADBA, ANUA. 4 Minutes, National Committee and ADB Editorial Board meetings (1959–61), box 64, Q31, ADBA, ANUA. From the beginning Getting the collaborative relationship right has been vital to the ADB’s wellbeing from the beginning. Fortunately for the ADB’s survival, its founder, Sir Keith Hancock, was always clear about that. As he well understood, creating the ADB had to be a collaborative effort, involving all the existing State-based universities. Indeed, if an authoritative product based on primary research was to eventuate, distinctively Australian circumstances meant it could be no other. Hancock was a historian of high international standing, whose leadership was unquestioned. Even so, the problem of intellectual authority and ownership of the dictionary project was not a straightforward one. At first, and for more than two decades, it was dealt with by establishing two committees to which the core staff in Canberra and the local working parties (of which more shortly) were ultimately to be responsible. The idea was that a National Advisory Committee consisting of State history professors and other senior men of the profession would meet annually, later biennially, and could also be consulted informally if need be. At the same time, a smaller, local Editorial Board was established, consisting of senior advisers from within the ANU, where it could meet regularly. It was to be responsible for the oversight of daily business and to hand if help and advice were called for.4 ADB Editorial Board, 2008. Standing: Beverley Kingston, Stephen Garton, Jill Roe, Nick Brown, Tom Griffiths (chair), Melanie Nolan, Geoffrey Bolton, David Dunstan. Seated: David Horner, Peter Howell, Pat Buckridge, John Lack ADB Editorial Board, 2008. Standing: Beverley Kingston, Stephen Garton, Jill Roe, Nick Brown, Tom Griffiths (chair), Melanie Nolan, Geoffrey Bolton, David Dunstan. Seated: David Horner, Peter Howell, Pat Buckridge, John Lack 280 9. National Collaboration: The ADB Editorial Board and the Working Parties That sounds like a sensible and trouble-free solution to the collaborative issue, especially given that the same person—that is, Sir Keith—would chair both bodies. Thereafter, with senior ANU history professors to follow him as chair, there could be no doubt about overall control. Under this arrangement, the general editor, a position created in 1962 after much tribulation (see Chapter 3) and filled full-time by Douglas Pike from 1964, would always know whom to approach in an emergency, as would the chairs of local working parties (if they were not already members of one or other of the committees). 5 Minutes, ADB Editorial Board meeting (2 May 1983), box 125, Q31, ADBA, ANUA, item 8, records that, although the requisite constitutional changes had been made at the previous meeting, ‘the national committee has not yet been invited to disband’. It is not referred to in the 1985 minutes. The 1986 review records that it was formally abolished, with the consent of its members, in 1983: Report of the Committee of Review of the Australian Dictionary of Biography, May 1986. 6 ‘ADB, Status and Operating Procedures’, ANU doc. 2623/1987, p. 2, Jill Roe, personal records. From the beginning This also applied to locally based section editors who were a bit like associate editors, appointed to help the general editor by preparing sections of the projected volumes. As the project got under way, the dynamics of national collaboration changed, or more precisely slowed. It was not long before the work of the National Advisory Committee (from 1961 the National Committee) formally ceased. There are no minutes after 1971, and Chris Cunneen, who joined the staff in 1974, cannot recall it meeting in the 1970s. Eventually, its members took a self-denying ordinance, and the committee was disbanded.5 The Editorial Board also slowed in the 1970s but survived into the 1980s, when it was restructured. Some parts of the old National Committee carried over, especially the ANU representation and some members of the previous board, including Heather Radi—as was only right since, as a section editor, she exemplified what the changes were about. Clearly there was no need for a national committee to ensure national collaboration by then, but the Editorial Board was still necessary to oversee the project. As articulated in ANU documents at this time, ‘it is responsible for the management and scholarly direction of the Dictionary project’; however, it needed to be more representative of the national effort and, to be useful, to ensure more effective interchanges between the editorial staff in Canberra and the working parties. This was recognised especially by Bede Nairn, and gradually achieved by pruning the membership of the Editorial Board and bringing the section editors onto it.6 The documents I have perused in preparing this chapter are replete with statements about the importance of national collaboration. Much less is said about the working parties, whose overall membership numbered 109 in 2007. It is pleasing to find that in the early days general editors did visit the working parties reasonably regularly; and due, apparently, to a sense that performance 281 The ADB’s Story was variable by the late 1970s, Nairn and Cunneen made a sustained effort in that regard. Indeed, it is probable that the changes of governance effected in 1985 have their origins in those visitations.7 was variable by the late 1970s, Nairn and Cunneen made a sustained effort in that regard. From the beginning Indeed, it is probable that the changes of governance effected in 1985 have their origins in those visitations.7 The working parties have been there from the beginning and, if anything, have become more important over time, due to the need for a national dictionary to stay abreast of rising levels of population throughout the country, and for the ADB, though hosted at the ANU, to appear truly ‘national’. During the past 50 years the number of working parties has hovered between seven and nine, with eight at first and nine currently. The original eight included three NSW working parties, in Newcastle and Armidale as well as Sydney, as was appropriate to the period covered by the first two volumes (1788–1850). Later there was a Pacific Working Party, which fitted the needs of the next period (1851–90); during that time also the North Queensland Subcommittee and the Armed Services Working Party appeared on the lists.8 These were functional additions: the Commonwealth Working Party, which was established in 1989 to advise on selections for the 1940–80 period, remains operational but the Indigenous Working Party, formed much later, was soon disbanded. No issue has touched more profoundly on the issue of national collaboration than the representation of Indigenous lives. Although the ADB’s demographics have been more or less correct overall—that is, Indigenous lives are represented at approximately the same proportion as in the population as a whole—this was not apparent to everyone. Indeed, during my time as chair of the Editorial Board (1996–2006), I learned of an informal threat to take the level of representation of Indigenous lives to an international tribunal. The board responded by establishing an Indigenous Working Party. This was a sound and effective response; but it proved to be a temporary solution, as Indigenous energies and skills were already spread too thin, and research into Indigenous lives has special challenges, some still to be mastered. Many remarkable Indigenous lives have, however, been documented—for example, in Volume 15, published in 2000, that of the Central Australian ‘clever man’ Mick McLean/ Irinyili. As more research is done, more will come to light and the greater is the likelihood that the representation not only is, but can be seen to be, beyond reproach.9 The difficulties encountered in establishing the Indigenous Working Party are suggestive of the working parties’ real tasks and responsibilities. These have not changed much over time. 9 A meeting to establish an Indigenous Working Party was convened in Canberra on 28 May 2005, and a precedent now exists for an Indigenous working party if possible or appropriate in the future. In 2008 Ann Curthoys was appointed as an expert national adviser on Indigenous biography. 7 Cunneen, Chapter 4, this volume. Chris Cunneen to Jill Roe (May 2010), my interpretation. p ( y 8 Data drawn from lists published in successive volumes of the ADB. From the beginning From official documentation, one might think 282 9. National Collaboration: The ADB Editorial Board and the Working Parties that the work undertaken has been merely advisory. That is true only in the most legalistic sense. Each of the working parties is responsible for selecting a specified number of significant names for inclusion in the ADB, deciding on appropriate word lengths for each entry (ranging from 500 words for a basic entry to 6000 words for prime ministers), and recommending suitably qualified authors to be invited to prepare the entries. Such a protracted process requires exceptional commitment and expertise from members of the working parties over time and, ultimately, a consensual approach, due to the quotas with which they must work. Those quotas have latterly attracted some misplaced criticism. Contrary to the criticism, which supposed that the quotas are based on occupational categories and thus open to manipulation, they are simply a matter of historical demography. They are statistically determined, on the basis of State and Territory populations at the census in the relevant period. Thus, each State working party receives an accurately enumerated proportion of the overall number of entries to be recommended for inclusion in the volume in question. (Specialist non– State-based working parties, on which more shortly, have small fixed quotas, determined by the general editor.) Quotas were introduced in the 1970s, along with many other significant methodological refinements to the ADB’s work. In this way, issues of ‘you have more than me’, which might have been a bone of contention nationwide, were effectively pre-empted.10 On average, the working parties have had about eight members. From the lists at the beginning of each printed volume, however, it will be apparent that they have varied in size, with the NSW Working Party usually the largest and, until recently, the Victorian the smallest. This may seem strange but everything depends on expertise, and in the case of Victoria, the expertise of Geoffrey Serle was unsurpassed, so that during his lifetime fewer members were needed. In Sydney, a larger membership of experts from various fields and representing at different times the universities at Armidale, Newcastle and Wollongong, has been thought necessary. At last count, there were 16 members of the NSW Working Party. 10 Paul Brunton, ‘Mysterious Quotas’, Australian Book Review (February 2006), pp. 19–20; and responses: Beverley Kingston, Australian Book Review (March 2006); Di Langmore, Australian Book Review (April 2006). 11 ‘ADB, Status and Operating Procedures’, ANU doc. 2623/1987, p. 3. From the beginning Historians from the universities, historical associations and relevant professional bodies such as the law societies, and also independent scholars, serve on working parties throughout Australia, all of them approved in some way by the ADB, and in the case of the chairs, once upon a time formally appointed by the ANU.11 Right now, the working parties seem to be in pretty good shape. To say that meetings can be stimulating would, in my experience, be an understatement. 283 The ADB’s Story Even allowing for differences of style across the working parties, they all share one unusual feature: they consist in varying proportions of representatives of the relevant academic and professional fields, from literature to the law, from music to sport, and medicine to popular culture—that is, of people in a position to assess the achievements and significance of particular individuals from the period under consideration. It is a rare thing to observe and participate in such multi-skilled and interdisciplinary intellectual work. Perhaps it should be added that the work is all in the field of historical biography—that is, all those under consideration must be dead. The present rule is for 10 years. Even allowing for differences of style across the working parties, they all share one unusual feature: they consist in varying proportions of representatives of the relevant academic and professional fields, from literature to the law, from music to sport, and medicine to popular culture—that is, of people in a position to assess the achievements and significance of particular individuals from the period under consideration. It is a rare thing to observe and participate in such multi-skilled and interdisciplinary intellectual work. Perhaps it should be added that the work is all in the field of historical biography—that is, all those under consideration must be dead. The present rule is for 10 years. Whatever the health of the working parties, the effectiveness of national collaboration depends in good part on the capacity and commitment of the chairs of the working parties and section editors. 12 Beverley Kingston, personal communication (6 June 2010). From the beginning Again, the rules are not very informative; however, a quick check of the listings at the beginning of each volume of the ADB will show that many distinguished and experienced Australian historians have served in these positions, some for many years— for example, Geoffrey Bolton (Western Australia), Michael Roe (Tasmania) and Beverley Kingston (New South Wales), whose work on the ADB began when she was a student at Monash University in the 1960s, writing entries on Queensland pastoralists. Even with some sad losses, worthy successors have come forward: Ross Johnston and then Patrick Buckridge to replace Denis Murphy in Queensland, Peter Howell to replace John Playford in South Australia, and John Lack, then David Dunstan, to replace Serle in Victoria. For the record, these days, and probably from the early days, the duty of the section editor is to read and comment on all the entries for his or her section/State as they come in, and to advise the research editor in Canberra of any additional or overlooked sources and/or obvious errors. After the Canberra research editor has checked the facts and edited it, the entry goes on to the deputy general editor and then the general editor.12 The general editor sits at the apex of the national structure. Previous chapters have outlined how these wise and learned persons have gone about their business. As a long-time contributor to the ADB, I can confirm that the final stage, when the general editor wields the red pen, may well be the most unnerving! In this chapter, however, the question is not so much editorial effectiveness—which is vital and goes without saying—but noticing ways in which the national collaborative effort has been fostered by the general editor. No doubt styles have varied. My personal experience came mainly later with John Ritchie, who famously sent us all ‘abiding affection’. No-one should delude herself that a major collaborative work of research and scholarship like the ADB can be done and maintained over a long period without 284 9. National Collaboration: The ADB Editorial Board and the Working Parties careful attention to the research base. Especially it needs to be emphasised that the work done is unpaid. Contributor payment is an old chestnut so far as the ADB is concerned—who, after all, would have to pay—and apart from exceptional circumstances, to which consideration has usually been given, the glory must suffice. 13 ‘Financial Paper and Payments to Contributors’, National Committee discussion paper (July 1961). See also Minutes, National Committee meeting (12–13 August 1931), box 64, Q31, ADBA, ANUA, pp. 5–7. Geoffrey Serle raised the issue with the Editorial Board in 1975 of paying ‘some’ non-academic contributors in certain cases but there was no funding for this: Minutes, ADB Editorial Board meeting (29 October 1975), box 66, Q31, ADBA, ANUA. From the beginning Some later dictionaries have operated under a more straightforward national structure, and/or are funded by sources other than universities, so can afford payments for contributors, though these still seem quite meagre; but this is not, nor is it likely to be, ‘the Australian way’.13 1985–1996: As a board member It is not to be expected that things changed dramatically after 1985. The change, as expressed in the list of committee members on the preliminary pages of Volume 10 of the ADB (1986), was more a foretaste of things to come; however, the integration of the two earlier committees meant that the Editorial Board was still a large body, and it would take the fresh eye of John Ritchie, and another decade or so, to streamline it. Moreover, like the old National Committee, the new Editorial Board would not be meeting too often. Biennial meetings made the board meetings quite an event for the members, who came from all over Australia for them, and certain constraints meant it kept to its consultative brief during what were once day-long meetings. With Ken Inglis, who succeeded John La Nauze as third chair of the board in 1977, matters were dealt with calmly and smoothly. Later it would be alleged that John Ritchie’s aim was to get through the business by lunchtime. Two new responsibilities came my way during the first decade of my membership of the revamped Editorial Board. Both increased my understanding of the delicate situation of the ADB as a project located within a single university but operational across the entire national system of research and scholarship. Adding to the delicacy, the single university had been an anomaly in the Australian university system, insofar as the research schools of the ANU were founded and funded on the basis of a block grant from the Commonwealth. Because of this, exceptional national responsibilities were expected of them; however, with the reduction of the block grant from 2001 onwards, the ANU was placed on a more equal footing with all other universities for funding, and 285 The ADB’s Story ADB staff, as employees of the ANU, came under increasing pressure, which in turn meant that when it came to big decisions, it was a case of the old saying ‘he who pays the piper calls the tune’.14 My first responsibility was the appointment of a new general editor. The appointment process took more than a year. First there had to be an ANU review to ensure that a senior position was justified. I played no part in this but, as anticipated, the outcome was positive, and things speeded up thereafter. Advertisements were placed internationally. 14 The operation of block funding is too large a question to be pursued here. One reference, for which I thank Darryl Bennet, suggests concern within the ANU was rising by the late 1990s: in 2001 the Institute of Advanced Studies began trading part of its Commonwealth block funding in order to be eligible to compete for national competitive grants: ANU Annual Report (2001), p. 6, <http://www.anu.edu.au/mac/images/ uploads/_AnnRpt2001.pdf> 14 The operation of block funding is too large a question to be pursued here. One reference, for which I thank Darryl Bennet, suggests concern within the ANU was rising by the late 1990s: in 2001 the Institute of Advanced Studies began trading part of its Commonwealth block funding in order to be eligible to compete for national competitive grants: ANU Annual Report (2001), p. 6, <http://www.anu.edu.au/mac/images/ uploads/_AnnRpt2001.pdf> 15 ‘Steady Hand at the Tiller’, Canberra Times (10 July 1996). 16 For the position of research editor, see Cunneen, Chapter 4, this volume. 16 For the position of research editor, see Cunneen, Chapter 4, this volume. 17 Publishing Agreement between the ANU and the University of Melbourne for MUP (24 March 1993), and reference to it, John Ritchie/MUP (24 April 1996), copies of both documents in my possession; also in my possession, related documents, 2003–04, including a draft new agreement, with MUP. See ‘Publishing Agreement between MUP and ANU’ (3 August 2005). 18 The medal proposal was approved by the Editorial Board in July 2002, and the first awards were made by Professor Chubb at a ceremony at University House, Canberra, to Martha Campbell, Bede Nairn, John Ritchie and Gerry Walsh in October 2002. ANU Reporter, 33 (14 November 2002), p. 20. 1985–1996: As a board member With six States, two Territories and a specialist working party on the military, it is a miracle that it has all worked so well for so long. Interestingly, the two most significant innovations of the early 1990s were the index to Volumes 1–12 and the CD-ROM, the former prepared in-house, the latter undertaken by Melbourne University Press, and both done with the approval of the board but with no input from it. They were a ‘touch on the times’, and a pointer to future needs. One thing I recall was running a very lively and up-to-date course in Australian women’s history at Macquarie University, based on the index. Another was the electric moment much later, at a meeting in Di Langmore’s office, when it emerged that when the CD-ROM was being produced, MUP had been granted all future electronic rights, a state of affairs that could have killed any possibility of an online edition of the ADB. Fortunately, MUP and its CEO, Louise Adler, and the ANU administration handled the situation constructively.17 Perhaps I labour the point here. But it is another delicate fact that the effectiveness of national collaboration depends on the integration of expertise at every level. With six States, two Territories and a specialist working party on the military, it is a miracle that it has all worked so well for so long. Interestingly, the two most significant innovations of the early 1990s were the index to Volumes 1–12 and the CD-ROM, the former prepared in-house, the latter undertaken by Melbourne University Press, and both done with the approval of the board but with no input from it. They were a ‘touch on the times’, and a pointer to future needs. One thing I recall was running a very lively and up-to-date course in Australian women’s history at Macquarie University, based on the index. Another was the electric moment much later, at a meeting in Di Langmore’s office, when it emerged that when the CD-ROM was being produced, MUP had been granted all future electronic rights, a state of affairs that could have killed any possibility of an online edition of the ADB. Fortunately, MUP and its CEO, Louise Adler, and the ANU administration handled the situation constructively.17 1985–1996: As a board member A selection committee was formed; again, to my surprise and, to be honest, gratification, I was appointed to the committee, which consisted largely of senior academic staff of the ANU. Without betraying committee confidentiality, I can now say that although not exactly in the first flush of youth, I was still one of the younger members of the committee, and I still had a lot to learn about committee work. The field was good and the selection committee showed foresight when it recommended the appointment of John Ritchie, a well-published researcher and hard worker who became the ADB’s longest-serving general editor. It is perhaps another measure of his effectiveness that I was able to tolerate him calling me ‘Jilly’. Ritchie’s appointment led to another job for me. With it, I saw at first hand the channels through which national collaboration operates on a regular basis. One winter evening in Sydney in 1990, John Ritchie, Beverley Kingston and I were walking up Crown Street after an ADB meeting when, at a pause for the traffic lights, John invited me to become section co-editor for New South Wales. Again, I was happy to accept, and formally speaking I served in that position until 1995 (though in reality for a shorter time, since I was away throughout the northern hemisphere academic year, 1994–95).15 As implied earlier, section editors must work quite hard (and, like most contributors to the ADB, on a voluntary basis). The NSW Working Party is usually responsible for sponsoring the most entries, so even as a co-editor there was a steady amount of work to be done. It was rare to receive less than 10 draft entries a month from Canberra for consideration and comment. The work was very interesting, but I fear I was not very good at it, not for want of commitment but because my knowledge base was not broad enough at the time. Moreover, at that stage I did not fully appreciate the needs of the research editors in Canberra, who could not be up and down to see if the requisite Mitchell Library holdings or those at some other local repository had been consulted.16 286 9. National Collaboration: The ADB Editorial Board and the Working Parties Perhaps I labour the point here. But it is another delicate fact that the effectiveness of national collaboration depends on the integration of expertise at every level. Since 1996: As chair of the board In 1996, following the retirement of Ken Inglis, I became the fourth chair of the ADB’s Editorial Board. Little did any of us realise what rough times lay ahead. More to the point, I was the first, and, to date, the only appointment from outside the ANU made to that position. I felt then, as I still do, that it was an appropriate appointment, as there was then no obvious Australianist on the staff of the History Program in RSSS to succeed Ken; but presumably not everyone saw it that way, at least not at first. On the one hand, I was working in Sydney and was seldom in Canberra. On the other hand, communications were quicker by then, and I had perspective—something that increasingly seemed to be lacking within the ANU. Things went smoothly at first. I do not recall being called to do much more than chair meetings, and we were able to do one or two good things without rocking the boat—in particular, to introduce a system of ADB medals ‘for long and meritorious service’. All credit to John Ritchie for taking this innovation on board. He even went down to the Royal Australian Mint to get the specialists to strike the medals!18 287 The ADB’s Story Whether Ritchie was distressed that destabilisation was in the air, no-one can know for certain. I suspect he was. As payment by results took hold in cash-strapped universities in the 1990s, and the measurers of research output set to work, things began to look grim for the future of the ADB. Not only did the Australian Research Council (ARC) as the main funding body refuse to acknowledge that most contributions to the ADB are of necessity based on original research, Australian history being a comparatively new and immature field, but also, it seemed, that the rising generation would be discouraged from participation in its distinctive deliberative processes. This was despite our strenuous representations on behalf of the ADB.19 Happily, the discriminatory regime no longer prevails. With an Australianist (Stuart Macintyre) heading the social science and humanities section of the ARC in 2002–04, the situation with regard to contributions was reversed; and as of 2011 there is a glimmer of hope for service on the working parties as well. 19 Jill Roe and John Ritchie to the Minister for Education, Training and Youth Affairs (4 April 1997), and reply (30 April 1997), copies in my possession. 20 Walter Bagehot, The English Constitution (London: Fontana Library, Collins, 1965), pp. 61–2, 110. Since 1996: As chair of the board Deride as we might the crude measures being advanced by the measurers of research output, it does seem that the addition of ‘esteem factors’ will mean that voluntary service on significant external committees is going to be counted, and that the voluntary principle will continue to sustain the ADB. As chair of the Editorial Board, I was sometimes reminded of the great British constitutional theorist Walter Bagehot. In his classic work The English Constitution (1867), Bagehot distinguished between what he called its dignified and its efficient parts. In plain language, he explained that practical men were wrong to dismiss the dignified component of the English Constitution, and showed how both aspects were vital. Of the ‘dignified’ element, he wrote: ‘They raise the army, though they do not win the battle’. He also elaborated on the rights of the ‘dignified’ component—at that time, a constitutional monarchy. The monarchy, he wrote, has the right to be consulted, the right to encourage, and the right to warn.20 Such an elevated analysis hardly applies to the Editorial Board of the ADB and its chair; however, it will be seen in successive prefaces to the volumes that general editors are always careful to thank the chair for support and advice. Whether they take it or not is beside the point. They are not obliged to. (There were one or two occasions when it was pointed out to me by officers of the ANU that my role was purely advisory.) Yet there may also be occasions when the board needs to do more than simply support and advise, and times when the chair must not only serve as a conduit for its views but also take the initiative. 288 9. National Collaboration: The ADB Editorial Board and the Working Parties Here I recount two important instances of the board doing more, both of which I was closely associated with. By 1999 it was obvious that the ADB must go online. The prior CD-ROM was difficult to use, and outdated technologically. As general editor, John Ritchie was cautious, though probably persuadable, but it took time, and several board meetings, the last of which followed a trip (by me) to New Zealand to attend the launch of the Dictionary of New Zealand Biography online at the New Zealand Historical Association conference in Christchurch in December 2001. 21 The DNZB online contained all 3049 entries from the five-volume DNZB and parallel Maori-language volumes. The project was located in the New Zealand Ministry for Culture & Heritage (<www.dnzb.gov.nz>). Ross Somerville to Jill Roe, email (10 December 2001), in my possession. Di Langmore was in favour of the online project from the beginning: Darryl Bennet to Jill Roe, personal communication (1 June 2010). Since 1996: As chair of the board It was arranged that the New Zealand general editor, Claudia Orange, and assistant editor, Ross Somerville, would come to Sydney and then to Canberra in June 2002, when the board was next meeting, to show us their work (a process partly funded by Macquarie University). The board was quickly and easily persuaded. There were practical problems, however: successive volumes of the ADB were planned, or in production, and adherence to the publishing schedule was deemed vital. More importantly, where would the money and expertise for such a big operation be found while the day-to-day work went on? Plainly the ANU could not provide it, being itself in financial straits, and still somewhat disoriented by the end of the research schools’ special funding arrangements.21 In fact there was more to it than a ‘who pays?’ impasse. The only way the university could contemplate proceeding was if the ADB became available online on a user-pays basis. As this was not board policy, and anathema to me personally, a tussle ensued. Several bodies within the ANU thought of the ADB as a nice database that might enhance their own activities, provided it was profitable. There was no conception of the ADB as a continuing national research operation; and the idea of the ANU as custodian and promoter of the national interest supporting a free-to-air humanities project did not begin to play with harassed, middle-level bureaucrats. Indeed, at that stage, the idea that the project would enhance the image of the ANU seemed not to impinge. After one such encounter, I was so angry I let things stand for a month, and by then they had moved on. The board stood firm. It understood the educational and other values of free-to- air. Thanks largely to a recently appointed board member, Janet McCalman, it found an answer to these problems in an association with a leading University of Melbourne e-team headed by Gavan McCarthy; and the in-house appointment of the wonderfully competent Darryl Bennet to prepare an application to the ARC clinched it. Later, as recounted in Chapter 6, a number of board members and ADB supporters undertook associated research projects (mine being mainly 289 The ADB’s Story with Miles Franklin’s bio-data) and persuaded their own universities to back the application, all of which was necessary for the only type of grant for which the project was eligible: an infrastructure grant. 22 ARC, Linkage—Infrastructure Equipment & Facilities (LIEF) Grant Application (2004), copy in my possession. Ian Chubb, ‘The ADB: Honouring its Foundational Culture’, Biography Footnotes, no. 4 (December 2009). ) 23 Draft Minutes, ADB Editorial Board meeting (7 June 1971), copy courtesy Chris Cunneen. Since 1996: As chair of the board The board did not itself do the work, but without the board’s initiative and massive national collaboration, an online ADB would not have been possible. Receiving 70 million ‘hits’ a year, ADB online is now seen as a ‘jewel in the ANU’s crown’, and a growth point.22 A second example of board activism pertains to the production of the supplement volume of the ADB, the so-called ‘Missing Persons’ volume, which appeared with the full support of the ADB and MUP in 2005. There was debate about this as a necessary step in the modernisation of the ADB. Some thought an update of the early volumes, where much new research has been undertaken since the 1960s, should come first; however, the need for supplements had been canvassed as early as 1971, and the prior value of an overall catch-up volume was widely accepted.23 ADB Editorial Board, December 2012. Clockwise from left: Michael Roe, David Horner, Stefan Petrow, Chris Cunneen, Beverley Kingston, Pat Buckridge, Tom Griffiths (chair), Melanie Nolan, Patrick Cornish, Geoffrey Bolton, Jill Roe, Carolyn Rasmussen, David Dunstan, Joy Damousi, John Lack ADB Editorial Board, December 2012. Clockwise from left: Michael Roe, David Horner, Stefan Petrow, Chris Cunneen, Beverley Kingston, Pat Buckridge, Tom Griffiths (chair), Melanie Nolan, Patrick Cornish, Geoffrey Bolton, Jill Roe, Carolyn Rasmussen, David Dunstan, Joy Damousi, John Lack Photographer: Brian Wimborne, ADB archives Photographer: Brian Wimborne, ADB archives Again there was an impasse: it was a big, full-time job. It did not fit in to the long- term production schedule in Canberra. Who, then, could do it? Fortunately, an 290 9. National Collaboration: The ADB Editorial Board and the Working Parties ideal editor for this volume was to hand. When Chris Cunneen retired as deputy general editor in 1996, he and his wife, Kerry Regan, moved to Sydney, where he became affiliated with the Department of Modern History at Macquarie University and was appointed an honorary senior research fellow. He was willing and able to face the challenge; the university was happy to sponsor the proposal; and in due course, with the involvement of the University of Sydney and the University of New South Wales, and Stephen Garton, Beverley Kingston and myself to serve as associate editors, a substantial research grant was obtained. The project took almost four years and, again, the entire ADB system cooperated. As with the online project, a major collaborative effort was undertaken and some 500 names of people, significant in fields of history hitherto little explored or overlooked in existing volumes, especially in Indigenous and women’s history, were added to the total.24 Regarding Indigenous history, for reasons outlined earlier, the supplement proved timely. Thanks to its suitably extended time span, 1580–1980, and the opportunity to take in new biographical research, the volume was able to include 49 Indigenous biographies, 10 per cent of total entries in the volume, for which the various working parties are to be highly commended. At present, an estimated average of 1.9 per cent of all entries in the ADB are for Indigenous Australians.25 A final and sad instance of when ‘the buck stops here’ came into play with the incapacitating stroke in 2001 and premature death in 2006 of John Ritchie. At this point I would like to acknowledge that I have had the benefit of a preview of Geoffrey Bolton’s chapter on the Ritchie years. The reader cannot help but feel its elegiac quality. John’s death came, as many deaths do, unexpectedly. In normal circumstances, he would probably have retired in 2005, and I would have ceased to be the chair of the board even earlier. As it was, the living soldiered on. Stopgap measures were put in place by the ANU, and the ADB staff, led by Langmore, coped splendidly. 24 Large Research Grants Scheme, application for 2001, copy in my possession. The project was awarded $272 000 over three years. 25 The average for the most recent volumes—ADB Volumes 13–17 plus the supplement—is 3.6 per cent. Material presented to ADB 2009 seminar by staff, copy courtesy Darryl Bennet. 26 Jill Roe to Vice-Chancellor Chubb (6 June 2003), and Request for support, copies in my possession. The meeting was held on 13 October 2003. Photographer: Brian Wimborne, ADB archives But increasingly it looked as if the bean-counters liked it that way. It took quite an effort, by Langmore herself if I recall correctly, for her to be adequately remunerated, albeit partially and on a temporary basis, for the extra work and responsibility that she had taken on as acting general editor; and at that point it seemed nothing more was going to happen, despite the support of successive directors of RSSS and the recommendations of the Roe, Bolton and Garton report described in 291 The ADB’s Story The ADB’s Story Chapter 6. Yet a formal appointment to replace Ritchie was needed, if only as a matter of wage justice, but more importantly to forestall any possible drift; and here I felt a special responsibility. Again, it took us all a lot of time and too many meetings with people who mostly had neither the power nor the motivation to move things along. Eventually, however, we (Di Langmore, Frank Jackson, then director of RSSS, and I) reached the vice-chancellor, Ian Chubb. It was a meeting worth recording, lasting at most two minutes. We had arrived full of trepidation, knowing this was the end of the road. Chubb waved us in, sat us down, picked up a recent volume of the ADB, and, opening it at the title page, said ‘where’s the ANU logo?’ One of us, probably Langmore, hastened to say that the omission would be remedied. Right, he said, that’s fine; arrange the advertisement. I have been a distant fan of Professor Chubb ever since.26 So things were back on track. In due course Langmore was appointed to (a fixed- term) general editorship, and it was my pleasure to be there when the volume she edited, Volume 17, was launched on 20 November 2007 by the governor of Victoria, David de Kretser, at the State Library of Victoria. The business of organising for Langmore’s successor, Melanie Nolan, in 2008, was by no means so troublesome. I should record that it was Ian McAllister, Frank Jackson’s predecessor as head of RSSS, who finally suggested we approach Professor Chubb directly, and Desley Deacon, as the then head of the History Program, who helped us through both processes. Photographer: Brian Wimborne, ADB archives With formal links between the ADB and the History Program re-established in 2003–04 and, after yet another review, its relocation in the newly established National Centre of Biography in 2008, a new chapter in the history of the ADB has opened. It is not hard to see institutional imperatives and intellectual developments at work, but it is difficult to predict the long-term effect of them. What is clear is that the ADB has survived when it might not have, the national collaborative network is intact and continuing, and esteem remains high. A new generation is taking command in Canberra, under circumstances far more decisive than those of 1985, and the changeover seems to be going smoothly, with plenty of youthful enthusiasm in evidence. My successor as chair of the Editorial Board, Tom Griffiths, will surely have much of interest to tell us about it all one day. With formal links between the ADB and the History Program re-established in 2003–04 and, after yet another review, its relocation in the newly established National Centre of Biography in 2008, a new chapter in the history of the ADB has opened. It is not hard to see institutional imperatives and intellectual developments at work, but it is difficult to predict the long-term effect of them. pfi p gf What is clear is that the ADB has survived when it might not have, the national collaborative network is intact and continuing, and esteem remains high. A new generation is taking command in Canberra, under circumstances far more decisive than those of 1985, and the changeover seems to be going smoothly, with plenty of youthful enthusiasm in evidence. My successor as chair of the Editorial Board, Tom Griffiths, will surely have much of interest to tell us about it all one day. 292 9. National Collaboration: The ADB Editorial Board and the Working Parties Tom Griffiths, W. K. Hancock Professor of History at the ANU, has chaired the Editorial Board since 2006 Photographer: Peter Fitzpatrick, ADB archives, 2010 9. National Collaboration: The ADB Editor Tom Griffiths, W. K. Hancock Professor of History a chaired the Editorial Board since 2006 Photographer: Peter Fitzpatrick, ADB archives, 2010 9. National Collaboration: The ADB Editorial Board and the Working Parties Tom Griffiths, W. K. Hancock Professor of History at the ANU, has chaired the Editorial Board since 2006 Photographer: Peter Fitzpatrick, ADB archives, 2010 Tom Griffiths, W. K. Photographer: Peter Fitzpatrick, ADB archives, 2010 27 Jill Roe, ‘Franklin, Stella Maria Sarah Miles (1879–1954)’, ADB, vol. 8, pp. 574–6. Jill Roe (ed.), My Congenials. Miles Franklin and Friends in Letters, 1879–1954 (Pymble, NSW: State Library of New South Wales in association with Angus & Robertson, 1993). Jill Roe, Stella Miles Franklin. A Biography (Pymble, NSW: Fourth Estate, 2008). Jill Roe, ‘Sawtell, Olaf (Michael) (1883–1971)’, ADB, Supplement 1580–1980, pp. 353–4. Photographer: Brian Wimborne, ADB archives Hancock Professor of History at the ANU, has chaired the Editorial Board since 2006 Photographer: Peter Fitzpatrick, ADB archives, 2010 293 The ADB’s Story The ADB’s Story My story perforce ends there. These days I serve as an ordinary member of the Editorial Board and as a member of the NSW Working Party; I hope to do so for a bit longer. With luck, I may ultimately be able to lay claim to having written 20 entries for the dictionary. Apart from an invitation from Bede Nairn in 1979 to write an entry on Stella Miles Franklin that set me off on a lifetime’s work, my favourite has probably been my entry in the supplement volume on Michael Sawtell, a SA-born radical and Emersonian who lived and worked in almost every State of Australia and never stopped talking.27 It has always come naturally to me to think of the ADB as a truly collaborative national project. Long may it flourish. Professor Emerita Jill Roe AO has been a member of the NSW Working Party since 1990; a member of the ADB’s Editorial Board since 1985 and was its chair in 1996–2006. She is currently writing about South Australia’s Eyre Peninsula, where she spent her early years. 294 9. National Collaboration: The ADB Editorial Board and the Working Parties Sources: Jan Zwar, ‘An Interview with Jill Roe’, Australian Humanities Review, no. 33 (August–October 2004), <http://www.australianhumanitiesreview. org/archive/Issue-August-2004/roe.html> (accessed 26 June 2012). Jill Roe, ‘Biography Today: A Commentary’, Australian Historical Studies, 34, no. 1 (March 2012), pp. 107–18. ADB archives Jill Roe (b. 1940) A graduate of the University of Adelaide (BA Hons, 1963) and ANU (MA Hons, 1965), Jill Roe was appointed a tutor in modern history at Macquarie University in 1967. She was already associated with the ADB as the author of the entry on Ada Cambridge, published in Volume 3 (1969), and has argued that she ‘grew with the ADB’. Since then she has written another 19 articles, two of which have led to published books: her entry on George Arundel, which resulted in Beyond Belief: Theosophy in Australia 1879–1939 (1986), and her entry on Miles Franklin, which led to a critically acclaimed, full-scale biography, published in 2008. She became professor at Macquarie in 1996 and, on her retirement in 2003, was appointed professor emerita. A member of the Editorial Board from 1985, Roe served two terms as chair (1996–2006). In this role she vigorously advocated the online development of the ADB; she supported the idea of a supplementary volume of missing persons and, subsequently, worked on it as an associate editor; and she oversaw the appointment of a general editor (Di Langmore) to succeed John Ritchie. A member of the NSW Working Party from 1988, she served (1990–95) as joint section editor. In 2013 she is still an active member of both the Editorial Board and the NSW Working Party. Roe believes that we are now living in a ‘golden age’ of biography, with its widening scope of inclusiveness, and argues that ‘what you learn from an individual biography may actually transform a whole field’. Moreover, if ‘you gather up cohorts and generations, then you get quite different understandings of social and cultural and intellectual dynamics in society’. Sources: Jan Zwar, ‘An Interview with Jill Roe’, Australian Humanities Review, no. 33 (August–October 2004), <http://www.australianhumanitiesreview. org/archive/Issue-August-2004/roe.html> (accessed 26 June 2012). Jill Roe, ‘Biography Today: A Commentary’, Australian Historical Studies, 34, no. 1 (March 2012), pp. 107–18. 295 The ADB’s Story y Jill Roe 2010 Jill Roe, 2010 Jill Roe, 2010 ADB archives 296 9. National Collaboration: The ADB Editorial Board and the Working Parties Sources: Geoffrey Bolton, in conversation with Melanie Nolan (8 June 2011). Citation for ADB Medal for Geoffrey Bolton (11 December 2012), NCB/ADB file. Geoffrey Bolton (b. 1931) Professor Geoffrey Bolton has been involved with the ADB since 1959 when, with Frank Crowley, he helped to set up the WA Working Party. In 1961, in partnership with Ann Mozley, he compiled a biographical register of the WA Legislative Assembly, the second in a series of political registers. Somewhat unusually, as he moved between several Australian universities—he was also foundation professor and head (1971–73) of the Australian Studies Centre at the University of London—he has been a member of three working parties at various times: Western Australia (chairman in 1967–82 and 1996–2011), Victoria and Queensland. Author of 84 entries, Bolton has contributed to every volume of the ADB. He has written award-winning biographies of Alexander Forrest (1958), Richard Boyer (1967), John Wollaston (1985) and Edmund Barton (2000)—all subjects of ADB articles by him—and is currently completing a biography of Paul Hasluck. His ADB entries also include people associated with the Kimberley, a region that he came to know well in his student days, among them Michael Durack and Lindsay Blythe as well as Forrest. He is known as a master of anecdote and his articles show an engaging familiarity with his subjects. His phenomenal memory and his oracular presence serve him well. As chair of the WA Working Party, he used all these attributes to advantage as he shared a story about a prospective candidate for inclusion. A great ‘fixer’, when the working party debates seemed endless, he would say ‘leave it with me’. A graduate of the University of Western Australia (BA Hons, 1952; MA, 1954), Bolton won a Hackett Research Scholarship that took him to Balliol College, Oxford (BA, 1956; DPhil, 1961). His has been a stellar career, culminating in the chancellorship of Murdoch University (2002–06). He has published widely on many aspects of Australian history and was named Western Australian of the Year in 2006. Bolton observed that his father always advised him to leave a pub under his own steam rather than stay too long and be thrown out; on that basis, with some reluctance but much resolve, he retired from both the WA Working Party and the Editorial Board in 2011. Sources: Geoffrey Bolton, in conversation with Melanie Nolan (8 June 2011). Citation for ADB Medal for Geoffrey Bolton (11 December 2012), NCB/ADB file. 1 W. G. Buick, ‘Whom Was Whom and Why’, Australian Book Review (April 1966), p. 112. 2 Noel McLachlan, ‘The Names in Our Past’, Age [Melbourne] (5 March 1966). 3 Geoffrey Blainey, Papers and Proceedings [Tasmanian Historical Research Association], 15, no. 2 (1967), p. 63; and Book review, Historical Studies, 14, no. 53 (1969), pp. 102–4. 4 A selection of such reviews includes: Walkabout (July 1966); George Johnston, Sydney Morning Herald (18 March 1967); Neville Hicks, Australian (26 April 1969), p. 17; John Lack, Monash Reporter (11 October 1972); Austin Cooper, Advocate [Melbourne] (18 January 1973); Humphrey McQueen, Nation Review (13–19 (January 1977); N. D. McLachlan, Historical Studies, 18 (1978), p. 344; Les Blake, Victorian Historical Journal Geoffrey Bolton (b. 1931) 297 The ADB’s Story The ADB’s Story Geoffrey Bolton, 2009 Photographer: Peter Fitzpatrick ADB archives Geoffrey Bolton, 2009 Photographer: Peter Fitzpatrick, ADB archives Photographer: Peter Fitzpatrick, ADB archives 298 10. Assessing the ADB: A Review of the Reviews Mark McGinness A too kindly reception? The greeting in March 1966 from W. G. Buick in the Australian Book Review, ‘Let us celebrate the birth of a giant’, must have been music to the ears of Douglas Pike and his team on the publication that month of Volume 1 of the Australian Dictionary of Biography.1 In the Age, Noel McLachlan concluded, ‘[a]s a work of reference the series will certainly be invaluable’, and Professor Pike’s modest hope that ‘it will inform and interest the lonely shepherd in his hut as readily as the don in his study’ ought to be richly fulfilled. Not just shepherds and dons, though: ‘Anyone with an ounce of interest in the myriad origins of his nation is bound to find it fascinating’.2 In a thoughtful review of the first two volumes, Geoffrey Blainey, surely its most eloquent critic, predicted the ADB would ‘probably be the most valuable reference work in Australian history; it is already one of the most readable works on Australian history. This twin achievement would have been unattainable without outstanding editors’. Blainey neatly concluded: The last article in these volumes records briefly the life of Yuranigh, an aboriginal guide and traveller who died west of the Blue Mountains in 1850. The anonymous author quotes a tribute by Sir Thomas Mitchell to this obscure aboriginal: ‘his intelligence and his judgment rendered him so necessary to me that he was ever at my elbow’. The same will be said of these volumes for years to come.3 Most other reviews since the late 1960s, although perhaps not as euphoric as Buick, have generally welcomed successive volumes of the ADB kindly. The ADB, like all biographical dictionary projects, understandably cites such laudatory reviews and praise whenever it can.4 Rod Moran believed that the ADB was ‘one 299 The ADB’s Story of the most important longitudinal research projects in the intellectual life of the Humanities in Australia’;5 Stephen Murray Smith praised it as ‘a remarkable gift to the nation’;6 while Eric Richards went even further to declare it as a ‘gift of scholarship to the nation and the world’.7 Allan Martin predicted: ‘The Dictionary seems destined to fulfil its promise as the most valuable working tool in the hands of Australian scholars’.8 Rob Inglis pronounced on radio that the writing is good. There is in it that grist and fibre which characterised English correspondence at the end of the eighteenth century. (May 1980), p. 115; Lloyd Robson, ‘The A.D.B.: International Precedent and the Australian Experience’, Meanjin, 3 (1980), p. 397; Edward Dukyer, Quarterly Bulletin [Sutherland Shire Historical Society], 75 (1991), p. 633; James Walter, Australian Historical Studies, 104 (1995), p. 489; Wayne Crawford, Mercury [Hobart] (4 November 1996), p. 29; Holly Kerr Forsyth, Australian (21–22 March 1998); Carl Bridge, ‘Good Blokes and Others’, Times Literary Supplement (16 October 1998), p. 10. (May 1980), p. 115; Lloyd Robson, ‘The A.D.B.: International Precedent and the Australian Experience’, Meanjin, 3 (1980), p. 397; Edward Dukyer, Quarterly Bulletin [Sutherland Shire Historical Society], 75 (1991), p. 633; James Walter, Australian Historical Studies, 104 (1995), p. 489; Wayne Crawford, Mercury [Hobart] (4 November 1996), p. 29; Holly Kerr Forsyth, Australian (21–22 March 1998); Carl Bridge, ‘Good Blokes and Others’, Times Literary Supplement (16 October 1998), p. 10. 5 Rod Moran, West Australian (3 June 2000). 6 Stephen Murray-Smith, Australian Historical Studies, 23 (1988), pp. 206–7. 7 Eric Richards, Journal of the Historical Society of South Australia, 34 (2006), p. 120. 8 A. W. Martin, ‘Australian Dictionary of Biography, Volume 2 (1967)’, Historical Studies, 12 (1967), p. 133. 9 Rob Inglis, Review, ‘Books for Comment No. 70’, Transcript of Broadcast, ABC Radio (27 May 1966). 10 Mark McGinness, Courier-Mail [Brisbane] (27 April 2000). 11 Ellis to Prof. Huxley, ANU Vice-Chancellor (9 June 1963), box 68, Q31, ADBA, ANUA. 6 Stephen Murray-Smith, Australian Historical Studies, 23 (1988), pp. 206–7. 7 Eric Richards, Journal of the Historical Society of South Australia, 34 (2006), p. 120. [ ] ( p ) 11 Ellis to Prof. Huxley, ANU Vice-Chancellor (9 June 1963), box 68, Q31, ADBA, ANUA. 8 A. W. Martin, ‘Australian Dictionary of Biography, Volume 2 (1967)’, Historical Studies, 12 (1967), p. 133 9 Rob Inglis, Review, ‘Books for Comment No. 70’, Transcript of Broadcast, ABC Radio (27 May 1966). 8 A. W. Martin, ‘Australian Dictionary of Biography, Volume 2 (1967)’, Historical Studies, 12 (1967), p. 13 9 Rob Inglis, Review, ‘Books for Comment No. 70’, Transcript of Broadcast, ABC Radio (27 May 1966). 10 Mark McGinness, Courier-Mail [Brisbane] (27 April 2000). A too kindly reception? This quality is something to do with describing an involvement in affairs— committees, business, expeditions, and with distance travelled arduously, on horseback or under sail; it arrestingly reflects the reaction of men with strong views on coming into contact with new lands and fresh experiences.9 Most of its reviewers have been, or became, contributors, which may explain the positive coverage; but it also reflects the extraordinary commitment and reach of the dictionary among Australia’s academics and writers and the consensus that the ADB is something worth contributing to, as well as drawing upon. In this chapter, I dwell not on the admiration for the ADB but on the criticism of it. I am on record myself as describing the ADB in a review as ‘one of our least known national literary treasures’.10 I come ‘not to bury’ the ADB, in this broader consideration, however, but to tease out its attributes so that we can better understand it. Amongst all the acclaim, there has also been criticism of the ADB. Malcolm Ellis’s two reviews in the Bulletin in 1966 and 1967 have always been discounted because he was regarded as a discontent. Ellis came armed with strong views, having been in contact with the ADB from its birth. In fact, he even suggested it was his idea.11 In any event, in the beginning of 1962 he had resigned as joint editor and the appearance of the dictionary’s first volume was an opportunity to share his views on the project he had abandoned. In his review, entitled ‘Disaster in Australian Research’, Ellis claimed that ‘the mountain of the 300 10. Assessing the ADB: A Review of the Reviews Australian Universities gave birth to a mouse, or half a mouse’.12 Too many of the entries were written by people without expertise. Contributions from Russel Ward (on Grey and Fitzroy), James Auchmuty (Hunter), Charles Currey (on some legal personalities), Ken Cable (Bishop Broughton), Frank Crowley, B. H. Fletcher, Jim Davidson and J. M. Bennett were commended but many of the biographies were ‘shockingly poor’ and ‘lamentably sparse and exhibit the writer’s lack of original research’. He condemned the absence of recording writers’ qualifications and was suspicious of the fact that many were unsigned. He also branded as utterly unsatisfactory and disastrous the decision to entrust some lives to direct descendants of subjects. 12 M. H. Ellis, ‘Disaster in Australian Research’, Bulletin (26 March 1966), pp. 48–9. 13 Ellis, ‘Disaster in Australian Research’, pp. 48–9. Photographer: Bob Cooper, ANUA226-689 13 Ellis, ‘Disaster in Australian Research’, pp. 48–9. Photographer: Neal McCracken, ANUA225-526-2 14 C. Hartley Grattan, ‘Australian Dictionary of Biography’, Journal of the Royal Australian Histori Society, 52, part 3 (September 1966), pp. 250–3. y p ( p ) pp 15 M. H. Ellis, ‘Biography Soup’, Bulletin (10 June 1967), p. 82. y p ( p ) pp 15 M. H. Ellis, ‘Biography Soup’, Bulletin (10 June 1967), p. 82. A too kindly reception? Finally, what concerned Ellis was the lack of balance: ‘One only has to attach the word “radical” to somebody, apparently, and he becomes of first importance’, while ‘Captain Cook gets only twenty anonymous inches, only five inches or 250 words of which deal with his experiences on and exploration of the Australian coast’.13 The launch of Volume 6 of the ADB, in 1976. Left to right: Nan Phillips, ANU vice-chancellor, Anthony Low, Olive Pike, John La Nauze, Bede Nairn and Geoffrey Serle The launch of Volume 6 of the ADB, in 1976. Left to right: Nan Phillips, ANU vice-chancellor, Anthony Low, Olive Pike, John La Nauze, Bede Nairn and Geoffrey Serle Photographer: Bob Cooper, ANUA226-689 301 The ADB’s Story The ADB’s Story C. Hartley Grattan joined Ellis in his complaint about unsigned entries in Volume 1. He expressed ‘a strong doubt of the utility of [an] unsigned entry, even though it is clear enough they were compiled in the editorial office in Canberra’. Grattan felt that total or even relative anonymity detracts from authority. ‘I say sign every piece and identify the signers’.14 Ellis remained unimpressed by Volume 2 when it appeared a year later, commenting that it was ‘no credit to the editors and the teeming committees of supervision advertised in the introductory lists’.15 Again, his strongest charge was one of imbalance: ‘when some of the most prominent men of the time are totally ignored one can only wonder about the standards of the University Historical Department’. For example, he condemned the fact that no less than three Macarthurs, sons of John, were ignored while his ‘unimportant nephew, Hannibal’ receives ‘a whole two and a half pages’. Prime minister, Bob Hawke, launched Volume 12 of the ADB at Parliament House, Canberra, in 1990 Prime minister, Bob Hawke, launched Volume 12 of the ADB at Parliament House, Canberra, in 1990 302 10. Assessing the ADB: A Review of the Reviews One can, of course, write a rejoinder to Ellis. He appears not to realise that many of the unsigned articles were often the consequence of dispute with authors over the extent of the editing of their original drafts. A number of authors decided that an article was no longer their own work after going through the ‘editing mill’ and they preferred not to sign their name to the final entry. A too kindly reception? Some other authors promised but did not deliver an article and so the job fell to ADB staff. The reason for staff’s modesty in leaving their pieces unsigned is unaccountable until one recalls that the still prevailing practice of the almighty Dictionary of National Biography (DNB) was to acknowledge authors with nothing more than their initials. There is no reason Ellis would know why so many early entries were unsigned because the preface was silent about this. Despite his early involvement in the project, Ellis must have misunderstood, too, the ADB’s floriut philosophy because two of those sons of John Macarthur, Sir Edward and Sir William, both subsequently appeared in Volume 5. The floriut principle was applied to the first 12 volumes of the ADB with the period of a person’s career, the period of his/her major flowering and contribution, rather than their death, determining what volume they appeared in. Three of Ellis’s criticisms are not so easy to address: the dictionary was unbalanced in the selection of subjects, especially the over-inclusion of radicals, people who achieved nothing and ‘unimportant scallawags’; it was poor in ‘the covering of facts and in accuracy of statement and judgement’, probably as a result of the failure to mine manuscript collections and as indicated by bibliographies that were sparse; and it fell short of greatness. Interestingly, even the reviewers who gushed over the ADB raised similar concerns. Indeed, rather than a mass of favourable reviews, with a few exceptions that prove the rule, reviewers fall into two other categories: those who forgive the ADB its blemishes as slight and unimportant and those who see those same flaws as disfiguring. 16 Blainey, Papers and Proceedings (1967) and Book review (1969). y , , p 19 ‘Preface’, Australian Dictionary of Biography, vol. 13 (Carlton, Vic.: Melbourne University Press, 1993), p 17 ‘Preface’, Australian Dictionary of Biography, vol. 7 (Carlton, Vic.: Melbourne University Press, 1979), p 18 Ryan, ‘The ADB’, p. 88. ADB archives , y f g p y, ( , y , ), p 18 Ryan, ‘The ADB’, p. 88. 19 ‘Preface’, Australian Dictionary of Biography, vol. 13 (Carlton, Vic.: Melbourne University Press, 1993), p. v. 18 Ryan, ‘The ADB’, p. 88. 17 ‘Preface’, Australian Dictionary of Biography, vol. 7 (Carlton, Vic.: Melbourne University Press, 1979 18 Ryan ‘The ADB’ p 88 17 ‘Preface’, Australian Dictionary of Biography, vol. 7 (Carlton, Vic.: Melbourne University Press, 1979), p. v. 18 Ryan, ‘The ADB’, p. 88. 19 ‘Preface’, Australian Dictionary of Biography, vol. 13 (Carlton, Vic.: Melbourne University Press, 1993), p. v. 17 ‘Preface’, Australian Dictionary of Biography, vol. 7 (Carlton, Vic.: Melbourne University Press, 1979), p. v. The preface: An opportunity lost In his review of the first volumes, Geoffrey Blainey wrote of ‘the merit of writing a much longer expository preface to the next series of volumes’.16 A succession of editors thought the first preface so good they barely changed a word—for almost 30 years. There was a slight concession to political correctness in the preface to Volume 7 in an explanation of the ADB’s selection criteria. Volume 6 had, like its predecessors, stated: ‘Many of the names were obviously significant and worthy of inclusion. Others, less notable, were chosen simply as samples of 16 Blainey, Papers and Proceedings (1967) and Book review (1969). 303 The ADB’s Story the Australian experience’.17 Volume 7, after mentioning the worthies, followed with: ‘Many others have been included as representatives of ethnic and social minorities and of a wide range of occupations, or as innovators, notorieties or eccentrics’. This single sentence may suggest a seismic shift on the part of the editors and working parties but it is probably more a case of moving with the times. As Peter Ryan put it in his Quadrant review, ‘[w]ithout yielding to the crasser excesses of political correctness, the Dictionary has not ignored modern trends’.18 Otherwise, the prefaces remained formulaic and frozen until Volume 13, John Ritchie’s third volume, which came to life with the opening: ‘In January 1940 cheering crowds farewelled soldiers of the 6th Division as they sailed to do battle in the deserts of the Middle East. In December 1980 an inquest into the death of Azaria Chamberlain began at Alice Springs’.19 If nothing else, this underlined the abiding commitment to continuity and the original vision for the ADB. But it remains to be said that had the early editors shared a less clipped and unyielding preface with their reviewers, if not their readers, they may have been saved much questioning from critics as to their policies and approach. Senator Jim McClelland launched Volume 13 of the ADB at the State Library of New South Wales in 1993 Senator Jim McClelland launched Volume 13 of the ADB at the State Library of New South Wales in 1993 304 10. Assessing the ADB: A Review of the Reviews Balance in selection George Shaw greeted Volume 11 (1891–1939: Nes to Smi) with an almost joyous response. He delighted in the Australian tendency towards irreverence in the face of the ponderous and serious. He seized upon the entries of Bridget Partridge—‘lapsed nun’; John Pomeroy—‘inventor and pieman’; and Joseph Perry—‘salvationist and showman’. He suggests, with what many a contributor might see as a touch of envy, the indulgence of the editor on allowing Peter Howell to ‘get away with’ the comment on Frederick Poole, who ‘when he found himself growing deaf in Ballarat, he returned to Adelaide to take over a choir school and later in life was chaplain to Adelaide’s hospital, its destitute asylum, its prison and two of its bishops, Harmer and Thomas’.20 Geoffrey Dutton also wrote of thoroughly enjoying himself in reviewing the same volume. He saw ‘the brief entries’ not as ‘gravestones but life-windows’, and delighted in finding among its subjects Helena Rubinstein (whose autobiography J. R. Poynter described as ‘a romance undermined by flashes of candour’), and the sheepdog expert John Quinn (1864–1937), whose kelpie Coll was, said the Bulletin, ‘to the dog world what Victor Trumper was to cricket’. He also praised the ‘wonderful women here: the artists Thea Procter (“I am not the sort of person who could sit at home and knit socks”), Kate O’Connor, Margaret Preston, Ellis Rowan’.21 The issue of inclusiveness is a fraught one for any compiler of a dictionary and most critics are unable to resist seeking and exposing those he or she thinks are missing. In 2005, a supplementary volume of the ADB was published, its own ‘missing persons’, with another 500 lives—from Dirk Hartog, born in 1580, to John McKeddie, who died in 1980.22 The DNB volume of missing biographies was published in 1994.23 The ADB’s version included 161 women, the greatest number in any volume. It might be suggested that the attempt to rectify the imbalance is undone by a preponderance of community and charity workers who, despite their worthiness, may not have warranted inclusion. It is true to say that these activities reflect the restricted scope of any sort of public life for many Australian women until the 1960s; but is that sufficient reason to include them all? As Paul Brunton noted of the supplement volume: ‘There are, for example, a lot of nurses. 21 Geoffrey Dutton, ‘Wonderful Windows to a Variety of Lives’, Sydney Morning Herald (26 November 1988), p. 89. pp 23 C. S. Nicholls (ed.), Dictionary of National Biography. Missing Persons (Oxford and New York: Oxford University Press, 1994). 20 George P. Shaw, ‘Book Review’, Australian Historical Studies, p. 119.f 20 George P. Shaw, ‘Book Review’, Australian Historical Studies, p. 119. 21 Geoffrey Dutton, ‘Wonderful Windows to a Variety of Lives’, Sydney Morning Herald (26 November 1988), p. 89. 22 ADB, Supplement 1580–1980. 23 C. S. Nicholls (ed.), Dictionary of National Biography. Missing Persons (Oxford and New York: Oxford University Press, 1994). 20 George P. Shaw, ‘Book Review’, Australian Historical Studies, p. 119. 22 ADB, Supplement 1580–1980. ) p 22 ADB, Supplement 1580–1980. Balance in selection If one is ill this may be a good thing, but it may be overkill in a 305 The ADB’s Story biographical dictionary. While they were all clearly worthy, conscientious, and necessary, perhaps this is not sufficient for inclusion in a national work’. He also questioned the inclusion of Mary Griffith, sister of Sir Samuel, and Paquita Mawson, wife of Sir Douglas, who ‘when all is said and done are there because of those connections’.24 In its inclusiveness, the supplement has remained true to the representative aim of the ADB, especially when one sees that Aborigines, Pacific Islanders, working people, criminals and non-white immigrants have been rescued from oblivion. There are 49 entries on Indigenous lives—as the preface states, ‘a far higher proportion than in earlier volumes’. Also embraced are the exceptional who were inexplicably missed, like Granny Smith and Arthur Yates, who do real credit to this exercise.25 The question of balance and inclusiveness remains a live one. Ellis, it will be remembered, was critical of the inclusion of ‘ordinary lives’. To include biographies of a sometimes flogged convict who did nothing in a rather misspent life save go on board the wreck of the Sirius at Norfolk Island in 1790 and allegedly “save” her, or a sergeant-major of the South Devons who did nothing whatever of note except leave behind a rather scrappy account book [was wrong].26 Ironically, in his review of Volume 17 of the ADB, Paul Pickering, while acknowledging the work as ‘a national treasure’ and praising it for its scholarship and quality, accused the ADB of elitism and of falling ‘a long way short of examining a cross-section of Australian society that would be necessary to justify the word “Australian” in the title. Labour historians’, he added, ‘looking for “biography from below” will not find it here’.27 This is a surprising charge, given the background and expertise of three former editors, Bede Nairn (a labour historian), Geoffrey Serle (who contributed to labour history) and John Ritchie (one-time editor of Labour History), and, on closer inspection, is probably unwarranted. It is indisputable that the country has, or has had, proportionately more Australian labourers and workers than any other occupation. There have, historically, also been even more Australians who would have described their occupations as ‘homemakers’ or ‘housewives’; but this does not justify their inclusion in the ADB. 24 Paul Brunton, ‘Mysterious Quotas’, Australian Book Review (February 2006), pp. 19–20. 25 Eric Richards, ‘The Grand Parade: A Review Essay on Volume 16 and the Supplement to the Australian Dictionary of Biography’, Journal of the Historical Society of South Australia, 34 (2006), pp. 116–20. 26 Ellis, ‘Biography Soup’. 27 Paul Pickering, ‘Review: Di Langmore (ed), Australian Dictionary of Biography, Volume 17’, Labour History, no. 95 (November 2008), pp. 271–3. 24 Paul Brunton, ‘Mysterious Quotas’, Australian Book Review (February 2006), pp. 19–20. Balance in selection Although he does not concede the point, Pickering proffers a solution to this ‘inequity’ by proposing that Australia follows Britain’s example with a Dictionary of Labour Biography. Indeed, Britain has produced 12 306 10. Assessing the ADB: A Review of the Reviews volumes of such a dictionary so far. A ‘Biographical Register of the Australian Labour Movement, 1788–1975’ was launched at the Labour History conference in 2011 and is being incorporated in the ADB’s companion web site Labour Australia. volumes of such a dictionary so far. A ‘Biographical Register of the Australian Labour Movement, 1788–1975’ was launched at the Labour History conference in 2011 and is being incorporated in the ADB’s companion web site Labour Australia. Despite Pickering’s concern, the depth and range of chosen subjects in the ADB remain impressive. In browsing through the Oxford Dictionary of National Biography (ODNB), the distinguished man of letters Alan Bell wrote of searching for Reverend Mr Cox of ‘Cox’s Orange Pippin’ fame and coming across three dozen other Coxes, few of them of high rank but most of them of some specific interest, with their biographies ‘well done’.28 This prompted a similar search in the ADB, with similar results. There are some 15 Coxes: a grazier, a pastoralist, a landowner, two clergymen, two doctors, a politician, a writer and a businessman. But, underlining the ADB’s consistently eclectic mix, there is also a pharmacist, an auctioneer, a real-estate agent, a military officer–road-maker–builder—and a ‘wild white man’ (Samuel Emanuel Cox, 1773–1891) (Volume 1). In reviewing Volume 14, Davis McCaughey argued that ‘the large number of entries and of authors, together with the exhaustive selection process, protects the volume from the charge of being arbitrary. The volume may be assumed to provide a fair cross-section of Australians who came to prominence in the mid- twentieth century’.29 The same volume was greeted with an enthusiastic review by Carl Bridge in the illustrious Times Literary Supplement.30 In an article entitled ‘Good Blokes and Others’, an almost exhilarated Bridge saw the volume as constituting ‘a sort of post-modern journey through Australia’s immediate past, peopled by a diverse cast of worthies, good blokes, crooks, eccentrics, rogues and grotesques’. ( ) p 29 Davis McCaughey, ‘Australian Dictionary of Biography, Volume 14’, Australian Historical Studies, no. 111 (1998), pp. 390–1. 28 Alan Bell, ‘Lt. Col. Finch and Other Worthies in the New ODB’, Sewanee Review, 115, no. 2 (2007), p. 281. 28 Alan Bell, ‘Lt. Col. Finch and Other Worthies in the New ODB’, Sewanee Review, 115, no. 2 (2007), p. 281. 29 Davis McCaughey, ‘Australian Dictionary of Biography, Volume 14’, Australian Historical Studies, no. 111 (1998), pp. 390–1. 30 Bridge ‘Good Blokes and Others’ 28 Alan Bell, ‘Lt. Col. Finch and Other Worthies in the New ODB’, Sewanee Review, 115, no. 2 (2007), p. 281. 29 Davis McCaughey, ‘Australian Dictionary of Biography, Volume 14’, Australian Historical Studies, no. 111 (1998), pp. 390–1. 30 Bridge, ‘Good Blokes and Others’. 28 Alan Bell, ‘Lt. Col. Finch and Other Worthies in the New ODB’, Sewanee Review, 115, no. 2 (2007), p. 281. 29 Davis McCaughey, ‘Australian Dictionary of Biography, Volume 14’, Australian Historical Studies, no. 111 (1998), pp. 390–1. 30 Bridge, ‘Good Blokes and Others’. 29 Davis McCaughey, Australian Dictionary of Biography, Volume 14 , Australian Historical Studies, no. 111 (1998), pp. 390–1. 30 Bridge, ‘Good Blokes and Others’. Balance in selection Yet for all these—the actress Dorothy Dunckley, who would return Christmas cards unopened, endorsing them with ‘and the same to you’; the skywriter Fred Hoinville; the loop-the-loop motorcyclist Jim Gerald; and the rainmaker Jack Johnson—Volume 14 was not just an amusement park rollcall (although Sir Leslie Stephen, the DNB’s first editor, used to emphasise the importance of ‘amusement’ as well as factual accuracy). Bridge also acknowledged the presence of Cardinal Norman Gilroy, Harold Holt, Howard Florey, Herbert Evatt, the Duke of Gloucester and Peter Finch. Even the estranged and disapproving Malcolm Ellis, who reviewed Volumes 1 and 2 so trenchantly, is accorded a sympathetic and measured entry in Volume 14. As for all of those who came before, there was a job to be done and the usual rollcall of less exciting eminences was captured and contained, including 59 politicians, 14 general practitioners and 13 judges. 307 The ADB’s Story Above all, the ADB has changed over time, quite obviously in gender and race, but also in occupation, State of origin and sexuality. Allan Martin made it clear in 1966 that the bias he saw in the subjects for the first period (up to 1850) was itself a reflection of what he believed to be the characteristic of Australian society: [C]andidates for such preservation are largely self-selecting: to then become more than a name on a registry file or shipping list one had to be literary enough to leave records, or noticeable enough to be written about contemporaneously by the literate. One result is that, despite the editor’s laudable admission of a few obscure individuals ‘simply as examples of the Australian experience’, this collection cannot represent a full cross-section of colonial society. We sense, for example, the shadowy presence of such types as town labourers, ordinary seamen, shopkeepers and bullockies, but none takes on substance unless he managed somehow to climb above his station or fall into terrible error. As is proper, there is a large contingent of convicts (fifty of them) but all are men who rate notice as examples of the exceptional—in culture, acumen, respectability or sheer devilry. Inevitably, the ‘cavalcade’ has its invisible men.31 Martin further notes, as has everyone else, that there were only 15 entries on locally born Australians and only five on Aborigines. Women hovered in the background with only half a dozen entries. 31 A. W. Martin, ‘Australian Dictionary of Biography, Volume 1’, Historical Studies: Australia and New Zealand, 12, no. 48 (April 1967), pp. 584–6. 32 Melanie Nolan, ‘The Place of the Few Among the Many? A Review Article on The Dictionary of New Zealand Biography, Volume Five, 1941–1960’, Making History [Ministry of Culture and Heritage E-journal], (2002) <http://www.mch.govt.nz/History/making-history/dnzb.html> E. Baigent, C. Brewer and V. Larmine, ‘Gender in the Archive: Women in the Oxford Dictionary of National Biography and the Oxford English Dictionary’, Archives, no. 113 (2005), pp. 13–35. 33 Jim Davidson, ‘It Takes All Sorts’, Eureka Street, 3, no. 2 (1995), p. 21. 31 A. W. Martin, ‘Australian Dictionary of Biography, Volume 1’, Historical Studies: Australia and New Zealand, 12, no. 48 (April 1967), pp. 584–6. 35 Lyndall Ryan, ‘Australian Dictionary of Biography, Volume 15’, Australian Historical Studies, 32, no. 2 (2001), pp. 153–4. Balance in selection As already noted, the old DNB recorded only 5 per cent of women among its entries while the ODNB has doubled this figure. The ADB has 14.3 per cent of women; the supplement volume had 29 per cent, similar to the Dictionary of New Zealand Biography, Volume 5, which boasts 28 per cent women.32 It is unanimously accepted that the percentage of women will increase in all national dictionaries as they progress, reflecting both the increasing number of prominent women and the ideological drive to include more. Jim Davidson noted that in the six volumes 1890–1939, the proportion of women had risen to 20 per cent. He quoted Patricia Grimshaw as observing that ‘[t]he only higher proportion of women will be found … in the index category “eccentrics”, where they stand at fifty per cent (of four)’.33 Most reviews, however, concentrated on the inclusions rather than the omissions. Martin noted that the two well-represented groups in the early volumes were ‘mediocre’ administrators—‘counting the twenty-two governors, they make up 308 10. Assessing the ADB: A Review of the Reviews more than a fifteenth of the whole’—and the respectable classes in the small communities, pursuing trade, landed or professional occupations. In assessing the first seven volumes, Lloyd Robson noted, too, but more sympathetically, the number of administrators from war and peace who were included: It is difficult to discuss the Great War without a knowledge of the men who made the crucial decisions, and it is equally impossible to discuss the first two generations of Australians without being aware that the archetypal convict was not a Great Man, and does not appear in the ADB, although his superiors do.34 Lyndall Ryan, while impressed by the entries in Volume 15—an incisive James McAuley, a commanding Robert Menzies, an outstanding Archbishop Howard Mowll, a superb Sir Rex Nan Kivell—found it had captured a fascinating but frustrating period in Australian history that shaped Australians who were dominated by World War II and the Cold War. 34 Robson, ‘The A.D.B.’, p. 397. 34 Robson, ‘The A.D.B.’, p. 397. 35 L d ll R ‘A t li Di ti f Bi h V l 15’ A t li Hi t i l St di 32 2 34 Robson, ‘The A.D.B.’, p. 397. 35 Lyndall Ryan, ‘Australian Dictionary of Biography, Volume 15’, Australian Historical Studies, 32, no. 2 y y (2001), pp. 153–4. 3 34 Robson, The A.D.B. , p. 397. 35 Lyndall Ryan, ‘Australian Dictionary of Biography, Volume 15’, Australian Historical Studies, 32, no. 2 (2001) pp 153–4 Balance in selection She was, however, encouraged by a brilliant entry on Johnny O’Keefe, which, while marking his demise, heralded the arrival of rock’n’roll, signalling ‘the end of what must now be seen as a sad and dreary era’.35 Table 10.1 Breakdown of ADB Entries in P Broad occupation Number Percentage Academics 96 6.7 Arts 229 16.2 Benefactors 7 0.5 Business 115 8.1 Community 67 4.7 Education 27 1.9 Journalism 62 4.4 Legal 44 3.1 Medical 81 5.7 Military 140 9.9 Miscellaneous 29 2.0 Politics 121 8.6 Professions 64 4.5 Public service 80 5.7 Religious 55 3.9 Rural 39 2.8 Science 78 5.5 Sport 75 5.3 Table 10.1 Breakdown of ADB Entries in Period 6 (those who died 1991–2000) Broad occupation Number Percentage Academics 96 6.7 Arts 229 16.2 Benefactors 7 0.5 Business 115 8.1 Community 67 4.7 Education 27 1.9 Journalism 62 4.4 Legal 44 3.1 Medical 81 5.7 Military 140 9.9 Miscellaneous 29 2.0 Politics 121 8.6 Professions 64 4.5 Public service 80 5.7 Religious 55 3.9 Rural 39 2.8 Science 78 5.5 Sport 75 5.3 able 10.1 Breakdown of ADB Entries in Period 6 (those who died 1991–2000) road occupation Number Percentage Table 10.1 Breakdown of ADB Entries in Period 6 (those who died 1991–2000) 309 y y (2001), pp. 153–4. The ADB’s Story The ADB’s Story Table 10.1 shows that the percentage of military entries has shrunk to less than one-tenth (9.9 per cent). Academics (6.7 per cent) and people involved in the arts (16.2 per cent) account for one-quarter of the entries. Table 10.1 shows that the percentage of military entries has shrunk to less than one-tenth (9.9 per cent). Academics (6.7 per cent) and people involved in the arts (16.2 per cent) account for one-quarter of the entries. Increasingly, commentary has noted that more recently published ADB articles are discussing the private lives of subjects. Volume 17, the last volume to appear before the ADB’s golden anniversary, retained the pace, standard and style of its predecessors but as it was the first to cover lives lost in the 1980s, it reflects the features and fortunes of that decade. Bobby Goldsmith succumbed, at the age of thirty-eight, to AIDS, that decade’s epidemic, while Dame May Couchman died at the age of one hundred and six (inexplicably, the editor, in her preface, overlooked the oldest dame in the history of the Commonwealth). Balance in selection Another sign of the times was the simple statement in Christopher Sexton’s entry on Sir Robert Helpmann: ‘Despite his showmanship, Helpmann was a private man. The great love of his life, with whom he shared a flat in London, was Michael Benthall (d. 1974)’.36 36 Christopher Sexton, ‘Helpmann, Sir Robert Murray (1909–1986)’, ADB, vol. 17, pp. 512–15. Change over time? Private lives: Sticking to the straight and narrow? A text search of the online ADB uncovered an extraordinary statistic. It revealed that the term ‘homosexual’ appears no more than 19 times. (Just to be sure, ‘gay’ was also searched: of the 54 occurrences, no more than four referred to a subject’s sexuality; the rest reflecting a proper name or the prevailing meaning of the word until the 1970s.) There is only one Australian identified in the 17 volumes as ‘bisexual’—the writer Colin Campbell McInnes (1914–76). And the term ‘lesbian’ appears but once—and even then to describe ‘Edwards, Marion (Bill) (1874–1956) transsexual barman, pony trainer and bookmaker’. Given that the first volume did not appear until 1966, and even allowing for editorial strictures on relevance and space, to identify some 20 men out of 10 500 as homosexual does seem rum. While this might smack of excessive circumspection, it should be noted that Michael Holroyd’s seminal life of Lytton Strachey that so boldly opened the bedroom doors of Bloomsbury did not appear until 1967 and it was another two decades, and The Times obituary of Sir Robert Helpmann, before obituarists turned their gaze upon the sexuality of their subjects. 310 10. Assessing the ADB: A Review of the Reviews Colin Matthew, editor of the ODNB, touched on this issue in his address to a conference on national biographies in 1995: [T]he public/private antithesis is one still followed by most DNBs, partly because the reaction against it is comparatively recent and partly because it is a serviceable way of incorporating such information in what is probably a brief article. To integrate fully the home and sexual life of a person who is, as most are, in a DNB for ‘public’ reasons, requires space, and space is money and time. But this incorporation is perhaps the central challenge for DNBs of our time.37 Mere statistics cannot be conclusive, but Matthew’s position may have influenced the ODNB, in which the term ‘homosexual’ appears 500 times. That said, it may not be quite fair to compare unfavourably the tight-lipped approach taken by the ADB in the mid 1960s with that of the ODNB three decades later. More recent ADB lives have indicated a shift. Elizabeth Webby’s comprehensive and elegant entry on Patrick White (Volume 18) has moved with the times and accorded Manoly Lascaris, his long-suffering companion, the status of ‘life partner’. 37 Colin Matthew, ‘Dictionary of National Biography’, in Iain McCalman, with Jodi Parvey and Misty Cork (eds), National Biographies and National Identity (Canberra: Humanities Research Centre, 1996), p. 11. 38 James Waldersee, Journal of Royal Australian Historical Studies, 57 (1971), p. 183. Change over time? Private lives: Sticking to the straight and narrow? While traditionally the ADB has taken the public road where the issue of sexuality is rarely crossed, with some lives it could simply not be avoided. The entry for Tasmanian-born actor and legendary swordsman Errol Flynn (Volume 8), by William Bryden, is remarkably bland and, at a mere three paragraphs, almost dismissive (his zoologist father, Theodore, with whom he shares the entry, has the lion’s share with four paragraphs). The great Grace Bussell suffered similar treatment in Volume 3: given a scant column inch while her obscure father garnered a full page.38 Having listed, with names and dates, but without more, Flynn’s three marriages, it follows with astonishing understatement: ‘Apparently a playboy all his life’. (Perhaps the fact-checkers, in the absence of an audit of assignations, would not permit anything firmer?) Two well-publicised trials for statutory rape that ended in Flynn’s acquittal may justify their omission, but do not his string of liaisons (including the last with a fifteen-year-old) bear upon the man, if not the actor, and warrant acknowledgment? Strangely, the author then cites, although without giving it credence, the allegation that ‘according to his most recent biographer, Charles Higham, [Flynn] was a friend to the Nazis during World War II’. Flynn, despite his shortcomings, deserves better. 311 The ADB’s Story This disappointing entry prompted a look at the entry of the American National Biography (ANB) on the ‘Tasmanian Devil’. At more than 2000 words (although it must be stressed that size does not matter), James Ross Moore’s exposition of Flynn’s life and legacy is excellent—rich in quotes and brimming with detail and insight: ‘Before he arrived in Hollywood in 1934, the man later called a “prince of liars” by his biographers essayed many adventures whose only common threads were twin lifelong loves: danger and the sea’. He also vividly marks the swashbuckler’s decline from ‘the true flower of chivalry’ and ‘a symbol for men of everything they longed to be and could not be’ to ‘a symbol of voracious sexuality’, ‘deferred from military service because a physical examination revealed malaria, a heart murmur, gonorrhoea, emphysema, and tuberculosis’. Bryden’s ADB entry on Flynn misses three available sources relied upon by Moore. Bryden does cite the North Shore Times but misses (as does Moore) the fascinating morsel that the young Errol, while at Shore School in Sydney, had shared the boarding house with John Grey Gorton. 39 Richard Brookhiser, ‘Who Counted?’ (Review of American National Biography), New York Times (23 January 2000). Change over time? Private lives: Sticking to the straight and narrow? Perhaps this coincidence might find its way into Sir John’s entry in a future volume of the ADB? In reviewing the ANB for The New York Times Book Review in 2000, Richard Brookhiser pronounced what he saw as the three elements that make a good biography: a clear exposition of the essential facts, vivid detail, and judgment.39 Mary Eagle’s essay on Sir William Dobell (Volume 14) is the model of what an entry should be and meets all three of Brookhiser’s criteria. The progress of his life is chronological and clear while vivid descriptions and wonderful anecdotes bring him to life. He ‘saved drastically on clothes’. His friend and fellow lodger Eric Wilson described him going out in the evening, ‘holding a newspaper under his right arm to cover the tear in his overcoat. Whenever his socks have holes … he simply paints his leg to match’. Eagle also matter-of-factly addresses his sexuality (‘From mid-1936 until September 1938 Donald Friend was based in London; he and Dobell were both homosexual and otherwise had similar tastes’). More importantly, she meets Brookhiser’s third criterion in assessing his importance: ‘Comparisons outside Australia may be made with the British painter Francis Bacon and the French photographer Henri Cartier-Bresson whose art was to choose “the decisive moment”’. Other lives that have found their way into both the ADB and the ANB deserve comparison—not to claim the superiority of one dictionary over the over, but to suggest the difference wrought by the winning combination of a lively author and a well-lived life. Peter Harrison’s ADB essay on Walter Burley Griffin is a model of eloquence and learning, although his judgment of Griffin’s legacy is perhaps too muted: ‘Although at the time of his death Griffin might have been 312 10. Assessing the ADB: A Review of the Reviews judged a failure, later generations regard his designs and ideas with a respect which would have astounded his contemporaries, and his surviving buildings are valued as part of Australia’s architectural history’. Paul Kruty’s considerably briefer entry for the ANB complements Harrison’s, taking a more global view of Griffin’s legacy: ‘Griffin stands as the third great member, after Sullivan and Wright, of the Chicago movement to create a decorated modern architecture for the twentieth century. 40 Peter Harrison, ‘Griffin, Walter Burley (1876–1937)’, ADB, vol. 9, pp. 107–10. Paul Kruty, ‘Griffin, Walter Burley’, American National Biography Online <http://www.anb.org/articles/17/17-01053. html?a=1&n=walter%20burley%20griffin&d=10&ss=0&q=1> accessed 2 July 2013. 41 David Horner, ‘MacArthur, Douglas (1880–1964)’, ADB, vol. 15, pp. 150–2. 43 ‘Grainger, George Percy (Percy Aldridge)’, American National Biography (New York: Oxford University Press, 1998). 44 Michael Piggott, ‘Brief Biography and the “all-round-man”’, Grainger Studies: An Interdisciplinary Journal, no. 1 (2011), pp. 5–20. 42 Kay Dreyfus, ‘Grainger, George Percy (1882–1961)’, ADB, vol. 9, pp. 69–72. Change over time? Private lives: Sticking to the straight and narrow? His buildings, landscapes, and town plans on three continents record a lifetime’s dedication to this goal’.40 Another Olympian American figure is Douglas MacArthur, who straddles the pages of both the ADB and the ANB. In the former, D. M. Horner does touch on the personal: ‘Conservative, moralistic and apparently religious, when he was chief of staff he had kept a young Eurasian mistress Isabel Rosario Cooper in a Washington hotel while his mother lived at his official residence’—which the ANB does not—but Horner quite properly focuses on the general’s time in Australia. Michael Schaller, in the ANB, takes an equally appropriate view of MacArthur, from an American perspective. Both entries refer to MacArthur’s address to Congress on his return home, and in doing so they highlight the different use to which quotes can be put. The ADB puts it thus: ‘he promised to “fade away—an old soldier who tried to do his duty as God gave him the light to see that duty”. Survived by his wife and son, he died on 5 April 1964’. The ANB concludes: ‘he closed his address by citing the words from an old army song: “Old soldiers never die. They just fade away”’. But it adds: ‘Clearly, the old general did not expect to fade away. He testified for several days during spring 1951 before congressional panels, trying to persuade the legislators of the wisdom of his strategy’. Schaller devotes a further three paragraphs to support his contention that the general was not for fading (as Horner suggests), and refers to MacArthur’s address at the 1952 Republican nominating convention in a bid for the White House. Suitably reflecting the national aspect of the ADB, however, Horner concludes: ‘Between 1942 and 1945 he had been the dominant figure in Australia’s conduct of World War II. Few figures who have spent less than three years in this country have had such an impact on Australian life’.41 Another lively double Australian–American entry is the tortured figure of Percy Grainger, who emigrated to the United States in 1914 and took US citizenship in 1918. Kay Dreyfus, in the ADB, is strong on Grainger the musician but she also provides a striking image of the man: 313 The ADB’s Story The fact that Grainger’s appearance matched his talent was a not insignificant component of his success. Change over time? Private lives: Sticking to the straight and narrow? As a young man, his Byronic good looks and his golden hair were almost as much admired and as often remarked as was the strength and vigour of his playing. In later years he affected a markedly eccentric presentation, a personal style which, if nothing else, made for good ‘copy’. Grainger’s pianistic feats were complemented by a vigorous athleticism; long-distance walking was a favourite if intermittent pastime. Throughout his life he abstained from alcohol and tobacco and in his middle years he became a vegetarian.42 In the ANB, J. Marshal Bevil presents a striking psychological portrait: His father’s philandering and alcohol abuse and his mother’s harshly domineering manner probably contributed to the emergence of a number of unusual traits in their son as he grew into manhood. These included immature emotional ties to his mother that lasted until her suicide in 1922, masochism, rigid self-discipline that included strenuous exercise, pervasive freneticism, comically bizarre behavior, and virtually uninhibited flights of creative fantasy.43 The ODNB also captures Grainger in an unflinchingly frank account: ‘He was one of the century’s more practised flagellants, equally at home in giving or receiving the lash’. The ADB is less forthcoming about Grainger’s relationship with Rose: His mother’s suicide in April 1922, from despair at rumours of incest and gathering effects of syphilis, was a crushing blow. She had been his constant companion, ‘managed’ his business, social and emotional affairs, guided his career with single-minded purpose. Her influence was definitive; her death left Grainger with a lifetime legacy of guilt and remorse. But, again, any account of Percy Grainger must be about his music and the ADB more than does justice to this: ‘His compositions for military band are regarded as classics of the genre; his settings of British and Danish folksongs are acclaimed for their sensitivity and appropriateness’.44 But, again, any account of Percy Grainger must be about his music and the ADB more than does justice to this: ‘His compositions for military band are regarded as classics of the genre; his settings of British and Danish folksongs are acclaimed for their sensitivity and appropriateness’.44 Sometimes the brilliance of the author makes any comparison, even with the same subject in another dictionary, absurd. A life in point is Manning Clark’s ADB entry on Joseph Furphy. Clark’s elegance, insight and wit shine from 314 10. Change over time? Private lives: Sticking to the straight and narrow? Assessing the ADB: A Review of the Reviews every paragraph: ‘he established a reputation as a Sterne in moleskins or a Munchhausen among the bullock-drivers. Nature had planted in him a vast fund of cheery optimism. All his life he was a stranger to the pessimism and the melancholy which weighed down Henry Lawson and other bush writers’. And later: ‘he began to have the “vision splendid”. It was to be a more serious- minded, non-Dionysian view of the fate of being a man in Australia’.45 This splendid essay makes one regret that Clark, although a section editor, has no more than four entries attributed to him. What conclusions can one reach from this perhaps indulgent and unnecessarily lengthy list of comparable lives between dictionaries? The most obvious is that the difference lies in the qualities of the author. The life and character of the subject are decisive but, despite the strictures and instructions of the editorial teams, or perhaps with their indulgence, a well-informed, well-written entry will shine through and make the obligatory, less dazzling entries more bearable. As Geoffrey Blainey noted of the first two volumes, and this has remained largely true of those that have followed, ‘individuality has not been suppressed’.46 Allan Martin echoed this: ‘No half-dozen pages lack an example of life bursting through as author answers to subject’.47 As he observed in reviewing Volume 2: As before, in entries great and small, the swift vignette is a source of life: Lang in full cry against Stuart’s ‘malice prepense of the foulest character imaginable’; Polding with a convict ‘kneeling by his side in the sanctuary, and by word and action, instructing all through one how to make their confessions’; Macquarie, the devoted husband and father, agreeing to have the family’s favourite old cow shipped all the way from Sydney to Mull.48 Surely, this is the stuff of biography. g p y p ( ) pp 46 Geoffrey Blainey, Papers and Proceedings [Tasmanian Historical Research Association], 15, no. 2 (1967), p. 59. 45 Manning Clark, ‘Furphy, Joseph (1843–1912)’, ADB, vol. 8, pp. 600–2. 48 Martin, ‘Australian Dictionary of Biography, Volume 2’, p. 133 g p y p ( ) pp 46 Geoffrey Blainey, Papers and Proceedings [Tasmanian Historical Research Association], 15, no. 2 (1967), p. 59. 47 Martin ‘Australian Dictionary of Biography Volume 1’ p 586 46 Geoffrey Blainey, Papers and Proceedings [Tasmanian Historical Research Association], f 47 Martin, ‘Australian Dictionary of Biography, Volume 1’, p. 586. y p g [ ‘Australian Dictionary of Biography, Volume 1’, p. 586. 47 Martin, Australian Dictionary of Biography, Volume 1 , p. 586. 48 Martin, ‘Australian Dictionary of Biography, Volume 2’, p. 133. The tyranny of space, the cramping form and the editor’s whip: Lean, mean and, most importantly, authoritative? Lawrence Goldman (editor of the ODNB since 2004) observed in his 2006 Seymour Lecture that ‘[t]he tone and style [of the DNB] was not grandiloquent, rhetorical and imperial, but business-like, factual and understated, and was praised as such in many quarters’. Significantly, he highlighted the distinct 315 The ADB’s Story ‘biographical memoir that has always characterised the DNB—the rounded, literary and rather more impressionistic portrait of the life and its context, inevitably longer and more discursive’. In contrast, Goldman admired ‘very much’ the ‘sharpness and focus of the entries in the ADB, even more so now that I appreciate the rigorous checking of each and every fact in a submitted article’.49 He realised it certainly in the wake of the fracas that broke through the general acclaim greeting the launch of the ODNB in 2004. It was said the ODNB was ‘riddled by error’.50 Its editors acknowledged error as ‘inevitable’ in such a large undertaking and pointed to the utility of online publication for it permitted ‘continual revision’.51 Allan Martin was typical in his review of Volume 2 of the ADB, noting two facts: ‘the high level of accuracy originally achieved by the editors and their staffs (the errors are, for the most part, trivial), and the continuing care devoted to revision and correction’.52 Yet he also observed: ‘Space tyrannises and a regular format cramps the multiple authorship, which sometimes cringes visibly under the editor’s whip. Plain, clear narrative is required, especially in the minor entries, and the pages fold quietly over corpses being decently docketted and laid back to rest’.53 Dedication to the truth is an abiding principle for the ADB and tends to explain its characteristic tautness and prudence. When interviewed in 1999, John Garraty, editor of the 24-volume American National Biography, published by Oxford University Press (OUP) that year, admitted that the OUP office in Cary, North Carolina, generated ‘well over a hundred thousand queries’ seeking confirmation of factual claims during the editorial process.54 In its five decades, the ADB will have well exceeded that number. Contributors could cite a plethora of examples. I will cite one from my own experience. My draft entry on Sir Edgar Tanner, sports administrator and politician (Volume 16), contained the assertion that 12 boys in his primary school class eventually became knights. 49 Lawrence Goldman, ‘Virtual Lives: History and Biography in an Electronic Age’, Australian Book Review (June 2007), p. 43. 50 Elizabeth Day, Sunday Telegraph (24 October 2004). Vanessa Thorpe, Observer (6 March 2005). Nikolai Tolstoy, Times Literary Supplement (3 December 2004). Lawrence Goldman, Times Literary Supplement (10 December 2004). 51 Giles Foden, Guardian [UK] (25 September 2004). Robin Fox, Journal of the Royal Society of Medicine. 52 Martin, ‘Australian Dictionary of Biography, Volume 2’, p. 133. 53 Martin, ‘Australian Dictionary of Biography, Volume 1’, p. 586. 54 William R. Ferris, ‘A Nation of Individuals’, Humanities, 20, no. 1 (1999). 55 Mark McGinness, ‘Tanner, Sir Edgar Stephen (1904–1979)’, ADB, vol. 16, pp. 361–2. 55 Mark McGinness, ‘Tanner, Sir Edgar Stephen (1904–1979)’, ADB, vol. 16, pp. 361–2. 52 Martin, ‘Australian Dictionary of Biography, Volume 2’, p. 133. y g p y p Martin, ‘Australian Dictionary of Biography, Volume 1’, p. 586. 51 Giles Foden, Guardian [UK] (25 September 2004). Robin Fox, Journal of the Royal Society of Medicine. , , , , ( ) 55 Mark McGinness, ‘Tanner, Sir Edgar Stephen (1904–1979)’, ADB, vol. 16, pp. 361–2. The tyranny of space, the cramping form and the editor’s whip: Lean, mean and, most importantly, authoritative? Some months later, in correspondence, the editor advised me that the team had only been able to confirm that seven boys in that class became knights.55 Ultimately, no mention was made at all of the subject’s early education. The 316 10. Assessing the ADB: A Review of the Reviews classic example of the ADB’s respect for truth appears in one of its corrigenda: ‘For “died in infancy” read “lived to a ripe old age in Orange”’.56 As Peter Ryan observed, ‘the Corrigenda show the conscience of the Dictionary at work’.57 For many years the ADB had a full-time staff member who compiled lists of corrigenda, which were consolidated and published with each new volume. Most of the corrigenda understandably relate to the earlier volumes, when authoritative material proved elusive, and much of it is prosaic, such as wrongly spelt names. A number of entrants have been found to have imagined themselves younger. Others, such as Daisy Bates, have been found guilty of inventing their early lives, only to be uncovered by full-scale biographies. Interestingly, since the ADB has gone online, protective descendants have plagued ADB staff with corrections. An assertion that one subject had a mistress was met with the (unfruitful) protest, a century on, that the woman was his ‘friend’. The ADB’s reputation for ‘sharpness and focus’ is a legacy of its founding editor. Bede Nairn’s essay on Douglas Pike (Volume 16) remarks on his passion for ‘conciseness, without the sacrifice of humanity and style’.58 Many a contributor has seen favourite anecdotes or observations scrapped. Again, I speak from experience. I thought it interesting and mildly amusing to say that when, in 1941, Sir Byrne Hart (Volume 17) was posted to Northern Command Headquarters as deputy assistant quartermaster general and required to arrange for the reception of the first American troops to arrive in Brisbane, ‘he proved most unpopular for feeding them mutton’. The editor thought otherwise. She may, however, have had good cause to jettison the observation that the only way the headmaster of the Southport School could tell Byrne and his twin brother apart was that one had webbed toes. 56 T. M. Perry, ‘Atkinson, James (1795–1834)’, ADB, vol. 1, pp. 42–3. 56 T. M. Perry, ‘Atkinson, James (1795–1834)’, ADB, vol. 1, pp. 42–3. 57 Peter Ryan, ‘The ADB’, Quadrant (June 2000), p. 88. 58 Bede Nairn’s essay on Douglas Pike: ADB, vol. 16. y ( ) 58 Bede Nairn’s essay on Douglas Pike: ADB, vol. 16. The tyranny of space, the cramping form and the editor’s whip: Lean, mean and, most importantly, authoritative? Though mine did not, many an anecdote has survived to publication and they add greatly to an appreciation of the subject and the readability of the text: John Aitken (Volume 1) carrying his sick lambs ashore one by one to found his flock; the Aborigine Arabanoo (Volume 1), who ‘was at first pleased by a handcuff on his wrist, believing it to be an ornament, but became enraged when he discovered its purpose’. Queensland silk Sir Arnold Bennett’s brilliance as an advocate is painted in one episode (Volume 17). Successfully defending, at a retrial, a man charged with poisoning a testatrix, Bennett suggested that the strychnine was self-administered. He stirred 40 Alophen pills into a glass of water and sipped it, ‘demonstrating to the jury that the extreme bitterness of the poison could not have been concealed’, and invited them to try it. 317 The ADB’s Story Rigorous pruning and paring of the entries by the ADB’s editors are justified on the bases of consistency, cost and proportion but one often longs for more. It might be said that many entries are simply too brief. The luxury of space accorded to the contributors (and readers) of the ODNB and the ANB is a cause for envy. And yet, in his review of Volume 17, Stephen Wilks observes that ‘almost all entries manage to be succinct without sounding disrespectfully terse’.59 With expansiveness comes a greater need for checking. In abiding by its doctrine of exactitude through concision, the ADB has been generally (except by Ellis) accepted as authoritative and untainted by error. Where the primacy of such a doctrine appears vulnerable for the dictionary is when according traits and values to its subjects. Of Volume 1, C. Hartley Grattan wondered whether ‘gently moralistic evaluations, usually to be found in final paragraphs, are to be too warmly encouraged from writers and, really, are of much use to readers. Maybe it is best to stick to “the facts”’.60 But surely some evaluation, some assessment of character or achievement is essential? Otherwise the result is merely a Who’s Who. Geoffrey Blainey raised the fundamental matter of sources, specifically the reliance on obituaries. 59 Stephen Wilks, ‘Dictionary Speaks Volumes of Our History’, Canberra Times (8 December 2007), p. 14. 60 Grattan, ‘Australian Dictionary of Biography’, p. 252. The tyranny of space, the cramping form and the editor’s whip: Lean, mean and, most importantly, authoritative? He noted an assertion in the entry on Sir Robert Officer (Volume 2)—Officer’s obituaries ‘made much of his unostentatious benevolence to the poor, his earnestness and personal piety’— and suggested it would be valuable if a historian could study the changing conventions underlying the portrayal of character, especially in newspaper obituaries. He proceeded to ask, ‘were such valuable judgments as “honesty”, “integrity”, “courageous”, “public-spirited”, “philanthropic”, “honourable”, used as we used them today? Were they used with some consistency throughout the nineteenth century?’ The same question could still be asked. The select bibliography throughout the ADB consistently contains references to subjects’ obituaries, which, until quite recently, have resembled eulogies in their tendency to gloss and extol, but again, they are cautiously employed in the manner of ‘obituaries praised his selfless…’, ‘obituaries portrayed…’; so perhaps Blainey’s advice has been heeded. In this regard, the development of Obituaries Australia, the digital repository of obituaries the NCB is publishing from newspapers, journals, magazines and bulletins, is welcomed. Comparing an ADB article with an obituary will expose the ADB craft. 60 Grattan, ‘Australian Dictionary of Biography’, p. 252. 61 Blainey, Book review (1969), p. 103. 62 Robson, ‘The A.D.B.’, pp. 3 and 95. y ( ) p 62 Robson, ‘The A.D.B.’, pp. 3 and 95. 61 Blainey, Book review (1969), p. 103. Conclusion How has the ADB been assessed? Most reviewers of the ADB considered it against some benchmark of good dictionary practice. Reviewers have been 318 10. Assessing the ADB: A Review of the Reviews largely indulgent of the ADB’s shortcomings in the face of its contribution to Australian history. Considering the ADB as a whole is difficult because one has to contextualise articles and take into account changing historical mores. Measuring comparable, or the same, lives between different dictionaries also requires indulgence because a dictionary based on submissions is necessarily patchy and individual examples are not necessarily indicative of the dictionary as a whole. Moreover some dictionaries, like the DNB, have been revised, while the ADB has not. What, then, makes the ADB distinctive from other dictionaries of biography? As early as Volume 3, the incisive Blainey ventured to identify three distinctive characteristics: ‘It is unusually sympathetic to confidence men, round pegs, and what the preface calls “samples of the Australian experience”’.61 What makes it different is its Australian-ness. The key remains the phrase repeated in the preface to successive volumes: the ADB’s inclusion of lives ‘as samples of the Australian experience’. As Lloyd Robson put it: [T]his would have shocked Stephen and Lee at the DNB, and the managers of the DAB [Dictionary of American Biography, precursor of American National Biography]: no one, however beneficent or favourable his conduct may have been towards his family and son, was to be a subject because he was ‘representative’, thundered Sir Sidney Lee, and both Britain and the United States set their faces against including such persons.62 The ADB’s sampling must be vulnerable to charges of imbalance, but its boldness in attempting to capture not just the exceptional but also the emblematic Australian is unique. The ADB’s sampling must be vulnerable to charges of imbalance, but its boldness in attempting to capture not just the exceptional but also the emblematic Australian is unique. Another abiding strength is devotion to truth. The dogged fact-checking begun in the 1960s continues unabated and, while it may annoy the more lyrical and speculative contributor, it does the ADB great credit. The other ADB trait that has also maddened two generations of contributors is dedication to concision. Another abiding strength is devotion to truth. Conclusion The dogged fact-checking begun in the 1960s continues unabated and, while it may annoy the more lyrical and speculative contributor, it does the ADB great credit. The other ADB trait that has also maddened two generations of contributors is dedication to concision. The loss of precious anecdotes and axing of prized adjectives have made many look longingly at more indulgent editors of other dictionaries. Some subjects may have been given such short shrift that one wishes they had been left d d l h ‘ ’ l h h h h b Another abiding strength is devotion to truth. The dogged fact-checking begun in the 1960s continues unabated and, while it may annoy the more lyrical and speculative contributor, it does the ADB great credit. The other ADB trait that has also maddened two generations of contributors is dedication to concision. The loss of precious anecdotes and axing of prized adjectives have made many look longingly at more indulgent editors of other dictionaries. Some subjects may have been given such short shrift that one wishes they had been left undiscovered until the ‘missing persons’ volume in which they may have been given more attention and space. But this discipline has also given space to more lives and lent each volume a consistency it would otherwise have lacked. As John Ritchie, the longest serving of all the ADB’s editors once observed, g The loss of precious anecdotes and axing of prized adjectives have made many look longingly at more indulgent editors of other dictionaries. Some subjects may have been given such short shrift that one wishes they had been left undiscovered until the ‘missing persons’ volume in which they may have been given more attention and space. But this discipline has also given space to more lives and lent each volume a consistency it would otherwise have lacked. As John Ritchie, the longest serving of all the ADB’s editors once observed, 319 The ADB’s Story ‘it is possible to craft an object of beauty in 500 words’.63 And, as the ADB’s reviewers have frequently found, there are many splendid examples of this in the 19 volumes that have so far appeared. Volume 18 of the ADB was launched at Government House, Queensland, in December 2012. g g g ( y ) p 64 Diana Streak, ‘Who, What, Where, When of Australia Online’, Canberra Times (7 July 2006), p. 2. 63 Robert Hefner, ‘Volumes of Work in a Long Reign of Editing’, Canberra Times (27 February 2000), p. 36. 64 Diana Streak, ‘Who, What, Where, When of Australia Online’, Canberra Times (7 July 2006), p. 2. 63 Robert Hefner, ‘Volumes of Work in a Long Reign of Editing’, Canberra Times (27 February 2000), p. 36. Conclusion From left: Pat Buckridge, chair of the Queensland Working Party, Melanie Nolan, General Editor, Penelope Wensley, Governor of Queensland, Tom Griffiths, chair of the Editorial Board B f C h J ki Volume 18 of the ADB was launched at Government House, Queensland, in December 2012. From left: Pat Buckridge, chair of the Queensland Working Party, Melanie Nolan, General Editor, Penelope Wensley, Governor of Queensland, Tom Griffiths, chair of the Editorial Board 65 Blainey, Book review (1969), p. 104. By courtesy of Cathy Jenkins Finally, the rarest quality of all to which the ADB can lay claim is democratic accessibility. Apart from New Zealand’s, no other dictionary of biography is freely available online to its readers. As John Ritchie’s successor, Diane Langmore, put it as the ADB went online, ‘I always felt it was eight million words of treasure locked up and … the online version will … unlock the treasures’.64 What Stephen Murray Smith had lauded in 1988 as ‘a remarkable gift to the nation’ had been given all over again. Many more people now access the ADB online than buy the book. The ADB site records some 70 million hits a year. And even if they are in a hurry, they could 320 10. Assessing the ADB: A Review of the Reviews not but be impressed by its scholarship and scope. Douglas Pike’s hope that the ADB ‘will inform and interest the lonely shepherd in his hut as readily as the don in his study’ must now be stretched to the homesick expatriate in his office offshore and the student on her laptop on campus. There has been a huge commentary on the ADB in the form of reviews over the years and this chapter has tried to summarise and analyse these critical assessments. Finally, as the essence of this chapter has been a review of the reviews, the words of Professor Blainey must again be called upon: a ‘review of a book which itself compresses the knowledge of several hundred contributors on a wide variety of these is bound to be subjective. Inadequacies of the book are far outweighed by the inadequacy of the reviewer’. As he wrote of Volume 3, and it remains apt, a reviewer cannot ‘really know how much this masterly book depended on the skills and efforts of the … editors … At the very least our debt to them is enormous’.65 Mark McGinness was a prosecutor in the Queensland Solicitor-General’s Office and, after a brief period in private practice, he joined the newly established Australian Securities Commission in 1991. He became coordinator of international enforcement in 1993, then director of international relations at the Australian Securities and Investments Commission, and has been director of international relations at the Dubai Financial Services Authority since 2005. 321 The ADB’s Story The ADB’s Story Book Reviews Hundreds of reviews of ADB volumes have been published in newspapers, magazines, and journals. These three, reprinted here, assess the ADB at its beginning, its midpoint (so far) and its most recent volume. It is fitting that the final review should be by Mark McGinness, the author of this chapter’s ‘Review of Reviews’. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) Douglas Pike, ed., Australian Dictionary of Biography, Volumes 1 and 2, 1788– 1850, Melbourne University Press, 1966, 1967. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) Douglas Pike, ed., Australian Dictionary of Biography, Volumes 1 and 2, 1788– 1850, Melbourne University Press, 1966, 1967. On first reading the inaugural volumes of the Australian Dictionary of Biography I realized how an early Australian settler must have felt when he received a packet of news from his home country. Indeed it would be more appropriate to liken the feeling to that of a settler answering an ‘anyone knowing the whereabouts’ advertisement and duly receiving his first home news for forty years. The dictionary brings news of hundreds of people whose name is more or less familiar to those interested in Australian history. It transforms our knowledge of many lives, adds much to our knowledge of others. If we had wondered why someone decided to migrate to Australia in 1813 or why he decided to go home in 1833, wondered what became of this New South Wales colonel or that judge, or had been forced to guess the social background of this squatter or that convict, the answer often is in these volumes. Even if this were the only service provided by the new dictionary, its publication would have been justified. But the dictionary provides many other services and clues for the practising historian and a remarkably sustained interest for general readers. In understanding the past there are, for most people, successive layers or levels of awareness. Sometimes the biographies in these volumes made me more aware of simple facets of early Australian society. By their pithiness, by the interest which a life story can arouse, they indirectly emphasise some themes with a force and clarity which no generalization can quite convey. For instance the life of Samuel Terry, told skillfully by Gwyneth Dow, makes one realize the social and economic mobility which was possible in early Australia at that time. Terry was a Manchester labourer, sentenced in 1800 to transportation for theft; if he had been born a century and a half later he might have risen to become a successful, and perhaps slightly shady, seller of secondhand cars without ever accumulating the capital to start his own car yard. In New South Wales, however, he landed on his feet, on ground fertile for those with commercial 322 10. Assessing the ADB: A Review of the Reviews acumen. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) When he died he had a personal estate of a quarter of a million and sufficient personal prestige to attract a regimental band to his funeral. Of course he was not typical, but neither was his experience rare, as many other biographies show. The dictionary indirectly conveys many other observations with a success which cannot be equalled by most general histories with their understandable emphasis on simplifying and generalising. It also suggests themes which I for one have not seen in other books and articles. One simple example: the number of rich Australians, who in the first sixty years retired to England points to a relevant factor in Australia’s balance of payments, a factor which probably so far has not been noticed. The volumes are well written, and this must be a tribute to the editors as well as the contributors. Some articles which might not add much to existing knowledge are still essays of distinction with the additional virtue that they marshall fragments of evidence hitherto widely dispersed. In reading I jotted down the articles which seemed so meritorious in presentation or so illuminating that they deserved reference in a review; the list became too long. L. R. Marchant’s articles on French navigators were, at least to me, a revelation. Michael Roe’s essays on men as different as a Tasmanian governor and a Victorian ‘beardy’ are eloquent and fascinating. Kenneth Cable on churchmen and teachers, Niel Gunson on missionaries, K. M. Dallas on Enderby the ship-owner, the late John O’Brien on Charles Laing the architect, Bede Nairn on Archbishop Polding, O. K. H. Spate on the Malay-Portuguese author, Eredia, and Peter Eldershaw on Lieutenant-Governor Davey are some of the articles which displayed differing techniques and facing different problems, seemed highly successful. Other reviewers, justifiably, could list a different set of articles; one virtue of these volumes is that individuality has not been suppressed. Occasionally an individual’s character appears too much in black and white. A New South Wales public servant is described as ‘both incompetent and dishonest’. Of an Adelaide candle-maker we are told: ‘His whole life was affected by a deep religious fervor’. A settler on the Hunter River is marked by ‘honesty of purpose’ and also by ‘sound common sense’—a phrase which, by the presence of a redundant adjective, incidentally hints that there is a trait known as ‘unsound common sense’. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) In most articles the prose is tight, and so a shortage of space perhaps justifies the use of emphatic phrases rather than conditional phrases such as ‘he was said by some to be honest’. But when some of the black and white judgments appear close together, the effect can be unsettling. Furthermore, the source material on some of these people being meagre, it may be dangerous to describe someone as honest or corrupt merely on the surviving evidence of one or two contemporary witnesses or on the strength of a court case which, judging by the recorded biographies of some magistrates, did not take place in the Court of Solomon. 323 The ADB’s Story Side by side with the sweeping depictions of personal character are far more which are careful without being over-timid. Thus Governor Macquarie, according to N. D. McLachlan, ‘probably had more integrity than most’ men of his day; this is the kind of realistic judgment which John Reynolds also displays in his articles. Much can be said for the practice—visible in some unsigned articles—of revealing the source of certain descriptions of character: ‘Officer’s obituaries’, notes the article on Sir Robert Officer, ‘made much of his unostentatious benevolence to the poor, his earnestness and personal piety’. Certainly, if a historian has studied a nineteenth-century life for a long period and if he has the aid of adequate sources, he is justified in making a more confident appraisal of character; but most contributors, understandably, did not possess these advantages. Many historians will be influenced, subtlety or strongly, by these opinions of character when weighing evidence and assessing the worth of witnesses in their own fields of research. The accuracy of these character sketches could therefore be of vital importance in view of the astronomical number of times the dictionary will be consulted. Indeed, before editorial work on the volumes covering the years 1851 to 1890 is completed, it would be valuable if a historian could study the changing conventions underlying the portrayal of character, especially in newspaper obituaries. Most writers in the next series of volumes will rely on the assessments of character and personality published in newspapers and magazines of the time; and yet we know very little about the conventions surrounding such obituary notices. For examples, was funereal courtesy more common in 1890 than in 1850? Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) Were such valuable judgments as ‘honesty’, ‘integrity’, ‘courageous’, ‘public-spirited’, ‘philanthropic’, ‘honourable’, used as we use them today? Were they used with some consistency throughout the nineteenth century, or did they rise or decline in the hierarchy of virtues? Similarly, does a slightly different set of assumptions underlie obituary notices in say the Hobart Mercury or the Launceston Examiner of the same year? I am not sure whether these questions are answerable; I suspect some are. This is a subject which probably justifies a doctoral thesis, and the Dictionary would be only one of many works which could gain from the findings. Without such analyses, contributors may be forced to accept at face value the judgments of obituary writers, when in fact such judgments can no more be translated uncritically into modern usage than say the pound-note of a century ago. It is difficult to assess character; it is perhaps even more difficult to assess the influence of an individual who has long been dead and whose life is sparsely documented. Most of us, in our historical research, more or less skirt the problem of weighing one man’s influence. In books which pursue a broad theme—the history of a colony or city or region—individuals tend to be drowned in the stream of events, and their actions come to seem inevitable, pre-ordained by 324 10. Assessing the ADB: A Review of the Reviews weightier trends and events. The unusual individual serves as a mere symbol, a bobbing piece of straw which indicates the force or direction of the current. Alternatively, in a biography, the author’s sympathy for and absorption in the one individual often magnifies that individual’s influence. In a general history, lack of space also assists in crowding out the individual, just as in the book- length biography an abundance of space elevates him. In a general history a writer usually takes full advantage of the valuable yet untrustworthy ally named Hindsight, which often makes events seem inevitable, an inevitability that the same historian would not assign so eagerly to the events and influence of his own life or the life of anyone else. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) These volumes are not easy to review, particularly because they represent both recent research and the specialized and long-accumulative knowledge of several hundred people. The number of times I was surprised by information is a reflection of my own previous ignorance and therefore my inability to write a comprehensive review. It is also risky for a reviewer to assess the merit of the editorial policy which shaped these volumes. One can only hope that in a future volume the national committee, general editor, or section editors will outline more fully the assumptions on which they are working. Any co-operative venture will gain if the aims and principles of the venture are disclosed as fully as possible to the co-operators. Moreover, this is a long-term project; and there seems to be some virtue in exposing the underlying principles to public discussion in the early stages, when these principles can, if necessary, be revised, rather than at a late hour when change is impossible. Finally, it is not unlikely that in the year 2017 historians may hold some different methodological assumptions and, if so, they may at times be wary of a work which is rather secretive about its own underlying principles. In the uniform preface to the first two volumes of the Dictionary of Australian Biography, the principles of selection receive two and a half sentences: Many of the names were obviously significant and worthy of inclusion. Others, less notable, were chosen simply as samples of the Australian experience. Some had to be omitted through lack of material… The phrases ‘obviously significant’ and ‘less notable’ are not (very) revealing. They are not really illuminating for the scoreboard school of history which learns a lot by adding up and categorizing: someday some of its adherents will probably use the dictionary to compute the importance of such types as London men, ex-servicemen, young men, in shaping early Australia. Fortunately, three roneoed sheets entitled ‘Analysis of Contributors’ and apparently compiled by the publishers, Melbourne University Press, were sent to potential reviewers with the aim of supplying more information of volume one. According to the analysis twelve biographies in volume one each received more than three thousand words; and of those twelve people eight were colonial governors. Similarly one in five of the biographies in the volume received more than 1250 words, and most of these longer biographies were administrators and professional men. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) Biographers make less use of hindsight, I suspect, partly because their narrative is absorbed with only one subject and can therefore go forward more evenly from year to year, whereas general historians have to push one phase of the story forward with a long leap and then return to pick up another thread which is similarly shuttled forward. All this has some relevance to the dictionary, because most people who contributed articles had had experience in writing about a general theme but not in writing biography. Furthermore in Australia, biography has had few skilled practitioners, and a biographical dictionary therefore poses problems; indeed this is one of its virtues. In most articles in these two volumes the problems of defining the individuals’ influence on their times did not arise; it was probably small, and the authors were wisely prepared to accept that assumption. The problem of assessing influence was usually tackled, however, by contributors writing articles on those pioneers who were regarded as significant and were therefore allotted a high quota of words by the editors. Thus Don Baker’s excellent article on John Dunmore Lang asked in the final paragraph: ‘Was Lang influential in this long process which culminated in a liberal, democratic and secular society? Or, was he like a man in a boat, shooting over the political Niagara, and furiously whipping the water to make it go faster?’ Baker concluded that Lang’s writings were of such a kind and volume that they ‘must have had a large, though unmeasurable, influence inculcating the colonial values which were dominant in Australia by the end of the nineteenth century’. Anyone reading the article will see how carefully he reaches this conclusion. On the other hand, Michael Persse in an absorbing essay summed up the influence of W. C. Wentworth: ‘More than any other man he secured our fundamental liberties and nationhood’. This is a bold conclusion: true, it could have been even stronger, for it only compares Wentworth’s influence to that of other men and not to that of wider and impersonal causes; but even within that context his judgment assumes a wide knowledge of a maze of events and many men. While some writers seem 325 The ADB’s Story rather too sweeping in asserting the influence of their favourite, most writers seem conscious of the difficulty of making judgment, especially at this stage of our knowledge of Australian history. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) The statistics point to some of the principles of selection and emphasis, but presumably only a minority of readers have access to them; one hopes that the statistics will be brought up to date and published in later volumes or in a learned journal. 326 10. Assessing the ADB: A Review of the Reviews An advertising leaflet which came with the review copy of volume one (but which does not accompany copies sold in shops) is more informative than the official preface. The general editor, Douglas Pike, remarks in the leaflet that the dictionary is primarily a reference work and so the ‘familiar’ names—the names which readers are most likely to look up—dominate the volumes. To these names, he writes, ‘have been added a few entries of almost forgotten characters, for no worse reason than they are samples of the Australian experience’. This note does not tie in with the official preface which allows one to assume that a considerable portion of the biographies were chosen as samples of the Australian experience. It would be interesting to know how many names were chosen because they were samples, and why such samples were thought necessary and indeed how they were selected. This is not a request for a mathematical formula or necessarily a criticism of the idea of selecting samples of the Australian experience; merely curiosity about the assumptions embodied in a work of importance. The preface in the first two volumes could mislead an intelligent reader into thinking that the dictionary embodies the experiences of a wide cross-section of Australian society whereas my impression, confirmed by the advertising leaflet, is that it concentrates largely on those people who had power, influence, success or notoriety. Of course the preface may be more accurate than the advertising leaflet. But even if the preface is correct, and the sample of the Australian experience is wide, it could be advisable to add a warning in the preface that the Australian dictionary is more democratic in content than biographical dictionaries of other countries, but is still much more a record of personal success than of failure and far more a record of the exceptional than the normal individual. Such a warning is necessary because the work aims to attract, and deservedly will attract, a wide audience. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) Some members of that audience will be tempted by the existing preface to jump to the conclusion that they are entitled to generalize about the Australian experience on the collective strength of these entries. Several other decisions of the national committee or the editors merit discussion; but any comment can only be speculative, because the volumes do not explain these decisions. The decision that many entries would be unsigned is puzzling, especially as some are of the highest standard. The decision to divide the project into self-contained series of volumes, one series ending at 1850 and the next at 1890, is not explained. I am not sure of the advantages of this policy; they may well outweigh the disadvantages. It is already clear, however, that this method has disadvantages. Many of the selected lives flourished both before and after 1850; thus a Tasmanian flour-miller, who was aged nineteen and a nonentity in 1850, and who lived on until the First World War, appears in the pre 1850 volumes. The speed with which many entries can be consulted will be 327 The ADB’s Story reduced by the gamble of deciding which volume to consult. This is not to argue positively that wrong decisions have been made, but to suggest instead the merit of writing a much longer expository preface to the next series of volumes. Judging by the initial volumes, the Australian Dictionary of Biography will probably be the most valuable reference work in Australian history; it is already one of the most readable works on Australian history. This twin achievement would have been unobtainable without outstanding editors. The general editor, Douglas Pike, and the section editors, A. G. L. Shaw and Manning Clark, claim no credit whatever for the success of these volumes. All their work has been inconspicuous, and we can only surmise how much energy, care, and scholarship they must have dedicated to the task. One imagines that in a team of several hundred players they were called on to bat on sticky wickets, catch in first slip, declare innings closed, protest against gloomy light, detect bodyline, check the scores, and makes centuries in even time on the last day—all this in addition to the obvious editorial functions of picking teams, deciding the order of batting and bringing on drinks. Unlike many captains they have not imitated W. G. Geoffrey Blainey, ‘The Australian Dictionary of Biography’, Papers and Proceedings [Tasmanian Historical Research Association], 15, no. 2 (November 1967), pp. 58–64. Geoffrey Blainey, Review of ADB, vols 1 and 2 (1967) Grace in refusing to be given out; a revised scoresheet labelled ‘corrigenda’ comes with each copy of the second volume. The last article in these volumes records briefly the life of Yuranigh, an aboriginal guide and traveller who died west of the Blue Mountains in 1850. The anonymous author quotes a tribute by Sir Thomas Mitchell to this obscure aboriginal: ‘his intelligence and his judgment rendered him so necessary to me that he was ever at my elbow’. The same will be said of these volumes for years to come. 328 10. Assessing the ADB: A Review of the Reviews Book Reviews Book Reviews Stuart Macintyre, Review of ADB, vol. 9 (1983) Bede Nairn and Geoffrey Serle, Gen. Eds., Australian Dictionary of Biography, Volume 9: 1891–1939, Gil-Lat, Melbourne University Press, 1983 Stuart Macintyre, Review of ADB, vol. 9 (1983) Bede Nairn and Geoffrey Serle, Gen. Eds., Australian Dictionary of Biography, Volume 9: 1891–1939, Gil-Lat, Melbourne University Press, 1983 The best way to appraise a reference series such as this is to live with it, consult it and browse it, thereby savouring its riches. To read a volume through is to dull the appetite; too many stories of achievement can pall, the structures of exposition grow formulistic, the overworked phrases turn into cliches. Yet the appearance of this, the ninth volume of a monumental series, demands a considered evaluation. The project, now moving towards completion barely a quarter-century after its inception, is a major feat of Australian scholarship. When finished we shall have 7000 lives recorded accurately, readably and accessibly. Praise is due to the editors, the Australian National University which has provided a home for the project, and the Melbourne University Press which has produced and keeps in print such handsome volumes. Beyond these principal partners, we owe thanks to the working parties in each of the States, which prepared the lists of biographical subjects, and to the many hundreds of authors who have provided the entries. For the ‘ADB’ is a co-operative project and as such it rests on compromise— or rather a series of compromises. The claims of one candidate for inclusion have to be measured against another. (Do you give the nod to this businessman or that bishop?) The weight of contemporary importance has to be balanced against retrospective criteria of representatives. (Yet another State politician or a pioneer female doctor?) Since they depend on voluntary labor, the editors rely to a degree on who they can find to execute their plans. (Hence there seems no shortage of military historians but, on the evidence of this volume, biographies of Australian Rules footballers are thin on the ground.) And as a commercial project, the needs of the scholar have to be set against the interests of the general reader. (Thus some entries suffer ‘who’s who’ constipation while others strive perhaps too hard for the colourful anecdote. 329 The ADB’s Story What is the outcome? As we would expect, there is a heavy emphasis upon conventional achievement. Almost a fifth of the entries and a quarter of the space are taken up by State and Federal politicians, an eighth by businessmen and another eighth by war heroes and leaders. Stuart Macintyre, Review of ADB, vol. 9 (1983) Other categories of eminence in descending order of emphasis, are: writers, artists, musicians and actors; scientists, inventors, architects and the like; religious figures; educationalists; doctors and nurses; lawyers; sportsmen; administrators. There are five subjects of Aboriginal descent, three Japanese, one Chinese. Women make up less than a tenth of the whole. My Procrustean bed would not be taken too seriously—how does one categorise an ‘artist, bimetallist and pioneer daylight surfer’, a ‘versifier and swindler’ or a ‘merchant and litigant’. But clearly if you had aspired for admission to this Hall of Fame, it was best to have been masculine, rich and to have made your mark in a field of conventional esteem. Hence the two Knox families of BHP and CSR fame earn five entries in this volume. If you were a sportsman, it was best to have played cricket or Rugby League, preferably in Sydney, and futile to have played any sport in Western Australia or Tasmania. Alternatively, if a scoundrel, you should have been a colourful or notorious one like Isabel Gray, the courtesan, or Handcock, the associate of Breaker Morant. Certain features are common to each entry. First the formalities: name, dates and field of activities. Next, a brief account of ancestry and circumstances of birth; then the main section, a biographical narrative. Here the tone is equable, praising judiciously (‘Kind, courteous and unassuming’), criticising by decorous allusion (‘her bedroom was a scene of great activity’) and gentle irony (‘the results were often controversial’). The penultimate paragraph will offer a thumbnail characterisation and, perhaps, suggest the magnitude of the achievement. The standard entry concludes, as it began, on a formal note: death, descendants, estate. It is an undemanding format, well suited to the uneven abilities of the contributors. The conventions assure that the enthusiastic will not wander too far off course, and they need not become monotonous unless you feel impelled to read from cover to cover. Nor is the formula necessarily restrictive. Like the fugue or the sonnet, it imposes rules of composition within which the writer can give free play to ingenuity, and it is possible to achieve a richly dramatic effect. Roger Joyce follows the form closely in his fine large-scale entry for Samuel Griffith; Patrick O’Farrell relaxes the narrative principle in his striking portrait of Archbishop Kelly. It is an undemanding format, well suited to the uneven abilities of the contributors. Stuart Macintyre, Review of ADB, vol. 9 (1983) The conventions assure that the enthusiastic will not wander too far off course, and they need not become monotonous unless you feel impelled to read from cover to cover. Nor is the formula necessarily restrictive. Like the fugue or the sonnet, it imposes rules of composition within which the writer can give free play to ingenuity, and it is possible to achieve a richly dramatic effect. Roger Joyce follows the form closely in his fine large-scale entry for Samuel Griffith; Patrick O’Farrell relaxes the narrative principle in his striking portrait of Archbishop Kelly. These are longer entries and the shorter entry of 800–1000 words is perhaps more challenging. The danger here is that the record can crowd out the person—so 330 10. Assessing the ADB: A Review of the Reviews many entries fail to establish a sense of personality or even to provide a physical description. Yet consider the force of this brief passage from Geoffrey Blainey’s entry for Paddy Hannan: He was short and slight and his face was weather beaten. A photograph in old age shows a bald head, wispy beard, strong nose and searching eyes. The account of the ‘gun’ shearer, Jacky Howe, achieves more with the description: ‘17-inch biceps and a hand the size of a small tennis racket’ than a list of tallies ever could. Again James Griffin’s masterly entry for William Hackett, priest and confidant of Mannix, tells us that he farewelled the boys leaving Xavier in 1939 with these instructions: ‘Keep fit. Don’t grumble. Shoot straight. Pray Hard’. Revealing in a different sense are the bromides and euphemisms that punctuate the more pious entries. Too often we hear the subject was ‘tough and determined’, a ‘firm disciplinarian’, ‘forthright in her speeches and opinions’, or—I like the modifiers here—was ‘remembered by his descendants as fairly remote and rather stern’, ‘strict when necessary’ and ‘took his responsibilities too seriously to be popular’. We have here an ideology of Australian leadership, challenging yet at the same time constrained by the egalitarian ethos. Cumulatively, these entries provide (mostly unwitting) commentary of the abilities of leadership, and the loneliness and strains it imposes. The more successful entries recognise frailties of temperament. The marriage of Charles Kingston, we are told, ‘was not a happy union and he soon returned to lechery’. Zelman Cowen acknowledges Issac Isaac’s ‘appalling certainty’, and the acknowledgement in no way diminishes his stature. Stuart Macintyre, ‘A Monumental Series Marches On’, Age [Melbourne] (1 October 1983), p. 18. Stuart Macintyre, Review of ADB, vol. 9 (1983) Others are alluded to be martinets; their families can disintegrate, they can hit the bottle and even take their own lives. Equally they can spend their declining years in uneventful happiness. In the end, one is left with a sense of the richness of individual experience. And also mutuality. My last impression from reading this volume is what a clubbable lot our notables were not just in the Melbourne Club or Sydney’s Union and Australia’s clubs but as Wallabies, Savages and Boobooks in the national capital that was Melbourne in the early years of this century. 331 The ADB’s Story Book Review Book Review Mark McGinness, Review of ADB, vol. 18 (2012) Review, Melanie Nolan, Gen. Ed., Australian Dictionary of Biography, Volume 18: 1981–1990, L–Z, Melbourne University Press, 2012 Mark McGinness, Review of ADB, vol. 18 (2012) And Ethel (Monte) Punshon, described in the 1980s as the world’s oldest lesbian. She died in 1989 aged 106, having taught English in Tokyo and was appointed to the Japanese Order of the Sacred Treasure. There are about 160 women—more than in any of the previous 17 volumes. Apart from nurses, nuns and educationists, there are three booksellers, a beautician, and a botanist, a pianist and a puppeteer. Dames Enid Lyons and Merlyn Myer sit comfortably among the entries with Enid Lorimer and Olga Masters, Christina Stead and Grace Cossington-Smith. And Ethel (Monte) Punshon, described in the 1980s as the world’s oldest lesbian. She died in 1989 aged 106, having taught English in Tokyo and was appointed to the Japanese Order of the Sacred Treasure. The ADB is something of a sacred treasure itself. When Volume 1 appeared, Professor Geoffrey Blainey predicted the ADB would ‘probably be the most valuable reference work in Australian history; it is already one of the most readable works on Australia history’. He concluded, ‘The last article in these volumes records briefly the life of Yuranigh, an aboriginal guide and traveller who died west of the Blue Mountains in 1850. The anonymous author quotes a tribute by Sir Thomas Mitchell to this obscure aboriginal: “his intelligence and his judgment rendered him so necessary to me that he was ever at my elbow.” The same will be said of these volumes for years to come’. Has the ADB held up to that promise? It’s true, most of its reviewers (including this one) have also been contributors, but a half-century of sustained scholarship and 12,000 Australian lives is an extraordinary achievement. Biographer (and contributor) A. W. Martin wrote, ‘Plain, clear narrative is required, especially in the minor entries, and the pages fold quietly over corpses being decently docketted and laid back to rest’. This reviewer’s entry on Sir Douglas Wadley, ‘solicitor and company director’, was one of these—a sober account of a good man and a gifted, public-spirited professional. There are many like this—so matter-of-fact, as dry as the outback in drought. Part of this is a legacy of the first editor, Douglas Pike, who had a distaste for adjectives and adverbs, maintaining, half in jest, as there were no adjectives in the Psalms there would be none in the ADB. Mark McGinness, Review of ADB, vol. 18 (2012) Review, Melanie Nolan, Gen. Ed., Australian Dictionary of Biography, Volume 18: 1981–1990, L–Z, Melbourne University Press, 2012 Last year the Australian Dictionary of Biography celebrated its 50th anniversary and to crown it, Melbourne University Press has published Volume 18, completing an account of Australian lives which ended between 1981 and 1990. It begins with Maurice Lachberg, trade unionist, communist and cabinet-maker; and finishes with Mervyn Zischke, apostle and leader of the Apostolic Church of Queensland. If this gives a hint of the eclectic mix, a flick through the pages and 669 lives confirms it—there’s Bing Lee and Ben Lexcen, John Meillon and Hephzibah Menuhin, Lloyd Ross and Lloyd Rees, Sir John Pagan and Sir Sidney Pope, Patrick White and Cyril Pearl, Douglas Stewart and Kenneth Slessor, Robert Trimbole and Kylie Tennant, Margaret Woodhouse and Olwen Wooster. One expects a solid representation of generals and judges, politicians and pastoralists, artists and academics and they duly appear. The convicts (50 of them) and pastoralists of the early volumes have given way to community workers and businessmen. There are no less than 100 knights in Volume 18. The two benighted Billies—McMahon and Snedden—are given fair and thorough assessments. Lionel Murphy’s eventful life and its tragic end are judiciously dealt with by Brian Galligan, with a generous tribute from Michael Kirby and a neat quote from Barry Jones, ‘a passionate participant in the human adventure. He was magnetic, fearless and even reckless’. The ADB formula is long-established—how they looked and what they did to make it in; but also their parentage, education, partners and issues—even the precise medical cause of death, the funeral arrangements and, until recently, the extent of the deceased’s estate. And while the great and the good are well represented, there has been a great effort to honour the aim to reflect ‘the Australian experience’. There is a solid representation of Indigenous Australians—Cinderella Simon and Valentine McGinness; councillors and activists, a cameleer, a clergyman, two campaigners and at last a governor, Sir Doug Nicholls. 332 10. Assessing the ADB: A Review of the Reviews There are about 160 women—more than in any of the previous 17 volumes. Apart from nurses, nuns and educationists, there are three booksellers, a beautician, and a botanist, a pianist and a puppeteer. Dames Enid Lyons and Merlyn Myer sit comfortably among the entries with Enid Lorimer and Olga Masters, Christina Stead and Grace Cossington-Smith. Mark McGinness, ‘The Aussie Experience’, Canberra Times (13 July 2013), ‘Panorama’, p. 23 Mark McGinness, Review of ADB, vol. 18 (2012) But more importantly, in its authoritativeness and its zeal for the truth, the ADB dares to be dull. It is, after all, a dictionary. Yet many an adjective, anecdote and vivid vignette survive, adding immeasurably to an appreciation of the subject and the readability of the text. There is a sparkling entry by K. S. Inglis of Stephen Murray-Smith. As a commissioning editor, ‘His imagined typical reader was a matron at a hospital somewhere near Port Hedland’. There is Lloyd Rees exhibition’s after his visit to Chartres Cathedral: ‘he envisaged Australia through European eyes, and Europe through Australian eyes’. And Sir Colin Syme, ‘one of the leading businessmen of his generation … although living in Toorak, he continued to drive an old Holden 333 The ADB’s Story car, used a battered plastic briefcase…’ And heart surgeon, Harry Windsor, ‘When he first started cardiac surgery he used to sleep next to the patient’s bed and he did this for years’. car, used a battered plastic briefcase…’ And heart surgeon, Harry Windsor, ‘When he first started cardiac surgery he used to sleep next to the patient’s bed and he did this for years’. While traditionally the ADB has stuck to the straight and narrow, taking the public road where the issue of sexuality is rarely crossed, the last few volumes have opened the odd bedroom door. We learn of Sir Billy Snedden, ‘Returning to his Rushcutters Bay motel room with a female companion in the early hours of 26 June, he died there soon after of coronary artery disease’. Hal Porter apparently had relations with a son of his biographer. After the war, journalist Sam White, ‘… returned to Europe and began an affair with the novelist Nancy Mitford, using his volatile friendship with her to gather stories on British expatriates in Paris’. In its impeccable devotion to the facts, the ADB, and the author, rely on an obituary by Robert Haupt in the Age as the source of the claim but the affair is a surprise to no less than four of Miss Mitford’s biographers. The ADB is full of surprises but the biggest surprise is how little known it remains. Since 2006 it has been available online—and free but, it must be said, that no Australian library, home or office, should be without those 18 royal blue-jacketed tomes, the ultimate source of the Australian experience. 334 ADB Volumes Douglas Pike, gen. ed. Volume 1: 1788–1850, A–H (1966) Volume 2: 1788–1850, I–Z (1967) Volume 3: 1851–1890, A–C (1969) Volume 4: 1851–1890, D–J (1972) Volume 5: 1851–1890, K–Q (1974) Bede Nairn, gen. ed. Volume 6: 1851–1890, R–Z (1976) Bede Nairn and Geoffrey Serle, gen. eds Volume 7: 1891–1939, A–Ch (1979) Volume 8: 1891–1939, Cl–Gib (1981) Volume 9: 1891–1939, Gil–Lat (1983) Volume 10: 1891–1939, Lat–Ner (1986) Geoffrey Serle, gen. ed. Volume 11: 1891–1939, Nes–Smi (1988) John Ritchie, gen. ed. Volume 12: 1891–1939, Smy–Z (1990) Volume 13: 1940–1980, A–De (1993) Volume 14: 1940–1980, Di–Kel 1996) Volume 15: 1940–1980, Kem–Pie (2002) John Ritchie and Diane Langmore, gen. eds Volume 16: 1940–1980, Pik–Z (2002) Diane Langmore, gen ed. Volume 17: 1981–1990, A–K (2007) Douglas Pike, gen. ed. Volume 1: 1788–1850, A–H (1966) Volume 2: 1788–1850, I–Z (1967) Volume 3: 1851–1890, A–C (1969) Volume 4: 1851–1890, D–J (1972) Volume 5: 1851–1890, K–Q (1974) Volume 2: 1788–1850, I–Z (1967) Volume 3: 1851–1890, A–C (1969) Volume 4: 1851–1890, D–J (1972) Volume 5: 1851–1890, K–Q (1974) Bede Nairn, gen. ed. Volume 6: 1851–1890, R–Z (1976) Bede Nairn and Geoffrey Serle, gen. eds Volume 7: 1891–1939, A–Ch (1979) Volume 8: 1891–1939, Cl–Gib (1981) Volume 9: 1891–1939, Gil–Lat (1983) Volume 10: 1891–1939, Lat–Ner (1986) Geoffrey Serle, gen. ed. Volume 11: 1891–1939, Nes–Smi (1988) John Ritchie, gen. ed. Volume 12: 1891–1939, Smy–Z (1990) Volume 13: 1940–1980, A–De (1993) Volume 14: 1940–1980, Di–Kel 1996) Volume 15: 1940–1980, Kem–Pie (2002) Bede Nairn, gen. ed. Volume 6: 1851–1890, R–Z (1976) Bede Nairn, gen. ed. Volume 6: 1851–1890, R–Z (1976) The ADB’s Story Melanie Nolan, gen. ed. Volume 18: 1981–1990, L–Z (2012) Christopher Cunneen with Jill Roe, Beverley Kingston and Stephen Garton Supplement, 1580–1980 (2005) Hillary Kent Index to Volumes 1–12, 1788–1939 (1991) The ADB’s Story Melanie Nolan, gen. ed. Volume 18: 1981–1990, L–Z (2012) Melanie Nolan, gen. ed. Volume 18: 1981–1990, L–Z (2012) John Ritchie and Diane Langmore, gen. eds Volume 16: 1940–1980, Pik–Z (2002) 337 Hillary Kent Index to Volumes 1–12, 1788–1939 (1991) 338 ADB Volumes ADB Volumes 339 The ADB’s Story 340 ADB Volumes 341 The ADB’s Story 342 ADB Volumes 343 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 Philip Carter Anniversaries, like that to mark the Australian Dictionary of Biography’s recent half-century, are principally times for looking back and reflecting on what has been done. But they can also be opportunities for assessing current situations and thinking about the future: what could be done, and what might be possible at the start of the next half-century. For most of the ADB’s first 50 years the sole medium for publishing Australian lives, and those of other national biographies, was print, either as sequential chronological volumes—as favoured by the ADB and the Dictionary of Canadian Biography (DCB) and the Dictionary of New Zealand Biography (DNZB)—or as complete series, as with the American National Biography (ANB) and the Oxford Dictionary of National Biography (ODNB), which appeared in 1999 and 2004 respectively. The last two titles were also notable for their simultaneous online editions, marking an important development in how national biographies are made available and may be used. By the time the ADB went online in 2006, it joined the ANB, DCB, ODNB and DNZB (and has itself since been joined by digital versions of the dictionaries of Swedish, Welsh, Ulster and most recently Irish national biography), as well as a range of specialist titles including dictionaries of Scottish architects, labour biography, the New Grove dictionaries of art and music, and the United Kingdom’s History of Parliament. As a solely print publication, the 25-volume Diccionario Biográfico Español (2011) is the exception that proves the rule. In response to online publishing’s ascendency, practices and expectations are being transformed as publishers, researchers and readers come to appreciate the close fit between that eminently traditional genre, biographical reference, and the contemporary medium of the Internet. The degree of this transformation is worthy of note. As recently as 2004–05 there was, among editors and publishers of the ODNB, a sense that its print and online versions were equal partners that most readers would use interchangeably. Now, as we approach the tenth anniversary of the ODNB’s publication, what is striking is the extent to which the online edition has become the dominant and preferred form for reference, research and also reading. An anniversary like the ADB’s therefore 345 The ADB’s Story allows us to appreciate how the recent past, the present and most certainly the future of national biography lie online. But the ADB anniversary also prompts consideration of several further issues. 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 What, for example, does the ascendancy of online reference mean for how national biographies are being (and could be) compiled? How might the online environment shape editors’ work as custodians of their respective national histories? To what extent are researchers willing to treat online dictionaries not just as ‘super-accessible print’ but as new resources in which the ability to make connections between people shifts perspectives from biography to history; from, in effect, discrete biographies of those who shaped a nation to a nation’s history told through the lives of its people? This chapter considers these topics by looking principally at the recent history of the ODNB online, though where possible also with reference to the ADB and to other national biographies. After setting the respective dictionaries in context, the chapter considers the ODNB’s experience—aims, challenges and, above all, opportunities—through several stages: its inception as a continuous online publication; the extension and interpretation of biographical content; the work to preserve and improve prompted by other online resources; and attempts to use digital publicity and social media to promote the dictionary as a national resource and institution. The chapter’s conclusion returns to challenges and opportunities—witnessed and perhaps future—with particular reference to research possibilities within and between national biographies, a subject of shared interest for the ODNB and the ADB. ODNB and ADB in context In early 2005 the ODNB’s publisher, Oxford University Press, began a program of three annual updates in which new biographies and other forms of content (along with revisions to existing entries) were added online in January, May and September of each year. By early 2013 the ODNB had published 25 such updates, which have extended its coverage (which stood at 55 113 people in 2004) by a further 3432 men and women, active between the first and twenty- first centuries, together with 504 ‘reference articles’ designed in various ways to place individuals in historical context. Continuation, extension and upkeep are not unique to the ODNB. Since 2005 the DNZB online has been part of the larger, interpretative Encyclopaedia of New Zealand site (<http:// TeAra.govt.nz>); in the following year, the ADB online began a program of corrections and amendments, while from 2000 the ANB has regularly revised and added to its coverage (1348 new lives in 32 sets by late 2012). The last is a model followed by the DCB, to which a small selection of biographies has been published ahead of the appropriate print volume, and by the new Dictionary of Irish Biography, with a first update of 36 biographies in November 2010, 346 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 and a further 153 lives in four subsequent updates to 2012. Relative to the ODNB, however, these currently remain limited exercises. What distinguishes the ODNB are the extent, complexity and ambition of its online edition, evident both in the amount of biographical and reference content published and in the attention given to its promotion as an accessible, national resource of relevance to multiple readerships. The attention paid to the ODNB’s development as a national record derives from particular circumstances, reminding us that, while national biographies may have shared aims and approaches, their forms reflect political, cultural and commercial contingencies. The degree to which national circumstances, and even character, might shape the creation and continuation of such works is an interesting question worthy of further consideration. Even a cursory comparison of the historical and cultural contexts in which the ODNB and ADB have been, and continue to be, compiled suggests an influence that is not insignificant. 1 For an early commentary on the influence of ‘national preoccupations’, with a specific focus on the ADB, see James Walter, ‘Seven Questions about National Biography’, in Iain McCalman, with Jodi Parvey and Misty Cork (eds), National Biographies and National Identity (Canberra: Humanities Research Centre, 1996), pp. 22–6. ODNB and ADB in context How, for example, does a historically rich, predominantly London-centric society like Britain’s create, view and look after its national figures compared with a younger, federal Australia with what (at least to an outsider) appears a more explicit interest in its national story?1 One implication is that since 2005 the ODNB online has existed, and as a subscription service must thrive, in a relatively more competitive cultural environment in which the telling of national history is variously undertaken by galleries, museums, archives, public broadcasters and a host of free, ‘open-web’ resources. Comparisons between the ODNB and the ADB point to further differences, most notably that the Oxford project is at a different phase in its academic and publishing cycle, with important consequences for what is required and possible for its respective digital editions. Thus, with a full A–Z sequence already published, editors at the ODNB are able to combine work to extend the dictionary’s coverage with that of ‘curating’ the 55 000 lives already in place. That we now see ourselves as curators as well as academic editors is a significant transition, and one directly attributable to an online format in which a traditional, alphabetical ‘national biography’ has become a digital ‘national collection’. The implications of this changing perception are wide ranging, intellectually stimulating and as yet little considered. Released from the presentational strictures of print reference, it is possible online to select, study, connect and present historical individuals or groups of people in new ways. Indeed, such is the importance of this idea that, as this chapter suggests, 347 The ADB’s Story it is as meaningful to understand today’s ODNB with reference to museums or galleries—to speak of acquisition and interpretation, preservation, curation and outreach—as it is to traditional book publishing. These specific national contexts and publishing histories inevitably make for distinctive forms of Australian and British biography. Equally the growing prominence of online formats in reference publishing, and the appreciation of editors in Oxford and Canberra as to its importance, also reminds us of the connections between our projects and those of other national biographies. Though online reference is now ubiquitous, the ODNB and ADB are examples of what is still quite a rare creature: an academically rigorous, trusted and sustained resource that has transferred or is in the process of transferring to a wholly online environment committed to further development. ODNB and ADB in context The particular focus on the ODNB, as here, seems warranted given the distance it has come since 2005 as a pioneer of this genre—serving to highlight the changing working methods, requirements and perceptions of national biography derived from being online. Some of these experiences remain particular to a project in a specific intellectual and cultural climate, but others do suggest shared opportunities for national biography. Online from 2005: Three decisions Publication of the ODNB in 2004 brought to a close a 12-year research and publishing project of the University of Oxford and Oxford University Press. The edition comprised newly written, or substantially revised, versions of the 38 607 biographies that had made up the ‘first’ DNB, consisting of Leslie Stephen and Sidney Lee’s ‘Victorian edition’—that is, 63 volumes (1885–1900) and its retrospective supplement (1901), together with the decennial and quinquennial volumes that mapped the twentieth century (published between 1912 and 1996), and a further ‘missing persons’ volume in 1993. To this set, the 2004 edition added biographies of a further 16 315 men and women active (with a handful of exceptions) between the first and the late-twentieth centuries and deceased on or before 31 December 2000. Well before publication of the complete series of 55 113 lives, attention turned to the dictionary’s future with a particular focus on its online presence after 2004. Here several options were available to a title that had been published as a complete sequence in then identical print and online editions. One possibility was to keep the content stable, at least for a few years, which was perhaps not unreasonable given the dictionary’s scale and the research opportunities awaiting its readers. That this was not considered, even then, owed much to the prevailing intellectual case for continuing to extend a collection whose 348 1. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 50 000 articles (in which the 55 113 lives appeared) had always been regarded as a sensible marker, not the sum total, of British history. Seeking to develop the dictionary’s content from publication also showed an appreciation that successful online reference, then in its infancy, both could and should ‘add value’ relative to print. Rejecting stasis in favour of ‘organicism’ now required decisions concerning the definition of ‘value’: what was to be added and why?2 The first decision was to ensure the dictionary’s chronological progression— that is, the addition of people who had died in or after 2001. This made lexicographical sense, being readily interpretable and innovative; then, and now, no other national biography systematically covers the ‘recently deceased’ and with it late-twentieth and twenty-first century history. Since 2005 it has led to the publication of one annual update (released each January), which adds about 220 biographies of people who died in a single calendar year. 2 On the notion of the ODNB online as ‘organic’, see Lawrence Goldman, ‘No Smoking Dons. The ODNB and the New Structures of Knowledge’, Times Literary Supplement (4 February 2005), <http://www.the-tls. co.uk/tls/archives/> Online from 2005: Three decisions Beginning in January 2005 with those who died in 2001, the current sequence involving just less than 1950 individuals, now includes (with the January 2013 update) men and women who died on or before 31 December 2009. Having committed to extending modern content, attention turned to editors’ responsibilities for the dictionary as a whole. The outcome saw January updates combined with two further annual releases (published each May and September) that would include people, from all historical periods, who were either known omissions in 2004 or recently identified subjects arising from new research or reviews of existing coverage. This second decision was perhaps the most important for the ODNB’s future course. It meant that the continuation project would not just be one of chronological extension, as practised in print by several ongoing biographies, including the ADB; it would also involve improving the work as a whole, a process that has seen the addition (by May 2013) of 1609 men and women covering 1000 years of British history worldwide. At the same time, a commitment to pre-2000 coverage was intended as more than filling known ‘gaps’. Rather, new additions across the dictionary should also serve as a means for editors to draw attention to, and make connections between, existing biographies. This was important given the scale of the dictionary, in which valuable content might otherwise remain hidden, and because of readers’ understandable preference for searching person-by-person rather than (as online now allowed) by historical topic or theme. Seeing new and existing content as interconnected also made clear the need for, and value of, maintaining the quality of individual entries throughout the dictionary. In 349 The ADB’s Story response came a third and final decision, notable for confirming the dictionary’s future organicism, to extend the remit of online updates to include also reviews of the complete text, providing corrections, additions and revisions as required. Extending ODNB online: New people Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 former empire (another growing area of research prompting extended coverage of Britons in Latin America, Russia and Japan), the nation-states of the United Kingdom, or prominent cities and regions within England. This thematic approach to new content serves editors, and readers, well in several ways. Above all, it allows us to add to the dictionary in a systematic and interpretable manner, akin to a special issue of an academic journal on a particular topic. In doing so editors seek to carry over some of the established and readily intelligible structures of print publishing to an online format where, now freed from chronology or alphabetical sequence, there is a risk of new material being added in a random, piecemeal manner. In-house, the thematic approach allows editors to accumulate suggestions from scholars and readers, often gathered over several years, and then to have external specialists assess candidates on their merits relative to others in a similar field, allowing for a more systematic application of the dictionary’s inclusion criterion of ‘noteworthiness’. In doing so, sets of new biographies in effect become short-term research projects in which editors immerse themselves in a particular subject (the history of policing or domestic service, and so on), enabling them better to identify and address limitations in the dictionary’s coverage. To think thematically is also to think lexicographically—that is, to consider the dictionary’s content, presentation, usefulness and readership in the round. Extending coverage since 2005 has encouraged greater editorial focus on the interests and expectations of readerships that now go well beyond the academic specialists who oversaw additions to the 2004 edition. Here in-house editors are well placed to guide the dictionary’s development, being both familiar with the existing coverage of subjects and aware of historical categories that were underplayed or not addressed prior to 2004. To this editors also bring an appreciation of the breadth of new content needed to maintain the dictionary as a national resource, within and beyond the academy. The implications of this approach may be seen in the recent set of British policemen and women active between the early nineteenth and late-twentieth centuries. For the ODNB—as scholarly reference work, public resource and national commentary—such selections must go beyond an ‘institutional’ survey to include people connected to well-known events or innovations about which readers may wish to learn more through biography. Extending ODNB online: New people Since 2005 two selection processes have been devised for identifying new candidates for inclusion in the dictionary. In the first, for updates covering people who died after 2001, the procedure has similarities to that for recent, and forthcoming, volumes of the ADB—that is, possible subjects (drawn principally from searches of national and international obituary records) are reviewed by external experts until a final listing of approximately 200 people is chosen as the dictionary’s coverage of a single calendar year. Where the process between the ODNB and the ADB differs is in the nature of selection and decision making. In contrast with the ADB’s State-based working parties, for whom the principal criterion is geographic, Oxford’s external advisers are thematic subject specialists (450 in more than 40 subject panels, from archaeology to zoology) who are asked to assess the relative contribution of individuals in their field and to make nominations for possible inclusion. Thereafter the final decision on who to include is made by the ODNB’s general editor and the section editor responsible for coverage of recent subjects. For subjects from earlier historical periods, a second, wholly thematic procedure has been developed, with sets of interconnected biographies linked by profession, place or research area, and often spanning several centuries in their consideration of a historical topic. Here a decision to include a specific set of biographies may have one of several origins. In some areas known imbalances in coverage have prompted long-term research projects to add new biographies in updates over several years; of these, examples include improved coverage of the later empire and early Commonwealth, and the inclusion of 100 early English bishops to provide a complete, and unique, biographical register of the pre-Reformation episcopacy. Other selections have addressed developments in the historical understanding of specific professions (for example, British domestic and imperial policing, a subject that, until recently, lagged behind that of criminality); of popular activities and recreations, including motoring and horticulture; and of emerging areas of historical study, such as domestic service or childhood. Several additional selections have provided historical interpretations of current events, most notably, British sporting pioneers for the 2012 Olympic Games. Further sets are chosen with reference to place, be this people active beyond the 350 1. Extending ODNB online: New people To offer several examples from the series: the pioneer of fingerprinting, Francis Cherrill (1892–1964); Walter Dew (1863–1947), the detective who crossed the Atlantic to arrest Dr Crippen in 1910; or WPC Yvonne Fletcher (1958–84) whose murder outside the Libyan Embassy led to the breakdown in relations between London and Tripoli and to new forms of public commemoration for officers killed on duty. When they do appear, chief constables are included not for their rank but for their activities—as in the case of Mowbray Lees Sant (1863–1943), who, infuriated by 351 The ADB’s Story ‘speeding’ motorists, introduced the country’s (and most probably the world’s) first speed traps three months before the death of Queen Victoria; or Eric St Johnston (1911–86), who, in promoting the move from policing on foot to motorised patrols, oversaw a profound change to the modern service. Up to a point, this recent approach to content echoes one long practised in the ADB. In 1998 the ADB’s editor, John Ritchie, gave a talk in Oxford in which he explained the policy of including ‘representative’ lives that encapsulated a social movement or new professional category, his example being Aileen Keldie, an airline stewardess killed in a plane crash between Sydney and Canberra in November 1961. At the time there was agreement that, here, the two dictionaries differed, with the ODNB requiring that a person be, if not exceptional, then at least historically noteworthy relative to others and identifiable for having left a mark on national life broadly defined. This principle still applies. And yet, in response to the inherited structures of the 2004 edition and in mind of modern readerships, the recent interest in thinking and commissioning lexicographically does now mean a greater focus on lives that represent different interests or offer a balanced representation of subject areas, such as policing. So, too, with geographical surveys of content: there has always been an element of this. For the 2004 edition, Oxford editors were commissioned with specific reference to Scotland, Wales and Ireland and in relation to people from or influential in former colonies. In Britain London dominates, unlike in Australia where the federal system foregrounds and privileges the States and Territories. Metropolitan dominance, coupled with the absence of pronounced expressions of English regionalism, meant that there was less historical motivation, or political encouragement, to consider coverage in terms of the north-east, Cornwall, East Anglia and so on. , , ( ), pp 4 For example, I. C. McManus (‘The Wealth of Distinguished Doctors: Retrospective Survey’, British Medical Journal, 331, no. 7531 [2005], p. 1520) compares wealth-at-death records within a profession. In- house surveys include Philip Carter, ‘Life on the Square: The Oxford DNB in WC2’, Trafalgar Chronicle, 18 (2008), pp. 264–71, which intersects people and place, and a forthcoming article on the social origins of the pre-Reformation episcopacy following completion of the ODNB’s listing of church leaders in spring 2011. These examples aside, studies of interconnectivity remain noticeably rare, with most surveys of sets of lives focusing on coverage, from the perspective of professions, the ‘four kingdoms’ or the nation at large. James 3 See Mark Curthoys, ‘Recent Additions to the Oxford DNB: Local Lives in National Biography’, Local Historian, 40, no. 4 (2010), pp. 324–8. Extending ODNB online: New people Since 2005, however, regionalism has emerged as an increasingly useful category for Oxford editors to assess and extend coverage. Derived directly from the dictionary’s online availability, a principal reason has been the growing numbers who access the ODNB through the UK public library network. This follows an agreement, initially with English library authorities in 2006, and subsequently extended to cover Northern Ireland and most of Wales and Scotland, by which the ODNB is provided as a free online resource, with most libraries now offering ‘remote access’, which allows members to login via a home computer (or from anywhere), at anytime. This agreement has been of considerable benefit, enabling us to promote the online edition as a genuinely national and public resource. Encouraging the dictionary’s use in libraries in turn prompts closer attention to the coverage of regional histories and ‘local figures’ deserving of national recognition. The outcome has seen the inclusion both of people and of groups: notable individuals, among them Jack Crawford (1775–1831), the sailor who ‘nailed the colours to the mast’, recently 352 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 commemorated with a statue in his native Sunderland; and thematic sets of biographies, including of brewers and school-founders, highlighting national professions and institutions with which readers also have close regional ties.3 Connecting and interpreting: Biography to history Though a key feature since 2005 has been the rapid take-up of the ODNB online, questions remain as to how the dictionary is being used. The challenge faced by editors and publishers is to persuade readers, even those comfortable with online research, that resources like the ADB and ODNB online offer more than the print edition on screen. So, while the growth of online use has been very welcome, it is also the case that it remains largely conservative: more than 90 per cent of entry points to <oxforddnb.com> are by personal name, as one would consult the print volumes. This means that only a small proportion of readers is using the online edition to its full potential as a research tool that not only records ‘what is already known’, but also offers opportunities for new discoveries in ways unachievable in print. This has surprised Oxford editors, not least because cross-subject searching, and the ability to create new sets of biographical data, is one aspect of functionality offered (to varying degrees) by the majority of national biographies online, but not available in popular alternatives such as Wikipedia. The ODNB’s electronic index is capable of searching for people by combinations of name, date, place, profession, gender and religious affiliation, as well as by wealth at death, archive holdings, and portrait records. Thus it is possible, in seconds, to bring together 20 female political activists resident in Manchester in the 1890s; 15 natives of Melbourne living in London during the Blitz; 200 people in the ODNB with a statue, bust or tomb in Westminster Abbey; or the six women writers with papers held by the National Library of Australia. Any connections between Manchester’s late-Victorian activists may be tenuous— but, then again, perhaps not. And for some researchers, the ODNB online has offered routes to new research.4 Similarly, in university teaching, related entries (for example, suffrage campaigners) are being studied prosopographically, while 353 The ADB’s Story comparisons between the DNB’s Victorian and late twentieth-century editions feature in courses on historiography and life writing.5 These initiatives are welcome but we would also like academics, teachers and students to make more of the ODNB online as a starting point for research, not just as a means of checking or confirming. 6 Despite recent statements on the usefulness of biography—for example, Nick Salvatore, ‘Biography and Social History: An Intimate Relationship’, Labour History, 87 (2004), pp. 187–92; and ‘AHR Roundtable: Historians and Biography’, American Historical Review, 114, no. 3 (2009), pp. 573–661—little has been said about the research potential of national biographies online. An exception is Barbara Caine’s discussion of national biography in the context of collected biography: Biography and History (Basingstoke, UK: Palgrave Macmillan, 2010), pp. 59–61. Raven’s review, while noting that the ODNB’s search facilities alter ‘fundamentally the definition and role of the collective biographical dictionary’, focuses principally on content: James Raven, ‘The Oxford Dictionary of National Biography: Dictionary or Encyclopaedia?’, Historical Journal, 50 (2007), pp. 991–1006. 5 For example, Alex Danchev [University of Nottingham], ‘The Power of Two’, Times Higher Education Supplement (18 September 2008); and ‘Lecturers Using the Oxford DNB’, <www.oup.com/oxforddnb/info/ learning/uni/usage/> ‘Learning Resources’ offering ideas for classroom and seminar use have also been developed for the online edition: <www.oup.com/oxforddnb/info/learning/> Raven’s review, while noting that the ODNB’s search facilities alter ‘fundamentally the definition and role of the collective biographical dictionary’, focuses principally on content: James Raven, ‘The Oxford Dictionary of National Biography: Dictionary or Encyclopaedia?’, Historical Journal, 50 (2007), pp. 991–1006. 5 For example, Alex Danchev [University of Nottingham], ‘The Power of Two’, Times Higher Education Supplement (18 September 2008); and ‘Lecturers Using the Oxford DNB’, <www.oup.com/oxforddnb/info/ learning/uni/usage/> ‘Learning Resources’ offering ideas for classroom and seminar use have also been developed for the online edition: <www.oup.com/oxforddnb/info/learning/> 6 Despite recent statements on the usefulness of biography—for example, Nick Salvatore, ‘Biography and Social History: An Intimate Relationship’, Labour History, 87 (2004), pp. 187–92; and ‘AHR Roundtable: Historians and Biography’, American Historical Review, 114, no. 3 (2009), pp. 573–661—little has been said about the research potential of national biographies online. An exception is Barbara Caine’s discussion of national biography in the context of collected biography: Biography and History (Basingstoke, UK: Palgrave Macmillan, 2010), pp. 59–61. g 5 For example, Alex Danchev [University of Nottingham], ‘The Power of Two’, Times Higher Education Supplement (18 September 2008); and ‘Lecturers Using the Oxford DNB’, <www.oup.com/oxforddnb/info/ learning/uni/usage/> ‘Learning Resources’ offering ideas for classroom and seminar use have also been developed for the online edition: <www.oup.com/oxforddnb/info/learning/> Connecting and interpreting: Biography to history Starting with an interest in, say, those involved in the Crimean War, a reader may quickly identify the secretary (or, as here, secretaries) of state for war or, indeed, others round the cabinet table in 1856, so creating profiles of formal networks at points in time. In addition, certain reference lists provide alternative forms of digital indexing that allow historical figures to be identified by criteria that could not be, or were not, tagged in the compilation of the dictionary’s metadata. Among this category of lists, and continuing the Crimean theme, are ‘Victoria Cross holders in the ODNB’ (unlike the ADB, not all British recipients have entries in the Oxford Dictionary), who otherwise could not be brought together for further study. Similar lists/indexes include the dictionary’s 100 Nobel laureates, 80 Oscar recipients, and its collection of saints and subjects of beatification (470 including, from 2010, Mary MacKillop and Cardinal John Henry Newman). The ODNB’s second approach to historical connections is 400 group biographies, which, on completion, will chart British associational life (its clubs, coteries, gangs, brother and sisterhoods), from the Magna Carta barons and Gunpowder plotters to the discoverers of penicillin and the Angry Young Men. Unlike lists of office-holders that exist elsewhere, there is no equivalent in print or online of the groups project for which 300 essays (each roughly 2500 words long) were in place by 2012. With their ability to connect and link to members’ biographies, group articles are particularly well suited to an online environment. Though a recent creation, they are, however, not a new idea, having been proposed in the 1990s by the ODNB’s founding editor, Colin Matthew, who foresaw networks as a requirement of modern national biography written and read by scholars now fully attuned to the collective means of historical change.7 Editors seek to achieve several things with groups. As with a person’s stand- alone biography, we aim to offer concise, informative accounts of the coteries, circles and sects that readers might encounter either in an ODNB article or in secondary literature and wonder, quite rightly: who or what were the Metaphysical poets, Bluestockings and Lunar Society, or, from overseas, the Founding Fathers, First Fleeters, Scottish Martyrs or Canterbury Association? Connecting and interpreting: Biography to history This is where two additional forms of online content— the ODNB’s ‘reference lists’ and ‘reference groups’—play a role: they serve as editors’ attempts to nudge readers towards treating the dictionary as a historical resource, capable of charting the connections and exchanges between people who are otherwise covered singly in the main text. It might initially seem odd to associate Donne’s ‘No man is an island, entire of it self’ with biographical reference and, maybe so in its alphabeticised, individuated print format. But online it is a sensible expectation and typically a discoverable reality.6 In showing how and where historical connections may be made, the ODNB and ADB currently follow different paths. We both, however, appreciate the potential for making links between people: with projects such as Obituaries Australia, editors at the ANU’s National Centre of Biography are creating opportunities to establish hitherto unknown connections from, in effect, the ‘bottom up’. These, moreover, are connections that go well beyond what is possible via the existing metadata of the ADB or the ODNB—for example, by bringing people together with reference to places of shared activity other than educational institution or residence, or by tracing sets of interrelated people as they move through different stages of life, from school to university to army service, and so on. In contrast, the ODNB pursues a more ‘top-down’ approach with its list and groups—that is, identifying pre-existing structures (be they public offices held consequentially or social networks in which membership was shared contemporaneously) and then highlighting connections between incumbents or members. Since 2005 Oxford editors have compiled and published 150 lists of office-holders. These serve several purposes of which the most obvious is ‘quick reference’, something that is available in print but which in the ODNB is more accessible and offers links to relevant biographies for further reading. A 354 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 second purpose is therefore to provide thousands of new routes into the main dictionary, so offering alternatives to ‘name’ search where an original inquiry starts with a known person. With lists, the focus shifts from people to events. 7 H. C. G. Matthew, Leslie Stephen and the New DNB (Cambridge: Cambridge University Press, 1995), pp. 26–7. 8 Cato [Michael Foot, Peter Howard and Frank Owen], Guilty Men new edn (London: Penguin, 1998). D. J. Dutton, ‘Guilty Men’ (act. 1940), <www.oxforddnb.com/public/themes/70/70401.html> Connecting and interpreting: Biography to history Several of these will likely be examined from alternative perspectives when the ADB begins its own program of online groups, to which no doubt will be added other, wholly Australian networks such as the Heidelberg School, the Seven Dwarfs, Angry Penguins and perhaps even the Kelly Gang. 355 The ADB’s Story The ODNB ‘reference group’ charting members of Captain Robert Scott’s Antarctic expedition, 1910–13 A key issue faced by Oxford editors when devising their own interpretative groups was definition: what is a network, and how best to distinguish associations of sufficient coherence from those too disparate or ahistorical to merit study? In response, specific requirements are set. Groups must be historically defined with a beginning and an end point, and they require an identifiable membership, even if participants did not see themselves as forming a group, as in the case of the 15 ‘Guilty Men’ who were externally labelled for their pro-appeasement stance in the late 1930s.8 Consequently, open-ended or retrospective affiliations such as ‘Scottish Enlightenment thinkers’ do not have a place while members of the Edinburgh Select Society (act. 1754–76) or the Aberdonian Wise Club (act. 1758–73) are included. In addition, ODNB group essays must, wherever possible, provide readers with full membership lists (regardless of whether these participants have entries in the main dictionary), as well as information on why and how they came together, what they did, their legacy and, where known, how associations changed individual careers or lives. 356 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 By being comprehensive it is possible to establish first-time connections between individuals who were members of the same group, as well as to identify history’s ‘serial joiners’ who were members of numerous networks. More broadly, we can consider how concepts of civil association have changed over time; how, why and where particular types of circles formed; and how the historical memory of particular networks has been shaped by subsequent events. Lastly, from the lexicographer’s perspective, groups (and lists) provide an effective means of systematically reviewing and combing existing content for notable ‘missing people’ who are, in turn, added to the dictionary in annual updates. Conserving the collection Finally, the recent launch of open web sites such as the ‘Clergy of the Church of England database 1540–1835’, with listings of more than 100 000 clerics; the ‘Old Bailey online, 1674–1913’, providing details of nearly 200 000 criminal trials and the life stories of 2500 victims of execution; and ‘London lives, 1690– 1800’, with 240 000 manuscripts naming nearly 3.5 million Londoners, provide wonderfully rich resources for investigating early modern social trends through biography. A principal benefit of resources like these is the opportunity to add information that in 2004 was either unknown (and undocumented in secondary sources) or could not be located from searches of printed catalogues. This applies most obviously to core biographical data that are now more easily available via digitised registration catalogues or census records, places and dates of birth, marriage and death, as well as details of subjects’ parents, spouses and immediate family. In 2004, terms such as ‘details of which are unknown’ or ‘remains elusive’ appeared at points across the dictionary’s text. Given the dominance of print resources and traditional cataloguing, such statements were inevitable and to be expected at this time; but within a couple of years this was changing, not least as researchers drew attention to previously unknown aspects of a life gleaned from new online sources. In response, ODNB editors began a project in which articles were combed for these (and similar) phrases, and new record searches were undertaken, resulting so far in details of more than 2000 previously unknown births, marriages and deaths being added throughout the dictionary. This work has been particularly rewarding in supplementing the lives of nineteenth and twentieth-century women, whose biographies are on occasions at risk of being obscured by multiple name changes, leading some to disappear from the historical record. Alternatively, there are instances where women have given false information about their age, often for professional reasons, which subsequently meant editors were led to the wrong register. One such case is the journalist and political activist Eleanor Vynne, who, as she became established as a writer in the 1890s, reduced her age in the census. As a result, in 2004 the ODNB’s best estimate was that she had been born in ‘1870?’, the daughter of Charles Vynne, a chemical manufacturer, with family ties in Norfolk. Conserving the collection If national biographies online have implications for how we encounter, study and teach aspects of the past, it is also the case that other digital resources are radically changing what is possible, and indeed expected, in works of record like the ODNB or ADB. Several factors make this particularly so for the ODNB, which benefits from the United Kingdom’s relatively limited privacy laws (copies of birth, marriage and death certificates, for example, are readily available to 2005) and, more recently, from a boom in the provision of such documents driven by a growing interest in family history. In its first incarnation, 1993–2004, the ODNB was in large part compiled with core biographical sources that had barely altered since the days of Stephen and Lee. But in its second, wholly online incarnation (2005 –) the opportunities for research are hugely expanded, and continue to be so at a remarkable rate. Of these, the most significant include: national census returns for eight surveys held between 1841 and 1911; searchable indexes of civil registration in England and Wales (births, marriages and deaths from 1838); an ever-growing selection of English parish registers (including those in the London Metropolitan Archive); Scottish parish registers from about 1500 and civil registration registers from 1855; English and Welsh probate registers (1861–1966), providing details of residence and death as well as wealth; and wills dating from the sixteenth century via The National Archives, Kew, and Scotland’s People web site, a partnership of the General Register Office for Scotland and the National Archives of Scotland. Many of these resources allow documents to be downloaded directly, giving quick access to a record that, prior to digitised searching, may have been impossible to locate. Beyond these core resources, the National Archives and commercial sites like Ancestry offer numerous other records of biographical relevance, from early modern seals and passenger shipping lists to military service records and telephone directories, providing details of residence for the years after the last 357 The ADB’s Story public census. Meanwhile, the British Library’s ‘British newspapers, 1800–1900’ service provides nearly 50 national and regional papers, to be used alongside existing resources such as the Times digital archive (1785–2006). Conserving the collection Alerted to the falsification, wider searches of newly available online resources identified Vynne as having been born 13 years earlier, on 31 October 1857, together with details of her place of birth (Kennington, Surrey), her immediate family, and a full account of her father, Charles, who, then an accountant, only later became manager of a fertiliser manufacturer following the family’s move to north-west England. 358 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 As well as improving existing biographies, digitised records allow editors to gather sufficient information to add to the dictionary people, perhaps notable for a well-documented event or once popular creative work, whose personal biography would previously have been too shadowy to justify an article. A century ago Henrietta Marshall’s rousing history of Britain, Our Island Story (1905), was familiar to schoolchildren nationwide.9 Far less was known about its author; indeed, writing as H. E. Marshall, she obscured even her gender, to the extent that a centenary reissue of this, her most famous work, could not provide Marshall with firm birth or death dates and declared that ‘little was known’ of her life. Online searches of Scottish genealogical records, however, identified Marshall as the daughter of a Bo’ness manufacturer, while digitised regional newspapers provided an obituary report and enough material to trace a death certificate and probate, and with it details of her later residence in Hampstead, north London. The outcome was Marshall’s inclusion in the ODNB with the first detailed account of her life in a recent selection of biographies relating to the history of children and childhood. As well as improving existing biographies, digitised records allow editors to gather sufficient information to add to the dictionary people, perhaps notable for a well-documented event or once popular creative work, whose personal biography would previously have been too shadowy to justify an article. A century ago Henrietta Marshall’s rousing history of Britain, Our Island Story (1905), was familiar to schoolchildren nationwide.9 Far less was known about its author; indeed, writing as H. E. Marshall, she obscured even her gender, to the extent that a centenary reissue of this, her most famous work, could not provide Marshall with firm birth or death dates and declared that ‘little was known’ of her life. Conserving the collection Online searches of Scottish genealogical records, however, identified Marshall as the daughter of a Bo’ness manufacturer, while digitised regional newspapers provided an obituary report and enough material to trace a death certificate and probate, and with it details of her later residence in Hampstead, north London. The outcome was Marshall’s inclusion in the ODNB with the first detailed account of her life in a recent selection of biographies relating to the history of children and childhood. Sir Henry and Lady Meux, subjects in an entry for the Meux brewing family (act. 1757–1910), published in 2007 9 H. E. Marshall, with pictures by A. S. Forrest, Our Island Story: A Child’s History of England (Edinburgh: T. C. & E. C. Jack, 1905). 359 The ADB’s Story Similar investigative work is being done worldwide by thousands of researchers, many of whom, with remarkable generosity, make their findings available to us. One example of collaboration concerns the hitherto fabricated life of Valerie, Lady Meux. Twice painted by James Whistler, Valerie married into the Meux brewing family, which made her one of the wealthiest women in Edwardian England, able to devote her widowhood to collecting Egyptian antiquities (now in the British Museum), training the 1901 Derby winner, and giving £20 000 for the purchase of guns for the defence of Ladysmith. To readers of Debretts this would have been ‘just so’ for there Lady Meux is listed, with reference to her marriage certificate, as ‘Valerie, daughter of Charles Langton, gentleman’, born in 1856. But thanks to research by family historians in New Zealand (to which, after her marriage, she sent many of her relatives), Lady Meux was identified as Susie Langton, born in 1852 (she changed her birth date to tally with her husband’s), the second daughter of William Langton, a village butcher from rural Devon. Digging further, researchers discovered how Susie sought her fortune in London in the 1870s. Here she changed her name to ‘Valerie Reece’ and worked as an actress and hostess in the clubs of Westminster, where she met Henry Meux, heir to the family business. With access to online resources, this new information could be verified prior to her biography being added to the dictionary, being an unlikely and unexpected member of our series on regional brewers. Conserving the collection To Susie Langton or Valerie Reece or Lady Meux, the discovery of her true past may not have been welcome, but for ODNB editors it becomes a key part of her story, a fascinating case study of late-Victorian social mobility, and the first opportunity to identify accurately the sitter of Whistler’s portraits. The contribution of readers to improving and supplementing the dictionary’s content is, if anything, even more pronounced for pre–nineteenth-century subjects whose lives, unrecorded in civil registration and other records, evade systematic reviews of near-comprehensive digital sources. For such subjects discoveries frequently originate with family historians who offer information from personal papers—that is, correspondence, diaries, portraits, even records of children in a family Bible—that have remained undisclosed and unknown until the ODNB’s worldwide circulation online. This coming together of genealogical research and national biography can be remarkably productive in adding to what is known about selected early modern lives. Take, for example, the case of the Tudor churchman Robert Johnstone (d. 1558), to whose entry more than 30 years of family life, education and clerical career have now been added as a prelude to his period as a religious controversialist in the 1550s. Or Eliza Fay (1755/6–1816), the traveller best known for her posthumous Original Letters from India, whose ODNB account has doubled in length owing to new research that minutely plots the troubled personal life that led her to travel repeatedly to India, and the business ventures she maintained there and in Britain as a single woman once separated from her wayward husband. 360 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 As the Fay example shows, the addition of biographical detail can serve (while also ‘humanising’ an individual story) to re-emphasise the historical possibilities of national biography, offering, as here, a more rounded life (missing, incidentally, from a 2010 print reissue of her Letters), which provides greater context for a subject’s better-known public actions. But even when there is less resonance between private and public lives, the supplementing of biographies with personal information remains a worthwhile activity. One of the great advantages of national biography online is that readerships extend well beyond those interested in the public actions of prominent figures. Consequently, new readers bring questions (and demands) that can relate equally to family, residence or places of residence and association. Conserving the collection These, in turn, have the potential to prompt new connections and research among some of the hundreds of thousands of ‘extras’ in national biography—mothers, fathers, children, kinsmen, colleagues, teachers—who surround the principal subjects. The revised article for Henry Pickersgill in which his wife, Jeanette, now appears as a fully searchable co-subject of the main headword entryf The revised article for Henry Pickersgill in which his wife, Jeanette, now appears as a fully searchable co-subject of the main headword entry The revised article for Henry Pickersgill in which his wife, Jeanette, now appears as a fully searchable co-subject of the main headword entry The revised article for Henry Pickersgill in which his wife, Jeanette, now appears as a fully searchable co-subject of the main headword entry Nor are such connections the preserve of readers alone. A welcome side effect of editors’ reviews of dictionary content is the chance to highlight historical ties previously submerged within 68 million words of text. In 2008, for example, one set of new lives considered people responsible for modern forms of domestic and public hygiene and sanitation, including a leading advocate of the nascent practice of cremation. Research for the series identified the first person to be legally cremated in Britain, in 1885, as Jeannette Pickersgill. A search of the dictionary showed that Pickersgill was not a subject, but that there was a passing reference to Jeanette Caroline Grover (then presented without birth or death dates) as the wife of the painter Henry Hall Pickersgill (1812–61). To the original contributor of the Pickersgill entry, an art historian, and to the editor of the biography in 2004, Jeannette Grover was understandably regarded as the spouse of a more famous subject; but four years on, and seen from a previously 361 The ADB’s Story unconsidered perspective, she emerges as a person of note, albeit one known by her married name. As a result, the entry has been recast to give Jeannette the status of a ‘co-subject’ within her husband’s article in which she now appears with life dates and a note detailing her singular mark on the national record. By her elevation to a ‘co-subject’, and hence to the dictionary’s searchable index, Pickersgill becomes identifiable in her own right and by any of her name variants, not just the precise (maiden) name by which she originally appeared. This promotion of noteworthy people to the status of ‘co-subjects’ makes particular sense in an online environment. 10 James Walter notes the hindrances to research from the structures of print reference and provides an early comment on the possibilities of electronic publishing: ‘Seven Questions about National Biography’, pp. 28–9. 11 Questions of balance have also been raised with regard to newspaper obituaries; see, for example, ‘Obituaries—Women’s Final Frontier’, Guardian [UK] (31 August 2010), reporting on criticism of New York The revised article for Henry Pickersgill in which his wife, Jeanette, now appears as a fully searchable co-subject of the main headword entry In 2004 the ODNB included 4809 individuals of this kind whose biographies, located within the text of another person, must in print be found through the relatively cumbersome procedure of cross-reference entries, often taking readers across several print volumes from the same edition (as with the 60-volume ODNB), or across different editions and several decades with the ADB10 online; however, such figures are as easily found through name or category searching as a Shakespeare or a Churchill, and for this reason editors have paid close attention since 2005 to identifying figures who, briefly discussed in others’ biographies, merit co-subject status. By dissolving the print hierarchy of principal and secondary subjects, the online edition offers readers a wider selection of ‘interesting’ people who may be worthy of further investigation regardless of whether they appear in the dictionary as ‘full’ or ‘co-’ subjects. What matters online therefore is less the lexicographical hierarchies and grammar of print than the discoverability and the research opportunities this might bring. More broadly, and over time, such work also has the potential to address perennial questions of coverage, not just in the ODNB but also in all national biographies. In compiling the 2004 edition, considerable effort was made to expand the number of female subjects, thus drawing on and reflecting twentieth- century research interests. The outcome was a threefold increase throughout the dictionary, making women 10 per cent of subjects in all historical periods and nearly 30 per cent in the twentieth century. These proportions have been maintained dictionary-wide since 2005 and exceeded in the coverage of those who died in the opening years of the twenty-first century. Such proportions do prompt occasional complaint, sometimes accompanied by calls for attempts at parity of gender representation. In truth, the parameters in which national biographies exist—that is, to record historical ‘noteworthiness’ of lasting interest—ensure that such calls underplay the historically grounded inequality of opportunity, even among the very recently deceased.11 This is not, however, 362 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 a reason to do nothing. Times’ limited inclusion of obituaries of women. 12 Recent additions to the ODNB include the tenth-century queen Eadgyth, whose remains were discovered in Germany in 2010; silk-woman Alice Barnham (1523–1604), the principal subject of Lena Cowen Orlin’s Locating Privacy in Tudor London (Oxford: Oxford University Press, 2007); the campaigning lawyer Gwyneth Bebb (1889–1921), whose achievements are only now being documented, as in Rosemary Auchmuty, ‘Whatever Happened to Miss Bebb? Bebb v The Law Society and Women’s Legal History’, Legal Studies, 31, no. 2 (2011), pp. 199–230; and Violet Piercy (b. 1889?), the first modern woman to run a timed marathon (in 1936), whose life was researched from scratch to coincide with the 2012 Olympics. 13 Examples include the artist Mary Maria Fielding (1804–95), who collaborated with her husband, the botanist Henry Borron Fielding, and whose work is now discussed as part of Henry’s entry; and Evan James (1809–78), lyricist of the Welsh national song, ‘Land of My Fathers’, the music for which was written by his son, James James, in whose entry Evan now appears. The revised article for Henry Pickersgill in which his wife, Jeanette, now appears as a fully searchable co-subject of the main headword entry Combing recent research for new biographies is one approach that continues to lead to the inclusion of full subjects in the ODNB.12 Another is the elevation to co-subjects of those (of whom many, though not all, are women) who appeared in 2004 as parents, siblings, spouses or children, but whose own lasting achievements, often in non-public or non-professional roles, now see them fully incorporated in the national record.13 Promoting and curating Over the past seven years the ODNB has been shaped by concurrent projects that have extended, contextualised, refined and supplemented its online edition. To these one final activity might be added: that of promoting or ‘curating’ our collection. In doing so we return to the idea that, in digital format, national biographies serve as more than resources for quick person-focused reference, essential though this is. An earlier section of this chapter highlighted several formal ways (for example, group entries) in which editors encourage readers to treat national biography historically and, hence, as a starting point for teaching and research. But alongside these initiatives, which result in permanent additions to the dictionary, the online environment also makes possible similar work using less formal, temporary ‘exhibitions’ of selected content assembled around anniversaries or events and drawn from its collection of 58 300 discrete items. For editors and publishers, a key purpose of online ‘outreach’ is to extend the ODNB’s take-up and use in schools, universities and via public libraries. Our intention is to make the <oxforddnb.com> site interesting and topical as a means of promoting the dictionary, its content and online possibilities, both to existing readers and to those who would naturally fight shy of traditional biographical reference, print or digital. In doing so, editors have drawn on established models of online subscription—notably for academic journals—where rates of renewal and uptake are linked to regular additions of new material or ‘value’ to a title. As a result, and in addition to its three annual updates, the ODNB now 363 The ADB’s Story seeks to promote itself as an online ‘service’ providing topical interpretations of its content in daily, weekly or monthly instalments. The common thread is an attempt to entertain, educate and highlight new ways of looking at and using the dictionary. The Armistice gallery, with links to 37 biographies, including that of the Unknown Warrior The Armistice gallery, with links to 37 biographies, including that of the Unknown Warrior The development of this notion of an online service has been gradual and experimental. In areas such as its topical ‘Life of the Day’, the ODNB followed existing templates set up by the ANB and since adopted (albeit without the facility for email distribution) by the ADB online. Elsewhere new kinds of material, unique to the ODNB, have come about as needs and opportunities are identified. 14 See, for example, Peter Salway, ‘The Rise and Fall of Roman Britain’ (2006), ODNB online, <www. oxforddnb.com/public/themes/92/92733.html>; Philip Carter, ‘Courage and Popular Heroism in the Oxford DNB, c. 1850–2000’ (2010), ODNB online, <www.oxforddnb.com/public/themes/101/101154.html>; and Paul Addison, ‘Life on the Home Front, 1939–45’ (2006), ODNB online, <www.oxforddnb.com/public/ themes/92/92741.html> Promoting and curating The dual role of updates in extending and drawing attention to existing content has, for example, given rise to accompanying ‘feature essays’, which place new and current subjects in historical perspective and offer routes into the main dictionary text. Written by editors and subject specialists, features of this kind include thematic surveys, from Roman Britain to concepts of heroism, as well as biographically focused studies of established historical topics, such as industrialisation, suffrage reform or life on the Home Front.14 On occasion, updates or significant anniversaries also lend themselves to visual presentations of content. The ninetieth anniversary of the Armistice, marked by the inclusion of 30 new wartime lives, was also commemorated with an interactive gallery combining familiar and less well-known aspects of the dictionary’s 1914–18 coverage, including women and war, war and empire, and remembrance. 364 1. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 15 Darryl Bennet, ‘NCB Collaborates with Museum of Australian Democracy’, Biography Footnotes, no. 2 (March–April 2009). Gardeners of the British Isles As the ODNB’s public profile grows, so it becomes easier to establish partnerships with other national institutions. Thus, the Armistice gallery was shared with the Imperial War Museum, London, while a number of joint events have been held with Tate Britain, the National Portrait Gallery, the BBC and the UK Parliament in which ODNB biographies, of artists, sitters or other featured historical figures, are made publicly available on respective sites to offer ‘further reading’. The result is, in effect, a parallel exhibition ‘curated’ by editors in which dictionary content is reconfigured and made accessible, akin to the ADB’s sharing of major lives in Australian democracy with the recently opened Museum of Australian Democracy at Old Parliament House, Canberra.15 The growing importance of the public library sector has similarly resulted in tie-ins with individual authorities in which bespoke web pages introduce library members to aspects of their local history while promoting the ODNB’s free online availability. Identifying the dictionary as a resource for regional as well as national history has also led to the creation of a series of ‘biographical maps’, highlighting individuals and professional groups (for example, prominent regional manufacturers or, as here, gardeners and horticulturists) with particularly strong attachments to place. Invariably such material is of greatest appeal to those with an existing interest in the past, be they museum and gallery goers or library and archive visitors studying local history. But an additional form of online publicity aims to push the dictionary’s appeal well beyond the traditional scope of print publishing by appropriating popular images that lend themselves well to digital curation. Released in 2007 to mark the album’s fortieth anniversary, the dictionary’s 365 The ADB’s Story adaptation of the Beatles’ ‘Sgt Pepper’ cover offers an unlikely combination of biographical reference, pop art and flower power. The result is an interactive graphic that introduces new readers not only to the ODNB’s entries on John Lennon and George Harrison, but also to other national figures featured in Peter Blake’s artwork, from Lewis Carroll to Oscar Wilde. Still one of the most popular online features released by the ODNB, the ‘Sgt Pepper’ graphic was also noteworthy for including links to open-access ANB content (Edgar Allan Poe to Marilyn Monroe), and followed a similar partnership with the ADB online to highlight some of the two countries’ greatest cricketers ahead of an Ashes series. Gardeners of the British Isles Sgt Pepper, with open-web links to ODNB and ANB biographies Sgt Pepper, with open-web links to ODNB and ANB biographies Two ‘historical Ashes’ teams selected from the ADB and ODNB by the commentators Jim Maxwell and Christopher Martin-Jenkins Sgt Pepper, with open-web links to ODNB and ANB biographies Two ‘historical Ashes’ teams selected from the ADB and ODNB by the commentators Jim Maxwell and Christopher Martin-Jenkins 366 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 Online curation has also become easier and more effective thanks to the growth of social networking media. This, coupled with the concept of the ODNB as a malleable, interpretable collection, creates new opportunities for traditional ‘biographical reference’ to be recast as ‘life stories’ marking popular anniversaries or offering historical perspectives on current events. The size of the audience willing to receive excerpted biographical content via social media like iTunes, Twitter and Facebook (in which the ODNB routinely participates) is large and growing. In 2012 annual downloads of the dictionary’s twice-monthly ‘biography podcast’, for example, reached about 650 000 people, while the fluidity of social media users allows for the re-promotion of popular features, such as the Armistice, Ashes or Sgt Pepper, on subsequent, related anniversaries. Responses and future opportunities Since 2005 a number of initiatives—editorial, conservational and promotional— have been set in train. But what have people made of this activity? For all its obvious importance, this is a far from easy question to answer given the difficulties of determining ‘success’ in an online environment in which comparisons of like with like are seldom as straightforward as those for print publishing. In short, when is a ‘large number’ of hits ‘large enough’; when is a session time adequate; or when is a visit sufficiently imaginative given the range of searches and connections now possible? In view of these problems, it is perhaps more constructive to consider broader trends of use. Here, eight years on, visits to the dictionary and its public features continue to increase, as does UK public library use, which has experienced a marked rise following the introduction of some of the regular promotional items described above. This is important not just because curation and promotion take editorial time but because increasing usage, together with comments from contributors and readers, suggests that these new, and sometimes populist, forms of online activity are not adversely affecting the ODNB’s scholarly reputation. Different kinds of readers, it appears, are able to take up or ignore the various means, popular or scholarly, by which aspects of content are brought together and promoted. Moreover, it is important to the project that the innovations since 2005—namely, new biographies, themes and public engagement—remain the work of the dictionary’s academic editors, who have decades invested in the ODNB, as well as academic profiles of their own. Consequently, nothing is done to risk compromising standing or reputation, with online outreach a mere ‘shop window’ on to biographical content that remains inviolable. There have been questions regarding the implications of being online for the dictionary’s wider reputation. Soon after publication came a concern that, 367 The ADB’s Story in its new form, a classic work like the ODNB would be too readily open to reinterpretation and revision. Surely, it was argued, a reference work should be ‘fixed’ not ‘organic’, with changes and revisions threatening the dictionary’s historical standing as the final word on a life. These concerns aside, it is our impression that a growing, improving and engaging digital edition is considered an asset by the majority of readers. Responses and future opportunities Most expect some omissions, inconsistencies and errors (inevitably easier to spot online) and are satisfied that these, and new additions to knowledge, can be frequently and systematically addressed in an academically moderated program that far exceeds what would be possible in print. Through these exchanges, Oxford editors are also building up a network of scholars who regularly submit information. The result is a ‘second tier’ of contributors, whom the ODNB has always prized highly as its potential ‘ambassadors’, who now also see their (credited) research findings woven into articles across the dictionary. Thus, by regularly improving and refining the content, we sense most readers appreciate that what they find is, broadly speaking, ‘as good as it can be’ at the time of access, rather than (as it remains in print) a fine but increasingly outmoded snapshot of scholarship at the end of the twentieth century. The opportunities (as well as the demands) to ‘add value’ mean that, six years on, a number of projects continue so as to improve the dictionary’s content, retrieval and presentation online. In 2013 such work, often ‘behind the scenes’, includes tidying and extending the metadata to make searches more accurate, consistent and complete; the retrospective addition of images to biographies without a portrait in 2004; better integration of biographies with ‘thematic reference’ (lists and groups) so that searches for people also identify the public offices held or the networks to which they belonged; and adding links to accredited external sites by which readers may further pursue their research. This inclusion of links out from the ODNB continues work started before 2004 at which time connections were in place to the British National Portrait Gallery and Register of Archives, and (where applicable) to the ANB online. In each case the link provides a stable, reciprocal link with a person’s record in the respective repository. Behind such work is an appreciation that the ODNB online could not, and should not, be a ‘one-stop/catch-all’ site, but rather a locus for high-quality biographical information that also serves as a way station to equivalent resources in which portraits, archives or alternative biographies are curated to similarly high standards. Responses and future opportunities Since 2005 this work of mediated connections has been extended to include secondary literature (the Royal Historical Society bibliographies) and additional OUP titles—notably, the eighteenth-century correspondence networks of the Voltaire Foundation’s ‘Electronic Enlightenment’, the new Oxford English Dictionary online (launched in 2010), which includes references to thousands of ODNB subjects in its 368 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 quotation evidence, and from 2012 Oxford’s Scholarly Editions online, which enables readers to click between an author’s biography and his or her texts as discussed or quoted from in the dictionary entry. It is hoped that future links will also bring together shared lives in other national biographies, including the Dictionary of Irish Biography and the ADB. Possibilities for greater reciprocity between the ODNB and its fellow biographical dictionaries may also have implications for future forms of online use. It is common for those involved with national biography to speak of linking dictionaries together, allowing readers to compare the respective treatments of individuals who played a part in multiple national stories.16 On certain occasions this works extremely well, as with the recent inclusion of Victoria Woodhull (1838–1927) in the Oxford Dictionary. The political life of Woodhull, the first woman to stand for the US presidency, is covered in detail by her ANB entry though little is said there about her equally colourful life in England, where she lived for 50 years, and which is now described for the first time by the ODNB.17 Linking resources with distinctive remits can allow readers to construct a more nuanced biography built upon several specialist sources. Readers of political lives in the ODNB, for example, have things to gain from the History of Parliament (HoP) online, with its more detailed coverage of parliamentary performance; likewise readers of HoP can turn profitably to the ODNB, with its more rounded studies, which take in an individual’s private and professional lives beyond Westminster. In general, however, the ODNB’s experience suggests that relatively few scholars and students are, as yet, embracing even stand-alone national biographies as comparative resources. So it remains to be seen, and open to question, whether they can be encouraged to do so between national biographies in an exercise that will remain primarily historiographical, and where research findings may be limited given the brevity of coverage for most subjects in this format. 17 Lawrence Goldman, ‘Victoria Clafin Woodhull (1838–1927), Women’s Rights Campaigner and First Female US Presidential Candidate’, ODNB online, <www.oxforddnb.com/view/article/98231> In England, Woodhull reinvented herself as a country landowner and campaigner for Anglo–American friendship. Cremated and commemorated in Tewkesbury Abbey, Gloucestershire, her ashes were scattered, fittingly, in the mid Atlantic. 16 The possibilities for, and limitations of, interconnected national biographies are considered in Lawrence Goldman, ‘Virtual Lives: History and Biography in an Electronic Age’, Australian Book Review (June 2007), pp. 37–44. 16 The possibilities for, and limitations of, interconnected national biographies are considered in Lawrence Goldman, ‘Virtual Lives: History and Biography in an Electronic Age’, Australian Book Review (June 2007), pp. 37–44. 17 Lawrence Goldman, ‘Victoria Clafin Woodhull (1838–1927), Women’s Rights Campaigner and First Female US Presidential Candidate’, ODNB online, <www.oxforddnb.com/view/article/98231> In England, Woodhull reinvented herself as a country landowner and campaigner for Anglo–American friendship. Cremated and commemorated in Tewkesbury Abbey, Gloucestershire, her ashes were scattered, fittingly, in the mid Atlantic. Responses and future opportunities Perhaps the research opportunities for interconnected national biography could take different forms. Thus, one alternative is to interest scholars in the potential of collective biography for studying specific social-historical topics in which the ODNB and ADB (and now Obituaries Australia) are rich in detail and, online, well placed to deliver developments in family sizes, name forms, ages of marriage, lifespans, causes of death, religious affiliations, war records, cultural ties, forms of education, social and geographical mobility within a country, to name a few. While alert to the particularities of individual national repositories 369 The ADB’s Story (and to the selective nature of these data sets), it may also be possible to compare social trends across different works or, in the case of mobility, to survey national biographies for what they might tell us about patterns of international travel and migration by people organised more nebulously by family, professional groups, places of origin or age. As the record of a former imperial power, the ODNB, in association with other national biographies, has potentially much to offer here, facilitating the development of recent interest in micro-histories of empire written from the perspective of life stories.18 * *** As the ADB enters its second half-century, we have an opportunity both to look back, on print volumes published, and to look forward to extended online coverage, enhanced interpretative reference and new research initiatives, such as Obituaries Australia. In terms of its chronology, the brief history of the ODNB is only one-tenth that of the ADB. By reflecting on aspects of this short history, this chapter has highlighted some of the opportunities the ODNB’s now predominant online edition offers its editors and readers, and may also create for those of other national biographies. Though at times demanding and labour intensive, the Oxford experience suggests that an online environment brings considerable benefits to the wider project in several ways. First, online activity provides editors with greater freedom to decide what is published and how editorial work is organised. Freed from the constraints of volumes and alphabetical sequences, it is possible to commission, review and edit thematically, allowing for more effective use by specialist authors and reviewers in assessing and reviewing future content. Second, an online presence shifts perceptions of national biography and, with it, the potential to appeal to existing and new readerships. 18 For example, the two volumes edited by Desley Deacon, Penny Russell and Angela Woollacott (eds): Transnational Ties: Australian Lives in theWorld (Canberra: ANU E Press, 2008) and Transnational Lives: Biographies of Global Modernity, 1700 to the Present (Basingstoke, UK, and New York: Palgrave MacMillan, 2010). Also David Lambert and Alan Lester (eds), Colonial Lives across the British Empire. Imperial Careering in the Long Nineteenth Century (Cambridge: Cambridge University Press, 2009); and Elizabeth Buettner, Empire Families. Britons in Late Imperial India (Oxford University Press: Oxford, 2004). 19 Here the situation may be changing. Recent research suggests that a new generation of students is learning to differentiate online between ‘starting-point’ resources such as Wikipedia and accredited, peer- reviewed resources such as the ODNB and ADB, to which they move on, especially when links are provided in open-web encyclopedias. See Alison J. Head and Michael B. Eisenberg, ‘How Today’s College Students use Wikipedia’, First Monday, 15, no. 3 (1 March 2010), <www.firstmonday.org/htbin/cgiwrap/bin/ojs/index. php/fm/article/view/2830/2476> Dr Philip Carter is Publication Editor at the Oxford Dictionary of National Biography. 1 The original ADB project involved 12 volumes (Period 1, Volumes 1–2; Period 2, 1851–90; Period 3, 1891–1939). The review of the ADB in 1986 considered whether the ADB should continue, following the completion of the original project in 1990–91 and, if so, on what scale and with what speed and staffing. The committee held it should ‘continue without pausing’, with the Editorial Board suggesting six volumes, 1940–80, for Period 4. ‘Report of the Committee of Review of the Australian Dictionary of Biography’ (May 1986), box 125, Q31, ADBA, ANUA, p. 9. Editorial Board meetings in 1994, 1996 and 1998 committed the ADB to Period 5, 1981–90, with the last meeting agreeing to two volumes, while meetings in 2000 and 2002 committed the ADB to two volumes, Period 6, 1991–2000, and a ‘missing persons’ volume. Responses and future opportunities Transformed from a static ‘publication’ to a flexible, interpretable ‘national collection’, the ODNB is gradually gaining a presence in public life that is no longer restricted to volume launches or even (as the idea of a regular online ‘service’ develops) to formal annual updates of new biographical content. Third, online activity brings unexpected benefits, scholarly and curatorial, throughout the project: extending biographical coverage can lead to better appreciation and visibility of existing content; adding lists and groups identifies omissions even when the editorial collective memory is strong; curation, as well as broadening readership, generates new information; while first-time contributors extend the dictionary’s advocates among scholars and students. 370 11. Opportunities for National Biography Online: The Oxford Dictionary of National Biography, 2005–2012 Fourth, online activity is popular and is being embraced even by seasoned readers of print reference in whom we might have expected greater reticence. Indeed, the ODNB’s short history suggests that future challenges lie less in convincing established scholars (who have moved quickly from print to online when publishing protocols and standards are maintained) than in shepherding younger users towards more considered online activity.19 For some scholars the attraction of online is evidently its opportunities for teaching and research although a further challenge remains how to encourage greater awareness of these research possibilities and methods in the move from singular biography to history through people. Finally, to compile and publish national biography online is to be part of something innovative and rewarding. Accessible, quality reference works, in touch with new research through updates and refinements, are still rare and immensely valuable. This of course brings its own pressures. The rapid growth of online sources and research means that keeping in step with what others are doing is now essential if digital biographies are not to become dated resources. This is not and will not be easy, but being online makes it possible in ways inconceivable in print. Dr Philip Carter is Publication Editor at the Oxford Dictionary of National Biography. 371 12. From Book to Digital Culture: Redesigning the ADB Melanie Nolan We suspect that the usefulness of the ADB could be extended significantly if means could be found to make it well known beyond a basic range of people such as academics, teachers, students, journalists and genealogists … we discussed a number of alternative methods for organising the entries in the next series of volumes (including the ingenious suggestions of one witness for using the new technology to achieve progressive and provisional publication). — Report of the Committee of Review of the Australian Dictionary of Biography (May 1986), p. 3. — Report of the Committee of Review of the Australian Dictionary of Biography (May 1986), p. 3. — Report of the Committee of Review of the Australian Dictionary of Biography (May 1986), p. 3. The Australian Dictionary of Biography (ADB) was designed for publication as a series of books.1 Three main activities lay at the heart of the project: the books, intended as repositories of concise, scholarly biographies of famous and representative Australians; the Biographical Register (BR); and the index. Preparation of the volumes involved working parties and staff in selecting, commissioning and research editing the entries. The BR (originally called the National Register) was a tool for establishing a pool of names, from which to make the selections for inclusion; it eventually developed into a publication in its own right. The index was compiled so that people could more easily navigate their way around the articles. From 1986 the ADB began to consider the application of new technology to these three traditional tasks. Technological ‘retooling’ involves more than changing the medium and attendant culture. A fundamental transformation of the project is concomitant with a digital redesign of the ADB 50 years after its beginning. 373 The ADB’s Story The ADB has been published in book form, CD-ROM and now on the Web Photographer: Peter Fitzpatrick, ADB archives, 2011 The ADB has been published in book form, CD-ROM and now on the Web Photographer: Peter Fitzpatrick, ADB archives, 2011 The ADB has been published in book form, CD-ROM and now on the Web Photographer: Peter Fitzpatrick, ADB archives, 2011 Photographer: Peter Fitzpatrick, ADB archives, 2011 2 ‘Report of the Committee of Review of the Australian Dictionary of Biography’ (May 1986), box 125, Q31, ADBA, ANUA, p. 3. Dictates of the book culture The demands of book publishing determined a number of features about the ADB, including the number of entries to be included, their length, the manner of dealing with corrigenda and the extent of indexing. For example, in 1976, having commissioned and begun work on the submitted articles, as Chris Cunneen discusses in Chapter 4, Peter Ryan, the director of Melbourne University Press, demanded that the length of Volume 6 be reduced by 10 per cent. In 2009, MUP said that we could add 10 per cent to period six. These are perhaps extreme examples but they do indicate how the constraints of the book flowed into all aspects of the ADB. The essence of the ADB has been editing for economy, in keeping with its own house style and according to the publishers’ requirements. Editing, the 1986 Committee of Review of the ADB decided, was a ‘modest term for procedures’ that involved ‘considerable new research and in all cases … careful checking back to source materials’.2 The work of ADB research editors became a defining 374 12. From Book to Digital Culture: Redesigning the ADB aspect of the ADB process. When the Oxford Dictionary of National Biography (ODNB) was published in 2004, several reviews pointed to errors, to which Philip Carter makes reference in his chapter. The editors of the ODNB argued ‘that the mistakes are rare … only 2 per cent of the entries’. They reminded critics that ‘when Sir Leslie Stephen’s first edition (1885–1900) came out, its mistakes were later corrected in a 300-page erratum’.3 Malcolm Ellis was highly critical of the first volumes of the ADB for this reason. Geoffrey Partington has subsequently pointed out that ‘[s]ince the corrigenda of Volume one soon stretched to three pages and contained over one-third of the corrigenda for the first twelve ADB volumes, Ellis may not have been all that wrong’.4 In contrast, Mark McGinness in Chapter 10 also indicates that careful observers like Allan Martin reckoned, however, that ‘most errors were trivial’, and praised instead the high level of accuracy achieved by both editors and staff and the obvious attention given to revision and correction.5 ADB staff, 2009. From left: Gail Clements, Janet Doust, Pam Crichton, Barbara Dawson, Brian Wimborne, Melanie Nolan (seated), Christine Fernon, Karen Ciuffetelli, Anthea Bundock ADB staff, 2009. 3 See, for example, Vanessa Thorpe, ‘At £7,500 for the Set, You’d Think They’d Get Their Facts Right: Throwing the Book at the DNB’, Observer (6 March 2005). 4 Geoffrey Partington, ‘Review of D. A. Low (ed.), Keith Hancock: The Legacies of an Historian (2001)’, Australian Public Intellectual Network (November 2001). 5 A. W. Martin, ‘Australian Dictionary of Biography, Volume 1’, Historical Studies: Australia and New Zealand, 12, no. 48 (April 1967), pp. 584–6. Photographer: Darren Boyd, ADB archives Dictates of the book culture From left: Gail Clements, Janet Doust, Pam Crichton, Barbara Dawson, Brian Wimborne, Melanie Nolan (seated), Christine Fernon, Karen Ciuffetelli, Anthea Bundock 375 The ADB’s Story Over the years the ADB developed an elaborate system of corrigenda, but has rarely accepted addenda. Given the constraints of a book project, however, the corrigenda had to be published separately. In 1991 a consolidated corrigenda, compiled by Darryl Bennet with assistance from Suzanne Edgar, was published.6 In 1992 ADB research assistant Hilary Kent suggested to John Ritchie after preparing an index for the first 12 volumes that a ‘systematic approach’ to the corrections in the ADB, especially in regard to births, deaths and marriages in the first volumes, be adopted, but it was regarded as subsidiary to the central work of publishing new volumes.7 Ritchie, the ADB’s longest-serving general editor (1987–2002), was as deeply committed to producing volumes of the ADB as his predecessors. When the director of the Research School of Social Sciences, Geoff Brennan, suggested that he write a strategic plan in 1994, he responded that ‘the ADB’s single research goal is straightforward: to produce a volume of half a million words, containing the lives of about 670 Australians, written by 500 authors and to do so in roughly thirty months’.8 Occasionally the Editorial Board has considered enhancing ADB entries.9 For example, in 1964 the board decided to include an article in Volume 1 on the Colonial Office, ‘together with a chronological table setting out dates and names of all these officials … [and] the governors of each colony’.10 The decision was revisited the next year but it was decided to abandon that proposal (even though the essay had been written) because of space constraints.11 The ODNB began including ‘thematic essays’ as well as companion reference material, reference lists and collective biographies in its online version in 2004; the ADB followed in 2012. 6 Darryl Bennet (comp.), Consolidated Corrigenda and Previously Unpublished Corrections (Canberra: Australian Dictionary of Biography/ANU, 1991). 7 Hilary Kent to John Ritchie and Chris Cunneen, ‘Births, Deaths and Marriages’ (n.d. [1992]), box 137, Q31, ADBA, ANUA. See Hilary Kent (index ed.), Australian Dictionary of Biography. Index: Volumes 1 to 12, 1788–1939 (Melbourne: Melbourne University Press, 1991). 8 John Ritchie to H. G. Brennan, ‘Strategic Plan’ (15 September 1994), NCB/ADB files. 9 The first thematic and collective biography essays appeared on the National Centre of Biography web site in 2012. 10 Minutes, Editorial Board meeting (10 April 1964), box 64, Q31, ADBA, ANUA. 11 Minutes, Editorial Board meeting (12 February 1965), box 64, Q31, ADBA, ANUA. 11 Minutes, Editorial Board meeting (12 February 1965), box 64, Q31, ADBA, ANUA. 10 Minutes, Editorial Board meeting (10 April 1964), box 64, Q31, ADBA, ANUA. 11 Minutes, Editorial Board meeting (12 February 1965), box 64, Q31, ADBA, ANUA. 10 Minutes, Editorial Board meeting (10 April 1964), box 64, Q31, ADBA, ANUA. 11 Minutes, Editorial Board meeting (12 February 1965), box 64, Q31, ADBA, ANUA. 10 Minutes, Editorial Board meeting (10 April 1964), box 64, Q31, ADBA, ANUA. 11 Minutes Editorial Board meeting (12 February 1965) box 64 Q31 ADBA ANUA The Biographical Register The collection of biographical data predated the ADB project by a number of years. Interviewed by Robin Gollan in 1982, Laurie Fitzhardinge, who started the BR, said that it was 376 12. From Book to Digital Culture: Redesigning the ADB conceived partly as a way of building up material until the time seemed to be right to launch the Dictionary, partly as it still is—as a separate research tool for people who would never get into the Dictionary but whom the searchers in Australian history were going to want to know about at some point, not necessarily know all about them, but be able to place them. He said that the register began ‘very modestly’, and was a means of putting on record, and making accessible for their reference, material found either by myself or by my students about these obscure people that I, or they, had to spend a week finding out about and save the next man doing it. And it probably started out of Allan Martin’s work, I think. Allan had an immense repertoire of knowledge about minor characters … on which the Parkes’ correspondence sheds some light. And this, I think, was probably the beginning of the register. But it grew quite informally and rather haphazardly in that way.12 To begin with, it was a box of cards on Fitzhardinge’s desk and an annotated copy of Who’s Who in Australia with deaths noted and ‘that sort of thing’. Fitzhardinge noted that from the beginning Hancock had recognised the importance of the BR for the ADB project.13 Many State and university libraries had similar indexes or registers of biographical material, but they tended to focus on the libraries’ collections, or special interests. The BR had a national focus. In 1960 Hancock wrote to State librarians, seeking access to their biographical indexes and files. After meeting with John Feely, chief librarian of the State Library of Victoria, in 1961, Geoff Serle, who was then chair of the Victorian Working Party, wrote to Hancock to inform him that he and his research assistant had gained access to the State library’s registers but found they were a ‘rather haphazard set of cards of references to obituaries, etc., with no collated information’.14 Rather than ask the ‘short-staffed and poverty-stricken’ library staff to build up their biographical registers, Serle preferred having someone ‘directly under my control doing the work’. 12 Laurie Fitzhardinge, interviewed by Robin Gollan (30 September 1982), box 70, Q31, ADBA, ANUA, typescript p. 2. 13 Keith Hancock, ‘Formation of the Australian Dictionary of Biography’ (n.d.), box 69, Q31, ADBA, ANUA. 14 Dianne Reilly, Paul de Serville and John Arnold, ‘Remembering the La Trobe Library’, La Trobe Journal, no. 80 (Spring 2007), pp. 22–37. 15 Geoffrey Serle to W. K. Hancock (30 October 1961), and W. K. Hancock, ‘Brief Report of Visit to State Library of Victoria on 17 November 1961’, W. K. Hancock file, 1959–1963, box 69, Q31, ADBA, ANUA. 13 Keith Hancock, ‘Formation of the Australian Dictionary of Biography’ (n.d.), box 69, Q31, ADBA, ANUA. 14 Dianne Reilly, Paul de Serville and John Arnold, ‘Remembering the La Trobe Library’, La Trobe Journal, no. 80 (Spring 2007), pp. 22–37.f 12 Laurie Fitzhardinge, interviewed by Robin Gollan (30 September 1982), box 70, Q31, ADBA, ANUA, typescript p. 2. i h k ‘ i f h li i i f i h ’ ( d ) b 15 Geoffrey Serle to W. K. Hancock (30 October 1961), and W. K. Hancock, ‘Brief Report of Visit to State Library of Victoria on 17 November 1961’, W. K. Hancock file, 1959–1963, box 69, Q31, ADBA, ANUA. 16 Jim Gibbney, ‘Biographical Register’ (6 May 1976), box 132, Q31, ADBA, ANUA. 17 H. Morin Humphrey, Men of the Time: Victoria (Melbourne: McCarron, Bird, 1882). G. E. Loyau, Notable South Australians, or, Colonists—Past and Present (Adelaide: Ferguson, 1885). Phillip Mennell, Dictionary of Australasian Biography (London: Hutchinson & Co., 1892). Fred Johns, Johns’s Notable Australians: Who They Are and What They Do: Brief Biographies of Men and Women of the Commonwealth (Melbourne: G. Robertson, 1906). 18 A. Mozley, ‘The Project of a National Register and a Dictionary of Australian Biography’, a work in Photographer: Peter Fitzpatrick, ADB archives ) 18 A. Mozley, ‘The Project of a National Register and a Dictionary of Australian Biography’, a work in progress seminar to the Department of History, RSSS, ANU (23 April 1959), box 67, Q31, ADBA, ANUA. 19 [Ann Mozley], ‘The Biographical Register’ (July 1961), p. 1. 16 Jim Gibbney, ‘Biographical Register’ (6 May 1976), box 132, Q31, ADBA, ANUA. 16 Jim Gibbney, ‘Biographical Register’ (6 May 1976), box 132, Q31, ADBA, ANUA. 17 H. Morin Humphrey, Men of the Time: Victoria (Melbourne: McCarron, Bird, 1882). G. E. Loyau, Notable South Australians, or, Colonists—Past and Present (Adelaide: Ferguson, 1885). Phillip Mennell, Dictionary of Australasian Biography (London: Hutchinson & Co., 1892). Fred Johns, Johns’s Notable Australians: Who They Are and What They Do: Brief Biographies of Men and Women of the Commonwealth (Melbourne: G. Robertson, 1906). 18 A. Mozley, ‘The Project of a National Register and a Dictionary of Australian Biography’, a work in progress seminar to the Department of History, RSSS, ANU (23 April 1959), box 67, Q31, ADBA, ANUA. 19 [Ann Mozley], ‘The Biographical Register’ (July 1961), p. 1. 17 H. Morin Humphrey, Men of the Time: Victoria (Melbourne: McCarron, Bird, 1882). G. E. Loyau, Nota South Australians, or, Colonists—Past and Present (Adelaide: Ferguson, 1885). Phillip Mennell, Dictionary Australasian Biography (London: Hutchinson & Co., 1892). Fred Johns, Johns’s Notable Australians: Who T Are and What They Do: Brief Biographies of Men and Women of the Commonwealth (Melbourne: G. Roberts 1906). The Biographical Register Seated: Paul Arthur, Christine Fernon, Karen Ciuffetelli, Melanie Nolan 379 The ADB’s Story In 1961 Hancock sent a letter to Australian newspapers, historical societies, pioneers’ clubs and genealogical societies informing them that the ADB was In 1961 Hancock sent a letter to Australian newspapers, historical societies, pioneers’ clubs and genealogical societies informing them that the ADB was compiling a Register of Australian biographical material on lesser known figures, so that we should be most grateful for information not only on prominent personalities such as will be found in the Dictionary, but also others who have played a significant, but less conspicuous, part in any aspect of Australian history, so that details may be recorded for future research workers.20 The usefulness of the BR was as an auxiliary to the dictionary, performing ‘a twofold service, both as a check against the omission of names from the lists of inclusions, and as a guide to possible contributors. In turn, names dropped from the Dictionary lists, are incorporated in the Register’.21 In 1959 and 1963, roneoed compilations of names and references, called ‘short lists’, were made available to libraries, university history departments and many historical societies in Australia.22 Pike indicated in the prefaces to the first three volumes of the ADB that copies of the BR would be ‘circulated at intervals to Australian libraries’, but there were never sufficient resources to do so. From Volume 4 onwards, readers were advised, in prefaces, that thousands of names and biographical information were ‘accumulating at the Dictionary headquarters at the ANU, which they were welcome to visit’.23 The BR flourished under Jim Gibbney’s supervision from 1965 to 1983. A trained librarian and archivist, Gibbney joined the ADB in 1965 as a research fellow ‘to act as general adviser on source material to the Dictionary and to change the direction of register work in certain directions desired by Professor Pike’.24 Pike was concerned, for instance, that the ‘current obituary collection was fairly haphazard’, and that the general name index cards should be accompanied by biographical files housing documents. Gibbney began systematically indexing the Australasian, the British Australasian and the Australian Town and Country Journal, as well as government gazettes, parliamentary papers and Colonial Office records for biographical material.25 Collecting biographical references was also added to the list of tasks set for State research assistants. The Biographical Register They agreed that the best strategy was for the ADB to coordinate State material and build up a central, consistent, biographically dedicated national register at the ANU.15 377 The ADB’s Story Examples of entries in the Biographical Register. The earliest citat were written in pencil. From the early 1980s citations were loade in-house database. In 2011 the Biographical Register was replace Obituaries Australia, a freely accessible, full-text and comprehens indexed companion web site to the ADB Examples of entries in the Biographical Register. The earliest citations were written in pencil. From the early 1980s citations were loaded into an in-house database. In 2011 the Biographical Register was replaced with Obituaries Australia, a freely accessible, full-text and comprehensively indexed companion web site to the ADB ADB archives 378 12. From Book to Digital Culture: Redesigning the ADB Ann Moyal tells the story of her first day at the ADB and being asked to fill in a BR card. Coordinating the collection of data for the register and publishing regular updates to it became two of her main tasks.16 A series of research assistants was employed to work on the project, including Pat Tillyard, Judith Robinson and Nan Phillips. References were collected from dictionaries such as H. Morin Humphrey’s Men of the Time in Australia (1882), George Loyau’s Notable South Australians (1885), Phillip Mennell’s Dictionary of Australasian Biography (1892) and Fred Johns’ Notable Australians (1906);17 as well as State encyclopedias and biographical information in periodicals and newspapers.18 ADB working parties also began to populate the register; a ‘block of biographical material from the Tasmanian State Archives’ filled a gap for that State.19 ADB staff, 2010. From left, standing: Niki Francis, Pam Crichton, Sam Furphy, Scott Yeadon, Max Korolev, Brian Wimborne, Barbara Dawson and Rani Kerin. Seated: Paul Arthur, Christine Fernon, Karen Ciuffetelli, Melanie Nolan ADB staff, 2010. From left, standing: Niki Francis, Pam Crichton, Sam Furphy, Scott Yeadon, Max Korolev, Brian Wimborne, Barbara Dawson and Rani Kerin. 20 W. K. Hancock, ‘Letter to Australian Newspapers, also Historical Societies, Pioneers’ Club, genealogical societies and a second letter was sent to newspapers in Great Britain and Ireland’, box 69, Q31, ADBA, ANUA. 21 ‘The Biographical Register’ (July 1961). 22 Ann Mozley to Professor Hancock, Memo (13 March 1962), and related material, box 73, Q31, ADBA, ANUA. 23 For example, D. P. [Douglas Pike], ‘Preface’, ADB, vol. 1, p. v. 24 Jim Gibbney, ‘Biographical Register’ (6 May 1976), box 132, Q31, ADBA, ANUA. 25 ‘ADB Annual Report’, RSSS Annual Report (1971), box 15, Q31, ADBA, ANUA, p. 17. 20 W. K. Hancock, ‘Letter to Australian Newspapers, also Historical Societies, Pioneers’ Club, genealogical societies and a second letter was sent to newspapers in Great Britain and Ireland’, box 69, Q31, ADBA, ANUA. 21 ‘The Biographical Register’ (July 1961). 22 Ann Mozley to Professor Hancock, Memo (13 March 1962), and related material, box 73, Q31, ADBA, ANUA. l [ l k ] ‘ f ’ l y g g ( y ) ‘ADB Annual Report’, RSSS Annual Report (1971), box 15, Q31, ADBA, ANUA, p. 17. nn Mozley to Professor Hancock, Memo (13 March 1962), and related material, box 73, Q31, ADBA, ANUA. or example D P [Douglas Pike] ‘Preface’ ADB vol 1 p v 23 For example, D. P. [Douglas Pike], ‘Preface’, ADB, vol. 1, p. v. example, D. P. [Douglas Pike], ‘Preface’, ADB, vol. 1, p. v. Gibb ‘Bi hi l R i t ’ (6 M 1976) b 132 Q31 26 ‘Biographical Register, Discussion Paper’ (n.d.), box 57, Q31, ADBA, ANUA; see also papers and report for ‘Australian Dictionary of Biography: Present State and Future Prospects’, seminar (22 October 1975), box 66, Q31, ADBA, ANUA. 27 B. Nairn to F. L. Jones (11 June 1980), box 124, Q31, ADBA, ANUA. The Biographical Register By 1973 the BR had more than 50 000 index cards covering 20 000 people. In 1976 it was decided that the publication of entries from the register should coincide with the publication of the last of the initial 12 volumes and would cover the same period (1788–1939), so that researchers would have access both to the 8100 scholarly 380 12. From Book to Digital Culture: Redesigning the ADB entries in the ADB and to brief epitaphs, and references of another 8000 ‘people from every State, from all walks of life, women as well as men, young and old, making a collection of lesser-known who are none the less relevant to the study of Australian regional, institutional and family history’.26 Anthea Bundock, the last of the ADB’s Biographical Register officers, consults the Biographical Register, 2009 Anthea Bundock, the last of the ADB’s Biographical Register officers, consults the Biographical Register, 2009 Photographer: Peter Fitzpatrick, ADB archives Photographer: Peter Fitzpatrick, ADB archives Assembling and publishing the entries was a large undertaking. Seeking extra assistance for the project, general editor Nairn told the director of RSSS in 1980 that, while the main administrative activity of the ADB had to be directed towards publication, the gathering of diverse biographical material, its ‘organising, copying and filing’ were major activities, too.27 By 1983 Gibbney had prepared 6000 of the entries that were to be published in the style of the 381 The ADB’s Story several biographical registers of parliamentarians.28 Ann Smith saw the project to conclusion following Gibbney’s departure that year from the ADB. The two volumes of the Biographical Register were finally published in 1987.29 The ADB continued to have a dedicated, full-time BR officer until 2005, and until 2009 on a part-time basis. The change was partly a response to the growing amount of biographical material now available online. By then it was estimated that the register contained citations on more than 300 000 index cards; an in- house database, created in 1981, held citations for a further 32 000 people. The BR had been a central part of the ADB’s work: it had been an important source for working parties when choosing subjects for inclusion in the ADB; and it had been of vital use to large numbers of other researchers who contacted the ADB with queries for sources on people, or came to the ADB’s offices to search the cards themselves. The Biographical Register By 2009, however, an average of only 270 people were consulting the register each year. 28 Minutes, Editorial Board meeting (23 May 1983), box 125, Q31, ADBA, ANUA. 29 H. J. Gibbney and Ann G. Smith (comps & eds), A Biographical Register 1788–1939. Notes from the Name Index of the Australian Dictionary of Biography (Canberra: Australian Dictionary of Biography/ANU, 1987). 30 Sidney Lee, Dictionary of National Biography Index and Epitome (London: Elder & Co., 1903), Preface, p. vi. 31 For example, L. L. Robson, ‘Review of the ADB, Volume 1’, Australian Journal of Politics and History, 12, no. 2 (August 1966), p. 307; and W. G. Buick, ‘Whom Was Whom and Why’, Australian Book Review (April 1966). 31 For example, L. L. Robson, ‘Review of the ADB, Volume 1’, Australian Journal of Politics and History, 12, no. 2 (August 1966), p. 307; and W. G. Buick, ‘Whom Was Whom and Why’, Australian Book Review (April 1966). , g ( y ), , Q , , 29 H. J. Gibbney and Ann G. Smith (comps & eds), A Biographical Register 1788–1939. Notes from the Name Index of the Australian Dictionary of Biography (Canberra: Australian Dictionary of Biography/ANU, 1987). 30 Sidney Lee, Dictionary of National Biography Index and Epitome (London: Elder & Co., 1903), Preface, p. vi. 28 Minutes, Editorial Board meeting (23 May 1983), box 125, Q31, ADBA, ANUA. 32 ADB Newsletter, no. 1 (December 1980), box 132, Q31, ADBA, ANUA. Also see Douglas Pike, ‘The Australian Dictionary of Biography’, Hemisphere (November 1966), p. 9. 33 ‘The Australian Dictionary of Biography. Present State and Future Prospects’ (5 October 1975), box 132, Q31, ADBA, ANUA. 34 Minutes, Editorial Board meeting (21 May 1981), box 125, Q31, ADBA, ANUA. Indexing and ‘rapid referencing’ In 1903 Sidney Lee published an index and epitome of the 66 volumes of the British Dictionary of National Biography to permit ‘as … rapid reference as possible’. All entries were summarised and references to leading facts and dates recorded in them were indexed, a massive task of cross-referencing. Lee admitted that it had taken him and ‘his assistants’ a ‘vast amount of time and trouble’.30 The ADB’s general editors were keen to achieve this final editorial task for the ADB, too. The ADB had always included simple indexing. At its most basic was the use of ‘quod vide’ (q.v.) in articles, to indicate that a person mentioned by name was also an ADB subject, in the same or another volume. In a book project this type of indexing can only be retrospective (you cannot index to a volume that is yet to be published) and quite limited. Reviewers of the ADB have often urged that a comprehensive index was urgently needed.31 General editors Serle and Nairn were keen to publish an index, saying that ‘a full-scale subject-index, as distinct from a simple name, place and occupation index’, would be a research 382 12. From Book to Digital Culture: Redesigning the ADB aid of great importance. ‘Consider, for example, of what potential benefit it would be’, they suggested, ‘what a flying start it would give, to anyone making a study of pastoralism, manufacturing, a profession, or dozens of other topics’.32 ADB staff consult Volume 18 in 2012. From left: Sam Furphy, Karen Fox, Melanie Nolan (General Editor) and Rani Kerin ADB staff consult Volume 18 in 2012. From left: Sam Furphy, Karen Fox, Melanie Nolan (General Editor) and Rani Kerin The ADB’s Story The issue of an index became a perennial issue. In 1979 the Editorial Board again considered the possibility of an index to the first six volumes, ‘including the commercial proposal for computer production, but … it was decided that the project is not suitable for action at present and the board could do no more than hope that eventually a scholarly index will be produced’.35 Resources were limited and Nairn and Serle decided ‘to wait until completing the original project to volume 12 and then to produce an index’. The issue of an index became a perennial issue. In 1979 the Editorial Board again considered the possibility of an index to the first six volumes, ‘including the commercial proposal for computer production, but … it was decided that the project is not suitable for action at present and the board could do no more than hope that eventually a scholarly index will be produced’.35 Resources were limited and Nairn and Serle decided ‘to wait until completing the original project to volume 12 and then to produce an index’. The two other tasks—producing volumes of the ADB and maintaining the BR— had priority. They believed that it was more important to push on, than to delay to produce an index to volumes 1–6, and we are sure that public opinion is with us on this question. Fairly soon now, however, if it could be funded and the right person turned up, we would be happy to make a start, provided our energies were not distracted to any great extent.36 In the meantime, others began to compile indexes. In 1979 sociologists Julie Marshall and Richard Trahai compiled an occupational index to the first six volumes of the ADB.37 Robert Buchanan, a visiting fellow at the ANU and a historian of technology at the University of Bath, compiled an index of engineers in 1983.38 About the same time, Serle announced in the ADB newsletter that he would be ‘grateful to be informed of any specialist indexes to the ADB, which readers are compiling’.39 In 1991 Malcolm Sainty and Michael Flynn compiled an index to the first two volumes but could not find a publisher to distribute it.40 An ADB seminar in 1988 suggested that the index for the first 12 volumes was a priority project for the dictionary and a proposal was put to the Editorial Board. 35 Minutes, Editorial Board meeting (8 November 1979), box 66, Q31, ADBA, ANUA. ( ) 37 Julie G. Marshall and Richard C. S. Trahair, Occupational Index to the Australian Dictionary of Biography (1788–1890), Volumes 1–6 (Bundoora, Vic.: Department of Sociology, School of Social Sciences, La Trobe University, 1979). g ( ) 36 ADB Newsletter, no. 1 (December 1980), box 132, Q31, ADBA, ANUA. 41 ‘Quiet Achievers in Indexing—Barry Howarth’, Australian and New Zealand Society of Indexers Newsletter, 8, no. 2 (2012), pp. 10–11. ( g ) 40 Malcolm R. Sainty and Michael C. Flynn (eds), Index to the Australian Dictionary of Biography, Volumes 1 & 2 (A to Z, 1788–1850) (Sydney: Library of Australian History, 1991), available from the Library of Australian History, Sydney. 42 Hilary Kent (ed.), Australian Dictionary of Biography Index to Volumes 1 to 12 (Melbourne: Melbourne University Press), Acknowledgements. 38 R. A. Buchanan, ‘The British Contribution to Australian Engineering: The Australian Dictionary of Biography Entries, Historical Studies, 20, no. 80 (April 1983), pp. 401–19. Photographer: Christine Fernon, ADB archives Photographer: Christine Fernon, ADB archives In 1975 the Editorial Board discussed suggestions by ‘reviewers and others’ about the need for an index for the first six volumes, a concise ADB and similar initiatives.33 This was thought to be especially necessary for casual readers who often found it difficult to locate a subject in a volume on the floruit principle (used up to Volume 12), which placed subjects in volumes according to when they made their most important contribution to Australian history and not their date of death. It was noted, though, that indexing work of this kind ‘would hold up production of regular volumes’, and the decision was made to wait. In 1979 Melbourne University Press raised concern about ‘the large size of an index (perhaps 500 pages alone)’, fearing it would be a daunting project for all concerned.34 383 The ADB’s Story 38 R. A. Buchanan, ‘The British Contribution to Australian Engineer Biography Entries, Historical Studies, 20, no. 80 (April 1983), pp. 401–19. g p y , , , ( p ), pp 39 ADB Newsletter, no. 3 (August 1983), box 132, Q31, ADBA, ANUA. 35 Minutes, Editorial Board meeting (8 November 1979), box 66, Q31, ADBA, ANUA. 36 ADB Newsletter, no. 1 (December 1980), box 132, Q31, ADBA, ANUA. 37 Julie G. Marshall and Richard C. S. Trahair, Occupational Index to the Australian Dictionary of Biography (1788–1890), Volumes 1–6 (Bundoora, Vic.: Department of Sociology, School of Social Sciences, La Trobe University, 1979). 38 R. A. Buchanan, ‘The British Contribution to Australian Engineering: The Australian Dictionary of Biography Entries, Historical Studies, 20, no. 80 (April 1983), pp. 401–19. 39 ADB Newsletter, no. 3 (August 1983), box 132, Q31, ADBA, ANUA. 40 Malcolm R. Sainty and Michael C. Flynn (eds), Index to the Australian Dictionary of Biography, Volumes 1 & 2 (A to Z, 1788–1850) (Sydney: Library of Australian History, 1991), available from the Library of Australian History, Sydney. 41 ‘Quiet Achievers in Indexing—Barry Howarth’, Australian and New Zealand Society of Indexers Newsletter, 8, no. 2 (2012), pp. 10–11. 42 Hilary Kent (ed.), Australian Dictionary of Biography Index to Volumes 1 to 12 (Melbourne: Melbourne University Press), Acknowledgements. 38 R. A. Buchanan, ‘The British Contribution to Australian Engineering: The Australian Dictionary of Biography Entries, Historical Studies, 20, no. 80 (April 1983), pp. 401–19. 39 ADB Newsletter, no. 3 (August 1983), box 132, Q31, ADBA, ANUA. The ADB’s Story Hilary Kent commenced work in July 1989. She consulted Barry Howarth, who had indexed the 1988 project, The Australian People: An Encyclopaedia of the Nation, Its People and Their Origins.41 She was assisted in the work by others, including Helen Boxall, Sheila Tilse and Darryl Bennet. It was published by MUP in 1991.42 Ritchie described the task as ‘herculean’ 384 12. From Book to Digital Culture: Redesigning the ADB and a ‘monumental effort’, taking 18 months: ‘she had to read and analyse each volume, to differentiate between every name (there are no fewer than eighty- seven Smiths, and eleven of them are William) and to re-check all birthplaces and to examine a host of occupations’, which were categorised into 379 kinds. The index focused on names, occupations and origins or places of birth and pointed to the rich connections that could be made between subjects. Only a trickle of historians, however, used ADB articles for group biography. R. S. Neale’s analysis of the first three volumes in terms of the social origins and characteristics of executive and administrative leaders in Australia from 1788 to 1856 was mentioned in Chapter 1.43 A decade later, Angus Buchanan used the data then available in the first six volumes of the ADB to consider the role of British engineering in Australia’s development.44 In 1990 Barry Smith attempted to use the lives of academics in the ADB and the published Biographical Register to begin to write a history of universities in Australia, although he felt constrained by the teleological nature of all but the best articles, shaped as they were by the ending rather than discussing unfulfilled ambitions and constraints on opportunities.45 All three historians discussed the difficulties they had ‘manually’ mining the ADB for social history using collective biography or prosopographical methodologies. It was simply hard work; and change was still some way off. 43 R. S. Neale, ‘The Colonies and Social Mobility: Governors and Executive Councilors in Australia, 1788– 1856’, in Class and Ideology in the Nineteenth Century (London: Routledge & Kegan Paul, 1972), pp. 97–120. 44 Buchanan, ‘The British Contribution to Australian Engineering’, pp. 401–19. 45 F. B. Smith, ‘Academics In and Out of the Australian Dictionary of Biography’, in F. B. Smith and Pamela Crichton (eds), Ideas for Histories of Universities in Australia (Canberra: Division of Historical Studies, Research School of Social Sciences, Australian National University, 1990), pp. 1–14. 46 S. G. Foster to the Director, RSSS (20 February 1988); see also, Stephen Foster to Geoff Serle (26 January 1988), box 144, Q31, ADBA, ANUA. y ) pp 46 S. G. Foster to the Director, RSSS (20 February 1988); see also, Stephen Foster to Geoff Serle (26 January 1988), box 144, Q31, ADBA, ANUA. The transition: CD-ROM, ADB online, People Australia, advanced indexing, 1986–2012 The ADB’s first steps towards adopting new technology for publication, research and indexing were faltering ones. In 1986 Stephen Foster, the executive editor of Australia 1788–1988, A Bicentennial History, made a submission to the 1986 Committee of Review of the ADB noting that the dictionary was a vast storehouse of knowledge about Australia’s past but suggesting that much of the information was inaccessible to potential users.46 The committee took evidence 385 The ADB’s Story about the possibility of using ‘machine readable data retrieval systems’ and noted sharply that ‘while we did not explore this issue in detail, we suspect that the ADB management may not have explored it at all’.47 A year later Foster came up with an innovative project that he put before the Australian Bicentennial Authority for a project called ‘Australians on Disc’, which would include a ‘Guide to Biographical Research in Australia’, as well as the ADB entries in Volumes 1–11, the entries published in the Biographical Register, the compilation of parliamentarian registers, together with some of the early dictionary compilations (when reliable), Who’s Who in Australia, and bibliographies.48 All of the projects were to be published on a CD-ROM, a new technology that had only been around for a year, and were to be fully searchable. Serle responded favourably to the project, conceding that in the long run ‘this [CD-ROM] will be how the ADB is primarily distributed and used, or [will] be an alternative form of production’.49 The proposal was strongly opposed, however, by the director of MUP, Peter Ryan,50 who was generally unenthusiastic about anything—paperback, illustrated, concise or abridged versions, as well as any indexes—that could potentially be a major threat to sales of the existing volumes of the ADB.51 Emphasising the ADB’s contractual obligations, he pointed out that MUP had invested heavily in the dictionary, set artificially low retail prices per volume and maintained all volumes in print, at great cost in terms of the capital thus tied up. He estimated MUP’s total investment in the ADB up to that point was in the order of $3 million; the total value of the stock in the warehouse in the mid 1980s alone was $420 000. Volumes 3 and 6 were being reprinted, which would add some $30–40 000 to this stock investment. 47 ‘Report of the Committee of Review of the Australian Dictionary of Biography, May 1986’, box 125, Q31, ADBA, ANUA, p. 8. 48 Draft paper by S. Foster, ‘The Australian Biographical database’ (8 January 1988), and paper on ‘Australians on Disc: A Report for the Australian Bicentennial Authority on the Feasibility of Developing an Australian Biographical Computer Database’ (February 1988), box 144, Q31, ADBA, ANUA. 49 Geoffrey Serle to Director, RSSS (2 September 1987), and Geoff Serle, ‘Proposal for Biographical Database’, box 144, Q31, ADBA, ANUA. 50 P. A. R. [Peter Ryan], ‘The ADB in Other Forms’, 27 February 1986. See also Melbourne University Press submission to the 1986 committee of review, ‘Report of the Committee of Review of the Australian Dictionary of Biography, May 1986’, box 125, Q31, ADBA, ANUA, Appendix 6. 51 Memo by ‘Ann’? [Ann Smith]. 52 Peter Ryan to Geoff Serle (29 May 1987), box 142, Q31, ADBA, ANUA. 53 Geoffrey Serle to Peter Ryan (6 February 1988), box 142, Q31, ADBA, ANUA. 47 ‘Report of the Committee of Review of the Australian Dictionary of Biography, May 1986’, box 125, Q31, ADBA, ANUA, p. 8. yf y 53 Geoffrey Serle to Peter Ryan (6 February 1988), box 142, Q31, ADBA, ANUA. 52 Peter Ryan to Geoff Serle (29 May 1987), box 142, Q31, ADBA, ANUA. 3 G ff l (6 b 1988) b 1 2 31 52 Peter Ryan to Geoff Serle (29 May 1987), box 142, Q31, ADBA, ANUA. 53 Geoffrey Serle to Peter Ryan (6 February 1988) box 142 Q31 ADBA ANUA 51 Memo by ‘Ann’? [Ann Smith].f The transition: CD-ROM, ADB online, People Australia, advanced indexing, 1986–2012 He also stressed that it was crucial to preserve the integrity of the present 12-volume scheme.52 Unable to obtain MUP’s support—and concerned that the CD-ROM would not include the full set of ADB volumes since Volume 12 had not yet been published—Serle withdrew his support for the ‘Australians on Disc’ project; but the venture had highlighted the fact that the new technology ‘won’t go away’.53 According to Serle, most of those involved on and around the ADB had come to 386 12. From Book to Digital Culture: Redesigning the ADB recognise (‘many of us unwillingly’) that it ought to be done, if not immediately. He argued that the ADB needed to adopt the new technology in order to control the process. recognise (‘many of us unwillingly’) that it ought to be done, if not immediately. He argued that the ADB needed to adopt the new technology in order to control the process. Ryan responded in 1988 that MUP was ‘neither canutes nor dogs-in-the-manger, and have for some years acknowledged the probable need for presenting the ADB in electronic form’.54 But Ryan claimed that MUP had ‘serious misgivings about the wisdom of proceeding on the basis of present technology. In both programming and in the “access” end we see difficulties, which will probably be overcome; but we should not paint ourselves into a corner by undue haste’. He claimed that though we don’t publicise it, MUP has always been at the forefront of Australian publishing in the use of the most advanced electronic techniques for typesetting and allied devices. One of our senior people is at present preparing for an overseas visit in which a specific study is to be made of disk presentation of volumes. Ryan suggested that MUP would develop a scheme that involved neither the ADB nor the ANU in any significant work or expense and that MUP would provide the capital, technique, promotion, marketing and selling of the electronic ADB as it did for the volumes. 54 Peter Ryan to Geoffrey Serle (9 February 1988), box 142, Q31, ADBA, ANUA. 55 Minutes, Editorial Board meeting (18 August 1988), box 125, Q31, ADBA, ANUA. 56 Minutes, Editorial Board meeting (21 May 1981), box 125, Q31, ADBA, ANUA. 57 Minutes, Editorial Board meeting (10 July 1992), box 125, Q31, ADBA, ANUA. 58 ‘Publishing Agreement between MUP and ANU’ (3 August 2005), NCB/ADB files. Photographer: Peter Fitzpatrick, ADB archives Obituaries Australia and People Australia In 2009 the ADB moved the 11 000 files that had been created while editing dictionary entries from its offices in the Coombs Building to the ANU Archives, so that they could be stored in the proper atmospheric conditions and be more accessible to researchers. The question then arose, what should we do with the 300 000 cards of the BR and the 100 000 citations on the in-house database? How could that information be made more accessible—and useful? Rather than simply digitise the cards and place them on the web, as some suggested, the decision was made to take a new approach, utilising the indexing and cross-referencing opportunities that the web afforded. As a first step an online obituaries database was started in 2011. Obituaries have always been the single most important source of information collected for the BR and are a major source of reference for ADB entries. The full text of obituaries is being published and is indexed using the same fields as those in the ADB, so that those searching the ADB can also be drawn to results in Obituaries Australia, and vice versa. The Obituaries Australia entries are also being indexed to show cause of death, place of education and work, awards won, association with pastoral properties and events, and any groups or organisations that the subjects were involved in. This level of indexing, which will be retrospectively applied to ADB entries, will enable all sorts of complex queries to be posited. Other biographical web sites have also been created, including Women Australia, Labour Australia and the overarching site People Australia, which searches all of the web sites for entries and also include a register for those for whom there is little published information. In a sense, we are returning to our ‘roots’ and revisiting the publications from which we first took information when starting the BR in the 1950s. This time around, however, we are digitising and indexing the entries in Mennell’s Dictionary of Australasian Biography and Johns’s Notable Australians. And we plan to seek the cooperation of the national and State libraries to digitise their biographical files (the National Library of Australia, alone, has 200 000 of them) and add them to our databases. The transition: CD-ROM, ADB online, People Australia, advanced indexing, 1986–2012 In 1988 the Editorial Board authorised Ritchie to negotiate with the new director of MUP for a CD-ROM version of the ADB.55 In 1992, when the ADB’s contract with MUP was renegotiated, Ritchie ceded all rights to produce the ADB in any form to MUP.56 In 1996 MUP produced a CD-ROM version of Volumes 1–12.57 Eight years later, it was suggested that the ADB should go online but MUP reminded the dictionary of its contractual obligation to work with it on any proposal. Following protracted negotiations, a new contract was drawn up allowing the ADB to proceed with an Australian Research Council proposal for funding to place the ADB online. It was agreed that the ANU would have all rights to online publications and MUP all hardcopy publishing rights.58 The ADB was then able to develop the dictionary as it saw fit. 387 The ADB’s Story The ADB s Story Obituaries Australia was launched at the ANU in 2011. Back row, fr left: Scott Yeadon, Christine Fernon, Max Korolev, Nigel Starck (aut of Life After Death) and Ian Young, ANU vice-chancellor. Front: Joh Farquharson, obituary writer, and Melanie Nolan, ADB general edito Photographer: Peter Fitzpatrick, ADB archives Obituaries Australia was launched at the ANU in 2011. Back row, fro left: Scott Yeadon, Christine Fernon, Max Korolev, Nigel Starck (auth of Life After Death) and Ian Young, ANU vice-chancellor. Front: John Obituaries Australia was launched at the ANU in 2011. Back row, from left: Scott Yeadon, Christine Fernon, Max Korolev, Nigel Starck (author of Life After Death) and Ian Young, ANU vice-chancellor. Front: John Farquharson, obituary writer, and Melanie Nolan, ADB general editor Photographer: Peter Fitzpatrick, ADB archives 388 12. From Book to Digital Culture: Redesigning the ADB )i 60 Robert Faber and Brian Harrison, ‘The Dictionary of National Biography: A Publishing History’, in Robin Myers, Michael Harris and Giles Mandelbrote (eds), Lives in Print: Biography and the Book Trade from the Middle Ages to the 21st Century (London: Oak Knoll, 2002), pp. 171–92. Photographer: Natalie Azzopardi, ADB archives 59 Gavan McCarthy, ‘The Australian Dictionary of Biography Online: The Foundation of an Online Encyclopedia of Australia’, in Computing Arts 2004, Noah’s Hotel, Newcastle, New South Wales (8–9 July 2004), NCB/ADB files. 59 Gavan McCarthy, ‘The Australian Dictionary of Biography Online: The Foundation of an Online Encyclopedia of Australia’, in Computing Arts 2004, Noah’s Hotel, Newcastle, New South Wales (8–9 July 2004), NCB/ADB files. 60 Robert Faber and Brian Harrison, ‘The Dictionary of National Biography: A Publishing History’, in Robin Myers, Michael Harris and Giles Mandelbrote (eds), Lives in Print: Biography and the Book Trade from the Middle Ages to the 21st Century (London: Oak Knoll, 2002), pp. 171–92. More than the book online? The ADB and digital culture The three main tasks of the ADB project have been radically changed by the application of new digital technology. Going online in 2006 has made the project widely accessible and facilitated advanced indexing and linking between 389 The ADB’s Story entries; but these developments, in many ways, are simply the book project online: electronic editions of print and paper resources or existing bodies of work brought together more efficiently than before. Some think that the ADB project should not develop beyond its original book or ‘liber’ objectives. Others, such as Gavan McCarthy, are conceiving more possibilities for the ADB in the new digital age. In 2004 McCarthy gave a conference paper, ‘The Australian Dictionary of Biography Online; the Foundation of an Online Encyclopedia of Australia’.59 Others have imagined a universal dictionary. The ODNB’s project director, Robert Faber, thought a universal dictionary possible, through interoperability—thereby linking all biographical dictionary web sites.60 ADB staff, past and present, at the launch of the online version of Volume 18, December 2012. Back row: Max Korolev, Scott Yeadon, Chris Clark, Nicole McLennan, Karen Fox (hidden), Chris Cunneen, Di Langmore, Nick Brown and Sam Furphy. Middle: Rani Kerin, Christine Fernon, Anthea Bundock (hidden), Janet Doust, Barry McGowan, Rosemary Jennings, Paul Arthur and Darryl Bennet. Front: Brian Wimborne, Edna Kauffman, Melanie Nolan, Niki Francis, Barbara Dawson, Gail Clements, Chris Wallace, Sue Edgar ADB staff, past and present, at the launch of the online version of Volume 18, December 2012. Back row: Max Korolev, Scott Yeadon, Chris Clark, Nicole McLennan, Karen Fox (hidden), Chris Cunneen, Di Langmore, Nick Brown and Sam Furphy. Middle: Rani Kerin, Christine Fernon, Anthea Bundock (hidden), Janet Doust, Barry McGowan, Rosemary Jennings, Paul Arthur and Darryl Bennet. Front: Brian Wimborne, Edna Kauffman, Melanie Nolan, Niki Francis, Barbara Dawson, Gail Clements, Chris Wallace, Sue Edgar 390 12. From Book to Digital Culture: Redesigning the ADB In this regard, the ADB is already a party to the Humanities Networked Infrastructure (HuNI) project, which aims to provide researchers around the world with access to the combined resources of Australia’s major cultural data sets and information assets. The HuNI project seems to be an advanced electronic version of the project that Foster imagined the ADB being involved in on disc in 1988. More immediately, the ADB is looking to use its own resources to develop e-research projects. Three reviews of the ADB online in 2009–10 considered this question. 61 ‘Between the Past and Future: The Australian Dictionary of Biography’, Closed workshop (2 December 2009), NCB/ADB files. 62 Orville Vernon Burton, ‘American Digital History’, Social Science Computer Review, 23, no. 2 (Summer 2005), p. 207. 63 Alan Atkinson and Marion Aveling (eds), Australians 1838 (Broadway, NSW: Fairfax, Syme & Weldon Associates, 1987). Graeme Davison, J. W. McCarty and Ailsa McLeary (eds), Australians, 1888 (Broadway, NSW: Fairfax, Syme & Weldon Associates, 1987). Patricia Grimshaw, Chris McConville and Ellen McEwen (eds), Families in Colonial Australia (Sydney: George Allen & Unwin, 1985). More than the book online? The ADB and digital culture The director of the ANU’s Supercomputer Facility, Ben Evans, and project officer Stuart Hungerford wrote a ‘Redevelopment Project Plan of the ADB’ in November 2009. A few months later, Tim Sherratt, a freelance web site content developer, presented his review of the ADB; while John Evershed and Kent Fitch, principals of a private-sector IT company, Project Computing, submitted their review in March 2010. The reviews, together, put a strong case for the ADB to begin the task of redeveloping the project’s software to provide for new functionality and to appoint its own computer programmer. These ideas were also the subject of a seminar of the ADB Editorial Board in December 2009.61 Central to these developments has been the creation of new databases and new methods of indexing to support e-research. For example, instead of simply hyperlinking between subjects in entries, the relationship between subjects is now being described. This enables family trees to be drawn and the visualisation of the links between family groups. Digital technology should be seen as an integral part of historical scholarship, providing tools and media to assist the historian in better research, better recording and better communication. As O. V. Burton acknowledges, ‘by incorporating the tremendous power of the computer with the practices and methodologies of the historian, the result should be better history’.62 Digitising resources and analysing a mega-database enable a range of research work to be focused on, for instance, kinship, associational life and place. The study of family history is not new in Australian history. 64 Wray Vamplew (ed.), Historical Statistics, Australians, A History: Bicentennial History Series (Broadway, NSW: Fairfax, Syme & Weldon Associates, 1987). Ann Larson, ‘Growing up in Melbourne: Transitions to Adulthood in the Late Nineteenth Century’ (PhD thesis, The Australian National University, Canberra, 1994). Ian Pool, Arunachalam Dharmalingam and Janet Sceats, The New Zealand Family from 1840: A Demographic History (Auckland: Auckland University Press, 2007). Amber Eyes (London: Chatto & Windus, 2010). 67 Janet Lyndall Doust, ‘English Migrants to Eastern Australia, 1815–1860’ (PhD thesis, The Australian National University, Canberra, 2004); ‘Two English Immigrant Families in Australia in the 19th Century’,The History of the Family, 13 (2008), pp. 2–25. Helen Elizabeth Pfeil, ‘Raising Colonial Families: The Upper- middle-class in Eastern Australia, 1840–1900’ (PhD thesis, The Australian National University, Canberra, 2009). In progress: Shelley Richardson, ‘A Collective Biography of the Urban Middle Class Professional Family in Australasia 1880–1930’; and Les Hetherington, ‘Vaillante Soeur: Marie Caroline Niau and her Family in France, England and Australia, 1870 to 1933’, ANU. 66 James Fox, Five Sisters. The Longehorns of Virginia (New York: Simon & Schuster, 2000). Martin Pugh, The Pankhursts: The History of One Radical Family (London: Penguin, 2002). Edmund de Waal, The Hare with Amber Eyes (London: Chatto & Windus, 2010). y ( y ) 65 Mary Durack, Kings in Grass Castles (London: Constable & Co., 1959). Bobbie Hardy, From the Hawkesbury to the Monaro (Kenthurst, NSW: Kangaroo Press, 1989). Stephen Foster, A Private Empire (Millers Point, NSW: Pier 9, 2010). 66 James Fox, Five Sisters. The Longehorns of Virginia (New York: Simon & Schuster, 2000). Martin Pugh, The Pankhursts: The History of One Radical Family (London: Penguin, 2002). Edmund de Waal, The Hare with Amber Eyes (London: Chatto & Windus, 2010). 67 Janet Lyndall Doust, ‘English Migrants to Eastern Australia, 1815–1860’ (PhD thesis, The Australian National University, Canberra, 2004); ‘Two English Immigrant Families in Australia in the 19th Century’,The 66 James Fox, Five Sisters. The Longehorns of Virginia (New York: Simon & Schuster, 2000). Martin Pugh, The Pankhursts: The History of One Radical Family (London: Penguin, 2002). Edmund de Waal, The Hare with Amber Eyes (London: Chatto & Windus, 2010). 67 Janet Lyndall Doust, ‘English Migrants to Eastern Australia, 1815–1860’ (PhD thesis, The Australian National University, Canberra, 2004); ‘Two English Immigrant Families in Australia in the 19th Century’,The History of the Family, 13 (2008), pp. 2–25. Helen Elizabeth Pfeil, ‘Raising Colonial Families: The Upper- middle-class in Eastern Australia, 1840–1900’ (PhD thesis, The Australian National University, Canberra, 2009). In progress: Shelley Richardson, ‘A Collective Biography of the Urban Middle Class Professional Family More than the book online? The ADB and digital culture In the 1980s there was considerable work on family-centred, community, social history.63 At the same 391 The ADB’s Story time, demographers worked on the aggregate antipodean family experience.64 Self-consciously ‘collective’ or ‘group’ family history has been written intermittently, in memoirs such as Mary Durack’s Kings in Grass Castles, studies like Bobbie Hardy’s From the Hawkesbury to the Monaro, and Stephen Foster’s A Private Empire.65 Collective and prosopographical biography methodologies have identified and drawn relationships between individuals, often using statistics and concentrating on prominent and powerful people, groups or families.66 Most recently, there has been interest in historiographical questions about networks of families using relational models.67 All of these studies share the view that the family and familial networks are at the heart of society but they can make no claims about representativeness or typicality for their particular case studies; nor can they develop a typology beyond the case studies. Work on families in the past has provided, effectively, a huge, unweighted list of candidate factors and cases of individual families in isolation. The NCB/ADB is amassing a large body of comprehensively indexed biographical records of Australian families for our community and providing data for social network and visualisation analysis. There is also research potential in the new online capacity to study the associational patterns of Australians and their place in biographical history. The ADB is fielding membership of associations for its biographies and obituaries, which, together with digitised associational membership lists, will be available for use for research projects. For example, obituaries from the Pastoral Review, when considered in light of lists of stockowners in New South Wales, Queensland, Victoria, South Australia, Western Australia, the Northern Territory and Tasmania and other sources such as Darrell Lewis’s ‘The Victoria River District Doomsday Book’, a compendium of Victoria River District cattle station histories and biographies of station 392 12. From Book to Digital Culture: Redesigning the ADB employees, will be able to shed social-history light, by way of biography, on place.68 The ADB, then, will not be just ‘a national record and a suggestive piece of social history’.69 employees, will be able to shed social-history light, by way of biography, on place.68 The ADB, then, will not be just ‘a national record and a suggestive piece of social history’.69 The ADB was significant for Australian history at its outset, when Australian history was in its infancy. 72 Daniel J. Cohen and Roy Rosenzweig, Digital History: A Guide to Gathering, Preserving and Presenting the Past on the Web (Philadelphia: University of Pennsylvania Press, 2005). More than the book online? The ADB and digital culture It is still important now that there is so much more information at hand and a plethora of sources available. New technology enables patterns to be established and hypotheses to be tested. 68 Darrell Lewis, ‘The Victoria River District Doomsday Book’, a compendium of Victoria River District cattle station histories and biographies of station employees, a copy of which he provided to the ADB. 73 A version of this phrase about relegating the many to the Biographical Register was in every preface, ADB, vols 1–17 (1966–2007). 71 Ian G. Anderson, History and Computing. Making History. The Changing Face of the Profession in Britain (London: Institute of Historical Research, University of London, 2008), <http://www.history.ac.uk/ makinghistory/resources/articles/history_and_computing.html> lists just some: historical demography, psephology, prosopography, elite structures, entrepreneurial, family, urban, political, social, economic, medical, educational history. 69 Richard Davenport-Hines, ‘Review of the ADB’, Times Literary Supplement (14 January 1986), pp. 1263–4. 70 David J. Staley, ‘Designing and Displaying Historical Information in the Electronic Age’, Journal of the Association for History and Computing, 1, no. 1 (June 1998). 68 Darrell Lewis, ‘The Victoria River District Doomsday Book’, a compendium of Victoria River District cattle station histories and biographies of station employees, a copy of which he provided to the ADB. 69 Richard Davenport-Hines, ‘Review of the ADB’, Times Literary Supplement (14 January 1986), pp. 1263–4. 70 David J. Staley, ‘Designing and Displaying Historical Information in the Electronic Age’, Journal of the Association for History and Computing, 1, no. 1 (June 1998). 71 Ian G. Anderson, History and Computing. Making History. The Changing Face of the Profession in Britain (London: Institute of Historical Research, University of London, 2008), <http://www.history.ac.uk/ makinghistory/resources/articles/history_and_computing.html> lists just some: historical demography, psephology, prosopography, elite structures, entrepreneurial, family, urban, political, social, economic, medical, educational history. 72 Daniel J. Cohen and Roy Rosenzweig, Digital History: A Guide to Gathering, Preserving and Presenting the Past on the Web (Philadelphia: University of Pennsylvania Press, 2005). 73 A version of this phrase about relegating the many to the Biographical Register was in every preface, ADB, vols 1–17 (1966–2007). Conclusion If the ADB had been designed, from the beginning, to be published online, many things would have been done differently.70 The evolution of technology has had a major impact on how history is recorded and communicated, since at least the time of the invention of the printing press. The advent of the Internet and the rapid development of digital technology have had a particular impact on the ADB. Digital media and computer tools are revolutionising biographical practice. They have allowed the ADB to present accumulated factual information simultaneously in print and in ways that traditional print methods simply could not achieve, and are allowing biography to be researched and analysed in new ways.71 The ADB has become more accessible and it has been linked in pathways with all kinds of other material online.72 Above all, the many subjects who ‘had to be omitted through pressure of space or lack of material’ from the book project are now being salvaged in the ADB online project.73 393 Appendix 1 June 1960 Agreement is reached that Ellis and Clark will edit Volumes 1 and 2 respectively, rather than jointly. August 1960 Anonymous donor (Bushell Trust) pledges £1500 per year for three years to the ADB. It will enable the dictionary to employ researchers and to pay some professional writers for entries. 21 June 1961 A Commonwealth working group on the arts is convened. July 1961 Updated short list of the Biographical Register is published. 12–13 August 1961 Second general meeting of the National Committee is held. January 1962 Myer Foundation pledges £1000 per year for three years to the ADB. 31 January 1962 Douglas Pike is appointed the ADB’s first general editor. 2–3 February 1962 Third general meeting of the National Committee is held. 2-3 February 1962 Ellis resigns from the editorship of Volume 1 and the Editorial Board. 6 February 1962 Editorial Board appoints A. G. L. Shaw editor of Volume 1. 11 April 1962 Manning Clark agrees to act with general editor, Douglas Pike, as joint editor of Volume 2. 12–13 August 1962 Pacific and armed services specialist working groups are convened; plans are made for scientific and medical working groups. The ADB’s Story The ADB’s Story 13 October 1959 13 October 1959 Hancock invites Ellis and Manning Clark to jointly edit the first two volumes of the Dictionary of Australian Biography. Biography. Joint meeting in Canberra of the Editorial Committee and the National Advisory Panel votes to reconstitute the two committees. The Provisional Editorial Committee is reconstituted as the Editorial Board with responsibility for producing the ADB. The National Advisory Panel is reconstituted as the National Committee whose duty it is to broadly define ADB policy. The chairman of the Editorial Board is to be appointed by the ANU vice- chancellor. The meeting puts on hold the suggestion to appoint a general editor, owing to a lack of funding. The meeting also reluctantly decides to change the name of the dictionary to Australian Dictionary of Biography to avoid confusion with Percival Serle’s earlier publication. Agreement is reached that Ellis and Clark will edit Volumes 1 and 2 respectively, rather than jointly. Anonymous donor (Bushell Trust) pledges £1500 per year for three years to the ADB. It will enable the dictionary to employ researchers and to pay some professional writers for entries. Appendix 1 Time Line Date Event 1947 Laurie Fitzhardinge visits Clarendon Press in London to study the publication of the Dictionary of National Biography. 1949 Percival Serle publishes his two-volume Dictionary of Australian Biography. 1951 Laurie Fitzhardinge, at the ANZAAS Congress, calls for the creation of an Australian dictionary of biography. 1954 Fitzhardinge starts the National Register (later called Biographical Register) in the History Department, RSSS, ANU. Pat Tillyard (Wardle) is employed as his clerical assistant. 24–27 August 1957 Conference of Australian historians, convened by Sir Keith Hancock and held at the ANU, agrees in principle to start work on a dictionary of Australian biography. May 1958 Malcolm Ellis confers with Hancock and Fitzhardinge about the prospect of commencing a dictionary of Australian biography. November 1958 Ann Mozley (Moyal) is appointed a research assistant (later research fellow) in the history department, RSSS, with a special interest in the development of the Dictionary of Australian Biography. 19 June 1959 First meeting of the Provisional Editorial Committee of the Dictionary of Australian Biography is held in Hancock’s office in the old Canberra Community Hospital, at the ANU. July 1959 Short list of the National Register is published in roneoed format. August 1959 Malcolm Ellis submits his plan for the organisation of the Dictionary of Australian Biography. August 1959 Mozley travels to Melbourne, Adelaide, Perth and Hobart to establish Dictionary of Australian Biography working parties. Short list of the National Register is published in roneoed format. 397 The ADB’s Story 13 October 1959 Hancock invites Ellis and Manning Clark to jointly edit the first two volumes of the Dictionary of Australian Biography. 23–24 April 1960 Joint meeting in Canberra of the Editorial Committee and the National Advisory Panel votes to reconstitute the two committees. The Provisional Editorial Committee is reconstituted as the Editorial Board with responsibility for producing the ADB. The National Advisory Panel is reconstituted as the National Committee whose duty it is to broadly define ADB policy. The chairman of the Editorial Board is to be appointed by the ANU vice- chancellor. The meeting puts on hold the suggestion to appoint a general editor, owing to a lack of funding. The meeting also reluctantly decides to change the name of the dictionary to Australian Dictionary of Biography to avoid confusion with Percival Serle’s earlier publication. Appendix 1 23–24 April 1960 Joint meeting in Canberra of the Editorial Committee and the National Advisory Panel votes to reconstitute the two committees. The Provisional Editorial Committee is reconstituted as the Editorial Board with responsibility for producing the ADB. The National Advisory Panel is reconstituted as the National Committee whose duty it is to broadly define ADB policy. The chairman of the Editorial Board is to be appointed by the ANU vice- chancellor. The meeting puts on hold the suggestion to appoint a general editor, owing to a lack of funding. The meeting also reluctantly decides to change the name of the dictionary to Australian Dictionary of Biography to avoid confusion with Percival Serle’s earlier publication. Agreement is reached that Ellis and Clark will edit Volumes 1 and 2 respectively, rather than jointly. Anonymous donor (Bushell Trust) pledges £1500 per year for three years to the ADB. It will enable the dictionary to employ researchers and to pay some professional writers for entries. A Commonwealth working group on the arts is convened. Updated short list of the Biographical Register is published. Second general meeting of the National Committee is held. Second general meeting of the National Committee is held. Myer Foundation pledges £1000 per year for three years to the ADB. Myer Foundation pledges £1000 per year for three years to the ADB. Editorial Board appoints A. G. L. Shaw editor of Volume 1. Manning Clark agrees to act with general editor, Douglas Pike, as joint editor of Volume 2. Pacific and armed services specialist working groups are convened; plans are made for scientific and medical working groups. 398 Appendix 1 Appendix 1 Appendix 1 April 1963 New edition of the Biographical Register short list is published. 6 June 1963 Ellis resigns from the National Committee. 7–8 June 1963 Fourth general meeting of the National Committee is held. 13 August 1964 Fifth general meeting of the National Committee is held. 15 December 1964 Publishing agreement is signed by the ANU and Melbourne University Press. 12 November 1965 Hancock resigns as chair of the ADB Editorial Board and National Committee. Geoffrey Sawer is appointed temporary chairman. 3 March 1966 Sir Robert Menzies, recently retired prime minister, launches Volume 1 of the ADB at the ANU. 4 March 1966 Sixth general meeting of the National Committee is held. John La Nauze is appointed chairman of the Editorial Board and National Committee. Appendix 1 February 1967 ANU agrees to pay a subsidy to MUP to ensure that Volume 2 of the ADB has the same price as Volume 1. 2 March 1967 Volume 2 of the ADB is published. 1969 Volume 3 of the ADB is published. 1969 Sections of the Biographical Register are published in mimeograph form. November 1969 Pike receives the Ernest Scott Prize for his work on Volumes 1 and 2 of the ADB. 1971 Pike receives the 1971 Britannica Australasia Award for his work with the ADB. 28–29 October 1971 Seventh and last general meeting of the National Committee is held. September 1972 Volume 4 of the ADB is published. 1973 Bede Nairn is appointed acting general editor. 1973 Volume 5 of the ADB is published. 1973 Biographical Register comprises more than 50 000 cards. 1974 Armed Services Working Party is formed. 1975 Bede Nairn and Geoff Serle are appointed joint general editors of the ADB. October 1976 Brian Gandevia agrees to advise ADB staff on precise causes of death for subjects in the dictionary. October 1976 Volume 6 of the ADB is published. 1 April 1977 Ken Inglis is appointed chair of the ADB Editorial Board. New edition of the Biographical Register short list is published. Ellis resigns from the National Committee. Hancock resigns as chair of the ADB Editorial Board and National Committee. Geoffrey Sawer is appointed temporary chairman. Sixth general meeting of the National Committee is held. John La Nauze is appointed chairman of the Editorial Board and National Committee. ANU agrees to pay a subsidy to MUP to ensure that Volume 2 of the ADB has the same price as Volume 1. Volume 2 of the ADB is published. Volume 3 of the ADB is published. Volume 3 of the ADB is published. Biographical Register comprises more than 50 000 cards. Ken Inglis is appointed chair of the ADB Editorial Board. 399 The ADB’s Story 1979 Volume 7 of the ADB is published. November 1979 Editorial Board decides to dismantle the National Committee (it is formally abolished in 1983 with the consent of its members) and expand the State membership of the Editorial Board. 1981 Volume 8 of the ADB is published. 23 November 1983 Ninian Stephen, governor-general, launches Volume 9 of the ADB at Government House. 1984 Bede Nairn retires as joint general editor; Serle continues as the sole general editor. Appendix 1 1986 ADB desk editors, who were classified as research assistants, successfully seek an increase in their salary and formal status as research editors. 1986 University review committee reports favourably on the ADB. 1986 Keith Hancock launches Volume 10 of the ADB at the ANU. 1987 ADB’s Biographical Register 1788–1939 is published. March 1988 John Ritchie is appointed general editor of the ADB. 17 October 1988 Bernard Smith launches Volume 11 of the ADB at the University of Melbourne. 1989 Commonwealth Working Party is formed. 7 November 1990 Bob Hawke, prime minister, launches Volume 12 of the ADB at Parliament House, Canberra. 14 October 1991 Senator Margaret Reid launches the index to Volumes 1–12 of the ADB at the ANU. 25 November 1993 Senator Jim McClelland launches Volume 13 of the ADB at the State Library of New South Wales. February 1995 The Humanities Research Centre, ANU, the National Library of Australia and the ADB hold a conference on ‘National Biographies and National Identity’. The conference proceedings are published as National Biographies & National Identity. 1 June 1996 Ken Inglis resigns as chairman of the ADB Editorial Board. ill i i d h i f h di i l d 23 November 1983 Ninian Stephen, governor-general, launches Volume 9 of the ADB at Government House. Bede Nairn retires as joint general editor; Serle continues as the sole general editor. ADB desk editors, who were classified as research assistants, successfully seek an increase in their salary and formal status as research editors. 1986 University review committee reports favourably on the ADB. 1986 Keith Hancock launches Volume 10 of the ADB at the ANU. Keith Hancock launches Volume 10 of the ADB at the ANU. 1987 ADB’s Biographical Register 1788–1939 is published. ADB’s Biographical Register 1788–1939 is published. March 1988 John Ritchie is appointed general editor of the ADB. John Ritchie is appointed general editor of the ADB. 17 October 1988 Bernard Smith launches Volume 11 of the ADB at the University of Melbourne. 1989 Commonwealth Working Party is formed. 7 November 1990 Bob Hawke, prime minister, launches Volume 12 of the ADB at Parliament House, Canberra. 91 Senator Margaret Reid launches the index to Volumes 1–12 of the ADB at the ANU. Senator Jim McClelland launches Volume 13 of the ADB at the State Library of New South Wales. at the State Library of New South Wales. 1 January 2010 April 2011 Appendix 1 bruary 1995 The Humanities Research Centre, ANU, the National Library of Australia and the ADB hold a conference on ‘National Biographies and National Identity’. The conference proceedings are published as National Biographies & National Identity. June 1996 Ken Inglis resigns as chairman of the ADB Editorial Board. June 1996 Jill Roe is appointed chair of the ADB Editorial Board. October 1996 Guy Green, Tasmanian governor, launches Volume 14 of th ADB 28 June 1996 Guy Green, Tasmanian governor, launches Volume 14 of the ADB. 29 October 1996 400 Appendix 1 1997 ADB Endowment Fund is launched with major donations from Caroline Simpson and the Myer Foundation. 1997 CD-ROM of Volumes 1–12 of the ADB is published by MUP. 11 April 2000 Major General Michael Jeffery, WA governor, launches Volume 15 of the ADB. 2002 Editorial Board subcommittee review of the ADB says the ADB must embrace ‘continuity and change’ through continued publication of the ADB and participation in the modern research culture. 12 November 2002 Marjorie Jackson-Nelson, SA governor, launches Volume 16 of the ADB. 2004 Di Langmore is appointed general editor of the ADB after acting in the position for three years. 2005 Meredith Burgmann launches the ADB supplement volume in Sydney. 2005 Indigenous Working Party is formed. 2006 Jill Roe resigns as chair of the ADB Editorial Board; she is succeeded by Tom Griffiths. 2006 Review of the RSSS calls for the ADB to be financially self-sufficient in five years. 6 July 2006 Michael Jeffery, governor-general, launches the ADB online at University House, ANU. 2007 Gregory Review of the ADB recommends the establishment of a National Centre of Biography (NCB), which would continue to produce the ADB and act as a focus for the study of biography. November 2007 David de Kretser, Victorian governor, launches Volume 17 of the ADB. 2 June 2008 Melanie Nolan is appointed director of the NCB and general editor of the ADB. December 2009 The ADB celebrates its fiftieth birthday with a conference, ‘Between the Past and Present: Celebrating the ADB’s 50th anniversary’, and a closed workshop on ‘The ADB and Digital Culture’. 1 January 2010 The NCB is integrated into the School of History, RSSS. April 2011 Obituaries Australia is launched as a replacement for the Biographical Register. ADB Endowment Fund is launched with major donations from Caroline Simpson and the Myer Foundation. Appendix 1 ADB Endowment Fund is launched with major donations from Caroline Simpson and the Myer Foundation. CD-ROM of Volumes 1–12 of the ADB is published by MUP. Major General Michael Jeffery, WA governor, launches Volume 15 of the ADB. Melanie Nolan is appointed director of the NCB and general editor of the ADB. December 2009 The ADB celebrates its fiftieth birthday with a conference, ‘Between the Past and Present: Celebrating the ADB’s 50th anniversary’, and a closed workshop on ‘The ADB and Digital Culture’. The NCB is integrated into the School of History, RSSS. Obituaries Australia is launched as a replacement for the Biographical Register. 401 The ADB’s Story March 2012 The NCB develops three new biographical web sites, Women Australia, Labour Australia and People Australia, as companion sites to the ADB. 5 December 2012 Penelope Wensley, Queensland Governor, launches Volume 18 of the ADB. 11 December 2012 ANU Vice-Chancellor, Ian Young, launches the online version of Volume 18 of the ADB. The ADB’s Story er 2012 Penelope Wensley, Queensland Governor, launches Volume 18 of the ADB. 11 December 2012 ANU Vice-Chancellor, Ian Young, launches the online version of Volume 18 of the ADB. 11 December 2012 ANU Vice-Chancellor, Ian Young, launches the online version of Volume 18 of the ADB. 402 Appendix 2 ADB Staff List, 1958–2013 Arthur, Paul 2010–2013 Deputy general editor Austin, M. A. (Brigadier) 1982–1985 Transcribed army service records Bankowski, Helen 1983–1984 Administration Bazley, Arthur 1964–1966 Research assistant (ACT) Bennet, Darryl 1989–2001 Armed services, Commonwealth, Small States and Victorian desk editor 2001–2008 Deputy general editor Birman, Wendy 1977–1996 Research assistant (WA) Bosworth, Michal 1973–1975 Research assistant (NSW) 1982–1986 Boxall, Helen 1990–1991 Research assistant (ACT) Brooks, Maureen 1998–1998 Research assistant (ACT) Brown, Frank 1979–2000 Consultant, armed services Brown, Margaret 1978–1979 Research assistant (WA) Brown, Nicholas 2004–2009 Victorian desk editor Browne, Geoff 1987–1994 Research assistant (Vic) Brudenall, Andrew 1983–1985 Student; worked as a temp on Biographical Register; died in a car accident on 27 April 1985 Bundock, Anthea 1998–2009 Research assistant and Biographical Register officer Burrows, Stephanie 1986–1987 Administration Campbell, Daniel 1995–1995 Replaced Gerard Oakes when he was on leave for five weeks Campbell, Martha 1967–2002 NSW desk editor Carey, Hilary 1985–? Research assistant (NSW) Ciuffetelli, Karen 1992– Administration Clements, Gail 2000–2008 Small States desk editor 2008–2010 Managing editor Colligan, Mimi 1976–1987 Research assistant (Vic) Consadine, Marion 1980–1985 Administration ADB Staff List, 1958–2013 403 Cook, Deborah 1967–1967 Research assistant (ACT) Coulthard-Clark, Chris 1999–2000 Armed services desk editor Crichton, Pam 2002–2011 NSW desk editor Cross, Marlene 1974–1979 Research assistant (SA) Crouchley, Betty 1977–1987 Research assistant (Qld) Cunneen, Chris 1974–1982 Research fellow 1982–1996 Deputy general editor Dale, Barbara 1980–1985 Research assistant (NSW) Davey, Lindie 1991–1991 Administration; replaced Anne- Marie Gaudrey when she was on leave for six months Dawson, Barbara 1999–2007 Research assistant 2007–2011 Commonwealth desk editor Dean, Monica 1983–1984 Research assistant Dempsey, Paul 1995–1997 Research assistant (Ireland) Dermody, Kathleen 1991–1992 Research assistant (ACT) Dingwall, Bronwyn 1983–1983 Administration (one month) Dinnerville, Frances 1980–1982 Administration Docherty, James 1974–? Research assistant Doust, Janet 2009–2010 Queensland desk editor Dunstan, David 1974–1975 Research assistant (Vic) Duplain, Raymond 1977–1977 Research assistant (Vic) Edgar, Sue 1969–1998 South Australian and Western Australian desk editor Edmonds, Leigh 1996–1998 Research assistant (Ireland) Elliot, Jane 1976–? Research assistant English, Bruce 2003–2004 Research assistant (Vic) Fairhill, Vicky 1992–1993 Administration; replaced Karen Ciuffetelli when on leave Ferguson, Audrey ?–1973 Research assistant (NSW) Ferguson, Sarah 1989–? Appendix 2 Administration Fernon, Christine 1999–2000 Small States desk editor 2000–2008 Bibliographer 2009– Online manager Fewster, Alan 1978–1979 Research assistant (NSW) Fielding, Jean 1974–1978 Armed services desk editor Flannery, Hannah 2010–2011 Research assistant 404 Appendix 2 Appendix 2 Fox, Karen 2011–2012 Victorian desk editor 2013– Managing editor Francis, Niki 2010–2013 Research assistant (ACT) Franks, Susan 1989–? Research assistant (NSW) Frappell, Ruth 1977–1984 Research assistant (NSW) Fulloon, Gillian 1984–1990 Research assistant (ACT) Furphy, Samuel 2010– Victorian desk editor Gan, Annie 1985–1987 Administration Gaudry, Anne-Marie 1989–1995 Administration Gibberd, Joyce 1974–2005 Research assistant (SA) Gibbney, Jim 1965–1984 Biographical Register officer and Queensland and Western Australian desk editor Gibson, David 1999–2003 Transcribed army service records (Vic) Glen, Leonie 1981–1986 Research assistant (UK) Glover-Scott, Margaret 1978–1984 Research assistant (Tas) 2009– Goodin, I. 1963–? Administration Grahame, Emma 1985–1986 Assisted with Biographical Register 1991–1992 Research assistant (NSW) Grahame, Rachel 1992– Research assistant (NSW) Graham-Taylor, Sue 1998–2001 Research assistant (WA) Gregson, Norma 1965–1978 Administration Griffin, Helga 1979–1998 Bibliographer, and Queensland and Western Australian desk editor Hall, Noeline 1976–? Research assistant (Qld) Harker, Margot 1998–1998 Research assistant (Vic) Harris, Paula 1985–1986 Desk editor while M. Stephens was on leave Harrison, Jennifer 1987–2008 Research assistant (Qld) Hewson, Rachel 1987–1989 Administration Hill, Eliza 1986–1987 Assisted with the Biographical Register Hogan, Susan ?–? Research assistant (NSW) Holmes, Jenny ?–? Research assistant 405 Hone, Ann 1965–1966 Research assistant Hope-Johnstone, Nerida 2008–2008 Administration Horner, Jolyon 2001–2007 Armed services desk editor Howe, Ann 1965–? Research assistant (Tas) Huxley, Mollie 1968–? Appendix 2 Research assistant (ACT) Iltis, Judith ?–1963 Research assistant (ACT) Inder, Julie 1995–1996 Worked on Biographical Register database Jennings, Rosemary 1999–2007 Research assistant (ACT) Johnston, Susan 1975–1976 Research assistant (NSW) Jordens, Ann Mari 1975–1976 Research assistant (ACT) Kauffman, Edna 1985–2007 Assisted with Biographical Register, administration Kellock, Peter 1971–1972 Research assistant (Vic) Kent, Hilary 1988–1992 Desk editor, Biographical Register officer, and worked on Bicentennial Project, ‘Heritage 200’ Korolev, Max 2010– Digitisation officer Kerin, Rani 2010– Small States desk editor Lack, John 1974–1975 Research assistant (Vic) Langmore, Di 1982–1997 Victorian desk editor 1997–2001 Deputy general editor 2001–2004 Acting general editor 2004–2008 General editor Lincoln, Merrilyn 1976–1989 Armed services and Tasmanian desk editor Linegar, Chris 2000–2001 Administration Long, Gavin 1963–1968 Research fellow Ly, Judith 1980–1981 Administration McBride, Dorothy 1978–1984 Administration McCalman, Janet 1977–1978 Research assistant (Vic) McCalman, Vicky 1974–1975 Research assistant (Melbourne) McConnell, Ruth 2004–2004 Researcher, ADB online project McGowan, Barry 2004–2007 Researcher, ADB online project McLennan, Nicole 1998–1999 Queensland desk editor McLeod, Beth 1974–1977 Research assistant (Tas) Mahalm, Dianne ? –? Administration Manners, Alison 1985–1987 Administration 406 Appendix 2 Meere, Ivy 1975–1992 Administration Mellor, Suzanne 1971–? Research assistant (Vic) Milthorp, Peter 1987–1988 Administration; worked student vacations Mitchell, Ann ?–1971 Research assistant (Vic) Molony, John 1964–1964 Research assistant for about two months Morris, Deirdre 1973–1976 Desk editor Moye, Ros 2008–2009 Research assistant (Vic) Mozley (Moyal), Ann 1958–1962 Assistant editor Murphy, William 1997–2001 Research assistant (Ireland) Nairn, Bede 1966–1973 Senior fellow 1973-1975 Acting general editor 1973–1984 Joint general editor Newell, Jenny 1992–1996 Assisted with Biographical Register, Research assistant (ACT) Newman, Betty ?–? Administration Newman-Martin, Andrew 2004–2006 Researcher, ADB online project Nicholls, Mary 1977–1978 Research assistant (Tas) Nissen, Judith 2008– Research assistant (Qld) Nolan, Melanie 2008– General editor Oakes, Gerard 1994–1996 Research assistant (ACT) O’Donoghue, Kathleen 1963–1966 Research assistant (ACT) Oglivie, Charlene 2006–2007 Administration O’Loghlin, Gillian 1998–2000 Bibliographer O’Neill, Sally 1967–2001 Victorian desk editor and UK researcher O’Shea, Helen 1988–? Desk editor, worked on Bicentennial Project, ‘Heritage 200’ Page, Carolyn 1982–1984 Administration, worked on Biographical Register publication Parks, Margaret 2004–2007 Researcher, ADB online project Parsons, Viviene 1964–1965 Research assistant (NSW) Pemberton, Penny 1987–1988 Employed on contract to prepare ADB files for transfer to ANU Archives Phillips, Nan 1967–1985 Administration 407 Pike, Douglas 1962–1973 General editor Pilger, Alison 1992–1998 Assisted with Biographical Register Playford, Aldona ?–1964 Assisted with Biographical Register Quirk, Sandon 1972–? Volume 1, 1788–1850, A–H (Carlton, Vic.: Melbourne University Press, 1966) Section editors: A. G. L. Shaw, Manning Clark. Editorial Board Manning Clark, Norman Cowper, Jim Davidson, Ernest Fisk, Laurie Fitzhardinge, Robin Gollan, Keith Hancock (chair), Ross Hohnen, Robert Parker, Douglas Pike, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. Appendix 2 Research assistant Rand, Anne 1988–2008 Research assistant (Tas) Refshauge, Richard 1969–1970 Research assistant (ACT) Ritchie, Joan 1998–1998 Research assistant (ACT) Ritchie, John 1988–2002 General editor Robertson, Heather 1995–? Assisted with Biographical Register; word-processor operator Robertson, Margaret 2001– Research assistant (WA) Robinson, Judith ?–1963 Assisted with Biographical Register Rowlands, Penny ?–1987 Research assistant (Tas) Sandow, W. 1972–? Research assistant (Vic) Serle, Geoff 1975–1984 Joint general editor 1984–1987 General editor Sharp, Patti 1985–1986 Research assistant Shoesmith, Dennis 1970–? Research assistant Singleton, Gwyn 1988–? Research assistant Smith, Ann 1977–1989 Biographical Register officer, and Victorian, Tasmanian and Commonwealth desk editor Smith, Dorothy 1973–1979 Administration Smith, Neil 1974–1976 Research assistant (Tas) Steven, Margaret 1978–1996 Commonwealth, Victorian and Queensland desk editor Stewart, Neil 1976–? Research assistant (Qld) Stretton, Pat 2005–? Research assistant (SA) Thomson, Mrs 1964–? Research assistant Tilse, Sheila 1989–1994 Biographical Register officer and Tasmanian desk editor Torney, Kim 2001–2007 Research assistant (Vic) Trigellis-Smith, Sydney 1989–1999 Research assistant (Vic) Turner, David 1983–1984 Administration (casual student) Turner, Naomi 1977–1980 Research assistant (NSW) 408 Appendix 2 Tyrie, Margaret 1984–1986 Administration Vazenry, Hank 1986–1989 Transcribed army service records Walsh, Gerry 1964–1964 Research assistant Walton, Margery ?–? Research assistant (New Zealand) Westwood, Susan 1975–? Casual typist Wimborne, Brian 1996–1996 Small States desk editor 1996–2011 Research assistant (ACT) 2011– Commonwealth and armed services desk editor Winter, Gillian 1985–1986 Research assistant (Tas) Woodhouse, Fay 1999–2001 Research assistant (Vic) 2009– Wright, Jill ?–1975 Administration Zalums, Elmar 1962–1964 Research assistant (ACT) 409 National Committee James Auchmuty, Geoffrey Bolton, Manning Clark, Norman Cowper, Frank Crowley, Jim Davidson, Ernest Fisk, Laurie Fitzhardinge, Gordon Greenwood, Robin Gollan, Keith Hancock (chair), Ross Hohnen, John La Nauze, Malcolm McRae, Allan Morrison, Robert Parker, Douglas Pike, John Salmon, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Edward Tapp, John Tregenza, John Ward, Russel Ward. Appendix 3 National Committee, Editorial Board and Working Parties by Volume Newcastle Newcastle John Bach, F. J. Cane, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. John Bach, F. J. Cane, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. New England Alan Cane, Jennifer Crew, Louise Daley, Peter Dangar, Ross Duncan, Eric Dunlop, Israel Getzler, Richard Lane-Poole, John R. Robertson, Edward Tapp (chair), Robin Walker, William Walker, Russel Ward, Mick (C. M.) Williams. 411 The ADB’s Story New South Wales Graham Abbott, Ken Cable, Brian Fletcher, W. S. Ford, Archibald Gray, Hazel King, Duncan MacCallum, David Macmillan, Gregory McMinn, Bruce Mansfield, Bede Nairn (chair), Gordon Richardson, John A. Ryan, A. G. L. Shaw, John M. Ward. Victoria Philip Brown, Colin McCallum, Ian McLaren, Geoffrey Serle (chair). Philip Brown, Colin McCallum, Ian McLaren, Geoffrey Serle (chair). Western Australia Osland Battye, Cara Cammilleri, Alfred Chate, Frank Crowley (chair), Henrietta Drake-Brockman, Merab Harris, Alexandra Hasluck, John Honniball, Mollie Lukis, David Mossenson, Malcolm J. Uren, Elmar Zalums. Volume 2, 1788–1850, I–Z (Carlton, Vic.: Melbourne University Press, 1967) Volume 2, 1788–1850, I–Z (Carlton, Vic.: Melbourne University Press, 1967) South Australia South Australia Harold Finnis (chair), Gerald Fischer, Eric Lanyon, John McLellan, Archibald Grenfell Price, John Tregenza. Tasmania Queensland Colin Austin, Don Dignan, Stuart Gunthorpe, Roger Joyce, Clem Lack, John Laverty, Allan Morrison (chair), Keith Rayner, Robert Sharman, James Stapleton, June Stoodley. Tasmania Peter Ross Eldershaw, Frank Clifton Green (chair), Malcolm McRae, Anne Rand, John Reynolds, Michael Roe, Geoffrey Stilwell. Editorial Board Manning Clark, Norman Cowper, Jim Davidson, Ernest Fisk, Laurie Fitzhardinge, Robin Gollan, Keith Hancock (chair), Ross Hohnen, Robert Parker, Douglas Pike, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. Manning Clark, Norman Cowper, Jim Davidson, Ernest Fisk, Laurie Fitzhardinge, Robin Gollan, Keith Hancock (chair), Ross Hohnen, Robert Parker, Douglas Pike, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. National Committee James Auchmuty, Geoffrey Bolton, Manning Clark, Norman Cowper, Frank Crowley, Jim Davidson, Ernest Fisk, Laurie Fitzhardinge, Gordon Greenwood, Robin Gollan, Keith Hancock (chair), Ross Hohnen, John La Nauze, Malcolm James Auchmuty, Geoffrey Bolton, Manning Clark, Norman Cowper, Frank Crowley, Jim Davidson, Ernest Fisk, Laurie Fitzhardinge, Gordon Greenwood, Robin Gollan, Keith Hancock (chair), Ross Hohnen, John La Nauze, Malcolm 412 Appendix 3 Appendix 3 McRae, Allan Morrison, Robert Parker, Douglas Pike, John Salmon, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Edward Tapp, John Tregenza, John M. Ward, Russel Ward. McRae, Allan Morrison, Robert Parker, Douglas Pike, John Salmon, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Edward Tapp, John Tregenza, John M. Ward, Russel Ward. McRae, Allan Morrison, Robert Parker, Douglas Pike, John Salmon, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Edward Tapp, John Tregenza, John M. Ward, Russel Ward. Queensland Colin Austin, Don Dignan, Stuart Gunthorpe, Roger Joyce, Clem Lack, John Laverty, Allan Morrison (chair), Keith Rayner, Robert Sharman, James Stapleton, June Stoodley. Harold Finnis (chair), Gerald Fischer, Eric Lanyon, John McLellan, Archibald Grenfell Price, John Tregenza. New South Wales Graham Abbott, Ken Cable, Brian Fletcher, W. S. Ford, Archibald Gray, Hazel King, Duncan MacCallum, David Macmillan, Gregory McMinn, Bruce Mansfield, Bede Nairn (chair), Gordon Richardson, John A. Ryan, A. G. L. Shaw, John M. Ward. Newcastle John Bach, F. J. Cane, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. New England Alan Cane, Jennifer Crew, Louise Daley, Peter Dangar, Ross Duncan, Eric Dunlop, Israel Getzler, Richard Lane-Poole, John R. Robertson, Edward Tapp (chair), Robin Walker, William Walker, Russel Ward, Mick Williams. Editorial Board Alan Barnard, Manning Clark, Norman Cowper, Jim Davidson, Ernest Fisk, Laurie Fitzhardinge, Robin Gollan, Ross Hohnen, John La Nauze (chair), Bede Nairn, Douglas Pike, Geoffrey Sawer, Geoffrey Serle, Russel Ward. National Committee James Auchmuty, Alan Barnard, Geoffrey Bolton, Manning Clark, Norman Cowper, Frank Crowley, Jim Davidson, Ernest Fisk, Laurie Fitzhardinge, Robin Gollan, Gordon Greenwood, John Hirst, Ross Hohnen, John La Nauze (chair), Jim Main, Allan Morrison, Bede Nairn, Douglas Pike, Gordon Rimmer, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Edward Tapp, John Tregenza, John M. Ward, Russel Ward. Volume 3, 1851–1890, A–C (Carlton, Vic.: Melbourne University Press, 1969) General editor: Douglas Pike. Section editors: Bede Nairn, Geoffrey Serle, Russel Ward. Victoria Philip Brown, Colin McCallum, Ian McLaren, Geoffrey Serle (chair Philip Brown, Colin McCallum, Ian McLaren, Geoffrey Serle (chair). Osland Battye, Cara Cammilleri, Alfred Chate, Frank Crowley (chair), Henrietta Drake-Brockman, Merab Harris, Alexandra Hasluck, John Honniball, Mollie Lukis, David Mossenson, Malcolm J. Uren, Elmar Zalums. Osland Battye, Cara Cammilleri, Alfred Chate, Frank Crowley (chair), Henrietta Drake-Brockman, Merab Harris, Alexandra Hasluck, John Honniball, Mollie Lukis, David Mossenson, Malcolm J. Uren, Elmar Zalums. Tasmania Peter Ross Eldershaw, Frank Clifton Green (chair), Malcolm McRae, Anne Rand, John Reynolds, Michael Roe, Geoffrey Stilwell. 413 The ADB’s Story Alan Cane, Jennifer Crew, Louise Daley, Peter Dangar, Richard Lane-Poole, John R. Robertson, Edward Tapp (chair), Russel Ward. Newcastle John Bach, F. J. Cane, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. John Bach, F. J. Cane, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. John Bach, F. J. Cane, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. Alan Cane, Jennifer Crew, Louise Daley, Peter Dangar, Richard Lane-Poole, John R. Robertson, Edward Tapp (chair), Russel Ward. 414 Appendix 3 New South Wales Graham Abbott, Ken Cable, Frank Crowley, Rae Else-Mitchell, Brian Fletcher, Archibald Gray, Hazel King, Egon Kunz, David Macmillan, Gregory McMinn, Bruce Mansfield, Gordon Richardson (chair), John A. Ryan, John M. Ward. Pacific Jim Davidson (chair), Niel Gunson, Henry Maude, Deryck Scarr, Dorothy Shineberg, Francis West. South Australia Harold Finnis (chair), Gerald Fischer, John McLellan, Jim Main, Archibald Grenfell Price, John Tregenza. Tasmania Peter Ross Eldershaw, Frank Clifton Green (chair), John Reynolds, Gordon Rimmer, Geoffrey Stilwell. Geoffrey Blainey, John La Nauze (chair), Allan Martin, Geoffrey Serle, F. Barry Smith. Queensland Colin Austin, Don Dignan, Stuart Gunthorpe, Roger Joyce, Clem Lack, John Laverty, Allan Morrison (chair), Mary O’Keeffe, Keith Rayner, Robert Sharman, James Stapleton, June Stoodley. Editorial Board Alan Barnard, Manning Clark, Norman Cowper, Jim Davidson, Laurie Fitzhardinge, Robin Gollan, Ross Hohnen, John La Nauze (chair), Bede Nairn, Douglas Pike, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. National Committee James Auchmuty, Alan Barnard, Geoffrey Bolton, Manning Clark, Norman Cowper, Frank Crowley, Jim Davidson, Laurie Fitzhardinge, Robin Gollan, Gordon Greenwood, John Hirst, Ross Hohnen, John La Nauze (chair), Jim Main, Allan Morrison, Bede Nairn, Douglas Pike, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Edward Tapp, John Tregenza, John M. Ward, Russel Ward. James Auchmuty, Alan Barnard, Geoffrey Bolton, Manning Clark, Norman Cowper, Frank Crowley, Jim Davidson, Laurie Fitzhardinge, Robin Gollan, Gordon Greenwood, John Hirst, Ross Hohnen, John La Nauze (chair), Jim Main, Allan Morrison, Bede Nairn, Douglas Pike, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Edward Tapp, John Tregenza, John M. Ward, Russel Ward. Western Australia Osland Battye, Wendy Birman, Geoffrey Bolton (chair), Cara Cammilleri, Alfred Chate, Henrietta Drake-Brockman, Merab Harris, Alexandra Hasluck, John Honniball, Mollie Lukis, Margaret Medcalf, David Mossenson, Arthur Staples, Mary Tamblyn, Malcolm J. Uren. Osland Battye, Wendy Birman, Geoffrey Bolton (chair), Cara Cammilleri, Alfred Chate, Henrietta Drake-Brockman, Merab Harris, Alexandra Hasluck, John Honniball, Mollie Lukis, Margaret Medcalf, David Mossenson, Arthur Staples, Mary Tamblyn, Malcolm J. Uren. Volume 4, 1851–1890, D–J (Carlton, Vic.: Melbourne University Press, 1972) General editor: Douglas Pike. Section editors: Bede Nairn, Geoffrey Serle, Russel Ward. General editor: Douglas Pike. 415 The ADB’s Story New England Alan Cane, Jennifer Crew, Louise Daley, Peter Dangar, Edward Tapp (chair), Russel Ward. Newcastle John Bach, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. Editorial Board Alan Barnard, Geoffrey Bolton, Manning Clark, Norman Cowper, Jim Davidson, Laurie Fitzhardinge, Robin Gollan, Ross Hohnen, John La Nauze (chair), Bede Nairn, Robert J. O’Neill, Douglas Pike, John Poynter, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. National Committee James Auchmuty, Alan Barnard, Geoffrey Bolton, Manning Clark, P. Cook, Norman Cowper, Frank Crowley, Jim Davidson, Laurie Fitzhardinge, Robin Gollan, Gordon Greenwood, Ross Hohnen, John La Nauze (chair), Jim Main, Allan Morrison, Bede Nairn, Robert J. O’Neill, Douglas Pike, John Poynter, Henry Reynolds, Barrie Rose, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, John Tregenza, John M. Ward, Russel Ward. Section editors: Bede Nairn, Geoffrey Serle, Russel Ward. Section editors: Bede Nairn, Geoffrey Serle, Russel Ward. Section editors: Bede Nairn, Geoffrey Serle, Russel Ward. New South Wales Graham Abbott, Ken Cable, Frank Crowley, Rae Else-Mitchell, Brian Fletcher, Archibald Gray, Hazel King, Egon Kunz, Gregory McMinn, Bruce Mansfield, Bede Nairn, Gordon Richardson (chair), John A. Ryan, John M. Ward. Pacific Jim Davidson (chair), Niel Gunson, Deryck Scarr, Dorothy Shineberg, Francis West. Queensland Don Dignan, Stuart Gunthorpe, Roger Joyce, Clem Lack, John Laverty, Allan Morrison (chair), Mary O’Keeffe, Robert Sharman, June Stoodley. South Australia Gordon Buxton, Harold Finnis (chair), Gerald Fischer, Jim Main, John Tregenza. Graham Abbott, Ken Cable, Frank Crowley, Rae Else-Mitchell, Brian Fletcher, Archibald Gray, Hazel King, Egon Kunz, Gregory McMinn, Bruce Mansfield, Bede Nairn, Gordon Richardson (chair), John A. Ryan, John M. Ward. Jim Davidson (chair), Niel Gunson, Deryck Scarr, Dorothy Shineberg, Francis West. Queensland Don Dignan, Stuart Gunthorpe, Roger Joyce, Clem Lack, John Laverty, Allan Morrison (chair), Mary O’Keeffe, Robert Sharman, June Stoodley. Gordon Buxton, Harold Finnis (chair), Gerald Fischer, Jim Main, John Tregenza. 416 Appendix 3 John Bach, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. Tasmania Tasmania Frank Clifton Green (chair), John Reynolds, Gordon Rimmer, Michael Roe, Geoffrey Stilwell. Victoria Osland Battye, Wendy Birman, Geoffrey Bolton (chair), Merab Harris, John Honniball, Mollie Lukis, Margaret Medcalf, David Mossenson, Arthur Staples, Mary Tamblyn, Malcolm J. Uren. Osland Battye, Wendy Birman, Geoffrey Bolton (chair), Merab Harris, John Honniball, Mollie Lukis, Margaret Medcalf, David Mossenson, Arthur Staples, Mary Tamblyn, Malcolm J. Uren. Volume 5, 1851–1890, K–Q (Carlton, Vic.: Melbourne University Press, 1974) General editor: Douglas Pike. Pacific Jim Davidson (chair), Niel Gunson, Deryck Scarr, Dorothy Shineberg, Francis West. Newcastle John Bach, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. 417 The ADB’s Story New England Alan Cane, Jennifer Crew, Louise Daley, Peter Dangar, Russel Ward (chair). New South Wales Ken Cable, Frank Crowley, Rae Else-Mitchell, Brian Fletcher, Hazel King, Beverley Kingston, Gregory McMinn, Bruce Mansfield, Bede Nairn, Gordon Richardson (chair), John A. Ryan, John M. Ward. Pacific Jim Davidson (chair), Niel Gunson, Deryck Scarr, Dorothy Shineberg, Francis West. Queensland Don Dignan, Stuart Gunthorpe, Roger Joyce, Clem Lack, John Laverty, Allan Morrison (chair), Mary O’Keeffe, June Stoodley. South Australia Gordon Buxton, Harold Finnis (chair), Gerald Fischer, Jim Main, John Tregenza. Tasmania Frank Clifton Green (chair), John Reynolds, Michael Roe, Barrie Rose, Geoffrey Stilwell. Victoria Geoffrey Blainey, Allan Martin, Geoffrey Serle (chair). Western Australia Osland Battye, Wendy Birman, Geoffrey Bolton (chair), Merab Harris, John Honniball, Mollie Lukis, Margaret Medcalf, David Mossenson, Arthur Staples, Mary Tamblyn, Malcolm J. Uren. Volume 6, 1851–1890, R–Z (Carlton, Vic.: Melbourne University Press, 1976) General editor: Bede Nairn. Section editors: Geoffrey Serle, Russel Ward. The ADB’s Story New England Alan Cane, Jennifer Crew, Louise Daley, Peter Dangar, Russel Ward (chair). Ken Cable, Frank Crowley, Rae Else-Mitchell, Brian Fletcher, Hazel King, Beverley Kingston, Gregory McMinn, Bruce Mansfield, Bede Nairn, Gordon Richardson (chair), John A. Ryan, John M. Ward. Editorial Board Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, Norman Cowper, Laurie Fitzhardinge, Robin Gollan, Ross Hohnen, John La Nauze (chair), Bede Nairn, Robert J. O’Neill, Douglas Pike, John Poynter, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, Norman Cowper, Laurie Fitzhardinge, Robin Gollan, Ross Hohnen, John La Nauze (chair), Bede Nairn, Robert J. O’Neill, Douglas Pike, John Poynter, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. Queensland Don Dignan, Stuart Gunthorpe, Roger Joyce, Clem Lack, John Laverty, Allan Morrison (chair), Mary O’Keeffe, June Stoodley. 418 Appendix 3 National Committee James Auchmuty, Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, P. Cook, Norman Cowper, Frank Crowley, Brian de Garis, Laurie Fitzhardinge, Robin Gollan, Gordon Greenwood, Ross Hohnen, John La Nauze (chair), Gregory McMinn, Jim Main, Allan Morrison, Bede Nairn, Robert J. O’Neill, Douglas Pike, John Poynter, Henry Reynolds, Barrie Rose, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, John Tregenza, John M. Ward, Russel Ward. Armed Services Maurice Austin, Frank H. Brown, Chris Clark, Rex Clark, Jean Fielding, Alec Hill, John McCarthy, Robert J. O’Neill (chair), Neil Primrose. Maurice Austin, Frank H. Brown, Chris Clark, Rex Clark, Jean Fielding, Alec Hill, John McCarthy, Robert J. O’Neill (chair), Neil Primrose. Newcastle John Bach, Ben Champion, Edward Flowers, Elizabeth Guilford, Gregory McMinn (chair), Charles E. Smith, Edna Travers. Pacific Niel Gunson, Deryck Scarr, Dorothy Shineberg, Francis West. Queensland New South Wales John Bennett, Ken Cable, Frank Crowley, Chris Cunneen, Russell Doust (chair), Rae Else-Mitchell, Frank Farrell, Brian Fletcher, Hazel King, Beverley Kingston, Gregory McMinn, Bruce Mansfield, Bruce A. Mitchell, Heather Radi, John A. Ryan, Gerry Walsh, John M. Ward. Victoria Weston Bate, Geoffrey Blainey, Leslie Blake, Sidney Ingham, Allan Martin, Stephen Murray-Smith, John Poynter (chair), John Rickard, Geoffrey Serle, Frank Strahan, John Thompson. Weston Bate, Geoffrey Blainey, Leslie Blake, Sidney Ingham, Allan Martin, Stephen Murray-Smith, John Poynter (chair), John Rickard, Geoffrey Serle, Frank Strahan, John Thompson. Tasmania Peter Chapman, Elizabeth McLeod, Mary McRae, Ian Pearce, John Reynolds (chair), Michael Roe, Geoffrey Stilwell. Western Australia Osland Battye, Wendy Birman, David Black, Geoffrey Bolton (chair), Brian de Garis, Rica Erickson, Alexandra Hasluck, John Honniball, Lyall Hunt, David Hutchinson, Mollie Lukis, Toby Manford, Margaret Medcalf, David Mossenson, Tom Stannage, Arthur Staples, Mary Tamblyn, Merab Harris Tauman, Malcolm J. Uren. Osland Battye, Wendy Birman, David Black, Geoffrey Bolton (chair), Brian de Garis, Rica Erickson, Alexandra Hasluck, John Honniball, Lyall Hunt, David Hutchinson, Mollie Lukis, Toby Manford, Margaret Medcalf, David Mossenson, Tom Stannage, Arthur Staples, Mary Tamblyn, Merab Harris Tauman, Malcolm J. Uren. Volume 7, 1891–1939, A–Ch (Carlton, Vic.: Melbourne University Press, 1979) General editors: Bede Nairn, Geoffrey Serle. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. Queensland Nick Bannenberg, Jacqueline Bell, Nancy Bonnin, Frederick Colliver, Don Dignan, Raymond Evans, David Gibson, James Gill, Stuart Gunthorpe, Noeline Hall, John Laverty, Denis J. Murphy (chair), Mary O’Keeffe, Spencer Routh, June Stoodley, Neil Stewart, Paul D. Wilson. 419 The ADB’s Story The ADB’s Story North Queensland Subcommittee North Queensland Subcommittee Douglas Hunt, Kett Kennedy, Ian Moles (convener), Michael Richards, Rodney Sullivan. Douglas Hunt, Kett Kennedy, Ian Moles (convener), Michael Richards, Rodney Sullivan. South Australia Douglas A. Dunstan, Ronald Gibbs, Peter Howell, Helen Jones, John Love, Jim Main, John D. Playford (chair), John Tregenza. Editorial Board Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, Norman Cowper, Robin Gollan, Ken Inglis (chair), John La Nauze, Bede Nairn, Robert O’Neill, John Poynter, Heather Radi, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, Norman Cowper, Robin Gollan, Ken Inglis (chair), John La Nauze, Bede Nairn, Robert O’Neill, John Poynter, Heather Radi, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward. New South Wales John Bennett, Ken Cable, Frank Crowley, Chris Cunneen, Russell Doust (chair), Rae Else-Mitchell, Frank Farrell, Brian Fletcher, Hazel King, Beverley Kingston, Gregory McMinn, Bruce Mansfield, Bruce A. Mitchell, Heather Radi, John A. Ryan, Gerry Walsh, John M. Ward. National Committee Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, P. Cook, Norman Cowper, Frank Crowley, Brian de Garis, Laurie Fitzhardinge, Robin Gollan, Gordon Greenwood, Ross Hohnen, Ken Inglis (chair), Gregory McMinn, Jim Main, Bede Nairn, Robert J. O’Neill, John Poynter, Henry Reynolds, B. Rose, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, John M. Ward, Russel Ward. 420 Appendix 3 South Australia Douglas A. Dunstan, Ronald Gibbs, Peter Howell, Helen Jones, John Love, John D. Playford (chair), John Tregenza. Armed Services Maurice Austin, Frank H. Brown, Peter Burness, Rex Clark, Chris Coulthard- Clark, Jean Fielding, Alec Hill, John McCarthy, Robert J. O’Neill (chair), Neil Primrose. Maurice Austin, Frank H. Brown, Peter Burness, Rex Clark, Chris Coulthard- Clark, Jean Fielding, Alec Hill, John McCarthy, Robert J. O’Neill (chair), Neil Primrose. Tasmania Peter Chapman, Elizabeth McLeod, Mary McRae, Ian Pearce, John Reynolds (chair), Michael Roe, Geoffrey Stilwell. Queensland Nick Bannenberg, Jacqueline Bell, Nancy Bonnin, Eddie Clarke, Frederick Colliver, David Gibson, James Gill, Lorna MacDonald, Denis Murphy (chair), Mary O’Keeffe, Margaret O’Hagan, Spencer Routh, June Stoodley, Neil Stewart, Paul D. Wilson. North Queensland Subcommittee Douglas Hunt, Kett Kennedy, Ian Moles (convener), Michael Richards, Rodney Sullivan. Editorial Board Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, Norman Cowper, Robin Gollan, Ken Inglis (chair), John La Nauze, Denis Murphy, Bede Nairn, Max Neutze, Robert J. O’Neill, John D. Playford, Colin Plowman, John Poynter, Heather Radi, Michael Roe, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward, Alexander Youngson. Volume 8, 1891–1939, Cl–Gib (Carlton, Vic.: Melbourne University Press, 1981) Volume 8, 1891–1939, Cl–Gib (Carlton, Vic.: Melbourne University Press, 1981) General editors: Bede Nairn, Geoffrey Serle. General editors: Bede Nairn, Geoffrey Serle. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. National Committee Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, P. Cook, Norman Cowper, Frank Crowley, Brian de Garis, Laurie Fitzhardinge, Robin Gollan, Gordon Greenwood, Ross Hohnen, Ken Inglis (chair), Gregory McMinn, Jim Main, Bede Nairn, Robert J. O’Neill, John Poynter, Henry Reynolds, B. Rose, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, John M. Ward, Russel Ward. Victoria Weston Bate, Leslie Blake, P. Cook, Sidney Ingham, Stephen Murray-Smith, John Poynter (chair), John Rickard, Frank Strahan, John Thompson. Weston Bate, Leslie Blake, P. Cook, Sidney Ingham, Stephen Murray-Smith, John Poynter (chair), John Rickard, Frank Strahan, John Thompson. 421 The ADB’s Story The ADB’s Story Western Australia Osland Battye, Wendy Birman, David Black, Geoffrey Bolton (chair), Brian de Garis, Rica Erickson, Alexandra Hasluck, John Honniball, Lyall Hunt, David Hutchison, Mollie Lukis, Toby Manford, Margaret Medcalf, David Mossenson, Tom Stannage, Arthur Staples, Mary Tamblyn, Merab Harris Tauman. Working parties Armed Services South Australia Douglas A. Dunstan, Ronald Gibbs, Peter Howell, Helen Jones, John Love, John D. Playford (chair), John Tregenza. Western Australia Wendy Birman, David Black, Geoffrey Bolton (chair), Brian de Garis, Rica Erickson, Alexandra Hasluck, John Honniball, Lyall Hunt, David Hutchison, Mollie Lukis, Toby Manford, Margaret Medcalf, Tom Stannage, Arthur Staples, Mary Tamblyn, Merab Harris Tauman. Volume 9, 1891–1939, Gil–Las (Carlton, Vic.: Melbourne University Press, 1983) General editors: Bede Nairn, Geoffrey Serle. General editors: Bede Nairn, Geoffrey Serle. Deputy general editor: Chris Cunneen. Deputy general editor: Chris Cunneen. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. Victoria Weston Bate, P. Cook, Graeme Davison, Sidney Ingham, Stephen Murray- Smith, John Poynter (chair), John Rickard, Judith Smart, Frank Strahan, John Thompson. Tasmania Peter Chapman, Margaret Glover, Elizabeth McLeod, Mary McRae, Ian Pearce, John Reynolds (chair), Michael Roe, Geoffrey Stilwell. North Queensland Subcommittee North Queensland Subcommittee North Queensland Subcommittee Kett Kennedy, Ian Moles (convener), Rodney Sullivan. Kett Kennedy, Ian Moles (convener), Rodney Sullivan. South Australia Armed Services Maurice Austin, Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Jean Fielding, Alec Hill, John McCarthy, Robert J. O’Neill (chair), Neil Primrose. Maurice Austin, Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Jean Fielding, Alec Hill, John McCarthy, Robert J. O’Neill (chair), Neil Primrose. New South Wales Barry G. Andrews, John Bennett, Ken Cable, Frank Crowley, Chris Cunneen, Russell Doust (chair), Rae Else-Mitchell, Frank Farrell, Brian Fletcher, Baiba Irving, Hazel King, Beverley Kingston, Gregory McMinn, Bruce Mansfield, Bruce A. Mitchell, Heather Radi, John A. Ryan, Gerry Walsh, John M. Ward. 422 Appendix 3 Queensland Nick Bannenberg, Nancy Bonnin, Eddie Clarke, Frederick Colliver, James Gill, Lorna McDonald, Denis Murphy (chair), Mary O’Keeffe, Margaret O’Hagan, Spencer Routh, Paul D. Wilson. Editorial Board Don Baker, Alan Barnard (acting chair), Geoffrey Bolton, Ken Cable, Manning Clark, Robin Gollan, Ken Inglis (chair), John La Nauze, Denis Murphy, Bede Nairn, Max Neutze, Robert J. O’Neill, John D. Playford, Colin Plowman, John Poynter, Heather Radi, Michael Roe, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward, Douglas Whalan. Don Baker, Alan Barnard (acting chair), Geoffrey Bolton, Ken Cable, Manning Clark, Robin Gollan, Ken Inglis (chair), John La Nauze, Denis Murphy, Bede Nairn, Max Neutze, Robert J. O’Neill, John D. Playford, Colin Plowman, John Poynter, Heather Radi, Michael Roe, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, Russel Ward, Douglas Whalan. National Committee Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, P. Cook, Norman Cowper, Frank Crowley, Brian de Garis, Laurie Fitzhardinge, Don Baker, Alan Barnard, Geoffrey Bolton, Ken Cable, Manning Clark, P. Cook, Norman Cowper, Frank Crowley, Brian de Garis, Laurie Fitzhardinge, 423 The ADB’s Story Robin Gollan, Gordon Greenwood, Ross Hohnen, Ken Inglis (chair), Gregory McMinn, Jim Main, Bede Nairn, Robert J. O’Neill, John Poynter, Henry Reynolds, B. Rose, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, John M. Ward, Russel Ward. Robin Gollan, Gordon Greenwood, Ross Hohnen, Ken Inglis (chair), Gregory McMinn, Jim Main, Bede Nairn, Robert J. O’Neill, John Poynter, Henry Reynolds, B. Rose, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, John M. Ward, Russel Ward. Robin Gollan, Gordon Greenwood, Ross Hohnen, Ken Inglis (chair), Gregory McMinn, Jim Main, Bede Nairn, Robert J. O’Neill, John Poynter, Henry Reynolds, B. Rose, John A. Ryan, Geoffrey Sawer, Geoffrey Serle, A. G. L. Shaw, John M. Ward, Russel Ward. New South Wales Barry G. Andrews, John Bennett, Ken Cable, Frank Crowley, Chris Cunneen, Russell Doust (chair), Rae Else-Mitchell, Frank Farrell, Brian Fletcher, Baiba Irving, Hazel King, Beverley Kingston, Gregory McMinn, Bruce Mansfield, Bruce A. Mitchell, Heather Radi, John A. Ryan, Gerry Walsh, John M. Ward. Queensland Armed Services Maurice Austin, Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Alec Hill (chair), Merrilyn Lincoln, John McCarthy, George Odgers, Robert J. O’Neill, Alan Sweeting. Maurice Austin, Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Alec Hill (chair), Merrilyn Lincoln, John McCarthy, George Odgers, Robert J. O’Neill, Alan Sweeting. Maurice Austin, Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Alec Hill (chair), Merrilyn Lincoln, John McCarthy, George Odgers, Robert J. O’Neill, Alan Sweeting. Queensland Nick Bannenberg, Nancy Bonnin, Eddie Clarke, Frederick Colliver, James Gill, Lorna McDonald, Denis Murphy (chair), Mary O’Keeffe, Margaret O’Hagan, Spencer Routh, Colin Sheehan, Paul D. Wilson. North Queensland Subcommittee North Queensland Subcommittee Douglas Hunt, Kett Kennedy, Ian Moles (convener), Rodney Sullivan. Douglas Hunt, Kett Kennedy, Ian Moles (convener), Rodney Sullivan. South Australia South Australia Carl Bridge, Douglas A. Dunstan, Ronald Gibbs, Peter Howell, Helen Jones, John Love, John D. Playford (chair), John Tregenza. Tasmania Editorial Board Don Aitkin, Don Baker, Alan Barnard, Geoffrey Bolton, Paul Bourke, Ken Cable, Manning Clark, Chris Cunneen, Ann Curthoys, Ken Inglis (chair), William Johnston, Bede Nairn, Max Neutze, Robert J. O’Neill, John D. Playford, Colin Plowman, John Poynter, Heather Radi, Jill Roe, Michael Roe, Geoffrey Serle, A. G. L. Shaw, Gavin Souter, Russel Ward, Douglas Whalan. Western Australia Wendy Birman (chair), David Black, Geoffrey Bolton, Peter Boyce, Chris Coggin, Brian de Garis, Rica Erickson, Alexandra Hasluck, John Honniball, Lyall Hunt, David Hutchison, Lenore Layman, Mollie Lukis, Toby Manford, Margaret Medcalf, Robert Reece, Tom Stannage, Arthur Staples, Mary Tamblyn, Merab Harris Tauman. Volume 10, 1891–1939, Lat–Ner (Carlton, Vic.: Melbourne University Press, 1986) General editors: Bede Nairn, Geoffrey Serle. Deputy general editor: Chris Cunneen. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. Victoria Weston Bate, Graeme Davison, John Hirst, Sidney Ingham, John Lack, Stephen Murray-Smith, John Poynter (chair), John Rickard, Judith Smart, Frank Strahan. Tasmania Peter Chapman, Margaret Glover, Elizabeth McLeod, Mary McRae, Ian Pearce, John Reynolds (chair), Michael Roe, Geoffrey Stilwell. 424 Appendix 3 Working parties Armed Services Armed Services Maurice Austin, Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Arthur Garrisson, Alec Hill (chair), Merrilyn Lincoln, John McCarthy, Perditta McCarthy, Alan Sweeting. New South Wales Victoria Weston Bate, Graeme Davison, John Hirst, Sidney Ingham, John Lack, Marilyn Lake, T. Marshall, Stephen Murray-Smith, John Poynter (chair), John Rickard, Judith Smart, Frank Strahan. North Queensland Subcommittee North Queensland Subcommittee North Queensland Subcommittee Kett Kennedy, Ian Moles (convener), Rodney Sullivan. Douglas A. Dunstan, Ronald Gibbs, Peter Howell, Helen Jones, John Love, John D. Playford (chair), John Tregenza. Douglas A. Dunstan, Ronald Gibbs, Peter Howell, Helen Jones, John Love, John D. Playford (chair), John Tregenza. Tasmania Peter Chapman, Raymond Ferrall, Margaret Glover, Elizabeth McLeod, Mary McRae, Mary Nicholls, Ian Pearce, John Reynolds (former chair), Michael Roe, Geoffrey Stilwell. New South Wales Barry G. Andrews, John Bennett, Ken Cable, Frank Crowley, Chris Cunneen, Russell Doust (chair), Rae Else-Mitchell, Frank Farrell, Brian Fletcher, Baiba Irving, Hazel King, Beverley Kingston, Gregory McMinn, Bruce Mansfield, Bruce A. Mitchell, Heather Radi, John A. Ryan, Gerry Walsh, John M. Ward. 425 The ADB’s Story Queensland Queensland Nick Bannenberg, Nancy Bonnin, Eddie Clarke, Frederick Colliver, Betty Crouchley, James Gill, Ross Johnston (chair), Lorna McDonald, Denis Murphy, Mary O’Keeffe, Margaret O’Hagan, Spencer Routh, Colin Sheehan, Paul D. Wilson. Editorial Board Don Aitkin, Don Baker, Alan Barnard, Geoffrey Bolton, Paul Bourke, Ken Cable, Manning Clark, Chris Cunneen, Ann Curthoys, Ken Inglis (chair), William Johnston, Bede Nairn, Max Neutze, Robert J. O’Neill, John D. Playford, Colin Plowman, John Poynter, Heather Radi, Jill Roe, Michael Roe, Geoffrey Serle, A. G. L. Shaw, Gavin Souter, Russel Ward, Douglas Whalan. Don Aitkin, Don Baker, Alan Barnard, Geoffrey Bolton, Paul Bourke, Ken Cable, Manning Clark, Chris Cunneen, Ann Curthoys, Ken Inglis (chair), William Johnston, Bede Nairn, Max Neutze, Robert J. O’Neill, John D. Playford, Colin Plowman, John Poynter, Heather Radi, Jill Roe, Michael Roe, Geoffrey Serle, A. G. L. Shaw, Gavin Souter, Russel Ward, Douglas Whalan. Western Australia Wendy Birman (chair), David Black, Geoffrey Bolton, Peter Boyce, Chris Coggin, Brian de Garis, Rica Erickson, Alexandra Hasluck, John Honniball, Lyall Hunt, David Hutchison, Lenore Layman, Mollie Lukis, Margaret Medcalf, Robert Reece, Tom Stannage, Arthur Staples, Merab Harris Tauman. Volume 11, 1891–1939, Nes–Smi (Carlton, Vic.: Melbourne University Press, 1988) General editor: Geoffrey Serle. Deputy general editor: Chris Cunneen. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. Volume 11, 1891–1939, Nes–Smi (Carlton, Vic.: Melbourne University Press, 1988) General editor: Geoffrey Serle. 426 Appendix 3 Queensland Nick Bannenberg, Nancy Bonnin, Eddie Clarke, Frederick Colliver, Betty Crouchley, James Gill, Ross Johnston (chair), Lorna McDonald, Margaret O’Hagan, Mary O’Keeffe, Spencer Routh, Colin Sheehan, Paul D. Wilson. North Queensland Subcommittee North Queensland Subcommittee Kett Kennedy, Ian Moles (convener), Rodney Sullivan. South Australia Douglas A. Dunstan, Ronald Gibbs, Peter Howell, Helen Jones, John Love, John D. Playford (chair), John Tregenza. Tasmania Armed Services Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Brian Eaton, Arthur Garrisson, Alec Hill (chair), Merrilyn Lincoln, John McCarthy, Perditta McCarthy, Alan Sweeting. New South Wales Barry G. Andrews, John Bennett, Baiba Berzins, Ken Cable, John Carmody, Alison Crook (chair), Chris Cunneen, Ross Curnow, Russell Doust, Rae Else-Mitchell, Frank Farrell, Brian Fletcher, Murray Goot, Hazel King, Beverley Kingston, Gregory McMinn, Bruce A. Mitchell, Ann Moyal, Bede Nairn, Heather Radi, John A. Ryan, Gerry Walsh. Barry G. Andrews, John Bennett, Baiba Berzins, Ken Cable, John Carmody, Alison Crook (chair), Chris Cunneen, Ross Curnow, Russell Doust, Rae Else-Mitchell, Frank Farrell, Brian Fletcher, Murray Goot, Hazel King, Beverley Kingston, Gregory McMinn, Bruce A. Mitchell, Ann Moyal, Bede Nairn, Heather Radi, John A. Ryan, Gerry Walsh. Working parties Working parties Armed Services Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Brian Eaton, Arthur Garrisson, Alec Hill (chair), Merrilyn Lincoln, John McCarthy, Perditta McCarthy, Alan Sweeting. Editorial Board Don Baker, Alan Barnard, Geoffrey Bolton, Paul Bourke, Ken Cable, Manning Clark, Chris Cunneen, Ann Curthoys, Ken Inglis (chair), William Johnston, Bede Nairn, Max Neutze, Robert J. O’Neill, John D. Playford, Colin Plowman, John Poynter, Heather Radi, John Ritchie, Jill Roe, Michael Roe, Geoffrey Serle, A. G. L. Shaw, Gavin Souter, Russel Ward, Douglas Whalan. Victoria Weston Bate, Graeme Davison, John Hirst, Sidney Ingham, John Lack, Marilyn Lake, T. Marshall, Stephen Murray-Smith, John Poynter (chair), John Rickard, Judith Smart, Frank Strahan. Deputy general editor: Chris Cunneen. Section editors: Geoffrey Bolton, Ken Cable, Robert J. O’Neill, John Poynter, Heather Radi. Tasmania Peter Chapman, Raymond Ferrall, Margaret Glover, Elizabeth McLeod, Mary McRae, Mary Nicholls, Ian Pearce, Michael Roe (chair), Geoffrey Stilwell. Peter Chapman, Raymond Ferrall, Margaret Glover, Elizabeth McLeod, Mary McRae, Mary Nicholls, Ian Pearce, Michael Roe (chair), Geoffrey Stilwell. 427 The ADB’s Story Western Australia Wendy Birman (chair), David Black, Geoffrey Bolton, Peter Boyce, Chris Coggin, Brian de Garis, Rica Erickson, Alexandra Hasluck, John Honniball, Lyall Hunt, David Hutchison, Lenore Layman, Mollie Lukis, Margaret Medcalf, Robert Reece, Arthur Staples. Wendy Birman (chair), David Black, Geoffrey Bolton, Peter Boyce, Chris Coggin, Brian de Garis, Rica Erickson, Alexandra Hasluck, John Honniball, Lyall Hunt, David Hutchison, Lenore Layman, Mollie Lukis, Margaret Medcalf, Robert Reece, Arthur Staples. Volume 12, 1891–1939, Smy–Z (Carlton, Vic.: Melbourne University Press, 1990) General editor: John Ritchie. Deputy general editor: Chris Cunneen. Cameron Hazlehurst (chair), Ann Hone, Colin Hughes, Anthea Hyslop, Margot Kerley, Clem Lloyd, Donald McDonald, Graeme Powell, Jerzy Zubrzycki. North Queensland Subcommittee North Queensland Subcommittee Kett Kennedy (convener), Dawn May, Diane Menghetti, Anne Smith, Paul Turnbull, Janice Wegner. Armed Services Armed Services Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Peter Dennis, Brian Eaton, Peter G. Edwards, Arthur Garrisson, Alec Hill (chair), David Horner, John McCarthy, Perditta McCarthy, Allan Morrison, Alan Sweeting. Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Peter Dennis, Brian Eaton, Peter G. Edwards, Arthur Garrisson, Alec Hill (chair), David Horner, John McCarthy, Perditta McCarthy, Allan Morrison, Alan Sweeting. Commonwealth Cameron Hazlehurst (chair), Ann Hone, Colin Hughes, Anthea Hyslop, Margot Kerley, Clem Lloyd, Donald McDonald, Graeme Powell, Jerzy Zubrzycki. 428 Appendix 3 New South Wales John Bennett, Ken Cable, John Carmody, Alison Crook (chair), Chris Cunneen, Ross Curnow, Ann Curthoys, Rae Else-Mitchell, Frank Farrell, Brian Fletcher, Stephen Garton, Murray Goot, Beverley Kingston, Ann Moyal, Bede Nairn, Heather Radi, Jill Roe, Gavin Souter, Gerry Walsh. South Australia Joyce Gibberd, Ronald Gibbs, Peter Howell, Helen Jones, John Love, Susan Marsden, John D. Playford (chair), Patricia Stretton, Robert Thornton, John Tregenza. Tasmania Peter Chapman, Shirley Eldershaw, Raymond Ferrall, Margaret Glover, Elizabeth McLeod, Mary McRae, Francis Neasey, Stefan Petrow, Anne Rand, Michael Roe (chair), Geoffrey Stilwell. Victoria Weston Bate, Mimi Colligan, Graeme Davison, John Kendall, John Lack, Marilyn Lake, T. Marshall, John Poynter (chair), John Rickard, Geoffrey Serle, Judith Smart, Frank Strahan. Western Australia Wendy Birman (chair), David Black, Geoffrey Bolton, Peter Boyce, Dorothy Erickson, Jenny Gregory, Mary Anne Jebb, Lenore Layman, Margaret Medcalf, Clement Mulcahy, Robert Reece, Arthur Staples. Queensland Nancy Bonnin, Manfred Cross, Helen Gregory, Ian Jobling, Ross Johnston (chair), Greg Logan, Robert Longhurst, Lorna McDonald, Margaret O’Hagan, Spencer Routh, Colin Sheehan, Val Vallis. Victoria Weston Bate, Mimi Colligan, Graeme Davison, John Kendall, John Lack, Marilyn Lake, T. Marshall, John Poynter (chair), John Rickard, Geoffrey Serle, Judith Smart, Frank Strahan. Editorial Board Don Baker, Geoffrey Bolton, Geoff Brennan, Chris Cunneen, Ann Curthoys, Cameron Hazlehurst, Ken Inglis (chair), William Johnston, Lenore Layman, Bede Nairn, Max Neutze, Robert J. O’Neill, John D. Playford, John Poynter, Heather Radi, John Ritchie, Jill Roe, Michael Roe, Geoffrey Serle, A. G. L. Shaw, Gavin Souter, Russel Ward, Douglas Whalan. New South Wales John Bennett, Ken Cable, John Carmody, Alison Crook (chair), Chris Cunneen, Ross Curnow, Ann Curthoys, Frank Farrell, Stephen Garton, Murray Goot, Beverley Kingston, Andrew Moore, Bede Nairn, Heather Radi, Jill Roe, Gavin Souter, Gerry Walsh. Volume 13, 1940–1980, A–De (Carlton, Vic.: Melbourne University Press, 1993) General editor: John Ritchie. General editor: John Ritchie. Deputy general editor: Chris Cunneen. p y g Section editors: Geoffrey Bolton, Cameron Hazlehurst, William Johnston, Robert J. O’Neill, John D. Playford, Heather Radi, Jill Roe, Michael Roe, Geoffrey Serle. Section editors: Geoffrey Bolton, Cameron Hazlehurst, William Johnston, Robert J. O’Neill, John D. Playford, Heather Radi, Jill Roe, Michael Roe, Geoffrey Serle. Armed Services Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Brian Eaton, Peter G. Edwards, William Graham, Alec Hill (chair), David Horner, John McCarthy, Perditta McCarthy, Allan Morrison, Alan Sweeting. Frank H. Brown, Peter Burness, Chris Coulthard-Clark, Brian Eaton, Peter G. Edwards, William Graham, Alec Hill (chair), David Horner, John McCarthy, Perditta McCarthy, Allan Morrison, Alan Sweeting. Commonwealth Commonwealth Patricia Clarke, Cameron Hazlehurst (chair), Ann Hone, Colin Hughes, Anthea Hyslop, Robert Hyslop, Margot Kerley, Clem Lloyd, Graeme Powell, John Thompson. Patricia Clarke, Cameron Hazlehurst (chair), Ann Hone, Colin Hughes, Anthea Hyslop, Robert Hyslop, Margot Kerley, Clem Lloyd, Graeme Powell, John Thompson. Western Australia Wendy Birman (chair), David Black, Geoffrey Bolton, Peter Boyce, Dorothy Erickson, Jenny Gregory, Mary Anne Jebb, Lenore Layman, Margaret Medcalf, Clement Mulcahy, Robert Reece, Arthur Staples. 429 The ADB’s Story Volume 13, 1940–1980, A–De (Carlton, Vic.: Melbourne University Press, 1993) Queensland Nancy Bonnin, Manfred Cross, James Gill, Helen Gregory, Ian Jobling, Ross Johnston (chair), Greg Logan, Robert Longhurst, Lorna McDonald, Dawn May, Margaret O’Hagan, Spencer Routh, Colin Sheehan, Val Vallis. 430 Appendix 3 South Australia Bill Gammage, Joyce Gibberd, Ronald Gibbs, Peter Howell, Helen Jones, John Love, Susan Marsden, John D. Playford (chair), Patricia Stretton, Robert Thornton. Bill Gammage, Joyce Gibberd, Ronald Gibbs, Peter Howell, Helen Jones, John Love, Susan Marsden, John D. Playford (chair), Patricia Stretton, Robert Thornton. Tasmania Peter Chapman, Shirley Eldershaw, Raymond Ferrall, Margaret Glover, Elizabeth McLeod, Francis Neasey, Stefan Petrow, Anne Rand, Michael Roe (chair), Geoffrey Stilwell. Volume 14, 1940–1980, Di–Kel (Carlton, Vic.: Melbourne University Press, 1996) General editor: John Ritchie. Deputy general editor: Chris Cunneen. Section editors: Geoffrey Bolton, Cameron Hazlehurst, William Johnston, Robert J. O’Neill, John D. Playford, Heather Radi, Jill Roe, Michael Roe, Geoffrey Serle. Victoria Weston Bate, Judith Brett, Geoff Browne, Mimi Colligan, Graeme Davison, John Kendall, John Lack, Marilyn Lake, John Poynter (chair), John Rickard, Geoffrey Serle, Judith Smart, Frank Strahan. Western Australia Wendy Birman (chair), David Black, Geoffrey Bolton, Peter Boyce, Dorothy Erickson, Jenny Gregory, Mary Anne Jebb, Lenore Layman, Margaret Medcalf, Clement Mulcahy, Robert Reece, Arthur Staples. Wendy Birman (chair), David Black, Geoffrey Bolton, Peter Boyce, Dorothy Erickson, Jenny Gregory, Mary Anne Jebb, Lenore Layman, Margaret Medcalf, Clement Mulcahy, Robert Reece, Arthur Staples. New South Wales Margy Burn, John Carmody, Chris Cunneen, Ross Curnow, Ann Curthoys, Frank Farrell, Stephen Garton, Murray Goot, Beverley Kingston (chair), John Kennedy McLaughlin, Andrew Moore, Bede Nairn, Heather Radi, Jill Roe, Gavin Souter, Gerry Walsh. Queensland Ysola Best, Pat Buckridge, Manfred Cross, Lyn Finch, Maurice French, James Gill, Helen Gregory, Ian Jobling, Ross Johnston (chair), Lorna McDonald, Dawn May, Spencer Routh, Colin Sheehan, Val Vallis. Editorial Board Geoffrey Bolton, Geoff Brennan, Chris Cunneen, Ann Curthoys, Cameron Hazlehurst, Ken Inglis (chair), William Johnston, John D. Playford, John Poynter, John Ritchie, Jill Roe, Michael Roe, Geoffrey Serle, A. G. L. Shaw, Douglas Whalan. 431 The ADB’s Story The ADB’s Story South Australia Bill Gammage, Joyce Gibberd, Ronald Gibbs, Peter Howell, Helen Jones, John Love, John D. Playford (chair), Judith Raftery, Jenny Tilby Stock, Patricia Stretton, Robert Thornton. Tasmania Peter Chapman, Shirley Eldershaw, Raymond Ferrall, Margaret Glover, Elizabeth McLeod, Stefan Petrow, Anne Rand, Michael Roe (chair), Geoffrey Stilwell. Working parties Armed Services Peter Burness, John Coates, Chris Coulthard-Clark, Alec Hill, David Horn (chair), John McCarthy, Perditta McCarthy, Philip Mulcare, Anthony Staunto Alan Stephens, Alan Sweeting. Commonwealth Nicholas Brown, Patricia Clarke, Graham Gilmour, Ian Hancock, Cameron Hazlehurst (chair), Anthea Hyslop, Robert Hyslop, Margot Kerley, Clem Lloyd, Graeme Powell, John Thompson. Nicholas Brown, Patricia Clarke, Graham Gilmour, Ian Hancock, Cameron Hazlehurst (chair), Anthea Hyslop, Robert Hyslop, Margot Kerley, Clem Lloyd, Graeme Powell, John Thompson. Editorial Board Geoffrey Bolton, Stephen Garton, Tom Griffiths, David Horner, Peter Howell, William Johnston, Beverley Kingston, John Lack, Di Langmore, Ian McAllister, Janet McCalman, John Poynter, John Ritchie, Jill Roe (chair), Michael Roe. Deputy general editor: Di Langmore. Section editors: Geoffrey Bolton, Tom Griffiths, Peter Howell, William Johnston, Beverley Kingston, John Lack, Robert J. O’Neill, Michael Roe. Armed Services Peter Burness, John Coates, Alec Hill, David Horner (chair), John McCarthy, Perditta McCarthy, Philip Mulcare, Anthony Staunton, Alan Stephens, David Stevens, Alan Sweeting. New South Wales John Carmody, Chris Cunneen, Ross Curnow, Frank Farrell, Stephen Garton, Murray Goot, Beverley Kingston (chair), John Kennedy McLaughlin, Alan Moore, Bede Nairn, Heather Radi, Jill Roe, Dagmar Schmidmaier, Gavin Souter, Alan Ventress. Volume 15, 1940–1980, Kem–Pie (Carlton, Vic.: Melbourne University Press, 2000) General editor: John Ritchie. General editor: John Ritchie. Deputy general editor: Di Langmore. Commonwealth Nicholas Brown, David Carment, Patricia Clarke, Bill Gammage, Tom Griffiths (chair), Ian Hancock, Robert Hyslop, Clem Lloyd, Graeme Powell, Libby Robin, John Thompson. Victoria Weston Bate, Geoff Browne, Mimi Colligan, Brian Costar, Graeme Davison, John Kendall, John Lack, Marilyn Lake, Robert Murray, John Poynter (chair), John Rickard, Geoffrey Serle, Judith Smart, Frank Strahan. Wendy Birman (chair), David Black, Geoffrey Bolton, Michal Bosworth, Peter Boyce, Dorothy Erickson, Jenny Gregory, Lenore Layman, Margaret Medcalf, Clement Mulcahy, Ken Spillman, Arthur Staples. 432 Appendix 3 Volume 15, 1940–1980, Kem–Pie (Carlton, Vic.: Melbourne University Press, 2000) Tasmania Peter Chapman, Shirley Eldershaw, Margaret Glover, Elizabeth McLeod, Stefan Petrow, Anne Rand, Michael Roe (chair), Geoffrey Stilwell. South Australia South Australia John Bannon, Joyce Gibberd, Ronald Gibbs, Peter Howell (chair), Helen Jones, John Love, Katharine Massam, Judith Raftery, Jenny Tilby Stock, Patricia Stretton, Robert Thornton. Victoria Geoff Browne, Mimi Colligan, Brian Costar, Jim Davidson, Graeme Davison, David Dunstan, John Kendall, John Lack (chair), Janet McCalman, Robert Murray, John Poynter, Carolyn Rasmussen, John Rickard, Judith Smart, Frank Strahan. Volume 16, 1940–1980, Pik–Z (Carlton, Vic.: Melbourne University Press, 2002) General editor: John Ritchie. Deputy general editor: Di Langmore. Section editors: Geoffrey Bolton, Pat Buckridge, Tom Griffiths, David Horner, Peter Howell, Beverley Kingston, John Lack, Michael Roe. Western Australia Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Jill Milroy, Clement Mulcahy, Jan Ryan, Tom Stannage. Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Jill Milroy, Clement Mulcahy, Jan Ryan, Tom Stannage. Queensland Ysola Best, Pat Buckridge, Manfred Cross, Marion Diamond, Maurice French, Helen Gregory, Jennifer Harrison, Ian Jobling, Ross Johnston (chairman), Lorna McDonald, Dawn May, Spencer Routh, Colin Sheehan. Ysola Best, Pat Buckridge, Manfred Cross, Marion Diamond, Maurice French, Helen Gregory, Jennifer Harrison, Ian Jobling, Ross Johnston (chairman), Lorna McDonald, Dawn May, Spencer Routh, Colin Sheehan. 433 The ADB’s Story The ADB’s Story Editorial Board Geoffrey Bolton, Pat Buckridge, Stephen Garton, Tom Griffiths, David Horner, Peter Howell, Beverley Kingston, John Lack, Di Langmore, Ian McAllister, Janet McCalman, John Poynter, John Ritchie, Jill Roe (chair), Michael Roe. 434 Appendix 3 New South Wales John Carmody, Chris Cunneen, Ross Curnow, Frank Farrell, Stephen Garton, Murray Goot, Bridget Griffen-Foley, Warwick Hirst, Beverley Kingston (chair), John Kennedy McLaughlin, Alan Moore, Bede Nairn, Heather Radi, Jill Roe, Dagmar Schmidmaier, Alan Ventress. Armed Services Armed Services Armed Services Peter Burness, Chris Clark, John Coates, Alec Hill, David Horner (chair), John McCarthy, Perditta McCarthy, Philip Mulcare, Anthony Staunton, Alan Stephens, David Stevens, Alan Sweeting. Queensland Pat Buckridge (chair), Manfred Cross, Kay Ferres, Richard Fotheringham, Maurice French, Helen Gregory, Jennifer Harrison, Ian Jobling, Lorna McDonald, Belinda McKay, Dawn May, Olivia Robinson, Spencer Routh, Joanne Scott, Colin Sheehan. South Australia Roger André, John Bannon, Joyce Gibberd, Ronald Gibbs, Peter Howell (chair), Helen Jones, John Love, Judith Raftery, Jenny Tilby Stock, Patricia Stretton. Commonwealth Nicholas Brown, David Carment, Patricia Clarke, Bill Gammage, Tom Griffiths (chair), Robert Hyslop, Graeme Powell, Libby Robin, John Thompson. Tasmania Peter Chapman, Shirley Eldershaw, Margaret Glover, Elizabeth McLeod, Stefan Petrow, Anne Rand, Michael Roe (chair), John Taylor. Peter Chapman, Shirley Eldershaw, Margaret Glover, Elizabeth McLeod, Stefan Petrow, Anne Rand, Michael Roe (chair), John Taylor. Victoria Western Australia Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Jill Milroy, Clement Mulcahy, Jan Ryan, Tom Stannage. Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Jill Milroy, Clement Mulcahy, Jan Ryan, Tom Stannage. Editorial Board Darryl Bennet, Geoffrey Bolton, Pat Buckridge, David Dunstan, Stephen Garton, Tom Griffiths, David Horner, Peter Howell, Frank Jackson, Beverley Kingston, John Lack, Di Langmore, Ian McAllister, Janet McCalman, John Poynter, John Ritchie, Jill Roe (chair), Michael Roe. Supplement 1580–1980 (Carlton, Vic.: Melbourne University Press, 2005) Editor: Chris Cunneen, with Jill Roe, Beverley Kingston and Stephen Garton. Editor: Chris Cunneen, with Jill Roe, Beverley Kingston and Stephen Garton. General editor: Di Langmore. General editor: Di Langmore. Deputy general editor: Darryl Bennet. Section editors: Geoffrey Bolton, Pat Buckridge, Tom Griffiths, David Horner, Peter Howell, Beverley Kingston, John Lack, Michael Roe. Section editors: Geoffrey Bolton, Pat Buckridge, Tom Griffiths, David Horner, Peter Howell, Beverley Kingston, John Lack, Michael Roe. Armed Services Peter Burness, Chris Clark, John Coates, Peter Dennis, Alec Hill, David Horner (chair), John McCarthy, Perditta McCarthy, Philip Mulcare, Anthony Staunton, Alan Stephens, David Stevens, Alan Sweeting. Peter Burness, Chris Clark, John Coates, Peter Dennis, Alec Hill, David Horner (chair), John McCarthy, Perditta McCarthy, Philip Mulcare, Anthony Staunton, Alan Stephens, David Stevens, Alan Sweeting. Victoria John Arnold, Geoff Browne, Mimi Colligan, Brian Costar, Jim Davidson, David Dunstan, John Kendall, John Lack (chair), Peter Love, Janet McCalman, Robert Murray, John Poynter, Carolyn Rasmussen, John Rickard, Judith Smart, Frank Strahan. 435 The ADB’s Story Nicholas Brown, Dawn Casey, Ann Curthoys, Ann McGrath, Margo Neale, Frances Peters-Little (chair), Kaye Price, Peter Read, Tim Rowse. Tasmania Peter Chapman, Shirley Eldershaw, Margaret Glover-Scott, Elizabeth McLeod, Stefan Petrow, Anne Rand, Michael Roe (chair), John Taylor. Victoria John Arnold, Geoff Browne, Mimi Colligan, Brian Costar, Jim Davidson, David Dunstan, Charles Fahey, John Kendall, John Lack (chair), Peter Love, Janet McCalman, David Merrett, Robert Murray, John Poynter, Carolyn Rasmussen, John Rickard, Judith Smart, Frank Strahan. Commonwealth Nicholas Brown (chair), David Carment, Patricia Clarke, John Farquharson, Bill Gammage, Tom Griffiths, Robert Hyslop, John Nethercote, Graeme Powell, Libby Robin, John Thompson, Jill Waterhouse. Nicholas Brown, Dawn Casey, Ann Curthoys, Ann McGrath, Margo Neale, Frances Peters-Little (chair), Kaye Price, Peter Read, Tim Rowse. 436 Appendix 3 New South Wales John Carmody, Chris Cunneen, Ross Curnow, Frank Farrell, Stephen Garton, Murray Goot, Bridget Griffen-Foley, Warwick Hirst, Beverley Kingston (chair), John Kennedy McLaughlin, Andrew Moore, Bede Nairn, Heather Radi, Jill Roe, Dagmar Schmidmaier, Alan Ventress. South Australia Margaret Allen, Roger André, John Bannon, Joyce Gibberd, Ronald Gibbs, David Hilliard, Peter Howell (chair), Helen Jones, John Love, Judith Raftery, Jenny Tilby Stock, Patricia Stretton. Queensland Pat Buckridge (chair), Manfred Cross, Kay Ferres, Richard Fotheringham, Maurice French, Jennifer Harrison, Ian Jobling, Lorna McDonald, Belinda McKay, Dawn May, Olivia Robinson, Spencer Routh, Joanne Scott, Colin Sheehan. Western Australia Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Jill Milroy, Clement Mulcahy, Jan Ryan, Tom Stannage. Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Jill Milroy, Clement Mulcahy, Jan Ryan, Tom Stannage. Volume 17, 1981–1990, A–K (Carlton, Vic.: Melbourne University Press, 2007) General editor: Di Langmore. Deputy general editor: Darryl Bennet. Section editors: Geoffrey Bolton, Pat Buckridge, Tom Griffiths, David Horner, Peter Howell, Beverley Kingston, John Lack, Michael Roe. General editor: Di Langmore. Deputy general editor: Darryl Bennet. Section editors: Geoffrey Bolton, Pat Buckridge, Tom Griffiths, David Horner, Peter Howell, Beverley Kingston, John Lack, Michael Roe. Section editors: Geoffrey Bolton, Pat Buckridge, Tom Griffiths, David Horner, Peter Howell, Beverley Kingston, John Lack, Michael Roe. 437 The ADB’s Story The ADB’s Story Editorial Board Darryl Bennet, Geoffrey Bolton, Nicholas Brown, Pat Buckridge, David Dunstan, Stephen Garton, Tom Griffiths (chair), David Horner, Peter Howell, Frank Jackson, Beverley Kingston, John Lack, Di Langmore, Janet McCalman, Frances Peters-Little, Jill Roe, Michael Roe. Darryl Bennet, Geoffrey Bolton, Nicholas Brown, Pat Buckridge, David Dunstan, Stephen Garton, Tom Griffiths (chair), David Horner, Peter Howell, Frank Jackson, Beverley Kingston, John Lack, Di Langmore, Janet McCalman, Frances Peters-Little, Jill Roe, Michael Roe. New South Wales John Carmody, Chris Cunneen, Ross Curnow, Nancy Cushing, Barry Dyster, Stephen Garton, Murray Goot, Bridget Griffen-Foley, Warwick Hirst, Beverley Kingston (chair), John Kennedy McLaughlin, Glen Mitchell, Andrew Moore, Jill Roe, Regina Sutton, Alan Ventress. Queensland Pat Buckridge (chair), Manfred Cross, Kay Ferres, Richard Fotheringham, Maurice French, Jennifer Harrison, Lorna McDonald, Belinda McKay, Spencer Routh, Joanne Scott. Commonwealth Nicholas Brown (chair), David Carment, Patricia Clarke, John Farquharson, Bill Gammage, Robert Hyslop, John Nethercote, Graeme Powell, Libby Robin, John Thompson, Jill Waterhouse. Indigenous Aileen Blackburn, Nicholas Brown, Dawn Casey, Ann Curthoys, Stephen Kinnane, Frances Peters-Little (chair), Kaye Price, Peter Read, Tim Rowse. Armed Services Peter Burness, Chris Clark, John Coates, Peter Dennis, Alec Hill, David Horner (chair), John McCarthy, Perditta McCarthy, Philip Mulcare, Anthony Staunton, Alan Stephens, David Stevens, Alan Sweeting. Tasmania Tasmania Peter Chapman, Shirley Eldershaw, Margaret Glover-Scott, Elizabeth McLeod, Stefan Petrow, Anne Rand, Michael Roe (chair), John Taylor. Deputy general editor: Paul Arthur. Section editors: Geoffrey Bolton, Nicholas Brown, Pat Buckridge, David Horner, Peter Howell, Beverley Kingston, John Lack, Michael Roe. Editorial Board Darryl Bennet, Geoffrey Bolton, Nicholas Brown, Pat Buckridge, Patrick Cornish, Chris Cunneen, Joy Damousi, David Dunstan, Stephen Garton, Adam Graycar, Tom Griffiths (chair), David Horner, Peter Howell, Beverley Kingston, John Lack, Dave Marsh, Melanie Nolan, Stefan Petrow, Paul Pickering, Carloyn Rasmussen, Jill Roe, Michael Roe. Victoria John Arnold, Geoff Browne, Mimi Colligan, Brian Costar, Jim Davidson, David Dunstan, Charles Fahey, John Kendall, John Lack (chair), Peter Love, Janet McCalman, David Merrett, Robert Murray, John Poynter, Carolyn Rasmussen, John Rickard, Judith Smart. South Australia Margaret Allen, Roger André, Carol Fort, Joyce Gibberd, Ronald Gibbs, David Hilliard, Peter Howell (chair), Helen Jones, Judith Raftery, Jenny Tilby Stock, Patricia Stretton. Margaret Allen, Roger André, Carol Fort, Joyce Gibberd, Ronald Gibbs, David Hilliard, Peter Howell (chair), Helen Jones, Judith Raftery, Jenny Tilby Stock, Patricia Stretton. 438 Appendix 3 Western Australia Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Jill Milroy, Clement Mulcahy, Jan Ryan, Tom Stannage. Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Jill Milroy, Clement Mulcahy, Jan Ryan, Tom Stannage. Volume 18, 1981–1990 L–Z (Carlton, Vic.: Melbourne University Press, 2012) Volume 18, 1981–1990 L–Z (Carlton, Vic.: Melbourne University Press, 2012) General editor: Melanie Nolan. Deputy general editor: Paul Arthur. Queensland Darryl Bennet, Pat Buckridge (chair), Libby Connors, Betty Cosgrove, Manfred Cross, Mark Cryle, Kay Ferres, Richard Fotheringham, Maurice French, Geoff Ginn, Jennifer Harrison, Dale Kerwin, Belinda McKay, Spencer Routh, Joanne Scott, Brian Stevenson. Commonwealth Commonwealth Nicholas Brown (chair), David Carment, Patricia Clarke, John Farquharson, Bill Gammage, Robert Hyslop, David Lee, John Nethercote, Graeme Powell, Libby Robin, Peter Stanley, John Thompson, Jill Waterhouse. Nicholas Brown (chair), David Carment, Patricia Clarke, John Farquharson, Bill Gammage, Robert Hyslop, David Lee, John Nethercote, Graeme Powell, Libby Robin, Peter Stanley, John Thompson, Jill Waterhouse. New South Wales Alex Byrne, John Carmody, Chris Cunneen, Ross Curnow, Nancy Cushing, Barrie Dyster, Stephen Garton, Murray Goot, Bridget Griffen-Foley, Warwick Hirst, Beverley Kingston (chair), John Kennedy McLaughlin, Glenn Mitchell, Andrew Moore, Jill Roe, Regina Sutton, Alan Ventress, Linda West. South Australia Margaret Allen, Roger André, Peter Donovan, Carol Fort, Joyce Gibberd, Ronald Gibbs, David Hilliard, Peter Howell (chair), Helen Jones, Catherine Kevin, Prudence McDonald, Bernard O’Neill, Judith Raftery, Kerry Round, Paul Sendzuik, Patricia Stretton, Jenny Tilby Stock, Bernard Whimpress. Tasmania Peter Chapman, Shirley Eldershaw, Margaret Glover-Scott, Elizabeth McLeod, John Morris, Stefan Petrow, Anne Rand, Michael Roe (chair), John Taylor. Indigenous Aileen Blackburn, Nicholas Brown, Dawn Casey, Ann Curthoys, Sam Faulkner, Shino Konishi, Frances Peters-Little (chair), Kaye Price, Peter Read, Tim Rowse. Armed Services Peter Burness, Chris Clark, John Coates, Peter Dennis, Alec Hill, David Horner (chair), Mark Lax, John McCarthy, Perditta McCarthy, Philip Mulcare, Melanie Oppenheimer, Anthony Staunton, Alan Stephens, David Stevens, Craig Stocking, Alan Sweeting. 439 The ADB’s Story The ADB’s Story The ADB’s Story John Arnold, Bain Attwood, Richard Broome, Geoff Browne (resigned), Mimi Colligan, Brian Costar, Des Cowley, Jim Davidson, David Dunstan (chair), Charles Fahey, Margaret Fitzherbert, Nikki Henningham, John Kendall, John Lack, Peter Love, Janet McCalman, David Merrett, Robert Murray, John Poynter, Carolyn Rasmussen, John Rickard, Judith Smart, John Waugh. Western Australia Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Patrick Cornish, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Clement Mulcahy, Jan Ryan, Tom Stannage. Wendy Birman, David Black, Geoffrey Bolton (chair), Michal Bosworth, Patrick Cornish, Dorothy Erickson, Charles Fox, Sue Graham-Taylor, Jenny Gregory, Lenore Layman, John McIlwraith, Jenny Mills, Clement Mulcahy, Jan Ryan, Tom Stannage. Victoria John Arnold, Bain Attwood, Richard Broome, Geoff Browne (resigned), Mimi Colligan, Brian Costar, Des Cowley, Jim Davidson, David Dunstan (chair), Charles Fahey, Margaret Fitzherbert, Nikki Henningham, John Kendall, John Lack, Peter Love, Janet McCalman, David Merrett, Robert Murray, John Poynter, Carolyn Rasmussen, John Rickard, Judith Smart, John Waugh. John Arnold, Bain Attwood, Richard Broome, Geoff Browne (resigned), Mimi Colligan, Brian Costar, Des Cowley, Jim Davidson, David Dunstan (chair), Charles Fahey, Margaret Fitzherbert, Nikki Henningham, John Kendall, John Lack, Peter Love, Janet McCalman, David Merrett, Robert Murray, John Poynter, Carolyn Rasmussen, John Rickard, Judith Smart, John Waugh. 440 Appendix 3 Darryl Bennet, Bob Clements, Ann Curthoys, Ian Hancock, Ken Inglis, John Molony, John Nethercote, Barry Smith. Editorial Fellows Darryl Bennet, Bob Clements, Ann Curthoys, Ian Hancock, Ken Inglis, John Molony, John Nethercote, Barry Smith. 441 441 Photographer: Natalie Azzapardi, ADB archives ADB files, Q31, Australian National University Archives, Canberra. Gibbney, Herbert James, Papers, MS 3131, National Library of Australia, Canberra. [Gibbney worked for the ADB as a desk editor and on the Biographical Register between 1965 and 1984. Some of his ADB entries are included in his papers.] Hancock, Keith, Papers, series 77, Australian National University Archives, Canberra. McDonald, Donald Ian, Papers, MS 5147, National Library of Australia, Canberra. [Includes copies of his ADB entries, correspondence with the general editors between 1968 and 1990 and papers relating to his time on the Commonwealth Working Party in 1989–90.] Pike, Douglas, Papers, MS 6869, National Library of Australia, Canberra. [Includes papers relating to his time as general editor of the ADB in 1962–73.] Ritchie, John, Papers, MS ACC03/290, National Library of Australia, Canberra. [Ritchie was general editor of the ADB in 1988–2002.] Serle, Geoffrey, Papers, MS 6808, National Library of Australia, Canberra. [Geoffrey Serle was general editor of the ADB in 1975–87. ADB Medal Recipients ADB Medals are awarded to people who have given long and distinguished service to the ADB. 443 443 The ADB’s Story The ADB’s Story The first ADB Medallists, Martha Campbell, John Ritchie, Gerry Walsh and Bede Nairn, with ANU vice-chancellor, Ian Chubb, 2002 The first ADB Medallists, Martha Campbell, John Ritchie, Gerry Walsh and Bede Nairn, with ANU vice-chancellor, Ian Chubb, 2002 Photographer: Neal McCracken, ANU Archives, ANUA226-797 Michael Roe (left), Geoffrey Bolton and John Lack received ADB Medals in 2012 Photographer: Neal McCracken, ANU Archives, ANUA226-797 Michael Roe (left), Geoffrey Bolton and John Lack received ADB Medals in 2012 444 Photographer: Natalie Azzapardi, ADB archives Photographer: Natalie Azzapardi, ADB archives Appendix 4 Martha Campbell October 2002 Bede Nairn October 2002 John Ritchie October 2002 Gerald Walsh October 2002 Joyce Gibberd November 2002 John Love November 2002 A. G. L. Shaw December 2002 Ken Cable March 2003 Spencer Routh December 2003 Frank Strahan December 2003 Alec Hill July 2004 Wendy Birman August 2004 John Poynter September 2004 Jennifer Harrison November 2008 Darryl Bennet May 2009 Diane Langmore May 2009 Helen Jones December 2009 Anne Rand December 2009 Geoffrey Bolton December 2012 John Lack December 2012 Michael Roe December 2012 Martha Campbell October 2002 Bede Nairn October 2002 John Ritchie October 2002 Gerald Walsh October 2002 Joyce Gibberd November 2002 John Love November 2002 A. G. L. Shaw December 2002 Ken Cable March 2003 Spencer Routh December 2003 Frank Strahan December 2003 Alec Hill July 2004 Wendy Birman August 2004 John Poynter September 2004 Jennifer Harrison November 2008 Darryl Bennet May 2009 Diane Langmore May 2009 Helen Jones December 2009 Anne Rand December 2009 Geoffrey Bolton December 2012 John Lack December 2012 Michael Roe December 2012 445 Archives and manuscripts ADB files, Q31, Australian National University Archives, Canberra Theses and unpublished papers Calvert, John. ‘Douglas Pike (1908–1974): South Australian and Australian Historian’ (MA thesis, University of Adelaide, 2008). Thompson, John. ‘Geoffrey Serle and His World: The Making of an Australian Historian’ (PhD thesis, The Australian National University, 2004). [The thesis was reworked into The Patrician and the Bloke: Geoffrey Serle and the Making of Australian History (Canberra: Pandanus Books, 2006).] 447 The ADB's Story Oral history interviews Cunneen, Chris. Interview with Geoffrey Bolton, 1998, TRC 3754, National Library of Australia, Canberra. [Includes a discussion of some of Bolton’s predecessors and contemporaries such as Keith Hancock, Douglas Pike and Geoffrey Serle, as well as the early days of the ADB, and the falling out with Malcolm Ellis.] Foster, Stephen. Interview with L. F. Fitzhardinge, 1992, ANU History Project, ANU Archives, Canberra. Marsden, Susan. Interview with Jill Roe, 2005, TRC 5383, National Library of Australia, Canberra. [Includes a discussion of Jill’s involvement with the ADB as an author, member of the NSW Working Party and chair of the Editorial Board in 1996–2006.] Nolan, Melanie. Interview with Suzanne Edgar, 2012, ADB Archives. Ross, Barbara. Interview with L. F. Fitzhardinge, 1987, TRC 2159, National Library of Australia, Canberra. [Includes a discussion of Laurie’s time working at the ANU, the influence of the ADB’s founder, Keith Hancock, and the launch of the dictionary. Also includes the typescript of an interview of Laurie, by Robin Gollan, about the Biographical Register.] Secondary sources ‘A Job Whose Future Depends on the Past’, Canberra Times (22 December 1971), p. 15. ‘ADB Seeks Charitable Donations from Writers’, Newsletter (Australian Society of Authors), no. 8 (October 1990), Shame file, p. 3. ‘ADB Volume’, ANU Reporter (September 1990), p. 5. ‘Australian Dictionary of Biography’, Australian Foreign Affairs Record, 59, no. 3 (March 1988), pp. 80–1. ‘Australian Dictionary of Biography: Of the People, For the People’, ANU Reporter (April 1988), p. 4. Birman, Wendy. ‘Sandgropers Immortalized: The Australian Dictionary of Biography—a Western Australian’, Early Days [Royal Western Australian Historical Society], 10, part 4 (1992), pp. 378–86. ‘“Bohemian” Breaks Missionary Stereotype’, ANU Reporter (25 March 1983), p. 6. 448 Appendix 5 ‘Boost for Biographical Dictionary’, ANU Reporter (April 1998), p. 2. Brunton, Paul. ‘Mysterious Quotas’, Australian Book Review (February 2006), pp. 19–20. Buchanan, R. A. ‘The British Contribution to Australian Engineering: The Australian Dictionary of Biography Entries’, Historical Studies, 20, no. 80 (1983), pp. 401–19. Bui, Minh. ‘Record of Our Great Finds a Benefactor’, Sydney Morning Herald (25 March 1998), p. 8. ‘Dictionary Staff Honoured’, ANU Reporter (November 2002), p. 2. Edgar, Sue and Campbell, Martha. ‘Obituary: Dictionary was Vocation of Nan Phillips’, ANU Reporter (May 1984), p. 6. Ellis, M. H. ‘History without Facts’, Bulletin (22 September 1962), pp. 36–7. Ellis, M. H. ‘Why I Have Resigned’, Bulletin (15 June 1963), pp. 25–31. Griffin, James. ‘Revisionism or Reality? Daniel Mannix in the Australian Dictionary of Biography’, Tirra Lirra, 6, no. 1 (1995), pp. 18–23. Hefner, Robert. ‘Grant Boosts Work on Biography’, Canberra Times (20 March 1998), p. 5. Hefner, Robert. ‘Volumes of Work in a Long Reign of Editing’, Canberra Times (27 February 2000), p. 36. Langmore, Di. ‘Representing the Nation: The Australian Dictionary of Biography’, NLA News, 11, no. 11 (August 2001), pp. 18–9. Langmore, Di. Response by ADB General Editor to Paul Brunton, Australian Book Review (May 2006), p. 4. Langmore, Di. ‘Eminent Canberrans in Volume 17 of the Australian Dictionary of Biography’, Canberra Historical Journal (August 2008), pp. 13–7. Langmore, Diane. ‘The Australian Dictionary of Biography: A National Asset’, Sydney Papers (Summer 2008), pp. 22–30. Layland, Penelope. ‘Australian Dictionary of Biography: Telling the Story’, National Library of Australia News (September 1993), pp. 4–6. Moore, Andrew. ‘“History without Facts”: M. H. Ellis, Manning Clark and the Origins of the Australian Dictionary of Biography’, Journal of the Royal Australian Historical Society, 85, no. 2 (1999), pp. 71–84. ‘Proud to Have Been Part of Such a Team’, ANU Reporter (26 September 1980), p. 1. Secondary sources 449 The ADB's Story Moyal, Ann. Breakfast with Beaverbrook: Memoirs of an Independent Woman (Sydney: Hale & Iremonger, 1995), pp. 137–47. Mozley, Ann. ‘The Australian Dictionary of Biography’, Historical Studies: Australia and New Zealand, 9, no. 35 (1960), pp. 313–4. Nairn, Bede. ‘The Australian Dictionary of Biography’, Teaching History, no. 17 (February 1967), pp. 5–7. Neale, R. S. ‘The Colonies and Social Mobility: Governors and Executive Councilors in Australia, 1788–1856’, in Class and Ideology in the Nineteenth Century (London: Routledge & Kegan Paul, 1972), pp. 97–120. Nolan, Melanie. ‘Who Deserves to be in the Australian Dictionary of Biography?’, <http://theconversation.edu.au/who-deserves-to-be-in-the-australian- dictionary-of-biography-233> (accessed 14 May 2012). O’Leary, Timothy. ‘Truth, Justice and the ADB Way’, Quadrant (January– February 1991), pp. 75–80. Page, Geoff. ‘A Dictionary of Public Figures’, in Collected Lives (North Ryde, NSW: Angus & Robertson, 1986), p. 1. Pike, D. ‘Making a Biographical Dictionary’, in David Dufty, Grant Harman and Keith Swan (eds), Historians at Work: Investigating and Recreating the Past (Sydney: Hicks Smith & Sons, 1973), pp. 103–9. Pike, Douglas. ‘The Australian Dictionary of Biography’, Business Archives and History, 11, no. 2 (August 1962), pp. 185–6. Pike, Douglas. ‘Historical Biography and Australian Libraries’, Papers [Library Association of Australia 13th Biennial Conference], 2 (1965), pp. 489–92. Pike, Douglas. ‘The Australian Dictionary of Biography’, Hemisphere (November 1966), pp. 8–10. Pike, Douglas. ‘The Commemorative Business’, Scholarly Publishing, 1, no. 4 (1970), pp. 331–46. Pike, Douglas. ‘The Making of a Biographical Dictionary’, Papers and Proceedings [Tasmanian Historical Research Association], 19, no. 4 (1972), pp. 139–46. Powell, Graeme. ‘The Readers of “68”’, NLA News, 12, no. 2 (November 2001), pp. 14–6. [The readers included ADB editorial staff Martha Campbell, Jim Gibbney, Nan Phillips and Keith Hancock.] ‘Proud to Have Been Part of Such a Team’, ANU Reporter (26 September 1980), p. 1. 450 Appendix 5 Rees, Jacqueline. ‘Editor of “Dictionary of Biography” Dies’, Canberra Times (21 May 1974), p. 3. Robson, Lloyd. ‘The A.D.B.: International Precedent and the Australian Experience’, Meanjin, no. 3 (1980), pp. 389–98. Rogers, Glenys. ‘Prime Minister to Launch Latest from ADB’, ANU Reporter (November 1990), p. 3. Rubinstein, William D. ‘Jews in the Australian Dictionary of Biography’, Australian Jewish Historical Society, 29, part 2 (2008), pp. 212–7. Rutledge, M. ‘Australian Dictionary of Biography’, ANU Historical Journal, no. 4 (1967), pp. 71–2. Ryan, Peter. ‘The ADB’, Quadrant (June 2000), pp. 87–8. Simonds, Shelly. Secondary sources ‘Di Langmore Named Deputy General Editor of ADB’, ANU Reporter (November 1996), p. 3. Smith, F. B. ‘Academics In and Out of the Australian Dictionary of Biography’, in F. B. Smith and P. Crichton (eds), Ideas for Histories of Universities in Australia (Canberra: Division of Historical Studies, Research School of Social Sciences, Australian National University, 1990), pp. 1–14. ‘TLS Praises Australian Dictionary of Biography’, ANU Reporter (December 1986), p. 4. Waller, Jean. ‘Four Down—Eight to Go in Mammoth Dictionary Project’, ANU Reporter (10 December 1971), p. 5. Walsh, G. P. ‘The Preparation of a Dictionary Entry: The Case of Colonel Kempt’, R.M.C Historical Journal, 1 (March 1972), pp. 25–30. Walsh, G. P. ‘“One and Two Dimensional Lives”: Writing for the Australian Dictionary of Biography’, Voices: The Quarterly Journal of the National Library of Australia, 5, no. 3 (1995), pp. 92–100. Walsh, Gerald. ‘Recording “the Australian Experience”: Hancock and the Australian Dictionary of Biography’, in D. A. Low (ed.), Keith Hancock: The Legacies of an Historian (Melbourne: Melbourne University Press, 2001), pp. 249–68. 451 The ADB's Story The ADB's Story Reviews of ADB, Volume 1 ‘A for Aaron, First Man In’, Sydney Morning Herald (3 March 1966), p. 4. ‘An Entertaining Dictionary Tells of … the Colonial Mystery that Never Was’, Mercury [Hobart] (26 March 1966), p. 4. Archdall, Don. ‘Lots of Lives—But Not Enough Life?’ Australian (7 May 1966), p. 9. ‘Australian Dictionary of Biography’, Newsletter [Royal Western Australian Historical Society], 5, no. 4 (May 1966), p. 2. ‘Australian Dictionary of Biography’, Royal Historical Society of Queensland Bulletin, no. 239 (April 1966), pp. 2–3. ‘Australian Dictionary of Biography’, Walkabout, 32, no. 7 (July 1966), pp. 50, 52. ‘Australian Dictionary of Biography Takes Shape’, Harvest [Hunter’s Hill, NSW] (July 1966), p. 41. Baker, D. W. A. ‘Australian Dictionary of Biography. Volume 1’, Australian Journal of Science, 30, no. 4 (October 1967), pp. 146–8. ‘Biographical Dictionary Released on Thursday’, Advertiser [Adelaide] (26 February 1966), p. 2. ‘Biographies’, West Australian (16 April 1966), p. 20. ‘Biographies’, West Australian (16 April 1966), p. 20. Birch, Alan. ‘535 “Lives” in Our Early History’, Sydney Morning Herald (19 March 1966), p. 15. Buick, W. G. ‘Whom Was Whom and Why’, Australian Book Review (April 1966), p. 112. de Garis, B. K. ‘Australian Dictionary of Biography’, Critic [Adelaide] (29 April 1966), pp. 19–20. Ellis, M. H. ‘Disaster in Australian Research’, Bulletin (26 March 1966), pp. 48–9. ‘Eminent Australians’, Times Literary Supplement (9 February 1967), p. 109. F. B. S. ‘Australian Dictionary of Biography’, University Gazette [Melbourne], 25, no. 10 (August 1966), p. 10. ‘First Volume in Biographical Series Ready’, Canberra Times (2 March 1966), p. 13. 13. 452 Appendix 5 ‘First Volume of Dictionary of Biography Released in March’, Australian National University News, 3, no. 5 (March 1966), p. 1. F. M. ‘Australian Biographical Dictionary’, Advocate [Melbourne] (24 March 1966), p. 16. Griffin, James. ‘Australian Biographies’, Catholic Worker (June 1966), p. 16. Grattan, C. Hartley. ‘Australian Dictionary of Biography’, Journal of the Royal Australian Historical Society, 52, part 3 (September 1966), pp. 250–3. Hayes, John. ‘Tasmania’s Pioneers—They’re a Mixed Bag’, Examiner [Launceston] (2 April 1966), p. 4. H. H. ‘Australian Dictionary of Biography’, Descent, 3, part 1 (1966), p. 37. J. K. M. ‘Prominent Pioneers Omitted from Biography’, Catholic Weekly (2 June 1966), p. 21. McLachlan, Noel. ‘The Names in Our Past’, Age [Melbourne] (5 March 1966), p. 22. Mant, J. H. ‘Australian Dictionary of Biography’, Australian Quarterly, 28, no. 3 (September 1966), pp. 126–7. Martin, A. W. Reviews of ADB, Volume 1 ‘Australian Dictionary of Biography, Volume I, 1788–1850, A–H’, Historical Studies: Australia & New Zealand, 12, no. 48 (April 1967), pp. 584–6. Morrell, W. P. ‘Australian Dictionary of Biography’, Journal of Pacific History, 2 (1967), pp. 234–5. Moss, Robert. ‘Australians: A to H’, Sydney Morning Herald (3 March 1966), p. 2. ‘Project Biography’, Canberra Times (12 March 1966), p. 11. Robson, L. L. ‘Australian Dictionary of Biography’, Australian Journal of Politics and History, 12, no. 2 (August 1966), pp. 307–9. Stephens, S. W. ‘Biography Project Vast in Scope’, Advertiser [Adelaide] (22 February1966). West, M. Julian. ‘Australian Dictionary of Biography’, Lot’s Wife [Monash University] (3 May 1966), p. 13. Whitelock, Derek. ‘Australian Biography Dictionary’, Northern Daily Leader [Tamworth] (8 October 1966), p. 4. 453 The ADB's Story The ADB's Story Reviews of ADB, Volume 2 ‘Names from the Past’, Age [Melbourne] (11 March 1967), p. 23. Whitelock, Derek. ‘Australian Notables’, Northern Daily Leader [Tamworth] (18 March 1967), p. 4. Wilkes, G. A. ‘“Australian Dictionary of Biography”’, Southerly, no. 3 (1968), pp. 225–6. [review of Volumes 1 and 2] Reviews of ADB, Volume 2 A. F. J. (Francis James). ‘Valuable Work of Reference’, Anglican [Sydney] (6 April 1967), p. 6. Archdall, Don. ‘Biography with Balance’, Australian (25 March 1967), p. 9. ‘Australian Dictionary of Biography’, Ideas Bookseller (April 1967), p. 19. ‘Australian Dictionary of Biography’, Landfall [New Zealand] (March 1967), pp. 108–11. ‘Australian Dictionary of Biography’, Walkabout (June 1967), pp. 41, 45, 46. Blainey, Geoffrey. ‘The Australian Dictionary of Biography’, Papers and Proceedings [Tasmanian Historical Research Association], 15, no. 2 (November 1967), pp. 58–64. [review of Volumes 1 and 2] Brissenden, Alan. ‘Australian Worthies from I to Z’, Advertiser [Adelaide] (6 May 1967), p. 12. ‘Chap Book: Australian Dictionary of Biography’, Times Literary Supplement (28 December 1967), p. 1263. ‘“Dictionary of Biography” Spans 62 Years’, Mercury [Hobart] (18 March 1967), p. 4. Ellis, M. H. ‘Biography Soup’, Bulletin (10 June 1967), p. 82. Farrow, Fergus. ‘More Australian Lives from the Past’, Educational Magazine [Victoria], 24, no. 4 (May 1967), pp. 178–9. Grattan, C. Hartley. ‘Australian Dictionary of Biography’, Journal of the Royal Australian Historical Society, 53, part 4 (December 1967), pp. 353–5. Griffin, James. ‘Australian Biographies’, Catholic Worker (May 1967), p. 16. Hay, John. ‘Biographies’, Courier-Mail [Brisbane] (11 March 1967), p. 2. Hayes, John. ‘Pageant of Colourful Characters’, Examiner [Launceston] (4 March 1967), p. 4. Hoffman, J. E. ‘Risks and Plunges in a Fragile World’, Herald [Melbourne] (7 March 1967), p. 26. J. A. M. ‘Australian Biographical Dictionary Progresses’, Catholic Weekly (27 April 1967), p. 21. 454 Appendix 5 J. B. W. ‘Australian Dictionary of Biography’, Gazette (University of Melbourne) (May 1967), pp. 15–6. J. H. ‘The Australian Dictionary of Biography’, Early Days [Royal Western Australian Historical Society], 6, part 6 (1967), pp. 85–7. Johnston, George. ‘Early Australia—From I to Z’, Sydney Morning Herald (18 March 1967), p. 16. Jones, Barry O. ‘Return to Pike’s Peak—Australian Dictionary of Biography’, Secondary Teacher (May 1967), p. 29. Martin, A. W. ‘Australian Dictionary of Biography, vol. II, 1788–1850, I–Z’, Historical Studies of Australia & New Zealand, 13, no. 49 (October 1967), pp. 132–3. Murray-Smith, S. ‘Fathers that Begat Us’, Overland, no. 36 (May 1967), pp. 42–3. M. W. ‘Australian Dictionary of Biography’, Australian Left Review, no. 3 (June– July 1967), pp. 69–70. ‘Pike’s Own Time’, Canberra Times (20 March 1967), p. 3. Robson, L. L. ‘Australian Dictionary of Biography’, Historian [Journal of the Victorian Historical Association], no. 15 (April 1967), p. 21. Sayers, Stuart. Reviews of ADB, Volume 3 ‘Australian Biographies’, West Australian (24 May 1969), p. 20. ‘Australian Dictionary of Biography’, Harvest [Hunter’s Hill, NSW] (June 1969), pp. 42–3. ‘Australian Dictionary of Biography’, Teaching History, 3, part 2 (September 1969). ‘Big-Hearted Bloke Book’, Times Literary Supplement (11 June 1970), p. 643. Blainey, Geoffrey. ‘Australian Dictionary of Biography’, Historical Studies, 14, no. 53 (October 1969), pp. 102–4. 455 The ADB's Story Coleman, Peter. ‘Brute Scholarship’, Bulletin (5 July 1969), pp. 44–5. de Garis, B. K. ‘Australian Dictionary of Biography’, Australian Journal of Politics and History, 15, no. 3 (1969), pp. 153–4. Dickey, Brian. ‘Taking Stock of Who’s Who’, Advertiser [Adelaide] (26 April 1969), p. 16. F. M. ‘Dictionary of Biography’, Advocate [Melbourne] (8 May 1969), p. 18. ‘Great Men of Australia from 1851 to 1890’, Rockhampton Morning Bulletin (26 June 1969). Hayes, John. ‘It Took All Sorts to Build a Colony’, Examiner [Launceston] (7 June 1969), p. 7. Hergenham, L. T. ‘Australian Dictionary of Biography’, Australian Literary Studies, 4, no. 2 (1969), pp. 198–9. Hicks, Neville. ‘From Archibald to Harriet Jemima Clisby’, Australian (26 April 1969), p. 17. J. I. M. ‘Australian Biography has a Place in its Pages for Frauds’, Daily Examiner [Grafton] (12 May 1969), p. 10. J. M. ‘Biographies of Early Settlers’, Catholic Weekly (1 May 1969), p. 21. Johnson, Fay. ‘Australian Biographies Continued’, Educational Magazine, 26, no. 7 (August 1969), pp. 334–6. Jones, Barry. ‘Australian Dictionary of Biography’, Secondary Teacher, no. 148 (August 1969), pp. 32–3. ‘Little Tommy Corrigan’, Telegraph [Sydney] (31 May 1969), p. 14. ‘Odd People Just Pop Up Unexpectedly’, South Pacific Post [Port Moresby] (6 June 1969), p. 34. P. J. C. ‘Australian Dictionary of Biography’, Australian School Librarian (October 1969), p. 41. Preston, Yvonne. ‘Of Australians and their Economic Origins’, Australian Financial Review (4 July 1969), p. 25. Sayers, Stuart. ‘Brief Life Stories’, Age [Melbourne] (19 April 1969), p. 11. Tebbutt, Geoffrey. ‘Yes, We had an Indian Orangeman’, Herald [Melbourne] (27 May 1969), p. 23. 456 Appendix 5 Waldersee, James. Book review, Journal of the Royal Australian Historical Society, 57, part 2 (1971), pp. 182–5. Reviews of ADB, Volume 4 ‘A Memory for “Only 500”’, ANU Reporter (25 August 1972), p. 3. Benson, Irving. ‘The Grave and the Gay’, Herald [Melbourne], 6 February 1973, p. 22. Blainey, Geoffrey. ‘Australian Dictionary of Biography’, Gazette [University of Melbourne], 29, no. 2 (June 1973), p. 16. Cannon, Michael. ‘Australian Dictionary of Biography’, Age [Melbourne] (2 September 1972), p. 14. Coleman, Peter. ‘A Fruit of Federation’, Bulletin (18 November 1972), p. 58. Costigan, Michael. ‘Australian Dictionary of Biography’, Sunday Review [Melbourne] (2 September 1972). Dickey, Brian. ‘Luminaries and Rogues’, Advertiser [Adelaide] (14 October 1972), p. 20. Evans, Lloyd. Book review, Historian (Journal of the Victorian Historical Association), no. 25 (October 1973), pp. 79–80. Grattan, C. Hartley. ‘Australian Dictionary of Biography’, Historical Studies, 15, no. 61 (October 1973), pp. 780–1. Jones, Barry. ‘Australian Dictionary of Biography’, Secondary Teacher, no. 181 (November–December 1972), p. 23. Lack, John. ‘Australian Dictionary of Biography’, Monash Reporter (11 October 1972), p. 6. Molony, John N. ‘Australian Dictionary of Biography’, RMC Historical Journal, 2 (1973), pp. 56–8. ‘New Volume for Biography Dictionary’, Harvest [Hunter’s Hill, NSW], no. 1 (January–February 1973), p. 31. Selth, P. A. ‘An Invaluable Asset: The Australian Dictionary of Biography’, Canberra Historical Journal (March 1974), p. 71. 457 The ADB's Story Reviews of ADB, Volume 5 Aitkin, Don. ‘Words in Print are the Bones of Ghosts that Haunt You’, National Times (6–11 September 1976), p. 28. ‘Aussie Myth not Dinkum’, Sunday Mail [Adelaide] (9 November 1975), p. 33. ‘Australian Dictionary of Biography’, Newsletter [Royal Western Australian Historical Society], 13, no. 10 (November–December 1974), pp. 6–7. Baker, D. W. A. ‘More Lives in Brief’, Canberra Times (18 October 1974), p. 13. Dickey, Brian. ‘Respect and Roguery’, Advertiser [Adelaide] (31 May 1975), p. 28. Dugan, Dennis. ‘The Nation Builders from K to Q’, Age [Melbourne] (21 September 1974), p. 17. Grattan, C. Hartley. ‘Australian Dictionary of Biography’, Historical Studies, 16, no. 64 (April 1975), pp. 462–4. Robson, L. L. ‘Australian Dictionary of Biography’, Gazette [University of Melbourne], 30, no. 5 (December 1974), pp. 11–2. Selth, D. V. ‘Australian Dictionary of Biography’, Canberra Historical Journal (March 1976), pp. 37–8. Start, Kenneth B. ‘Australian Dictionary of Biography’, Gazette [University of Melbourne], 30, no. 5 (December 1974), pp. 11–2. Thompson, Roger C. ‘Australian Dictionary of Biography’, RMC Historical Journal, 4 (1975), pp. 43–6. Reviews of ADB, Volume 6 Adams, Ted. ‘“Monumental”—A Just Claim’, Advocate [Melbourne] (14 April 1977), p. 15. Cannon, Michael. ‘Those Who Shaped Our Early History’, Age [Melbourne] (30 October 1976), ‘Books’, p. 19. Cockburn, Stewart. ‘History—Warts and All’, Advertiser [Adelaide] (15 October 1976), p. 7. Featherstone, Guy. ‘Australian Dictionary of Biography’, Victorian Historical Journal, 49, no. 4 (November 1978), pp. 240–1. 458 Appendix 5 Hoffman, John. ‘The Italians were Coming’, Herald [Melbourne] (19 October 1976), p. 25. Jones, Barry. ‘Half Way Point’, Overland, no. 66 (1977), pp. 71–2. L. T. H. ‘Australian Dictionary of Biography’, Australian Literary Studies, 8, no. 1 (May 1977), pp. 108–9. McLachlan, N. D. ‘Australia to 1890: The Dictionary of Biography’, Historical Studies, 18 (October 1978), pp. 339–44. McQueen, Humphrey. ‘The RSSS Estate’, Nation Review (13–19 January 1977), p. 309. Rappolt, Patricia. ‘Encapsulating Biographies’, Canberra Times (16 October 1976), p. 10. R. C. B. ‘Frame Refired’, Mercury [Hobart] (13 November 1976), p. 6. Ruhen, Olaf. ‘The Famous from A to Zox’, Australian (24 November 1976), p. 10. Souter, Gavin. ‘The Best Lives of Our Years’, Sydney Morning Herald (16 October 1976), ‘Weekend Magazine’, p. 13; and West Australian (27 November 1976), ‘Magazine’, p. 35. Townsend, Norma. ‘Australian Dictionary of Biography’, Canberra Historical Journal (March 1977), pp. 23–4. Whitington, Don. ‘Book Review’, Riverine Herald [Echuca] (14 March 1977), p. 6. Reviews of ADB, Volume 7 Blake, Les. ‘Australian Dictionary of Biography’, 151, no.2, Victorian Historical Journal (May 1980), pp. 115–6. Cannon, Michael. ‘Famous Australians Who Left Too Soon’, Age [Melbourne] (28 July 1979), p. 25; and Newcastle Morning Herald (11 August 1979), p. 6. Carnell, Ian. ‘Australian Dictionary of Biography’, Canberra Historical Journal, no. 5 (March 1980), pp. 38–9. Davies, Chris Lawe. ‘The Book Column’, Chronicle [Adelaide] (10 October 1979). Dickey, Brian. ‘Collection with Character’, Advertiser [Adelaide] (25 August 1979), p. 25. Frizell, Helen. ‘Dictionary of Gossip’, Sydney Morning Herald (28 July 1979), p. 17. 17. 459 The ADB's Story Hawken, Noel. ‘Doctor’s Strange Mixture’, Herald [Melbourne] (31 July 1979), p. 22. Kenny, John. ‘A Gift from God to a Biographer’, Bulletin (21 August 1979), pp. 83-4. McQueen, Humphrey. ‘Flourishing in War and Strife’, National Times (6 October 1979), p. 54. Mansfield, Bruce. ‘Australian Dictionary of Biography’, Historical Studies, 19, no. 75 (October 1980), pp. 296–8. Petersen, J. ‘Facts on Noted People’, Advocate [Melbourne] (30 August 1979), p. 16. Roderick, Colin. ‘A Rich Prize’, Townsville Daily Bulletin (24 October 1979), p. 8. Ward, Peter. ‘Who Was Who in Australia?’ Australian (8–9 September 1979), ‘Mag’, p. 10. Watson, Don. ‘Everything but the Warts’, Australian Book Review (April 1980), p. 11. Reviews of ADB, Volume 9 Dickey, Brian. ‘Greats and Others Worth Knowing’, Advertiser [Adelaide] (26 November 1983), p. 32. Harris, John. ‘Two to Pore Over. Australian Dictionary of Biography’, Daily Sun [Brisbane] (8 October 1983). Jones, Barry. ‘The Naming of Names’, Overland, no. 96 (September 1984), pp. 69–70. Macintyre, Stuart. ‘A Monumental Series Marches On’, Age [Melbourne] (1 October 1983), ‘Books’, p. 18. Main, J. ‘Australian Dictionary of Biography’, Historical Studies, 21, no. 83 (October 1984), pp. 300–1. Millar, T. B. ‘People in Australia’s History’, Canberra Times (4 August 1984), p. 16. Rennick, Elizabeth. ‘A Chunk of History in 678 Portraits’, Advocate [Melbourne] (26 January 1984), p. 14. Ward, Leonard. ‘Australian Dictionary of Biography’, Canberra Historical Journal, [NS] no. 13 (March 1984), pp. 35, 46. Waterson, Duncan. ‘Anzac Dominates Biographical Visit to “Old Australia”’, Australian (5–6 November 1983), ‘Mag’, p. 19. Reviews of ADB, Volume 8 Cannon, Michael. ‘Rogues and Notables from Australia’s Past’, Age [Melbourne] (19 September 1981), p. 31. Corris, Peter. ‘Insight into Years of Great Adventure’, National Times (11–17 October 1981), p. 41. Jones, Barry. ‘Disappointing Crop’, Overland, no. 88 (July 1982), pp. 61–2. McDonald, D. I. ‘Australian Dictionary of Biography’, Canberra Historical Journal (March 1982), pp. 36–7. Pringle, John Douglas. ‘English Lives are More Interesting’, Sydney Morning Herald (8 May 1982), ‘Good Weekend’, p. 45. Robson, L. L. ‘Australian Dictionary of Biography’, Historical Studies, 20, no. 78 (April 1982), pp. 117–9. Sprod, Dan. ‘Australian Dictionary of Biography’, Papers and Proceedings [Tasmanian Historical Research Association], 29, no. 1 (March 1982), p. 34. ‘Valuable Reference and Research on Australians’, Catholic Advocate [Melbourne] (8 October 1981), p. 14. 460 Appendix 5 Ward, Peter. ‘Another 672 Who Shaped the Nation’, Australian (9–10 January 1982), ‘Mag’, p. 9. Reviews of ADB, Volume 10 Campion, Edmund. ‘The Judges and Jokers of the ADB’, Bulletin (29 July 1986), pp. 86–7. Childs, Kevin. ‘The Alliterative Elect’, Australian Book Review (December 1986 – January 1987), pp. 20–1. Davenport-Jones, Richard. ‘All Sorts and Condition’, Times Literary Supplement (14 November 1986), p. 1263. Dugan, Dennis. ‘Australian Dictionary of Biography’, Victorian Historical Journal, 58, no. 2 (June 1987), pp. 43, 45. 461 The ADB's Story Else-Mitchell, R. Book review, Canberra Historical Journal (September 1986), p. 19. Fewster, Alan. ‘Glimpses of History in an Adventurous Tome’, Australian (23 July 1986), p. 18. Jones, Barry. ‘Mannix, Monash and a Cast of Hundreds’, Overland, no. 106 (1987), pp. 72–3. Macintyre, Stuart. ‘Eminent Australian Heroes and Eccentrics’, Age [Melbourne] (26 July 1986), ‘Saturday Extra’, p. 10. McQueen, Humphrey. ‘Typical Bloody Aussies, and their Women’, National Times on Sunday (17 August 1986), ‘Books’, p. 34. O’Leary, Timothy. ‘Daniel Mannix: The Dictionary of Biography’s Hatchet Job’, AD2000: A Journal of Religious Opinion (April 1988), pp. 12, 13. Roderick, Colin. ‘Australia’s (Mostly) Notables’, Courier-Mail [Brisbane] (16 May 1987), ‘Books’, p. 7. York, Barry. ‘Makers of Australia’, Canberra Times (13 September 1986), p. B3. Reviews of ADB, Volume 11 Clarke, Patricia. Book review, Canberra Historical Journal, no. 23 (March 1989), pp. 49-50. Dickey, Brian. ‘Spectrum of Life Preferred to Stories of Derring-Do’, Advertiser [Adelaide] (26 November 1988), ‘Books’, p. 7. Dutton, Geoffrey. ‘Wonderful Windows to a Variety of Lives’, Sydney Morning Herald (26 November 1988), p. 90. Duyker, Edward. ‘Australian Dictionary of Biography’, Quarterly Bulletin [Sutherland Shire Historical Society], no. 67 (February 1989), pp. 424–5. Jones, Barry. ‘A Salute to Geoff Serle’, Overland, no. 114 (1989), pp. 89–90. Kizilos, Kathy. ‘Variety of Human Experience’, Herald [Melbourne] (28 October 1988), p. 16. Murray-Smith, Stephen. ‘Australian Dictionary of Biography’, Australian Historical Studies, 23, no. 91 (October 1988), pp. 206–7. York, Barry. ‘Keeping “Egalitarianism” Alive’, Canberra Times (12 November 1988), ‘Magazine: Books’, p. B4. 462 Appendix 5 Reviews of ADB, Volume 12 Campion, Edmund. ‘Greats and Not-So-Greats’, Bulletin (13 November 1990), p. 126. Campion, Edmund. ‘Greats and Not-So-Greats’, Bulletin (13 November 1990), p. 126. Connolly, Anne. ‘Looking Back from Here to Eternity’, Australian (6 November 1990), p. 9. Corris, Peter. ‘Eternally Yours, A. M. Stace’, Australian (3 November 1990), ‘Review’, p. 6. Duyker, Edward. ‘Australian Dictionary of Biography’. Quarterly Bulletin [Sutherland Shire Historical Society], no. 75 (February 1991), p. 633. Fitzgerald, Ross. ‘First-Class Glimpse of Remarkable Lives’, Age [Melbourne] (17 November 1990), ‘Extra: Books’, p. 8. Hasluck, Paul. ‘Milestone in Truly National Project’, Canberra Bulletin of Public Administration, no. 64 (May 1991), pp. 73–4. Hill, Robin. ‘Australians Bound’, Sydney Morning Herald (6 October 1990), ‘Books’, p. 78. Jones, Barry. ‘The End of the Beginning’, Overland, no. 122 (Autumn, 1991), pp. 67–9. Jones, Helen. ‘Beyond Who’s Who’, Advertiser [Adelaide] (10 November 1990), ‘People’, p. 16. MacCulloch, Jennifer. Book review, Culture and Policy, 3, no. 2 (1991), pp. 121– 5. Robinson, T. J. Book review, Journal of the Royal Australian Historical Association, 77, part 1 (June 1991), p. 69. Shields, John. ‘Australian Dictionary of Biography’, Labour History, no. 60 (May 1991), pp. 141–3. Spate, Oscar. ‘All Sorts and Conditions’, Canberra Times (3 November 1990), p. B5. Walker, David. ‘Australian Dictionary of Biography’, Australian Historical Studies, 25 (April 1992), pp. 130–1. 463 The ADB's Story Reviews of ADB, Volume 13 Barrett, John. ‘Australian Dictionary of Biography’, Journal of the Royal Historical Society of Victoria, 65, no. 1 (June 1994), pp. 64–5. Blainey, Geoffrey. ‘Lives of the Rich and Famous’, Age [Melbourne] (5 December 1993), p. 7. Campion, Edmund. ‘ABC of Australian Lives’, Bulletin (30 November 1993), p. 105. Corris, Peter. ‘Mean-Spirited’, Letter to the editor, Australian (18–19 December 1993), p. 16. Craven, Peter. ‘Pitched at Cricket Fans’, Australian (22 December 1993), p. 14. Cutlack, Marianne. ‘Too Many Allowed into the Club’, Australian (11–12 December 1993), ‘Review’, p. 6. Fogarty, Michael. ‘Australian Dictionary of Biography’, Journal of the Australian Naval Institute, 20, no. 3 (August–October 1994), pp. 63–4. Frappell, Ruth. ‘The Australian Dictionary of Biography: Very Readable’, History (December 1994), pp. 18–9. Jones, Barry. ‘A New Beginning’, Overland, no. 136 (1994), pp. 80–2. Lucas, Robin. ‘ABC of Australian Lives’, Bulletin (30 November 1993), p. 105. McClelland, Jim. ‘A Face that Launched a Thousand (er, 670) Obits’, Sydney Morning Herald (27 November 1993), p. 30. ‘Ordinary Lives Extolled’, Sydney Morning Herald (6 November 1993), ‘Good Weekend Magazine’, p. 7. Price, Barry. ‘Australian Dictionary of Biography, Volume 13, 1940–1980: A–De’, Canberra Historical Journal, no. 33 (March 1994), p. 40. Ritchie, John. ‘Not Guilty of Omission’, Letter to the editor, Australian (12 January 1994), ‘Higher Education Supplement’, p. 16. Roderick, Colin. ‘From Barmaids to Bishops’, Townsville Bulletin (21 January 1994), p. 24. Rolfe, Patricia. ‘Dictionary of Our National Soul’, Bulletin (24 August 1993), p. 90. Snape, Robyn. ‘The Australian Dictionary of Biography’, National Historic Racing Register Newsletter, no. 137 (1 October 1994), p. 2. 464 Appendix 5 Walter, James. ‘Australian Dictionary of Biography’, Australian Historical Studies, 26, no. 104 (April 1995), pp. 487–9. Warden, Ian. ‘The Great and the Small’, Canberra Times (9 December 1993), ‘Capital Letter’, p. 10. Webby, Elizabeth. ‘People Who Made a Nation’, Sydney Morning Herald (4 December 1993), ‘Spectrum’, p. 10A. York, Barry. ‘Motley Mosaic of Native Sons’, Canberra Times (11 December 1993), p. C14. Reviews of ADB CD-ROM Carlyle, Diane and Nick Walker. ‘Hot off the Academic Press’, Australian (7 May 1997), ‘Higher Education Supplement’, p. 38. Dunlevy, Maurice. ‘7000 Australians at Your Fingertips’, Canberra Times (22 February 1997), p. C11. Morris, Deirdre. ‘Australian Dictionary of Biography CD-ROM’, Guide to New Australian Books, 7, no. 2 (March 1997), p. 63. Morton, Richard. ‘Australian Dictionary of Biography CD-ROM’, Rostrum [Carlton], 15, no. 2 (April 1997), pp. 22–4. Stephens, Laraine. ‘Australian Dictionary of Biography CD-ROM’, Orana, 33, no. 3 (August 1997), p. 164. ‘Biographies Strike Balance’, Townsville Bulletin (14 December 1996). ‘Biographies Strike Balance’, Townsville Bulletin (14 December 1996). Blainey, Geoffrey. ‘Men with a Mission’, Australian’s Review of Books (March 1997), pp. 26–7. Bridge, Carl. ‘Good Blokes and Others’, Times Literary Supplement (16 October 1998), p. 10. Campion, Edmund. ‘Riches Galore in Illuminating Profile’, Bulletin (5 November 1996), pp. 86-7. Coleman, Peter. ‘The Book of Life’, Sydney Morning Herald (1 March 1997), ‘Spectrum’, p. 10. Craven, Peter. ‘Prominent and Notorious’, Australian (2 October 1996), p. 33. 465 The ADB's Story Crawford, Wayne. ‘Home-Town Hero’, Mercury [Hobart] (4 November 1996), pp. 29, 34. Dunlevy, Maurice. ‘Portrait of a Population: The Latest Instalment’, Canberra Times (12 October 1996). Hyslop, Robert. ‘Australian Dictionary of Biography’, Canberra Historical Journal, no. 42 (September 1998), p. 41. McCaughey, Davis. ‘Australian Dictionary of Biography’, Australian Historical Studies, no. 111 (October 1998), pp. 390–1. McCooey, David. ‘A Great Australian Institution’, Age [Melbourne] (25 January 1997), ‘Books’, p. 8. Maloney, Shane. ‘Bringing the Dead Back to Life’, Age [Melbourne] (6 October 1996), p. 7. Roe, Jill. ‘Never-Ending Job’, Letter to the editor, Bulletin (15 June 1999), p. 10. Sheehan, Martin. ‘An Optimistic Era’, News Weekly (28 June 1997), pp. 20–1. Reviews of ADB, Volume 15 ‘Australian History’, Australian (5 April 2000), ‘Higher Education Supplement’, p. 36. Campion, Edmund. ‘The Where and Why of Who’, Bulletin (30 May 2000), p. 101. Capp, Geraldine. ‘Personal Mosaics of Our National Picture’, West Australian (14 April 2000), p. 35. Cappello, Anthony. ‘History’s Passions, Prejudices’, News Weekly (12 August 2000), p. 20. Carmody, John. Response to Peter Coleman, Australian (29–30 April 2000), p. 18. Coleman, Peter. ‘Lives that Made the Cut’, Australian (22–23 April 2000), ‘Books’, p. 11. Coleman, Peter. Response to John Carmody, Australian (29–30 April 2000), p. 18. Crawford, Wayne. ‘Mosaic of Australia’, Sunday Tasmanian (19 November 2000), Coleman, Peter. Response to John Carmody, Australian (29–30 April 2000), p. 18. Crawford, Wayne. ‘Mosaic of Australia’, Sunday Tasmanian (19 November 2000), p. 17. 466 Appendix 5 Hoyle, Arthur. ‘Australian Dictionary of Biography’, Canberra Historical Journal, no. 46 (September 2000), pp. 36–7. Jones, Philip. ‘Extraordinary People’, Sydney Morning Herald (30 September 2000), ‘Spectrum’, p. 5. McGinness, Mark. ‘From Pollies to Piemen’, Courier-Mail [Brisbane] (29 April 2000), ‘Weekend’, p. 7. McGinness, Mark. ‘Books of the Year’, Australian (9–10 December 2000), ‘Review’, p. 12. Moran, Rod. ‘Who’s Youse’, West Australian (27 May 2000), ‘Big Weekend’, p. 7. Ryan, Lyndall. ‘Australian Dictionary of Biography’, Australian Historical Studies, 32, no. 116 (April 2001), pp. 153–4. Thomas, Mark. ‘Revisiting the Lives of 682 Australians’, Canberra Times (20 May 2000), ‘Panorama’, p. 24. Wallace-Crabbe, Chris. ‘Black Jack to Slim Jim’, Age [Melbourne] (1 July 2000), p. 8. Reviews of ADB, Volume 16 ‘Australian Biography’, Australian (6 November 2002), p. 26. ‘Australian Dictionary of Biography’, Age [Melbourne] (18 January 2003), p. 8. Griffin, James. ‘Bio-Picks’, Eureka Street, 13, no. 2 (March 2003), pp. 45–7. Jory, Rex. ‘History’s Cool Gaze Plays No Favourites’, Advertiser [Adelaide] (13 November 2002), p. 22. Moyal, Ann. ‘Remarkable Cavalcade of Australians’, Canberra Times (23 November 2002), ‘Panorama’, p. 16. O’Brien, Anne. ‘Australian Dictionary of Biography’, Australian Historical Studies, 35, no. 123 (April 2004), pp. 181–2. Reviews of ADB, Volume 17 Christie, David. ‘Australian Dictionary of Biography’, Newcastle Herald (9 February 2008), ‘Weekender’, p. 31. Davidson, Jim. ‘History is Catching up with Us’, Age [Melbourne] (19 January 2008), p. 19. Forsyth, Holly Kerr. ‘Gifts that Give Again’, Australian (8–9 December 2007), p. 64. Glover, Dennis. ‘Grasping our National Evolution through History Makers’, Australian (2 February 2008), p. 12. Pickering, Paul. ‘Australian Dictionary of Biography’, Labour History, no. 95 (November 2008), pp. 271–3. Wilks, Stephen. ‘Dictionary Speaks Volumes of Our History’, Canberra Times (8 December 2007), ‘Panorama’, p. 15. Reviews of ADB supplement volume Davidson, Jim. ‘Lest We Forget’, Age [Melbourne] (14 January 2006), p. 19. Forsyth, Holly Kerr. ‘Planting Some Gift Ideas’, Australian (17–18 December 2005), p. 56. 467 The ADB's Story Hope, Deborah. ‘Missing Persons’, Australian (29 September 2001), ‘Books’, pp. 2-3. Moran, Rod. ‘A Definitive Look at the Past’, West Australian (14 January 2006), ‘Weekend Extra’, p. 7. Stephens, Tony. ‘Recognition at Last for Mad Dan and Granny’, Age [Melbourne] (3 December 2005), p. 3. Review of ADB, Volume 18 McGinness, Mark. ‘The Aussie Experience’, Canberra Times (13 July 2013), ‘Panorama’, p. 23. Millmow, Alex. ‘Canberrans Who Steered the Course of Australia’, Canberra Times (4 December 2012), p. 11. 468 American Council of Learned Societies 36, 65 American Council of Learned Societies 36, 65 ADB Volume 2 (1967) 26, 32, 35, 44, 61, 69, 80-83, 90, 99, 116, American National Biography (ANB) 11- 12, 36, 52, 65, 108, 109, 140, 178, 192, 312, 313, 316, 318, 319, 345, 346, 364, 366, 368, 369 117, 133, 144, 169, 213, 252, 273, 282, 299, 302, 315, 316, 192, 312, 313, 316, 318, 319, 345, 318, 322-327, 337, 339, 398, 399, 346, 364, 366, 368, 369 412-14, 454-55 ADB Volume 3 (1969) 26, 29, 32, Andrews, Barry G. 172, 228, 422, 424, 425, 427 44, 70, 71, 116, 117, 128, 134, 140, 169, 219, 273, 295, 319, 321, Angas, George Fife 113, 213 Angas, George Fife 113, 213 337, 339, 399, 414-15, 455-57 Angus & Robertson 65, 67, 90, 95, 97 ADB Volume 4 (1972) 26, 29, 116 117 134 169 218 219 2 ADB Volume 4 (1972) 26, 29, anonymous or unsigned articles 113, 299, 328, 333 116, 117, 134, 169, 218, 219, 246, 337, 339, 380, 399, 415-17, 457 Ansett, Reginald 186 ADB Volume 5 (1974) 26, 29, Arabanoo 317 116, 118, 119, 134, 140, 169, 219, Archer, Joseph 271 303, 337, 340, 399, 417-18, 458 Armed Forces Working Party see working parties Allgemeine Deutsche Biographie 7 411-12, 452-53 Abbreviations ADB Australian Dictionary of Biography ADBA ADB Archives, ANU Archives AHS Australian Historical Studies ANUA The Australian National University Archives, ANU ANU The Australian National University ANB American National Biography b. born BR Biographical Register CDB Canadian Dictionary of Biography CASS College of Arts and Social Sciences, ANU DNB Dictionary of National Biography DNZB Dictionary of New Zealand Biography IAS Institute of Advanced Studies NCB National Centre of Biography NLA National Library of Australia NSW New South Wales OA Obituaries Australia OUP Oxford University Press ODNB Oxford Dictionary of National Biography RSSS Research School of Social Sciences RSPS Research School of Pacific Studies ADB Australian Dictionary of Biography ADBA ADB Archives, ANU Archives AHS Australian Historical Studies ANUA The Australian National University Archives, ANU ANU The Australian National University ANB American National Biography b. born BR Biographical Register CDB Canadian Dictionary of Biography CASS College of Arts and Social Sciences, ANU DNB Dictionary of National Biography DNZB Dictionary of New Zealand Biography IAS Institute of Advanced Studies NCB National Centre of Biography NLA National Library of Australia NSW New South Wales OA Obituaries Australia OUP Oxford University Press ODNB Oxford Dictionary of National Biography RSSS Research School of Social Sciences RSPS Research School of Pacific Studies 469 (ANZAAS) 37, 50 Australian Defence Force Academy, NSW, Canberra 261 see also Royal Military College, Duntroon addenda and revision 376 adjectives and verbs in the ADB 110, 134, 319, 333 adjectives and verbs in the ADB 110, Armed Forces Working Party see working parties ADB Volume 6 (1976) 26, 29, 109, 116, 118, 134, 136, 138, 140, 169, Index Auchmuty, James 57, 59, 67, 72, 301, 411, 412, 414, 416, 417, 419 Austin, C. G. 412, 413, 415 Austin, Maurice (Bunny) 136, 242-43, 403, 419, 421, 422, 424, 425 Abbott, Graham 412, 415, 416 Australasian Pioneers Club 63 Abdullah, George 186 Australian and New Zealand Association for the Advancement of Science (ANZAAS) 37, 50 Aborigines 23, 24, 25-26, 170, 186, 244- 45, 282, 291, 306, 308, 317, 332 see also working parties, Indigenous Allan, James Thomas 256 99, 110, 111, 113, 115, 117, 133, Allen, George 95 162, 169, 213, 252, 271, 273, 282, Allen, George Wigram 95, 128 299, 302, 307, 315, 318, 322-327, Allen, Margaret 437, 438, 440 337, 339, 375, 376, 398, 399, Allgemeine Deutsche Biographie 7 Duntroon Australian Dictionary of Biography (ADB) ADB, old Canberra Hospital building 10, 54, 56, 249-50, 397 ADB, Coombs Building 171, 275,389 ADB Volume 1 (1966) 24, 26, 32, Adler, Louise 97, 287 see also Melbourne University Press Aitken, John 317 Aitken, John 317 ADB, Coombs Building 171, 275,389 Aitkin, Don 277, 425, 427, 458 ADB Volume 1 (1966) 24, 26, 32, Alafaci, Annette 197 35, 44, 61, 63, 69, 75, 79-80, 90, Allan, James Thomas 256 see also ADB Archives ADB General Editor see General Editor, 162, 169, 175, 304, 337, 342, 400, see also endowment ADB entries see unsigned ADB entries ADB Volume 12 (1990) 26, 162, 176, 219, 223, 337, 341, 384, g ADB files 1, 164, 166, 185, 209, 242, 269- i 70, 380, 389, 407, 447 ADB Volume 13 (1993) 26, 29, Australian National Bibliographic Database (ANBD) 198-99 ADB Volume 18 (2012) 26, 179, Australian National University (ANU) 5, 10, 12, 13, 17, 20, 31, 32, 54, 57, 59, 60, 62, 65, 68, 88, 92, 93, 101, 111, 115, 116, 119, 125, 128, 134, 150, 155, 157, 167, 168, 169, 170, 171, 176, 178, 181, 183, 188, 190, 193, 195, 196, 197, 200, 201, 205, 216, 225 236, 240, 244, 249, 273, 275, 277, 278, 280 281, 282, 283, 285, 286, 287, 288, 289, 290, 291, 292, 380, 384, 387, 397, 398, 399, 400 ADB index, Volumes 1 to 12 (1788-1939), (1991) 287, 338, 342, 384, 400 150, 155, 157, 167, 168, 169, 170, 171, 176, 178, 181, 183, 188, 190, ADB CD-Rom 29, 162, 181, 196, 226, 287, 289, 374, 385-87, 401, 465 parties Arnold, John 435, 437, 439, 440 219, 223, 301, 337, 340, 374, 399, 418 20 458 59 219, 223, 301, 337, 340, 374, 399, Arthur, George 99 418-20, 458-59 Arthur, Paul 3, 203, 379, 390, 403, 406, 439 ADB Volume 7 (1979) 26, 29,140, 146, 176, 219, 227, 304, 337, 340, 420-22, 459-60 Arundel, George 32, 295 Attwood, Bain 440 471 The ADB's Story 's Story ADB Volume 8 (1981) 26, 146, 176, 219, 223, 340, 400, 422-423, 460-61 ADB Volume 9 (1983) 26, 146, 176, 219, 223, 329-331, 337, 341, 400, 423-25, 461 ADB Volume 10 (1986) 23, 26, 42-45, 144, 146, 176, 219, 223, 278, 285, 425-26, 461-62 ADB Volume 11 (1988) 26, 140, 146, 162, 176, 219, 221, 223, 305, 337 341, 400, 426-28, 462 ADB Volume 12 (1990) 26, 162, 176, 219, 223, 337, 341, 384, 400, 428-29, 463 ADB Volume 13 (1993) 26, 29, 162, 169, 175, 304, 337, 342, 400, 430-31, 464-65 ADB Volume 14 (1996) 24, 26, 162, 169, 307, 312, 342, 400, 431-32, 465-66 ADB Volume 15 (2000) 26 144, 162, 309, 337, 343, 401, 433-34, 466-67 ADB Volume 16 (2002) 26, 162, 183, 185, 244, 317, 337, 343, 401, 434-36, 467 ADB supplement (2005) 3, 26, 147, 185, 224, 225, 226, 231, 232, 236, 257, 273, 290-91, 294, 295, 305-06, 308, 338, 343, 390, 401, 436-37, 467-68 ADB Volume 17 (2007) 26, 145, 170, 183, 185, 186, 244, 292, 304, 306, 310, 317, 337, 343, 401, 437-39, 468 ADB Volume 18 (2012) 26, 179, 183, 188, 311, 332-33, 338, 343, 383, 402, 439-41, 468 ADB index, Volumes 1 to 12 (1788-1939), (1991) 287, 338, 342, 384, 400 ADB CD-Rom 29, 162, 181, 196, 226, 287, 289, 374, 385-87, 401, 465 ADB preface 278 rchives 1, 15, 68, 209, 389, 407, 447 uthors see authors ADB ADB Volume 8 (1981) 26, 146, 176, 219, 223, 340, 400, 422-423, 460-61 ADB Volume 9 (1983) 26, 146, 176, 219, 223, 329-331, 337, 341, 400, 423-25, 461 ADB Volume 10 (1986) 23, 26, 42-45, 144, 146, 176, 219, 223, 278, 285, 425-26, 461-62 ADB Volume 11 (1988) 26, 140, 146, 162, 176, 219, 221, 223, 305, 337 341, 400, 426-28, 462 ADB Volume 12 (1990) 26, 162, 176, 219, 223, 337, 341, 384, 400, 428-29, 463 ADB Volume 13 (1993) 26, 29, 162, 169, 175, 304, 337, 342, 400, 430-31, 464-65 ADB Volume 14 (1996) 24, 26, 162, 169, 307, 312, 342, 400, 431-32, 465-66 ADB Volume 15 (2000) 26 144, 162, 309, 337, 343, 401, 433-34, 466-67 ADB Volume 16 (2002) 26, 162, 183, 185, 244, 317, 337, 343, 401, 434-36, 467 ADB supplement (2005) 3, 26, 147, 185, 224, 225, 226, 231, 232, 236, 257, 273, 290-91, 294, 295, 305-06, 308, 338, 343, 390, 401, 436-37, 467-68 ADB Volume 17 (2007) 26, 145, 170, 183, 185, 186, 244, 292, 304, 306, 310, 317, 337, 343, 401, 437-39, 468 ADB Volume 18 (2012) 26, 179, 183, 188, 311, 332-33, 338, 343, 383, 402, 439-41, 468 ADB index, Volumes 1 to 12 (1788-1939), (1991) 287, 338, 342, 384, 400 ADB CD-Rom 29, 162, 181, 196, 226, 287, 289, 374, 385-87, 401, 465 ADB preface 278 rchives 1, 15, 68, 209, 389, 407, 447 uthors see authors ADB ADB constitution (rules and procedures) 19, 40, 68, 90, 93, 178-79 ADB covers 117, 271, 274, 339-43 ADB covers 117, 271, 274, 339-43 ADB Deputy Editor see Deputy Editor, ADB ADB Editorial Board see Editorial Board, ADB ADB Editorial Board see Editorial Board, ADB Endowment Fund xi, 29, 93, 95, ADB Volume 11 (1988) 26, 140, 146, 162, 176, 219, 221, 223, 305, 170, 190, 191, 401 ADB ADB medal and medallists 99, 135, 136, ADB Volume 14 (1996) 24, 26, 162, 169, 307, 312, 342, 400, 160, 234, 246, 443-45 162, 169, 307, 312, 342, 400, 431-32, 465-66 ADB National Committee see National Committee, ADB ADB Volume 15 (2000) 26 144, 162, 309, 337, 343, 401, 433-34, 466-67 ADB online xii, 1, 27, 29, 33, 144, 162, 171, 192-200, 201-04, 226, 275, 287, 289-90, 295, 310, 317, 334, 348, 353-54, 366, 370-71, 385-93 ADB Volume 16 (2002) 26, 162, 183, 185, 244, 317, 337, 343, ADB subject lists see subject lists, ADB ADB working parties see working parties Australian Encyclopedia 30, 37, 65, 390 Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) 244 401, 437-39, 468 p Architects 31 207, 208, 209, 216, 221, 224, 225, 230, 231, 232, 234, 244, 250, 283, Biographical Register 5, 9, 12, 17, 30, 33, 34, 38, 39, 41, 43, 45, 52, 54, 56, 57, 58, 62, 78, 84-85, 86, 108, 216, 223, 249, 273, 373, 376-382, 397, 398, 399, 401 303, 307, 315, 325, 329, 376 ( Ian Young (2011-) y Beaverbrook, Lord, Max Aitken 54, 86 Bell, Alan 307 Australian Research Council grants 288 Linkage-Infrastructure, Equipment and Facilities (LIEF) 29, 170, 195, 387 Bell, Jacqueline 419, 421 Biographical Dictionary of Artists and Architects 31 Biographical Dictionary of Artists and Architects 31 Bell, Jacqueline 419, 421 Bennet, Daryl 3, 147, 155, 167, 187, 199, 200, 201-02, 203, 204, 230, 277, 279 289, 376, 384, 390, 403, 436, 437, 438, 439, 440, 441, 445 Australian Rules Football 153, 329 Australian Science Archives Project 203 j Australian Science and Technology Heritage Centre (Austechc) see eScholarship Research Centre Australian Society for the Study of Labour History 134, 306, 307 Bennett, Arnold 317 Bennett, Arnold 317 Australian Science and Technology Heritage Centre (Austechc) see eScholarship Research Centre Bennett, John 240, 301, 419, 421, 422, Bennett, John 240, 301, 419, 421, 422, 424, 425, 427, 429, 430 424, 425, 427, 429, 430 Australian Society for the Study of Labour History 134, 306, 307 Benthall, Michael 310 Berzins, Baiba 427 Australian Society of the History of Medicine 149 Best, Ysola 432, 433 Bevil, J. Marshall 314 Australian War Memorial 149, 243 bibliographer, ADB 13, 145, 181, 404, 405, 407 Australians on Disc (bicentennial project) 386, 391 Australians on Disc (bicentennial project) 386, 391 bibliographies attached to ADB articles 318 authors, ADB xii, 1, 3, 9, 10, 13, 14, 17, 19, 20, 22, 28, 30, 42, 43, 75, 81, 90 99, 108, 109, 111, 113, 114, 115, 116, 135, 140, 164, 166, 168, 181, 207, 208, 209, 216, 221, 224, 225, 230, 231, 232, 234, 244, 250, 283, 303, 307, 315, 325, 329, 376 see also unsigned ADB entries authors, ADB, payment of 10, 59, 285 Bach, John 411, 413, 414, 416, 417, 419 Bagehot, Walter 288 authors, ADB xii, 1, 3, 9, 10, 13, 14, 17, 19, 20, 22, 28, 30, 42, 43, 75, 81, 90, 99, 108, 109, 111, 113, 114, 115, 116, 135, 140, 164, 166, 168, 181, 207, 208, 209, 216, 221, 224, 225, 230, 231, 232, 234, 244, 250, 283, 303, 307, 315, 325, 329, 376 l i d ADB t i bicentennial history projects 25, 150, 165, 385, 386, 406, 407 99, 108, 109, 111, 113, 114, 115, Bigge commission of inquiry 92, 156 116, 135, 140, 164, 166, 168, 181, ADB preface 278 ADB Archives 1, 15, 68, 209, 389, 407, 447 ADB Archives 1, 15, 68, 209, 389, 407, 447 288, 289, 290, 291, 292, 380, 384, 387, ADB authors see authors ADB 397, 398, 399, 400 472 Index ANU Archives 1, 3, 209, 389, 40 ANU Bill 1946 12 ANU Council 5, 7, 8, 9, 11, 12, 13, 34, 36, 40, 41, 43, 95, 200 ANU Overseas Scholarships scheme 49 ANU Press 9, 57 ANU publication committee 67, 93, 105 ANU Vice-Chancellors: see Douglas Copland (1948-53) Leslie Melville (1953-60) Leonard Huxley (1960-67) John Crawford (1968-73) Robin Williams (1973-75) Anthony Low (1975-82) Peter Karmel (1982-87) Lawrence Nichol (1988-93) Deane Terrell (1994-2001) Ian Chubb (2001-11) Ian Young (2011-) ANU Archives 1, 3, 209, 389, 407 ANU Bill 1946 12 ANU Council 5, 7, 8, 9, 11, 12, 13, 34, 36, 40, 41, 43, 95, 200 ANU Archives 1, 3, 209, 389, 407 Baker, Don 74, 273, 325, 419, 420, 421, 422, 423, 424, 425, 427, 428, 430, 452, 458 ANU Bill 1946 12 ANU Bill 1946 12 ANU Council 5, 7, 8, 9, 11, 12, ANU Council 5, 7, 8, 9, 11, 12, 13, 34, 36, 40, 41, 43, 95, 200 Bankowski, Helen 141, 403 13, 34, 36, 40, 41, 43, 95, 200 ANU Overseas Scholarships scheme 49 Bannenberg, Nick 419, 421, 423, 424, 426, 427 ANU Press 9, 57 Banning, Lex 164 ANU publication committee 67, 93, 105 Bannon, John 434, 435, 437 Barnard, Alan 146, 277, 414, 416, 417, 419, 420, 421, 422, 423, 424, 425, 427, 428 ANU Vice-Chancellors: see Douglas Copland (1948-53) g Leslie Melville (1953-60) Barton, Edmund 297 ( ) Leonard Huxley (1960-67) Bate, Weston 420, 421, 423, 425, 426, Bate, Weston 420, 421, 423, 425, 426, 428, 429, 431, 432 428, 429, 431, 432 John Crawford (1968-73) ( ) Robin Williams (1973-75) Bates, Daisy 166, 317 Anthony Low (1975-82) Battye, Osland 412, 414, 415, 417, 418, 420, 422 Battye, Osland 412, 414, 415, 417, 418 Peter Karmel (1982-87) Lawrence Nichol (1988-93) Battye Library 238 Bazley, Arthur 114, 403 Beasley, Jack 145 Bogle, Gilbert 240 Bogle, Gilbert 240 Register of the NSW Parliament, 1901-70 (1979) 31, 220 Bolton, Geoffrey 2, 3, 19, 28, 60, 72, 81, Bolton, Geoffrey 2, 3, 19, 28, 60, 72, 81, 85, 106, 136, 146, 171, 187, 188, 189, 191, 231, 238, 277, 279, 280, 284, 290, 291, 297-98, 411, 412, 414 415, 416, 417, 418, 419, 420, 421, 422, 423, 424 , 425, 426, 427, 428, 429, 430, 431, 432, 433, 434, 436, 437, 438, 439, 441, 444, 445 85, 106, 136, 146, 171, 187, 188, Scott Bennett & Barbara Bennett, Biographical Register of the Tasmanian Parliament 1851-1960 (1980) 31 Scott Bennett & Barbara Bennett, 189, 191, 231, 238, 277, 279, 280, Biographical Register of the 284, 290, 291, 297-98, 411, 412, 414, Tasmanian Parliament 1851-1960 (1980) 31 Tasmanian Parliament 1851-1960 415, 416, 417, 418, 419, 420, 421, D. B. Waterson and John Arnold, Biographical Register of the Queensland Parliament 1930- 1980 (1982) 31, 218 C. N. Connolly, Biographical Register of the New South Wales Parliament 1856-1901 (1983) 31 422, 423, 424 , 425, 426, 427, 428, 429, 430, 431, 432, 433, 434, 436, 437, 438, 439, 441, 444, 445 Bonnin, Nancy 166, 419, 421, 423, 424, 426, 427, 429, 430 Bonnin, Nancy 166, 419, 421, 423, 424, 426, 427, 429, 430 C. N. Connolly, Biographical Register of the New South Wales Parliament 1856-1901 (1983) 31 Bosworth, Michal 403, 432, 434, 436, 437, 439, 441 Biographical Register of the Australian Labour Movement, 1788-1975 307 see also Labour Australia 389 Biographical Register Officer 164, 165, 181, 381, 382, 403, 405, 406, 408 Biographie Universelle 7 Biography Footnotes 1 b h Bosworth, Mike 136 Biographical Register of the Australian Labour Movement, 1788-1975 307 see also Labour Australia 389 Bourke, Paul 167, 425, 427, 428 Boxall, Helen 384, 403 Boyce, Peter 425, 426, 428, 429, 431, 432 Biographical Register Officer 164, 165, 181, 381, 382, 403, 405, 406, 408 Boyd, Benjamin 250 Boyd, Robin 144 see also unsigned ADB entries see also unsigned ADB entries g authors, ADB, payment of 10, 59, 285 y Bach, John 411, 413, 414, 416, 417, 419 Biographical Register 1788-1939 (1987) 72, 122, 135, 176, 385, 386, 400 473 The ADB's Story Biographical registers of state parliaments 30-32 Birman, Wendy 2, 136, 146, 200, 238-39, 403, 415, 417, 418, 420, 422, 423, 425, 426, 428, 429, 431, 432, 434, 436, 437, 439, 441, 445i Biographical registers of state parliaments 30-32 A. W. Martin & P. Wardle, Members of the Legislative Assembly of New South Wales, 1856-1901 (1959) 30-31, 57, 85 G. C. Bolton & Ann Mozley, The Western Australian Legislature, 1870-1930, (1961) 31, 60, 297 D. B. Waterson, A Biographical Register of the Queensland Parliament: 1860-1929 (1972) 31,218 Kathleen Thomson & Geoffrey Serle, A Biographical Register of the Victorian Legislature, 1859- 1900 (1972) 31 Joan Rydon, A Biographical Register of the Commonwealth Parliament, 1901-1972 (1975) 31 Heather Radi, Peter Spearritt & Elizabeth Hinton, A Biographical Register of the NSW Parliament, 1901-70 (1979) 31, 220 Scott Bennett & Barbara Bennett, Biographical Register of the Tasmanian Parliament 1851-1960 (1980) 31 D. B. Waterson and John Arnold, Biographical Register of the Queensland Parliament 1930 Members of the Legislative 436, 437, 439, 441, 445 birth, death and marriage certificates 29, 135-36, 209, 357 Black, David 420, 422, 423, 425, 426,428, 429, 431, 432, 434, 436, 437, 439, 441 G. C. Bolton & Ann Mozley, The Western Australian Legislature, 1870-1930, (1961) 31, 60, 297 1870-1930, (1961) 31, 60, 297 Blackburn, Aileen 224, 438, 440 D. B. Waterson, A Biographical Register of the Queensland Blacklock, Walter 229 Blainey, Geoffrey 82, 104, 144, 299, 303, 315, 318, 319, 321, 322-28, 331, 333, 415, 417, 418, 420 Parliament: 1860-1929 (1972) 31,218 415, 417, 418, 420 Kathleen Thomson & Geoffrey Serle, A Biographical Register of the Victorian Legislature, 1859- 1900 (1972) 31 Serle, A Biographical Register of Blake, Leslie 420, 421, 427 Blake, Leslie 420, 421, 427 Blake, Peter 366 Joan Rydon, A Biographical Joan Rydon, A Biographical Register of the Commonwealth Register of the Commonwealth block grant from the Commonwealth 20, block grant from the Commonwealth 20, 285-86 block grant from the Commonwealth 20, Parliament, 1901-1972 (1975) 31 Heather Radi, Peter Spearritt & bluey see cover sheet, ADB files bluey see cover sheet, ADB files Elizabeth Hinton, A Biographical Blythe, Lindsay 297 Blythe, Lindsay 297 Burton Hall, ANU 155 Burton Hall, ANU 155 Casey, Maie 183 Burton, O. V. 391 Busby, John 250 Busby, John 250 Central Army Records Office 242 Central Army Records Office 242 Bushell Trust 95, 115, 259, 398 see also certificates 29, 31, 125, 135, 136, 142, Bushell Trust 95, 115, 259, 398 see also endowment Brown, George 37 Cammilleri, Cara 412, 414, 415 Brown, George 37 Campbell, Daniel 403 Brown, Margaret 403 Campbell, Kate 186 Brown, Nicholas 187, 189, 195, 200, 244, 277, 279, 280, 390, 403, 432, 433, 435, 436, 438 Campbell, Martha 114, 120, 121,134, 144, 159, 167, 170, 192, 200, 266-67, 403, 444, 445 Brown, Philip 82, 412, 414, 439, 440 Canadian Biography Centre, University of Toronto 12 Browne, Geoff 136, 403, 431, 432, 434, 435, 437, 439, 440 Biography Footnotes 1 Boyer, Richard 297 Bradley, William 255, 256 biography, writing 7, 8, 9, 10, 13, 14, 15, 16-17, 23, 25, 27, 32, 49, 90, 107-08, 140, 150, 186, 188, 190, 225, 254, 257 279, 306, 312, 325, 348, 355, 358, 385, 392-93 Bradman, Donald 44-45, 166-67, 261 Brady, Matthew 271 Brennan, Geoff 376, 430, 431 Brett, Judith 431 biography podcasts 367 Bridge, Carl 307, 424 Brisbane, Thomas Makdougall 99 474 Index Byrne, Alex 440 Cable Clerical Index 264 Cable, Ken 71, 146, 219, 228, 264-65, 301, 323, 412, 413, 415, 416, 418, 419, 420, 421, 422, 423, 424, 425, 426, 427, 428, 429, 430, 445 Briscoe, Gordon 25, 244-45 Britannica Australasia Prize, 1971 399 Cable Clerical Index 264 British Civil Histories of the War 21, 88 Cable, Ken 71, 146, 219, 228, 264-65, 301 323, 412, 413, 415, 416, 418, 419, 420, 421, 422, 423, 424, 425, 426, 427, 428, 429, 430, 445 British Museum Library 109, 253, 360 British Museum of Natural History 150 427, 428, 429, 430, 445 British Survey of Commonwealth Affairs 54 Cable, Leonie 264 Brookes, Mabel 246 Cahill, Tony 144 Brookhiser, Richard 312 Brooks, Maureen 403 Calvert, John D. 2, 3, 119 Cambridge, Ada 295 Broome, Richard 440 Brown, Frank 136, 242, 243, 403, 419, 421, Cambridge University 74, 104, 110, 11 Cambridge University 74, 104, 110, 116, 117, 264 Brown, Frank 136, 242, 243, 403, 419, 421, 422, 424, 425, 427, 428, 430, 431 422, 424, 425, 427, 428, 430, 431 Toronto 12 Brudenall, Andrew 403 Canadian Dictionary of Biography (CDB) 12, 24, 35, 37, 52, 58, 59, 65, 97, 109, 195, 345 Brunton, Paul 305 Bryan, James 256 Bryden, William 311-12 Canberra & District Historical Association 43, 273 Buchanan, Robert 384 Buckridge, Pat 195, 229, 230, 277, 280, 284, 290, 320, 432, 433, 434, 435, 436, 437, 438, 439 Canberra Community Hospital Building 10, 54, 56, 249-50, 397 Canberra University College 10, 49, 263 Buick, W. G. 299 Cane, Alan 411, 413, 416, 418 Cane, F. J. 411, 413, 414 Bulletin 63, 77, 90, 92, 300, 305 Bundock, Anthea 167, 187, 200, 279,375, 381, 390, 403 Cardno, James 10 Carey, Hilary 403 Burgis, Peter 144 Carlyle, Thomas 7 Carment, David 3, 195, 433, 435, 436, 438, Carment, David 3, 195, 433, 435, 436, 438, 440 Carment, David 3, 195, 433, 435, 436, 438, 440 Burgmann, Meredith 401 Burn, Margy 221, 222, 432 Carmody, John (Jack) 218, 222, 427, 429, 430, 432, 433, 435, 437, 438, 440 Burness, Peter 421, 422, 424, 425, 427, Burness, Peter 421, 422, 424, 425, 427, 428, 430, 432, 433, 435, 436, 438, 439 428, 430, 432, 433, 435, 436, 438, 439 Carter, Philip 3, 371, 375 Burrows, Stephanie 403 Casey, Dawn 244, 245, 436, 438, 440 Cross, Jack 110 Cross, Jack 110 Cross, Manfred 429, 430, 432, 433, 436, 437, 438 endowment 417, 419, 420, 421, 422, 423 Copland, Douglas 9 432, 435, 436, 438, 439 copyright issues 65, 93, 198 Clark, Manning 8, 10, 14, 15, 16, 35, 58, 59, 61, 63, 65, 67, 69, 70, 72, 74, 79, 90, 92, 103, 111, 122, 138, 155, 157, 200, 205, 250, 273, 314-15, 328, 398, 411, 412, 413, 414, 416, 417, 419, 420, 422, 423, 424, 425, 427, 428 Cornish, Patrick 290, 439, 441 Corrigan, Tommy 158 corrigenda 174, 210, 317, 328, 374, 375, 376 Cosgrove, Betty 440 411, 412, 413, 414, 416, 417, 419, Cossington-Smith, Grace 333 420, 422, 423, 424, 425, 427, 428 Costar, Brian 432, 434, 435, 437, 439, 440 Clark, Rex 419, 421, 422 Clarke, Eddy 421, 423, 424, 426, 427 Couchman, May 310 Coulthard-Clark, Chris see Clark, Chris Clarke, Patricia 430, 432, 433, 435, 436, 438, 440 cover sheet, ADB files 166, 209 Clements, Bob 441 Cowley, Des 440 Clements, Gail 3, 187, 200, 279, 375, 390, 403 Cowper, Norman 95-96, 128, 411, 412, 413, 414, 416, 417, 419, 420, 421, Coates, John 432, 433, 435, 436, 438, 439 Coggin, Chris 425, 426, 428 422, 423 Coggin, Chris 425, 426, 428 Crago, Margaret 114 Crago, Margaret 114 collective biography 31, 169, 327, 369, 376, 385, 392 Crawford, Jack 352 Crawford, John 116, 250 see also family biographies Crawford, Max 9, 10, 82, 153, 155 College of Arts and Social Sciences endowment 143, 149, 209, 357 Bussell, Grace 311 Chamberlain, Azaria 23, 304 , , Champion, Ben 411, 413, 414, 416, 417, 419 Chandler, Margaret 240 Champion, Ben 411, 413, 414, 416, 417, 419 Butlin, Noel 250 Butlin, Noel 250 Butlin, Syd 9, 74 Chandler, Margaret 240 Chandler, Margaret 240 Buxton, Gordon 16, 418 475 The ADB's Story ADB National Advisory Panel and Editorial Board, ANU, 1960 39, 67-68, 105 ‘National Biographies and National Identities’, NLA, 1995 14, 311, 400 ‘Past & Present: the ADB’, ANU, 2009 2, 3, 401 Chapman, Peter 420, 421, 423, 424, 426, 427, 429, 431, 432, 434, 435, 437, 439, 440 Charles Darwin University 195 Chate, Alfred 412, 414, 415 Chauvel, Harry 242 Cherrill, Francis 351 ‘Past & Present: the ADB’, ANU, 2009 2, 3, 401 Chubb, Ian 3, 76, 189, 197, 292, 444 Connolly, Chris 31 Churchill, Clive 145, 186 Connors, Libby 230, 440 Ciuffetelli, Karen 167, 187, 200, 207, 279, 375, 403, 404 Consadine, Marion 133, 403 Clarendon Press, Oxford 36, 37, 49, 65, 397 Cook, Deborah 414 Clark, Chris 31, 167, 242, 390, 404, 419, Cook, James 301 Clark, Chris 31, 167, 242, 390, 404, 419, 421, 422, 424, 425, 427, 428, 430, 432, 435, 436, 438, 439 Cook, P. (CASS), ANU 190 Crawford, Richard 44 Colligan, Mimi 136, 403, 429, 431, 432, 434, 435, 437, 439, 440 Crew, Jennifer 411, 413, 414, 416, 418 Crichton, Pam 3, 187, 200, 379, 404 Colliver, Frederick 419, 421, 423, 424, 426, 427 cricket 44-45, 145, 166, 256, 259, 261, 264, 330, 366 Crisp, Fin 273 Commonwealth National Library 8, 49, 122 Croll, Bob 144 see also National Library of Australia Crook, Alison 221, 228, 427, 429, 430 Commonwealth Working Party see working parties conferences Australian Historians, ANU, 1957 5, 16-17, 30, 34, 38, 43, 51, 52, 58, 90, 101, 397 see also People Australia Dignan, Don 412, 413, 415, 416, 418, 419 414, 415, 416, 417, 418, Dingwall, Bronwyn 404 Dingwall, Bronwyn 404 Davidson, Jim (Keith Hancock’s biographer) 2, 419, 15-16, 34, 88, 144, 301, 308, 434, 435, 437 Dinnerville, Frances 146, 404 Dixon, Owen 59 Dixon, Owen 59 Dobell, William 312 Davison, Graeme 153, 196, 279, 423, 425, 426, 428, 429, 431, 432, 434 Dobell, William 312 Docherty, James 414 Dawson, Barbara 3, 167, 187, 200, 279, 375, 379, 390, 404 Donovan, Peter 217, 440 Doust, Janet 3, 279, 375, 390, 404 Doust, Russell 3, 134, 146, 221, 227-28, 419, 421, 422, 424, 425, 427 de Garis, Brian 419, 420, 422, 423, 425, 426, 428 Currey, Charles 301 Dictionary of Australian Biography 8, 42, 49, 140, 326, 397 Curthoys, Ann 36, 244, 245, 277, 425, 427, 428, 429, 430, 431, 432, 436, 438, 440, 441 see also Serle, Percival Dictionary of Irish Biography 345, 346, 369 Dictionary of Irish Biography 345, 346, 369 Curtin, John 144 Dictionary of National Biography (DNB) 7, 8, 9, 11, 20, 23, 29, 49 see also Oxford Dictionary of National Biography Curtin University 195 Cushing, Nancy 218, 223, 438, 440 Dale, Barbara 136, 404 Dale, Barbara 136, 404 Dictionary of New Zealand Biography 1, 171, 195, 289, 308, 320, 345 Daley, Louise 411, 413, 414, 416, 418 Damousi, Joy 290, 439 Dangar, Peter 411, 413, 414, 416, 418 Digby, Everard 7 Digby, Everard 7 Darling, Ralph 99 Darwin, Charles 61 Diggers 31, 164 Davey, Lindie 404 Cunningham, Peter 257 curating dictionaries online 347, 363-67 Diamond, Marion 433 Dickson, Frank 145 Curnow, Ross 218, 427, 429, 430, 432, 433, 435, 437 438, 440 Curnow, Ross 218, 427, 429, 430, 432, Dickson, John 250 Currey, Charles 301 conferences Cross, Marlene 404 Crouchley, Betty 136, 410, 426, 427 Cross, Marlene 404 Crouchley, Betty 136, 410, 426, 427 476 Index Crowley, Frank 8, 59, 60, 67, 72, 73, 74, 81, 84, 85, 218, 219, 228, 297, 301, 411, 412, 414, 415, 416, 417, 418, 419, 420, 421, 422, 423, 424, 425, 440 Deakin, Alfred 174, 178 Dean, Monica 404 Dempsey, Paul 404 Dennis, Peter 428, 436, 438, 439 Deputy General Editor, ADB 28, 181,188, 189, 191, 284 Bede Nairn (1966-73) Chris Cunneen (1982-97) Diane Langmore (1997-01) Darryl Bennett (2001-08) Paul Arthur (2010-13) Dennis, Peter 428, 436, 438, 439 Deputy General Editor, ADB 28, 181,188, 189, 191, 284 Bede Nairn (1966-73) Chris Cunneen (1982-97) Diane Langmore (1997-01) Darryl Bennett (2001-08) Paul Arthur (2010-13) Cunneen, Chris 2, 3, 22, 26, 27, 77, 133, 146, 147-48,158, 159, 170, 185, 201, 218, 219, 221, 225, 227, 228, 232, 257, 274, 277, 279, 281, 282, 290, 291, 374, 390, 404, 419, 421, 422, 423, 424, 425, 426, 427, 428, 429, 430, 431, 432, 433, 435, 436, 437, 438, 439, 440 Chris Cunneen (1982-97) Diane Langmore (1997-01) Darryl Bennett (2001-08) 430, 431, 432, 433, 435, 436, 437, see also Military digital culture and developments 27, 32, Davey, Thomas 323 192, 196-97, 203, 318, 346-71, 373-93 Davidson, Jim (Pacific historian) 10, 54, 58, 59, 66, 67, 250, 411, 412, 413, 414, 415, 416, 417, 418, Dermody, Kathleen 404 Dermody, Kathleen 404 Dew, Walter 351 Cunningham, Peter 257 Paul Arthur (2010-13) 438, 439, 440 Drake-Brockman, Henrietta 412, 414, 415 Drake-Brockman, Henrietta 412, 414, 415 de Kock, W. J. 109 Tom Griffiths (2006-) Edmonds, Leigh 404 Farquharson, John 436, 438, 440 Edwards, Marion (Bill) 310 Farrell, Frank 228, 419, 421, 422, 424, 425, 427, 429, 430, 432, 433, 435, 437 Edwards, Peter G. 428, 430 Faulkner, Samantha 245, 440 see also representation Eldershaw, Peter Ross 79, 83, 412, 413, 415, Eldershaw, Shirley 429, 431, 432, 434, 435, 437, 439, 440 Ferguson, Audrey 404 Dyster, Barry 218, 223, 438, 440 428, 430 egalitarianism 168, 331 see also representation Eldershaw, Peter Ross 79, 83, 412, 413, 415, Eldershaw, Shirley 429, 431, 432, 434, 435, 437, 439, 440 Elliot, Jane 404 Ellis, Malcolm 15, 16-21, 35, 52, 56, 59, 63 73 75 77 79 90 92 95 99 105 Evans, Joanne 197 Evans, Joanne 197 Evans, Raymond 419 Evatt, H. V. 92, 166, 307 Evershed, John 391 138, 140, 143, 147, 149, 150, 170, 171, 422, 424, 425, 427, 428, 430, 431, 433, 422, 424, 425, 427, 428, 430, 431, 433, Lindsays 144 Stricklands 256 see also collective biography family history 32, 357, 360, 381, 391-93 egalitarianism 168, 331 Fay, Eliza 360-61 Duncan, Ross 411, 413 de Kretser, David 292, 401 Dunckley, Dorothy 307 Deacon, Desley 292 477 The ADB's Story Dunlop, Eric 411 413 Else-Mitchell, Rae 228, 415, 416, 418, 419, 421, 422, 424, 425, 427, 429 Dunstan, David 277, 279, 280, 284, 290, 404, 434, 435, 436, 437, 438, 439, 440 Dunstan, David 277, 279, 280, 284, 290, 404, 434, 435, 436, 437, 438, 439, 440 419, 421, 422, 424, 425, 427, 429 Encyclopedia of New Zealand 12, 37 see also later Dictionary of New Zealand endowment xi, 12, 20, 29, 35, 36, 37, 93, 95, 115, 170, 174, 190, 191, 398, 401 English, Bruce 404 Erickson, Dorothy 429, 431, 432, 434, 436, 437, 439, 441 Erickson, Rica 420, 422, 423, 425, 426, 428 Ernest Scott Prize 117, 399 errors in ADB entries see corrigenda eScholarship Research Centre, Uni. of Melbourne 192, 201, 203 Evans, Ben 279, 391 Evans, Gareth xi Evans, Joanne 197 Evans, Raymond 419 Evatt, H. V. 92, 166, 307 Evershed, John 391 Faber, Robert 390 Fahey, Charles 437, 439, 440 Fairfax family 170 Fairhill, Vicky family biographies Ballieus 246 Grimwades 246 Lindsays 144 Stricklands 256 see also collective biography family history 32, 357, 360, 381, 391-93 Farquharson, John 436, 438, 440 Farrell, Frank 228, 419, 421, 422, 424, 425, 427, 429, 430, 432, 433, 435, 437 Faulkner, Samantha 245, 440 Fay, Eliza 360-61 Feely John 377 Felton, Alfred 246 Ferguson, Audrey 404 Ferguson, George 65 Ferguson, Ronald Munro 246 Ferguson, Sarah 404 Fernon, Christine xii, 1, 167, 187, 197, Encyclopedia of New Zealand 12, 37 Encyclopedia of New Zealand 12, 37 see also later Dictionary of New Dunstan, Douglas A. 420, 421, 423, 424, 426, 427 Dyster, Barry 218, 223, 438, 440 Dyster, Barry 218, 223, 438, 440 Erickson, Rica 420, 422, 423, 425, 426, 428 Ernest Scott Prize 117, 399 Eagle, Mary 312 errors in ADB entries see corrigenda eScholarship Research Centre, Uni. of Melbourne 192, 201, 203 Eaton, Brian 427, 428, 430 Melbourne 192, 201, 203 Ebden, Charles 144 Evans, Ben 279, 391 Edgar, Sue 2, 3, 114, 115, 120, 121, 134, 144, 159, 266-68, 269-70, 376, 390, 404 Edgar, Sue 2, 3, 114, 115, 120, 121, 134, 144, Evans, Gareth xi Evans, Gareth xi , , , , , Editorial Board, ADB xi, xii, 5, 11, 17, 20 21, 23, 26, 29, 30, 38-39, 40, 41, 59-60, 62, 63, 65, 67, 68, 69, 73, 75, 90, 93, 95, 97, 99, 105, 111, 113, 118, 125, 138, 140, 143, 147, 149, 150, 170, 171, 181, 193, 195, 201, 221, 225, 245, 277- 94, 376, 383, 384, 387, 391, 398, 399- 401, 411, 413,, 414, 416, 417, 419, 421, 422, 424, 425, 427, 428, 430, 431, 433, 434, 436, 438 439 see also Chairs: Keith Hancock (1959-65) John La Nauze (1966-77) Ken Inglis (1977-96) Jill Roe (1996-2006) Tom Griffiths (2006-) Edmonds, Leigh 404 Edwards, Marion (Bill) 310 Edwards, Peter G. 428, 430 egalitarianism 168, 331 see also representation Eldershaw, Peter Ross 79, 83, 412, 413, 415, Eldershaw, Shirley 429, 431, 432, 434, 435, 437, 439, 440 Elliot, Jane 404 Ellis, Malcolm 15, 16-21, 35, 52, 56, 59, 63-73, 75, 77, 79, 90-92, 95, 99, 105, 108, 111, 114, 133, 158, 221, 300, 301 302 303 306 307 318 375 Editorial Board, ADB xi, xii, 5, 11, 17, 20 21, 23, 26, 29, 30, 38-39, 40, 41, 59-60, 62, 63, 65, 67, 68, 69, 73, 75, 90, 93, 95, 97, 99, 105, 111, 113, 118, 125, 138, 140, 143, 147, 149, 150, 170, 171, 181, 193, 195, 201, 221, 225, 245, 277- 94, 376, 383, 384, 387, 391, 398, 399- 401, 411, 413,, 414, 416, 417, 419, 421, 422, 424, 425, 427, 428, 430, 431, 433, 434, 436, 438 439 see also Chairs: Keith Hancock (1959-65) John La Nauze (1966-77) Ken Inglis (1977-96) Jill Roe (1996-2006) Tom Griffiths (2006-) Edmonds, Leigh 404 Edwards, Marion (Bill) 310 Edwards, Peter G. Zealand endowment xi, 12, 20, 29, 35, 36, 37, 93, Duplain, Raymond 404 endowment xi, 12, 20, 29, 35, 36, 37, 93, 95, 115, 170, 174, 190, 191, 398, 401 English, Bruce 404 Erickson, Dorothy 429, 431, 432, 434, 436, 437, 439, 441 E i k Ri 420 422 423 425 426 428 Durack, Mary 392 Durack, Michael 297 Durack, Michael 297 Dutton, Geoffrey 305 Dwyer, Michael 357 Erickson, Rica 420, 422, 423, 425, 426, 428 Gaudry, Anne-Marie 163, 405 y, , genealogists and their societies 196, 252, 253, 373 General Editor, ADB see also: Douglas Pike (1962-73) Bede Nairn (1973-87) Geoffrey Serle (1973-86) John Ritchie (1987-2002) Diane Langmore (2002-08) Melanie Nolan (2008-) General Register Office Scotland 357 genealogists and their societies 196, 252, 414, 416, 417, 419, 420, 422, 423 Fitzherbert, Margaret 440 Fitzpatrick, Brian 16, 144 Fitzpatrick, Kathleen 154 Flannery, Hannah 404 Fletcher, Brian 228, 301 412, 413, 415, 416, 418, 419, 421, 422, 424, 425, 427, 429 John Ritchie (1987-2002) Diane Langmore (2002-08) Fletcher, Yvonne 351 Getzler, Israel 411, 413 Flynn, Michael 384 Gibberd, Joyce 135, 136, 200, 405, 429, 431, Ford, W. S. 412, 413 432, 434, 435, 437, 438, 440, 448 Gibbney, Jim 57, 72, 113, 114, 122-24, Forrest, Alexander 297 Forrest, Alexander 297 Gibbney, Jim 57, 72, 113, 114, 122-24, 135, 176, 229, 274, 380, 381, 382, 405 Fort, Carol 438, 440 Foster, Stephen 385, 386, 391, 392 Gibbs, Ronald 216, 420, 421, 423, 424, Gibbs, Ronald 216, 420, 421, 423, 424, 426, 427, 429, 431, 432, 434, 436, 426, 427, 429, 431, 432, 434, 436, Fotheringham, Richard 435, 437, 438, 440 437, 438, 440 Fox, Charles 434, 436, 437, 439, 441 Fox, Charles 434, 436, 437, 439, 441 Fox, Karen 383, 390, 405 Gibson, David 405, 419, 421 Fitch, Kent 279, 391 Garrisson, Arthur 425, 427, 428 Garton, Stephen 26, 170, 185, 187, 188, Fitzhardinge, Laurie 2, 5, 8, 9, 10, 12, 17 Fitzhardinge, Laurie 2, 5, 8, 9, 10, 12, 17, 28, 30, 37, 38, 43, 45, 49, 50, 51, 52, 53, 54, 56, 57, 58, 59, 61, 65, 67, 74, 77, 90, 93, 97, 110, 120, 205, 216, 249, 250, 376, 377, 397, 411, 412, 413, 414, 416, 417, 419, 420, 422, 423 Garton, Stephen 26, 170, 185, 187, 188, 189, 191, 195, 218, 225, 257, 277, 280, 291, 429, 430, 432, 433, 434, 435, 436, 437, 438, 439, 440 189, 191, 195, 218, 225, 257, 277, 28, 30, 37, 38, 43, 45, 49, 50, 51, 52, 53, 54, 56, 57, 58, 59, 61, 65, 67, 74, 280, 291, 429, 430, 432, 433, 434, 77, 90, 93, 97, 110, 120, 205, 216, 435, 436, 437, 438, 439, 440 249, 250, 376, 377, 397, 411, 412, 413, Gaudry, Anne-Marie 163, 405 Fox, Lindsay 231 Fox, Lindsay 231 Gibson, Pat, see Stretton, Pat Elliot, Jane 404 Ferguson, George 65 Ferguson, Ronald Munro 246 Ellis, Malcolm 15, 16-21, 35, 52, 56, 59, 63-73, 75, 77, 79, 90-92, 95, 99, 105, 108, 111, 114, 133, 158, 221, 300, 301, 302, 303, 306, 307, 318, 375, 397, 398, 399 Ferguson, Sarah 404 Fernon, Christine xii, 1, 167, 187, 197, Fernon, Christine xii, 1, 167, 187, 197, 200, 279, 379, 388, 404 Ferrall, Raymond 426, 427, 429, 431, 432 Ferrall, Raymond 426, 427, 429, 431, 432 478 Index Ferres, Kay 435, 437, 438, 440 Fry, Eric 49, 273 Fewster, Alan 146, 404 Fulloon, Gillian 148, 161, 405 Fiaschi, Thomas Henry 255 Fielding, Jean 146, 404, 419, 421, 422 Furphy, Joseph 314, Finch, Lyn 432 Furphy, Samuel 3, 383, 390, 405 Finch, Peter 307 Gammage, Bill 431, 432, 433, 435, 436, Gammage, Bill 431, 432, 433, 435, 436, 438, 440 Finnis, Harold 60, 80, 136, 213, 215, Finnis, Harold 60, 80, 136, 213, 215, 216, 217, 412, 413, 415, 416, 418 216, 217, 412, 413, 415, 416, 418 First Fleeters 250, 254, 257, 259, 355 Gan, Annie 405 Fischer, Gerald 412, 413, 415, 416, 418 Gandevia, Bryan 142, 143, 149, 399 Fisk, Ernest 411, 412, 413, 414 Garraty, John 316 Fitch, Kent 279, 391 178, 249, 383 Flowers, Edward 411, 413, 414, 416, 417, 419 Gerald, Jim 307 Getzler, Israel 411, 413 Flynn, Errol 311-12 Melanie Nolan (2008-) Florey, Howard 307 floruit 29, 61, 108, 140, 142, 144, 162, floruit 29, 61, 108, 140, 142, 144, 162, 178, 249, 383 General Register Office, Scotland 357 General Register Office (Somerset House) 253 Gibson, Pat, see Stretton, Pat Gill, James 421, 423, 424, 426, 427, 430, 432 Francis, Niki 3, 379, 390, 405 Gregson, Norma 146, 405 Hawker, Charles 116 Hawker, Charles 116 Hazlehurst, Cameron 153, 166, 240-41, 428, 430, 431, 432 Griffen-Foley, Bridget 218, 222, 435, 437, 438, 440 Griffin, Helga 141, 145, 146, 159, 266, 405i headstones and lapidary inscriptions 253-57 headstones and lapidary inscriptions 253-57 Heaton, J. Henniker 7 Hegel, Georg 7 Helpmann, Robert 310 Henningham, Nikki 440 Hewson, Rachel 405 Higham, Charles 311 Griffin, James 23, 144, 331 Griffin, James 23, 144, 331 Griffin, Walter Burley 252, 312-13 Heaton, J. Henniker 7 Griffith, Mary 306i Griffith, Mary 306 Hegel, Georg 7 Helpmann, Robert 310 Goldsmith, Bobby 310 Goldsmith, Bobby 310 Grover, Jeanette see Pickersgill, Jeannette Gollan, Robin (Bob) 10, 11, 17, 21, 22, 49, 53, 56, 58, 59, 61, 65, 67, 71, 72, 73, 74, 118, 376, 411, 412, 413, 414, 416, 417, 419, 420 421, 422, 424, Guilford, Elizabeth 411, 413, 414, 416, 417, 419 Gunson, Niel 323, 415, 416, 418, 419 Goodin, I. 405 Goodin, I. 405 Gunthorpe, Stuart 412, 413, 415, 416, 418, 419 Goot, Murray 218, 427, 429, 430, 432, 433, 435, 437, 438, 440 Hacking, Henry 250, 257 Gorton, John Grey 252, 312 Hall, Noeline 405 Governors-general, naval governors & governors 10, 21, 59, 61, 75, 147, 158, 159, 200, 213, 240, 250, 256, 257, 273, 292, 308-9 323, 324, 326, 332, 376, 400, 401, 402 Hancock, Ian 200, 432, 433, 441 158, 159, 200, 213, 240, 250, 256, Hancock, Keith xi, 2, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 23, 28, 33, 34-45, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 67, 68, 69, 71, 72, 73, 74, 75, 77, 86, 88-89, 90, 93, 97, 99, 101, 103, 104, 105, 106, 110, 111, 114, 116, 119, 120, 158, 176, 178, 250, 279, 280, 377, 380, 397, 398, 399, 400, 411, 412, 413 Hancock, Keith xi, 2, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 23, 257, 273, 292, 308-9 323, 324, 326, 28, 33, 34-45, 51, 52, 53, 54, 55, 56, 332, 376, 400, 401, 402 Graham, William 430 Graham, William 430 57, 58, 59, 60, 61, 62, 63, 65, 67, 68, Graham-Taylor, Sue 405, 434, 436, 437, 439, 441 69, 71, 72, 73, 74, 75, 77, 86, 88-89, Graham-Taylor, Sue 405, 434, 436, 437, 90, 93, 97, 99, 101, 103, 104, 105, 106, Grahame, Emma 157, 405 110, 111, 114, 116, 119, 120, 158, 176, 178, 250, 279, 280, 377, 380, 397, 398, Grahame, Rachel 200, 405 399, 400, 411, 412, 413 399, 400, 411, 412, 413 Grainger, Percy 313-14 Hardy, Bobbie 392 Grattan, C. Hartley 72, 302, 318 Gray, Archibald 412, 413, 415, 416 Harker, Margot 405 Gray, Isabel 330 Harris, Merab (also Harris Tauman, Merab) 412, 414, 415, 417, 418, 420, 422, Harris, Merab (also Harris Tauman, Merab) 412, 414, 415, 417, 418, 420, 422, 423, 425, 426 Graycar, Adam 439 Great Australians 116 423, 425, 426 423, 425, 426 Green, Frank Clifton 60, 79, 412, 413, Green, Frank Clifton 60, 79, 412, 413, 415, 417, 418 Harris, Paula 405 Harrison, Jennifer 136, 200, 230, 405, 433, 435, 437, 438, 440, 445 Greenway, Francis 16, 63, 90, 92 433, 435, 437, 438, 440, 445 Harrison, Peter 312-13 Greenwood, Gordon 59, 62, 67, 68, 71, 72, 74, 411, 414, 416, 417, 419, 420, 422, 424 Hart, Byrne 317 Hart, Philip 144 Hart, Philip 144 Gregory, Augustus 238 Gregory, Augustus 238 Hartog, Dirk 305 Gregory, Bob & ‘Gregory Review’ 190-91, 401 Hasluck, Alexandra 60, 81, 412, 414, Hasluck, Alexandra 60, 81, 412, 414, 415, 420, 422, 423, 425, 436, 428 Gregory, Helen 429, 430, 432, 433, 435 415, 420, 422, 423, 425, 436, 428 Hasluck, Paul 297 Gregory, Jenny 429, 431, 432, 434, 436, 437, 439, 441 Hawke, Bob 302, 400 Hawke, Bob 302, 400 Gregson, Norma 146, 405 Francis, Rosemary 197 Francis, Rosemary 197 Franklin, Miles 32, 290, 294, 295 Gilroy, Norman Thomas 307 Franks, Susan 405 Frappell, Ruth 128-29, 136, 405 Glover-Scott, Margaret 405, 435, 437, 439, 440 Freeman, George David 289 French, Maurice 432, 433, 435, 437, 438, 440 French, Maurice 432, 433, 435, 437, 438, 440 479 The ADB's Story Groom, Littleton 8 Griffith, Samuel 330i Griffith, Samuel 330 Henningham, Nikki 440 Griffiths, Tom xi-xii, 3, 187, 195, 203, 277, 279, 290, 292, 293, 320, 401, 433, 434, 435, 436, 437, 438, 439 Henningham, Nikki 440 Hewson, Rachel 405 Higham, Charles 311 Hewson, Rachel 405 433, 434, 435, 436, 437, 438, 439 Grimshaw, Patricia 25, 308 Grimshaw, Patricia 25, 308 480 Index Hill, Alec 136, 146, 242-43, 419, 421, 422, 424, 425, 427, 428, 430, 432, 433, 435, 436, 438, 439, 445 Howe, Jacky 331 Howell, Peter 136, 217, 277, 279, 284, Howell, Peter 136, 217, 277, 279, 284, 305, 420, 421, 423, 424, 426, 427, 429, 431, 432, 433, 434, 435, 436, 437, 438, 439, 440 Hill, Eliza 405 437, 438, 439, 440 Hill, Ernestine 166 Hilliard, David 217, 437, 438, 440 Hughes, Colin 428, 430 Hindmarsh, John 113 Hughes, William Morris 43, 74 Hinton, Elizabeth 31, 220 Humanities Networked Infrastructure Holt, Harold 307 Institute of Commonwealth Studies, Hone, Ann 263, 406, 428, 430 Historical Society Historical Studies, later Australian Historical Studies 82, 97, 99 Imperial War Museum, London 365 Imperial War Museum, London 365 Inder, Julie 406 Inder, Julie 406 index cards 9, 30, 52, 164, 252, 376-82 index cards 9, 30, 52, 164, 252, 376-82 History Department, General Studies, ANU 155, 183, 205 indexing 15, 17, 29, 32, 41, 50, 80, 213, indexing 15, 17, 29, 32, 41, 50, 80, 213, 216, 264, 287, 308, 338, 353, 355, 216, 264, 287, 308, 338, 353, 355, History Program, RSSS, ANU 5, 34, 35, 41, 49, 50, 51, 54, 58, 59, 88, 118, 120, 397 357, 364, 373, 374, 376, 377, 382-85, 357, 364, 373, 374, 376, 377, 382-85, 386, 389, 391, 392, 400 386, 389, 391, 392, 400 Hogan, Susan 136, 405 Indigenous see Aborigines Institute of Commonwealth Studies, Honniball, John 412, 414, 415, 417, 418, 420, 422, 423, 425, 426, 428 University of London 37, 88, 93 Institute of Historical Research, University of London 37, 88, 93 Institute of Historical Research, University of London 72, 253 International Institute of Strategic Studies, London 125 Iremonger, John 97, 274 see also Melbourne University Press University of London 72, 253 International Institute of Strategic Studies, London 125 Iremonger, John 97, 274 see also Melbourne University Press Hope-Johnstone, Nerida 406 Inglis, Rob 300 Inglis, Rob 300 Holt, Harold 307 (HuNI) 203, 391 (HuNI) 203, 391 Hirst, John 414, 416, 425, 426, 428 Hirst, Warwick 221, 435, 437, 438, 440 Hungerford, Stuart 391 Hunt, Douglas 420, 421, 424 historical connections between articles, 355-57 historical connections between articles, Hunt, Lyall 420, 422, 423, 425, 426, 428 Hutchinson, David 420 Historical Division of the Royal Geographical Society of Australasia (South Australian Division) 216 Huxley, Leonard 39, 41, 77, 300, 398 Huxley, Mollie 420, 406 historical societies 20, 38, 43, 60, 61, 63, 78, 79, 82, 83, 84, 85, 99, 128, 200, 236 273, 283, 289, 380 see also Canberra & District Historical Society Huxley, Thomas 61 historical societies 20, 38, 43, 60, 61, 63, 78, 79, 82, 83, 84, 85, 99, 128, 200, 236 273, 283, 289, 380 Hyslop, Anthea 428, 430, 432 Hyslop, Robert 430, 432, 433, 435, 436, Hyslop, Robert 430, 432, 433, 435, 436, 438, 440 Indigenous see Aborigines Ingham, Sidney 420, 421, 423, 425, 426, 428 Ingham, Sidney 420, 421, 423, 425, 426, 428 Hohnen, Ross 51, 67, 72, 74, 93-94, 116, 411, 412, 413, 414, 416, 417, 419, 420, 422, 424 Inglis, Ken 28, 42, 49, 51, 60, 74, 81, 104, Inglis, Ken 28, 42, 49, 51, 60, 74, 81, 104, 105, 120, 125, 146, 167, 168, 178-80, 200, 216, 285, 287, 333, 399, 400, 420, 421, 422, 424, 425, 427, 428, 430, 431, 441 105, 120, 125, 146, 167, 168, 178-80, Hoinville, Fred 307 420, 421, 422, 424, 425, 427, 428, Holmes, Jenny 405 430, 431, 441 Holroyd, Michael 310 Karmel, Peter 277 Lake, Marilyn 24, 426, 428, 429, 431, 432 Lane-Poole, Richard 411, 413, 414 Kauffman, Edna 146, 155, 167, 187, 200, 207, 390, 406 Lang, Jack 144, 145 Keldie, Aileen 352 Lang , John Dunmore 315, 325 Kellock, Peter 406 Langmore, Di 1, 27, 29, 119, 142, 153, 155, 159, 163, 181-200, 201, 244, 266, 287, 291, 292, 295, 320, 390, 401, 406, 433, 434, 436, 437, 438, 445 Kelly, Michael 330 Kelly, Ned & Kelly Gang 205, 355 433, 434, 436, 437, 438, 445 Kempt, Joseph Francis 258-59 Kendall, John 429, 431, 432, 434, 435, 437, 439, 440 Kendall, John 429, 431, 432, 434, 435, Lanyon, Eric 412, 413 437, 439, 440 Lap, Phar 172-73 Keneally, Tom 186 Lascaris, Manoly 311 Latham, John 144 Kennedy, Kett 420, 421, 423, 424, 426, 427, 429 Kennedy, Kett 420, 421, 423, 424, 426, Laverty, John 412, 413, 415, 416, 418, 419 Labour Australia website 220 Lack, Clem 412, 413, 415, 416, 418 Joyce, Roger 330, 412, 413, 415, 416, 418 Lack, John 277, 279, 280, 284, 290, 406, 425, 428, 429, 431, 432, 433, 434, 435, 436, 437, 438, 439, 444 juliana typeface & book production features 97-98 Hope-Johnstone, Nerida 406 Horner, David 195, 242, 277, 280, 290, 313, 428, 430, 432, 433, 434, 435, 436, 437, 438, 439 Horner, Jolyon 187, 200, 406 Howarth, Barry 384 Jackson, Archie 145 Jackson, Frank 292, 436, 438 Howe, Ann 406 Jackson, Frank 292, 436, 438 Howe, Jackie 231 481 The ADB's Story Kerley, Margot 428, 430, 432 Jackson-Nelson, Marjorie 401 Jalland, Patricia 195 Kerwin, Dale 440 Kerr, Colin 113, 213 James, Gwyn F. 67, 74, 97-98 see also Melbourne University Press Kerr, John 231 see also Melbourne University Press Kevin, Catherine 217, 440 Jamison, John 250 Kieran, Bernard Bede 256 Jebb, Mary Anne 429, 431 Jeffery, Michael 197, 200, 401 King, Hazel 228, 412, 413, 415, 416, 418, 419, 421 422, 424, 425, 427 419, 421 422, 424, 425, 427 Jennings, Reece 166 Jennings, Rosemary 167, 185, 187, 200, 390 406 Kingston, Beverley 3, 26, 225, 228, 280 Jobling, Ian 429, 430, 432, 433, 435, 437 286, 290, 291, 418, 419, 421, 422, 424, 425, 427, 429, 430, 432, 433, John Oxley Library 85, 231 434, 435, 436, 437, 438, 439, 440 Johns, Fred 8, 379, 389 Johnson, Jack 307 Kinnane, Stephen 438 Johnson, Samuel 23, 25 Kivell, Rex Nan 309 Kivell, Rex Nan 309 Knowles, George 174 Johnston, George 156, Konishi, Shino 440 Johnston, Susan 406 Korolev, Max 379, 388, 390 Johnston, William (Ross) 146, 166, 229, Korolev, Max 379, 388, 390 284, 425, 426, 427, 428, 429, 430, Kramer, Leonie 225 Kramer, Leonie 225 Kruty, Paul 313 Johnstone, Robert 360 Kunz, Egon 415, 416 Jones, Barry 174-5, 332 La Nauze, John 2, 15, 52, 58, 67, 72, 78, 82, 85, 105, 118, 119 134, 138, 153, 176, 178-79, 285, 399, 411, 412, 414, 415, 416, 417, 419, 421, 422, 424 La Nauze, John 2, 15, 52, 58, 67, 72, 78, 82, 85, 105, 118, 119 134, 138, 153, 176, 178-79, 285, 399, 411, 412, 414, 415, 416, 417, 419, 421, 422, 424 Jones, David 250 Jones, Helen 216, 420, 421, 423, 424, 426, 427, 429, 431, 432, 434, 435, 437, Jones, Helen 216, 420, 421, 423, 424, 426, 427, 429, 431, 432, 434, 435, 437, 438, 440, 445 Labour Australia website 220 Jordens, Ann Mari 406 Award 200 Mannix, Daniel 23, 144, 331 Linegar, Chris 406 Mansergh, Nicholas 54 links to ADB Online, interoperability 198-99, 354, 366-69, 390, 391 Mansfield, Bruce 228, 412, 413, 415, 416, 418, 419, 421, 422, 424, 425 lists, subjects, see subject lists, ADB 418, 419, 421, 422, 424, 425 manufacturers, merchants and businessmen 249-50, 252, 259, 261, 383 Lloyd, Clem 144, 428, 430, 432, 433 Logan, Greg 429, 430 Long, Gavin 16, 72, 114, 242, 408 see also representation see also representation Longhurst, Robert 429, 430 Marsden, Susan 429, 431 Marsh, Dave 439 Love, John 136, 420, 421, 423, 424, 426, 427, 429, 431, 432, 434, 435, 437, 445 Marshall, Henrietta, aka H. E. Marshall 359 Love, Peter 435, 437, 439, 440 Marshall, Juli 384 Low, Anthony 95, 301 Marshall, T. 426, 428, 429 Lowe, Charles 246 Martin, Allan 24, 30, 31, 49, 57, 74, 85, 167, 300, 308, 315, 316, 333, 375, 377, 415, 417, 418, 420 Loyau, George 379 Lukis, Mollie 60, 81, 85, 412, 414, 415, 377, 415, 417, 418, 420 417, 418, 420, 422, 423, 425, 426, 428 Massam, Katharine 434 Ly, Judith 408 Matthew, Colin 311, 355 Maude, Henry 415 Lycett, Joseph 258 Mawson, Douglas 45 Lyons, Enid 333 Lyons, Joe 144 Mawson, Paquita 306 May, Dawn 429, 430, 432, 433, 435, 437 MacArthur, Douglas 313 McAllister, Ian 187, 292, 433, 434, 438 Macarthur, Hannibal 133, 302 McAuley, James 309 Macarthur, John (and his sons) 8, 16, 63, 90, 302, 303 McBride, Dorothy 406 McCallum, Colin 412, 414 McCalman, Janet 193, 195, 289, 406 MacCallum, Duncan 412, 413 MacCallum, Mungo 264 McCalman, Vicky 406 MacDonagh, Oliver 167 McCarthy, Davis 197 Kent, Bill 153 Lawson, Henry 315 Kent, Hilary 146, 164, 165, 376, 384, 406 Kerin, Rani 3, 379, 383, 390, 406 482 Index Layman, Lenore 425, 426, 428, 429, 430, 431, 432, 434, 436, 437, 439, 441 Mackillop, Mary 355 Mackinnon, Alison 195 Lazzarini, Hubert 174 Macmillan, David 412, 413, 415 Lee, David 440 Macquarie, Lachlan 8, 16, 63, 90, 92, 99, 147, 158, 169, 273, 315 Macquarie, Lachlan 8, 16, 63, 90, 92, 99, Lee, Margaret 197 147, 158, 169, 273, 315 Lee, Sidney 36, 319, 348, 357, 382 Macquarie University 168, 170, 195, 287, 289, 291, 295, 324 289, 291, 295, 324 Leeper, Alexander 246 Mahalm, Dianne 406 Lewis, Darrell 392, Mahon, Hugh 122, 332 Lewis, Essington 144 Main, Jim 216, 414, 415, 416, 417, 418, libraries, association with ADB (including state library boards) xii, 31, 34, 38, 58, 60, 78, 84, 85, 192, 196, 199, 252, 271, 273, 377, 380, 389 419, 420, 422, 424 Mander-Jones, Phyllis 72 Mandle, Bill 157 Manford, Toby 420, 422, 423, 425 see also National Library of Australia Manners, Alison 143, 406 see also National Library of Australia Lincoln, Merrilyn 146, 156, 266, 406, 424, 425, 427 Lincoln, Merrilyn 146, 156, 266, 406, Manning Clark House, National Cultural Award 200 representation 437, 439, 440 Mills, Jenny 434, 436, 437, 439, 441 Milne, Taylor 72 Milne, Taylor 72 McManners, John 79, 84 Milroy, Jill 434, 436, 437, 439 McMinn, Gregory 222, 411, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, 422, 424, 425, 427 McRae, Malcolm 79, 411, 412, 413 McRae, Malcolm 79, 411, 412, 413 McRae, Mary 79, 83, 420, 421, 423, 424, 426, 427, 429 Mitchell, Ann 407 Mitchell, Ann 407 Mitchell, Bruce 171, 228, 419, 421, 424, 427 McCarthy, Davis 197 MacDonald, Lorna 421 McCarthy, Gavin 195, 197, 203-4, 289, 390 Macintyre, Stuart 144, 195, 288, 329-31 483 The ADB's Story McCarthy, John 419, 421, 422, 424, 425, 427, 428, 430, 432, 433, 435, 436, 438, 439 McCarthy, John 419, 421, 422, 424, 425, 427, 428, 430, 432, 433, 435, 436, 438, 439 McCarthy, Perditta 427 428 430 432 433 435 436 Medcalf, Margaret 415, 417, 418, 420, 422, 423, 425, 426, 428, 429, 431, 432 Medley, John 144 McCarthy, Perditta Meere, Ivy 146, 159, 207, 407 McCarthy, Perditta 427, 428, 430, 432, 433, 435, 436, Melba, Nellie 23, 45, 144 Melbourne University Press (also Melbourne University Publishing, 2003-) 12, 14, 35, 90, 93, 97-98, 134, 162, 164, 181, 191, 192, 208, 274, 287, 290, 326, 332, 374, 383, 386-87, 399 advance and royalties 170, 196, 399 book sales of the ADB 162, 196, 386 contract and publishing agreements with ADB 29, 162, 196, 287 see also Directors: Gwyn James (1943-62) Peter Ryan (1962-88) Brian Wilder (1989) John Iremonger (1990-93) Brian Wilder (1993-96) John Meckan (1997-2002) Louise Adler, CEO (2003-) 438, 439 Melbourne University Press (also Melbourne University Publishing, 2003-) 12, 14, 35, 90, 93, 97-98, 134, 162, 164, 181, 191, 192, 208, 274, 287, McCaughey, Davis, 307 McClelland, Jim 304 McConnell, Ruth 197, 406 162, 164, 181, 191, 192, 208, 274, 287, McCrae, George Gordon 95 McCrae, Georgiana 95 McCrae, Malcolm 59, 60, 72 McDonald, Donald 240, 273, 274, 428 McDonald, Jessie see Serle, Jessie McDonald, Lorna 423, 424, 426, 427, 429, 430, 432, 433, 435, 437, 438 McDonald, Lorna 423, 424, 426, 427, 429, 430, 432, 433, 435, 437, 438 McDonald, Prudence 217, 440 McGiness, Valentine 332 McGinness, Mark 3, 22, 332-34, 375 McGowan, Barry 197, 390, 406 McGowen, Jim 144 McGrath, Ann 244, 436 John Iremonger (1990-93) McIlwraith, John 434, 436, 437, 439, 441 McInnes, Colin Campbell 310 John Meckan (1997-2002) McKay, Belinda 435, 437, 438, 440 Louise Adler, CEO (2003-) McKell, William 159 Mellor, Suzanne 407 Mellor, Suzanne 407 McKernan, Michael 31, 172 Melville, Leslie xi, 12, 34, 51, 56, 60, 65, 93 McLachlan, Noel 299, 324 Menghetti, Diane 429 Mennell, Philip 7, 379, 389 McLaren, Ian 82, 412, 414 Menzies, Robert 115, 309, 399 McLaughlin, John Kennedy 432, 433, 435, 437, 438, 440 Merrett, David 437, 439, 440 McLean/Irinyili, Mick 282 Meux, Lady see Langton, Valerie McLellan, John 213, 412, 413, 415 military, 23, 24, 61, 79, 164, 173, 201, military, 23, 24, 61, 79, 164, 173, 201, military, 23, 24, 61, 79, 164, 173, 201, 242-43, 243, 250, 287, 310, 329, 357 see also diggers and representation Miller, Eric 274, 275 Mills, Jenny 434, 436, 437, 439, 441 242-43, 243, 250, 287, 310, 329, 357 McLennan, Nicole 390, 406 McLeod, Beth 136, 406 McLeod, Elizabeth 420, 421, 423, 424, 426, 427, 429, 431, 432, 434 435, 437, 439, 440 Milthorp, Peter 407 missing subjects or ‘missing persons’ 26, 170, 290, 295, 305, 319, 348, 357, 361 Meckan, John 97 Mitchell, Glen 223, 438, 440 see also Melbourne University Press 484 Index Mitchell Library 85, 128, 221, 222, 226, 228, 252, 286 museums xii, 109, 150, 192, 195, 253, 347, 348, 360, 365 Mitchell Library 85, 128, 221, 222, 226, 228, 252, 286 museums xii, 109, 150, 192, 195, 253, 347, 348, 360, 365 museums xii, 109, 150, 192, 195, 253, 347, 348, 360, 365 Mitchell, Thomas 299, 328, 333 Mutch, T. D. & Mutch index 252 Mockridge, Russell 240 Myer Foundation 115, 170, 398, 401 Moles, Ian 420, 421, 423, 424, 426, 427 Molony, John 157, 167, 200, 205-06, 407, 441 Myer, Merlyn 333 Molony, John 157, 167, 200, 205-06, 407, 441 Monash, John 23, 142, 144 Nairn, Bede 22, 27, 28, 29, 44, 108, 109, Nairn, Bede 22, 27, 28, 29, 44, 108, 109, Monash University 93, 139, 155, 195, Monash University 93, 139, 155, 195, 218, 263, 284 114, 118, 119, 131-46, 147, 158, 174, 205, 219, 227, 266, 278, 281, 282, Moncrieff, Gladys 144 294, 301, 306, 317, 323, 381, 382, 30, 432, 433, 294, 301, 306, 317, 323, 381, 382, Moore, Andrew 16, 218, 430, 432, 433, 435, 437, 438, 440 384, 399, 400, 407, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, Moore, John Ross 312 422, 423, 424, 425, 427, 428, 429, Moran, Geoff 144 Moran, Patrick Francis 250 430, 432, 433, 435, 437, 444, 445 Moran, Rod 299 National Archives, Australia 195, 199, 357 Morgan, Helen 197 National Archives, Kew 357 Morris, Deirdre 134, 407 National Army Museum (Chelsea) 253 Morris, John 440 National Centre of Biography (NCB) 3, 32, 191, 292, 318, 354, 392, 401 proposed National Life History Project 2002 188, 189 Morrison, Allan 72, 73, 74, 411, 412, 413, 414, 415, 416, 417, 418, 419, 428, 430 414, 415, 416, 417, 418, 419, 428, 430 Mossenson, David 412, 414, 415, 417, 418, 420, 422 National Committee, ADB 10, 17, 19-20, 34, 40-41, 42, 58, 59, 62, 68, 72, 74, 74, 77, 80, 93, 95, 99, 101, 105, 111, 133, 134, 140, 179, 188, 246, 264, 280-82, 285, 286, 326, 327, 397, 398, 399, 400, 401, 411, 412-13, 414, 416, 417, 419, 422 Mowll, Howard 309 Moyal, Ann 2, 3, 13, 14, 15, 16, 53, 76, 77, 78-85, 86-87, 90, 279, 379, 397, 407, 427, 429 Moye, Ros 407 Women Australia O’Neill, Bernard 217, 440 periodisation in ADB 10, 23, 26, 29, 36, O’Shea, Helen 407 O’Shea, Helen 407 New South Wales Geographical Names Board 227 New South Wales Working Party see working parties Newell, Jenny 407 Newman, Betty 407 Newman, John Henry 355 Newman-Martin, Andrew 197, 407 Nichol, Lawrence 42 Nicholls, Mary 407 Nicholson, James 109 Ninham, Barry 205 Nissen Judith 200 407 New South Wales Geographical Names Board 227 New South Wales Working Party see working parties Newell, Jenny 407 Newman, Betty 407 Newman, John Henry 355 Newman-Martin, Andrew 197, 407 Oxford Dictionary of National Biography (ODNB) 307, 308, 311, 314, 315, 316, 318, 345-71, 375, 376, 390, 392 see also Dictionary of National Oxford Dictionary of National Biography (ODNB) 307, 308, 311, 314, 315, 316, 318, 345-71, 375, 376, 390, 392 see also Dictionary of National Biography O f d U i i P 9 116 192 283 316 Newman, Betty 407 Oxford University Press 9, 116, 192, 283, 316 Newman, John Henry 355 Newman-Martin, Andrew 197, 407 Pacific Working Party see working parties Nichol, Lawrence 42 Nichol, Lawrence 42 Pacific Working Party see working parties Page, Carolyn 407 Page, Carolyn 407 Nicholls, Mary 407 Page, Geoff ix, 3 Nicholson, James 109 Nicholson, James 109 Palmer, Vance 144 Ninham, Barry 205 Parker, Fabian 197 Nissen, Judith 200, 407 Parker, Robert 411, 413 Nolan, Melanie xii, 1, 33, 191, 277, 279, 280, 290, 292, 320, 375, 379, 383, 388, 390, 401, 407, 439 Parks, Margaret 407 g Parsons, Vivienne 407 Partington, Geoffrey 375 Partridge, Bridget 305 Oakes, Gerard 407 Labour Australia O’Loghlin, Gillian 167, 407 O’Neill, Bill 10 O’Neill, Bill 10 39, 144, 168-69, 213, 220, 223, 257, O’Neill, Robert J. (Bob) 24, 125-27, 136, 146, 242, 243, 417, 419, 420, 421, 422, 423, 424, 425, 426, 427, 429, 430, 431, 433 O’Neill, Robert J. (Bob) 24, 125-27, 136, 146, 242, 243, 417, 419, 420, 421, 422, 423, 424, 425, 426, 427, 429, 430, 431, 433 282, 303, 327, 349-50, 362, 373, 380 282, 303, 327, 349-50, 362, 373, 380 Period 1 (1788 to 1859) 99, 168, 308 (1788 to 1826) 10, 35, 44, 59, 79 (1826 to 1850) 35, 44, 59, 80, 82 Period 2 (1851 to 1890) 44, 60, 61, 68, 73, 82 Period 3 (1891 to 1939) 52, 140, 142, 176, 217, 242 Period 4 (1940 to 1980) 25 162, 183, 201, 221, 278, 309 Period 5 (1981 to 1990) 29, 170, 183 O’Neill, Sally 114, 115, 125-26, 134, 142, 144, 407 Online Heritage Resource Manager Oakes, Gerard 407 obituaries 209, 223, 231, 232, 318, 324, 377 Partridge, Perc 9 Pastoral Review 392 Obituaries Australia website 33, 354, 369, 370, 389, 401 Pasts and Present Conference 2009 see conferences O’Brien, Eris 16 Paton, George 10 O’Brien, John 323 O’Brien, John 323 Paton, John 256 O’Connor, Kate 305 O’Connor, Kate 305 payment (non-payment) of authors see authors, ADB, payment of Odgers, George 424 Odgers, George 424 O’Donnell, Jonathon 197 O’Donnell, Jonathon 197 p y Pearce, Ian 420, 421, 423, 424, 426, 427 O’Donoghue, Kathleen 407i O’Donoghue, Kathleen 407i Peart, Charles Owen 256 Officer, Robert 318, 324 Officer, Robert 318, 324 Pederson, Peter 242 Oglivie, Charlene 407 Oglivie, Charlene 407 Pemberton, Penny 407 O’Hagan, Margaret 421, 423, 424, 426, 427, 429, 430 People Australia 29, 198, 389 402 see also: Obituaries Australia Labour Australia Women Australia O’Keeffe, Mary 415, 416, 418, 419, 421 423, 424, 426, 427 People Australia 29, 198, 389 402 see also: Obituaries Australia Labour Australia Women Australia periodisation in ADB 10, 23, 26, 29, 36, 39, 144, 168-69, 213, 220, 223, 257, 282, 303, 327, 349-50, 362, 373, 380 Period 1 (1788 to 1859) 99, 168, 308 (1788 to 1826) 10, 35, 44, 59, 79 (1826 to 1850) 35, 44, 59, 80, 82 Period 2 (1851 to 1890) 44, 60, 61, 68, 73, 82 Period 3 (1891 to 1939) 52, 140, 142, 176, 217, 242 Period 4 (1940 to 1980) 25 162, 183, 201, 221, 278, 309 Period 5 (1981 to 1990) 29, 170, 183 Moye, Ros 407 Mozley, Ann see Moyal, Ann Mulcahy, Clement 429, 431. 432, 434, Mulcahy, Clement 429, 431. 432, 434, 436, 437, 439, 441 National Library of Australia (NLA) 120, 122, 135, 195, 198, 199, 252, 273, 353, 389, 400 Picture Australia deal 198 see also Commonwealth National Library Mulcare, Philip 432, 433, 435, 436, 438, 439 Munro, David ‘Darby’ 144 Murdoch, Keith 144 Murdoch University 297 Murphy, Denis J. 136, 144, 229, 230, 234, 284, 419, 421, 422, 423, 424, 426 National Museum of Australia 195 National Register see Biographical Register Murphy, Herbert Dyce 23, Murphy, Herbert Dyce 23, Neale, Margo 244, 436 Neale, Margo 244, 436 Murphy, John Joseph 274, 275 Neale, R. S. 32, 385 Neasey, Francis 429, 431 Murphy, Lionel 332 Murphy, William 407 Neish, Peter 197 Murray, Jack 144 Murray, Jack 144 Nethercote, John 3, 279, 436, 438, 440, 441 Murray, Richard 256 network analysis (of associational lives, family history, kinship and place) 32, 198, 199, 354-55, 357, 391-93 Murray, Robert 437, 439, 440 Murray-Smith, Stephen 300, 320, 333, 420, 421, 423, 425, 426, 428, 430, 432 Murray-Smith, Stephen 300, 320, 333, 420, Neutze, Max 422, 424, 425, 427, 428, 430 421, 423, 425, 426, 428, 430, 432 New England subcommittee see working parties Museum of Australian Democracy 365 485 The ADB's Story (OHRM) 203 Oppenheimer, Melanie 439 Pickersgill, Jeannette 361-62 Radi, Heather 25, 31, 146, 150-51, 171, 219, 228, 279, 281, 419, 420, 421, 422, 423, 424, 425, 426, 427, 428, 429, 430, 431, 432, 433, 435, 437 Radi, Heather 25, 31, 146, 150-51, 171, Portus, G. V. 104 Portus, G. V. 104 Powell, Graeme 428, 430, 432, 433, 435, 436, 438, 440 Poynter, John 2, 146, 246-47, 305, 417, 419, 420, 421, 422, 423, 424, 425, 426, 427, 428, 429, 430, 431, 432, 433, 434, 436, 437, 439, 440 Poynter, John 2, 146, 246-47, 305, 417, see also selection criteria Research School of Social Sciences (RSSS), Research School of Social Sciences (RSSS), see also Dictionary of New 486 Index Primrose, Neil 419, 421, 422 Procter, Thea 305 provisional Editorial Board 10, 38, 58, 59, 63, 65, 67, 88, 90, 93, 397, 398 publication subsidy 12, 35, 399 Primrose, Neil 419, 421, 422 Period 6 (1991 to 2000) 170, 188, 374 Perdriau, Henry Carter 256 Perry, Joseph 305 persistent identifiers 198-99 P t Littl F 244 45 436 438 440 Procter, Thea 305 Perry, Joseph 305 persistent identifiers 198-99 Peters-Little, Frances 244-45, 436, 438, 440 Petherick Reading Room, NLA 120, 122, 135 Queensland Working Party see working parties Quinn, John 305 Quirk, Sandon 408 quod vide (qv) 382 quotas see working party quotas Petrow, Stefan 290, 429, 431, 432, 434, 435, 437, 439, 440 Phillips, Nan 45, 114, 120-21, 134, 137, 141, 209, 250, 251, 273, 301, 379, 407 Quinn, John 305 Quirk, Sandon 408 Pickering, Paul 26, 277, 306, 307, 439 quod vide (qv) 382 Pickersgill, Henry Hall 361 quotas see working party quotas Pickersgill, Jeannette 361-62 Piggott, Michael 1 Pike, Douglas 2, 5, 14, 17, 27, 28, 36, 41, 43, 44, 59, 60, 67, 72, 73, 74, 75, 77 80, 81, 84, 93, 97, 99, 101-19, 120, 122, 125, 131, 133, 134, 136, 140, 142, 178, 213, 216, 250, 251, 266, 271, 278, 281, 299, 317, 321, 327, 328, 333, 380, 398, 399, 408, 411, 412, 413, 414, 415, 416, 417, 419 80, 81, 84, 93, 97, 99, 101-19, 120, 429, 430, 431, 432, 433, 435, 437 122, 125, 131, 133, 134, 136, 140, Raftery, Judith 217, 432, 434, 435, 437, 438, 440 Raftery, Judith 217, 432, 434, 435, 437, 142, 178, 213, 216, 250, 251, 266, 271, 278, 281, 299, 317, 321, 327, Rand, Anne 136, 200, 408, 412, 413, 429, 431, 432, 434, 435, 437, 439, 440, 445 328, 333, 380, 398, 399, 408, 411, 412, 413, 414, 415, 416, 417, 419 Rasmussen, Carolyn 290, 434, 435, 437, 439, 440 Pike, James E. 173 Rayner, Keith 412, 413, 415 Pike, Olive 301 Pilger, Alison 408 Read, Peter 244, 436, 438, 440 Pioneers Association of South Australia 216 Reece, Robert 425 426, 428, 429, 431 Pitt, George 80, 81, 213 Refshauge, Richard 408 Playford, Aldona 408 Registrars General (state) 135-36, 357, 367 Playford, John D. 136, 146, 213, 216, 217, 284, 420, 421, 422, 423, 424, 425, 426, 427, 428, 429 430, 431, 432 Reibey, Mary 250 Reibey, Mary 250 Reid, Margaret 400 Reid, Margaret 400 426, 427, 428, 429 430, 431, 432 representation in the ADB 21-27, 44, 168- 9, 170, 223, 231, 234, 255, 282, 284, 304, 305-10, 319, 329, 332, 362, 392 of Aborigines 25-26, 170, 244- 45, 291, 306, 332 of scientists 263 of sexuality 310-15, 334 of women 24-25, 26, 150, 169, 170, 219, 223, 291, 305-06, 308, 330, 333 Plowman, Colin 422, 424, 425, 427, 428 Polding, John Bede 133, 315, 323 Pomeroy, John 305 Pomeroy, John 305 Poole, Frederick 305 Evershed and Kent Fitch) 391 Rowlands, Penny 408 ) Reynolds, Henry 24, 419, 422 Rowse, Tim 244, 245, 436, 438, 440 Reynolds, John 83, 324, 412, 413, 415, 417, 418, 420, 421, 423, 424, 426 Royal Australian Historical Society 63, 83, 128 Richards, Eric 300 Journal of the RAHS 144 Royal Geographical Society of Austr Royal Geographical Society of Australasia (SA branch) 216 Richards, Michael 420, 421 Richards, Michael 420, 421 Robertson, Heather 408 Robertson, Heather 408 Robertson, John 145 Robertson, John R. 411, 413, 414 Robertson, Margaret 200, 408 Robin, Libby 433, 435, 436, 438, 440 Robinson, Judith 72, 379, 408 Robinson, Olivia 435, 437 Robson, Lloyd 309, 319 Roe, Jill 3, 26, 27, 32 160 168, 170, 171, 185, 187, 188, 189, 191, 192, 195, 218, 225, 257, 277-94, 295-96, 400, 401, 425, 427, 428, 429, 430, 431, 432, 433, 434, 435, 436, 437, 438, 439, 440 Romano, Azzalin 158 reviews of ADB Online 391 2009 ANU Supercomputer Facility (Ben Evans and Stuart Hungerford) 391 2010 (Tim Sherratt) 391 2010 Project Computing (John Evershed and Kent Fitch) 391 Rookwood cemetery 254, 256 Rose, Barrie 417, 418, 419, 420 Routh, Spencer 136, 229- 33, 234-5, 419, 421, 423, 424, 426, 437, 429, 430, 432, 433, 435, 437, 438, 440, 445 432, 433, 435, 437, 438, 440, 445 2010 (Tim Sherratt) 391 Rowan, Ellis 305 2010 Project Computing (John Evershed and Kent Fitch) 391 (SA branch) 216 Richardson, Gordon 134, 219, 220, 221, 227, 412, 413, 415, 416, 418 ( ) Royal Military College, Duntroon 125, 261 Rickard, John 420, 421, 423, 425, 426, 428, 429, 431 432, 434, 435, 437, 439, 440 Rubinstein, Helena 246, 305 Preston, Margaret 305 ANU 5, 9, 10, 16, 51, 57, 68, Directors of RSSS 72, 118, 168, 169, 178, 187, 189-91, 194, 249, 250, 278, 287, 291, 292, 381, 397, 401 Price, Archibald Grenfell Price, Archibald Grenfell 28, 80, 112, 113, 114, 213, 216, 412, 413, 415 Price, Archibald Grenfell 28, 80, 112, 113, 114, 213, 216, 412, 413, 415 Price, Kaye 244, 436, 438, 440 28, 80, 112, 113, 114, 213, 216, 41 Price, Kaye 244, 436, 438, 440 487 The ADB's Story Geoffrey Sawer (1949-56) Keith Hancock (1956-61) P. H. Partridge (1961-68) W. D. (Mick) Borrie (1968-73) [Acting Director] Geoffrey Sawer (1973-74) A. J. (Sandy) Youngson (1974-80) Max Neutze (1980-85) Paul Bourke (1985-91) Geoffrey Brennan (1991-96) Ian McAllister (1997-2004) Frank Jackson (2004 -05) [Acting Director] Rod Rhodes (2005-07) Rod Rhodes (2007-08) Dave Marsh (2008-10) Adam Graycar (2010-) 285, 286, 287, 288, 289, 291, 292, 295, 302, 304, 306, 319, 320, 352, 376, 384, 387, 400, 428, 430, 431, 433, 434, 436, 444, 445 reviews of ADB reviews of ADB 1986 (Paul Bourke, chair) 30, 179, 205, 266, 385, 400 2002 Editorial Board sub- committee (Jill Roe chair) 187- 89, 286, 401 2006 as part of a general review of RSSS (Colin Lucas chair) 189-90, 401 2007 (Bob Gregory chair) 190-91, 292, 401 Roe, Michael 49, 92, 136, 146, 236-37, 277, 279, 290, 323, 412, 413, 417, 418, 420, 421, 422, 423 424, 425, 426, 427, 428, 429, 430, 431, 432, 433, 434, 435, 436, 437, 438, 439, 440, 444, 445 418, 420, 421, 422, 423 424, 425, 426, 427, 428, 429, 430, 431, 432, 433, 434, 435, 436, 437, 438, 439, 440, 444, 445 Romano, Azzalin 158 Rudd, Kevin 186 Rudd, Kevin 186 Rutledge, Martha, see Martha Campbell Ryan, Jan 434, 436, 437, 439, 441 Rutledge, Martha, see Martha Campbell South African Dictionary of Biography 37, 109 306, 377, 382, 384, 386, 399, 400, 408, 411, 412, 413, 414, 415, 416, South Australian Working Party see 417, 418, 419, 420, 421, 422, 423, 424, 425, 426, 427, 428, 429, 430, working parties Spate, Oscar 92, 250, 323 Spate, Oscar 92, 250, 323 Spearritt, Peter 31, 220 Serle, Jessie 139 Serle, Percival 8, 37, 42, 49, 397, 398 Spillman, Ken 432 spin-offs, ADB 31 Service, James 144 Sainty, Malcolm 384 Sainty, Malcolm 384 424, 425, 427, 428, 430, 445 Shaw, George 305 Salmon, J. H. (Jock) 72, 133, 411, 413 Sheehan, Colin 424, 426, 427, 429, 430, Sandow, W. 408 Sheehan, Colin 424, 426, 427, 429, 430, 432, 433, 435, 437 432, 433, 435, 437 Sant, Mowbray Lees 351 Sawer, Geoffrey 68, 72, 93-94, 250, 399, Sherratt, Tim 391 Sawer, Geoffrey 68, 72, 93-94, 250, 399, 411, 413, 414, 416, 417, 419, 420, 421, 422, 424 Sawer, Geoffrey 68, 72, 93-94, 250, 399, 411, 413, 414, 416, 417, 419, 420, Shineberg, Dorothy 273, 415, 416, 418, 419 411, 413, 414, 416, 417, 419, 420, 421, 422, 424 421, 422, 424 Shoesmith, Dennis 408 Sawtell, Michael 294 Simpson, Caroline 170, 401 Scarr, Deryck 415, 416, 418, 419 Singleton, Gwyn 408 Schaller, Michael 313 Skemp, J. R. 271 Schmidmaier, Dagmar 221, 228, 433, 435, 437 Skuthorp, Lance 232 Scott, Joanne 435, 437, 438, 440 Smart, Judith 423, 425, 426, 428, 429, Smart, Judith 423, 425, 426, 428, 429, 431, 432, 434, 435, 437, 439, 440 selection criteria or principles 431, 432, 434, 435, 437, 439, 440 selection criteria or principles 22, 30, 34, 43, 61, 74,80, 81, 82, 83, 85 105, 109, 164, 208, 216-17, 219, 221, 223, 224, 225, 229, 231, 244, 253, 256, 259, 283, 291, 311, 326, 327, 373, 376, 380 Smith, Allie 197 Smith, Ann 72, 122, 135, 142, 144, 159, 176-77, 383, 408 221, 223, 224, 225, 229, 231, 244, Smith, Anne 429 253, 256, 259, 283, 291, 311, 326, 327, 373, 376, 380 Smith, Bernard 31, 144, 400 Smith, Bruce 197 see also representation in the ADB 415, 441 sequence: alphabetical, chronological or thematic 7, 27, 31, 58, 80, 108, 144, 347, 351, 370 Smith, George, M. 36 Smith, Granny 306 Serle, Geoffrey 2, 14, 25, 27, 28, 29, 44, 52, 58, 61, 67, 68, 71, 72, 73, 74, 78, 82, 84, 85, 93, 119, 120, 131-46 147, 158, 159, 160, 166, 174, 218, 263, 266, 277, 278, 283, 284, 301, 306, 377, 382, 384, 386, 399, 400, 408, 411, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, 422, 423, 424, 425, 426, 427, 428, 429, 430, 431, 432 Serle, Geoffrey 2, 14, 25, 27, 28, 29, 44, 52, 58, 61, 67, 68, 71, 72, 73, 74, Smith, Neil 408 Smuts, Jan 9, 17, 37, 88 78, 82, 84, 85, 93, 119, 120, 131-46, Somerville, Ross 289 Souter, Gavin 164, 222, 425, 427, 428, 429, 430, 432, 433 147, 158, 159, 160, 166, 174, 218, 263, 266, 277, 278, 283, 284, 301, South African Dictionary of Biography 37, 109 439, 440 Ryan, Jan 434, 436, 437, 439, 441 Rimmer, Gordon 414, 415, 417 488 Index Ryan, John A. 228, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, 422, 424, 425, 427 sexuality of subjects, see representation 308, 310-15, 334 shared ADB entries 128 Ryan, Lyndall 309 Sharman, Robert 60, 79, 412, 413, 415, 416 Sharp, Patti 408 Ryan, Peter, 14, 25, 97, 134, 162, 304, Sharp, Patti 408 317, 374, 386, 387 Shaw, A. G. L. 59, 67, 328, 72, 74, 75, 99-100, 111, 271, 398, 411, 412, 413, 414, 416, 417, 419, 420, 421, 422, 424, 425, 427, 428, 430, 445 see also Melbourne University Press 414, 416, 417, 419, 420, 421, 422, see also representation in the ADB see also representation in the ADB Selth, Don 271 Selth, Don 271 Smith, Charles E. 411, 413, 414, 416, 417,419 Selth, Philip 3, 271-75 Smith, Dorothy 114, 146, 408 Selth, Philip 3, 271-75 Smith, F. Barry 167, 176-77, 178, 385, Smith, F. Barry 167, 176-77, 178, 385, 415 441 Sendzuik, Paul 217, 440 Sendzuik, Paul 217, 440 Smith, F. Barry 167, 176-77, 178, 385, 415, 441 parties Staunton, Anthony 432, 433, 435, 436, 438, 439 Tauman, Merab Harris see Harris, Merab Taylor, John 435, 437, 439, 440 Stephen, Leslie 36, 109, 307, 319, 348, 357, 375 Terrell, Deane 168 Thomson, Mrs 408 Stephen, Ninian 400 Thompson, John 138, 140, 420, 421, 423 430, 432, 433, 435, 436, 438, 440 Stephens, Alan 432, 433, 435, 438 Steven, Margaret 146, 150-51, 159, 266, 408 Thornton, Robert 429, 431, 432, 434 Stevens, David 433, 435, 436, 438, 439 Tillyard, Patricia see Wardle, Pat Stevenson, Brian 230, 440 Tilse, Sheila 146, 384, 408 Stewart, Neil 408, 419, 421 Titterton, Ernest 9 Stilwell, Geoffrey 83, 412, 413, 415, 417, 418, 420, 421, 423, 424, 426, 427, 429, 431, 432, 434 Tolhurst, Richard 174 Torney, Kim 200, 408 Trahai, Richard 384 Stock, Jenny Tilby 432, 434, 435, 437, Stock, Jenny Tilby 432, 434, 435, 437, 438, 440 Travers, Edna 411, 413, 414, 416, 417, 419 Stocking, Craig 439 Tregenza, John 49, 74, 213-17, 411, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, 423, 424, 426, 427, 429 Stoodley, June 412, 413, 415, 416, 418, 419, 421 420, 421, 423, 424, 426, 427, 429 Trigellis-Smith, Sydney 408 Strachey, Lytton 310 Sturt, Charles 113, 213 Sturt, Charles 113, 213 Tyrie, Margaret 409 Tasmanian Working Party see working Tasmanian Working Party see working parties Tasmanian Historical Research Association 60, 79, 83, 236 Association 60, 79, 83, 236 The Makers of the Sporting Sexton, Christopher 310 Tradition 31 489 The ADB's Story The Diggers 31, 164 sport 31, 162, 172, 350 Sutton, Regina 438, 440 The Diggers 31, 164 Sweeting, Alan 424, 425, 427, 428, 430, 432, 433, 435, 436, 438, 439 sport 31, 162, 172, 350 Squire, James 250, 254, 255, 257, 259 Stanley, Peter 440 Stanley, Peter 440 Tamblyn, Mary 415, 417, 418, 420, 422, 423, 425 Stannage, Tom 195, 420, 422, 423, 425, 426, 434, 436, 437, 439, 441 Tanner, Edgar 316 Staples, Arthur 415, 417, 418, 420, 422, 423, 425, 426, 428, 429, 431, 432 Tapp, Edward 411, 413, 414, 416 Stapleton, James 412, 413, 415 Tasmanian Historical Research Association 60, 79, 83, 236 Tasmanian Historical Research Strachey, Lytton 310 Trollope, Anthony 61 Strahan, Frank 420, 421, 423, 425, 426, 428, 429, 431, 432, 434, 435, 437, 445 Trompf, Gary 153 Tropea, Rachel 197 Strategic and Defence Studies, ANU 125 Trumper, Victor 131, 145, 305 Stretton, Hugh 60, 74, 81, 84, 118 Turnbull, Paul 429 Stretton, Pat 200, 216, 408, 429, 431, 432 434, 435, 437, 438, 440 Turner, David 408 Turner, Naomi 138, 408 Strickland, Edward 253, 255, 256 Twain, Mark 61 Tasmanian Working Party see working parties State Records Office of Western Australia 238 Association 60, 79, 83, 236 Starck, Nigel 388 subject lists, ADB subject lists, ADB 13, 17, 19, 20, 25, 32, 34-35, 37, 39, 42, 60-61, 71, 72, 73, 74, 79-82, 84, 85, 99, 108, 125, 134, 140, 144, 201, 216, 217, 219, 221, 223-25, 231, 240, 242, 244, 250, 253, 269, 302, 329, 350, 354-57, 358, 368, 376, 380, 392, 397, 398, 399 S lli R d 420 421 423 424 426 427 13, 17, 19, 20, 25, 32, 34-35, 37, 39, University House, ANU 54, 63, 194, 200, 401 42, 60-61, 71, 72, 73, 74, 79-82, 84, University of Adelaide 58, 59, 88, 104, 110, 113, 178, 266, 271, 295 University of Melbourne 52, 58, 74, 85, 88, 90, 93, 97, 99, 103, 105, 117, 139, 144, 153, 176, 183, 192, 195, 197, 201, 203, 246, 263, 400 Sullivan, Rodney 420, 421, 423, 424, 426, 427 490 Index Waterson, Duncan 218 Watson, Chris 145 Waugh, John 440 Weakley, Russ 197 Webb, Leicester 67 W bb Eli b th 311 Waterson, Duncan 218 Watson, Chris 145 Waugh, John 440 Weakley, Russ 197 Webb, Leicester 67 University of New England 58, 85, 283 University of New South Wales 58, 85 University of Newcastle 85, 283 University of Papua New Guinea 183 Weakley, Russ 197 University of Queensland 58, 85 Webb, Leicester 67 University of South Australia 58, 85, 195 Webby, Elizabeth 311 University of Sydney 58, 74, 85, 99, 131, 195 Wegner, Janice 429 Wensley, Penelope 320, 402 University of Sydney Press 9 University of Tasmania 58, 60, 74, 85, 101, 104, 105, 250 University of Tasmania 58, 60, 74, 85, Wentworth, D’Arcy and family biography 169, 171, 273, 325 101, 104, 105, 250 West, Francis 415, 416, 418, 419 University of Western Australia 58, 85, 104, 178 West, John 271 University of Wollongong 58, 85, 283 West, Linda 221, 440 Westwood, Susan 409 unsigned ADB entries 113-14, 213, 301, Whalan, Douglas 424, 425, 427, 428, 430, 431 302, 303, 324, 327 Uren, Malcolm J. 412, 414, 415, 417, 418, 420 Wheare, Kenneth 246 Whimpress, Bernard 217, 440 Vallis, Val 429, 430, 432 White, Michael 238 White, Patrick 311, 332 van den Bosch, Alan 197 White, Richard 21 Vazenry, Hank 409 White, Sam 334 Ventress, Alan 192, 193, 221, 226, 433, 435, 437, 438, 440 Whitlam, Gough 174-75, 240 verbs, use of in ADB entries 110, 134, 333 Whitlam, H. F. Wade, Abdul 231 Wade, Abdul 231i Williams C. M (Mick) 411, 413 Wakefield, E. G. 117 Williams, James 197 424, 425, 427, 429, 430, 432, 444, 445 Williams, Robin see ANU Vice-Chancellors Walker, Robin 413 Wilshire, James 250-1 Wilson, Paul D. 136, 229, 419, 421, 423, 424, 426, 427 Walker, William 411, 413 Walsh, Gerry 2, 3, 16, 219, 228, 249-60, Walsh, Gerry 2, 3, 16, 219, 228, 249-60, 261-2, 409, 419, 421, 422 Wimborne, Brian 167, 187, 200, 279, 375, 379, 390, 409 261-2, 409, 419, 421, 422 Walton, Margery 409 subject lists, ADB (Fred) 240 Who’s Who 223 Vial, William 256 Victoria River District Doomsday Book 392-93 Wikipedia 353, 371 Wilder, Brian 97 Wilder, Brian 97 Victoria Cross 256 see also Melbourne University Press Victoria Cross 256 see also Melbourne University Press Wilks, Stephen 318 Vynne, Eleanor 358 Vynne, Eleanor 358 Williams, Bill 20 Wade, Abdul 231 Wakefield, E. G. 117 424, 425, 427, 429, 430, 432, 444, 445 Walton, Margery 409 Winter, Gillian 136, 409 Ward, John M. 15, 59, 67, 69, 71, 72, 74, Ward, John M. 15, 59, 67, 69, 71, 72, 74, 75, 99, 228, 411, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, 422, 424 75, 99, 228, 411, 412, 413, 414, 415, Women Australia website 389, 402 416, 417, 418, 419, 420, 421, 422, 424 women in the ADB 23, 24-25, 26, 73, 150, 169, 170, 219, 223, 287, 291, 305-06, 308, 330, 333, 389, 402 Wollaston, John 297 Woodfull, W.M. 166 Woodhouse, Fay 409 Woodhouse, Margaret 332 women in the ADB 23, 24-25, 26, 73, 150, 169, 170, 219, 223, 287, 291, 305-06, 308, 330, 333, 389, 402 Wollaston, John 297 Woodfull, W.M. Walton, Margery 409 166 Woodhouse, Fay 409 Woodhouse, Margaret 332 Ward, Russel 21-2, 49, 67, 74, 134, 301, 411, 413 414, 416, 417, 418, 419, 420, 421, 422, 424, 425, 427, 428, 430 Wardle, Patience 30-31, 45, 50, 54, 57, 85, 273, 397 Wollaston, John 297 Waterhouse, Jill 436, 438, 440 Waterhouse, Jack 173 491 The ADB's Story Woodhull, Victoria 369 Woolley, John 264 working parties Armed Forces Working Party 72, 242-43 Commonwealth Working Party 20, 24, 34, 166, 189, 240, 263, 282, 400 Indigenous Working Party 20, 25, 244-45, 282, 401, 436, 438, 440 naval governors of New South Wales 10, 59 Newcastle Working Party 72 New England or Armidale, subcommittee 67, 72, 411, 413, 414, 416, NSW Working Party 69, 72, 171, 218-26, 227-28, 418 Pacific Working Party 10, 59 Queensland Working Party 229-33, 234-35 South Australian Working Party 80-81, 213-17 Tasmanian Working Party 82-3, 236-37 Victorian Working Party 61, 82 246-47 Western Australian Working Party 81, 238-39 informal sub-committee on foreign immigrant groups working party quotas 20, 23-24, 188, Youngson, Alexander 422 Woodhull, Victoria 369 Woolley, John 264 Zalums, Elmar 409, 412, 414 Zubrzycki, Jerzy 428 Newcastle Working Party 72 NSW Working Party 69, 72, 171, 218-26, 227-28, 418 Pacific Working Party 10, 59 Queensland Working Party 229-33, 234-35 South Australian Working Party 80-81, 213-17 Tasmanian Working Party 82-3, 236-37 working party quotas 20, 23-24, 188, 216, 240, 283, 325 216, 240, 283, 325 working party system xii, 20, 21, 27, 30, 34, 39, 42-43, 61, 108, 181 Manual of Instructions for Working Parties 61 proposed art working party 25, 31 proposed legal working party 25 proposed medical working party 25 proposed New Zealand working party 18 Wright, Jill 409 Yates, Arthur 306 Yeadon, Scott 379, 388, 390 Young, Ian 3, 338, 402 492
https://openalex.org/W3129149353	https://findresearcher.sdu.dk/ws/files/179223777/Larrabee_sonderlund_2021_The_association_between_maternal_ex.pdf	English	null	The Association between Maternal Experiences of Interpersonal Discrimination and Adverse Birth Outcomes: A Systematic Review of the Evidence	International journal of environmental research and public health/International journal of environmental research and public health	2,021	cc-by	20,503	Download date: 24. Oct. 2024 Citation for pulished version (APA): Sonderlund, A. L., Schoenthaler, A., & Thilsing, T. (2021). The association between maternal experiences of interpersonal discrimination and adverse birth outcomes: A systematic review of the evidence. International Journal of Environmental Research and Public Health, 18(4), Article 1465. https://doi.org/10.3390/ijerph18041465 Citation: Larrabee Sonderlund, A.; Schoenthaler, A.; Thilsing, T. The Association between Maternal Experiences of Interpersonal Discrimination and Adverse Birth Outcomes: A Systematic Review of the Evidence. Int. J. Environ. Res. Public Health 2021, 18, 1465. https://doi.org/10.3390/ ijerph18041465 Academic Editor: Alessandra Casuccio Received: 21 December 2020 Accepted: 1 February 2021 Published: 4 February 2021 Academic Editor: Alessandra Casuccio Received: 21 December 2020 Accepted: 1 February 2021 Published: 4 February 2021 Keywords: discrimination; birth outcomes; women’s health Anders Larrabee Sonderlund 1 Department of Public Health, University of Southern Denmark, 5230 Odense, Denmark; tthilsing@health.sdu.dk 2 Department of Population Health, New York University, New York City, NY 10003, USA; Antoinette.Schoenthaler@nyulangone.org * Correspondence: asonderlund@health.sdu.dk 1 Department of Public Health, University of Southern Denmark, 5230 Odense, Denmark; tthilsing@health.sdu.dk 2 Department of Population Health, New York University, New York City, NY 10003, USA; Antoinette.Schoenthaler@nyulangone.org * Correspondence: asonderlund@health.sdu.dk Department of Public Health, University of Southern Denmark, 5230 Odense, Denmark; tthilsing@health.sdu.dk 2 Department of Population Health, New York University, New York City, NY 10003, USA; Antoinette.Schoenthaler@nyulangone.org g 2 Department of Population Health, New York University, New York City, NY 10003, USA; Antoinette.Schoenthaler@nyulangone.org * Correspondence: asonderlund@health.sdu.dk Abstract: In the present systematic review, we argue that maternal experiences of interpersonal discrimination at least partially account for the disproportionate rates of adverse birth outcomes in minority populations. Since the 1990s, research in this area has slowly, but steadily increased, shedding more light on the insidious nature of interpersonal discrimination and its toxic health effects. With the aim of bringing this topic to the fore in academic as well as clinical settings, this paper provides a state-of-the-art review of the empirical knowledge on the relationship between maternal experiences of discrimination and birth outcomes. Of 5901 articles retained in the literature search, 28 met the predeﬁned inclusion criteria. Accounting for a range of health and behavioral factors, the vast majority of these studies support the notion that maternal experiences of interper- sonal discrimination predict a range of adverse birth outcomes, including preterm birth, low birth weight, and various physiological markers of stress (allostatic load) in both mother and child pre- and postpartum. Several moderators and mediators of this relationship were also identiﬁed. These related primarily to the type (ﬁrst-hand and vicarious), timing (childhood, adolescence, and adulthood), frequency, and pervasiveness of discrimination experienced, as well as to maternal mental health and coping. More research into these factors, however, is required to deﬁnitively determine their signiﬁ- cance. We discuss these ﬁndings as they relate to the general health repercussions of interpersonal discrimination, as well as in terms of applied prenatal care and interventions. Ultimately, we argue that assessing maternal experiences of interpersonal discrimination in prenatal care may represent a considerable asset for mitigating existing majority-minority disparities in adverse birth outcomes. University of Southern Denmark Citation for pulished version (APA): Sonderlund, A. L., Schoenthaler, A., & Thilsing, T. (2021). The association between maternal experiences of interpersonal discrimination and adverse birth outcomes: A systematic review of the evidence. International Journal of Environmental Research and Public Health, 18(4), Article 1465. https://doi.org/10.3390/ijerph18041465 Go to publication entry in University of Southern Denmark's Research Portal Terms of use This work is brought to you by the University of Southern Denmark. Unless otherwise specified it has been shared according to the terms for self-archiving. If no other license is stated, these terms apply: g y y y Unless otherwise specified it has been shared according to the terms for self-archiving. If no other license is stated, these terms apply: • You may download this work for personal use only y p y You may not further distribute the material or use it fo y y p g • You may freely distribute the URL identifying this open access version If you believe that this document breaches copyright please contact us providing details and we will investigate your claim. Please direct all enquiries to puresupport@bib.sdu.dk If you believe that this document breaches copyright please contact us providing details and we will investigate your claim. Please direct all enquiries to puresupport@bib.sdu.dk International Journal of Environmental Research and Public Health International Journal of Environmental Research and Public Health Int. J. Environ. Res. Public Health 2021, 18, 1465. https://doi.org/10.3390/ijerph18041465 The Association between Maternal Experiences of Interpersonal Discrimination and Adverse Birth Outcomes: A Systematic Review of the Evidence Anders Larrabee Sonderlund 1,* , Antoinette Schoenthaler 2 and Trine Thilsing 1 Citation: Larrabee Sonderlund, A.; Schoenthaler, A.; Thilsing, T. The Association between Maternal Experiences of Interpersonal Discrimination and Adverse Birth Outcomes: A Systematic Review of the Evidence. Int. J. Environ. Res. Public Health 2021, 18, 1465. https://doi.org/10.3390/ ijerph18041465 1. Introduction 1.1. Background Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional afﬁl- iations. Adverse birth outcomes represent a signiﬁcant public health issue. In developed countries, over 10% (1.25 million) of all births are preterm [1–7], and approximately 8% (1 million) are low birth weight (LBW) [8–11]. Preterm birth (PTB) and LBW comprise two of the biggest risk factors for infant mortality and contribute to a host of lifelong consequences, including stunted growth, learning disabilities, and various chronic condi- tions such as obesity and diabetes [9,10]. The likelihood of adverse birth outcomes is far from equally distributed across the population, affecting minority status and stigmatized populations at a disproportionate rate. Indeed, a central and persistent risk factor—and the focus of this review—relates to the discrimination experienced by minorities. Current evidence clearly demonstrates existing and persistent disparities in birth outcomes along ethnic and racial lines. In the US, for example, Black women are signiﬁcantly more likely than White women to give birth preterm (18.3% vs. 11.5%, respectively), have LBW infants Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Int. J. Environ. Res. Public Health 2021, 18, 1465. https://doi.org/10.3390/ijerph18041465 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 1465 2 of 31 2 of 31 (13.8% vs. 7.2%, respectively), and/or have their child die in the ﬁrst year of life (1.3% vs. 0.6%, respectively) [12,13]. Similarly, ethnic minority women in the EU have higher rates of PTB and LBW infants than their majority counterparts, as do M¯aori populations in New Zealand, and Australian Aboriginals [8,14]. Importantly, these discrepancies in birth outcomes persist even when accounting for other known risk factors. These include, but are not limited to, quality of pre- and postnatal care, maternal comorbidity during pregnancy, parity, age, socio-economic status (SES), education, and a range of behavioral and environmental factors, such as smoking/alcohol use, poor diet, pollution, and living in deprived areas [15,16]. In other words, there is something beyond these factors that increases the risk of adverse birth outcomes disproportionately for minorities compared to the general population. By way of explanation, the literature points to the increased burden of everyday psychosocial stress borne by minority populations. 1. Introduction 1.1. Background Past research particularly emphasizes the stress associated with the persistent interpersonal discrimination that minorities are uniquely subjected to on a regular basis throughout their lives [17]. This evidence centers on the chronic physiological repercussions of this type of stress and the related health implications. Speciﬁcally, allostatic load (AL), denotes the activation of the hypothalamic– pituitary–adrenal (HPA) axis in response to persistent chronic external stressors (such as e.g., discrimination) [18]. Over time, AL signiﬁcantly weathers the sympathetic nervous system, increasing the individual’s risk of a range of chronic illnesses and physical complications, including cardiovascular disease, diabetes, and cancer [19–21]. Thus, all other things being equal, it may be the singular stress associated with the regular experience of discrimination that accounts for the increased rates of adverse birth outcomes in minority populations. y p p Within this context, two separate lines of research have extensively documented the positive associations between both discrimination and AL and between AL and adverse pregnancy and birth outcomes. For example, in a comprehensive meta-analysis, Pascoe and Richman [6] extracted data from 134 empirical samples and found that perceived discrimination correlated positively and strongly with psychological stress and AL. Simi- larly, numerous studies have found positive associations between maternal AL and risk of PTB and LBW, as well as various other pregnancy-related complications, including preeclampsia [5,19,22,23]. Integrating this evidence, emerging scientiﬁc studies have directly examined the extent to which maternal experiences of interpersonal discrimination predict adverse birth outcomes in minority populations [17,24–26]. Most of this research concludes in favor of a signiﬁcant link. However, spanning just over 20 years and featuring multiple research designs and methodologies, it also comprises a somewhat disjointed empirical narrative. Thus, the aim of the present paper is to consolidate, review, and synthesize existing knowledge on the relationship between maternal experiences of interpersonal discrimination and adverse birth outcomes in minority populations. 1.2. Rationale We identiﬁed three systematic reviews of the evidence on the link between maternal experiences of interpersonal discrimination and adverse birth outcomes. In 2011 Giurgescu et al. [13] appraised 10 relevant studies and found an overall positive relationship between interpersonal racial discrimination and likelihood of PTB and LBW. Next, in 2016, Alhusen et al. [27] retained nine quantitative studies (and four qualitative) on the effects of inter- personal racism on minority birth outcomes. Consistent with Giurgescu et al., the authors concluded that racial discrimination predicted PTB, LBW, and infant size for gestational age. However, they also found that the evidence on the matter was somewhat mixed and complicated by variable research designs across studies. Finally, Mutambudzi et al. [28] re- viewed 12 studies in 2016 and argued that racial discrimination accounted for at least some of the disparity in adverse birth outcomes between Black and White American women, but also that the evidence base was small and limited. Thus, while all three reviews share the general conclusion that racial disparities in birth outcomes are related to maternal Int. J. Environ. Res. Public Health 2021, 18, 1465 3 of 31 experiences of discrimination, they also highlight the relatively limited evidence base and a general lack of understanding of the mechanisms that underpin the relationship in focus. While these reviews differ slightly in terms of scope and angle, the consistency in their conclusions makes sense when acknowledging the fact that they overlap nearly perfectly in terms of the literature they assessed. Indeed, Mutambudzi et al. included two unique studies more (N = 12) than Giurgescu et al. (N = 10), and three more than Alhusen et al. (N = 9). For the present review, however, we have retained a total of 28 empirical studies on the topic of interest. Given the apparent growth in research in this area in the past four years, previous reviews currently appear to be considerably outdated. y p y pp y In light of the conﬁnes of previous assessments of the evidence, we argue that the knowledge in this area can be signiﬁcantly expanded by updating past review efforts and critically integrating new and emerging empirical ﬁndings. In particular, we will identify any relevant themes and variations in the evidence base that might have been unclear in past reviews, or that have emerged in subsequent research. 2.1. Protocol This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (see Supplementary Table S1). Full protocol details can be accessed at www.prisma-guidelines.org. 1.2. Rationale In order to build a more complete, empirical model of the relationship between maternal experiences of interper- sonal discrimination and adverse birth outcomes, we also aim to determine any potential pathways that might explain this relationship and highlight any gaps in knowledge that require further study. Additionally, in contrast to past efforts, we will explicitly evaluate the quality of the evidence base, using validated research quality assessment tools. Ultimately, with the present review, we hope to make two key scientiﬁc contributions: 1. To facilitate, through our review of the evidence, a greater understanding and aware- ness of the extent to which discrimination “gets under the skin” of minority women and their offspring, eroding their physical health and wellbeing. 2. To push this topic to the fore not only in research endeavors, but also importantly in applied health care settings. Speciﬁcally, we argue that maternal experiences of discrimination may be operationalized as a risk factor in prenatal and postpartum care and underscores the need for care approaches designed to mitigate the health repercussions associated with discrimination. 2.2. Literature Search Strategy We searched a diverse range of scientiﬁc journals for literature on the association between maternal experiences of interpersonal discrimination and pregnancy outcomes in minority populations. Speciﬁcally, we executed an extensive and rigorous search of the following databases: Academic Search Premier; AMED; Global Health; SocINDEX with Full Text; CINAHL Plus with Full Text; E-Journals; MEDLINE; Psychology and Behavioral Sciences Collection; SCOPUS; Science Direct, Women’s Studies International. We also searched Web of Knowledge and Google Scholar for any references that might have been missed in the database search. Finally, we manually combed through reference lists of relevant papers and reviews for any additional articles that were not picked up in the previous two search strategies. p g The predeﬁned Boolean/phrase search terms that we employed related directly to the variables of interest: Interpersonal discrimination and pregnancy outcomes. We deﬁned interpersonal discrimination broadly as any form of discriminating interpersonal behavior. As such, this term covered any explicit, implicit, and covert (e.g., so-called microaggres- sions, coded language, and behavior) person-to-person discriminatory behavior towards individuals from any minority group, including those deﬁned by race, ethnicity, gender, sexuality, religion, nationality, and physical disability. We chose not to include studies on systemic discrimination as this type of discrimination impacts on people via pathways Int. J. Environ. Res. Public Health 2021, 18, 1465 4 of 31 and processes (e.g., policies and legislation) that differ considerably from interpersonal discrimination. In terms of pregnancy outcomes, we focused on pregnancy and birth complications, including gestational age at delivery, PTB, birth weight, birth initiation (spontaneous vs. induced), and stillbirth. Other outcomes of interest included postpartum child development and health. The exact literature search syntax was as follows: “Discrimination” and/or “prejudice” and/or “stereotype” and/or “bias” and/or “stigma” and/or “racism” and/or “sexism” and/or “ageism” AND “birth” and/or “birth outcomes” and/or “delivery outcomes” and/or “vaginal birth” and/or “labor induction” and/or “preterm birth” and/or “ges- tation” and/or “birth weight” and/or “stillbirth” and/or “birth complications” and/or “pregnancy complications”. Search limiters were speciﬁed to exclude non-peer-reviewed studies, newspaper articles, and non-English language text. We did not limit search results by publication date. Once the search had been executed, articles were scrutinized and retained based on the following inclusion criteria: 1. The paper reported empirical studies on the relationship between the maternal expe- rience of interpersonal discrimination and pregnancy- and/or birth-related outcomes. 2. The paper reported quantitative results. 1. 3.1. Literature Search Results The database search turned up a total of 5901 hits (Figure 1). Of these, 146 papers were identiﬁed that in one way or another concerned the association between discrimination and pregnancy. The vast majority of these articles were rejected based on one or more of the following reasons: The paper focused exclusively on types of discrimination other than interpersonal discrimination (e.g., structural/systemic discrimination) (n = 80); the paper reported on mental health issues (e.g., pre- or post-natal depression) rather than physical pregnancy- or birth-related health complications for mother or baby (n = 13); the paper did not cite empirical research (e.g., editorial, comment) (n = 6); the paper reported exclusively on qualitative results (n = 14); the paper provided insufﬁcient statistical or methodological detail for assessment (n = 5); or a combination of some or all of these issues. Ultimately, a total of 28 papers were retained for the review. In the following sections, we will present the main ﬁndings from these studies. 2.2. Literature Search Strategy The paper reported empirical studies on the relationship between the maternal expe- rience of interpersonal discrimination and pregnancy- and/or birth-related outcomes. 2 The paper reported quantitative results p 2. The paper reported quantitative results. 3. The paper was in English. 4. The full text was available. 5. The paper had undergone scientiﬁc peer review. Each database hit was evaluated by the authors in three rounds against the inclusion criteria. First, papers that clearly did not relate to the topic of interest were rejected (usually based on title). Second, abstracts of papers retained in the ﬁrst round were reviewed. Any articles that failed to meet the inclusion criteria were discarded. Finally, the search results that remained after the ﬁrst two rounds of evaluation were downloaded and examined in full-text detail for relevance (see Figure 1). Only papers that passed through each of these three rounds were included in the present review. 1, 18, x FOR PEER REVIEW 5 of 39 Figure 1. Flow chart for each step of article evaluation and retainment. 3 R l Publications identified in literature search n = 5901 Title read – publication met inclusion criteria Abstract read – publication met inclusion criteria Full text read – publication met inclusion criteria Publications retained for review N = 28 Publications discarded n = 5755 Publications discarded n = 98 Publications discarded n = 20 Yes/unclear Yes/unclear Yes/unclear Yes No No No Figure 1. Flow chart for each step of article evaluation and retainment. Figure 1. Flow chart for each step of article evaluation and retainment. Figure 1. Flow chart for each step of article evaluation and retainment. 5 of 31 Int. J. Environ. Res. Public Health 2021, 18, 1465 2.3. Research Quality Appraisal In the ﬁnal round of results evaluation, we systematically appraised the methodologi- cal quality of the retained papers. To this end, we used the Quality Assessment Tool for Quantitative Studies (QATQS) [29]. The QATQS evaluates research along six dimensions, including study population selection bias, study design, confounding variables, researcher blinding, data collection methods, and participant withdrawal, and attrition. Each dimen- sional score for a given paper is averaged and combined into an overall assessment of the paper in terms of “weak”, “moderate”, or “strong” quality. The primary author and a qualiﬁed research assistant independently coded each paper retained for the review. Any discrepancies in the ﬁnal assessment outcome for any given paper were resolved through discussion and re-examination of the paper(s) in question. 3.2. Study Characteristics and Methodology Of the 28 papers included in the present review, a single study was published in the 1990s, nine studies were published in the 2000s, 17 articles were published in the 2010s, and one paper was published in 2020. As such, the evidence included in this review spans four decades, though all but two studies were published between 2000 and 2019. Further, 25 articles reported on US-based studies. The remaining three papers were from Germany (n = 1) and New Zealand (n = 2). In terms of study populations, all of the articles centered on racial/ethnic minorities in White-majority societies. Most focused purely on Black women in the US (n = 21); however, papers also reported on Turkish immigrants in Germany (n = 1), ethnic minorities in New Zealand (n = 2), or Latina, Asian, Dominican, and/or Puerto Rican women in the US (n = 4). The average sample size across studies was N = 1602 (min = 39, max = 11,582, median = 480). Various research designs were employed in the retained papers, including prospective cohort (n = 10), cross-sectional (n = 7), case-control (n = 5), hybrid retrospective/prospective cohort (n = 2), retrospective cohort (n = 1), descriptive correlational (n = 1), and longitudinal designs (n = 2). The main predictor and outcome measures varied somewhat across studies (see Table 1). In all of the articles, interpersonal discrimination was assessed in terms of racial or eth- nic discrimination. Three studies included other bases for discrimination such as gender (n = 2) [30,31] and/or age, religion, physical appearance, sexual orientation, SES, nation- ality, and physical disability (n = 1) [2]. Most studies assessed discrimination with vali- dated scales (n = 23), including Krieger et al.’s [32] Experiences of Discrimination Scale (n = 13) [3,4,30,31,33–41], Williams et al.’s [42] Everyday Discrimination Scale (n = 5) [2,43–46], the Racism and Life Experiences scale (RALES) (n = 3) [43,47,48], the Perceived Racism scale (n = 2) [34,49], and the Daily Life Experiences of Racism and Bother (DLE-B) scale (n = 1) [50]. Six studies either did not report which scales were implemented to measure discrimina- tion or had devised one for the specific purposes of the given research [7,51–55]. Most studies operationalized discrimination in terms of frequency within a given timespan (e.g., Int. J. Environ. Res. 3.3. Research Methodology and Quality The inter-rater research quality evaluations were conducted by the first author and a research assistant. Overall, independent assessments were well-aligned (see Supplementary Table S2 QATQS). Specifically, the initial round of assessments deviated on only one qualitative dimension (population selection bias in two papers, and confounding variables in one) in each of three papers (88.9% inter-rater reliability). These discrepancies were resolved through reexamination of the given papers and subsequent discussion. Ultimately, scoring each paper on each of the six QATQS dimensions, 12 papers were assessed as ‘strong’ and thus reported high-quality evidence, 13 were based on evidence of ‘moderate’ quality, and three articles were deemed to be of ‘weak’ quality (see Table 1). The current evidence base on the association between maternal experiences of discrimination and birth outcomes thus comprises research of overwhelmingly moderate-strong methodological quality. 3.2. Study Characteristics and Methodology Public Health 2021, 18, 1465 6 of 31 every day, during pregnancy, past 12 months, lifetime) (n = 13) [2,30,31,43,45–50,52,54,55], pervasiveness in individuals’ lives (i.e., in how many different life domains has discrim- ination been experienced] (n = 7) [3,7,33,35,39–41], or both frequency and pervasiveness (n = 7) [4,26,34,36,38,44,53]. Several studies also distinguished between first-hand vs. vi- carious experiences of discrimination (n = 5) [4,39,43,44,48], while others included measures of subjective severity of discriminatory experiences (n = 4) [43,47,50,52]. In terms of outcome variables, most articles reported on PTB (n = 14), birth weight (n = 14), gestational age at birth (n = 7), or a combination of these. PTB was defined as less than 37 weeks of gestation in all relevant studies. Studies also focused on maternal and child physiological outcomes, however, including hypertension, maternal and child cortisol secretion and stress reactivity, inflammation, and diastolic blood pressure (n = 4). 3.4. Study Findings In the following paragraphs, a brief description will be given of the main ﬁndings of each of the papers retained for this review (see Table 1 for details on study samples, research design and methodology). Unless otherwise stated, the results summarized here are adjusted for all covariates included in a given study (see Table 1). Given the general uniformity across articles in terms of outcome variables, we will present the evidence in three main sections based on explicit outcome variable. Speciﬁcally, we will ﬁrst review research that focuses on the impact of maternal experiences of interpersonal discrimination on gestational age at birth (n = 15), before moving on to studies that look at infant birth weight (n = 14). Finally, we review evidence on pregnancy-related physiological outcomes (n = 4). While we categorize results by the outcome deﬁnitions provided in each article, we consider it pertinent to acknowledge the potential interrelationships between these outcomes. For example, low birth weight is often comprised of potentially overlapping outcomes of preterm birth and/or fetal growth restriction (i.e., small for gestational age). Thus, in spite of our categorical presentation of the evidence in terms of outcome, we implore the reader to consider these effects as potentially interconnected. 3.4.1. Maternal Experiences of Interpersonal Discrimination and Infant Gestational Age at Birth In a population-based cross-sectional study, using data from the 2004–2012 Pregnancy Risk Assessment Monitoring System, Bower et al. [51] assessed the extent to which experiences of racism accounted for racial disparities in birth outcomes in a sample of Black women (N = 11,582). The study sample included people from 11 US states and New York City. The authors focused on the extent to which participants had been upset by experiences of racism in the 12 months prior to giving birth. They also tested whether prenatal care moderated any such relationship. Taking into account a range of socioeconomic and health-related variables, results indicated that compared to mothers who did not report feeling upset by experienced racism, mothers who had been upset by such racism (n = 1645) had 29% higher odds of giving birth preterm (OR = 1.29, 95% CI, 1.04–1.59). While this relationship appeared to vary by level of prenatal care, the interaction term was statistically non-significant. 7 of 31 Int. J. Environ. Res. Public Health 2021, 18, 1465 Table 1. Design, samples, and methodology for research studies included in present review. 3.4. Study Findings ation Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality states, USA Non-Hispanic Black mothers (N = 11,582). Cross-sectional • Experienced discrimination in past year (single-item, binary measure). • Adequacy of prenatal care • Age • Education • Marital status • Maternal smoking • Pre-pregnancy BMI • Pre-pregnancy insurance status (proxy SES) • Regional differences. • Preterm birth (<37 w) • Overall, 14.2% (95% CI, 13.3–15.2) of participants had experienced racism in the past year. • Controlling for all covariates, women who had experienced racism in the past year were 1.29 (95% CI, 1.04–1.59) more likely than women who had not experienced racism to give birth preterm. • Moderation analyses indicated that experience of racism was positively associated with odds of preterm birth for women who received intermediate (AOR, 2.03, 95% CI, 1.04–3.97) or adequate prenatal care (AOR, 1.57, 95% CI, 0.95–2.59). There was no association for inadequate or adequate-plus prenatal care. Moderate ginaw unty, USA Mothers (N = 629, Black n = 407, White n = 222). Cross-sectional • Frequency of experiences of past-year racism (Everyday Discrimination Scale) • Perceived group-impact racism (Racism and Life Experiences Scale) • Racism-related stress (Racism and Life Experiences scale) • Emotional reactions to racism (Racism-related Experiences Scale). • Age • Parity • Education • Self-identiﬁed race • Beliefs and experiences of racism • Self-reported physical/mental health • Smoking • Pregnancy and birth experiences. • Birth weight • Frequency of racial discrimination was positively associated with likelihood of smoking and negatively correlated with mental and physical health. • Emotional responses to racism was the only racism measure that predicted pregnancy or birth outcome. Experiencing racism that elicited emotional reactions increased the odds of low birth weight by 24% (OR = 1.24, 95% CI, 0.93–1.48). • This effect attenuated in the fully-adjusted model, rendering the statistical effect marginally signiﬁcant. Moderate , USA Pregnant women (N = 56, Black n = 38, White n = 18). Longitudinal • Pervasiveness of lifetime experiences of discrimination (Experiences of Discrimination Scale). • Age • Race/ethnicity • Marital status • Education • Income • Gravidity • Parity • Pre-pregnancy BMI • Depression • Stress (general) • Stress (pregnancy-related) • Anxiety • Smoking • Exercise • Prenatal vitamin use. • Epstein-Barr virus reactivation (IgG antibody titers) during pregnancy and post-partum. 3.4. Study Findings • Black women exhibited substantially higher levels of IgG antibody titers than White women during each trimester and postpartum: 1st trimester, m = 3.13 (95% CI, 3.02–3.26) vs. m = 2.62 (95% CI, 2.45–2.80), respectively. 2nd trimester, m = 3.13 (95% CI, 3.01–3.25) vs. m = 2.62 (95% CI, 2.47–2.81), respectively. 3rd trimester, m = 3.09 (95% CI, 2.97–3.20) vs. m = 2.64 (2.47–2.81), respectively. Postpartum, m = 3.14 (95% CI, 3.02–3.26) vs. m = 2.66 (95% CI, 2.48–2.83), respectively. • Black women who reported high discrimination showed higher EBV VCA IgG antibody titers than Black women who reported low discrimination in the ﬁrst (p = 0.03) and second trimesters (p = 0.04) as well as postpartum (p = 0.06). • Black women who reported high discrimination showed higher EBV VCA IgG antibody titers than White women in all trimesters and postpartum (p < 0.001) Moderate Table 1. Design, samples, and methodology for research studies included in present review. Int. J. Environ. Res. Public Health 2021, 18, 1465 8 of 31 Table 1. Cont. r Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality t al. 5] Chicago, IL, USA Black women (N = 85). Mothers of very-low-birth- weight (VLBW) children (n = 25) vs. mothers of healthy-weight children (n = 60). Case-control study. • Pervasiveness of racism during pregnancy (Experiences of Discrimination Scale). • Age • Education • Marital status • Parity • Prenatal care • Smoking • Alcohol use • Illicit drug use • Social support • Internalization of discrimination. • Birth weight. • The odds of giving birth to VLBW children for women who reported racial discrimination vs. those who did not was OR = 4.4 (95% CI, 1.1–18) for mothers with two or more of the following risk factors: high parity, poor pre-natal care, lacking social support, tobacco use, alcohol, or illicit drug use. Moderate t al. 4] Chicago, IL, USA Black women (N = 312). Mothers of VLBW children (n = 104) vs. mothers of normal-weight children (n = 208). Case-control study. • Pervasiveness of lifetime/pregnancy exposure to interpersonal racial discrimination (Experiences of Discrimination Scale), • Frequency of experienced interpersonal racial discrimination at place of employment in past year (Perceived Racism Scale). • Age • Education • Marital status • Parity • Prenatal care • Gestational age • Smoking • Alcohol use. • Birth weight. For each one-unit increase in adolescent direct racial discrimination, there was a 48% increase in odds for preterm labor (OR = 1.48, 95% CI, 1.00–2.19). For each one-unit increase in childhood vicarious racial discrimination, there was a 45% increase in odds for preterm labor (OR = 1.45, 95% CI, 1.01–2.09). Adult direct or vicarious racial discrimination was not statistically associated with preterm birth. Moderate 3.4. Study Findings • Exposure to interpersonal racial discrimination during pregnancy did not appear to impact on birth weight. • Lifetime exposure to racial discrimination signiﬁcantly predicted VLBW. Having experienced this type of discrimination in at least one of ﬁve domains (work, getting a job, school, getting medical care, patronizing a restaurant) increased the odds of VLBW by 1.9 (95% CI, 1.2–3.1). Being the target of discrimination in three or more domains increased the odds of VLBW to 3.2 (95% CI, 1.5–6.6). This suggests a dose-response relationship. • This relationship was stronger for women who had other risk factors (alcohol use, poor pre-natal care, low SES) Moderate al. 2] Northern CA, USA Pregnant Black women (N = 108) Prospective cohort study. • Frequency of experienced general discrimination (Everyday Discrimination Scale). • Exposure to traumatic event • Spirituality • Social support • SES • Lifelong trauma • Smoking • Alcohol • Illicit drug use • Pregnancy-induced hypertension • Gestational diabetes • Bacterial vaginosis • Anemia • Birth weight. • Overall, 86% of participants reported experiences of general discrimination, typically race-, gender-, or age-based discrimination). • Women who reported discrimination due to religion were more likely than women who reported no such discrimination to have infants with lower birth weight (t = 2.39, p = 0.02). Moderate t al. [44] San Francisco Bay Area, CA, USA Black women (N = 173) Cross-sectional • Frequency and pervasiveness of direct and vicarious racial discrimination in three life stages (childhood, adolescence, adulthood) (Everyday Discrimination Scale). • Parity • Income • Education • Employment status • Marital status. • Preterm birth. • For each one-unit increase in adolescent direct racial discrimination, there was a 48% increase in odds for preterm labor (OR = 1.48, 95% CI, 1.00–2.19). • For each one-unit increase in childhood vicarious racial discrimination, there was a 45% increase in odds for preterm labor (OR = 1.45, 95% CI, 1.01–2.09). • Adult direct or vicarious racial discrimination was not statistically associated with preterm birth. Moderate Table 1. Cont. Int. J. Environ. Res. Public Health 2021, 18, 1465 9 of 31 Table 1. Cont. Author Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality Dixon et al. (2012) [3] Eastern MA, USA Mother-infant pairs (N = 539; Black n = 294, Hispanic n = 127, Asian n = 110, Other n = 8) in Eastern MA. Prospective cohort study. 3.4. Study Findings • Pervasiveness of lifetime discrimination across eight life domains (Experiences of Discrimination Scale). • Maternal age • Pre-pregnancy BMI • Smoking • Breastfeeding duration • Nativity • Gestational weight • Parity • College graduate • Household income • Sex of child • Postnatal depression (during pregnancy and 6 m postpartum). • Birth weight for gestational age • Age- and sex-speciﬁc weight for 6-month-old • Age- and sex-speciﬁc BMI for 3-year-old. • Approx. 33% of participants had not experienced racial discrimination. However, 33% had experienced racial discrimination in 1–2 life domains, and another 35% had experienced racial discrimination in 3 or more domains. • Adjusting for all covariates, children of women who had experienced discrimination in >2 life domains had infants with lower birth weight for gestational age (β = −0.25, 95% CI, −0.45 to −0.04), lower weight-for-age at six months (β = −0.34, 95% CI, −0.65 to −0.03), and lower BMI-for-age at three years (β = −0.33, 95% CI, −0.66 to 0.00) than children of women who had not experienced discrimination. • Children of women who had experienced discrimination in 1–2 domains were generally intermediate in size and weight, suggesting a dose-response relationship. Strong Dole et al. (2003) [30] Central NC, USA Pregnant women (N = 1962; Black n = 707, White n = 1134, other n = 121). Prospective cohort study. • Frequency of experienced racial or gender discrimination (Experiences of Discrimination Scale). • Education • Age • Parity • Marital status • Height • BMI during pregnancy • % poverty index • Bacterial vaginosis infection • Alcohol use during pregnancy • Smoking during months 1–6 of pregnancy • Social support • Pregnancy-related anxiety • Perceived neighborhood safety • Stressful life events. • Preterm labor (<37 w). • There was an increased risk of preterm birth among Black women who had experienced racial discrimination (RR = 1.4, 95% CI, 1.0–2.0). • Gender discrimination was not statistically associated with preterm birth. Strong Dole et al. (2004) [31] Central NC, USA Pregnant women (N = 1898; Black n = 727, White n = 1174). Prospective cohort study. • Frequency of experienced racial or gender discrimination (Experiences of Discrimination Scale). • Age, • Parity, • Education, • Marital status, • Economic status, • Pre-pregnancy BMI, • Diet, • Alcohol use, • Illicit drug use, • Smoking, • Pre-natal care site, • Bacterial vaginosis. • Perceived neighborhood safety. • Preterm birth (<37 wks). • Preterm birth (<37 wks). • There was an increased risk of preterm birth for Black women who had experienced higher (vs. lower) levels of racial discrimination (RR = 1.8, 95% CI, 1.1–2.9). • Gender discrimination predicted spontaneous preterm birth (as opposed to induced preterm) for Black women (RR = 2.1, 95% CI, 1.0–4.3). Strong 3.4. Study Findings • There was an increased risk of preterm birth for Black women who had experienced higher (vs. lower) levels of racial discrimination (RR = 1.8, 95% CI, 1.1–2.9). • Gender discrimination predicted spontaneous preterm birth (as opposed to induced preterm) for Black women (RR = 2.1, 95% CI, 1.0–4.3). Strong Int. J. Environ. Res. Public Health 2021, 18, 1465 10 of 31 10 of 31 Table 1. Cont. Author Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality Dominguez et al. (2008) [4] Los Angeles, CA, USA Pregnant women (N = 124; Black n = 51, White n = 73). Prospective, repeated- measures observational study. • Pervasiveness and frequency of direct and vicarious racial discrimination in lifetime, adulthood, adolescence, childhood (Experiences of Discrimination Scale). • 21 medical risk conditions, including medical history, pregnancy history, and current pregnancy. • Pregnancy weight, • Age, • Cohabitation with father, • Employment status, • Race, • SES, • Education, • Income, • Income incongruity, • Pregnancy stress, • Gestational age, • General stress. • Birth weight. • For Black women, each unit increase in lifetime perceived racism was associated with a 39.59 g decrease in birth weight, ∆R2 = 0.02, β = −0.17, p < 0.05. • Accounting for life stage racism, childhood-vicarious racism emerged as the main driver of this effect with each unit increase being associated with a 167.85 g decrease in birth weight (β = −0.25, p < 0.01). • Black women were more likely to give birth to children of low birth weight than White women (280.83 g difference between Black and White babies). In a fully adjusted mediation model, childhood-vicarious racism was found to mediate this effect (∆R2 = 0.02, p < 0.05; Sobel test = −1.74, p < 0.05, one-tailed). Moderate Earnshaw et al. (2013) [45] New York, NY, USA Pregnant Black/Latina women (N = 420, Black n = 158, Latina n = 262). Prospective cohort study. • Frequency of experiences of everyday discrimination (Everyday Discrimination Scale). • Age, • Race/ethnicity, • Birth country, • Education, • Relationship status, • Pregnancy history, • Health behavior, • Nutrition, • Exercise, • Depression, • Gestational age, • Prenatal distress. • Birth weight. • Everyday discrimination was associated with greater odds of low birth weight, OR = 2.78, p < 0.05. 3.4. Study Findings • The association between everyday discrimination and birth weight was mediated by increases in depressive symptoms during pregnancy (β = −0.04, p < 0.01), such that for every one-point increase in everyday discrimination, birth weight decreased by 49 g (β = −49.27, p < 0.05). Strong Gillespie and Anderson (2018) [36] OH, USA Pregnant Black women (N = 96). Prospective cohort study. • Frequency and pervasiveness of lifetime exposure to racial/ethnic discrimination (Experiences of Discrimination Scale). • Pre-pregnancy BMI, • Smoking, • Sleep, • Stress • Internalization of experienced discrimination. • Plasma cortisol levels, • Leukocyte glucocorticoid levels. • Gestational age at birth. • There were no effects of discrimination on gestational age at birth. • There was no main effect of discrimination on maternal cortisol levels. However, compared to women in discrimination tertile 1 (no discrimination, n = 46), women in tertile 2 (medium discrimination), who internalized experiences of discrimination (n = 19) exhibited higher levels of maternal cortisol (b = 0.68, p = 0.001). • Racial discrimination correlated negatively with leukocyte glucocorticoid sensitivity. • Each ng/mL increase in maternal cortisol level predicted birth 0.15 days earlier among women in discrimination tertile 1 vs. tertile 2 (medium) and 3 (high, n = 26). Moderate Table 1. Cont. Int. J. Environ. Res. Public Health 2021, 18, 1465 11 of 31 11 of 31 Table 1. Cont. Author Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality Giurgescu et al. (2012) [37] Chicago, IL, USA Black mothers (N = 72). Descriptive correlational comparative study. • Frequency and pervasiveness of lifetime experienced racial discrimination (Experiences of Discrimination Scale). • Age, • Marital status, • Education, • Income, • Gestational age, • Medical history, • Psychological distress past month, • Neighborhood social disorder, • Perceived neighborhood physical disorder, • Perceived neighborhood crime, • Objective neighborhood environment. • Preterm birth. • Participants reported low levels of racial discrimination. • No statistically signiﬁcant relationship between racial discrimination and gestational age at birth was found. • Racial discrimination predicted psychological distress (β = 0.524, p < 0.01). Weak Grobman et al. (2018) [38] Nine states, USA Pregnant women (N = 9470; Black n = 1307, White n = 5721, Hispanic n = 1586, Asian n = 379, other n = 477) Cross-sectional study. • Frequency and pervasiveness of lifetime exposure to racial discrimination (Experiences of Discrimination Scale). 3.4. Study Findings • Maternal age, • BMI, • Smoking, • Medical co-morbidities, • Stress, • Anxiety, • Social Support, • Postnatal depression, • Resilience. • Preterm birth, • Hypertensive disease of pregnancy, • Low birth weight. • Black women were more likely than White women to give birth preterm (12.3% vs. 8.1%, OR = 1.6, 95% CI, 1.32–1.93), have low-birth weight children (17.2% vs. 8.6%, OR = 2.20, 95% CI, 1.86–2.62), and to have hypertensive disease of pregnancy (16.7 vs. 13.4, OR = 1.3, 95% CI, 1.3–1.10). • None of the predictors, other than social support, accounted for statistically signiﬁcant portions of variance in the discrepancy between Black and White women’s pregnancy outcomes. Moderate Hilmert et al. (2014) [39] Los Angeles and Orange counties, CA, USA Pregnant Black women (N = 39). Prospective cohort study. • Pervasiveness of direct and vicarious exposure to racial discrimination in childhood and adulthood (Experiences of Discrimination Scale). • Maternal age, • BMI, • Parity, • SES, • Income, • Education, • Gestational age at birth. • Birth weight, • Diastolic blood pressure during pregnancy. • Adjusting for confounding variables, results indicated a marginally signiﬁcant inverse relationship between exposure to any racial discrimination and birth weight (β = −0.27, p < 0.10). • Direct exposure to racial discrimination in adulthood was signiﬁcantly and inversely associated with birth weight (β = −0.26, p < 0.05). • Change in diastolic blood pressure during pregnancy and childhood vicarious and direct racial discrimination interacted to predict lower birth weight (β = −0.25, ∆R2 = 0.04, p < 0.05; β = −0.22, ∆R2 = 0.03, p < 0.10, respectively). • For Black women who had experienced childhood vicarious racial discrimination in at least two life domains, birth weight declined by 19.98 g for every 1 mm Hg increase in diastolic blood pressure (B = −160.65, p < 0.05). Moderate Table 1. Cont. Int. J. Environ. Res. Public Health 2021, 18, 1465 12 of 31 Table 1. Cont. Author Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality Lespinasse et al. (2004) [40] Chicago, IL, USA Black mothers of very-low- birth-weight infants (<1500 g) (n = 104) vs. healthy weight infants (approx. 2500 g) (n = 208). Case-control study. • Pervasiveness of lifetime experienced racial discrimination (Experiences of Discrimination Scale). 3.4. Study Findings • Maternal age, • Marital status, • Cohabitation status, • Pre-natal care, • Parity, • Smoking, • Alcohol use, • Income, • Desirable/undesirable pregnancy, • Companion in delivery room, • Stressful life events, • Social environment, • Religion. • Birth weight. • Experienced racial discrimination in one or more life domains was associated with a two-fold increase in the odds of very low birth weight (OR = 1.9, 95% CI, 1.2–3.0). • Experienced racial discrimination in three or more life domains was associated with a near three-fold increase in the odds of very low birth weight (OR = 2.7, 95% CI, 1.3–5.4). • Lack of social support was associated with a more than three-fold increase in the odds of having a baby with very low birth weight. Strong Mendez et al. (2014) [52] Philadelphia, PA, USA Pregnant women (N = 3462). Cross-sectional study. • Frequency of experienced everyday discrimination, • Major discriminatory instances (y/n). • Maternal race/ethnicity, • Age at time of study, • Income, • Education, • Marital status, • Smoking, • Alcohol use, • Parity, • Housing tenure/home ownership, • Years lived in the neighborhood. Residential segregation, • Neighborhood redlining, • Stress, • Neighborhood quality. • Preterm birth (<37 w). • Black women were nearly twice as likely to give birth pre-term (14.9%) than White (7.7%) or Hispanic women (8.3%). • Every day and major discrimination was not associated with pre-term birth. Weak Misra et al. (2010) [47] Baltimore, MD, USA Pregnant Black women (N = 832). Hybrid retrospective and prospective cohort study. • Frequency of lifetime exposure to racism (Racism and Lifetime Experiences Scale, RALES). • Frequency of daily exposure to racism (RALES Daily Life Experiences Scale). • Response to racism (Racism-Related Experiences, RRE Scale). • Stress, • Depression symptoms, • Pregnancy locus of control, • Mastery, • Anxiety, • Social support, • Maternal age, • Education, • Income, • Family resources, • SES, • Smoking, • Alcohol use, • Illicit drug use, • Vaginal douching, • Parity, • Pre-natal care, • Chronic diseases. • Preterm birth (<37 w). • There were no main effects of either of the three racism measures on preterm birth. • A score above the median on the RALES, however, was associated with an increased risk of preterm birth in women with high (vs. 3.4. Study Findings low) levels of stress (HR = 1.32, 95% CI, 0.64–3.57, p = 0.05) and in women with high (vs. low) levels of depressive symptoms (HR = 1.55, 95% CI, 0.90–2.64, p = 0.08). • For women with low scores on both stress and depressive symptoms, experienced racism had a slight protective effect (HR = 0.63, 95% CI, 0.36–1.08). Strong Table 1. Cont. Int. J. Environ. Res. Public Health 2021, 18, 1465 13 of 31 Table 1. Cont. Author Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality Mustillo et al. (2004) [41] Birmingham, AL, Chicago, IL., Oakland, CA, Min- neapolis, MN, USA Pregnant women, Chicago, IL., Oakland, CA., Minneapolis, MN. (N = 352). Prospective cohort study. • Pervasiveness of lifetime experience of racial discrimination (Experiences of Discrimination Scale). • Race/ethnicity, • Smoking, • Alcohol use, • Depressive symptoms, • Education, • Age, • Marital status, • SES • Response to unfair treatment, • Income. • Preterm birth (<37 w), • Birth weight. • Among Black women, 50% (n = 16) of those with preterm deliveries and 61% (n = 8) of those with low-birth-weight infants had experienced racial discrimination in at least 3 situations. The corresponding rates for White women were 5% and 0%, respectively. • The odds of giving birth preterm or to low-birth-weight infants were 205% (OR = 3.05, 95% CI, 1.29–7.24) and 398% (OR = 4.98, 95% CI, 1.43–17.39) greater, respectively, for women who had experienced racial discrimination >2 life domains compared to women who had not experienced discrimination. Depressive symptoms did not mediate these relationships. Strong Rankin et al. (2011) [49] Chiacgo, IL, USA Black mothers (N = 277). Case-control, repeated measures study. • Frequency of past-year and lifetime experienced public-setting racism (Perceived Racism Scale), • Coping with experienced racism. • Age, • Education, • Marital status, • Parity, • Prenatal care, • Income, • Smoking, • Alcohol use. • Preterm birth (<37 w). • Lifetime and past-year experienced racial discrimination was associated with increased odds of preterm birth, (OR = 1.5, 95% CI, 0.9–2.8; OR = 2.5, 95% CI, 1.2–5.2, respectively). • In terms of passive coping behavior, there was no moderating effect on the association between experienced racial discrimination and preterm birth. Strong 3.4. Study Findings • In terms of active coping behavior, women who reported ‘working harder to prove perpetrator wrong’ or ‘getting violent’ had lower risk of preterm birth (p < 0.05). Strong Rosenberg et al. (2002) [53] 12 states, USA Non-Hispanic Black mothers (N = 4966). Mothers of preterm children (n = 422) and normal-term children (n = 4544). Case-control study. • Frequency and pervasiveness of experienced racial discrimination. • Age, • Parity, • Previous preterm birth, • Mother born preterm, • Education, • Smoking, • Alcohol use, • Second job, • Asthma, • Vaginal douching, • High blood pressure, • Diabetes during pregnancy, • BMI, • Geographic area of residence, • Marital status. • Preterm birth (<37 w). • Women who reported unfair treatment at work (n = 251) were more likely to give birth preterm (OR = 1.3, 95% CI, 1.1–1.6). • Women who reported that people acted afraid of them at least once a week (n = 50) were more likely to give birth preterm (OR = 1.4, 95% CI, 1.0–1.9). • Preterm birth was also more likely for women who had less than 12 years education (n = 46) and who had experienced discrimination in housing (OR = 2.4, 95% CI, 1.2–4.6), in receiving service at least once a week (OR = 3.4, 95% CI, 1.5–7.7), and in terms of being feared by others at least once a week (OR = 2.0, 95% CI, 1.0–4.1). Strong Int. J. Environ. Res. Public Health 2021, 18, 1465 14 of 31 14 of 31 Table 1. Cont. r Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality et al. 4] Germany Non- immigrant German women (n = 2308) and Turkish immigrants (n = 217). Longitudinal nation-wide panel study • Frequency of experienced ethnic discrimination in past 12 and 24 months. • Infant sex, • Maternal age, • Parity, • Education, • Generation status (1st vs. 2nd) (for Turkish-German cohort only). • BMI, • Smoking during pregnancy, • Pregnancy complications (e.g., hypertension, pre-eclampsia, etc.). • Preterm birth (<37 w), • Birth weight. • Preterm birth was more likely for Turkish immigrants compared to non-immigrant women (b = 1.29, SE = 0.38, p < 0.001, OR = 3.61, 95% CI, 1.76–7.79). In unadjusted as well as adjusted models, experienced discrimination was not associated with infant birth weight. 3.4. Study Findings • Parity, • Recruitment status (prenatal, postnatal), • Education, • Employment during pregnancy, • Receipts of Medicaid insurance, • Maternal height, • Family Resource Scale (time and money). • Birth weight for gestational age. • • Thayer et al. (2019) [7] Aotearoa, New Zealand Pregnant M¯aori (n = 510), Paciﬁc (n = 452), Asian (n = 691) women (N = 1653). Longitudinal cohort study. • Pervasiveness of past-year and lifetime ethnic discrimination. • Maternal age, • Maternal BMI, • Household income, • Education, • Relationship status, • Smoking, • Offspring sex • Gestational age at birth, • Birth weight. • • • Table 1. Cont. Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality Black women (N = 1410). Retrospective cohort study. • Frequency and stressfulness of past-year experienced racial microaggressions (Daily Life Experiences of Racism and Bother (DLE-B) scale). • Prenatal depressive symptoms (1 week), • Stress past month, • Maternal age, • Education, • Financial situation, • Pre-natal smoking, • Self-rated physical health. • Preterm birth (<37 w). • Women in the second quartile of experienced discrimination exhibited a greater probability of preterm birth than women with higher (3rd & 4th quartile) or lower scores (1st quartile). E.g., women in the second discrimination quartile had 67% higher odds of preterm birth than women in the ﬁrst discrimination quartile (OR = 1.67, 95% CI, 1.16–2.40). Women in the 3rd and 4th discrimination quartile also had greater odds of preterm birth than women in the 1st quartile, but these results were statistically non-signiﬁcant. • Experienced racism interacted with depression to impact preterm birth, but in a non-linear fashion. For women with mild to moderate depressive symptoms, the predictive probability of preterm birth increased from 0.10 for women in the 1st discrimination quartile (low) to 0.20 for women in the 2nd quartile (low-medium) and then decreased again to 0.10 in the 4th quartile (p < 0.05). Strong Black women (N = 778). Hybrid retrospective and prospective cohort study. • Frequency of past-year and lifetime experienced racial discrimination (Racism and Life Experiences Scale). • Frequency of past-year and lifetime group-based experiences of racism (Racism and Life Experiences Scale). • Parity, • Recruitment status (prenatal, postnatal), • Education, • Employment during pregnancy, • Receipts of Medicaid insurance, • Maternal height, • Family Resource Scale (time and money). • Birth weight for gestational age. Strong • M¯aori women who reported lifetime experiences of discrimination at work or in acquiring housing had lower-birth-weight children than those who had not experienced such discrimination (β = −243 g, 95% CI, −425 g, −60.2 g; (β = −146 g, 95% CI, −286 g, −6 g, respectively). 3.4. Study Findings • Turkish immigrants who had experienced discrimination before birth had higher risk of preterm birth (35.42%) than those who had not experienced discrimination (11.84%) (χ2(1, 109) = 8.18, p < 0.01, OR = 4.19), with lower gestational age (t(87.68 = 3.29, p < 0.01, d = 0.65) and birth weight (t(76.60 = 2.25, p < 0.05, d = 0.45). • Overall, women who had experienced discrimination vs. those who had not, had a ﬁve-fold increase in risk of preterm birth, OR = 5.76, 95% CI, 1.95–19.38). Moderate al. 5] Chicago, IL, and New York, NY, USA Pregnant Black, Chinese, Dominican, Puerto Rican, Mexican, and White women (N = 1150). Cross-sectional study. • Frequency of experienced racial discrimination during pregnancy. • Maternal age, • Marital status, • Education, • Residence, • Ethnicity, • Place of birth, • Language, • Parity, • Previous abortion, • Previous low-birth weight baby, • Pre-pregnancy BMI, • SES • Insurance, • Medical care, • Diet • Housing, • Housing density, • Housing stability, • Anxiety, • Depression, • Undesired pregnancy, • Locus of control, • Adverse life events, • Social support, • Support group, • Smoking, • Second-hand smoking, • Alcohol use, • Illicit drug use, • Abuse, • Fasting, • Exercise, • Material hardship, • Social adversity. • Birth weight. • In unadjusted as well as adjusted models, experienced discrimination was not associated with infant birth weight. Weak Weak 15 of 31 15 of 31 Int. J. Environ. Res. Public Health 2021, 18, 1465 Table 1. Cont. Author Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Slaughter-Acey et al. (2016) [50] Detroit, MI, USA Black women (N = 1410). Retrospective cohort study. • Frequency and stressfulness of past-year experienced racial microaggressions (Daily Life Experiences of Racism and Bother (DLE-B) scale). • Prenatal depressive symptoms (1 week), • Stress past month, • Maternal age, • Education, • Financial situation, • Pre-natal smoking, • Self-rated physical health. • Preterm birth (<37 w). • • Slaughter-Acey et al. (2019) [48] Baltimore, MD, USA Black women (N = 778). Hybrid retrospective and prospective cohort study. • Frequency of past-year and lifetime experienced racial discrimination (Racism and Life Experiences Scale). • Frequency of past-year and lifetime group-based experiences of racism (Racism and Life Experiences Scale). 3.4. Study Findings • Maternal age and experienced racial discrimination interacted to impact on birth weight. Women over 25 (n = 257) had greater odds of giving birth to small-for-gestational-age babies for each one-unit increase in experienced overall and group-based racism (OR = 1.45, 95% CI, 1.02–2.08; OR = 2.84, 95% CI, 1.10–7.32, respectively). • No such relationship was evident for younger women. Strong Pregnant M¯aori (n = 510), Paciﬁc (n = 452), Asian (n = 691) women (N = 1653). Longitudinal cohort study. • Pervasiveness of past-year and lifetime ethnic discrimination. • Maternal age, • Maternal BMI, • Household income, • Education, • Relationship status, • Smoking, • Offspring sex • Gestational age at birth, • Birth weight. • M¯aori women who reported lifetime experiences of discrimination at work or in acquiring housing had lower-birth-weight children than those who had not experienced such discrimination (β = −243 g, 95% CI, −425 g, −60.2 g; (β = −146 g, 95% CI, −286 g, −6 g, respectively). • Compared to Asian women who reported no discrimination in housing, Asian women who had experienced lifetime discrimination in housing were more likely to have higher birth-weight-children (β = 188 g, 95% CI, 7 g, 369 g). • Shorter gestation length was evident for M¯aori women who reported lifetime experiences of ethnically motivated physical attacks (β = −1.06 week, 95% CI, −1.8 week, −0.3 week) or unfair treatment in the workplace (β = −0.95 week, 95% CI, −1.6 week, −0.3 week), the criminal justice system (β = −0.55 week, 95% CI, −1.1 week, 0.02 week), or in banking (β = −0.73 week, 95% CI, −1.4 week, −0.02 week). Strong Maternal age and experienced racial discrimination interacted to impact on birth weight. Women over 25 (n = 257) had greater odds of giving birth to small-for-gestational-age babies for each one-unit increase in experienced overall and group-based racism (OR = 1.45, 95% CI, 1.02–2.08; OR = 2.84, 95% CI, 1.10–7.32, respectively). • M¯aori women who reported lifetime experiences of discrimination at work or in acquiring housing had lower-birth-weight children than those who had not experienced such discrimination (β = −243 g, 95% CI, −425 g, −60.2 g; (β = −146 g, 95% CI, −286 g, −6 g, respectively). Int. J. Environ. Res. Public Health 2021, 18, 1465 16 of 31 Table 1. Cont. 3.4. Study Findings Accounting for a broad range of psychosocial factors, results showed that the experience of racial discrim- ination was associated with a 40% increased risk of PTB. This effect was replicated in a follow-up study that revealed an 80% (RR = 1.8, 95% CI, 1.1–2.9) increased risk of PTB for Black women who had experienced high levels (as opposed to low levels) of racial discrimination. This study also indicated a 110% increased risk among Black women who had experienced gender discrimination [31]. p g Another prospective cohort study focused on the link between birth outcomes and frequency of lifetime experiences of racial discrimination. This research included a sample of 352 Black (n = 152) and White (n = 200) pregnant women in Birmingham, AL, Oakland, CA, Chicago, IL, and Minneapolis, MN [41]. Consistent with the aforementioned studies, results showed that Black women were more than twice as likely (21.1% vs. 10%) to give birth preterm than White women. Further, of Black women who gave birth preterm, 50% (n = 16) had experienced racial discrimination in at least three situations. By contrast, only 5% (n = 1) of White women who had given birth preterm had experienced any discrimination. Further analyses revealed that the odds for PTB among women who had experienced three or more instances of racial discrimination were 205% higher (OR = 3.05, 95% CI, 1.29–7.24) than for women who had not experienced any such discrimination. ) p y In a case-control repeated-measures study of 277 Black women in Chicago, IL, Rankin et al. [49] found that lifetime and past-year maternal experiences of racial discrimination were positively associated with odds of PTB. In particular, women who reported high-level (as opposed to medium- or low-level) lifetime exposure to racial discrimination had 50% greater odds of giving birth preterm than women who reported little or no exposure. Similarly, women who reported high-level exposure to racism in the 12 months prior to giving birth had 150% higher odds of PTB than women reporting medium- and low-level exposures. Rankin et al. also assessed the extent to which coping style moderated the impact of racial discrimination on birth outcomes. While passive coping mechanisms (e.g., internalizing, avoiding, or ignoring the event) appeared to have no moderating effect, active coping behaviors did. 3.4. Study Findings Location Population (N) Research Design Discrimination Measure (Scale Name) Covariates Outcome Variables Findings Research Quality nd 015) Auckland, New Zealand Pregnant women (N = 64). Prospective cohort study. • Frequency of lifetime experienced discrimination (Everyday Discrimination Scale). • Maternal age, • Maternal height, • Maternal weight • SES • Ethnicity, • Education, • Smoking, • Exercise, • Depression, • Material deprivation • PTSD. • Morning/evening cortisol levels, • Infant stress reactivity (cortisol levels post vaccination). • Women who had been treated with less respect because of their ethnicity (n = 10) were more likely to self-report poor health than women who had not experienced discrimination (OR = 1.58, SE = 0.72, p = 0.03, R2 = 0.06). • Women who had experienced ethnic discrimination exhibited (n = 22) higher levels of evening cortisol levels (1.25 ng/mL) than women who had experienced low levels of discrimination (0.9 ng/mL, p < 0.01) or none at all (0.8 ng/mL, p < 0.001). • Infants (n = 19) of women who had experienced discrimination vs. those who had not, had greater cortisol response to vaccination (β = 6.43, SE = 2.60, t = 2.47, p < 0.05). Moderate 17 of 31 Int. J. Environ. Res. Public Health 2021, 18, 1465 17 of 31 A similar cross-sectional study by Daniels et al. [44] drew data from the African- American Women’s Heart & Health Study (AAWHHS; N = 173) to examine the association between preterm labor and direct and vicarious racial discrimination among Black women. The study speciﬁcally concerned frequency of racism experienced in childhood, adoles- cence, and/or adulthood. The authors found that for each one-unit increase in reported direct racial discrimination during adolescence (measured using the Everyday Discrimina- tion Scale) the odds of PTB increased by 48% (OR = 1.48, 95% CI, 1.00–2.19). Likewise, each one-unit increase in reported vicarious racial discrimination (i.e., witnessing discrimination perpetrated against a similar other) experienced in childhood was associated with a 45% increase in odds of preterm labor (OR = 1.45, 95% CI, 1.01–2.09). There was no relationship between adult direct or vicarious racial discrimination and PTB. In a prospective cohort study of 1962 pregnant women in Central North Carolina between 1996 and 2000, Dole et al. [30] investigated the link between PTB and maternal stress from multiple sources, including everyday racial discrimination. 3.4. Study Findings The authors also discovered a non-linear moderating effect of depression where women with mild-to-moderate depressive symptoms (as opposed to severe symptoms) in the second discrimination quartile had a predictive probability of PTB twice as high as their ﬁrst-quartile counterparts. In other words, racial discrimination predicted PTB only in women with lower-grade depression as opposed to severe depression. Slaughter-Acey et al.’s results resonate with those of Misra et al. [47]. They investi- gated the extent to which frequency of lifetime and maternal daily experiences of racial discrimination impacted on PTB in a sample of 832 Black women in Baltimore, MD. They also looked at the effect of individuals’ responses to such discrimination. Controlling for a broad range of psychosocial, demographic, and health-related risk factors, results revealed no statistically signiﬁcant main effects of any measure of racial discrimination on PTB. However, women who scored above the median on lifetime exposure to racial discrimina- tion, and who had high vs. low levels of stress or high vs. low levels of prenatal depression, had 32% (HR = 1.32, 95% CI, 0.64–3.57) and 55% (HR = 1.55, 95% CI, 0.90–2.64) increased odds of PTB, respectively. Thus, similar to Slaughter-Acey et al.’s results, Misra et al. also found a moderating effect of mental health factors, including stress and depression, on the link between racial discrimination and birth outcomes. Finally, two studies from outside the US provide further support for the link between maternal experience of discrimination and PTB. Scholaske et al. [54] conducted a longitudi- nal, nation-wide panel study of pregnant non-immigrant (n = 2308) and Turkish immigrant women in Germany (n = 217). Results indicated that Turkish women who had experienced ethnic discrimination in the 12 months prior to giving birth had 319% increased odds of giving birth preterm than women who had not experienced discrimination (11.84%, χ2(1, 109) = 8.18, p < 0.01, OR = 4.19). Similarly, in a longitudinal cohort study from New Zealand, Thayer et al. [7] found signiﬁcant links between pervasiveness of maternal experi- ences of discrimination and PTB in a sample of pregnant M¯aori, Paciﬁc, and Asian women (N = 1653). 3.4. Study Findings Speciﬁcally, women who dealt with racial discrimination by “working harder to prove the perpetrator wrong” and/or “getting violent towards the perpetrator” had 20% (OR = 0.80, 95% CI, 0.40–1.90) and 70% (OR = 0.30, 95% CI, 0.10–1.70) lower odds, respectively, of giving birth preterm than participants who did not report these coping behaviors. Another case-control study examined the link between PTB and different types of everyday racial discrimination (e.g., discrimination at work, as a customer, interacting with police or people in general). The sample included 422 Black mothers of preterm babies compared to 4544 Black mothers of full-term babies. Controlling for a wide range of health, demographic, and SES factors, Rosenberg et al. [53] found that women who had been treated unfairly at work (n = 251) or reported that people had acted afraid of them at least once a week (n = 50), had 30% (OR = 1.3, 95% CI, 1.1–1.6) and 40% (OR = 1.4, Int. J. Environ. Res. Public Health 2021, 18, 1465 18 of 31 18 of 31 95% CI, 1.0–1.9) higher odds of giving birth preterm, respectively, than those who did not report such treatment. For women with less than 12 years of education (n = 46), racial discrimination in housing, as a customer, and in terms of being feared by others, similarly increased the odds of PTB by 140% (OR = 2.4, 95% CI, 1.2–4.6), 240% (OR = 3.4, 95% CI, 1.5–7.7), and 100% (OR = 2.00, 95% CI, 1.0–4.1), respectively. p y In a similar retrospective cohort study on the impact of racial microaggressions on birth outcomes, Slaughter-Acey et al. [50] found that the frequency and stressfulness of everyday maternal experiences of racial microaggressions predicted PTB. This research centered on a sample of Black women from Detroit, MI, (N = 1410). For the purposes of the study, the sample was divided into quartiles designating extent and stressfulness of experienced discrimination (ﬁrst quartile = low, fourth quartile = high). Women in the 2nd to 4th discrimination quartiles (i.e., women who had experienced more and more stressful discrimination relative to women in the ﬁrst quartile) had greater odds of PTB than women the ﬁrst quartile. However, only differences between the 1st and 2nd quartiles were statistically signiﬁcant, with women in the second quartile having 67% greater odds of PTB than women in the ﬁrst quartile (OR = 1.67, 95% CI, 1.16–2.40). 3.4. Study Findings Indeed, shorter gestation period was evident for M¯aori women who reported ethnically motivated physical attacks (β = −1.06 week, 95% CI, −1.8 week, −0.3 week) or unfair treatment in the workplace (β = −0.95 week, 95% CI, −1.6 week, −0.3 week), the criminal justice system (β = −0.55 week, 95% CI, −1.1 week, 0.02 week), or in banking (β = −0.73 week, 95% CI, −1.4 week, −0.02 week). β In addition to the 11 articles described above that all indicate a negative impact of maternal experiences of interpersonal discrimination on PTB and/or gestational age at birth, another four studies report null effects. Speciﬁcally, Gillespie and Anderson [36] conducted a prospective cohort study of 96 Black women in Ohio, US. They assessed the extent to which the frequency and pervasiveness of interpersonal discrimination in individuals’ lives predicted gestational age at birth and various physiological risk factors of PTB (see Table 1). The authors found no main effects of maternal experiences of discrimination Int. J. Environ. Res. Public Health 2021, 18, 1465 19 of 31 19 of 31 on gestational age, and their results for physiological variables were mixed. Speciﬁcally, they found an interaction effect in the expected direction between discrimination and coping mechanisms on cortisol levels during pregnancy. Among women who tended to internalize experiences of discrimination (n = 32), those who experienced medium levels of discrimination exhibited higher cortisol levels (a known risk factor for PTB) during pregnancy than those who experienced low levels of discrimination (b = 0.68, p = 0.001). Overall, however, greater cortisol levels predicted earlier birth only for mothers who reported low levels of discrimination. Further, results also indicated a protective effect of discrimination on leukocyte glucocorticoid sensitivity (another risk factor for PTB). y g y Comparable results were generated in a study by Giurgescu et al. [37] on the link between frequency and pervasiveness of lifetime maternal experiences of racial discrim- ination and PTB. In a sample of Black women from Chicago, US, the authors found a signiﬁcant positive association between experienced discrimination and psychological distress (β = 0.52, p < 0.01), but not PTB (p > 0.05). Similar to the study by Gillespie and Anderson, however, these results were based on an exceedingly small sample (N = 72) who reported generally low levels of discrimination. p g y In another two studies that collected data from much larger samples, Grobman et al. 3.4. Study Findings [38] (N = 9470) and Mendez et al. [52] (N = 3462) found no statistically signiﬁ- cant association between PTB and frequency or pervasiveness of maternal experiences of lifetime or everyday discrimination. In particular, the former study found that while Black women had greater odds of giving birth preterm (OR = 1.6, 95% CI, 1.32–1.93) than White women, this relationship was not accounted for by discrimination. Similarly, Mendez et al. found that Black women were nearly twice as likely (14.9%) as White (7.7%) or Hispanic (8.3%) women to give birth preterm, but this disparity in PTB was not explained by inter- personal discrimination. Both Mendez et al. and Grobman et al. cited demographically uneven sample sizes and small subgroup sizes as potential explanations as to why their analyses, in contrast to the rest of the relevant evidence base, failed to detect a statistically signiﬁcant contribution of interpersonal discrimination to PTB. 3.4.2. Maternal Experiences of Interpersonal Discrimination and Infant Birth Weight mothers of normal-weight infants ≥2500 g n = 208) in Chicago, IL, the authors found that experiencing racial discrimination in one or more life domains increased the odds of VLBW by 90% (OR = 1.9, 95% CI, 1.2–3.0). For women who had experienced racial discrimination in three or more life domains, odds of VLBW increased by 170% (OR = 2.7, CI 95% 1.3–5.4). Dixon et al. [3] conducted a similar prospective cohort study on the pervasiveness of maternal racial discrimination and infant-toddler birth weight in a sample of Black, Hispanic, and Asian women (N = 539) in MA, USA. They found negative associations between maternal lifetime pervasiveness of racial discrimination and both birth and child weight. Speciﬁcally, compared to mothers who had not experienced any racial discrimi- nation, mothers who had experienced racial discrimination in three or more life domains had children of lower weight at birth (z-score β = −0.25, 95% CI, −0.45 to −0.04), at six months of age (z-score β = −0.34, 95% CI, −0.65 to −0.03), and at three years of age (z-score β = −0.33, 95% CI, −0.66 to 0.00). The offspring of mothers who reported racial discrimina- tion in 1–2 life domains were (though non-signiﬁcantly) in between the two other cohorts (discrimination in 0 vs. >3 life domains) in terms of weight, suggesting a dose-response relationship. p Next, in a cross-sectional study of Black (n = 407) and White (n = 222) mothers in Sagi- naw County, MI, Carty et al. [43] investigated the link between frequency of interpersonal racial discrimination and child birth weight. The authors operationalized discrimination in terms of sheer frequency of experiences in the past year, perceived group racism (i.e., vicarious racism), racism-related stress, and individual emotional reaction to experienced interpersonal racism. Results indicated that only emotional reactions to racial discrimina- tion was associated with child birth weight. Speciﬁcally, the more extreme the individual’s emotional response, the greater the odds of giving birth to a child of LBW (<2500 g) (OR = 1.24, 95% CI, 0.93–1.48). Adjusting for race and educational level, this association attenuated and was only marginally signiﬁcant (OR = 1.17, 95% CI, 0.93–1.48). y g y g ( ) Further, while the studies by Collins et al., Lespinasse et al., and Dixon et al. ex- amined frequency and/or pervasiveness of racial discrimination in various life domains, Dominguez et al. 3.4.2. Maternal Experiences of Interpersonal Discrimination and Infant Birth Weight 3.4.2. Maternal Experiences of Interpersonal Discrimination and Infant Birth Weight Two case-control studies conducted by Collins et al. in 2000 [43] and 2004 [34] focused on samples of Black women who gave birth to healthy-weight (>2500 g) children vs. very- low-birth-weight (VLBW; <1500 g) children. The former study centered on 85 Black women in Chicago, IL, 25 of whom had VLBW children, while the rest had normal-weight children. In the fully adjusted model, results indicated that the odds of infant VLBW were marginally greater for women who had been exposed to racial discrimination during pregnancy (OR = 3.3, 95% CI, 0.9–11.3). These odds increased for women who had two or more of the following risk factors: high parity, poor or no prenatal care, inadequate social support, or tobacco, alcohol, or illicit drug use (OR = 4.4, 95% CI, 1.1–18). Indeed, with the exception of education, every risk factor included in the analyses (see Table 1) appeared to interact with maternal experience of racial discrimination to increase the odds of giving birth to VLBW children. However, possibly due to the exceedingly small cell sizes, these increases were marginally signiﬁcant at best. In Collins et al.’s second study [34], the sample was bigger, but identical in charac- teristics, focusing on Black mothers of VLBW children (n = 104) vs. Black mothers of normal-weight children, (n = 208). The authors found that the experience of lifetime dis- crimination in at least one of ﬁve life domains (work, getting a job, school, medical care, and receiving service) (n = 58) increased the odds of giving birth to VLBW children by 90% (OR = 1.9, 95% CI, 1.2–3.1). Being the target of discrimination in at least two domains, increased the odds to 110% (OR = 2.1, 95% CI, 1.2–3.8), and having these experiences in three or more life domains, increased the odds further to 220% (OR = 3.2, 95% CI, 1.5–6.6). This pattern suggests a dose-response relationship between pervasiveness of lifetime racial discrimination and risk of infant VLBW. Int. J. Environ. Res. Public Health 2021, 18, 1465 20 of 31 20 of 31 Complementing the ﬁndings of Collins et al., Lespinasse et al. [40] also looked at the effect of pervasiveness of maternal lifetime experiences of racial discrimination on infant birth weight. In a case-control study of 312 mothers (mothers of VLBW infants <1500 g n = 104 vs. 3.4.2. Maternal Experiences of Interpersonal Discrimination and Infant Birth Weight [4] focused on the effects of discrimination experienced in different life stages (childhood, adolescence, adulthood, and lifetime). As in Carty et al., this study also operationalized racial discrimination in terms of direct and vicarious experiences. The sample comprised 124 pregnant women (Black n = 51, White n = 73) in Los Angeles, CA. Ac- counting for a wide range of SES, demographic, and health factors, the authors found that for each one-unit increase in overall maternal experience of lifetime racial discrimination infant birth weight decreased by 39.59 g. Breaking this association down, the authors found that racial discrimination experienced vicariously in childhood was the main driver of this effect. Indeed, for each one-unit increase in maternal vicarious childhood experiences of discrimination, infant birth weight decreased by 167.85 g (β = −0.25, p < 0.01), suggesting a dose-response relationship. Similar to Carty et al. and Dominguez et al., Hilmert et al. [39] also investigated the extent to which the pervasiveness of direct and vicarious racial discrimination experienced in childhood and/or adulthood impacted on infant birth weight. This prospective cohort study included a sample of Black pregnant women (N = 39) in Los Angeles, CA. Total maternal racial discrimination (direct and vicarious combined) emerged as a statistically marginal predictor of birth weight (β = −0.27, p < 0.10), while direct racial discrimination experienced in adulthood accounted for a signiﬁcant amount of variance in birth weight (β = −0.26, p < 0.05). Further, maternal vicarious and direct childhood experiences of racial discrimination interacted with change in prenatal diastolic blood pressure (DBP) to impact negatively on birth weight (β = −0.25, ∆R2 = 0.04, p < 0.05; β = −0.22, ∆R2 = 0.03, p = 0.10, respectively). Speciﬁcally, for women who had vicariously experienced racial Int. J. Environ. Res. Public Health 2021, 18, 1465 21 of 31 21 of 31 discrimination in approximately two childhood domains, infant birth weight decreased by 19.98 g for every 1 mmHg increase in maternal DBP (B = −160.65, p < 0.05). This association was not evident in women who had experienced no such discrimination. p Extending the line of research into the impact of direct and vicarious maternal discrim- ination, Slaughter-Acey et al. [48] conducted a hybrid retrospective/prospective cohort study of 778 Black women in Baltimore, MD. 3.4.2. Maternal Experiences of Interpersonal Discrimination and Infant Birth Weight The authors operationalized racism in terms of frequency of experienced direct racism, group-based (vicarious) racism, and overall racism (direct and vicarious combined). Results indicated an interaction between maternal age and frequency of both overall and vicarious racism. For women over the age of 25 years (n = 257), each one-unit increase in overall racism was associated with 45% greater odds of low infant birth weight (OR = 1.45, 95% CI, 1.02–2.08). Disentangling this effect, the authors found that the odds for low infant birth weight increased 184% for each one-unit increase in vicariously experienced racism in women over 25 years old (OR = 2.84, 95% CI, 1.10–7.32). A similar, but non-signiﬁcant trend in direction was evident for the link between infant birth weight and direct racism in women over 25 years old. These associations did not emerge in the results for women under 25 years old. g y Next, Earnshaw et al. [45] conducted a prospective cohort study into the association between frequency of maternal experiences of everyday discrimination and infant birth weight. They focused on a sample of Black (n = 158) and Latina (n = 262) women in New York City, NY. Consistent with the previously cited research, results indicated an inverse association between frequency of maternal everyday discrimination and infant birth weight (OR = 2.78, p < 0.05). Interestingly, the authors also found that this association was mediated by increased depressive symptoms during pregnancy (β = −0.04, p < 0.01). In raw numbers, this translates into an infant birth weight decrease of 49 g for every one-point increase in maternal everyday discrimination. While maternal prenatal stress also correlated with maternal experiences of discrimination (β = 0.27, p < 0.01), this variable did not predict or mediate birth outcome. In a similar prospective cohort study that also took into account antenatal depression, Mustillo et al. [41] looked at pervasiveness of racial discrimination and birth weight in a sample of pregnant women in Chicago, IL, Oakland, CA, and Minneapolis, MN, (N = 352). The odds of giving birth to low-birth-weight infants was 398% (OR = 4.98, 95% CI, 1.43–17.39) greater for women who had experienced racial discrimination in >2 life domains compared to women who had experienced none. In contrast to Earnshaw et al., analyses failed to detect a statistically signiﬁcant mediating effect of maternal depressive symptoms. 3.4.2. Maternal Experiences of Interpersonal Discrimination and Infant Birth Weight y p The only article that reported on maternal discrimination and infant birth weight and was conducted outside of the US, was the aforementioned longitudinal cohort study by Thayer et al. [7]. Complementing their ﬁndings on discrimination and gestational age at birth described in the previous section, their results also indicated a link between perva- siveness of maternal experiences of discrimination and infant birth weight. Indeed, M¯aori women who experienced discrimination at work or in acquiring housing had children with lower birth weight than those who had not experienced such discrimination (β = −243 g, 95% CI, −425 g, −60.2 g; (β = −146 g, 95% CI, −286 g, −6 g, respectively). Somewhat counter-intuitively, Asian women who had experienced discrimination in housing (vs. Asian women who had not experienced such discrimination) were more likely to have children of higher birth weight (β = 188 g, 95% CI, 7 g, 369 g). g g β g g g Finally, of the articles that included infant birth weight as an outcome variable, three reported only marginal or no effect of experienced discrimination. Speciﬁcally, in a prospec- tive cohort study of 108 Black women in Northern CA, Daiely [2] found no link between infant birth weight and maternal experience of general discrimination. Results did indicate that maternal experience of religious discrimination was negatively associated with infant birth weight (t = 2.39, p = 0.02), though given the exceedingly small cell size (only n = 10 women reported religious discrimination), this outcome may at best be suggestive rather than actually statistically meaningful. Similarly, while Grobman et al. [38] found that Black Int. J. Environ. Res. Public Health 2021, 18, 1465 22 of 31 22 of 31 women had 120% higher odds than White women of giving birth to low-weight infants (OR = 2.2, 95% CI, 1.86–2.62), neither frequency nor pervasiveness of maternal discrimina- tion accounted for this difference. The authors indicated that in spite of the overall large sample, individual cell sizes were relatively small and might have accounted for the lack of statistically signiﬁcant results. Finally, in their cross-sectional study of 1150 pregnant minority and White women in Chicago, IL, and New York City, NY, Shiono et al. [55] failed to detect any statistically signiﬁcant impact of frequency of maternal experience of racial discrimination on infant birth weight. 3.4.3. Maternal Experiences of Interpersonal Discrimination and Physiological Pregnancy Outcomes While other articles retained for this review tested physiological variables as mediators of the relationship between maternal experience of discrimination and birth outcomes (including Grobman et al., Gillespie et al., and Hilmert et al.), two studies focused explicitly on pregnancy- and/or birth-related physiological outcome variables. Christian et al. [33] examined Epstein–Barr virus (EBV) reactivation as a proxy for cellular immune competence during pregnancy and postpartum. Speciﬁcally, they focused on increased levels of EBV virus capsid antigen immunoglobulin G (VCA IgG)—a known marker of chronic stress and AL, and risk factor for adverse birth outcomes. The authors focused on a sample of pregnant women (Black n = 38, White n = 18) in Ohio, US, and measured lifetime pervasiveness of experienced maternal discrimination. Results showed that Black women exhibited substantially higher levels of IgG antibody titers than White women during each trimester and postpartum. Further, women who reported high discrimination showed higher EBV VCA IgG antibody titers than women who reported low discrimination in the ﬁrst (p = 0.03) and second trimesters (p = 0.04) as well as postpartum (p = 0.06). The authors note that the small cell sizes represent a limitation, however, and the results should be interpreted cautiously. In a similar study, Thayer et al. [46] assessed the extent to which frequency of ex- perienced discrimination was associated with pregnant women’s morning and evening cortisol levels during pregnancy as well as infant cortisol levels at postpartum vaccina- tion (as a proxy for stress reactivity). The study sample comprised an ethnically diverse group of 64 women in Auckland, New Zealand. Results indicated that women who had experienced ethnic discrimination (n = 22) exhibited higher levels of evening cortisol levels (m = 1.25 ng/mL) than women who had experienced low levels of discrimination (m = 0.9 ng/mL, p < 0.01) or none at all (m = 0.8 ng/mL, p < 0.001). Further, the infants of women who had experienced discrimination (n = 19) vs. those of women who had not experienced discrimination (n = 41), exhibited greater cortisol responses to vaccination (β = 6.43, SE = 2.60, t = 2.47, p < 0.05). 3.4.2. Maternal Experiences of Interpersonal Discrimination and Infant Birth Weight Various methodological issues were suggested as potential causes for these non-signiﬁcant results, including most prominently study sample diversity in terms of cultural background and English language ability/comprehension, as well as questionable accuracy of survey translations. . Discussion 1 M i Fi di 4.1. Main Findings .1. Main Findings The results reported in the reviewed papers overwhelmingly support the onclusion that maternal experiences of interpersonal discrimination are pos- tively associated with increased risk of adverse pregnancy outcomes. Con- rolling for an extensive range of covariates, 24 out of 28 articles presented mpirical evidence that indicate strong links between interpersonal discrimi- nation and infant birth weight, PTB, gestational age at birth, and both mater- nal and infant physiological stress reactivity. Of the remaining four studies, hree reported inverse, albeit statistically non-significant connections between he variables of interest [37,38,52], and one excluded non-significant statistics rom their results, preventing assessment of directionality [55]. Thus, taken ogether, these results resonate strongly with the extant literature on the health effects of experienced discrimination in minority populations, empha- izing the very real and physical toll of the stress caused by interpersonal dis- rimination [58–64]. This research may also have implications for prenatal and The results reported in the reviewed papers overwhelmingly support the conclusion that maternal experiences of interpersonal discrimination are positively associated with increased risk of adverse pregnancy outcomes. Controlling for an extensive range of covariates, 24 out of 28 articles presented empirical evidence that indicate strong links between interpersonal discrimination and infant birth weight, PTB, gestational age at birth, and both maternal and infant physiological stress reactivity. Of the remaining four studies, three reported inverse, albeit statistically non-signiﬁcant connections between the variables of interest [37,38,52], and one excluded non-signiﬁcant statistics from their results, preventing assessment of directionality [55]. Thus, taken together, these results resonate strongly with the extant literature on the health effects of experienced discrimination in minority populations, emphasizing the very real and physical toll of the stress caused by interpersonal discrimination [58–64]. This research may also have implications for prenatal and postpartum care in minority populations—for example, with regard to the potential of screening for maternal experiences of discrimination as a signiﬁcant risk factor for adverse birth outcomes. [ ] y p p postpartum care in minority populations—for example, with regard to the po- ential of screening for maternal experiences of discrimination as a significant risk factor for adverse birth outcomes. While the overall association between maternal experiences of discrimi- While the overall association between maternal experiences of discrimination and adverse birth outcomes is rather clear, there are nonetheless a number of notable themes and variations that emerge from the reviewed studies. 3.4.4. Preliminary Process Model To sum up our review of the evidence, we have created a preliminary process model for the relationship between interpersonal discrimination and adverse birth outcomes (Figure 2). While the pathways that we have deﬁned here are somewhat tenuous given the general scarcity of studies on each speciﬁc mechanism, they are nonetheless con- sistent with the broader literature on the physical health repercussions of interpersonal discrimination [56–58]. 23 of 31 Int. J. Environ. Res. Public Health 2021, 18, 1465 nt. J. Environ. Res. Public Health 2021, 18, x FOR P Figure 2. A preliminary, evidence-based model of the psychophysiological impact of interpersonal discrimination on birth outcomes. Figure 2. A preliminary, evidence-based model of the psychophysiological impact of interpersonal discrimination on birth outcomes. igure 2. A preliminary, evidence-based model of the psychophysiological impact of nterpersonal discrimination on birth outcomes. Figure 2. A preliminary, evidence-based model of the psychophysiological impact of interpersonal discrimination on birth outcomes. . Discussion 1 M i Fi di 4.1. Main Findings These include principally the type of discrimination (e.g., frequency vs. pervasiveness, lifetime vs. past year vs. everyday Int. J. Environ. Res. Public Health 2021, 18, 1465 24 of 31 24 of 31 experiences, vicarious vs. direct), and the recurring moderating or mediating roles of stress and depression. p In virtually all of the studies, the frequency and/or pervasiveness of interpersonal discrimination in individuals’ lives comprised the main gauge of discrimination. However, across studies, the time spans tapped for discriminatory experiences varied. Most studies (n = 16) measured lifetime experiences of discrimination, while others focused on past-year discrimination (n = 10) or everyday discrimination (n = 3). These different conceptualizations of discrimination ﬂuctuated markedly in predictive reliability. Speciﬁcally, of the 16 studies that included measures of lifetime discrimination, all but two [37,38] found a signiﬁcant association between this construct and birth outcomes. Three of the six studies that focused exclusively on past-year experiences of discrimination, however, found either no signiﬁcant relationship at all [55] or generated mixed results [43,50]. Finally, four studies employed both lifetime and short-term measures of discrimination, affording a more direct comparison. In two of these studies, lifetime, but not past-year discrimination predicted birth outcomes [7,34]. The other two studies reported signiﬁcant associations between both discrimination measures and birth outcomes [48,49]. Taken together, these ﬁndings indicate relatively clearly that in terms of adverse birth outcomes, lifetime experiences of discrimination are the most consequential. q Four studies also included extra measures of vicarious experiences of discrimination across the lifespan and demonstrated that discrimination need not be experienced ﬁrst- hand to impact on birth outcomes. Speciﬁcally, Daniels et al. [44], Dominguez et al. [4], and Hilmert et al. [39] all found that vicarious maternal childhood experiences of racism, perpetrated against close ingroup members (e.g., family or friends), were associated with PTB and decreased birth weight. Similarly, Slaughter-Acey et al. [48] found that experi- ences of vicarious discrimination in women over 25 years of age were negatively associated with infant weight for gestational age. Theoretically, this effect may be due to the chronic situational vigilance (and stress) that might result from the awareness that if a relative or friend can be discriminated against, so too can the individual themselves be a target of discrimination. In other words, “merely” witnessing a close, similar other being discrim- inated against may have severe stress-related health implications later in life. . Discussion 1 M i Fi di 4.1. Main Findings This line of reasoning resonates well with other studies that show that stereotype threat and/or worry about becoming a target of discrimination, has comparable consequences for birth outcomes as those associated with experiences of actual discrimination [65,66]. As mea- sures of vicarious experiences of discrimination typically, if not exclusively, relate to the experiences of “close others”; however, it is unclear whether this effect extends to more distal members of the individual’s perceived ingroup as well. p g p A total of 14 articles included mental health covariates of stress and/or depression in their analyses. Of these, six studies found that stress and/or depression mediated or moderated the relationship between maternal experiences of discrimination and birth outcomes [33,36,45–47,50]. Speciﬁcally, Slaughter-Acey et al. [50] found that depression (but not stress) moderated the effects of discrimination on birth outcomes, whereas in Misra et al. [47] both of these variables were signiﬁcant moderators. Earnshaw et al. [45], however, found that depression (but not stress) mediated the effects. Further, Christian et al. [33], Gillespie et al. [36], and Thayer et al. [46]. were largely unanimous in their conclusion that maternal experiences of discrimination likely caused increases in maternal and infant stress and allostatic load markers (cortisol, cellular immune response, glucocorticoid sensitivity)— a known risk factor for adverse birth outcomes and general health. Taken together then, these results suggest that not only may depression and stress make birth outcomes more vulnerable to the impact of discrimination, but it might also be the case that discrimination gives rise to stress and depression, which in turn cause adverse birth outcomes and maternal and infant health issues. In other words, these factors may moderate and/or mediate the effects of maternal experiences of discrimination on birth outcomes and infant health. More research, however, is required to disentangle these relationships and deﬁnitively determine how and when stress and depression factor into this association. Int. J. Environ. Res. Public Health 2021, 18, 1465 25 of 31 The remaining eight studies that included measures of depression and/or stress found no significant explanatory power associated with any of these variables [3,4,30,37,38,43,52,55]. It should be noted, however, that all but two of these studies focused on recent symptoms of maternal depression and/or stress (typically past month or prenatal). By contrast, the six studies in which stress and/or depression were found to be significant predictors, used more general, life-time measures to gauge these emotions. 4.2. Strengths and Limitations There are several strengths and limitations to the reviewed evidence base. As noted in Section 3, the quality of the reviewed studies is predominantly high, with 12 articles based on strong research methodologies, and another 13 on moderate-quality methods. These ratings were mainly due to the rigorous research designs employed (e.g., cohort studies, longitudinal designs, etc., see Table 1), the large and representative study populations, and the extensive effort to control for a broad range of covariates. Indeed, the longitudinal cohort studies by Thayer et al. [7] and Dixon et al. [3] as well as the case-control study by Rosenberg et al. [53], stand out as particularly noteworthy examples of the overall high research quality. Further, our quality assessment contrasts with those of previous reviews, which have pointed to methodological issues and limitations in the evidence base. As noted in the introduction, however, these reviews were based on a small pool of studies, less than half as big (max N = 12) as the present review (N = 28). Further, all of the studies published since these previous reviews were conducted have been of moderate or high quality (see Table 1). In other words, the evidence base appears to have not only expanded, but also qualitatively improved. Another strength relates to the conceptualization of interpersonal discrimination in the reviewed studies. Past research has emphasized the tendency in discrimination research to deﬁne this behavior in somewhat simplistic, unidimensional terms—often as a frequency within a certain timeframe [32,58]. However, of the reviewed studies, all but two [30,31] used multidimensional scales of discrimination that tapped frequency, pervasiveness across individuals’ life domains, stressfulness, etc. This lends considerable credence to the results, as these measures are likely to have captured relatively richer, more accurate data on the nature and extent of experienced discrimination than studies focusing on more narrow deﬁnitions. Finally, from the perspective of the broader ﬁeld of discrimination, stress, and health, the rather objective dependent variable of birth outcomes and/or maternal and infant physiological stress reactivity is a clear strength. Most other studies in the area rely on self- reported health or stress—measures that are prone to bias and error given their subjective nature. The reviewed studies, however, circumvent this issue by focusing on tangible, corporeal endpoints (birth weight, PTB, and allostatic load) associated with discrimination- related stress. . Discussion 1 M i Fi di 4.1. Main Findings This suggests that the mediating/moderating role of stress and depression in this context may be better captured by tapping lifetime chronic and pervasive stress and/or depression rather than confining measurement of these variables to more specific and shorter-term bouts (e.g., prenatal and postpartum). This resonates well with the findings noted above that it is lifetime exposure to discrimination, as opposed to more recent shorter-term exposures, which appear to impact on birth outcomes. These conclusions also dovetail nicely with the broader literature on the weathering effect of discrimination. Here, it is, namely, the cumulative build-up of discrimination-related stress and allostatic load that over time wears and tears on the body, slowly causing it to break down [56,62]. 4.2. Strengths and Limitations In conjunction with past evidence on these types of physical outcomes (such as, e.g., the literature on discrimination and hypertension), this research thus helps solidify more objective insight into the harmful biological consequences of being subjected to interpersonal discriminatory behavior. p y There are also a few limitations to the evidence base that need to be noted. First and foremost, with the exception of two studies from New Zealand and one from Germany, all of the research retained for this review is from the US. Further, the vast majority of these articles focus on discrimination against Black Americans, with only a handful including Int. J. Environ. Res. Public Health 2021, 18, 1465 26 of 31 other ethnicities as well. Based on the current evidence then, conclusions about the present subject matter extends nearly exclusively to Black women in the US. In other words, given the unique history of subjugation and discrimination against Black Americans, the evidence base may not generalize in the exact same way to other minority populations. Of additional relevance in this context is the fact that the for-proﬁt model of the US health care system poses signiﬁcant challenges in terms of equal access compared to other, government-funded models such as those implemented in Germany and New Zealand. Further, determining whether other bases for discrimination—be it gender, age, mental health, disability, sexuality, etc.—have comparable effects on birth outcomes is somewhat tricky, and ultimately requires further research. Another shortcoming relates to the measure of discriminatory experiences employed in the reviewed studies. While we listed the multidimensional operationalization of dis- crimination as a strength above, this is mostly by comparison to existing research. That is, beyond the effects of frequency and pervasiveness, other elements of discrimination ap- peared largely untapped in the research or lacked in detail. For example, more knowledge is required on the extent to which vicarious experiences of discrimination are moderated by social proximity of the target. That is, are the harmful effects of vicarious experiences of discrimination dependent on the extent to which the perceiver is personally connected to the target (e.g., a “close other” vs. an acquaintance vs. an ingroup member with no personal connection to the perceiver)? This may be a pertinent avenue for future research— particularly given the increasing number of cases of racial and gender-based discrimination that make it into the public eye in the US, the EU, and elsewhere. 4.2. Strengths and Limitations Further, the most common discrimination measure across studies was the Krieger Everyday Discrimination Scale (n = 13). While this scale has high validity and reliability scores [32], the items focus mainly on overt, active discrimination, priming the individual to recall whether they “have [ . . . ] ever been prevented from doing something, been hassled, or made to feel inferior”. As such, without explicitly asking about discrimination of a more subtle, passive, or covert nature (e.g., coded language, micro-aggressions, and social invisibility), these types of experiences may not have been captured in many of the studies included in this review. Recent research, however, indicates that this type of discrimination is pervasive and harmful [67–70]. p As is the case with most systematic reviews, the evidence base in focus is potentially limited by positive ﬁndings publication bias [71]. That is, any number of studies may have been conducted on this topic but rejected for publication due to statistically non-signiﬁcant results. Lastly, given the nature of the relationship between discrimination and birth outcomes, the evidence base consists exclusively of correlational data. Thus, deﬁnitive conclusions about cause and effect cannot be drawn. That said, the detailed cohort study methodology employed in most of the retained studies may be the next-best thing. 4.3. Theoretical, Social, and Clinical Implications All strengths and limitations considered, the evidence synthesized in this review may have several meaningful implications. From a socio-theoretical perspective, the overarching theme that maternal experiences of interpersonal discrimination have serious and independent consequences for birth outcomes, lends further credence to the weathering effect hypothesis. While this theory has already received considerable support [72–74], this review indicates that discrimination not only erodes the health and wellbeing of the immediate target but may also transcend generation and cause physical harm to her unborn child. Extending the plethora of research on the mental health repercussions of interpersonal discrimination, this article thus highlights the very toxic biological impact associated with the perpetration of this type of behavior [58]. The growing evidence base on the exceedingly pernicious and visceral effect of interpersonal discrimination may serve to further illustrate the crucial importance of addressing this issue in a comprehensive and preventive manner. This may include, but is not limited to, the consistent prioritization Int. J. Environ. Res. Public Health 2021, 18, 1465 27 of 31 of extensive schooling and critical dialogue about discrimination in core curricula at all levels of education. Similarly, public awareness campaigns and training interventions in particular settings (e.g., health care, education, and the workplace) have also shown some success [75,76]. These types of approaches might focus on illuminating the nature, mechanisms, and the implicit as well as the overt enactment of both interpersonal and institutional discrimination. The roots of discrimination run deep in most Western cultures, however, and any effective and lasting remedy will also require pervasive and meaningful bottom-up policies and legislation that target structural prejudice and discrimination and promote social and economic equity in all parts of society [76]. of extensive schooling and critical dialogue about discrimination in core curricula at all levels of education. Similarly, public awareness campaigns and training interventions in particular settings (e.g., health care, education, and the workplace) have also shown some success [75,76]. These types of approaches might focus on illuminating the nature, mechanisms, and the implicit as well as the overt enactment of both interpersonal and institutional discrimination. The roots of discrimination run deep in most Western cultures, however, and any effective and lasting remedy will also require pervasive and meaningful bottom-up policies and legislation that target structural prejudice and discrimination and promote social and economic equity in all parts of society [76]. 4.3. Theoretical, Social, and Clinical Implications p q y p y In addition, and from a clinical, and more reactive standpoint, the cumulation of evidence on this matter may inform various aspects of maternal health care. Incorporating measures of maternal experiences of discrimination in maternal health-risk algorithms, for instance, may improve preconception and/or prenatal care. There is also promising evidence (non-peer-reviewed) of the effectiveness of prenatal care approaches in the US that take a more patient-centered approach than most hospital protocols. These programs are based on providing extensive social, emotional, and instrumental support during pregnancy as a protective buffer against psychosocial stressors such as discrimination. Some of these have produced impressive preliminary results. Of particular note, a com- prehensive evaluation of the JJ Way—an independent maternity care model implemented in Orange County, Florida—compared birth outcomes for their patients with those of women in prenatal care at local hospitals. They found that the JJ Way care model signif- icantly decreased racial disparities in terms of low-birth-weight babies, and altogether eliminated the gap for preterm birth outcomes [77]. The results were attributed primarily to the stress-protective effects of the expansive interpersonal and structural support system that formed the bedrock of this prenatal care model. The key components of the JJ Way center speciﬁcally on building the social capital of the women in their care by creating a safe pre- and postnatal environment based on interpersonal respect, support, education, and empowerment. These types of approaches ﬁt well with the broader literature on the buffering effect of social support and connectedness against stress, allostatic load, and disease [78]. 5. Conclusions Discrimination is an omnipresent, persistent, and insidious societal issue. This review contributes to the growing body of literature on the link between discrimination and health. Speciﬁcally, it emphasizes the fact that maternal experiences of interpersonal discrimination have grave physical implications that may extend beyond women’s individual health to negatively affect their pregnancy and offspring. As illustrated in Figure 2, this effect appears to occur via chronic mental strain (stress, depression) and associated allostatic load. However, given the relative scarcity of research on the speciﬁc mediating and moderating factors, the illustration serves primarily as a jumping-off point for future research than a deﬁnitive exposé of the mechanisms of the relationship. Future study should delve deeper into these processes to more deﬁnitively conﬁrm their place and role in the relationship between interpersonal discrimination and adverse birth outcomes. Speciﬁcally, the maternal health repercussions of vicarious discrimination and lifelong vs. prenatal experiences of discrimination require further study. So too, does the role of implicit vs. explicit discrimination, as well as childhood vs. adult experiences. Crystallizing the pathways that underpin the relationship in focus may help inform and specify interventions, risk algorithms, and clinical care, and ultimately decrease the ethnic and racial disparities in adverse birth outcomes. Supplementary Materials: The following are available online at https://www.mdpi.com/1660-460 1/18/4/1465/s1, Table S1: PRISMA Checklist 2009. Table S2: QATQS assessment scores. Author Contributions: The authors contributed to the manuscript in the following ways: Concep- tualization, A.L.S., A.S., and T.T.; methodology, A.L.S.; formal analysis, A.L.S., A.S., and T.T.; data Int. J. Environ. Res. Public Health 2021, 18, 1465 28 of 31 28 of 31 curation, A.L.S.; writing—original draft preparation, A.L.S.; writing—review and editing, A.L.S., A.S., and T.T. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: No new data were created or analyzed in this study. Data sharing is not applicable to this article. Data Availability Statement: No new data were created or analyzed in this study. Data sharing is not applicable to this article. Data Availability Statement: No new data were created or analyzed in this study. Data sharing is not applicable to this article. Conﬂicts of Interest: The authors declare no conﬂict of interest. Conﬂicts of Interest: The authors declare no conﬂict of interest. References 1. Allen, A.M.; Thomas, M.D.; Michaels, E.K.; Reeves, A.N.; Okoye, U.; Price, M.M.; Hasson, R.E.; Syme, S.L.; Chae, D.H. Racial discrimination, educational attainment, and biological dysregulation among midlife African American women. Psychoneuroen- docrinology 2019, 99, 225–235. [CrossRef] [PubMed] gy 2. Dailey, D.E. Social stressors and strengths as predictors of infant birth weight in low-income African American women. Nurs. Res. 2009, 58, 340–347. [CrossRef] [PubMed] 3. Dixon, B.; Rifas-Shiman, S.L.; James-Todd, T.; Ertel, K.; Krieger, N.; Kleinman, K.P.; Rich-Edwards, J.W.; Gillman, M.W.; Taveras, E.M. 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https://openalex.org/W2783875166	https://www.nature.com/articles/s41598-017-19020-3.pdf	English	null	Bacterial iron reduction and biogenic mineral formation for the stabilisation of corroded iron objects	Scientific reports	2,018	cc-by	9,221	Bacterial iron reduction and biogenic mineral formation for the stabilisation of corroded iron objects Received: 7 September 2017 Accepted: 20 December 2017 Published: xx xx xxxx Wafa M. Kooli1,2, Lucrezia Comensoli1,2,5, Julien Maillard3, Monica Albini1,2, Arnaud Gelb3, Pilar Junier1 & Edith Joseph2,4 Exploiting bacterial metabolism for the stabilisation of corroded iron artefacts is a promising alternative to conventional conservation-restoration methods. Bacterial iron reduction coupled to biogenic mineral formation has been shown to promote the conversion of reactive into stable corrosion products that are integrated into the natural corrosion layer of the object. However, in order to stabilise iron corrosion, the formation of specific biogenic minerals is essential. In this study, we used the facultative anaerobe Shewanella loihica for the production of stable biogenic iron minerals under controlled chemical conditions. The biogenic formation of crystalline iron phosphates was observed after iron reduction in a solution containing Fe(III) citrate. When the same biological treatment was applied on corroded iron plates, a layer composed of iron phosphates and iron carbonates was formed. Surface and cross-section analyses demonstrated that these two stable corrosion products replaced 81% of the reactive corrosion layer after two weeks of treatment. Such results demonstrate the potential of a biological treatment in the development of a stabilisation method to preserve corroded iron objects. Iron is an ubiquitous material. Since the industrial revolution, iron alloys (especially steel and cast) have been used at a large scale in fields as diverse as architecture, civil engineering, transport, food industry, and art1. Nowadays, iron is the most mined element in the world and constitutes 90% of all refined metals1. The wide- spread use of iron is explained by its metallurgical properties (ductility, hardness, strength)2. However, iron can be easily corroded by electrochemical reactions or by microbiologically influenced corrosion (MIC)3,4. Corrosion of metals leads to the modification of the exposed surface and the formation of a corrosion layer5. Depending on the environmental conditions, the corrosion products formed can protect the surface from further change (chemically stable corrosion products)3,6,7. Indeed, some studies have demonstrated that the presence of magnet- ite (Fe3O4), siderite (FeCO3) or vivianite (Fe3(PO4)·2H2O) plays a significant role in the preservation of archaeo- logical iron objects and of iron water pipes8,9. These minerals are less reactive (especially to oxygen and humidity), and their formation leads to the preservation of the object8. In other cases, the corrosion products formed can cause degradation and irreversible damage (active corrosion)1,10. www.nature.com/scientificreports www.nature.com/scientificreports www.nature.com/scientificreports Received: 7 September 2017 Accepted: 20 December 2017 Published: xx xx xxxx www.nature.com/scientificreports/ www.nature.com/scientificreports/ Iron corrosion causes considerable economic losses due to the costs of maintenance and replacement of dam- aged of iron items9–18. Therefore, limiting the formation of reactive corrosion products or converting those into more stable ones are two key issues for the preservation of iron surfaces. The former can be achieved by storage under anoxic conditions, increasing pH (passivation), or by applying coatings or anticorrosion agents. Chemical transformation of the reactive corrosion products promotes the latter. Given that the procedures used so far for limiting iron corrosion can be harmful, costly, time consuming, and also produce large amounts of waste1,14,16–19, there is a growing interest in developing green alternatives to traditional iron stabilisation methods20. g g p g g Using bacteria or bacterial enzymes to stabilise iron surfaces has been investigated previously3. For example, the iron reducing bacterium Geobacter sulfurreducens or a purified hydrogenase obtained from Ralstonia eutropha were used in separate studies to produce iron phosphates on steel6,7. Likewise, the incubation of mild steel in a culture inoculated with biofilm-forming Rhodococcus sp. strain C125 and Pseudomonas putida mt2 led to the for- mation of a protective surface layer of the mineral vivianite21. Recently a study with Desulfitobacterium hafniense showed that this bacterium can reduce reactive Fe(III) oxyhydroxides from corroded iron objects, favouring the biogenic production of vivianite22. However, abiotic reduction and undesirable formation of additional corrosion products were observed alongside biological iron reduction due to the composition of the growth medium. In addition, working with a strictly anaerobic bacterium such as D. hafniense could be challenging for the transfer of a biotechnological solution from the laboratory into real conservation praxis. Using a facultative anaerobe to per- form iron reduction in a two-step procedure is an alternative to solve both of these issues. In the first step biomass can be produced aerobically in optimal growth conditions. After collecting the bacterial biomass and removing any carryovers from the culture medium used for aerobic growth, the concentrated cells are injected, in a second step, to an anaerobic chemical matrix. Under anaerobic conditions iron reduction can take place and crystalline mineral phases can be formed due to the interaction of reduced iron and the chemical precursors in the matrix. Handling of a facultative anaerobe under these conditions facilitates the transfer of technology into praxis. Results R d ti Reduction of ferric citrate and ferric chloride and characterization of the minerals formed. S. loihica is known for its ability to grow using iron as electron acceptor for respiration and to form doped magnetite parti- cles after 75 days of incubation24. We first investigated iron reduction in three chemically defined matrices using biomass produced under aerobic conditions. For this, we first grew S. loihica aerobically in LB medium overnight and collected the biomass. Biomass (108 cells for 20 mL) was washed to avoid any carry over of the spent growth medium and then transferred to anaerobic bottles containing three different anoxic chemical matrices. These chemical matrices were designed to favour the production of iron oxides (IOx), iron carbonates (ICarb), or iron sulphides (ISulp) as biogenic minerals. Ferric citrate (Fe citrate) or FeCl3 were used as iron sources. Controls were performed using the same chemical matrices in the absence of bacteria. Iron reduction was monitored for 24 h by measuring the concentration of Fe(II) in solution. The increase of Fe(II) in the bottles containing the bacteria confirmed that S. loihica could reduce the two iron sources (SI-1).t i Biogenic mineral formation was assessed after one, two, and six weeks of incubation. In general, a change in the colour of the solutions incubated with bacteria was observed in comparison to the abiotic controls (SI-2). In addition, in presence of bacteria, the formation of solid structured mineral phases was observed in the IOx (after six weeks) and ICarb (visible from one week onwards) matrices containing Fe citrate (Fig. 1A). The size of the mineral particles increased overtime in the ICarb solution (Fig. 1A). Elemental analyses (Energy Dispersive Spectroscopy-EDS) of the mineral particles indicated that they are composed of iron, oxygen, carbon, and phos- phorus (Table 1). The latter was only detected when a precipitate was observed (Fig. 1A, SI-2, and SI-3). In the controls without bacteria the composition of the particles observed after lyophilisation suggested only the pre- cipitation of the salts present in the medium (with Na and Cl among the major elements detected; SI-3). The presence of phosphorus was unexpected, as no phosphate was added to the chemical matrices for performing iron reduction. In addition, this element was not detected when solid structured phases were absent (SI-3). www.nature.com/scientificreports/ The overall hypothesis in this approach is that active biomass will still perform iron reduction with minimal growth requirements, inducing the formation of specific minerals as by-products of the interaction with the chemical precursors present in the matrix. This hypothesis was tested here. We evaluated iron reduction and biogenic iron mineral formation using Shewanella loihica strain PV-4, a halophilic facultative anaerobe that reduces iron and was involved in magnetite production23,24. Active biomass of S. loihica was obtained from aerobic batch cultures and used for the production of crystalline iron minerals in various chemical matrices. Finally, conditions leading to the formation of crystalline minerals were applied on corroded iron coupons to demonstrate the performance of the proposed treatment. Bacterial iron reduction and biogenic mineral formation for the stabilisation of corroded iron objects Examples of such active corrosion products include some Fe(III) oxyhydroxides, goethite α-FeO(OH), and lepidocrocite γ-FeO(OH)11. In particular, active corrosion is promoted by chloride ions that can be part of the formed corrosion products (for instance in akage- neite β-FeO(OH)Cl)10,12–15. When the relative humidity is high, Fe(II) chloride salts absorb water vapor, dissolve, and form wet droplets of an orange colour causing a phenomenon described as weeping of iron16. Ultimately, if no conservation-restoration intervention is undertaken, these reactive corrosion products create physical stress and can lead to the integrity loss of the artefact17. 1Laboratory of Microbiology, Institute of Biology, University of Neuchâtel, 2000, Neuchâtel, Switzerland. 2Laboratory of Technologies for Heritage Materials, Institute of Chemistry, University of Neuchâtel, 2000, Neuchâtel, Switzerland. 3Laboratory for Environmental Biotechnology, ENAC-IIE-LBE, Ecole Polytechnique Fédérale de Lausanne, 1015, Lausanne, Switzerland. 4Haute Ecole Arc Conservation-Restauration, HES-SO, 2000, Neuchâtel, Switzerland. 5Present address: Laboratory of Mechanical Systems Engineering, Swiss Federal Laboratories for Materials Science and Technology, 8600, Dübendorf, Switzerland. Correspondence and requests for materials should be addressed to P.J. (email: pilar.junier@unine.ch) or E.J. (email: edith.joseph@unine.ch) Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 1 Results R d ti Since the biomass was washed prior to the transfer into the iron reduction matrices, is unlikely that phosphate originates from spent medium used during the step of production of the biomass. p g p p Fourier Transform Infrared Spectroscopy (FTIR) analyses were performed to identify the minerals formed. The results obtained with the IOx (SI-4) and ICarb chemical matrices were comparable (Fig. 1B). After one and two weeks of incubation typical vibration bands for proteins (amide I peak around 1640 cm−1 and amide II peak around 1520 cm−1) and lipids (C-H stretching around 2930, 2854 cm−1 and binding peaks at 1397 cm−1) were observed, indicating the presence of bacteria. The peaks comprised between 1040 and 940 cm−1 correspond to the phosphate absorbance region25,26, which confirmed the elemental analyses, and thus the formation of iron phos- phates. Also, according to the differences observed in the spectra collected overtime, iron phosphates changed from an amorphous to a more crystalline phase. In amorphous compounds, water is not as coordinated as in crystalline forms. Absorbance bands corresponding to the coordinated water associated with iron phosphates can be observed at 3447 and 797 cm−1 only after six weeks of incubation. According to the obtained FTIR spectra the biogenic minerals belong to the family of vivianites or barbosalites25,26. Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 2 www.nature.com/scientificreports/ Figure 1. Soluble Fe(III) reduction and biogenic mineral formation. (A) Scanning electron microscopy (SEM) images of samples collected during iron reduction in Fe citrate-containing iron oxides (IOx) and carbonate (ICarb) matrices in presence (+S. loihica) or absence (−S. loihica) of Shewanella loihica. The results show the formation of a solid structured mineral phase after 1, 2, and 6 weeks of incubation. The white arrows indicate the sites where elemental analysis was performed. Continuous and dashed white scale lines correspond respectively to 5 µm and 10 µm. (B) ATR-FTIR spectra of culture pellets from iron-reducing ICarb solution contaning Fe citrate after 1, 2 and 6 weeks of incubation. The spectral region corresponding to the absorbance peaks of lipids, proteins, and phosphates are marked out by dashed lines. Figure 1. Soluble Fe(III) reduction and biogenic mineral formation. (A) Scanning electron microscopy (SEM) images of samples collected during iron reduction in Fe citrate-containing iron oxides (IOx) and carbonate (ICarb) matrices in presence (+S. loihica) or absence (−S. loihica) of Shewanella loihica. Results R d ti (B) Scanning electron microscopy (SEM) images and visual aspect of the iron coupons treated with S. loihica (+S. loihica) and of the abiotic control (−S. loihica) in the presence of 1% NaCl, after 1, 2, and 6 weeks of incubation. The letters f and s indicate foil-like biogenic mineral habita and spherical agregates respectively. Scale bars: orange: 20 µm and green: 10 µm. Figure 2. Solid Fe(III) reduction and biogenic mineral formation. (A) Iron reduction in cultures of S. loihica without (grey circles) and with 1% NaCl (black circles). (B) Scanning electron microscopy (SEM) images and l d d d b l f d l f l h Figure 2. Solid Fe(III) reduction and biogenic mineral formation. (A) Iron reduction in cultures of S. loihica without (grey circles) and with 1% NaCl (black circles). (B) Scanning electron microscopy (SEM) images and visual aspect of the iron coupons treated with S. loihica (+S. loihica) and of the abiotic control (−S. loihica) in the presence of 1% NaCl, after 1, 2, and 6 weeks of incubation. The letters f and s indicate foil-like biogenic mineral habita and spherical agregates respectively. Scale bars: orange: 20 µm and green: 10 µm. Iron reduction with corroded iron plates and characterization of the minerals formed. As the aim of the study was the production of stable iron minerals by the conversion of reactive corrosion products, we performed further experiments with corroded iron plates using exclusively the ICarb chemical matrix, which clearly favoured crystalline mineral formation in the previous experiment. The iron source was in this case the corrosion products (mainly goethite and lepidocrocite; SI-5) formed on an iron plate corroded in a marine atmos- phere. The plates were sterilised and added under anoxic conditions to anaerobic bottles containing the ICarb sterile matrix. Biomass of S. loihica was prepared and inoculated as described before (108 cells in 20 mL).f p p ( ) S. loihica is a halophile that requires the presence of salt for growth. We tested growth at different concen- trations of NaCl (SI-6) and with different sodium sources (SI-7), confirming that 2% NaCl is the optimal salt concentration for bacterial growth. The addition of a salt containing chlorides to the reductive chemical matrix is not ideal given the deleterious role of chloride ions as active iron corrosion instigators. Therefore, we tested iron reduction without NaCl (0%) and 1% added NaCl on corroded iron coupons. Results R d ti The results show the formation of a solid structured mineral phase after 1, 2, and 6 weeks of incubation. The white arrows indicate the sites where elemental analysis was performed. Continuous and dashed white scale lines correspond respectively to 5 µm and 10 µm. (B) ATR-FTIR spectra of culture pellets from iron-reducing ICarb solution contaning Fe citrate after 1, 2 and 6 weeks of incubation. The spectral region corresponding to the absorbance peaks of lipids, proteins, and phosphates are marked out by dashed lines. Elements (AT%) ICarb condition IOx condition 1 week 2 weeks 6 weeks 6 weeks Fe 15.37 15.26 19.18 15.61 O 24.00 33.66 46.42 51.02 C 33.74 26.64 19.22 20.75 P 5.60 9.89 12.77 11.23 Trace elements 21.29 14.55 2.41 1.39 Table 1. Elemental composition in terms of atomic percentage (AT%) obtained using energy-dispersive X-ray spectroscopy (EDS) for the treatments using Fe citrate with S. loihica (+), which resulted in the formation of biogenic minerals (ICarb and IOx conditions). Elements (AT%) ICarb condition IOx condition 1 week 2 weeks 6 weeks 6 weeks Fe 15.37 15.26 19.18 15.61 O 24.00 33.66 46.42 51.02 C 33.74 26.64 19.22 20.75 P 5.60 9.89 12.77 11.23 Trace elements 21.29 14.55 2.41 1.39 Table 1. Elemental composition in terms of atomic percentage (AT%) obtained using energy-dispersive X-ray spectroscopy (EDS) for the treatments using Fe citrate with S. loihica (+), which resulted in the formation of biogenic minerals (ICarb and IOx conditions). Elements (AT%) ICarb condition IOx condition 1 week 2 weeks 6 weeks 6 weeks Fe 15.37 15.26 19.18 15.61 O 24.00 33.66 46.42 51.02 C 33.74 26.64 19.22 20.75 P 5.60 9.89 12.77 11.23 Trace elements 21.29 14.55 2.41 1.39 Table 1. Elemental composition in terms of atomic percentage (AT%) obtained using energy-dispersive X-ray spectroscopy (EDS) for the treatments using Fe citrate with S. loihica (+), which resulted in the formation of biogenic minerals (ICarb and IOx conditions). Table 1. Elemental composition in terms of atomic percentage (AT%) obtained using energy-dispersive X-ray spectroscopy (EDS) for the treatments using Fe citrate with S. loihica (+), which resulted in the formation of biogenic minerals (ICarb and IOx conditions). Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 3 www.nature.com/scientificreports/ Figure 2. Solid Fe(III) reduction and biogenic mineral formation. (A) Iron reduction in cultures of S. loihica without (grey circles) and with 1% NaCl (black circles). Results R d ti “f” corresponds to the foil-like aggregates, while “s” refers to the spherical-shaped minerals. nd stands for “not detected”. dark grey (Fig. 2B, SI-8B). EDS analyses showed the presence of phosphorus associated to the production of crys- talline mineral phases (Table 2). Phosphorus was absent from the plates incubated in the abiotic medium (Table 2; −S. loihica). Likewise, phosphorus was not detected by EDS analyses on the coupons treated at 0% NaCl, with and without the bacteria, as well as in the untreated coupons (SI-9). dark grey (Fig. 2B, SI-8B). EDS analyses showed the presence of phosphorus associated to the production of crys- talline mineral phases (Table 2). Phosphorus was absent from the plates incubated in the abiotic medium (Table 2; −S. loihica). Likewise, phosphorus was not detected by EDS analyses on the coupons treated at 0% NaCl, with and without the bacteria, as well as in the untreated coupons (SI-9). p On the coupons treated with bacteria at 1% NaCl, two types of mineral forms were observed simultaneously after two and six weeks of incubation: foil-like habita (indicated as “f” in Fig. 2B and visible already at 1 week) and spherical aggregates (indicated as “s” in Fig. 2B). The EDS spectra of the two mineral phases differed. While the presence of phosphorus was a chemical signature of the foil-like habita (Table 2, f), the spherical-shaped aggregates contained only Fe, C, and O, but no traces of phosphorus (Table 2, s). As in the case of the soluble iron sources, the presence of phosphorus in the foil-like habita minerals was surprising given that no P source was added to the reductive chemical matrix. It is known that some bacteria are able to accumulate phosphate inside the cells in the form of polyphosphates. Depending on the metabolic state of the bacterial cells, phosphorus can later be released in the form of orthophosphates in the solution27,28. DAPI staining and microscopic observations of S. loihica showed that this bacterium is indeed able to accumulate polyphosphates in granules in oxic condi- tions, releasing orthophosphates in anoxic conditions during the treatment (SI-10). These orthophosphates are a likely P source for the biogenic formation of iron phosphates. Effect of biogenic mineral formation on the corrosion layer of iron coupons. Mineral identifica- tion before and after the bacterial treatment of iron coupons was conducted using XRD analysis. Results R d ti In the treatment without NaCl we wanted to test if the salts potentially contained in the natural corrosion patina (i.e. salts deposited from aerosols produced by the marine environment in which the coupons were corroded) were enough to meet the salt require- ments of a halophilic strain, such as S. loihica. Iron reduction using corroded coupons as iron source was assessed by the increase of Fe(II) concentration in the solution. The results showed that S. loihica was only able to reduce solid Fe(III) when 1% NaCl was added (Fig. 2A). Therefore salts present in the corrosion layer of the iron plates do not provide the required salt concentration for the metabolic activity of S. loihica. Without NaCl, no reduction was observed although the bacterial cells remained intact when observed under the microscope. The fact that iron reduction did not occur at 0% NaCl provided an ideal inactive biological control to establish the effect of the bacterial treatment (at 1% NaCl) on the conversion of the corrosion layer. As expected, no mineral formation was observed for the treatment with bacteria at 0% NaCl (SI-8). On the contrary, with 1% NaCl, SEM observations of the coupons’ surface confirmed the presence of a crystalline mineral phase already after one week of incubation (Fig. 2B). The production of minerals occurred alongside a change in the colour of the iron plates, from red to Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 4 www.nature.com/scientificreports/ Elements (AT%) 1 week 2 weeks 6 weeks + − + − + − f s f s Fe 20.45 33.10 26.31 24.76 43.69 22.88 21.48 44.25 O 50.69 65.41 38.36 50.67 54.89 51.09 51.79 54.35 C 15.37 nd 23.09 24.57 nd 10.65 26.73 nd P 12.49 nd 12.25 nd nd 15.38 nd nd Cl nd 0.37 nd nd nd nd nd nd Trace elements 1.00 1.12 0.00 0.00 1.42 0.00 0.00 1.4 Table 2. Elemental composition in terms of atomic percentage (AT%) obtained using energy-dispersive X-ray spectroscopy (EDS) for the minerals obtained in the treatment with 1% NaCl with (+) and without (−) S. loihica. “f” corresponds to the foil-like aggregates, while “s” refers to the spherical-shaped minerals. nd stands for “not detected”. Table 2. Elemental composition in terms of atomic percentage (AT%) obtained using energy-dispersive X-ray spectroscopy (EDS) for the minerals obtained in the treatment with 1% NaCl with (+) and without (−) S. loihica. Results R d ti The results were consistent with the EDS analyses, showing the presence of a Fe(II) phosphate mineral (vivianite), already after one week of incubation (Fig. 3A). In addition, Fe(II) carbonate (siderite; FeCO3), was detected on the treated coupons after two and six weeks of incubation (Fig. 3A). The XRD results also demonstrated the absence of Fe(II) phosphates or Fe(II) carbonates in the abiotic controls and on the untreated coupons (Fig. 3B). Moreover, the intensity of the XRD peaks related to reactive corrosion products (e.g. hematite and lepidocrocite) decreased over time in coupons treated with bacteria at 1% NaCl (Fig. 3B). This result clearly demonstrated the effectiveness of the biological treatment to replace reactive corrosion products by stable biogenic minerals. g p p y g In addition to the surface analyses, cross-section analyses were performed. Untreated iron coupons displayed a corrosion layer with dark-brown, red and orange tonalities (Fig. 4, SI-11). The same was observed for the abi- otic control coupons (SI-11 and SI-12). In contrast, a precipitation of grey-green minerals was observed on the outermost corrosion layer of the coupons treated with bacteria (SI-11). An overall decrease on the thickness of the original corrosion layer was measured after the treatment with bacteria. The continuity of the biogenic layer was estimated and the results confirmed that bacteria produced a relatively homogeneous mineral layer on top of the original corrosion layer covering already 81% of the coupons’ surface after 2 weeks of incubation (SI-11). SEM observations of the cross-sections after six weeks of treatment revealed that untreated coupons (Fig. 4) and abiotically treated coupons (SI-12) had a corrosion layer mainly composed of iron, oxygen and chlorine. In contrast in the coupons treated with bacteria, Fe and O were found to be the main components of the corrosion layer (Fig. 4). Additional molecular analyses carried out on the cross-sectioned coupons after 1 week of treatment confirmed that the biogenic layer was mainly composed of vivianite with the presence of a characteristic Raman shift at 964 cm−1 (Fig. 5). Below this layer, the same corrosion products detected on the untreated coupons were also located and identified as goethite, lepidocrocite, and ferrihydrite (Fig. 5). No chlorinated compounds such as akaganeite β-FeO(OH)Cl were individuated by Raman investigation, neither on the untreated nor on the treated coupons. This is probably due to the concomitant presence of ferrihydrite whose Raman shifts superimpose those of akageneite. www.nature.com/scientificreports/ www.nature.com/scientificreports/ Figure 3. X-Ray diffraction (XRD) spectra of iron coupons. (A) Spectra recorded on the coupons treated with S. loihica after 1 (T1), 2 (T2) and 6 (T6) weeks of incubation. (B) Spectra recorded after 6 weeks of incubation of the coupons treated with S. loihica (T6), the abiotic control (C6), and the untreated coupons (NT). Figure 3. X-Ray diffraction (XRD) spectra of iron coupons. (A) Spectra recorded on the coupons treated with S. loihica after 1 (T1), 2 (T2) and 6 (T6) weeks of incubation. (B) Spectra recorded after 6 weeks of incubation of the coupons treated with S. loihica (T6), the abiotic control (C6), and the untreated coupons (NT). reported for S. loihica (pH 6.5–7) precluded the formation of magnetite24,31. Also, recent studies have shown that under specific conditions (e.g. H2 as electron donor) magnetite could be destabilised by iron reducing bacteria32,33 and hence its formation may not be desirable. In the case of the chemical matrix to favour the production of iron sulphides, the formation of an amorphous phase of FeS instead of a crystalline one is probably the result of an insufficient concentration of dissolved sulphides31. The condition favouring the production of iron carbonates was suitable for biogenic mineral formation. However, in addition to the production of siderite after prolonged incu- bation (2 weeks onwards), vivianite was also precipitated. Vivianite (solubility constant −36.0034) is expected to be the initial Fe(II) phase to precipitate in a phosphorus-containing medium at a near neutral pH8. Experiments performed by Zachara et al.35 confirmed that in presence of 4 mM phosphates the formation of vivianite precedes the one of siderite (solubility constant −10.68)34,36, and that the latter precipitates only after the complete incor- poration of phosphorus in vivianite35. Vivianite and siderite are biogenic by-product minerals of dissimilatory Fe(III) reduction in bicarbonate buffers31,35,37,38. For instance, Rhodococcus sp. C125 and Pseudomonas putida mt2 are able to induce vivianite formation on mild steel coupons in a phosphates-containing solution39. However, the production of iron phosphates under the treatment conditions used here was unexpected given the lack of added phosphorus in the reductive chemical matrix. Although dead bacterial biomass and/or the release of proteins containing phosphate groups as well as degradation of nucleic acids40 are a possible source of phospho- rus, accumulation of polyphosphates by S. Discussionh The aim of the proposed biological treatment to stabilise corroded iron is the production of specific iron miner- als by the conversion of reactive corrosion products. Minerals such magnetite or siderite are desirable because they have a colour similar to the native colour of iron (black-grey). Moreover, these minerals are reported to be thermodynamically stable and are naturally found on iron objects acting as protective layer8,11,16,29,30. In this study, we developed a two-step approach based on the aerobic production of bacterial biomass followed by the anaer- obic reduction of iron for the formation of specific biogenic minerals. Buffering the medium at the optimal pH Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 5 www.nature.com/scientificreports/ loihica during aerobic growth and release of orthophosphates during the treatment under anoxic conditions is a more likely explanation as to the source of phosphorus for vivianite precipitation. 39h reported for S. loihica (pH 6.5–7) precluded the formation of magnetite24,31. Also, recent studies have shown that under specific conditions (e.g. H2 as electron donor) magnetite could be destabilised by iron reducing bacteria32,33 and hence its formation may not be desirable. In the case of the chemical matrix to favour the production of iron sulphides, the formation of an amorphous phase of FeS instead of a crystalline one is probably the result of an insufficient concentration of dissolved sulphides31. The condition favouring the production of iron carbonates was suitable for biogenic mineral formation. However, in addition to the production of siderite after prolonged incu- bation (2 weeks onwards), vivianite was also precipitated. Vivianite (solubility constant −36.0034) is expected to be the initial Fe(II) phase to precipitate in a phosphorus-containing medium at a near neutral pH8. Experiments performed by Zachara et al.35 confirmed that in presence of 4 mM phosphates the formation of vivianite precedes the one of siderite (solubility constant −10.68)34,36, and that the latter precipitates only after the complete incor- poration of phosphorus in vivianite35. Vivianite and siderite are biogenic by-product minerals of dissimilatory Fe(III) reduction in bicarbonate buffers31,35,37,38. For instance, Rhodococcus sp. C125 and Pseudomonas putida mt2 are able to induce vivianite formation on mild steel coupons in a phosphates-containing solution39. However, the production of iron phosphates under the treatment conditions used here was unexpected given the lack of added phosphorus in the reductive chemical matrix. Although dead bacterial biomass and/or the release of proteins containing phosphate groups as well as degradation of nucleic acids40 are a possible source of phospho- rus, accumulation of polyphosphates by S. loihica during aerobic growth and release of orthophosphates during the treatment under anoxic conditions is a more likely explanation as to the source of phosphorus for vivianite precipitation. ( )f , p p are able to induce vivianite formation on mild steel coupons in a phosphates-containing solution39. However, the production of iron phosphates under the treatment conditions used here was unexpected given the lack of added phosphorus in the reductive chemical matrix. www.nature.com/scientificreports/ Although dead bacterial biomass and/or the release of proteins containing phosphate groups as well as degradation of nucleic acids40 are a possible source of phospho- rus, accumulation of polyphosphates by S. loihica during aerobic growth and release of orthophosphates during the treatment under anoxic conditions is a more likely explanation as to the source of phosphorus for vivianite precipitation.h Production of vivianite has been proposed as an anti-corrosion treatment for steel39. Therefore, according to the results obtained, the proposed biological treatment seems to be a good alternative to stabilise corrosion of iron objects. Analyses performed on the corrosion layer of iron coupons demonstrated that the biological treatment led to the decrease of reactive corrosion products along with an increase in the formation of biogenic minerals that are integrated in the natural corrosion layer. This was accompanied by a pleasing aesthetical change in the colour of the coupons to grey after 2 weeks of incubation. In addition, chlorides appeared to be almost completely extracted from the corrosion layer, avoiding any further harmful cyclic and active corrosion to start again. The biogenic minerals produced using S. loihica, vivianite and siderite, are reported to have a protective effect on water distribution pipes and archaeological iron objects8,12. Moreover, using a facultative anaerobe and the production of biomass under aerobic conditions facilitates the practical use of bacteria, compared to strict anaerobes22. Next, scaling up of the process and assessing the stability of the biogenic minerals produced and their long-term protective effect on corroded iron surfaces are required for the application of this stabilisation Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 6 www.nature.com/scientificreports/ tificreports/ Figure 4. Cross-section analysis of the corrosion layer in iron coupons. Optical microscopy and scanning electron microscopy (SEM) images of the untreated and treated coupons after 6 weeks of incubation. The area where elemental mapping was performed is indicated by a grey box. Elemental mapping showing the presence of iron (pink), oxygen (green), chlorine (yellow), and phosphorus (blue). Figure 5. Raman mapping of a bacterial-treated coupon after 1 week of incubation. (A) Scanning electron microscopy image with the area analysed by Raman mapping indicated by a black box. (B) Raman spectra of vivianite (Vi), goethite (Go), lepidocrocite (Le), and ferrihydrite (Fe), extracted from the map dataset and indicating the vibrational bands used for the elaboration of the chemical maps. www.nature.com/scientificreports/ (C) Raman chemical maps of vivianite (964 cm−1) in blue, of goethite (384 cm−1) in green, of lepidocrocite (248 cm−1) in orange, and of ferrihydrite (705 cm−1) in yellow. Figure 4. Cross-section analysis of the corrosion layer in iron coupons. Optical microscopy and scanning electron microscopy (SEM) images of the untreated and treated coupons after 6 weeks of incubation. The area where elemental mapping was performed is indicated by a grey box. Elemental mapping showing the presence of iron (pink), oxygen (green), chlorine (yellow), and phosphorus (blue). Figure 4. Cross-section analysis of the corrosion layer in iron coupons. Optical microscopy and scanning electron microscopy (SEM) images of the untreated and treated coupons after 6 weeks of incubation. The area where elemental mapping was performed is indicated by a grey box. Elemental mapping showing the presence of iron (pink), oxygen (green), chlorine (yellow), and phosphorus (blue). Figure 4. Cross-section analysis of the corrosion layer in iron coupons. Optical microscopy and scanning electron microscopy (SEM) images of the untreated and treated coupons after 6 weeks of incubation. The area where elemental mapping was performed is indicated by a grey box. Elemental mapping showing the presence of iron (pink), oxygen (green), chlorine (yellow), and phosphorus (blue). Figure 5. Raman mapping of a bacterial-treated coupon after 1 week of incubation. (A) Scanning electron microscopy image with the area analysed by Raman mapping indicated by a black box. (B) Raman spectra of vivianite (Vi), goethite (Go), lepidocrocite (Le), and ferrihydrite (Fe), extracted from the map dataset and indicating the vibrational bands used for the elaboration of the chemical maps. (C) Raman chemical maps of vivianite (964 cm−1) in blue, of goethite (384 cm−1) in green, of lepidocrocite (248 cm−1) in orange, and of ferrihydrite (705 cm−1) in yellow. Figure 5. Raman mapping of a bacterial-treated coupon after 1 week of incubation. (A) Scanning electron microscopy image with the area analysed by Raman mapping indicated by a black box. (B) Raman spectra of vivianite (Vi), goethite (Go), lepidocrocite (Le), and ferrihydrite (Fe), extracted from the map dataset and indicating the vibrational bands used for the elaboration of the chemical maps. (C) Raman chemical maps of vivianite (964 cm−1) in blue, of goethite (384 cm−1) in green, of lepidocrocite (248 cm−1) in orange, and of ferrihydrite (705 cm−1) in yellow. method into real conservation-restoration praxis. Material and Methods Bacterial strain and aerobic growth conditions. Shewanella loihica PV-4 (DSM 17748) was used in this study. The strain was purchased from the DSMZ (Deutsche Sammlung von Mikroorganismen und Zellkulturen GmbH,). Regular cultivation was performed aerobically using Luria-Bertani medium (LB; 1% (w/v) tryptone, 0.5% (w/v) yeast extract, and 1% (w/v) sodium chloride (NaCl)) at pH 7 and at 20 °C under agitation at 130 rpm. For the experiments the bacterium was cultivated aerobically overnight. Cell biomass was then collected by cen- trifugation (1700 × g for 10 min) and the pellet was washed three times with an oxic basal solution containing 20 mM 1,4-Piperazinediethanesulfonic acid (PIPES) and the same (w/v) concentration of NaCl of the reducing matrix (see below) to avoid the carryover of spent LB medium. Between the washing steps the cells were centri- fuged at 1700 × g for 10 min, discarding the supernatant at every step. Finally the pellet was resuspended in the same solution without NaCl and adjusted to a density of 108 cells/mL to be added to the defined chemical matri- ces containing iron (SI-13). Reduction of ferric citrate and ferric chloride. Three chemical matrices were used for iron reduction using ferric citrate and ferric chloride as electron acceptors. For this, sodium lactate (final concentration of 5 mM) as electron donor, and ferric citrate (Fe citrate) or ferric chloride (FeCl3) (final concentrations of 10 mM) as electron acceptors were added to the same basal solution (20 mM PIPES, 2% (w/v) NaCl). For the production of specific iron minerals, sodium hydroxide (NaOH) or sodium bicarbonate (NaHCO3) (final concentrations of 20 and 50 mM, respectively), were added to favour iron oxides (e.g. magnetite; IOx) or (e.g. siderite; ICarb), respec- tively. A third treatment consisted of 20 mM NaOH supplemented with 10 mM sodium sulphide (Na2S) to induce the production of iron sulphides (ISulp) (SI-13). In the case of ISulp, after assessing iron reduction for 24 h in the (IOx) matrix, sodium sulphide was added to favour iron sulphide mineral production. The final pH of the three matrices was between 6.5 and 7 (optimal pH for S. loihica). To render the iron reduction matrices anoxic, the solutions were first boiled to remove dissolved oxygen and then flushed with nitrogen. The FeCl3 stock solution (final concentration 0.5 M) was filter sterilized under anoxic conditions, because we have observed the formation of precipitates if the solution was sterilized by autoclaving. Material and Methods All the other solutions were sterilized by autoclaving at 120 °C for 20 min. The NaHCO3 solution was added after autoclaving to avoid CO2 degassing. Biomass was prepared as described above and added to the reducing matrix to a final concentration of 5 × 106 cells/mL. To evaluate iron reduction, 900 µL samples were collected every 2 h for 24 h to measure the concentration of Fe(II) in solution (see below). The production of iron minerals was evaluated after 1, 2, and 6 weeks of incubation at room temperature under agitation (120 rpm). Experiments were performed in triplicates including abiotic controls. In the latter the same defined matrices were incubated in the absence of bacteria to investigate abiotic iron reduction and chemical mineral formation. Reduction of corroded iron plates. For the validation of the treatment on real objects, we used iron plates (50 × 50 × 2–3 mm) naturally corroded after one-year exposure in an outdoor marine environment containing chlorinated aerosols (French Institute of Corrosion, Brest, France). The orientation and position of the iron plates during exposure were selected according to ISO 9223 standard, which defines the standards for the corrosion of metals and alloys. Plates were exposed south skyward at 45° from the horizontal. For the experiment, the plates were then cut in coupons of 10 × 10 × 2–3 mm. The preparation of the plates for the experiments was performed under oxic conditions. Iron reduction and biogenic mineral formation with the corroded iron coupons was performed in a matrix composed of 20 mM PIPES, 5 mM sodium lactate, and 50 mM NaHCO3. In this case, two conditions were com- pared: no NaCl (0%) and 1% NaCl. The final pH of the matrices was between 6.6 and 7.4. For the sterilization of the iron coupons, autoclaving was avoided as an enhancement of the corrosion layer was observed under both oxic and anoxic conditions. Instead of autoclaving, coupons were washed with 70% (v/v) ethanol and dried under UV exposure for 1 h for each side. A control for this sterilization method was performed by incubating UV-sterilized plates on solid LB medium under oxic and anoxic conditions, which showed no bacterial growth after one week of incubation.i t Biomass was prepared as described above and added to the reducing matrix to a final concentration of 5.106 cells/mL. www.nature.com/scientificreports/ Nevertheless, exploiting bacterial metabolic activity to stabilise corroded iron objects is an innovative biotechnological process that can have a significantly positive impact on the preservation and maintenance of iron-based surfaces. Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 7 www.nature.com/scientificreports/ Material and Methods A Philips ESEM XL30 FEG environmental scanning electron microscope equipped with an energy-dispersive X-ray analyser was used. The samples and coupons were observed in secondary electrons mode at an acceleration potential of 10–25 keV and with a 10 mm working distance. Fourier Transform Infrared Spectroscopy (FTIR) analyses. FTIR measurements were performed on the same samples used for SEM-EDS analyses. An iS5 Thermo Scientific spectrometer with a diamond Attenuated Total Reflectance (ATR) crystal plate (iD5™ ATR accessory) was used. All spectra were acquired in the range 4000–650 cm−1, at a spectral resolution of 4 cm−1. A total of 32 scans were recorded and the resulting interfero- grams averaged. Data collection and post-run processing were carried out using Omnic™ software. X-Ray Diffraction crystallography (XRD) analyses. XRD analyses were performed on untreated, abiotic control and bacterially-treated iron coupons. The preparation of the iron coupons was the same as for SEM-EDS analyses. High-statistics θ−2θ (bulk) measurements were performed with a PANalytical X’Pert Pro MPD diffractometer equipped with a fast-linear detector and sample spinner. The measurement time was 60 h to acquire high statistics for better signal-to-noise ratio. The sensitivity of the XRD phase analyses was about 1% weight. ICSD codes were used for the identification of siderite (98–004–6078), vivianite (98-004-6142), magnetite (98-001-1782), hematite (98-001-2733), lepidocrocite (98-000-0843) and goethite (98-001-7328). Cross-section analyses. One sample for each condition tested (untreated, abiotic control and bacte- rial treatment) was embedded in methacrylate resin employing the EpoFix Kit (resin and hardener, Struers). Cross-polishing was performed with silicon carbide abrasive paper with 250, 500, and 1000 grit and Micro-Mesh abrasive cloths 1800, 2400, 3200, 3600, 4000, 6000, 8000, and 12000 grades. Microscopic observations on the cross-sectioned samples were carried out with a Polyvar MET optical microscope and microphotographs were collected with Axio Vision LE software. An estimation of the percentage of original corrosion layer covered by the biogenic crystals was extrapolated from the microscopic images. Using the working conditions indicated above, SEM-EDS mapping was carried out to ascertain the distribution and the elemental composition of the newly formed biogenic minerals. Non-destructive Raman spectroscopy was performed directly on the cross-sectioned samples to define the molecular composition of the corrosion layer before and after bacterial treatment. The analysis was carried out with a Horiba-Jobin Yvon Labram Aramis microscope equipped with a Nd:YAG laser of 532 nm at a power lower than 1 mW. Material and Methods The spectral interval analysed was between 100 and 1600 cm−1. Single points analyses were carried out with the following conditions: 400-µm hole, 200-µm slit, and 10 accumulations of 10 s. Raman mapping was performed in selected areas of cross-sectioned samples with a step size of 2.5 µm in x and y directions. The spectra recorded were corrected (automatic baseline correction) using LabSpec NGS spectral software. Reference spectra were used for identifying the compounds present and for elaborating chemical maps. Polyphosphate staining with 4’,6-diamidino-2-phenylindole (DAPI). Polyphosphate detection was performed in bacterial cultures cultivated overnight in LB medium. A washing step with 1× Phosphate-buffered saline (PBS buffer; 137 mM NaCl, 10 mM Na2HPO4, 2.7 mM KCl, 1.8 mM KH2PO4, pH 7.4) buffer was done twice in order to remove the media components. One mL from a bacterial culture of 1 OD unit (at 600 nm) was centri- fuged, the pellet was collected, washed 2 times with 1 mL of ice-cold 1× PBS and resuspended in 1 mL of ice-cold 4% (w/v) paraformaldehyde (PFA). The sample was incubated for 1 h at 4 °C. The pellet was then collected by centrifugation and washed three times with 1× PBS. This washing step was repeated twice in order to remove residual PFA that would produce auto-fluorescent particles. For DAPI staining, a solution of 50 µg/mL DAPI was used. Cells were placed onto a microscope slide and left to dry at room temperature. Cells were then covered with the DAPI solution and incubated in the dark at room temperature for 30 min. The slides were washed by dipping into distilled water and then air-dried. An anti-fading agent (Citifluor AF2) was applied on the slides before placing the cover slip. Observations were done with an epi-fluorescence microscope Zeiss Axioplan2 imaging, using UV excitation light. Excitation wavelength was 350 nm. DNA-DAPI combination results in a blue colour (maximum fluorescence emission at around 450 nm) while polyphosphate-DAPI complex has a bright yellow colour (emission at around 550 nm)43. Quantification of orthophosphate (orthoP) release using malachite green. The orthoP released by the cells was measured every hour during 24 h following the same procedure of sample collection as for the iron reduction experiment. Cells were incubated in the anoxic ICarb solution (20 mM PIPES, 2% NaCl, 5 mM sodium lactate, 10 mM Fe citrate and 50 mM NaHCO3). Material and Methods To evaluate iron reduction, Fe(II) was measured in 900 µL samples collected every 2 h for 24 h (see below). The production of iron minerals was evaluated after 1, 2, and, 6 weeks of incubation at room tempera- ture under agitation (120 rpm). Experiments were performed in triplicates including abiotic controls (without bacteria). Measurements of Fe(II) concentration. To measure the reduction of Fe(III) into Fe(II), the ferrozine assay was performed following a modified protocol from Bell et al.41. First, 100 µL of 5 M HCl were added imme- diately after sampling to the 900 µL of collected samples and stored at 4 °C. The samples were centrifuged for 1 min at 6700 × g, then 100 µL of the supernatant were taken and 900 µL of ferrozine solution (0.1% ferrozine in a 100 mM HEPES solution at pH 7) were added. Fe(II) concentration was determined by measuring the absorbance at 562 nm with a UV-Vis spectrophotometer (Thermo Scientific Genesis 10 s). A calibration curve was obtained using serial dilutions of 1 mM ferrous ammonium sulphate solution in acidic MilliQ water (pH 2). Scanning Electron Microscopy coupled with Energy Dispersive X-Ray Spectroscopy (SEM-EDS) analyses. Samples from Fe citrate and FeCl3 amended cultures were centrifuged and fixed for 1 h with 2.5% glutaraldehyde solution in 0.1 M sodium cacodylate, washed twice by centrifugation with the same solution and fixed again for 2 h with 1% osmium tetraoxide in 0.1 M sodium cacodylate. After the secondary fixation, the samples were washed twice with distilled water. Then dehydration steps were performed using different concen- trations of ethanol (25%, 50%, 75%, 90%, 100% (v/v)) and then pure acetone following a modified protocol from Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 8 www.nature.com/scientificreports/ Pearson et al.42. Finally, samples were mounted on stubs using carbon conductive tape and coated with a 23 nm layer of gold using a Bal-Tec sputter coater SCD 005 (60 mA current, distance of the gold pastille to the sample: 5 cm, 60 s duration, argon gas). As there were no precipitates in the abiotic controls with Fe citrate, samples were lyophilised prior to stub mounting. The iron coupons were washed twice with deionised water and ethanol 70% (v/v) before being mounted on stubs using carbon conductive tape without gold sputtering. To avoid humidifi- cation, the stubs were stored in desiccators with silica gel. 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Scientific REPOrts \| (2018) 8:764 \| DOI:10.1038/s41598-017-19020-3 10 www.nature.com/scientificreports/ Author Contributions W.M.K. performed the experiments, analysed the data and wrote the manuscript. L.C. performed the Raman analysis; J.M. performed the polyphosphate experiment; M.A. performed the SEM mapping; A.G. performed imaging of polyphosphate experiment; P.J. and E.J. designed the experiments, analysed the data and wrote the manuscript. All the co-authors corrected the manuscript. Additional Information Additional Information Supplementary information accompanies this paper at https://doi.org/10.1038/s41598-017-19020-3 Competing Interests: The authors declare that they have no competing interests. Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 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https://openalex.org/W3096213570	https://link.springer.com/content/pdf/10.1007/s10531-020-02064-9.pdf	English	null	Drying microclimates threaten persistence of natural and translocated populations of threatened frogs	Biodiversity and conservation	2,020	cc-by	10,527	Biodiversity and Conservation (2021) 30:15–34 https://doi.org/10.1007/s10531-020-02064-9(0123456789().,-volV)(0123456789().,-volV) Biodiversity and Conservation (2021) 30:15–34 https://doi.org/10.1007/s10531-020-02064-9(0123456789().,-volV)(0123456789().,-volV) ORIGINAL PAPER Drying microclimates threaten persistence of natural and translocated populations of threatened frogs Emily P. Hoffmann1 • Kim Williams2 • Matthew R. Hipsey3 • Nicola J. Mitchell1 Emily P. Hoffmann1 • Kim Williams2 • Matthew R. Hipsey3 • Nicola J Mitchell1 Received: 20 July 2020 / Revised: 6 October 2020 / Accepted: 7 October 2020 / Published online: 27 October 2020 The Author(s) 2020 Communicated by Dirk Sven Schmeller. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10531-020- 02064-9) contains supplementary material, which is available to authorized users. & Emily P. Hoffmann emily.hoffmann@research.uwa.edu.au Extended author information available on the last page of the article & Emily P. Hoffmann emily.hoffmann@research.uwa.edu.au Extended author information available on the last page of the article Keywords Amphibian conservation Climate Habitat Population decline Soil moisture Geocrinia & Emily P. Hoffmann emily.hoffmann@research.uwa.edu.au Extended author information available on the last page of the article Introduction Deﬁning the environmental factors that determine species distributions is invaluable for effective species conservation and management. Population declines due to environmental change are prevalent worldwide (Pereira et al. 2012) and so understanding the environ- mental limits of species is critical for predicting future biodiversity. Species-habitat associations can be used to identify threatening processes and enable management actions that may halt or reverse declines, and ultimately prevent species extinctions (Caughley 1994). For example, deﬁning species’ habitat requirements can improve recovery actions, such as conservation translocations (Morris et al. 2015; McCulloch and Norris 2001). A key challenge for recovering threatened species is identiﬁcation of suitable reintroduction sites, and low habitat suitability or a lack of consideration of micro-habitat are prime reasons for translocation failure (Germano and Bishop 2009; Bennett et al. 2013). Yet despite potential beneﬁts to conservation, the ﬁne-scale habitat associations that determine a species occurrence are often unknown. The availability of detailed information on environmental requirements is particularly important for amphibians. Over 40% of amphibian species are threatened (IUCN Red List 2020), and the causes of declines and local extinctions are not universally known (Stuart et al. 2004). Being ecothermic vertebrates, the body temperature of amphibians is largely determined by their microenvironment, and their permeable skin and unshelled eggs make them especially sensitive to water loss and pollutants (Hillman et al. 2009). As a conse- quence, amphibians are highly sensitive to changes in habitat and are more vulnerable to changes in climate than other vertebrates (Blaustein et al. 2010; Walls et al. 2013; Rolland et al. 2018). Detailed knowledge of species-habitat associations can hence improve our understanding of how the amphibians may respond to future changes, such as hotter and/or drier climates, and can aid recovery actions such as translocations (Li et al. 2013). White- and orange-bellied frogs (Geocrinia alba and Geocrinia vitellina; Wardell- Johnson and Roberts, 1989) are terrestrial-breeding species with highly restricted distri- butions in south-western Australia (Fig. 1). The species are allopatric with at least 6 km between their range edges and occur in naturally fragmented sub-populations clustered along drainage lines and headwater streams. Geocrinia alba is Critically Endangered, with over half the known populations going extinct in recent decades, and extant populations continuing to decline (TSSC 2019). Abstract Deﬁning species habitat requirements is essential for effective conservation management through revealing agents of population decline and identifying critical habitat for con- servation actions, such as translocations. Here we studied the habitat-associations of two threatened terrestrial-breeding frog species from southwestern Australia, Geocrinia alba and Geocrinia vitellina, to investigate if ﬁne-scale habitat variables explain why popula- tions occur in discrete patches, why G. alba is declining, and why translocation attempts have had mixed outcomes. We compared habitat variables at sites where the species are present, to variables at immediately adjacent sites where frogs are absent, and at sites where G. alba is locally extinct. Dry season soil moisture was the most important predictor of frog abundance for both species, and explained why G. alba had become extinct from some areas. Sites where G. alba were present were also positively associated with moss cover, and negatively with bare ground and soil conductivity. Modelling frog abundance based exclusively on dry season soil moisture predicted recent translocation successes with high accuracy. Hence, considering dry season soil moisture when selecting future translocation sites should increase the probability of population establishment. We propose that a regional drying trend is the most likely cause for G. alba declines and that both species are at risk of further habitat and range contraction due to further projected regional declines in rainfall and groundwater levels. More broadly, our study highlights that con- servation areas in drying climates may not provide adequate protection and may require interventions to preserve critical habitat. Keywords Amphibian conservation Climate Habitat Population decline Soil moisture Geocrinia y p moisture Geocrinia Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10531-020- 02064-9) contains supplementary material, which is available to authorized users. Extended author information available on the last page of the article 123 123 Biodiversity and Conservation (2021) 30:15–34 16 123 Introduction Considerable habitat clearance and land-use change in the region has been attributed to earlier extinction events, but more recently populations are disappearing in areas within conservation reserves that are apparently undisturbed (Page et al. 2018). Geocrinia vitellina is known from a very small area (\ 6 km2) and is listed as Vulnerable, however populations have remained relatively stable over time and are all within a contiguous national park (Department of Parks and Wildlife 2015). The causes of the patchy distributions of both species are unclear, as is the reason why some G. alba populations are declining in areas with apparently intact habitat. Conservation translocations of head-started juvenile Geocrinia began in the 20000s and aimed to increase the number of sub-populations, but have had varying outcomes (Department of Parks and Wildlife 2015). One translocation site for G. alba has become a large self-sustaining population, whilst few or no calling males have been detected at other sites in the years following translocation. Juvenile frogs were all released into suit- able looking riparian habitats near existing populations during spring and involved the release of a comparable number of individuals. Why some translocations have been more 123 123 Biodiversity and Conservation (2021) 30:15–34 17 Fig. 1 Map of a the study area in southwest Western Australia b showing present (circles), extinct (crosses) and translocated (triangles) Geocrinia alba (black) and Geocrinia vitellina (orange) populations and sites sampled in this study (white symbols), c an example of the sampling design along drainage lines, showing sampled present site where frogs occur (circle), an immediately adjacent site (square) where frogs are absent, and a nearby extinct site (cross), and d an example of sampling quadrats at a site. Population locations and hydrology layers provided by Western Australian Department of Biodiversity Conservation and Attractions Fig. 1 Map of a the study area in southwest Western Australia b showing present (circles), extinct (crosses) and translocated (triangles) Geocrinia alba (black) and Geocrinia vitellina (orange) populations and sites sampled in this study (white symbols), c an example of the sampling design along drainage lines, showing sampled present site where frogs occur (circle), an immediately adjacent site (square) where frogs are absent, and a nearby extinct site (cross), and d an example of sampling quadrats at a site. Introduction Population locations and hydrology layers provided by Western Australian Department of Biodiversity Conservation and Attractions successful than others has not been determined, and not knowing what makes a translo- cation site successful is currently constraining conservation management. Patterns of population occurrence and persistence for both natural and translocated populations of G. alba and G. vitellina may relate to ﬁne-scale differences in habitat. Both species exhibit extreme site philopatry, with 90% of individuals moving less than 20 m within and between years (Driscoll 1997). This low dispersal is evident from genetic studies that showed almost no gene ﬂow between populations (Driscoll 1998a). As the species are specialised terrestrial breeders with entirely endotrophic (non-feeding) devel- opment (Mitchell 2001; Anstis 2010), their lifecycle is completed in and immediately adjacent to breeding sites. Breeding sites are vulnerable to extremes of ﬂooding and desiccation, as eggs develop in moist soils but cannot be submerged (Wardell-Johnson and Roberts 1993). Hence if a habitat becomes unsuitable, these species have very limited ability to disperse to suitable habitat elsewhere. Habitat ﬂoristics do not distinguish between persisting and extinct populations (Pauli 1999), but habitat structure may play a key role in where frogs occur. Both species live and breed under moss, litter and other vegetation (Driscoll 1998a; Conroy 2001) and therefore the availability of these features is likely important in determining their presence. Like- wise, microclimate characteristics of nest sites and soil parameters, such as pH and con- ductivity, are other factors known to inﬂuence amphibian occurrence (Wyman 1988; Mitchell 2002a; Dodd 2010) that could also play a role in determining the distribution of G. alba and G. vitellina. In this study our aim was to identify if variation in ﬁne-scale habitat attributes could explain why populations of G. alba and G. vitellina occur in discrete patches along 123 Biodiversity and Conservation (2021) 30:15–34 18 seemingly suitable riparian habitat, why G. alba is declining and has become absent from some sites whilst G. vitellina sites are more stable, and why translocation efforts for both species have had mixed outcomes. Based on current knowledge of the species, we explored four hypotheses to explain their persistence at sites. We hypothesised that frog occurrence, population declines, and translocation success are driven by differences in (1) site hydrology, (2) micro-climate, (3) habitat structure, and/or (4) soil characteristics. Study area Geocrinia alba and Geocrinia vitellina occur along drainage areas and headwater streams in the Margaret River region in southwest Australia (Fig. 1). Drainage lines typically consist of dense riparian and rhizomatous vegetation with a shrub overstorey (e.g. Astartea fascicularis, Taxandria linearifolia, Homalospermum ﬁrmum), surrounded by jarrah (Eu- calyptus marginata) and marri (Corymbia calophylla) forests, and are characterised by shallow water ﬂows in winter (Wardell-Johnson and Roberts 1993). The region has a Mediterranean climate with a distinct wet period from May to October, and a dry period from November to April characterised by very little rainfall and high temperatures (Fig. 2). Cool wet winters and early spring coincide with frog breeding activity, and metamorphosis from terrestrial nest sites occurs from November to January. Introduction We predicted that sites where frogs persist would have higher year-round soil moisture, lower temperature extremes, more ground cover and soils with lower conductivity. We then use our ﬁndings on habitat associations based on occupied frog sites and successful translo- cation sites to provide recommendations for recognising critical habitat, and to identify key threats to the persistence of both species. 123 Site selection Geocrinia alba and G. vitellina habitats were sampled across four distinct site types, selected with reference to long-term acoustic monitoring records maintained by the Western Australian Department of Biodiversity, Conservation and Attractions (DBCA) (Fig. 1). The G. alba and G. vitellina monitoring program has been identiﬁed as an exemplary monitoring program for threatened frogs in Australia (Scheele and Gillespie 2018), with over 1760 surveys conducted across 150 sites since 1983. Frog populations are monitored annually or biannually, and monitoring includes point counts (where frog abundances are estimated from a single location) at all sites, as well as linear counts at selected sites, which involves counting all individuals and locating the ﬁrst and last calling male in a breeding chorus along a drainage line. Translocation sites have census moni- toring, where all calling individuals are located and recorded. Present sites (n = 21) were locations where populations of G. alba or G. vitellina have consistently occurred, based on acoustic surveys conducted in spring. Present sites were selected at random from a list of all known present sites, where they were accessible (i.e. property access was permitted) and separated from another present site by at least 500 m. Adjacent sites (n = 21) were unoccupied sites along potential riparian habitat for frogs, either 50 m directly upstream or downstream of a present population site. While typical adult movements between years are less than 20 m, the distance of 50 m is within the dispersal range of these species (Driscoll 1997), and so adjacent sites were 123 123 Biodiversity and Conservation (2021) 30:15–34 19 Fig. 2 Monthly averages (with 5% and 95% percentiles) of rainfall (vertical bars) and temperature (solid line) for the Margaret River region, showing distinct cool-wet winter and warm-dry summer periods. The relative timing of breeding activity (calling), larval development and metamorphosis of G. alba and G. vitellina (based on Conroy 2001; Anstis 2010) are shown by horizontal bars. Climate data are from weather stations at Witchcliffe (temperature from 1999 to 2018) and Forest Grove (rainfall from 1925 to 2018), located approximately 5 and 3 kms from the study area (Bureau of Meteorology 2019) Fig. 2 Monthly averages (with 5% and 95% percentiles) of rainfall (vertical bars) and temperature (solid line) for the Margaret River region, showing distinct cool-wet winter and warm-dry summer periods. The relative timing of breeding activity (calling), larval development and metamorphosis of G. alba and G. Site selection vitellina (based on Conroy 2001; Anstis 2010) are shown by horizontal bars. Climate data are from weather stations at Witchcliffe (temperature from 1999 to 2018) and Forest Grove (rainfall from 1925 to 2018), located approximately 5 and 3 kms from the study area (Bureau of Meteorology 2019) potentially available to frogs, but could be conﬁrmed as unoccupied due to their proximity to present sites that are routinely surveyed. Upstream or downstream sites were chosen at random (by the ﬂip of a coin), unless only one direction ﬁtted our selection criteria (i.e. there was only unoccupied habitat in one direction). Extinct sites (n = 11) were nearby sites where the species had occurred in the past but was not recorded by the DBCA for at least three years prior. Translocation sites (n = 6) were sites where head-started juvenile frogs (ranging from 68 to 145 individuals) had been introduced between 2010 and 2017 in locations where they had not been recorded previously (Table S1). Habitat characteristics Habitat surveys were conducted towards the end of the warm-dry period, from April 14 to May 2 2018, following pilot surveys to determine the number of quadrats and samples required to quantify characteristics of a site. Habitat variables were sampled in three 3 9 3 m quadrats at each site. The quadrats were established along a 15 m transect run- ning along the edge of the riparian vegetation (7.5 m apart), and then positioned at a random distance from the edge (into the riparian habitat) (Fig. 1). At each quadrat, ﬁfteen habitat characteristics were measured relating to our four hypotheses; site hydrology, micro-climate, habitat structure, and soil characteristics (Table 1). 3 3 Soil moisture (volumetric water content, m3 m-3) was measured in the top 6 cm of soil using a hand-held moisture meter (ICT International, MP306). Five measurements were taken, one in each corner and one in the centre of the quadrat, and then were averaged per quadrat. Additional soil moisture measurements were taken at the end of the wet period (December 18–20 2018), but only in the central quadrat. The soil moisture meter was calibrated using soil samples from ﬁve sites that included all soil texture categories (see below). Soils were air-dried then wetted to create a range of moisture levels and the meter value was recorded and compared to the actual water content by oven drying the sample at 105 C for 24 h. Bulk density was determined with the core method using the same samples as were used for calibration of the meter. Table 1 Fine-scale habitat variables used to investigate habitat associations of G. alba and G. Estimates of frog abundance We estimated frog abundance from acoustic monitoring data collected by DBCA staff during September–November, when the majority (76–96%) of calling males in a popu- lation can be reliably detected (Driscoll 1998b). Frog call surveys were conducted after dusk by experienced DBCA staff, when the maximum number of males’ call (Driscoll 1998b). The number of calling males was estimated over a 10-min period, and was con- sidered to be a proxy for frog abundance that reﬂected relative differences in population size across sites. The number of males calling at a site was allocated to one of six categories (0, 1–4, 5–10, 11–20, 21–50, [ 50), and the minimum value in each category was used as the estimate of male abundance for each site. This was the most conservative approach and was more informative than presence-absence data as it distinguished sites with only a few calling males from sites that supported much larger choruses. At translocation sites, frog abundance was estimated using a similar call survey technique but a censusing approach was employed, where the exact number of calling males were identiﬁed by marking their positions. 123 Biodiversity and Conservation (2021) 30:15–34 20 Statistical analysis All statistical analyses were carried out in R (R Core Team 2019). To visualise differences in habitat characteristics across site types we used non-metric multidimensional scaling (NMDS). Plots were produced identifying site type (present, adjacent or extinct) using the ‘vegan’ package (Oksanen et al. 2019). Analysis of similarity (ANOSIM) was used to test whether there was a signiﬁcant difference between habitat characteristics and site types. To investigate which habitat features best explained frog abundance we used gener- alised linear mixed-effect models (GLMMs) with Poisson error distributions. We con- ducted three sets of analyses—ﬁrst comparing present versus adjacent sites for G. alba and G. vitellina to investigate why frog populations occur in discrete patches, and then com- paring present versus extinct sites for G. alba to examine possible mechanisms of G. alba decline. The response variable was the minimum estimated abundance of frogs at a site, and there were 15 potential explanatory habitat variables thought to be important in determining frog abundance. To avoid over parametrisation, we reduced correlated pairs of variables (r [ 0.5) and retained one with the strongest effect on the model as a proxy (Booth et al. 1994). The reduced predictor variables set included dry season soil moisture, maximum temperature, canopy cover, bare ground, moss cover, litter cover, soil con- ductivity and soil pH (Table 1). Predictors were scaled and centered to have a mean of 0 and standard deviation of 1 (Harrison et al. 2018), allowing for comparison of effect sizes (Grueber et al. 2011). The areas containing paired sites (e.g. a present and nearby adjacent site) within the same catchment were included as a random effect. Models were ﬁtted using the ‘glmer’ function in the package ‘lme4’ (Bates et al. 2015). All possible variable subsets were created and ranked based on Akaike information criterion adjusted for small sample size (AICC). Model averaging was then conducted on the subset of models with high support (DAICC B 6 with the top ranked model, which includes the 95% conﬁdence model set (Richards et al. 2011) using the ‘modavg’ function in the ‘MuMIn’ package (Barton´ 2019)). Rather than single best model methods, this allowed for model selection uncertainty, as inference was based on the entire candidate model set (Burnham and Anderson 2002). The relative importance of each variable across all models was determined by the sum of Akaike weights (Wi) (Burnham and Anderson 2002). Habitat characteristics vitellina populations in south–west Western Australia Category (Hypothesis) Variable Description Hydrology SoilMoist_Drya Volumetric soil water content (m3 m-3) measured at the end of the dry season, April 2018 SoilMoist_Wet Volumetric water content (m3 m-3) measured following the wet season, December 2018 Micro-climate TempMaxa Average daily soil temperature maximum (C) in the hottest month, February 2019 TempRange Average daily soil temperature range (C) in the hottest month, February 2019 Habitat structure CanopyCovera Average canopy cover (%) BareGrounda Average cover of bare ground (%) Mossa Average cover of moss (%) SedgeCover Average cover of sedges (%) WoodyDebris Average cover of coarse woody debris and logs (%) LitterCovera Average cover of leaf litter (%) LitterDepth Average depth of the litter layer (cm) Soil properties Texture Soil texture classiﬁcation based on ﬁve categories ranging from sand (1) to clay (3) OrganicCarbon Soil organic carbon (%) Conductivitya Soil electrical conductivity (dS m-1) pHa Soil pH (CaCl2) aVariables used in the ﬁnal generalised linear mixed-effect modelling Table 1 Fine-scale habitat variables used to investigate habitat associations of G. alba and G. vitell populations in south–west Western Australia 12 21 Biodiversity and Conservation (2021) 30:15–34 One HOBO temperature logger (UA-001-08) was placed in each sites’ central quadrat to obtain soil surface temperature data at hourly intervals. Loggers were placed in the most open patch of the quadrat, buried into the top layer of soil (0–2 cm) under any present surface covering (e.g. leaf litter) and secured with a survey pin. Canopy cover was esti- mated at each quadrat using a densiometer held approximately 1.2 m above ground level at each cardinal direction, and then averaged for each quadrat. Ground cover was estimated as the percent area of bare ground, moss, sedge, leaf litter, and coarse woody debris within the quadrat, and litter depth was measured at three random points using a ruler and then averaged for the quadrat. Soil samples were collected by scraping away any litter or moss covering and extracting three cores (of the top 10 cm) from within each quadrat. Soil samples were bulked per site and analysed for texture (scale 1–3; Sand-Clay), organic carbon (%), conductivity (dS m-1), and pH (CaCl2) by an accredited soil laboratory (CSBP Soil and Plant Analysis Laboratory). Differences between G. alba and G. vitellina sites Analysis of microhabitat characteristics using NMDS showed there was a signiﬁcant difference in the habitat characteristics of present, adjacent and extinct sites (Fig. 3; ANOSIM global r = 0.1802, p = 0.001). Present sites of both species had considerable overlap and were more similar to each other than their paired adjacent sites (50 m upstream or downstream) and extinct G. alba sites. Present sites for G. vitellina had some separation along the ﬁrst ordination axis indicating higher soil moisture, moss and soil electrical conductivity than at the present sites for G. alba (Table S3). Adjacent and extinct sites were also separated mostly along the ﬁrst ordination axis, signifying these sites had more bare ground, warmer temperatures and lower soil moisture and moss cover than present sites (Fig. 3). Statistical analysis Model diagnostics were investigated using the ’DHARMa’ package (Hartig 2020) and indicated no overdispersion, outliers, or heteroscedasticity of the model residuals. We 123 Biodiversity and Conservation (2021) 30:15–34 22 checked for collinearity among ﬁxed effects by calculating variable inﬂation factors in all top models using ‘vif’ function in the ‘car’ package (Fox and Weisberg 2019). Once dry season soil moisture was identiﬁed as one of the best explanatory variables of frog abundance (consistently signiﬁcant for both species), we tested the accuracy of model predictions for translocation outcomes by comparing them with the actual outcomes of translocations (note that data from translocation sites were not used in the models described above). As the number of years since frogs were ﬁrst introduced varied across translocation sites, we initially used abundance estimates from two years following the initial release of frogs, as this could be applied to all translocation sites. However, as the 2-year results did not differ from those using frog abundances from the year of the habitat surveys (2017), we used the more recent estimates from 2017. Generalised linear models of frog abundance were made for each species with dry season soil moisture as the explanatory variable, using the data from naturally occurring present and absent sites described above. Predictions of frog abundance were then made for existing translocation sites based on their dry season soil moisture, and the accuracy of predictions was inves- tigated using Spearman’s rank-order correlation. We also converted predicted and actual frog abundances into categories in order to construct a confusion matrix using the ‘carot’ package (Kuhn 2018). A cut-off value of C 10 frogs was used to deﬁne ‘success’ at a translocation site based on the criteria deﬁned in the Geocrinia Recovery Plan (Department of Parks and Wildlife 2015). Habitat associations Frog abundance was posistively associated with dry season soil moisture for both G. alba and G. vitellina, and dry season soil moisture was present in all top models (DAICC B6) across all three model sets (Table 2; Fig. 4). Dry season soil moisture also had the highest relative importance and effect size for models comparing G. alba present vs extinct sites and G. vitellina present vs adjacent sites, and was equally important in G. alba present vs adjacent sites (Table 2). Geocrinia alba abundance (comparing present sites with extinct sites) was positively associated with moss cover and pH but the effect size was smaller. The conﬁdence interval for pH was almost zero, specifying less evidence of an effect. Compared to adjacent sites, G. alba abundance was negatively associated with the area of bare ground and soil 123 Biodiversity and Conservation (2021) 30:15–34 23 −1.0 −0.5 0.0 0.5 1.0 −1.0 −0.5 0.0 0.5 1.0 NMDS1 NMDS2 −1.0 −0.5 0.0 0.5 1.0 −1.0 −0.5 0.0 0.5 1.0 NMDS1 NMDS2 SoilMoist_Wet SoilMoist_Dry TempRange TempMax CanopyCover BareGround Moss LitterCover WoodyDebris SedgeCover LitterDepth OrganicCarbon Conductivity G.vitellina adjacent G.vitellina present G.alba present G.alba extinct G.alba adjacent (a) (b) Fig. 3 Non-metric MDS ordination of site microhabitat characteristics showing a G. alba and G. vitellina present (shaded, solid line), adjacent (unshaded, dashed line) and extinct site types (unshaded, dotted line), and b vectors of environmental variables signiﬁcantly related to the ordination (p \ 0.01). Ellipses in a) show 95% conﬁdence intervals. Stress = 0.17 −1.0 −0.5 0.0 0.5 1.0 −1.0 −0.5 0.0 0.5 1.0 NMDS1 NMDS2 G.vitellina adjacent G.vitellina present G.alba present G.alba extinct G.alba adjacent (a) 0 (b) −1.0 −0.5 0.0 0.5 1.0 −1.0 −0.5 0.0 0.5 1.0 NMDS1 NMDS2 SoilMoist_Wet SoilMoist_Dry TempRange TempMax CanopyCover BareGround Moss LitterCover WoodyDebris SedgeCover LitterDepth OrganicCarbon Conductivity (b) (a) Fig. 3 Non-metric MDS ordination of site microhabitat characteristics showing a G. alba and G. vitellina present (shaded, solid line), adjacent (unshaded, dashed line) and extinct site types (unshaded, dotted line), and b vectors of environmental variables signiﬁcantly related to the ordination (p \ 0.01). Ellipses in a) show 95% conﬁdence intervals. Stress = 0.17 conductivity, which had the biggest effect sizes (Table 2; Fig. 5a, b). Geocrinia alba abundance was also positively associated with moss cover, similarly to present vs extinct sites (Fig. 5c). All four variables had equal relative importance (Table 2). For G. Habitat associations vitellina, several other variables were contained in the top models (DAICC B 6), but conﬁdence intervals of the estimates included zero, indicating weak evidence for an effect (Table 2). conductivity, which had the biggest effect sizes (Table 2; Fig. 5a, b). Geocrinia alba abundance was also positively associated with moss cover, similarly to present vs extinct sites (Fig. 5c). All four variables had equal relative importance (Table 2). For G. vitellina, several other variables were contained in the top models (DAICC B 6), but conﬁdence intervals of the estimates included zero, indicating weak evidence for an effect (Table 2). Dry season soil moisture, which was present in all top models for both species, was strongly negatively correlated with maximum soil temperature (t57 = - 6.45, p \ 0.001, r = - 0.65) and soil temperature range (t57 = - 8.23, p \ 0.001, r = - 0.74) and was inﬂuenced by soil texture, with soils with higher clay content generally having higher soil moisture than sandier soils (Fig. S1). Dry season soil moisture, which was present in all top models for both species, was strongly negatively correlated with maximum soil temperature (t57 = - 6.45, p \ 0.001, r = - 0.65) and soil temperature range (t57 = - 8.23, p \ 0.001, r = - 0.74) and was inﬂuenced by soil texture, with soils with higher clay content generally having higher soil moisture than sandier soils (Fig. S1). Predicting translocation outcomes Generalised linear models using dry season soil moisture as the sole predictor variable were good predictors of G. alba and G. vitellina abundances at translocation sites (Fig. 6). Predicted abundance was signiﬁcantly correlated with actual abundances at translocation sites (rs = 0.89, p = 0.015). Using a cut-off value of C 10 calling males as a ‘successful’ translocation site, models of frog abundance exclusively based on dry season soil moisture correctly predicted translocation success or failure at with an overall accuracy of 0.83 (Table S5). Agreement between observed and predicted was substantial (Kappa = 0.67). Discussion Studies of species-habitat relationships often produce a myriad of complex associations, but here we were able to identify a single predictor that explained the majority of variation in frog abundance for both G. alba and G. vitellina and was validated using empirical data. Fine-scale habitat variables—particularly soil moisture during the warmer-drier months— explained not only the patchy distribution of each species, but also explained local extinctions of G. alba populations and translocation outcomes of G. alba and G. vitellina. 123 Biodiversity and Conservation (2021) 30:15–34 24 Table 2 Averaged model coefﬁcients from the top model set predicting abundance of G. alba (present vs extinct sites and present vs adjacent sites) and G. vitellina (present vs adjacent sites) Variable Estimate 95% conﬁdence interval Relative importance n models Lower Upper Geocrinia alba—present vs extinct sites (Intercept) 0.8475 - 0.42 2.12 SoilMoist_Dry 2.2326 1.03 3.43 1.00 26 Moss 1.1782 0.17 2.19 0.93 22 pH 1.0139 0.02 2.01 0.76 18 Conductivity - 0.6349 - 1.31 0.04 0.48 13 CanopyCover 0.5146 - 0.14 1.17 0.39 12 TempMax - 0.1974 - 1.60 1.20 0.13 5 BareGround - 0.2788 - 1.04 0.48 0.11 5 LeafLitter 0.1326 - 0.75 1.02 0.09 5 Geocrinia alba—present vs adjacent sites (Intercept) 0.68 - 0.01 1.36 Conductivity 2 1.78 2 2.44 2 1.12 1.00 9 BareGround 2 1.40 2 2.05 2 0.75 1.00 9 SoilMoist_Dry 1.02 0.45 1.60 1.00 9 Moss 0.61 0.14 1.08 1.00 9 CanopyCover 0.42 - 0.30 1.14 0.29 4 LeafLitter 0.33 - 0.33 1.00 0.19 3 pH - 0.14 - 0.70 0.42 0.12 3 TempMax - 0.01 - 0.53 0.51 0.12 2 Geocrinia vitellina—present vs adjacent sites (Intercept) - 0.39 - 2.26 1.49 SoilMoist_Dry 3.38 1.58 5.18 1.00 15 CanopyCover 1.19 - 0.52 2.90 0.31 6 BareGround - 1.17 - 3.30 0.96 0.20 5 Moss 0.67 - 0.62 1.97 0.13 3 pH 0.47 - 0.47 1.42 0.13 3 LeafLitter - 0.10 - 1.43 1.23 0.06 2 TempMax 0.41 - 1.14 1.97 0.09 3 Variables in bold indicate those with 95% conﬁdence intervals that did not span zero. The relative importance of each variable (sum of Akaike weights) and the number of models in the top set containing the variable are also displayed Table 2 Averaged model coefﬁcients from the top model set predicting abundance of G. alba (present extinct sites and present vs adjacent sites) and G. Discussion vitellina (present vs adjacent sites) Variables in bold indicate those with 95% conﬁdence intervals that did not span zero. The relative importance of each variable (sum of Akaike weights) and the number of models in the top set containing the variable are also displayed Geocrinia alba and G. vitellina appear to share the same environmental niche. The similarity in their habitat associations is not surprising as they are the most closely related species within the Geocrinia rosea complex, which includes four direct-developing frog species endemic to southwestern Australia (Read et al. 2001). Despite no overlap in their distributions, NMDS analysis revealed that present sites of each species had signiﬁcant overlap in their habitat attributes and were more similar to each other than to riparian sites only * 50 m from the edge of areas where frogs occur. This was particularly stark for G. 123 Biodiversity and Conservation (2021) 30:15–34 25 vitellina, where there was no overlap between present and adjacent sites. The presence of both species was positively related to soil moisture at the ends of the wet (December) and dry (April) seasons, and to moss cover, and was negatively associated with bare ground, temperature maximum and temperature range during summer (February). This demon- strates that both species require relatively cooler, wetter, and mossier sites, with more ground cover. Dry season soil moisture measured in April was the principal habitat factor determining G. alba and G. vitellina occurrence and abundance at sites. This time is towards the end of a drier-hotter period (Fig. 2) and when the drainage areas where frogs occur are likely at Fig. 4 Predicted abundance of G. alba a, b and G. vitellina c as a function of dry season soil moisture (volumetric water content, m3 m-3) based on a present versus extinct sites or b and c present versus adjacent sites. Circles are actual observations, solid lines are the model predictions, and grey areas denote 95% conﬁdence intervals. Predicted abundance and conﬁdence intervals were generated with a GLM without random effects, holding all other signiﬁcant variables constant on their means Biodiversity and Conservation (2021) 30:15–34 25 vitellina, where there was no overlap between present and adjacent sites. Discussion vitellina breeding period in spring (Driscoll 1996; Pauli 1999; Conroy 2001; Mitchell 2001), and little is known about their behaviour and habitat in the drier and warmer summer–autumn period. Fig. 6 Estimates of the number of calling males at Geocrinia translocation sites and predicted abundance (± standard error) based on models using dry season soil moisture as the predictor variable Fig. 6 Estimates of the number of calling males at Geocrinia translocation sites and predicted abundance (± standard error) based on models using dry season soil moisture as the predictor variable breeding conditions. Currently, nearly all research conducted has focused on the G. alba and G. vitellina breeding period in spring (Driscoll 1996; Pauli 1999; Conroy 2001; Mitchell 2001), and little is known about their behaviour and habitat in the drier and warmer summer–autumn period. breeding conditions. Currently, nearly all research conducted has focused on the G. alba and G. vitellina breeding period in spring (Driscoll 1996; Pauli 1999; Conroy 2001; Mitchell 2001), and little is known about their behaviour and habitat in the drier and warmer summer–autumn period. Lower frog abundance or absence at drier sites could be due to desiccating conditions experienced by frogs and their egg masses. The physiological constraints of moisture on amphibians is well known (Shoemaker et al. 1992), and drier conditions at the end of the breeding period could lead to reduced or failed recruitment. Both species breed over a prolonged period following winter rains, laying eggs in moist depressions in the soil adjacent to winter streams. Egg laying and development can continue into December and January, several months into the drier period (Driscoll 1996; Conroy 2001) (Fig. 2). Incubation in drier conditions causes terrestrial frog eggs to lose water from their jelly capsules and embryos have higher rates of deformations and mortality (Bradford and Seymour 1988; Mitchell 2002b; Andrewartha et al. 2008). If soils remain saturated throughout embryonic and larval development, newly metamorphosed frogs emerge just prior to the warmest and driest time of year (around November–January, Fig. 2) and are vulnerable to desiccation due to their very small size (* 0.03 g at metamorphosis) and large surface area to volume ratio. Juvenile amphibians consequently lose more moisture and experience lower survival than adults in hotter and drier landscapes (Cayuela et al. 2016). The juvenile stage is not only the most vulnerable, but also prolonged, lasting at least two years (Driscoll 1999). Discussion The presence of both species was positively related to soil moisture at the ends of the wet (December) and dry (April) seasons, and to moss cover, and was negatively associated with bare ground, temperature maximum and temperature range during summer (February). This demon- strates that both species require relatively cooler, wetter, and mossier sites, with more ground cover. Dry season soil moisture measured in April was the principal habitat factor determining G. alba and G. vitellina occurrence and abundance at sites. This time is towards the end of a drier-hotter period (Fig. 2) and when the drainage areas where frogs occur are likely at their driest. Soil moisture varied considerably during this time, even across small distances, with sites where frogs were present having signiﬁcantly higher soil moisture than adjacent patches in the same riparian habitat 50 m away. As the surrounding open woodland habitat is drier (E. Hoffmann, unpublished data), both species appear to be utilising patches along 123 Biodiversity and Conservation (2021) 30:15–34 26 Fig. 5 Predicted abundance of Geocrinia alba as a function of a soil conductivity, b bare ground and c moss cover, based on present versus adjacent sites. Solid lines are the model predictions, grey areas denote 95% conﬁdence intervals, and circles are actual observations. Predicted abundance and conﬁdence intervals were generated with a GLM without random effects, holding all other signiﬁcant variables constant on their means Fig. 5 Predicted abundance of Geocrinia alba as a function of a soil conductivity, b bare ground and c moss cover, based on present versus adjacent sites. Solid lines are the model predictions, grey areas denote 95% conﬁdence intervals, and circles are actual observations. Predicted abundance and conﬁdence intervals were generated with a GLM without random effects, holding all other signiﬁcant variables constant on their means drainage lines that retain the highest moisture in the dry season. Soil water availability in summer–autumn may therefore be the deﬁning factor that determines the patchy and restricted distributions for both species. Soil temperature (both maximum and range) was signiﬁcantly correlated with soil moisture, and therefore drier areas were also warmer. The summer dry season may therefore be a critical period for G. alba and G. vitellina and potentially more important in determining population persistence than winter-spring Biodiversity and Conservation (2021) 30:15–34 27 breeding conditions. Currently, nearly all research conducted has focused on the G. alba and G. Discussion South-west Western Australia has experienced a 15–20% decline in rainfall and a consequent 35–50% reduction in streamﬂow since the 1970s, with the biggest rainfall changes occurring at the start of the wetter winter period in May and June (Petrone et al. 2010; McFarlane et al. 2020). Reduced rainfall in winter is increasing the length of the ‘no- ﬂow’ period in rivers of the region, with surface ﬂows in ephemeral creek lines com- mencing later and ending earlier (e.g. Smettem et al. 2013). Furthermore, riparian habitats may also be impacted by decreasing groundwater levels in the region (McFarlane et al. 2020). Streamﬂow is dominated by winter rainfall, but some catchments in Geocrinia habitats overlie sedimentary aquifers (e.g. Upper Chapman Brook) and may receive groundwater inputs during summer (Department of Water 2015). If sites rely on ground- water seepage to retain moisture over summer and autumn, lower groundwater levels could be resulting in drier summer conditions. As we showed that drier soils had higher maxi- mum temperatures and greater temperature ranges, drier sites are also likely to be more impacted by the warmer air temperatures that have been observed and predicted to increase in the region (Charles et al. 2010). Therefore, regional changes in climate and hydrology are likely to be resulting in drainage habitats receiving less surface water and groundwater inputs, and consequently, experiencing more extreme temperatures and drying. The changes being experienced in headwater systems may be ampliﬁed as the relationship between rainfall decline and streamﬂow can be highly non-linear (e.g. 1% rainfall decline C 3% runoff decline; McFarlane et al. 2020) and through a disconnection of groundwater-surface water connectivity due to declining groundwater levels (Petrone et al. 2010). If drying of some G. alba habitats is due to regional changes in climate or hydrology, why is G. vitellina not declining? Geocrinia vitellina occurs in sites that are less sandy than G. alba sites and thereby retain higher soil moisture. Geocrinia vitellina also occurs on drainage lines that may receive groundwater inputs from the deeper Yarragadee and Leederville aquifers, buffering these areas from drying over summer (CSIRO 2009). Therefore, G. vitellina habitats may be less vulnerable to hydrological changes. However, G. vitellina also appears to be highly restricted to wetter patches within riparian drainage habitats in the dry period, as adjacent areas where frogs didn’t occur were signiﬁcantly drier. Discussion Both Geocrina species rely on high juvenile survival due to low fecundity (with an average of 11 eggs per clutch) and because most adults only breed once (Driscoll 1999; Conroy 2001). Population viability modelling of G. alba and G. vitellina has indicated that a reduction in juvenile survival would have the biggest impact on population trends compared with other life stages (Conroy and Brook 2003). Therefore, we infer that frogs are at risk of desiccation during the dry phase, and juveniles are likely the most vulnerable life stage. Local extinctions throughout the range of G. alba also appear to be driven by habitat differences, with extinct sites being signiﬁcantly drier in summer and less mossy than present and adjacent sites. Hydrological change had been suggested as one of the main threats to G. alba (e.g. Driscoll 1996; Pauli 1999; Conroy 2001), but until this study, there were no quantitative data to evaluate the importance of site hydrology, speciﬁcally soil moisture, as a factor in G. alba declines. Considerable land clearance and land-use change 123 123 Biodiversity and Conservation (2021) 30:15–34 28 has occurred within G. alba’s range. It is estimated that 70% of potentially suitable habitat has been removed and most of the clearance has occurred relatively recently, between 1960 and 1980 (Pauli 1999; Page et al. 2018). Clearing of native vegetation may increase stream ﬂows and groundwater levels, at least in the short term (Bari et al. 1996), but these increases may have been offset by extensive land-use change following vegetation clear- ance, such as expansions of orchards, forestry plantations, barriers to ﬂow (e.g. roads) and installation of dams, and could be reducing ﬂows to G. alba catchments (Department of Parks and Wildlife 2015). Despite the clear attribution of local extinctions of some pop- ulations to land clearance and adjacent land use change, most of the extinct G. alba sites sampled in this study were within stands of native vegetation and conservation estate (with the upstream catchment entirely within reserve or native vegetation block) and so should be less impacted by land clearance and hydrological alterations, such as dams. Conse- quently, the pattern of extinctions at drier sites may also reﬂect hydro-climatological changes that are occurring in the region on a broader scale. There is mounting evidence of substantial climatic and hydrological change occurring in the region. Management implications Here we have demonstrated that gaining a detailed understanding of species habitat-as- sociations can provide vital information for conservation management. Studies of habitat requirements typically compare occupied and unoccupied habitats, but we additionally evaluated the outcomes of translocations in the context of habitat variability. This approach highlighted that ﬁne-scale habitat attributes are likely to be a key driver of translocation success, as we were able to hindcast translocation outcomes with high accuracy using only dry season soil moisture as the predictor variable. Therefore, using dry season soil moisture to select translocation sites should increase the likelihood of success of new translocations. We suggest that sites should have soil moisture contents of at least 40% during the drier period to sustain a population of [ 10 calling males. Very few frogs were recorded at sites where soil moisture content was below 20%, indicating that sites below this moisture threshold are unlikely to support G. alba or G. vitellina populations long-term. These recommendations are tentative in recognition that our predictions are based on one year of data, and the variability and extremes the sites experience throughout the year is unknown. Further, soil moisture per se has limited biological relevance to amphibians, as soil water potential drives water availability and varies substantially with soil type (Shoemaker et al. 1992). However, as soil moisture content can be measured more simply than water potential, it is a practical method to rapidly detect relatively wetter and drier areas. More broadly, we highlight that conservation areas may not provide a buffer against wider regional threats, such as drying brought about by climate change. This corroborates our related study showing that physiological tolerance limits of G alba. and G. vitellina are being breached in atypically warm periods (Hoffmann et al. in review), and other studies that have recorded impacts of drought on amphibians within conservation estates in other regions of Australia (Scheele et al. 2012) and the world (McMenamin et al. 2008; Cayuela et al. 2016). Mitigating broad scale impacts of changing hydrology and climate (e.g. those that are occurring across entire species ranges) including in protected areas, is an imposing management challenge. Some suggested strategies include providing microclimate refugia through watering actions, such as sprinkler systems to wet soils or artiﬁcial ﬁlling of wetlands (see Shoo et al. 2011 for a summary), which may help alleviate pressures at key sites in the short term. Discussion They also share the same specialised breeding requirements, limited dispersal ability, and very small area of occurrence as G. alba. Therefore, whilst only G. alba has shown extreme declines, both species are threatened by habitat and range contraction associated with climatic and hydrological changes occurring in the region. For example, groundwater 123 Biodiversity and Conservation (2021) 30:15–34 29 tables in the Blackwood plateau underlying G. vitellina habitat are currently declining at * 1.2 m/year and are predicted to drop 10 m in some areas by 2030 (CSIRO 2009). More recent population monitoring has also indicated that some G. vitellina populations are showing signs of decline (K. Williams, unpublished observation). tables in the Blackwood plateau underlying G. vitellina habitat are currently declining at * 1.2 m/year and are predicted to drop 10 m in some areas by 2030 (CSIRO 2009). More recent population monitoring has also indicated that some G. vitellina populations are showing signs of decline (K. Williams, unpublished observation). In addition to soil moisture levels, habitat structure and other soil parameters were also important in determining G. alba abundance. Most notably, compared with sites where G. alba were present, extinct sites had less moss cover. Adjacent areas were also associated with lower moss cover, as well as more bare ground and higher soil conductivity. More moss and ground cover at sites where G. alba are present would provide frogs with more habitat for nest construction, as well as greater protection from desiccation (Glime and Boelema 2017). The electrical conductivity levels in the drainage lines were generally low (\ 1 dS m-1) but indicated that G. alba prefer areas with lower soil conductivity. Con- ductivity is an indicator of salinity, which can cause osmotic stress (Smith et al. 2007) and can decrease growth and survival of amphibians at higher concentrations (Chinathamby et al. 2006; Kearney et al. 2012). Management implications Groundwater levels are heavily linked to rainfall but also vegetation 123 123 Biodiversity and Conservation (2021) 30:15–34 30 (CSIRO 2009). Reversing groundwater declines, as well as increases in streamﬂow, could potentially be achieved by a reduction in upland vegetation via thinning (Jones et al. 2018) and has been trialled in Jarrah forests in Western Australia (e.g. Stoneman, 1993), but requires consideration of other biodiversity values. Another conservation approach when habitats become marginal due to climate change is assisted colonisation, where species are moved to areas outside of their indigenous range that will become suitable in the near future (Mitchell et al. 2013; Gallagher et al. 2015). Our ﬁndings suggest that the conditions that led to the loss of G. alba populations have not alleviated, and that sites where the species became extinct are not suitable for recolonisation, making assisted colonisation worthy of consideration. A priority should be to detect areas that currently stay moist or retain shallow surface water year-round and to evaluate their resilience to future hydro- logical change, as these areas may provide important refugia for the species into the future. g g y p p g p Our ﬁndings also have implications for other taxa and locations. Local extinctions of G. alba are potentially among the ﬁrst signs of impacts of changes to the hydrology of drainage areas and headwaters on regional biodiversity, and the impacts on other water- dependent fauna and ﬂora that occur in these systems is unknown (e.g. threatened Engaewa spp.—endemic burrowing crayﬁsh). We also detected critical habitat differences on an extremely ﬁne-scale, just tens of meters along drainage lines. These distances are much ﬁner in scale than the focus of much climate and species distribution modelling, empha- sising the need to consider modelling habitat variables at the scale most relevant to that species. Many mid-latitude areas of the world are experiencing a drying and warming trend, and our study highlights the vulnerability of sedentary and specialised water-sen- sitive species in an era of rapid environmental change. Acknowledgements We thank the Western Australian Department of Biodiversity, Conservation and Attractions, in particular Christine Taylor, for assistance with project planning, logistics and site access. This research was completed under a DBCA Regulation 4 Permit and University of Western Australia Animal Ethics Permit RA/3/100/1554. Management implications This research was supported by the Australian Government’s National Environmental Science Program through the Threatened Species Recovery Hub, the Forrest Research Foundation, the Mohamed bin Zayed Species Conservation Fund, the Holsworth Wildlife Research Endowment and The Ecological Society of Australia. We are grateful to landholders for property access, and to Irene Wegener and Bruno Buzatto for ﬁeldwork assistance. The study was enhanced by discussions with the Geocrinia Recovery Team, Dale Roberts and Natasha Pauli, and statistical advice from Bruno Buzatto. Authors contributions EPH—Conceptualization, Methodology, Formal Analysis, Writing—Original Draft, Writing—Review & Editing, Visualization, Funding acquisition. KW—Conceptualization, Resources, Writing—Review & Editing. MRH—Writing–Review & Editing, Supervision. NJM—Conceptualization, Supervision, Writing–Review & Editing, Funding acquisition. Authors contributions EPH—Conceptualization, Methodology, Formal Analysis, Writing—Original Draft, Writing—Review & Editing, Visualization, Funding acquisition. KW—Conceptualization, Resources, Writing—Review & Editing. MRH—Writing–Review & Editing, Supervision. NJM—Conceptualization, Supervision, Writing–Review & Editing, Funding acquisition. Funding This research was supported by the Australian Government’s National Environmental Science Program through the Threatened Species Recovery Hub, the Forrest Research Foundation, the Mohamed bin Zayed Species Conservation Fund, the Holsworth Wildlife Research Endowment and The Ecological Society of Australia. Data availability Due to the sensitive nature of the species locations the datasets from the current study are not publicly available but are available from the corresponding author on reasonable request. Code availability Not applicable. References Andrewartha SJ, Mitchell NJ, Frappell PB (2008) Phenotypic differences in terrestrial frog embryos: effect of water potential and phase. J Exp Biol 211:3800–3807 Anstis M (2010) A comparative study of divergent embryonic and larval development in the Australian frog genus Geocrinia (Anura: Myobatrachidae). 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Mitchell1 1 School of Biological Sciences, The University of Western Australia, Crawley, WA 6009, Austra 1 School of Biological Sciences, The University of Western Australia, Crawley, WA 6009, Australia 2 Department of Biodiversity Conservation and Attractions, Parks and Wildlife Service, Bunbury, WA, Australia 3 School of Agriculture and Environment, The University of Western Australia, Crawley, WA 6009, Australia 3 School of Agriculture and Environment, The University of Western Australia, Crawley, WA 6009, Australia 123
https://openalex.org/W3010748121	https://europepmc.org/articles/pmc7586827?pdf=render	English	null	Digital morphology analyzers in hematology: Comments on the ICSH review and recommendations	International journal of laboratory hematology	2,020	cc-by	1,982	Dear Editors, Dear Editors, We read the article “Digital morphology analyzers in hematology: ICSH review and recommendations” by Kratz et al1 published in this journal with great interest. While publication of a review article and recommendations for such a new and exciting technology was timely, there seems to have been some misunderstandings in the ar- ticle which we would like to address. While the authors stated that in their article “strengths and weaknesses of digital imaging were de- termined,” our review revealed examples where the authors seemed to have misunderstood the findings of previous research. As a re- sult, there is a potential that the reader might get a negative view of digital morphology in general and be discouraged from its use, which we believe was not the intention of this review. In order to highlight some of our concerns, we have selected a small number of examples to support our findings. An example is the use of the word “detection” in the review article. The authors state “Briggs et al similarly reported poor de- tection of immature granulocytes, eosinophils, and basophils.”1 We found the use of the word “detection” misleading and wish to point out that Briggs et al2 did not use this word anywhere in their ar- ticle. Furthermore, no statement is made on the detectability of these cell types, instead correlation between the manual and the automated differential, and preclassification accuracy is discussed. Briggs et al2 explained that lower correlation between the manual and the CellaVision® DM96 (DM96) differential results for eo- sinophils was potentially due to “a staining issue which could be modified.” Regarding basophils and immature myeloid cells, they concluded that the lower correlation was due to the low number of counted cells (implying that the reason for the low correlation was partly in the manual method) as this part of the study was performed only counting 100 cells.2 In summary, Briggs et al con- cluded that “We have demonstrated that the differential from the DM96 is as good as that by a laboratory scientist; however, the laboratory scientist operating the DM96 must be skilled in blood cell morphology.”2 To conclude, the use of the word “detection” by Kratz et al1 in a context not consistent with the referenced articles may create incorrect perceptions about the capability of digital morphology analyzers. We also found statements in the review article that were not supported by scientific references. L E T T E R T O T H E E D I T O R L E T T E R T O T H E E D I T O R Int J Lab Hematol. 2020;42:e213–e215. ember 2019 \| Accepted: 17 February 2020 ember 2019 \| Accepted: 17 February 2020 Received: 17 December 2019 \| Accepted: 17 February 2020 DOI: 10.1111/ijlh.13181 Accepted: 17 February 2020 Received: 17 December 2019 DOI: 10.1111/ijlh.13181 L E T T E R T O T H E E D I T O R Digital morphology analyzers in hematology: Comments on the ICSH review and recommendations refer to weaker correlation between manual microscopy and using the DM96 analyzer but judged this as satisfactory—not poor; they did not make any conclusions regarding the detection of these cell types. Park et al3 referred to the term “detection” when they did a concordance analysis for the following six abnormalities: “[ie, the presence of atypical lymphocytes, blasts, promyelocytes > 3%, my- elocytes > 3%, and metamyelocytes > 3%, nucleated red blood cells (RBCs)].” The result according to Park et al was satisfactory, espe- cially for blasts.3 The only time Park et al3 discuss “low detection” was in another context in relation to positive predictive value of promyelocytes. They also point out one case where two manual dif- ferential counts were completely discordant, while the suggestion of the DM96 was in agreement with one of the manual differential counts, which “was determined to be correct after review by the lab- oratory hematologist.”3 Dear Editors, An example is “The review speed may be expected to be slower in busy laboratories with large num- bers of samples that have low WBC counts as well as abnormal cells,”1 in which case we did not manage to locate the source(s) of this statement in the scientific literature. In fact, the above article by Briggs et al2 clearly contradicts this statement showing that the av- erage time for the analysis of 30 blood films—including samples with low WBC count and highly abnormal cells—was 1 hour 20 minutes using the DM96, while it was 2 hour 54 minutes by manual analysis. Time saving using the DM96 analyzer is also confirmed by other au- thors.4,5 Similarly, the authors state without reference “Therefore, depending on the patient population, 10 to 20% of all slides may still require manual microscopic review.” It is unclear what these num- bers are based on. Some of the limitations mentioned in Table 2 of the review ar- ticle (“Situations in which CellaVision has limitations and for which a manual microscopic review should be considered”)1 also seem to be in contradiction with references cited throughout the paper. For example, one of the limitations, “Suspicion of the presence of pathological cell types, including blasts, plasma cells, and immature Another example where the use of the word “detection” by Kratz et al1 is misleading is the following statement: “In contrast, Park et al found that detection of basophils and band neutrophils was poor, but blast detection showed high sensitivity and specific- ity.” Regarding band neutrophils and basophils, Park et al3 actually wileyonlinelibrary.com/journal/ijlh Int J Lab Hematol. 2020;42:e213–e215. LETTER TO THE EDITOR e214 Criel et al,11 the authors of the review article comment “However, evaluation of the images by an experienced observer remained nec- essary,” suggesting that this was a negative property of the system. granulocytes,”1 is not consistent with conclusions made by Briggs et al2 and Park et al,3 as discussed above. Similarly, another limita- tion in Table 2 of the review article, “All samples from newborns and from patients with leukemia,”1 seems to conflict with the findings of Herishanu et al.6 Furthermore, Marionneaux et al7 found that the DM96 can be used as “a feasible, rapid and inexpensive screening tool” to subclassify patients with CLL into typical or atypical CLL subgroups. REFERENCES 1. Kratz A, Lee SH, Zini G, Riedl JA, Hur M, Machin S. On behalf of the international council for standardization in haematology. digital morphology analyzers in hematology: ICSH review and recommen- dations. Int J Lab Hematol. 2019;41(4):437-447. 2. Briggs C, Longair I, Slavik M, et al. Can automated blood film analy- sis replace the manual differential? An evaluation of the CellaVision DM96 automated image analysis system. Int J Lab Hematol. 2009;31(1):48-60. We also found that the authors of this review article might not have fully understood how digital morphology analyzers function today. At several places in the article, the authors seem to fault the analyzer for requiring a competent user for its operation and expect it to function as a fully automated self-reporting device. As an exam- ple, the review criticizes the fact that the study written by Lee et al10 evaluated reclassified rather than preclassified results and concluded that “Therefore, the study may be unable to test the possibility of full automation of PBS [peripheral blood smear] analysis.”1 While Lee et al10 mentioned this as a limitation of their study, their stated aim was “to assess the ability of the CellaVision DM96 (DM96) system and software to classify leukocytes by comparing it with the manual PBS examination.” Just like manual microscopy, the DM96 system per de- sign includes a competent user; therefore it is not correct to expect a fully automated digital morphology system as they are not currently designed to operate in that manner. Similarly, regarding the study by 3. Park SH, Park CJ, Choi MJ, et al. Automated digital cell morphology identification system (CellaVision DM96) is very useful for leuko- cyte differentials in specimens with qualitative or quantitative ab- normalities. Int J Lab Hematol. 2013;35(5):517-527. 4. Ceelie H, Dinkelaar RB, van Gelder W. Examination of peripheral blood films using automated microscopy; evaluation of diffmaster octavia and CellaVision DM96. J Clin Pathol. 2007;60(1):72-79. 5. Kratz A, Bengtsson HI, Casey JE, et al. Performance evaluation of the CellaVision DM96 system: WBC differentials by automated dig- ital image analysis supported by an artificial neural network. Am J Clin Pathol. 2005;124(5):770-781. 6. Herishanu Y, Kay S, Joffe E, et al. Integration of automated mor- phological features resolves a distinct group of atypical chronic lymphocytic leukemias with chromosomal aberrations. Leuk Res. 2014;38(4):484-489. 7. Marionneaux S, Maslak P, Keohane EM. Morphologic identification of atypical chronic lymphocytic leukemia by digital microscopy. Correspondence The review also sets out to propose recommendations for im- provement of digital imaging; however, the standards they recom- mend for manufacturers to follow are mainly relevant for whole slide imaging (WSI) or other medical imaging technologies and not specific to digital morphology analyzers. While it was mentioned that these standards “are applicable to digital analyzers only in general terms and not as specific recommendations,”1 it would have been bene- ficial to point out specific parts of these standards the authors find applicable for digital morphology systems used in hematology. There is a considerable difference between WSI and other medical imaging technologies and digital morphology analysis in hematology which was not explained by the authors. Hans-Inge Bengtsson, CellaVision AB, Mobilvägen 12, 22362, Lund, Sweden. Hans-Inge Bengtsson, CellaVision AB, Mobilvägen 12, 22362, Lund, Sweden. Email: Hans-Inge.Bengtsson@Cellavision.se Email: Hans-Inge.Bengtsson@Cellavision.se Dear Editors, Finally, the comment in the review article in relation to the two tables talks about “advantages of the CellaVision systems” and “Situations in which the CellaVision has limitations.”1 While we feel honored to be regarded as a synonym for digital morphology, it would be more appropriate to use “digital morphology” in the title of both Tables.1 There are a number of other comments we could have made regarding the review article; however, we omitted them from this letter. For those who are interested, we would be happy to share our complete list of comments. KEY WORDS Regarding the review article's recommendations, we found it remarkable that while the authors mention that digital morphology analyzers display only a limited number of cells, they only recom- mend “to always reconcile the flags of the automated analyzer with the report of the digital imaging. In the presence of any discrepancy, a manual differential with the microscope should be performed”,1 instead of the obvious first choice of examining an increased num- ber of cells as it is recommended by the CLSI document H20-A2 standard.9 This would limit the number of slides requiring manual microscopy to those referred to in the authors' example, where pathological cells are located exclusively in the margins of the slide. digital imaging, laboratory hematology, laboratory standards, recommendations The author is an employee of CellaVision AB. Hans-Inge Bengtsson Hans-Inge Bengtsson Director Scientific Affairs, CellaVision AB, Lund, Sweden CONFLICT OF INTEREST The author is an employee of CellaVision AB. The author is an employee of CellaVision AB. 8. Eilertsen H, Henriksson CE, Hagve TA. The use of CellaVision DM96 in the verification of the presence of blasts in samples flagged by the Sysmex XE-5000. Int J Lab Hematol. 2017;39(4):423-428. 9. Clinical and Laboratory Standards Institute, Reference Leukocyte (WBC) Differential Count (Proportional) and Evaluation of Instrumental Methods; Approved Standard – Second Edition. CLSI Document H20–A2. [ISBN 1-56238-628-X]. REFERENCES Int J Lab Hematol. 2014;36(4):459-464. 10. Lee LH, Mansoor A, Wood B, Nelson H, Higa D, Naugler C. Performance of CellaVision DM96 in leukocyte classification. J Pathol Inform. 2013;4:14. LETTER TO THE EDITOR e215 10. Lee LH, Mansoor A, Wood B, Nelson H, Higa D, Naugler C. Performance of CellaVision DM96 in leukocyte classification. J Pathol Inform. 2013;4:14. 11. Criel M, Godefroid M, Deckers B, Devos H, Cauwelier B, Emmerechts J. Evaluation of the red blood cell advanced software application on the CellaVision DM96. Int J Lab Hematol. 2016;38(4):366-374.
https://openalex.org/W4281741894	https://www.researchsquare.com/article/rs-1712309/latest.pdf	English	null	ANN-aided Mechanophenotyping of Biological Cells Using AFM	Research Square (Research Square)	2,022	cc-by	9,109	ANN-aided Mechanophenotyping of Biological Cells Using AFM Yuvaraj Kamble Indian Institute of Technology Patna Abhishek Raj Indian Institute of Technology Patna Atul Thakur (  athakur@iitp.ac.in ) Indian Institute of Technology Patna 1 Introduction Mechanical properties of biological cells are considered important biomarkers for indicating various diseases (Di Carlo 2012; Suresh 2007; Xu et al. 2012), for instance, cancer cells are more elastic (Nematbakhsh et al. 2017) and in sickle cell disease (SCD) human erythrocytes are significantly stiffer (Maciaszek and Lykotrafitis 2011) than their normal counterparts cells. In general, in mechanophenotyping, a known force is applied on the target cell and the deformation caused thereby is used to determine the cell's mechanical properties (Raj and Sen 2018). The application of force is done via various conventional techniques like micropipette aspiration (MA) (González- Bermúdez et al. 2019; Lee and Liu 2015), optical tweezers (Arbore et al. 2019), magnetic tweezers (Tanase et al. 2007), atomic force microscopy (AFM) (Weber et al. 2021; Krieg et al. 2019) and other microfluidics-based techniques (Liu et al. 2020; Raj and Sen 2018; Raj et al. 2017; Luo et al. 2015). In AFM the target cell material properties are determined by first obtaining experimental force- indentation data followed by the application of the Hertz model (Sajeesh et al. 2016; Wang and Zhang 2019; Ding et al. 2017; Liang et al. 2016). This model works on assumptions such as linear elastic behaviour, small deformations, homogeneity of cell material, and infinite plate shape of indented material, which behaves like a flat surface during indentation (Dintwa et al. 2008). However, it has been reported that during the cell indentation process, the cell often behaves as hyperelastic (El Kennassi et al. 2020). Also, studies have shown that cell morphology plays a significant role in estimating cell mechanical properties (Chen 2014; Boccaccio et al. 2020). In the Hertz model, the cell geometry is approximated as a sphere (Dintwa et al. 2008; Guz et al. 2014). Though the Hertz model-based approach yields acceptable results for regular cell shapes such as spherical or elliptical, it has not been investigated thoroughly for cells of uneven shapes. Moreover, literature reports the uneven shapes of cells (Beicker et al. 2018; Li et al. 2017; Chen 2014). Hence there is a need to develop a new technique for determining the mechanical properties of biological cells with uneven shapes. Some attempts have been put to capture the effect of cell shape by incorporating correction factors in the Hertz model (Sun et al. 2021; Cao and Chandra 2010). However, the correction factors are derived considering rectangular (Sun et al. Keywords: Mechanophenotyping, AFM, ANN, FEM, nanoindentation Keywords: Mechanophenotyping, AFM, ANN, FEM, nanoindentation ANN-aided Mechanophenotyping of Biological Cells Using AFM Yuvaraj Kamble1 · A. Raj1 · A. Thakur1* 1 Department of Mechanical Engineering, Indian Institute of Technology Patna, Bihta, Bihar, 801106, India * Corresponding author, E-mail address: athakur@iitp.ac.in (A. Thakur) Research Article Keywords: Mechanophenotyping, AFM, ANN, FEM, nanoindentation Posted Date: June 9th, 2022 DOI: https://doi.org/10.21203/rs.3.rs-1712309/v1 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License 1 Abstract Mechanical properties of biological cells can serve as biomarkers for indicating various diseases like cancer and sickle cell disease. Hertzian model-based prediction of mechanical properties of biological cells, although most widely used, has shown to have limited potential in determining constitutive parameters of cells of uneven shape and non-linear force-indentation responses of AFM-based cell nanoindentation. We report a new artificial neural network-aided approach, which takes into account, the variation in cell shapes and their effect on the predictions in cell mechanophenotyping. We have developed an artificial neural network (ANN) model which could predict the mechanical properties of biological cells by utilizing the force vs. indentation curve of AFM and we obtained a recall of 0.98 ± 0.03 and 1 ± 0.0 for hyperelastic and elastic cells respectively for the prediction error of less than 10%. We envisage that the developed technique can be used for the validation of quantitative biomechanical markers for diagnoses of diseases like cancer and sickle cell disease which could help to improve clinical decision- making. 1 Introduction 2021; Cao and Chandra 2010) or spherical (Ding et al. 2017) cell shapes which is a limitation while dealing with other cell shapes thus there is a need for a general approach that can work on a wide variety of cell shapes. This paper presents a neural network-based approach that uses cell shapes and force-deformation curve data to predict cell material parameters. In this work, we have proposed an ANN-aided approach in which FEM simulations of AFM-based nanoindentation (El Kennassi et al. 2020; Qian and Zhao 2018) are used for computing force-indentation data for a variety of cell geometries and mechanical constitutive properties. In particular, we consider two types of constitutive parameters: (a) Hyperelastic parameter (Lamé parameter μ) of a cell, considering cell response as 2 2 hyperelastic (El Kennassi et al. 2020), and (b) Young’s modulus (E) of a cell, considering cell response as Hookean (Sun et al. 2021). Over 1300 FEM simulations for above each case of mechanical constitutive parameters were performed. Further, we trained the neural networks using computed force-indentation data and cell geometrical parameters for the prediction of the constitutive parameters in both the mechanical constitutive relations. The trained neural networks are capable of and can be used for predicting constitutive properties for a given force-indentation data and target cell geometry obtained from the experiment. We report that selection of appropriate cell geometrical parameters in neural network input vectors can improve the performance of a neural network in the prediction of constitutive parameters. We also show that the use of a neural network for cell mechanophenotyping can diminish the reliance of AFM on theoretical models to estimate cells' constitutive properties. The problem of cell mechanical parameter estimation in our case involves three important aspects: the effect of cell shape in cell mechanophenotyping, the Cell’s constitutive properties in FEM simulations, and the use of the neural network in cell biomechanics. The literature on the above aspects concerning cell mechanophenotyping is summarised below: Mostly, a variety of regular cell shapes have been used in finite element analysis for the purpose of modeling cell mechanophenotyping. Boccaccio et al. (2020) modeled rounded and elongated cells using finite element simulations to quantify cell mechanical properties. Wang et al. (2020) used a spherical cell model for epithelial cell analysis using AFM nanoindentation. Sun et al. (2021) have used a cylindrical shape cell model for AFM-based finite element modeling. McGarry et al. 1 Introduction (2004) have modeled rounded adherent cells in various spread configurations to study three-dimensional eukaryotic cells. Most of the researchers have approximated the cell shapes to standard geometry shapes like spherical or rounded. However, El Kennassi et al. (2020), Cao and Chandra (2010), Tang et al. (2019), Saeed and Weihs (2020), and Ferrazzi (2011) have reported the use of irregular cell shapes to study the cellular deformations. Attempts have been made to account for the effect of cell shape on the prediction of cell mechanical properties by the introduction of correction factors in the Hertz model (Darling et al. 2007; Sun et al. 2021; Cao and Chandra 2010). Darling et al. (2007) reported a correction factor that includes the cell height in the Hertz model to quantify cell mechanical properties. Sun et al. (2021) proposed a modified Hertz formula to reduce the effects of cell radius and cell thickness in cell mechanophenotyping. This model is similar to the one reported by Dimitriadis et al. (2002), which also presents the cell thickness in the Hertz model. Cao and Chandra (2010) introduced the correction factor, which relates the cell geometrical parameters to mechanical properties. The correction factors introduced in the Hertz models are based on the curve fitting process derived using finite element simulations and are applicable in cell mechanophenotyping of specific cell profiles reported in respective literature (Sun et al. 2021). So from the above discussion, we conclude that,  Most of the literature uses regular cell shapes such as spherical or elliptical shapes for finite ele modeling of cells which distinctly vary from actual cell shapes. Finite element simulation is a useful way to simulate a wide range of cell profiles that could mimic an cover a wide range of actual cell behaviors.  Consideration of cell morphology parameters such as cell height (in case of spread cell) and cell diameter (in case of a spherical cell) can give us a better estimation of cell mechanical properties. A vast body of literature exists in the areas of computational modeling-based approach to study the cell deformations and quantify cell constitutive parameters (Sun et al. 2021; Wang et al. 2020; Tang et al. 2019; Wang et al. 2019). In FEM simulations of cell indentations, the exact model of cells' constitutive parameters used in FEM is not fully acknowledged. Depending on the experimental observations, researchers have reported cell responses as elastic (Sun et al. 1 Introduction 2021), viscoelastic (Li et al. 2017), hyperelastic (Müller et al. 2021), and viscohyperelastic (Wang et al. 2020; Florea et al. 2017). Literature suggests that cell usually behaves as elastic; the common cells like human osteosarcoma cells, cell line MG63 (Procell) (Sun et al. 2021), leukemia myeloid cells (HL60), human umbilical vein endothelial cells (HUVECs), 3T3 fibroblast, U2OS cells (Barreto et al. 2013), HeLa cells (Wang et al. 2019), RBCs, Raji, Hut, and K562 cells (Li et al. 2012) have been observed to be exhibiting elastic behavior. However, cells like Living MDA- MB-231 (Tang et al. 2019), REF52 (rat embryonic fibroblast) cells (Müller et al. 2021), and mouse oocyte and embryo cells (Abbasi et al. 2018) exhibit hyperelastic behaviors. Also, soft biological materials derived from artery and cardiac muscle (Comsol 2008), spleen, liver and kidney, breast and lung (Wex et al. 2015), and brain and fat tissues (Mihai et al. 2015) behave as hyperelastic materials. ( ) yp Wang et al. (2019) and Sun et al. (2021) have reported finite element modeling of cells with an elastic response for cell mechanophenotyping. McGarry et al. (2004) presented a 3D finite element model of an adherent 3 3 cell using elastic material properties to study the cell's structural behaviors. Also, Structural finite element analysis of cells with elastic material properties is addressed by Barreto et al. (2014) and Barreto et al. (2013). For large deformation regimes, there are multiple instances where the hyperelastic cells’ finite element modeling has been reported in the literature, for example, to predict AFM experimental data and quantify the mechanical properties of living MDA-MB-231 cells, finite element modeling with hyperelastic cell assumptions is used by Tang et al. (2019). Also, Zhou et al. (2021) and Müller et al. (2021) advocate coupling AFM with finite element simulations to acquire more quantifiable information on heterogeneous cells and to quantify REF52 cells deformation, respectively. Later also states the importance of hyperelastic material assumption for cells to improve the intimacy of numerical models towards the actual behavior of the cells. The Nano-mechanical hyperelastic behavior of eukaryotic cells is modeled by El Kennassi et al. (2020), using nanoindentation simulations of cells. In summary, as the exact model of cell material properties is not fully understood, we can assume cell behavior as both hyperelastic and elastic in finite element simulations of AFM-based nanoindentation on cells. 2.1 Terminology i. Cell geometry: In a cell mechanophenotyping experiment; Let the cell shape be defined as 𝐶, which is represented by a closed 2D curve, adhered to substrate 𝑆 (see Fig. 1a). Let 𝐿 be the contact length of the cell over the substrate and ℎ be the maximum height of the cell over the substrate (see Fig. 1b). Let 𝐶𝑝 be cell profile perimeter and 𝐶𝑐𝑠 be cell cross-sectional area (see Fig. 1c). 𝐶𝑔𝑚 is the cell geometry markers formed by normalizing an array of ℎ𝑖 s, i.e. cell heights from the cell base, measured at 𝑛 different positions along the cell contact length at a fixed interval of 𝐿′ where 𝑖= 1, 2,3, … , 𝑛 (see Fig. 1b). ii. Indenter geometry: The hemispherical indenter 𝐼, with a diameter 𝑑, is placed at a distance 𝑝 over the adhered cell to perform indentation (see Fig. 1d). iii. Boundary conditions: We define boundary conditions as 𝐵𝑐 in which the substrate 𝑆, is fixed at the bottom and the indenter 𝐼, is free to move only in the vertical direction (see Fig. 1d). iv. Constitutive parameters: We define cell’ constitutive parameters as a case (a) Hyperelastic parameter μ, for hyperelastic relation and case (b) Young’s modulus 𝐸, for elastic relation. Assumptions:  The cell is composed of homogeneous material.  The cell is composed of homogeneous material.  The cell has adhered well to the substrate.  The influence of the substrate on cell mechanical properties is neglected 1 Introduction The use of Artificial Intelligence in the mechanophenotyping of cells has been recently reported by Graybill et al. (Graybill et al. 2021). In recent studies Graybill et al. (2021), Park and Desai (2017), and Minelli et al. (2017) have used artificial neural networks for characterizing cell mechanical properties and cell classifications. Graybill et al. (2021) determined the stiffness of grades II and III astrocytoma using a combination of ANN with a constriction channel device. Park and Desai (2017) propose a feasible diagnostic procedure to localize cancerous regions using machine learning by taking experimental local tissue elasticity into account. Minelli et al. (2017) have used a neural network to automatically analyze AFM force-distance curves and further used it for cancer tissue diagnosis. Furthermore, the neural network-based approach is widely used in cell classification and cell sorting (Nyberg et al. 2018; Lin et al. 2017; Darling and Guilak 2008). Thus studies demonstrating the use of artificial neural networks directly toward cell mechanophenotyping are limited in the literature. To capture the effect of uneven shapes in determining cell mechanical properties ANN-based approach could act as an important tool. To sum up:  The ANN-based approach is prominently used in disease diagnostic, cell sorting, and analyzing of the AFM-generated force-indentation curves.  The ANN-based approach is prominently used in disease diagnostic, cell sorting, and analyzing of the AFM-generated force-indentation curves.  The use of ANN towards relating the variation in cell shapes with cell mechanical properties can be explored. 3 Overview of Approach We follow the below-mentioned stepwise approach to solve the problem described in Section 2.2 (see Fig. 2 i. FEM Simulations of AFM-based Nanoindentation iii. Neural Network Training for Prediction of Constitutive Parameters iv. Prediction of Constitutive Parameters Using Trained Neural Network 2.2 Problem Statement predict the cell constitutive parameters using a trained neural network from (ii) by providing cell geometry parameters and force-indentation curves measured and obtained from mechanophenotyping experiments respectively. i. perform finite element modeling of AFM-based nanoindentation on a cell to obtain the force-indentation curves for both the cases of cell constitutive parameters, i.e. hyperelastic as well as elastic models. ii. train the neural network using a dataset comprising cell geometry parameters 𝐶𝑝, 𝐶𝑐𝑠, and 𝐶𝑔𝑚 with force- indentation curve data obtained from (i) for both the constitutive parameters cases separately to predict respective constitutive parameters used while neural network training. iii. predict the cell constitutive parameters using a trained neural network from (ii) by providing cell geometry parameters and force-indentation curves measured and obtained from mechanophenotyping experiments respectively. 2.2 Problem Statement A cell 𝐶, with measured geometrical parameters 𝐿, 𝐶𝑝, 𝐶𝑐𝑠, and 𝐶𝑔𝑚 is indented using indenter 𝐼 with provided boundary conditions as 𝐵𝑐 and cell constitutive parameters for case (a) and case (b) respectively, (see Fig. 1d). The aim is to: 4 4 Fig. 1 a Schematic image of adhered cell C, on substrate S. b Schematic representation of Cell contact length L along the substrate and height h over the substrate. The geometry markers Cgm, formed by normalizing array of hi s, i.e. cell heights from the cell base, measured at n different positions along the cell contact length at a fixed interval of L′ where i = 1, 2,3, … , n. c Schematic representation of the cell profile perimeter Cp, and cross- sectional area Ccs. d Schematic of finite element modeling of AFM-based nanoindentation of cell C, where hemispherical indenter I, of diameter d, is placed above cell at height 𝑝, from the cell surface. The substrate S is fixed at the bottom and the indenter is free to move in the vertical direction for the indentation Fig. 1 a Schematic image of adhered cell C, on substrate S. b Schematic representation of Cell contact length L along the substrate and height h over the substrate. The geometry markers Cgm, formed by normalizing array of hi s, i.e. cell heights from the cell base, measured at n different positions along the cell contact length at a fixed interval of L′ where i = 1, 2,3, … , n. c Schematic representation of the cell profile perimeter Cp, and cross- sectional area Ccs. d Schematic of finite element modeling of AFM-based nanoindentation of cell C, where hemispherical indenter I, of diameter d, is placed above cell at height 𝑝, from the cell surface. The substrate S is fixed at the bottom and the indenter is free to move in the vertical direction for the indentation i. perform finite element modeling of AFM-based nanoindentation on a cell to obtain the force-indentation curves for both the cases of cell constitutive parameters, i.e. hyperelastic as well as elastic models. ii. train the neural network using a dataset comprising cell geometry parameters 𝐶𝑝, 𝐶𝑐𝑠, and 𝐶𝑔𝑚 with force- indentation curve data obtained from (i) for both the constitutive parameters cases separately to predict respective constitutive parameters used while neural network training. iii. 4.1 Cell Model for FEM Simulations Experimental observations show that when cells are seeded onto a substrate, initially, they gain spherical or round morphology. After cells adhere to the surface, they tend to spread on an underlying substrate (Rodriguez et al. 2013; Na et al. 2004). In 2D, the adherent homogeneous cell showcases morphology as represented in Fig. 1a. Analogous cell spreading morphology is being adapted by many research works for cell finite element modeling (El Kennassi et al. 2020; Tang et al. 2019; Ferrazzi 2011). We used a similar adherent cell profile for modeling cells in our FEM simulation work. We generated multiple 2D cell model profiles using an automated approach with MATLAB. We fixed the cell contact length 𝐿 as 1μm for all cell profiles as in El Kennassi et al. (2020). And maximum cell height ℎ varied between 0.2-0.275μm for different profiles. Every cell profile is unique and has different curve variations. We generated 65 different 2D cell profiles with height and overall profile variations. We performed AFM nanoindentation simulations on each of created profiles using the finite element package COMSOL Multiphysics 5.4 (El Kennassi et al. 2020). 4 FEM Simulations of AFM-based Nanoindentation This section presents the details of finite element simulations of AFM-based nanoindentation on the adhered cell to compute force-indentation curves. 5 Fig. 2 Flowchart of an overview of the approach Fi 2 Fl h t f i f th h Fig. 2 Flowchart of an overview of the approach 4.3 FEM Simulations In this step, we modeled AFM-based nanoindentation on homogenous cells in 2-Dimensional plane strain models instead of 3-Dimensional models. This helps us to reduce computational costs. Most prior studies have adopted a similar approach for modeling (El Kennassi et al. 2020; Graybill et al. 2021). The numerical or analytical relations are derived based on the determined computational results—these derived results aid in evaluating the mechanical properties of homogenous cells. Experimental data can be applied to derive relations for the mechanophenotyping of actual cells. The generated random cell profiles were imported to COMSOL and substrate and indenter were modeled in COMSOL using predefined features. We choose a solid mechanics interface in COMSOL for FEM simulations with a stationary study type. The validation of FEM simulation and mesh independence study is provided in the supplementary information. 4.3.1 Boundary Conditions and Meshing In AFM-based nanoindentation simulations, the main boundary condition is the contact pair between the indenter and cell profile. The substrate is modelled at the bottom portion of the cell while the indenter diameter of 0.2μm is placed over the cell profile. The contact between the cell and substrate is chosen as prescribed displacement. The indenter displacement is permitted in a vertical direction, i.e., y-direction. The physics-controlled meshing was used for the said system. The parametric sweep study with a step size of 10𝑛𝑚 was launched for indentation. The indenter is set to displace for 100𝑛𝑚 from its initial position during the operation. We perform AFM-based nanoindentation simulations on all 65 homogeneous cell profiles. The force- indentation curves for each of the simulations are stored. The recorded force-indentation points and cell morphological parameters were used for neural network training. 4.3.2 Cell’s Hyperelastic Constitutive Properties For the first case of simulations, we used the Neo-Hookean hyperelastic material model for cells and the nonlinear elastic material model for indenter and substrates, as reported in El Kennassi et al. (2020). The hyperelastic cell parameters used are Lamé parameter λ and Lamé parameter μ. The Lamé parameter value μ is taken from the above-reported literature as 7.2 × 106 𝑁𝑚2 ⁄ . Also, it is reported that Lamé parameter λ is 20 times that of Lamé parameter μ (Comsol 2008). So we only consider Lamé parameter μ for the prediction of cell mechanical properties using a neural network. 4.2 Measured Cell Geometrical Parameters This study measures cell contact length 𝐿 over the substrate, cell profile perimeter 𝐶𝑝, cell cross-sectional area 𝐶𝑐𝑠, and cell geometrical markers 𝐶𝑔𝑚 which are being used to train the neural network for the prediction of constitutive parameters. 6 We note the cell contact length 𝐿 from the cell profile generation step in MATLAB. We have kept it fixed as 1μm for every generated cell profile as used in El Kennassi et al. (2020). Also in the same step, the array of cell profile heights is stored for every randomly generated cell profile. The array consists of cell heights ℎ𝑖 s, from the cell base, noted at 𝑛 different positions along the cell contact length at a fixed interval of 𝐿′ where 𝑖= 1, 2,3, … , 𝑛. To normalize the cell heights, every element of the array is then divided by contact length 𝐿. This newly formed array of normalized heights is then used as cell geometrical markers 𝐶𝑔𝑚 (see Fig. 3a). The cell profile perimeter 𝐶𝑝, and cell cross-sectional area 𝐶𝑐𝑠 are measured using an existing tool in COMSOL during the finite element modeling step (see Fig. 3b). In experimental data acquisition of cell profiles, image data can be used to note the cell geometry parameters. Here, the cell morphology can be captured using one of the promising reported techniques of combined sideway imaging and vertical light sheet illumination system, which can be integrated with AFM (Beicker et al. 2018) or with side-view light-sheet fluorescence microscope imaging (Hobson et al. 2021; Wang et al. 2020). Subsequently, we can use ImageJ software to acquire cell parameters 𝐿, 𝐶𝑝, and 𝐶𝑐𝑠 along with cell profile elevations (Graybill et al. 2021). 4.3.3 Cell’s Elastic Constitutive Properties We adopted Hookean behaviour for cell material properties for the second case of simulations. We choose a linear elastic material model for cells. The Poisson’s ratio for the cell was chosen as 0.49 (Barreto et al. 2014). As there 7 Fig. 3 a The geometry markers 𝐶𝑔𝑚, formed by normalizing array of ℎ𝑖′s, i.e. cell heights from the cell base, measured at 𝑛 different positions along the cell contact length at a fixed interval of 𝐿′ where 𝑖= 1, 2, 3, … , 𝑛. b Cell profile perimeter 𝐶𝑝, and cross-sectional area 𝐶𝑐𝑠 measured using an inbuilt tool in COMSOL during the finite element modelling step. c Array of force-indentation curve data points generated from AFM-based nanoindentation simulation on cell Fig. 3 a The geometry markers 𝐶𝑔𝑚, formed by normalizing array of ℎ𝑖′s, i.e. cell heights from the cell base, measured at 𝑛 different positions along the cell contact length at a fixed interval of 𝐿′ where 𝑖= 1, 2, 3, … , 𝑛. b Cell profile perimeter 𝐶𝑝, and cross-sectional area 𝐶𝑐𝑠 measured using an inbuilt tool in COMSOL during the finite element modelling step. c Array of force-indentation curve data points generated from AFM-based nanoindentation simulation on cell is substantial variation in reported elastic modulus for cells, we decided to take elastic parameters well within the reported range in Ding et al. (2017), i.e., 250𝑃𝑎 – 5000 𝑃𝑎. 4.4 Force-indentation Data The AFM simulations were performed on all 65 randomly generated cell geometries in COMSOL. A separate set of simulations were performed for both the cases of constitutive parameters. As a result of simulation, von Mises stress in cell deformation and force-indentation curve, data were computed. The curve points are the results of applied indentation and corresponding reaction force values generated on the indenter. The force-indentation data points table of all the simulations is noted and used for neural network training. 5 Coding of Input Vectors for Neural Network: As we aimed to develop a general approach for cell mechanophenotyping which can work on a wide variety of cell shapes, we choose to adopt the neural network-based approach for data processing. To capture the effect of cell geometry in neural networks, the available cell geometry parameters 𝐶𝑝, 𝐶𝑐𝑠, and 𝐶𝑔𝑚were clubbed with force-indentation data to form a set of input vectors. The input vectors are coded into two major parts which are force-indentation data and cell shape parameters. Force-indentation curve coding: Force-indentation curves are computed from finite element simulations of AFM-based nanoindentation. As the total indentation of 100𝑛𝑚 is provided in a step size of 10nm, the force- 8 8 Table 1 Network performance for selection of input vectors for the neural network from available cell morphological parameters based on adjusted Ra 2 values Input Vector Parameters k (Independent Variables) R (Testing) R2 𝐑𝐚 𝟐 (Adjusted R2) Input Vector 1 Force-Indentation Data 1 0.99145 0.9829 0.9828 Input Vector 2 Force-Indentation Data Geometry Markers 𝐶𝑔𝑚 2 0.99541 0.9908 0.9907 Input Vector 3 Force-Indentation Data Geometry Markers 𝐶𝑔𝑚 Cell Profile Perimeter 𝐶𝑝 3 0.99327 0.9865 0.9862 Input Vector 4 Force-Indentation Data Geometry Markers 𝐶𝑔𝑚 Cell Profile Perimeter 𝐶𝑝 Cell Cross-sectional Area 𝐶𝑐𝑠 4 0.99332 0.9866 0.9863 indentation curve includes 11 data points. The force values corresponding to every step of indentation are stored in an array (see Fig. 3c). Cell shape coding: The cell geometry parameters measured during cell profile generation and finite element modelling steps were used as one of the input vectors in the neural network. Among the available cell geometry parameters 𝐶𝑝 and 𝐶𝑐𝑠 includes only single elements respectively (see Fig. 3b). For cell geometry marker 𝐶𝑔𝑚, initially, we took 09 elements to form an input vector (see Fig. 3a). So with the available force-indentation curve and cell shape components, we formed 4 different sets of input vectors:  Input Vector 1 (IP1): Force-indentation curve data points (11 Elements)  Input Vector 2 (IP2): Force-indentation curve data points (11 Elements) + Cell geometry markers 𝐶𝑔𝑚, (09 Elements)  Input Vector 3 (IP3): Force-indentation curve data points (11 Elements) + Cell geometry markers 𝐶𝑔𝑚, (09 Elements) + Cell perimeter 𝐶𝑝, (01 Element)  Input Vector 4 (IP4): Force-indentation curve data points (11 Elements) + Cell geometry markers 𝐶𝑔𝑚, (09 Elements) + Cell perimeter 𝐶𝑝, (01 Element) + Cell cross-sectional area 𝐶𝑐𝑠, (01 Element) Fig. 5 Schematic representation of the neural network architecture. The network predicts cell constitutive parameter based on inputs: force-indentation curve data and cell geometry markers 𝐶𝑔𝑚 Fig. 5 Schematic representation of the neural network architecture. The network predicts cell constitutive parameter based on inputs: force-indentation curve data and cell geometry markers 𝐶𝑔𝑚 We used 202 testing simulations to determine the network performance. For input vectors IP1, IP2, IP3 and IP4, we found adjusted 𝑅𝑎 2 network performance values as 0.9828, 0.9907, 0.9862, and 0.9863 respectively (see Table 1). For IP2 we got the best prediction performance with 𝑅𝑎 2 of 0.9907 in the trained neural network. Henceforth we will use the same input vector combination for neural network training and testing. 6 Neural Network Training for Prediction of Constitutive Parameters In this section, we developed a MATLAB-based artificial neural network for cell mechanophenotyping. The feedforward net is used in the neural network. The selection of the training algorithm, the number of hidden layers, and the number of neurons in each layer is a quite challenging and intricate task. A trial-and-error approach is selected to finalize suitable training parameters to achieve an accurate neural network. 5.1 Selection of Input Vectors for Neural Network 6 Neural Network Training for Prediction of Constitutive Parameters In this section, we developed a MATLAB-based artificial neural network for cell mechanophenotyping. The 5.1 Selection of Input Vectors for Neural Network To decide the appropriate input training vector among the available set of input vectors, we ran trial neural network training. We train a set of neural networks using each of the above combinations as an input vector set. We checked the network performance of trained neural networks to decide the best combination of input vectors. The neural network performance was arbitrated based on the best adjusted 𝑅𝑎 2 value. The formula used for the calculation of adjusted 𝑅𝑎 2 is given as: 𝐑𝐚 𝟐= 1 − [ (𝑛−1)(1−𝑅2) (𝑛−𝑘−1) ] (1) (1) 9 Fig. 4 Regression plots during testing of trained neural network for a different combination of input vectors as a Force-indentation data points only b Force-indentation data points with cell geometry markers 𝐶𝑔𝑚 c Force- indentation data points with cell geometry markers 𝐶𝑔𝑚 and cell perimeter 𝐶𝑃 d Force-indentation data points with cell geometry markers 𝐶𝑔𝑚, cell perimeter 𝐶𝑃 and cell profile cross-sectional area 𝐶𝐶𝑆 Fig. 4 Regression plots during testing of trained neural network for a different combination of input vectors as a Force-indentation data points only b Force-indentation data points with cell geometry markers 𝐶𝑔𝑚 c Force- indentation data points with cell geometry markers 𝐶𝑔𝑚 and cell perimeter 𝐶𝑃 d Force-indentation data points with cell geometry markers 𝐶𝑔𝑚, cell perimeter 𝐶𝑃 and cell profile cross-sectional area 𝐶𝐶𝑆 Where n is the number of observations considered for testing and k is the number of independent variables in the input vector. The R2 is the regression value in neural network testing. The regression plots during testing of the trained neural network for each set of input vectors are given in Fig 4. 10 Fig. 5 Schematic representation of the neural network architecture. The network predicts cell constitutive b d i f i d i d d ll k 𝐶 Fig. 5 Schematic representation of the neural network architecture. The network predicts cell constitutive parameter based on inputs: force-indentation curve data and cell geometry markers 𝐶𝑔𝑚 We used 202 testing simulations to determine the network performance. For input vectors IP1, IP2, IP3 and IP4, we found adjusted 𝑅𝑎 2 network performance values as 0.9828, 0.9907, 0.9862, and 0.9863 respectively (see Table 1). For IP2 we got the best prediction performance with 𝑅𝑎 2 of 0.9907 in the trained neural network. Henceforth we will use the same input vector combination for neural network training and testing. 7.1 Performance of Trained Neural Network To calculate the success rate or performance of the network, we decided to calculate the recall value of the trained neural network by converting the regression problem to a classification problem. The recall is based on True Positives (TP) and False Negatives (FN). The recall is a measure of the quantity i.e., how many relevant items are predicted by the network. The high recall values represent that an algorithm returns most of the relevant results. The recall is calculated as: 𝑅𝑒𝑐𝑎𝑙𝑙= 𝑇𝑃 𝑇𝑃+𝐹𝑁 (2) 𝑅𝑒𝑐𝑎𝑙𝑙= 𝑇𝑃 𝑇𝑃+𝐹𝑁 (2) We decided to treat prediction values with less than 10% error as Positive Predictions and values with more than 10% error as negative ones. With this, we can decide between True Positives and False Negatives from predicted values. The percentage error in prediction is plotted against the testing simulation number to estimate the number of TP during neural network testing on random cell profiles. As stated earlier, we checked network performance based on the number of cell geometry markers by studying how they affect recall values. In neural network input vector IP2, we tried 7 combinations of geometry markers 𝐶𝑔𝑚 with force-indentation data as 7, 9, 11, 14, 20, 25, and 33 geometry markers. These geometry markers 𝐶𝑔𝑚, are clubbed together with 11 force-indentation data points to form an input vector to the neural network. Finally, we get input vectors of sizes 18, 20, 22, 25, 31, 36, and 44 respectively to predict one cell constitutive parameter. All the trained neural networks were tested by providing testing simulation data, and their performance was compared based on network recall values to obtain the final neural network. 7 Prediction of Constitutive Parameters Using Trained Neural Network: We simulated 65 cell profiles for the generation of neural network data set. Each profile was simulated for a set of multiple material parameter values. We tested trained network performance by simulating 25 new random cell profiles. A set of the randomly generated cell profiles are shown in Fig. 6. Each new testing profile was simulated for 10 random material parameter values within the training range. So we generated 250 such force-indentation curves which were divided into 3 sets for testing purposes. The neural network performances for new testing profiles were examined in terms of recall values. 6.1 Neural Network Training After finalising the input vector combinations for neural network training, we worked towards developing a final neural network for cell mechanophenotyping. We used the Bayesian Regularization backpropagation training algorithm to train the neural network. We tried different hidden layer neuron size combinations with the feedforward net to get the best R-value. We found 8 and 2 neurons as an optimum number of hidden layer neurons for the first and second hidden layer, respectively. In our study, this hidden layer and neuron combination give us an efficient network. The schematic representation of the neural network architecture is given in Fig. 5. We used 100 epochs for each case of neural network training. We used an IP2 input vector combination for the training of the neural network. In IP2 combination, we also tried to combine a different number of geometry markers 𝐶𝑔𝑚, with force-indentation data points, which decide the number of input layer neurons. Our neural network has only one output layer neuron that gives cell constitutive parameters as neural network prediction. The random division of data is done to create training-testing data sets. The network training was done using 70-30% training–testing data division. We trained our network for repeated cycles until we got the best fit between input and output variables in testing. 11 Fig. 6 a - j A set of randomly generated cell profiles with initial indenter position in FEM simulations of AFM- based nanoindentation which were used for testing of trained neural network Fig. 6 a - j A set of randomly generated cell profiles with initial indenter position in FEM simulations of AFM- based nanoindentation which were used for testing of trained neural network 12 7.2 Prediction of Hyperelastic Constitutive Parameter In simulations, we created a hyperelastic constitutive parameter set only for Lamé parameter μ as Lamé parameter λ is given as 20 times that of μ. (Comsol 2008). We consider the Lamé parameter μ = 7.2 × 106 𝑁𝑚2 ⁄ (El Kennassi et al. 2020) as a base value. We tried to cover a broad range of material parameter values for the neural network training data set. The cell constitutive parameter set has values of ± 50% of the base Lamé parameter μ. We took 21 intermediate values at a constant interval within the above range. Every cell profile is simulated for all material parameter ranges in a set. Based on the above combinations altogether, we generated 1365 force- indentation curves. We used this simulation data for neural network training. Also, the neural network training performance improvement was observed by varying geometry markers in the neural network input vector and by changing the acceptance range of percentage error in predicted values. The recall values were calculated considering less than 10% error in prediction as TP. For 7, 9, 11, 14 and 20 geometry markers, we observed that the average recall values for all testing sets were 0.92 ± 0.10, 0.92 ± 0.01, 0.87 ± 0.04, 0.95 ± 0.04 and 0.93 ± 0.05 respectively (see Fig. 7a). But for 25 and 33 geometry markers, we got consistently better neural network performance with recall values of 0.98 ± 0.03 and 0.97 ± 0.05 respectively. We witnessed the saturation in recall values after 25 geometry markers. The highest average recall was obtained for 25 geometry markers as 0.98 ± 0.03 for all testing sets. This was the best network performance we observed while predicting hyperelastic constitutive parameters with less than 10% error in prediction. During the process, if we compromised a little on prediction accuracy by considering less than 15% error in prediction as TP, we got better recall values than in the earlier case. For 14, 20, 25 and 33 geometry markers, we observed saturation in recall value of 1 ± 0.0 (see Fig. 7b)). The neural network performance at 25 geometry markers in both the TP considerations is consistent and better than any other input vector combinations. Hence, we can consider 25 geometry markers as the best value of marker, which can capture cell morphology best. So 25 geometry markers 13 Fig. 7.2 Prediction of Hyperelastic Constitutive Parameter 7 a & b Neural network performance for hyperelastic cell material parameter estimation for less than 10% & 15% error in prediction respectively. c & d Neural network performance for elastic cell material parameter estimation for less than 10% & 15% error in prediction respectively; Comparison in terms of the number of geometry markers used in input vectors along with force-indentation data points combined with force-indentation data (11 data points) are the most appropriate input vector set, which gives the best neural network performance to predict the hyperelastic constitutive parameter of cells. The neural network, once trained, could estimate cell hyperelastic constitutive parameter, i.e., Lamé parameter μ, for any cell of similar dimensions when 25 geometry markers of cell profile elevations and force- indention data values of AFM based nanoindentation were given as input into the neural network. 8 Discussion Numerous methods have been implemented in studies related to cell mechanophenotyping to investigate the cell's mechanical properties. Studies have reported a wide range of mechanical properties for single-cell types (Rodriguez et al. 2013). Even several studies have tried to reproduce the published experimental results. But no produced results have exactness as previously reported results. There are multiple factors associated with it, due to which reproduction of experimental results is challenging (Kontomaris et al. 2022). This study used an artificial neural network-based approach to predict cell mechanical properties independent of mentioned affecting factors. Using finite element simulations of AFM-based nanoindentation on homogenous cells, we trained a neural network to predict cell hyperelastic and elastic constitutive parameters based on cell profile geometry markers and force-indentation data points. Several studies have used artificial neural networks and machine learning to classify cells based on their physical properties (Graybill et al. 2021). These studies used experimental data to train their neural network models. In contrast, Graybill et al. used finite element simulation data to train the neural network (Graybill et al. 2021). In a contemporary move, our study also uses the finite element modelling simulation data to train our artificial neural network. Our reported approach predicts the homogenous cell constitutive parameters with less than 10% error with a recall of 0.98 ± 0.03 for hyperelastic cells and a recall value of 1 ± 0.0 for elastic cells. And if we compromised a little on the accuracy, it gives the recall of 1 ± 0.0 for less than 15% error in predicted values in both cases. We also showed the role of cell shapes in cell mechanical properties. We attempted to capture cell morphology in terms of cell profile elevations from the cell base. The normalise cell heights are used as cell geometry markers. Normalized cell heights are the significant advantage of the proposed approach to capture cell morphology. This allows us to predict the mechanical properties of any adhered cell with varying dimensions as long as the cell profile resembles training profiles. We showed that if we can capture cell morphology very well in a neural network, the recall value increase by predicting more TP. Though our model predicts homogenous cell constitutive parameters with a recall value of 1 ± 0.0 for a prediction error of less than 15%, a limitation needs to be overcome. 8 Discussion We indented adhered cells at their axisymmetric mid location, but changing the indentation region could also affect the cell's mechanical properties. The effect of the cell indentation region needs to be captured through neural network input vectors. We leave this to a future study. In future works, we could add up more variation in cell profiles to refine the current proposed approach with the inclusion of the cell indention region. Also, more experimental parameters could be used to train an artificial neural network for a more reliable prediction of cell mechanical properties from AFM-based nanoindentation data. 7.3 Prediction of Elastic Constitutive Parameter We simulated all the 65 cell profiles for a range of elastic moduli in elastic cell simulations. We selected 20 intermediate elastic values with constant intervals of 250Pa within a range of 250 – 5000 Pa (Ding et al. 2017) as a constitutive parameter variation in simulations. A total of 1300 simulations were performed to generate the force-indentation curves by simulating each profile for the above elastic modulus range. We followed a similar procedure to the above section for dividing the neural network data and performing input vector variations while training the neural network. As discussed earlier section, the network performance for the prediction of cell elastic modulus was also determined by checking the recall values of the network and like cell hyperelastic constitutive property predictions here also considered less than 10% error in prediction as TP. We found that for input vectors consisting of 7, 9 and 11 geometries markers, the recall values were 0.80 ± 0.12, 0.94 ± 0.07 and 0.98 ± 0.02 respectively (see Fig. 7c). And for the input vector with 14 geometry markers, we got a higher recall value i.e. 1 ± 0.0. This indicates that the network trained well enough to predict cell elastic modulus for provided cell profile with less than 10% 14 accuracy. And if we take less than 15% error in prediction as TP, we observed saturation in network performance after 9 geometry markers input with the constant recall of 1 ± 0.0 (see Fig. 7d). Hence, for cell elastic modulus prediction, we consider 14 geometry markers as the best marker value that can best capture cell morphology. So 14 geometry markers in combination with force-indentation data (11 data points) are the most appropriate input vector set, which gives the best neural network performance to predict the elastic material parameter of cells. The trained neural network with the above combination of input vectors could estimate cell elastic constitutive parameter, i.e. young’s modulus E for any cell of similar dimensions. Compliance with ethical standards Disclosure of potential conflicts of interest: The authors declare that there is not potential conflict of interest. Disclosure of potential conflicts of interest: The authors declare that there is not potential conflict of interest. Research involving Human Participants and/or Animals: No human or animal subjects participated in this research. Financial interests: The authors have no relevant financial or non-financial interests to disclose. 9 Conclusion: This study used a combined approach of finite element simulations of AFM-based nanoindentation with a neural network to predict adhered hyperelastic and elastic cells' constitutive properties. Using cell profile geometry markers and AFM simulation force-indentation data, we predicted Lamé parameter μ and Young’s modulus E for the cell. The constructed computational framework diminishes the reliance of AFM on theoretical models to estimate cells' mechanical properties. Finally, we evaluated the trained neural network performance in terms of recall and we obtained a recall of 0.98 ± 0.03 for hyperelastic cells and a recall of 1 ± 0.0 for elastic cells for a prediction error of less than 10%. Overall we found that capturing appropriate cell shape parameters along with AFM force indentation curves helps in improving the prediction performance of the neural network used for 15 cell mechanophenotyping. Our proposed approach can be integrated with experimental AFM data to predict actual cells' mechanical properties with reasonable accuracy. cell mechanophenotyping. Our proposed approach can be integrated with experimental AFM data to predict actual cells' mechanical properties with reasonable accuracy. References: Abbasi AA, Ahmadian MT, Alizadeh A, Tarighi S (2018) Application of hyperelastic models in mechanical properties prediction of mouse oocyte and embryo cells at large deformations. 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https://openalex.org/W3107384108	https://iris.unito.it/bitstream/2318/1766053/1/jcm-09-03915%20%281%29.pdf	English	null	Influence of Photon-Induced Photoacoustic Streaming (PIPS) on Root Canal Disinfection and Post-Operative Pain: A Randomized Clinical Trial	Journal of clinical medicine	2,020	cc-by	6,513	Received: 21 October 2020; Accepted: 30 November 2020; Published: 2 December 2020 Abstract: The aim of this study was to evaluate the ability of a PIPS (photon-induced photoacoustic streaming) Er:YAG laser to reduce the root canal system bacterial count in vivo in comparison to the traditional irrigation technique. The post-operative patients’ quality of life (QoL) after endodontic therapy was evaluated through a questionnaire. Fifty-four patients aﬀected by pulp necrosis with or without apical periodontitis bioﬁlm disease were selected for endodontic treatment and randomly assigned to Group A (n = 27) with traditional irrigation and Group B (n = 27), with PIPS irrigation applied according to the protocol. Shaping was performed with ProGlider and ProTaper Next, and irrigation was performed with 5% NaOCl and 10% EDTA. Intracanal samples for culture tests were collected before and after irrigation. The microbiological analysis was evaluated by the Kolmogorov–Smirnov normality and Mann–Whitney tests (p < 0.05). A self-assessment questionnaire was used to evaluate the QoL during the 7 days after treatment; diﬀerences were analysed with Student’s t-test. Irrigation with the PIPS device was signiﬁcantly eﬀective in reducing bacterial counts, which were higher for facultative than obligate anaerobic strains, particularly for Gram-negative bacteria, without statistical signiﬁcance (p > 0.05). There were no signiﬁcant diﬀerences among the QoL indicators, except for the maximum pain (p = 0.02), eating diﬃculty (p = 0.03) and diﬃculty performing daily functions (p = 0.02) in the ﬁrst few days post-treatment. PIPS may represent an aid to root canal disinfection not aﬀecting the patients’ QoL, particularly for the ﬁrst day after treatment. Keywords: root canal; disinfection; lasers; quality of care; irrigation; pain; post-operative; periodontitis; endodontic therapy Journal of Clinical Medicine Journal of Clinical Medicine Journal of Clinical Medicine Journal of Clinical Medicine Inﬂuence of Photon-Induced Photoacoustic Streaming (PIPS) on Root Canal Disinfection and Post-Operative Pain: A Randomized Clinical Trial Narcisa Mandras 1,, Damiano Pasqualini 2 , Janira Roana 1 , Vivian Tullio 1 , Giuliana Banche 1 , Elena Gianello 2, Francesca Bonino 2, Anna Maria Cuﬃni 1, Elio Berutti 2 and Mario Alovisi 2 Narcisa Mandras 1,, Damiano Pasqualini 2 , Janira Roana 1 , Vivian Tullio 1 , Giuliana Banche 1 , Elena Gianello 2, Francesca Bonino 2, Anna Maria Cuﬃni 1, Elio Berutti 2 and Mario Alovisi 2 1 Department of Public Health and Pediatrics, University of Turin, 10126 Turin, Italy; janira.roana@unito.it (J.R.); vivian.tullio@unito.it (V.T.); giuliana.banche@unito.it (G.B.); annamaria.cuﬃni@unito.it (A.M.C.) 2 Department of Surgical Sciences, Dental School, University of Turin, 10126 Turin, Italy; damiano.pasqualini@unito.it (D.P.); gianello.elena@gmail.com (E.G.); bonino.francesca@icloud.com (F.B.); elio.berutti@unito.it (E.B.); mario.alovisi@unito.it (M.A.) * Correspondence: narcisa.mandras@unito.it www.mdpi.com/journal/jcm J. Clin. Med. 2020, 9, 3915; doi:10.3390/jcm9123915 1. Introduction Apical periodontitis bioﬁlm disease is a periradicular inﬂammatory disease related to the presence of bacteria and toxins within the root canal system [1,2]. Diﬀerent studies have focused on the behavior of bacteria and microbial products in the etiopathogenesis of apical periodontitis [2,3]. Several bacteria are responsible for polymicrobial primary endodontic infections: among these, obligate anaerobic bacteria predominate [4]. The obligate anaerobes are rather easily eradicated during root canal treatment. Facultative anaerobes such as non-mutans streptococci (such as Streptococcus anginosus, S. constellatus, S. intermedius, enterococci and Lactobacillus spp.) are often resistant J. Clin. Med. 2020, 9, 3915; doi:10.3390/jcm9123915 www.mdpi.com/journal/jcm 2 of 11 J. Clin. Med. 2020, 9, 3915 to chemo-mechanical instrumentation and root canal dressings. In particular, Enterococcus faecalis can frequently be isolated from root canals in the case of failed root canal treatments [5]. The only way to achieve periapical healing is endodontic treatment, which aims to reduce the intracanal bacterial load through shaping, cleaning and ﬁlling [6]. Previous epidemiological studies showed that the technical quality of the endodontic treatment is a fundamental prognostic factor [7,8]. However, it is impossible to completely shape the root canal walls and isthmuses by using rotary or reciprocating instruments due to the complexity of the endodontic anatomy [9]. Therefore, the cleaning procedure plays a fundamental role in achieving complete disinfection [10]. The current trend of developing less-invasive endodontics, accompanied by the simpliﬁcation of operational sequences and a reduction in working time, places an even more marked emphasis on this topic [1]. Several irrigant activation methods have been proposed [11,12]. The most commonly used irrigant is sodium hypochlorite (NaOCl). Ethylenediamine tetraacetic acid (EDTA) and citric acid (CA) are the other large group of endodontic irrigants. Chlorhexidine (CHX) is a cationic bisbiguanide antiseptic with broad-spectrum antibacterial activity. The other irrigants used in endodontics include sterile water, hydrogen peroxide, physiological saline, urea peroxide and iodine compounds [11]. Recently, laser technology was proposed to improve the results obtained with traditional disinfection methods [13]. A photon-induced photoacoustic streaming system (PIPS) requires the use of an Er:YAG laser to activate the water molecules contained in the irrigant solutions [14–16]. The laser light actively pushes the irrigating solutions three-dimensionally through the isthmuses, anastomoses and lateral canals, allowing a deeper cleaning of the entire root canal system. The extremely low energy level required to activate irrigants is below the dentin ablation threshold due to the very short pulse duration [15–17]. 1. Introduction However, despite the tip insert position being at the level of the access cavity, there is still a potential risk of the extrusion of irrigants and debris beyond the apex. It is well known that extruded dentinal debris may induce periradicular inﬂammation, leading to post-operative pain, negatively aﬀecting the patients’ quality of life (QoL) and their subjective assessment of alternative treatments [2,18–20]. The primary objective of this randomized clinical trial was to evaluate the ability of the PIPS technique to reduce the intracanal bacterial count in vivo compared to the traditional endodontic irrigation method. The secondary objective was to assess the inﬂuence of the PIPS technique on post-operative patients’ QoL. 2. Materials and Methods This randomized controlled clinical trial (two-parallel-group design) was prepared following the CONSORT guidelines [21] and was performed according to the principles of the Helsinki Declaration [22]. This study was authorized by the Local Ethics Committee, and the treatment protocol was explained to all the patients through an information sheet and was approved with informed consent. Eligibility criteria. Consenting and healthy subjects of both genders were enrolled until the required sample size was reached. The patients presented a ﬁrst or second maxillary or mandibular molar with a diagnosis of pulp necrosis with or without symptomatic or asymptomatic apical periodontitis bioﬁlm disease. Patients with a sinus tract, periapical abscess or facial cellulitis were not enrolled due to the possibility of confounding the QoL perception regardless of the treatment. Patients with physical or psychological disabilities or an inability to understand the study instructions were excluded. Additionally, patients who had received emergency endodontic care were not included in the study. Interventions. The medical and dental status and history of each patient were collected. Intraoral examination was performed with 3.5× dental loupes. The pulpal and periradicular statuses were assessed with thermal and electric pulp tests (Diagnostic Unit, Sybron, Orange, CA, USA), palpation and percussion. The periodontal status was also recorded. Preoperative periapical radiographs were obtained using a Rinn XCP (Rinn Corp, ELgin, IL, USA) and a digital Photostimulable Phosphor Plates (PSP) system. The data were processed and archived by a dedicated scanner (OpTime Soredex, Tuusula, Finland). Teeth with a loss of lamina dura and periodontal ligament enlargement >2 mm were classiﬁed as having lesions of endodontic origin (LEOs). The clinical and radiological data Eligibility criteria. Consenting and healthy subjects of both genders were enrolled until the required sample size was reached. The patients presented a ﬁrst or second maxillary or mandibular molar with a diagnosis of pulp necrosis with or without symptomatic or asymptomatic apical periodontitis bioﬁlm disease. Patients with a sinus tract, periapical abscess or facial cellulitis were not enrolled due to the possibility of confounding the QoL perception regardless of the treatment. Patients with physical or psychological disabilities or an inability to understand the study instructions were excluded. Additionally, patients who had received emergency endodontic care were not included in the study. Interventions. The medical and dental status and history of each patient were collected. Intraoral examination was performed with 3.5× dental loupes. 2. Materials and Methods Kyoto, Japan) three times: during canal scouting, with a #10 size stainless-steel K-File; at the end of the glide path, with a #17 size stainless-steel K-File; and during shaping after X1, with a #17 size stainless-steel K-ﬁle. At the end of the glide path, a radiographic check of the WL was performed, using a #17 size stainless steel K-File. All the canals in both groups were instrumented to the working length with each instrument, except for the ProTaper Next X2, which was kept 0.5 mm shorter than the working length, to reduce the risk of debris extrusion and to ensure homogeneous study conditions between the traditional irrigation group and the PIPS irrigation group. The apical ﬁnishing was then completed with K-Files NiTiFlex #25 at the WL. Irrigation protocol. Before the second sampling after instrumentation, the patients were randomly assigned to one of the two irrigation groups (Group A or Group B) by a single-blinded operator, and the root canals were irrigated in the two groups with alternating 5% NaOCl and 10% EDTA solutions for a total of 10 mL for each. Standard endodontic manual irrigation (Group A) was performed using a 30 G side-vented steel needle (Kendall, Mansﬁeld, MA, USA) after every instrument before apical ﬁnishing. The needle was positioned inside the canal without engagement with the walls and about 3 mm from the working length during the whole process. For the activation of the irrigation solutions, the needle moved with an amplitude of approximately 2 mm. The PIPS group (Group B) was exposed to laser irradiation with an Er:YAG laser (Fotona LightWalker ST-E Ljubljana, Slovenia), characterized by a wavelength of 2940 nm in exposure intervals of 30 s. The laser was set with frequency values of 15 Hz and an energy of 20 mJ, guaranteeing a total power of 0.30 W. The pulse duration was set to the Super Short Pulse (SSP), equal to 50 µs. During use, the air/water spray of the handpiece was deactivated. The control panel had standard PIPS parameters of 20 mJ and 15 Hz in SSP mode (50 µs), resulting in an average power of 0.30 W [17]. A standardized quartz tip (diameter, 600 µm, and length, 9 mm) was used, characterized by having the conical end part uncoated by the polyamide protective sheath. 2. Materials and Methods The pulpal and periradicular statuses were assessed with thermal and electric pulp tests (Diagnostic Unit, Sybron, Orange, CA, USA), palpation and percussion. The periodontal status was also recorded. Preoperative periapical radiographs were obtained using a Rinn XCP (Rinn Corp, ELgin, IL, USA) and a digital Photostimulable Phosphor Plates (PSP) system. The data were processed and archived by a dedicated scanner (OpTime Soredex, Tuusula, Finland). Teeth with a loss of lamina dura and periodontal ligament enlargement >2 mm were classiﬁed as having lesions of endodontic origin (LEOs). The clinical and radiological data 3 of 11 J. Clin. Med. 2020, 9, 3915 were analyzed by three blinded Assistant Professors within the Endodontic Department, and their concordance was analyzed according to the Fleiss’ K score until inter-examiner reliability (K > 0.70) was expected. Only teeth with primary root curvatures between 0◦and 40◦in bucco-palatal or lingual vision were included according to the Schneider method, and teeth with excessive calciﬁcation were excluded. The American Association of Endodontists (AAE) diﬃculty form was ﬁlled out for every clinical case [23]. All treatments were performed by a single expert clinician with more than 3 years of experience. After local anesthesia, the teeth were isolated with a rubber dam, and the dental surface was disinfected with a 30% hydrogen peroxide solution. After the removal of the carious tissue, an endodontic pre-treatment with composite was carried out, in order to ensure an adequate irrigation reservoir. After the access cavity preparation, each canal was irrigated with saline solution, and the pre-shaping microbial sample was taken using sterile paper cones inserted inside the canal up to the point of engagement with the walls (1st sample: baseline bacterial sample). The ﬁrst ﬁle to bind the canal walls was a K-File with a minimum size #15 up to the root canal middle third, in order to standardize the canal width. Afterwards, for all the canals, a manual canal scouting was performed with K-File #10 (Dentsply Maillefer), a mechanical glide path using ProGlider (PG) (Dentsply Maillefer) and mechanical shaping using ProTaper Next (PTN) X1 and X2 (Dentsply Maillefer) up to the working length (WL). Apical patency was established and conﬁrmed with a size #10 K-File 0.5 mm beyond the apex. The electronic WL (EWL) was recorded with an apex locator (Denta Port ZX, J. Morita MFG, Corp. 2. Materials and Methods All the samples were serially diluted 1:10 in normal saline (0.9% NaCl) and plated on selective and diﬀerential media to quantify the total microbiota and the number of obligate and facultative anaerobic bacterial strains: in detail, Brain Heart Infusion Agar (BHA, Becton Dickinson, BD, Franklin Lakes, NJ, USA) was used to determine the number of facultative anaerobic strains, Columbia CNA Agar with 5% Sheep Blood (SCNA, BD) was used to determine the total number of Gram-positive anaerobic (obligate and facultative) bacterial strains, and Schaedler Agar with Vitamin K1 and 5% sheep blood (SCV, BD) and Schaedler Kanamycin-Vancomycin Agar with 5% Sheep Blood (SKV, BD) were used for Gram-positive and Gram-negative obligate anaerobes, respectively. All plates were incubated at 37 ◦C: BHA plates for 24–48 h under aerobic conditions, and the other ones, for about two weeks under anaerobic conditions in an anaerobic system (Gaspak EZ anaerobe pouch system kit, BD). All the aerobic cultures were examined after 24 and 48 h of incubation, whereas the anaerobic cultures were examined for growth every 3 days. The microbial counts are reported as colony-forming units/mL (CFU/mL). Post-operative pain self-assessment questionnaire. All the patients were scheduled for a subsequent appointment after 7 days to ﬁll the root canals, and they were dismissed with post-operative instructions and a prescription for optional analgesics. The patients’ post-operative pain (mean and maximum) was assessed through a visual analogue scale (VAS) made of a 10 cm line, where 0 = no pain and 10 = unbearable pain. The patients also received a self-assessment questionnaire, in order to evaluate post-operative QoL within the following 7 days after shaping. The following indicators of the patient’s QoL were used: diﬃculty in chewing, speaking, sleeping, performing daily functions and social relations and overall QoL. A Likert scale (LS) was used with a numerical value from 0 (none) to 10 (very much). In addition, the analgesic intake, evaluated by the number of analgesic tablets taken in the post-operative period, and the number of days to complete pain resolution were also evaluated. The progressively numbered questionnaires were returned anonymously in a collecting box. Only the principal investigator was aware of the correspondence between the codes and patients and was excluded from the data analysis. 2. Materials and Methods The tip was placed in the coronal part of the pulp chamber, without the need to introduce it into the root canal. During the activation of the laser, a continuous irrigation ﬂow was guaranteed with a plastic syringe with a 30 G side-vented steel needle, positioned inside the canal without engagement with the walls and within 3 mm of the working length. After each instrument, PIPS irrigation for 30 s with 10% EDTA was carried out to clean the canals of the debris. The laser-activated irrigation (LAI) was performed as follows: - Thirty seconds of PIPS with a continuous ﬂow of 10% EDTA (5 mL); - Thirty seconds of PIPS with a continuous ﬂow of 10% EDTA (5 mL); - Thirty seconds of PIPS with a continuous ﬂow of sterile distilled water (5 mL); J. Clin. Med. 2020, 9, 3915 4 of 11 - Thirty seconds of PIPS three times with a continuous ﬂow of 5% NaOCl (5 mL) with 30 s pauses between cycles; - Thirty seconds of PIPS three times with a continuous ﬂow of 5% NaOCl (5 mL) with 30 s pauses between cycles; - Thirty seconds of PIPS with a continuous ﬂow of sterile distilled water (5 mL) as a ﬁnal s - Thirty seconds of PIPS with a continuous ﬂow of sterile distilled water (5 mL) as a ﬁnal step. This irrigation protocol was performed after having instrumented the canal with ProTaper Next X2 0.5 mm shorter than the WL, but before the completion of the apical ﬁnishing with K-Files NiTiFlex #25, to reduce the risk of the apical extrusion of debris. For all the groups, after a ﬁnal profuse irrigation with saline solution, the post-treatment microbial sample was taken with sterile paper cones and inserted within the canal up to 2 mm from the WL (2nd sample). Finally, the canals were re-irrigated with 5% NaOCl and dried with paper cones, and the access cavity was sealed with a temporary ﬁlling (IRM, Dentsply International Inc., York, PA, USA). No occlusal adjustments were performed. Microbiological analysis. Microbial samples collected before (1st sample) and after irrigation treatment (2nd sample) were placed in a sodium thioglycolate broth (Biolife, Milano) and sent to the Bacteriology and Microbiology Laboratory, Department of Public Health and Pediatrics, University of Turin. 2. Materials and Methods The root canal obturation was completed in the second appointment after 7 days with the ThermaﬁlTM technique (Dentsply Maillefer) in association with the use of a eugenol-based canal sealer (Pulp Canal Sealer EWT, Kerr Endodontics, Orange, CA, USA). A ﬁnal post-operative radiograph was performed, and a follow-up was established after 3, 6 and 12 months. Sample size. To detect a diﬀerence of 5% (a change of 0.5 points on the visual scale) in the post-operative pain values between groups, an alpha-error of 0.05 and a power (1-beta) of 80% were considered, requiring a sample size of 23 patients for each group. In the present study, 27 patients for each group were analyzed. Randomization. The randomized order was obtained using computer-generated tables. The following parameters were considered for randomization to control for potential confounders: the prevalence of pain before treatment, mean pain before treatment and clinical diagnosis. An operator, J. Clin. Med. 2020, 9, 3915 5 of 11 external from the clinical treatment, prepared blinded envelopes containing the randomized allocation for each patient. The same operator communicated the allocation to the clinician after the initial patient assessment and before root canal instrumentation. The operator was not blinded to the allocation group, as each instrument required a speciﬁc technique. However, the randomization, allocation and statistical analysis were performed by blinded operators. Statistical analysis. The obtained data were analyzed descriptively and inferentially. The randomization, group assignment and statistical analysis were performed by a blinded operator. The distribution of the microbial analysis data was evaluated by means of the Kolmogorov–Smirnov normality test. The diﬀerences between the groups were analyzed by the Mann–Whitney test (p < 0.05). The variation in the QoL indicators in the 7 post-treatment days was assessed using a speciﬁc variance analysis model for repeated measures (two groups compared). Student’s t-test was used for the amount of painkillers taken. All the statistical analyses were performed with the SPSS statistical software, version 17.0. 3. Results A total of 80 subjects were selected for inclusion, and 60 patients were ﬁnally enrolled and randomized between traditional endodontic irrigation (Group A, n = 30) and PIPS irrigation (Group B, n = 30). The distributions of occupation, education and socio-economic background between the groups were uniform. Three patients in Group B and two in Group A were lost to follow-up before the second visit, while one patient in Group A required an unscheduled intervention during the observation period, due to a post-operative ﬂare-up. Finally, data analysis was performed on 27 patients for each group (48% male; 52% female; 21% 16–30 years; 37% 31–45 years; 42% 46–60 years). The patient ﬂow and the patients’ baseline characteristics are presented in Figure 1 and in Table 1. Statistical analysis revealed that the demographic and clinical variables were similarly distributed among the experimental groups (p > 0.05). Figure 1. Randomized clinical trial patient ﬂow diagram. Group A: Standard endodontic manual irrigation; Group B: photon-induced photoacoustic streaming (PIPS) laser-activated irrigation. Figure 1. Randomized clinical trial patient ﬂow diagram. Group A: Standard endodontic manual irrigation; Group B: photon-induced photoacoustic streaming (PIPS) laser-activated irrigation. 6 of 11 J. Clin. Med. 2020, 9, 3915 Table 1. Group baseline characteristics. Group A, Standard endodontic manual irrigation; Group B, PIPS laser-activated irrigation. AAE = American Association of Endodontists, NS = No statistically signiﬁcant diﬀerence, p > 0.05; LEO = Lesion of endodontic origin >2 mm; LS = Likert scale. Pre-Operative Status Group A (n = 27) Group B (n = 27) p < 0.05 Male 17 14 NS Female 10 13 NS AAE diﬃculty (minimal/moderate/high) (n) 11/15/1 19/6/2 NS Pulp necrosis (%) 100 100 NS Symptomatic apical periodontitis (%) 51.9 44.4 NS LEO prevalence (%) 66.7 48.1 NS Pain prevalence (%) 70.4 63.1 NS Mean pain score (LS) 4.3 2.9 NS Maximum pain score (LS) 5.6 3.7 NS Quality of life (medium) 2.8 1.9 NS Microbiological analysis. The results obtained from the microbiological analysis are shown in Table 2. A bacterial load reduction (BLR) was observed for both techniques, even if the PIPS laser technology irrigation in Group B showed a greater antibacterial eﬃcacy than the conventional endodontic manual irrigation in Group A for facultative anaerobes (BLR = 98.18%), total anaerobic strains (BLR = 92.6%) and Gram-negative obligate anaerobes (BLR = 100%). These diﬀerences were not statistically signiﬁcant (p > 0.05). 3. Results The correspondence between the BLR and mean and maximum post-operative pain on Day 1 in both groups is reported in Table 3. For each group, the total BLR seemed not to be statistically correlated to the intensity of pain calculated through the VAS scores on Day 1 post-disinfection (p > 0.05). Table 2. Bacterial load reduction (BLR) values for different bacterial culture media. Group A, Standard endodontic manual irrigation; Group B, PIPS laser-activated irrigation. Brain Heart Infusion Agar (BHA) to determine the number of facultative anaerobic strains, Columbia CNA Agar with 5% Sheep Blood (SCNA) to determine the total number of anaerobic (obligate and facultative) bacterial strains, and Schaedler Agar with Vitamin K1 and 5% Sheep Blood (SCV) and Schaedler Kanamycin-Vancomycin agar with 5% Sheep Blood (SKV) for Gram-positive and Gram-negative obligate anaerobes. SD, Standard deviation. Table 2. Bacterial load reduction (BLR) values for different bacterial culture media. Group A, Standard endodontic manual irrigation; Group B, PIPS laser-activated irrigation. Brain Heart Infusion Agar (BHA) to determine the number of facultative anaerobic strains, Columbia CNA Agar with 5% Sheep Blood (SCNA) to determine the total number of anaerobic (obligate and facultative) bacterial strains, and Schaedler Agar with Vitamin K1 and 5% Sheep Blood (SCV) and Schaedler Kanamycin-Vancomycin agar with 5% Sheep Blood (SKV) for Gram-positive and Gram-negative obligate anaerobes. SD, Standard deviation. Group A (n = 27) Group B (n = 27) p-Value Mean (%) ± SD Mean (%) ± SD Facultative anaerobes (BHA medium) 94.19 ± 18.5 98.19 ± 3.72 0.95 Facultative and obligate anaerobes (SCNA medium) 89.95 ± 15.1 92.6 ± 15.1 0.37 Gram-positiveobligate anaerobes (SCV medium) 94.83 ± 11.2 91.67 ± 19.7 0.20 Gram-negative obligate anaerobes (SKV medium) 98.43 ± 6.2 100 ± 0.2 0.97 Post-operative pain and quality of life indicators. The baseline QoL indicators did not show statistically signiﬁcant diﬀerences between the groups (p > 0.05). Signiﬁcant results were found between Groups A and B for the following indicators on Day 1 post-operation: maximum pain (p = 0.02), eating diﬃculty (p = 0.03) and diﬃculty performing daily functions (p = 0.02) (Figure 2). These indicators appeared to be lower for patients treated with PIPS irrigation. For the other indicators, from Days 1 to 7 post-treatment, the trend values seemed to be lower in the PIPS group but without signiﬁcance (p > 0.05). 7 of 11 J. Clin. Med. 2020, 9, 3915 Table 3. 4. Discussion The laser energy exploited with the LAI (laser-activated irrigation) methods has been claimed to improve the eﬀectiveness of endodontic irrigants [11,24,25]. The recent PIPS laser technique has the peculiarity of being based on sub-ablative photoacoustic rather than photothermal phenomena, lowering the risk of scaling the dentinal surface [26,27]. The low energy levels (between 20 and 50 mJ), with a frequency between 10 and 15 Hz and with very short pulses (50 ms), generate photoacoustic shockwaves [17]. The shockwaves generated during PIPS activation may create a three-dimensional ﬂow in the root canal system, removing more debris and pulp residues [1,17]. Preliminary in vitro studies reported that the PIPS protocol should remove more microbial bioﬁlm inside the canal system and open more dentinal tubules compared to traditional endodontic irrigation [27,28]. However, no data are available about the eﬃcacy of photoacoustic streaming laser-based irrigation for root canal disinfection in vivo. Moreover, the use of laser-activating techniques may extrude more debris beyond the apical foramen compared to the traditional irrigation methods, negatively aﬀecting the patients’ post-operative pain and QoL [29]. The QoL is a very complex phenomenon related to the state of health and socio-economic and cultural needs in a context of individual standards and expectations, thus concerning physical, psychological and social well-being [30,31]. Patient satisfaction is an important aspect to take into account when performing dental treatment [19,32], and the QoL following dental treatment can be assessed through a self-assessment questionnaire [33,34]. In the present randomized clinical trial, the microbiological analysis was carried out on diﬀerent types of medium that allow the growth and isolation of diﬀerent bacterial species within the canals. An in vivo approach is more complex from a microbiological point of view, since the bacterial types are more diversiﬁed and there are several species to isolate [2,35]. In order to avoid endodontic sample contamination from carious or oral bacteria, it is important to perform proper tooth isolation with a rubber dam and dental surface disinfection with a hydrogen peroxide solution at 30% [35]. Within the limits of this study, PIPS showed interesting disinfectant eﬃcacy, although this was not statistically diﬀerent from that of conventional irrigation for facultative anaerobic and Gram-negative obligate anaerobic strains. However, a correlation between residual bacteria at the end of the instrumentation and the post-operative pain did not emerge. 4. Discussion Therefore, it can be assumed that the presence or absence of residual bacteria in the canal is not the direct cause of post-operative pain and worse QoL perception. It is likely that the onset of post-operative pain may be related to the extrusion of debris or irrigant solution beyond the apex [20,36]. Therefore, to standardize the experimental conditions in both patient groups, the canal shaping was made 0.5 mm shorter than the apex, and an apical ﬁnishing with K-Fine NiTiﬂex #25–#30 was ensured. Several literature studies have analyzed the apical extrusion of debris and associated issues [24,37]. The factors inﬂuencing this risk are related to the presence of a large, viable apical foramen; the pressure generated in the ﬂuids within the canal when the laser devices are used; the energy applied; and the position of the tip [24,37]. The present study did not report a risk of irrigant solution and debris extrusion beyond the apex due to irrigant activation by the laser, resulting in a better perception of post-operative pain in the PIPS group. The QoL indicators appeared to be more favorable on post-operative Day 1 for the patients enrolled in the PIPS group. As regards the other analyzed variables, the PIPS method appears to generally lead to less discomfort than the traditional irrigation protocol, even if the data are not statistically signiﬁcant. This appears to contradict the literature data according to which the PIPS presents a risk of irrigant solution and debris extrusion beyond the apex due to the activation and agitation of the irrigant systems by the laser, resulting in major discomfort for the patient [20,36,38]. However, the patients’ post-operative perception is highly subjective, and a larger study population could be advisable. 3. Results The correspondence between bacterial load reduction (BLR) and mean and maximum post-operative pain on Day 1. Group A, Standard endodontic manual irrigation; Group B, PIPS laser-activated irrigation. Mean Pain (Day 1) Maximum Pain (Day 1) Bacterial Load Reduction (BLR) (%) Group A (n = 27) Group B (n = 27) p < 0.05 Group A (n = 27) Group B (n = 27) p < 0.05 100% 2.02 1.72 NS 3.12 1.41 NS < 100% 2.61 2.12 NS 3.30 1.76 NS Figure 2. Significant results between Groups A and B for the following indicators on Day 1 post-operation: maximum pain (p = 0.02), eating difficulty (p = 0.03) and difficulty performing daily functions (p = 0.02). Group A, Standard endodontic manual irrigation; Group B, PIPS laser-activated irrigation. Table 3. The correspondence between bacterial load reduction (BLR) and mean and maximum post-operative pain on Day 1. Group A, Standard endodontic manual irrigation; Group B, PIPS laser-activated irrigation. Mean Pain (Day 1) Maximum Pain (Day 1) Bacterial Load Reduction (BLR) (%) Group A (n = 27) Group B (n = 27) p < 0.05 Group A (n = 27) Group B (n = 27) p < 0.05 100% 2.02 1.72 NS 3.12 1.41 NS < 100% 2.61 2.12 NS 3.30 1.76 NS Figure 2. Significant results between Groups A and B for the following indicators on Day 1 post-operation: maximum pain (p = 0.02), eating difficulty (p = 0.03) and difficulty performing daily functions (p = 0.02). Group A, Standard endodontic manual irrigation; Group B, PIPS laser-activated irrigation. J. Clin. Med. 2020, 9, 3915 8 of 11 5. Conclusions Based on the present results, the PIPS method could be considered a viable system for endodontic disinfection, especially in the case of simpliﬁed operational protocols and reduced instrumentation 9 of 11 J. Clin. Med. 2020, 9, 3915 times. The improvement of endodontic disinfection systems is a key step for an ever increasingly modern, easy, fast and minimally invasive treatment plan, despite the traditional irrigation protocol, which continues to be extremely competitive with regard to eﬀectiveness in reducing bacterial infections. times. The improvement of endodontic disinfection systems is a key step for an ever increasingly modern, easy, fast and minimally invasive treatment plan, despite the traditional irrigation protocol, which continues to be extremely competitive with regard to eﬀectiveness in reducing bacterial infections. Author Contributions: Conceptualization: E.B., D.P., M.A., N.M., J.R. and A.M.C.; methodology: D.P., N.M., E.G., M.A., F.B., G.B., V.T. and J.R.; software: J.R., N.M., V.B., A.M.C., D.P., E.G. and V.T.; data analysis: V.T., M.A., J.R., N.M., A.M.C., F.B. and E.G.; visualization: E.B., D.P., M.A., A.M.C., N.M., F.B. and E.G.; supervision and project administration: E.B., D.P., A.M.C., N.M.P., J.R., M.A., G.B. and V.T.; writing: F.B., E.G., M.A., D.P., N.M. and J.R.; reviewing and editing: E.B., A.M.C., N.M., J.R., M.A., D.P. and G.B. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Acknowledgments: The authors declare no competing interests or conﬂicts of interest regarding the materials discussed in this manuscript. The clinical study was performed at the C.I.R. Dental School—University of Turin (Italy). The PIPS device was granted by Fotona (Ljubljana, Slovenia). This study was supported by Ministero dell’Istruzione, dell’Università e della Ricerca (MIUR), under the programme “Dipartimenti di Eccellenza ex L.232/2016”, with a grant to the Dept. of Surgical Sciences, University of Torino. Conﬂicts of Interest: We, the authors, aﬃrm that we have no ﬁnancial aﬃliations (e.g., employment, direct payments, stock holdings, retainers, consultantships, patent licensing arrangements or honoraria) or involvement with any commercial organizations with a direct ﬁnancial interest in the subject or materials discussed in this manuscript, nor have any such arrangements existed in the past three years. Any other potential conﬂicts of interest are disclosed. References 1. 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https://openalex.org/W2991087622	https://link.springer.com/content/pdf/10.1007/s00256-019-03317-7.pdf	English	null	Reporting Discrepancy Resolved by Findings and Time in 2947 Emergency Department Ankle X-rays	Skeletal radiology	2,019	cc-by	5,110	* Thomas James York thomas.york@nhs.net Abstract Aims To identify common errors in ankle X-ray reporting between initial interpretation and final assessment at the virtual fracture clinic. Also, to assess time of initial reporting as a causative factor for discrepancy. Methods Two thousand nine hundred forty-seven final reports were reviewed by standard of agreement to the initial interpre- tation. Where discrepancy was found, it was classified and collated by specific finding. Comparison was made between reports with discrepancy and the complete dataset, allowing rates of error by finding to be established. The reports containing discrep- ancy were further classified by time period, this was compared against an expected value to establish if initial reporting outside of routine working hours was as accurate as that conducted within routine working hours. Results 94.4% of reports were in agreement with the initial interpretation, 2.9% contained minor discrepancy, and 2.7% major discrepancy. In 45.6% of reports there was no radiologically observable injury. 16.4% of reports contained a lateral malleolar fracture, most commonly Weber type B. 40.0% of all navicular fractures, and 33.3% of all cuboidal fractures were not commented upon in the initial reporting. Lower rates of more frequently observed findings were missed with 2.5% of Weber type B fractures not commented upon. An increased proportion of major discrepancy reports were generated from 00:00 to 07:59 (expected = 15.0%, observed = 22.2%; p = 0.07908). Similarly, a greater than expected number of minor discrepancy reports were found between 20:00 and 23:59 (expected = 18.0%, observed = 34.1%, p = 0.00025). ( p , , p ) Conclusions The initial reporting of ankle X-rays in the emergency department is performed to a high standard, however serious missed findings emphasise the need for timely senior review. Reporters should increase their awareness of navicular, cuboid, talar, and Weber A fractures which were missed at disproportionate rates. This study also finds evidence to support increased rates of error in initial reporting of ankle X-rays outside of normal working hours (17:00–07:59), particularly with a significantly increased rate of minor discrepancy seen from 20:00 to 23:59. Keywords Ankle fractures . X-ray reporting . Reporting discrepancy . Time resolved discrepancy . Reporting errors https://doi.org/10.1007/s00256-019-03317-7 Skeletal Radiology (2020) 49:601–611 https://doi.org/10.1007/s00256-019-03317-7 Skeletal Radiology (2020) 49:601–611 SCIENTIFIC ARTICLE Reporting Discrepancy Resolved by Findings and Time in 2947 Emergency Department Ankle X-rays Thomas James York1 & P. J. Jenkins2 & A. J. Ireland2 Received: 1 June 2019 /Revised: 13 September 2019 /Accepted: 16 September 2019 # The Author(s) 2019 /Published online: 21 November 201 2 Department of Orthopaedic Surgery, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK 1 St Mary’s Hospital, Praed Street, London W2 1NY, UK 1 St Mary’s Hospital, Praed Street, London W2 1NY, UK 2 Department of Orthopaedic Surgery, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK Introduction Recent research has indicated the annual incidence of ankle fractures is as high as 169 per 100,000 in Northern European populations [3]. In the elderly patient, they are amongst the 3 most common fracture types, along with fractures of the hip and distal radius [4]. Ankle injuries represent a significant proportion of emergency department work. They are the most common musculoskeletal injury [1] and of those presenting to the emergency depart- ment with ankle injury as their primary complaint, 15% will have an ankle fracture [2]. Whilst the widespread adoption of the Ottawa Ankle Criteria has reduced unnecessary X-ray imaging of the ankle [5], they still set a relatively low threshold for investigation [6] and a busy emergency department is likely to conduct many hundreds of these per year. The high rate of requesting and perceived ordinariness of these injuries means it frequently falls to more junior physi- cians to make the first assessment of an ankle radiograph. Despite this, inadequate treatment of radiologically identifi- able injuries results in significant complication; unstable 602 Skeletal Radiol (2020) 49:601–611 syndesmosis, cartilage degeneration, and mal-union may all lead to loss of function and pain [7]. This makes a timely, accurate assessment critical to a patient’s initial management. To address the study’s secondary aim, the 2947 total reports and 166 discrepancy reports were further categorised by time period during which the initial report was generated: 08:00– 16:59, 17:00–19:59, 20:00–23:59, and 00:00–07:59. These intervals reflect shift patterns in the emergency department and extended duration shifts. In the associated department at Glasgow Royal Infirmary, the initial emergency department interpretation of an ankle X- ray is reviewed at a virtual fracture clinic where a definitive report is issued. This study sought to investigate cases where there was discrepancy between these two assessments. The primary objective being to identify commonly missed radio- logical findings on the initial assessment of an ankle X-ray. An expected number of discrepancy reports for each time period was generated on the basis of a null hypothesis. This stipulated that the number of reports containing discrepancy would be directly proportional to the number of initial reports generated, therefore that time period had no impact on reporting accuracy. Comparison was then made between the expected and observed values to test if this was the case. Results For each of these an initial report of findings was issued by the requesting physician during the emergency department visit. Doctors generating this report ranged in experience from their second year of practice to senior registrars and consultants. Patients and methods The methodology of this study and the database used therein was approved by radiology department data release, and local Caldicott and audit committees. No research ethics committee opinion was required as treatment was not allocated or concealed, and patients were not contacted. This study takes the form of a retrospective audit performed at a University Teaching Hospital, serving a metropolitan area of approximately 350,000 people. The radiology department ad- ministrative database was examined to produce an anonymised list of 6886 sequential ankle X-rays, comprising a standardised anteroposterior and lateral view. These were taken between October 2011 and January 2014. Introduction The secondary objective involved a working-time resolved analysis of discrepancy, the aim being to establish the time of initial interpretation as a potential factor in the likelihood of reporting disagreement. Such a link, between clinical errors and non-standard working hours, has been increasingly re- ported in medical literature [8, 9] but is less tested in this specific domain. Biostatistical analysis was performed using Chi square test- ing for goodness-of-fit to assess the significance of variation in reporting errors. The conventional threshold of p value < 0.05 was set as the cut off for significance. Overall findings The most common finding across all included reports was of no radiologically observable injury, seen in 1345 reports (45.6%). There were a total of 484 reports (16.4%) demon- strating a fracture of the lateral malleolus; 47 (1.6%) categorised as Weber type A, 315 (10.7%) type B, and 122 (4.1%) type C. Taken in combination, these injuries were the most common bony finding. All ankle X-rays were then reviewed by a consultant MSK radiologist and consultant orthopaedic surgeon at a virtual fracture clinic. This generated a final report of findings, in- cluding an assessment of agreement with the initial report to which they had access. There were 215 reports (7.3%) including fracture of the medial malleolus, and 75 (2.5%) with a posterior malleolus fracture. Polymalleolar fractures were found less frequently than unimalleolar, bimalleolar fractures appeared in 96 (3.3%) and trimalleolar in 49 (1.7%). This was categorised as ‘agreement’ where no difference of interpretation was found, ‘minor disagreement’ where there was discrepancy not judged to require change to the patient’s management, and ‘major disagreement’ where intervention was required. The reports were then screened to exclude those where an assessment of agreement was not recorded or was insufficient- ly recorded. Following this, a total of 2947 suitable reports remained for inclusion. A single observer reviewed these for standardised written descriptors to identify the frequency of radiological findings. Ankle mortice dislocation was seen in 104 reports (3.5%). There were a total of 67 (2.3%) including a fracture of the hindfoot; 35 (1.2%) calcaneal fractures and 32 (1.1%) talar fractures. 15 reports (0.5%) showed navicular fracture and a smaller number, 6 (0.2%) showed cuboid fracture. There were 19 (0.6%) with a fracture to the base of the 5th metatarsal. The frequency of each finding was collated across the data series as a whole and, in those reports where discrepancy was found, compared between the initial and final report. The least commonly reported finding was of suspected osteomyelitis, recorded in 3 reports (0.1%) See Table 1. 603 Skeletal Radiol (2020) 49:601–611 e 1 Total incidence 45.6 24.1 16.4 10.7 7.3 4.1 3.5 3.3 2.5 1.7 1.6 1.2 1.2 1.1 0.6 0.5 0.2 0.1 Findin N g o. Discussion In the remaining 61 reports (75.3%) with missed findings, soft tissue swelling had been initially unreported in 33 (40.7%). There were 22 (27.2%) missed fractures of the lateral malleolus, with 12 (14.8%) categorised as Weber C. A bimalleolar fracture pattern was missed in 2 (2.5%), along with a single missed trimalleolar fracture. Hind foot fractures were missed in a total of 9 (11.1%). There were 5 (6.2%) of unreported navicular fracture, and 1 (1.2%) cuboid fracture See Table 3. Overall findings The overall results of this study support earlier findings that fractures of the lateral malleolus represent the most common ankle fractures, with the highest incidence being of Weber type B, followed by type A and then C [10]. There is also strong evidence to support the finding that isolated malleolar injuries make up the majority of ankle fractures, with relatively lower proportions of bimalleolar and trimalleolar fractures [10, 11]. Minor discrepancy In those 85 reports with minor discrepancy there were 48 (56.5%) with no radiologically observable injury, representing a false positive in the initial findings. The remaining 37 reports (43.5%) included a missed find- ing; a false negative. In 24 (28.2%) soft tissue swelling had not been initially commented upon. There were 6 (7.1%) missed fractures of the lateral malleolus, all characterised as Weber A. A further 4 (4.7%) medial malleolar, and 3 (3.5%) posterior malleolar fractures were found not to have been highlighted in the initial report See Table 2. However, in the time period 00:00–07:59, an increased proportion of reports with major discrepancy were generated; 18 reports (22.2%), compared to an expected 12 (15.0%). Biostatistical analysis for this indicated a Chi Square p value- = 0.07908, suggesting this finding narrowly missed the con- ventional threshold for significance. In the time period 20:00–23:59 a significant increase in the number of reports with minor discrepancy was observed, 29 (34.1%) compared with 15 expected (18.0%), p value = 0.00025 See Table 5. Reporting discrepancy In 2781 reports (94.4%) there was agreement with the initial findings. There were 85 (2.9%) that recorded minor discrep- ancy, and 81 (2.7%) with major discrepancy. The time period 08:00–16:59 saw the majority of initial reports being generated; 1503 reports (51.0%) of the total. 472 (16.0%) were generated from 17:00 to 19:59, 530 (18.0%) between 20:00–23-59, and 442 (15.0%) between 00:00–07:59. During standard working hours, 08:00–16:59, 40 initial reports (49.4%) were generated containing major discrepancy, compared to the 41 expected (51.0%) with a directly propor- tional relationship to the number of initial reports generated. Those reports with minor discrepancy during this time period related similarly, with 36 observed (42.4%) compared to 43 expected (51.0%). Missed findings The data does demonstrate somewhat different hindfoot findings than indicated in a review of the existing literature, where fractures of the calcaneus are by far the most common tarsal fractures, seen significantly more frequently than talar fractures [12], (http://www.smo.edu.mx/pdf/0804_publica_ talus.pdf), and making up as many as 2% of all fractures [13]. In this study, fractures of both the calcaneus and talus appeared equally in approximately 1% of the included reports. The cause for this is uncertain but in part is likely due to the relatively low numbers of these injuries found within the series. With regard to unreported findings in bony anatomy, navicular fractures were not initially commented upon in 6 of 15 in- stances (40.0%); a greatly increased percentage compared to the rate of reporting error across all findings, p value < 0.0001. Similarly, 2 of the 6 (33.3%) cuboid fractures were missed, p value < 0.0001. Talar (21.9%), Weber A (17.0%), and 5th metatarsal fractures (10.5%) were also disproportion- ately missed in the initial report. Only 68 of 1345 initial reports (5.1%) failed to reach the final report’s conclusion of no injury. Fractures of the lateral malleolus were missed in 28 of 484 (5.8%); Weber B fractures being the least commonly missed sub-type with 8 of 315 (2.5%), Weber C with 12 of 122 (9.8%) and Weber A the most with 8 of 47 (17.0%). Only 1 of 104 (1.0%) joint dislocations was initially unreported See Table 4. Major discrepancy The 81 reports with major discrepancy featured 20 (24.7%) with no radiologically observable injury, again representing false positives. Overall findings of reports Percentage of reports in which ﬁnding appears (%) Displaced (n/%) No Injury 1345 45.6 e swelling 709 24.1 Fracture-Lateral Malleolus 484 16.4 Weber A 47 1.6 Weber B 315 10.7 Weber C 12 4 2 .1 Fracture-Medial Malleolus 21 7 5 .3 90 /41.9 Fracture-Posterior Malleolus 75 2.5 18/24.0 Joint disloca n 10 3 4 .5 Fracture-Calcaneus 35 1.2 14/40.0 Fracture-Navicular 15 0.5 9/60.0 Fracture-Talus 32 1.1 14/43.8 s 0 3 .1 Fracture-5th Metatarsal 19 0.6 13/68.4 Osteoporosis 34 1.2 Fracture-Cuboid 0 6 .2 2/33.3 Fracture-Bimalleolar 96 3.3 Fracture-Trimalleolar 49 1.7 0 5 10 15 20 25 30 35 40 45 50 Finding Percentage of reports in which finding appears (%) l incidence of findings across the included 2947 reports 1 Total incidence Findin N g o. of reports Percentage of reports in which ﬁnding appears (%) Displaced (n/%) No Injury 1345 45.6 e swelling 709 24.1 Fracture-Lateral Malleolus 484 16.4 Weber A 47 1.6 Weber B 315 10.7 Weber C 12 4 2 .1 Fracture-Medial Malleolus 21 7 5 .3 90 /41.9 Fracture-Posterior Malleolus 75 2.5 18/24.0 Joint disloca n 10 3 4 .5 Fracture-Calcaneus 35 1.2 14/40.0 Fracture-Navicular 15 0.5 9/60.0 Fracture-Talus 32 1.1 14/43.8 s 0 3 .1 Fracture-5th Metatarsal 19 0.6 13/68.4 Osteoporosis 34 1.2 Fracture-Cuboid 0 6 .2 2/33.3 Fracture-Bimalleolar 96 3.3 Fracture-Trimalleolar 49 1.7 45.6 24.1 16.4 10.7 7.3 4.1 3.5 3.3 2.5 1.7 1.6 1.2 1.2 1.1 0.6 0.5 0.2 0.1 0 5 10 15 20 25 30 35 40 45 50 Finding Percentage of reports in which finding appears (%) Total incidence of findings across the included 2947 reports 45.6 24.1 16.4 10.7 7.3 4.1 3.5 3.3 2.5 1.7 1.6 1.2 1.2 1.1 0.6 0.5 0.2 0.1 0 5 10 15 20 25 30 35 40 45 50 Finding Percentage of reports in which finding appears (%) otal incidence of findings across the included 2947 reports Total incidence of findings across the included 2947 reports Skeletal Radiol (2020) 49:601–611 604 Reporting discrepancy This study demonstrates a reassuringly high accuracy in initial emergency department reporting of ankle X-rays, with dis- crepancy only being noted in 5.6% of final reports. This Skeletal Radiol (2020) 49:601–611 605 Table 2 Minor discrepancy incidence 48 24 6 6 4 3 1 1 1 Finding No. of reports Percentage of minor discrepancy reports appearing in (%) Displaced (n/%) So ssue swelling 24 28.2 Fracture-Lateral Malleolus 6 7.1 2/33.3 Weber A 6 7.1 Fracture-Medial Malleolus 4 4.7 2/50.0 Fracture-Posterior Malleolus 3 3.5 1/33.3 Fracture-Navicular 1 1.2 0/0.0 Fracture-Talus 1 1.2 1/100.0 Fracture-Cuboid 1 1.2 0/0.0 No Injury 48 56.5 0 10 20 30 40 50 60 Finding Minor Discrepancy Incidence Table 2 Minor discrepancy incidence 48 24 6 6 4 3 1 1 1 Fracture-Cuboid 1 1.2 0/0. No Injury 48 56.5 0 10 20 30 40 50 60 Finding Minor Discrepancy Incidence Total incidence of findings across the 85 reports classified as containing minor discrepancy 48 24 6 6 4 3 1 1 1 0 10 20 30 40 50 60 Finding Minor Discrepancy Incidence Total incidence of findings across the 85 reports classified as containing minor discrepancy Total incidence of findings across the 85 reports classified as containing minor discrepancy interpretation [14]. The reliability of initial X-ray reporting is strong evidence to support its practice in guiding early compares closely to a 3.8% rate of error seen across all lower limb imaging in a similar study of emergency department Table 3 Major discrepancy incidence 33 22 20 12 9 8 6 5 3 2 2 2 2 1 1 1 1 Finding No. Reporting discrepancy of reports Percentage of major discrepancy reports appearing in (%) Displaced (n/%) So ssue swelling 33 40.7 Fracture-Lateral Malleolus 22 27.2 Weber A 2 2.5 Weber B 8 9.9 Weber C 12 14.8 Fracture-Medial Malleolus 9 11.1 3/33.3 Fracture-Posterior Malleolus 1 1.2 1/100.0 Joint dislocaon 1 1.2 Fracture-Calcaneus 3 3.7 2/66.6 Fracture-Navicular 5 6.2 2/40.0 Fracture-Talus 6 7.4 3/50.0 Osteomyelis 2 2.5 Fracture-5th Metatarsal 2 2.5 2/100.0 Fracture-Cuboid 1 1.2 0/0.0 No Injury 20 24.7 Fracture-Bimalleolar 2 2.5 Fracture-Trimalleolar 1 1.2 0 5 10 15 20 25 30 35 Finding Major Discrepancy Incidence Total incidence of findings across the 81 reports classified as containing major discrepancy Skeletal Radiol (2020) 49:601–611 606 Skeletal Radiol (2020) 49:601–611 606 Table 3 Major discrepancy incidence 33 22 20 12 9 8 6 5 3 2 2 2 2 1 1 1 1 Finding No. of reports Percentage of major discrepancy reports appearing in (%) Displaced (n/%) So ssue swelling 33 40.7 Fracture-Lateral Malleolus 22 27.2 Weber A 2 2.5 Weber B 8 9.9 Weber C 12 14.8 Fracture-Medial Malleolus 9 11.1 3/33.3 Fracture-Posterior Malleolus 1 1.2 1/100.0 Joint dislocaon 1 1.2 Fracture-Calcaneus 3 3.7 2/66.6 Fracture-Navicular 5 6.2 2/40.0 Fracture-Talus 6 7.4 3/50.0 Osteomyelis 2 2.5 Fracture-5th Metatarsal 2 2.5 2/100.0 Fracture-Cuboid 1 1.2 0/0.0 No Injury 20 24.7 Fracture-Bimalleolar 2 2.5 Fracture-Trimalleolar 1 1.2 0 5 10 15 20 25 30 35 Finding Major Discrepancy Incidence Total incidence of findings across the 81 reports classified as containing major discrepancy Skeletal Radiol (2020) 49:601–611 606 Table 3 Major discrepancy incidence Finding No. Reporting discrepancy of reports Percentage of major discrepancy reports appearing in (%) Displaced (n/%) So ssue swelling 33 40.7 Fracture-Lateral Malleolus 22 27.2 Weber A 2 2.5 Weber B 8 9.9 Weber C 12 14.8 Fracture-Medial Malleolus 9 11.1 3/33.3 Fracture-Posterior Malleolus 1 1.2 1/100.0 Joint dislocaon 1 1.2 Fracture-Calcaneus 3 3.7 2/66.6 Fracture-Navicular 5 6.2 2/40.0 Fracture-Talus 6 7.4 3/50.0 Osteomyelis 2 2.5 Fracture-5th Metatarsal 2 2.5 2/100.0 Fracture-Cuboid 1 1.2 0/0.0 No Injury 20 24.7 Fracture-Bimalleolar 2 2.5 Fracture-Trimalleolar 1 1.2 33 22 20 12 9 8 6 5 3 2 2 2 2 1 1 1 1 0 5 10 15 20 25 30 35 Finding Major Discrepancy Incidence Total incidence of findings across the 81 reports classified as containing major discrepancy Total incidence of findings across the 81 reports classified as containing major discrepancy Skeletal Radiol (2020) 49:601–611 607 Table 4 Missed findings 1 2 2.1 2.5 5.1 5.3 5.8 6 8 8.6 9.8 10.5 17 21.9 33.3 40 66.7 Finding Total incidence Incidence missed Percentage missed (%) Osteomyelis* 3 2 66.7 Fracture-Navicular 15 6 40.0 Fracture-Cuboid 6 2 33.3 Fracture-Talus 32 7 21.9 Weber A 47 8 17.0 Fracture-5th Metatarsal 19 2 10.5 Weber C 122 12 9.8 Fracture-Calcaneus 35 3 8.6 So ssue swelling 709 57 8.0 Fracture-Medial Malleolus 215 13 6.0 Fracture-Lateral Malleolus 484 28 5.8 Fracture-Posterior Malleolus 75 4 5.3 No Injury 1345 68 5.1 Weber B 315 8 2.5 Fracture-Bimalleolar 96 2 2.1 Fracture-Trimalleolar 49 1 2.0 Joint dislocaon 104 1 1.0 0 10 20 30 40 50 60 70 80 Finding Percentage missed (%) Total incidence of findings against incidence of findings missed on initial report 1 2 2.1 2.5 5.1 5.3 5.8 6 8 8.6 9.8 10.5 17 21.9 33.3 40 66.7 0 10 20 30 40 50 60 70 80 Percentage missed (%) 1 2 2.1 2.5 5.1 5.3 5.8 6 8 8.6 9.8 10.5 17 21.9 33.3 40 66.7 0 10 20 30 40 50 60 70 80 Finding Percentage missed (%) tal incidence of findings against incidence of findings missed on initial report Total incidence of findings against incidence of findings missed on initial report Total incidence of findings against incidence of findings missed on initial report Skeletal Radiol (2020) 49:601–611 608 Time resolved discrepancy 12 18 13 1 41 40 43 36 Period No. Reporting discrepancy of reports (n/%) Expected Major Discrepancies Observed Major Discrepancies (n/%) Expected Minor Discrepancies Observed Minor Discrepancies (n/%) -0759 442/15.0 12 18/22.2 13 1/1.2 -1659 1503/51.0 41 40/49.4 43 36/42.4 -1959 472/16.0 13 14/17.3 14 19/22.4 -2359 530/18.0 15 9 /11.1 15 29/34.1 l 2947/100.0 81 81/100.0 85 85/100.0 0 2 4 6 8 10 12 14 16 18 20 Expected Major Discrepancies Observed Major Discrepancies Expected Minor Discrepancies Observed Minor Discrepancies Finding Time Period - 0000-0759 32 34 36 38 40 42 44 Expected Major Discrepancies Observed Major Discrepancies Expected Minor Discrepancies Observed Minor Discrepancies Finding Time Period - 0800-1659 12 18 13 1 0 2 4 6 8 10 12 14 16 18 20 Expected Major Discrepancies Observed Major Discrepancies Expected Minor Discrepancies Observed Minor Discrepancies Finding Time Period - 0000-0759 41 40 43 36 32 34 36 38 40 42 44 Expected Major Discrepancies Observed Major Discrepancies Expected Minor Discrepancies Observed Minor Discrepancies Finding Time Period - 0800-1659 Time Period - 0800-1659 609 Skeletal Radiol (2020) 49:601–611 5 (continued) 13 14 14 19 0 2 4 6 8 10 12 14 16 18 20 Expected Major Discrepancies Observed Major Discrepancies Expected Minor Discrepancies Observed Minor Discrepancies Finding Time Period - 1700-1959 15 9 15 29 0 5 10 15 20 25 30 35 Expected Major Discrepancies Observed Major Discrepancies Expected Minor Discrepancies Observed Minor Discrepancies Finding Time Period - 2000-2359 reports by time period, including expected and observed incidence 15 9 15 29 0 5 10 15 20 25 30 35 Expected Major Discrepancies Observed Major Discrepancies Expected Minor Discrepancies Observed Minor Discrepancies Finding Time Period - 2000-2359 reports by time period, including expected and observed incidence Total reports by time period, including expected and observed incidence other findings; in total 40.0% of all navicular and 33.3% of all cuboid fractures were missed on the initial report. This is consistent with an existing understanding that their appearance on X-ray can be ‘frequently difficult and occasionally elusive’ [15]. The navicular in particular is of significant importance to the overall stability of the foot and ankle. Its role in forming the keystone of the medial longitudinal arch of the foot means that missed injuries can lead to significant loss of function and pain [16]. Increased awareness of these fractures and their radiolog- ical appearance should be promoted in emergency department physicians and those reviewing ankle X-rays. Reporting discrepancy clinical management, suggesting that radiologically apparent ankle findings can be accurately identified on X-ray by emer- gency department physicians. Despite this, the presence of 166 reports containing dis- crepancy emphasises the need for a timely senior review of ankle X-rays. Of particular note are the 81 cases of major discrepancy where the virtual fracture clinic intervened to make changes to the patient’s management. The majority of these (75.3%) represented a false negative finding, which is likely reflected in the greater potential risk of a missed diag- nosis in this setting. A total of 3 reports included concerns for osteomyelitis, this was not mentioned in the initial findings of 2 reports. Although appearing relatively infrequently, midfoot frac- tures were missed with significantly greater regularity than 610 Skeletal Radiol (2020) 49:601–611 Whilst a high standard of accuracy supported the use of initial reporting to determine early clinical management, the presence of 166 reports with discrepancy indicates a continued need for timely senior review of ankle X-rays. Cuboid and navicular fractures were identified as frequently missed and should be a focus of increased awareness amongst initial reporters. Despite a very high proportion appearing as false negatives, the sensitivity and specificity of X-ray for osteomyelitis is insufficient for accurate diagnosis [17] and as such this finding is of minimal importance. Despite a very high proportion appearing as false negatives, the sensitivity and specificity of X-ray for osteomyelitis is insufficient for accurate diagnosis [17] and as such this finding is of minimal importance. References 1. Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T. Review article: best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculo- skeletal injuries rapid review series). Emerg Med Australas. 2017;30(2):152–80. 2. Bruno F, Arrigoni F, Splendiani A, Di Cesare E, Zappia M, Guglielmi G, et al. Emergency and trauma of the ankle. Semin Musculoskelet Radiol. 2017;21(03):282–9. 3. Elsoe R, Ostgaard S, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg. 2018;24(1):34–9. 4. Kadakia R, Ahearn B, Schwartz A, Tenenbaum S, Bariteau J. Ankle fractures in the elderly: risks and management challenges. Orthop Res Rev. 2017;9:45–50. Time resolved discrepancy Finally, there was evidence to support an increased rate of errors in initial reporting conducted outside of normal working hours (08:00–16:59). This adds to a growing evidence base suggesting the influence of fatigue, workload, and shift pat- terns on physician performance. There has been significant research on hours worked and time of day as potential causes for error in medical practice [9, 18, 19]. This study finds evidence to support the conclusion that ankle X-rays initially reported outside of routine working hours (08:00–16:59) display increased rates of discrepancy. This is true for the time period 00:00–07:59 where an increase in major discrepancies of 7.2% was found, though it should be noted that this narrowly missed the statistical threshold for significance, and from 20:00 to 23:59 where an increase in minor discrepancy of 16.1% was found. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appro- priate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The data used in this study does not precisely reflect the numbers of hours worked by the initial reporting physician and further research is needed to clarify how hours worked may affect this phenomenon independently of time of day. It has also been suggested that higher rates of reporting discrep- ancy may be attributable to a reduced workload on night shifts [20]. Such an explanation would be consistent with the lower volumes of initial reporting generated outside of 08:00–16:59 and is in-line with the overall trend of the data seen in this study; this makes the hypothesis of reduced workload a com- pelling explanation for these observations. Limitations A limitation of this study was the high proportion of the pre- liminary 6886 reports that failed to meet inclusion criteria due to an absent or incomplete assessment of agreement. Although the included 2947 reports represent a significant sample size, the remaining reports would have strengthened the evidence presented. Inertia in the uptake of a new reporting system likely represented the primary reason for this. 5. Stiell I. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269(9):1127–32. 6. 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Lam V, Stephenson J. A retrospective review of registrar out-of- hours reporting in a university hospital: the effect of time and se- niority on discrepancy rates. Clin Radiol. 2018;73(6):590.e9– 590.e12. Conclusions 12. Mitchell M, McKinley J, Robinson C. The epidemiology of calca- neal fractures. Foot. 2009;19(4):197–200. This study found a distribution of ankle X-ray findings con- sistent with that seen in existing data, with isolated malleolar fractures and specifically Weber type B lateral malleolar frac- tures representing the most common injuries [10, 11]. 13. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ. 2014;349(jul24 5):g4483. Skeletal Radiol (2020) 49:601–611 611 19. Ehsani SR, Cheraghi MA, Nejati A, Salari A, Esmaeilpoor AH, Nejad EM. Medication errors of nurses in the emergency depart- ment. J Med Ethics Hist Med. 2013;6:11. 15. Eichenholtz S, Levine D. Fractures of the tarsal navicular bone. Clin Orthop Relat Res. 1964;34:142–60. 20. Lam V, Stephenson J. A retrospective review of registrar out-of- hours reporting in a university hospital: the effect of time and se- niority on discrepancy rates. Clin Radiol. 2018;73(6):590.e9– 590.e12. 16. Penner M. Late reconstruction after navicular fracture. Foot Ankle Clin. 2006;11(1):105–19. 17. Lee Y, Sadigh S, Mankad K, Kapse N, Rajeswaran G. The imaging of osteomyelitis. Quant Imaging Med Surg. 2016;6(2):184–98. Publisher’s note Springer Nature remains neutral with regard to jurisdic- tional claims in published maps and institutional affiliations. 18. Ruutiainen A, Durand D, Scanlon M, Itri J. Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight. Acad Radiol. 2013;20(3): 305–11.
https://openalex.org/W2096221929	https://dash.harvard.edu/bitstream/1/32541453/3/nihms286875.pdf	English	null	Mucin-Producing Neoplasms of the Pancreas: An Analysis of Distinguishing Clinical and Epidemiologic Characteristics	Clinical gastroenterology and hepatology	2,010	cc-by	7,052	Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAA Permanent link http://nrs.harvard.edu/urn-3:HUL.InstRepos:32541453 Published Version doi:10.1016/j.cgh.2009.10.001 doi:10.1016/j.cgh.2009.10.001 Citation Crippa, Stefano, Carlos Fernández–del Castillo, Roberto Salvia, Dianne Finkelstein, Claudio Bassi, Ismael Domínguez, Alona Muzikansky, et al. 2010. Mucin-producing neoplasms of the pancreas: An analysis of distinguishing clinical and epidemiologic characteristics. Clinical Gastroenterology and Hepatology 8(2): 213–219. doi:10.1016/j.cgh.2009.10.001 Published Version doi:10.1016/j.cgh.2009.10.001 Published Version doi:10.1016/j.cgh.2009.10.001 NIH Public Access Author Manuscript NIH-PA Author Manuscript Clin Gastroenterol Hepatol. 2010 February ; 8(2): 213–219. doi:10.1016/j.cgh.2009.10.001. STEFANO CRIPPA, CARLOS FERNÁNDEZ–DEL CASTILLO‡, ROBERTO SALVIA, DIANNE FINKELSTEIN§, CLAUDIO BASSI, ISMAEL DOMÍNGUEZ‡, ALONA MUZIKANSKY§, SARAH P. THAYER‡, MASSIMO FALCONI, MARI MINO–KENUDSON\|\|, PAOLA CAPELLI¶, GREGORY Y. LAUWERS\|\|, STEFANO PARTELLI, PAOLO PEDERZOLI, and ANDREW L. WARSHAW‡ STEFANO CRIPPA, CARLOS FERNÁNDEZ–DEL CASTILLO‡, ROBERTO SALVIA, DIANNE FINKELSTEIN§, CLAUDIO BASSI, ISMAEL DOMÍNGUEZ‡, ALONA MUZIKANSKY§, SARAH P. THAYER‡, MASSIMO FALCONI, MARI MINO–KENUDSON\|\|, PAOLA CAPELLI¶, GREGORY Y. LAUWERS\|\|, STEFANO PARTELLI, PAOLO PEDERZOLI, and ANDREW L. WARSHAW‡ ‡ Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts NIH-PA Author Manuscript \|\| Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts § Department of Biostatistics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts § Department of Biostatistics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts § Department of Biostatistics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts * Department of Surgery, Policlinico “GB Rossi”, University of Verona, Verona, Italy ¶ Department of Pathology, Policlinico “GB Rossi”, University of Verona, Verona, Italy © 2010 by the AGA Institute Reprint requests: Address requests for reprints to: Carlos Fernández-del Castillo, MD, Department of Surgery, Massachusetts General Hospital, Wang Ambulatory Care Center 460, 15 Parkman Street, Boston, Massachusetts 02114. cfernandez@partners.org; fax: (617) 724-3383. Drs Pederzoli and Warshaw contributed equally to this work. Conflicts of interest The authors disclose no conflicts. Supplementary Data Note: to access the supplementary materials accompanying this article, visit the online version of Clinical Gastroenterology and Hepatology at www.cghjournal.org. Share Your Story The Harvard community has made this article openly available. Please share how this access benefits you. Submit a story . Accessibility NIH-PA Author Manuscript Mucin-Producing Neoplasms of the Pancreas: An Analysis of Distinguishing Clinical and Epidemiologic Characteristics or Manuscript NIH-PA Author Manuscript © 2010 by the AGA Institute Reprint requests: Address requests for reprints to: Carlos Fernández-del Castillo, MD, Department of Surgery, Massachusetts General Hospital, Wang Ambulatory Care Center 460, 15 Parkman Street, Boston, Massachusetts 02114. cfernandez@partners.org; fax: (617) 724-3383. D P d li d W h ib d ll hi k Supplementary Data Note: to access the supplementary materials accompanying this article, visit the online version of Clinical Gastroenterology and Hepatology at www.cghjournal.org. Abstract BACKGROUND & AIMS—Mucin-producing neoplasms (MPNs) of the pancreas include mucinous cystic neoplasms (MCNs) and main-duct, branch-duct, and combined intraductal papillary mucinous neoplasms (IPMNs). MCNs and branch-duct IPMNs are frequently confused; it is unclear whether main-duct, combined, and branch-duct IPMNs are a different spectrum of the same disease. We evaluated their clinical and epidemiologic characteristics. BACKGROUND & AIMS—Mucin-producing neoplasms (MPNs) of the pancreas include mucinous cystic neoplasms (MCNs) and main-duct, branch-duct, and combined intraductal papillary mucinous neoplasms (IPMNs). MCNs and branch-duct IPMNs are frequently confused; it is unclear whether main-duct, combined, and branch-duct IPMNs are a different spectrum of the same disease. We evaluated their clinical and epidemiologic characteristics. METHODS—Patients who underwent resection for histologically confirmed MPNs were identified (N = 557); specimens were reviewed and eventually re-classified. METHODS—Patients who underwent resection for histologically confirmed MPNs were identified (N = 557); specimens were reviewed and eventually re-classified. NIH-PA Author Manuscript RESULTS—One hundred sixty-eight patients (30%) had MCNs, 159 (28.5%) had branch-duct IPMNs, 149 (27%) had combined IPMNs, and 81 (14.5%) had main-duct IPMNs. Patients with MCNs were significantly younger and almost exclusively women; 44% of patients with main-duct or combined IPMNs and 57% of those with branch-duct IPMNs were women. MCNs were single lesions located in the distal pancreas (95%); 11% were invasive. IPMNs were more frequently found in the proximal pancreas; invasive cancer was found in 11%, 42%, and 48% of branch-duct, combined, and main-duct IPMNs, respectively (P =.001). Patients with invasive MCN and those with combined and main-duct IPMNs were older than those with noninvasive tumors. The 5-year disease-specific survival rate approached 100% for patients with noninvasive MPNs. The rates for NIH-PA Author Manuscript Page 2 CRIPPA et al. those with invasive cancer were 58%, 56%, 51%, and 64% for invasive MCNs, branch-duct IPMNs, main-duct IPMNs, and combined IPMNs, respectively. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH- CONCLUSIONS—MPNs comprise 3 different neoplasms: MCNs, branch-duct IPMNs, and main-duct IPMNs, including the combined type. These tumors have specific clinical, epidemiologic, and morphologic features that allow a reasonable degree of accuracy in preoperative diagnosis. Twenty-five years ago, Ohashi et al1 described 4 cases of an unusual form of pancreatic adenocarcinoma characterized by overproduction of mucus and diffuse distention of the pancreatic ductal system. Abstract A decade later, small case reports referred to this condition as “mucinous ductal ectasia,”2–4 and in 1996 the new classification for tumors of the exocrine pancreas by the World Health Organization labeled these tumors as intraductal papillary mucinous neoplasms (IPMNs),5 which could in different cases involve the main pancreatic duct (MPD) alone, the main duct and the branch ducts, or exclusively the side branches of the pancreas.6 During the last decade, IPMNs have become commonly diagnosed, often in patients with mild or no symptoms.7,8 Increasing evidence indicates that branch-duct IPMN is much less likely to harbor cancer than IPMN affecting the MPD,9–11 and in fact, recent guidelines put forward by the International Association of Pancreatology recommend observation alone for asymptomatic patients with branch-duct IPMNs that measure less than 3 cm in diameter and have no nodules.11 For many years another mucin-producing lesion of the pancreas, the mucinous cystic neoplasm (MCN), was confused or misdiagnosed with IPMN. Whereas IPMNs arise in the ductal system, MCNs do not, and unlike IPMNs, they characteristically contain an ovarian-like stroma.11–13 Inasmuch as the distinction between main-duct, branch-duct, and combined IPMNs is relatively recent and because the distinction between small MCNs and small branch-duct IPMNs can be quite difficult without full histologic analysis, accurate epidemiologic data distinguishing among the different mucin-producing neoplasms (MPNs) of the pancreas have been unreliable.11,12,14,15 It is still unclear whether main-duct and branch-duct IPMNs are different points on a spectrum or altogether different diseases, and where combined IPMNs fit. NIH-PA Author Manuscript The purpose of this study was to re-examine and compare the characteristics of a large cohort of patients with pathologically confirmed MPNs of the pancreas. Although we have previously reported the treatment of many of these patients,13,14,16 this new analysis brings together this group of neoplasms to highlight their differences and similarities. NIH-PA Author Manuscript Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Methods All patients who underwent pancreatic resection between January 1988 and December 2006 with a final histologic diagnosis of pancreatic MPNs were identified from prospective databases maintained at the Departments of Surgery of Massachusetts General Hospital, Boston, MA and of the University of Verona, Verona, Italy. Approval for this study was obtained from the Institutional Review Board at each institution. Because the pathologic criteria for the classification of pancreatic MPNs have changed over time, all surgical specimens were re-reviewed by senior pancreatic pathologists and classified as MCNs, main-duct, branch-duct, and combined-IPMNs. The number of histologic slides analyzed for all the specimens, including both MCNs and IPMNs, ranged from 3–94. Indeterminate mucinous cystic lesions were excluded from this study. Detailed diagnostic criteria5,6,11 are reported as supplementary material (Supplementary Document 1). Figure 1 and Supplementary Figures 1 and 2 show examples of radiologic, endoscopic, and pathologic images of different MPNs. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Page 3 Page 3 NIH-PA Author Manuscript CRIPPA et al. Study Population During the study period 592 patients were found to have pancreatic MPNs. Thirty-five (6%) had an indeterminate mucinous cystic lesion and were excluded from this analysis, leaving 557 patients to constitute the study population. Of these, 168 (30%) had MCNs, 159 (28.5%) had branch-duct IPMNs, 149 (27%) had combined IPMNs, and 81 (14.5%) had main-duct IPMNs. During the study period 592 patients were found to have pancreatic MPNs. Thirty-five (6%) had an indeterminate mucinous cystic lesion and were excluded from this analysis, leaving 557 patients to constitute the study population. Of these, 168 (30%) had MCNs, 159 (28.5%) had branch-duct IPMNs, 149 (27%) had combined IPMNs, and 81 (14.5%) had main-duct IPMNs. Information including demographics, clinical history, family history of pancreatic cancer, history of other malignant neoplasms, pathologic findings, and long-term follow-up was obtained from our prospective databases. For the purpose of survival analysis, patients with adenoma, borderline neoplasm, and carcinoma in situ were grouped as non-invasive and were compared with patients with invasive carcinoma arising from either MCNs or IPMNs. Detailed information regarding clinical history, symptoms, and timing of follow-up are reported as supplementary material (Supplementary Document 2). Statistical Analysis The goal of the present analysis was to elucidate (1) whether branch-duct, main-duct, and combined IPMNs represent distinct diseases and (2) the similarities and differences between MCNs and IPMNs, because these 2 entities have been largely confused.11–15 NIH-PA Author Manuscript Results are presented as frequencies and percentages for categorical variables and as median (range) for continous variables. Categorical variables were compared by using a χ2 test and Fisher exact test as appropriate. When comparing 2 groups, normally distributed continuous variables were analyzed by using a 2-sample Student t test, whereas the Mann–Whitney U test was used for non-normally distributed variables. One-way analysis of variance with post hoc analysis was performed for multiple comparisons with normal distribution, and the probability was adjusted by Tukey’s correction. Multivariate logistic models were fit by using stepwise regression. A P value was considered statistically significant if the two-sided test P value was <.05. Survival analysis was done by using the Kaplan–Meier function, comparing patients with different histotypes with the log-rank test. Combined, and Branch-Duct Intraductal Papillary Mucinous Neoplasms Table 1 shows the characteristics of patients with main-duct, combined, and branch-duct IPMNs. Patients were elderly, with no age differences among the 3 groups. Main-duct and combined IPMNs occured more frequently in men (55.5% of main-duct IPMNs and 56% of combined type), whereas branch-duct IPMNs occurred more frequently in women (57%) (main-duct versus branch-duct, P =.04; combined versus branch-duct, P =.01). Approximately 20% of patients with IPMNs, regardless of type, had a clinical history of other malignant neoplasms (Supplementary Table 1). All IPMN subtypes were more frequently located in the proximal pancreas. Diffuse neoplasms were found in 4% of main- duct IPMNs, 10% of combined type, and 37% of branch-duct IPMNs. Main-duct and combined type neoplasms extended continually along the MPD, whereas branch-duct IPMNs presented discontinually as multiple distinct lesions. NIH-PA Author Manuscript Incidental diagnosis was significantly more common in branch-duct IPMNs (34.5%) compared with main-duct (13.5%) and combined (19%) types. Abdominal pain or discomfort was a common symptom at diagnosis in all IPMN types; however, objective Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Page 4 Page 4 symptoms (ie, jaundice) were significantly more frequent in main-duct and combined IPMNs. ptoms (ie, jaundice) were significantly more frequent in main-duct and combined Ns symptoms (ie, jaundice) were significantly more frequent in main-duct and combined IPMNs. NIH-PA Author Manuscript Adenoma was the most common histotype in branch-duct IPMNs (44%). The prevalence of adenomas in main-duct and combined IPMNs was significantly lower (11% and 8%, respectively). Conversely, invasive cancer was significantly higher in main-duct (48%) and combined IPMNs (42%) compared with branch-duct lesions (11%). In patients with IPMNs containing invasive cancers, the frequency of lymph node metastases was 33% in main-duct IPMNs, 48.5% in combined, and 23.5% in branch-duct IPMNs. Moreover, although the age of patients with invasive versus noninvasive branch- duct IPMNs was similar (median, 66 versus 68 years; P =.2), patients with invasive main- duct IPMNs were significantly older than those with noninvasive ones (median, 69 versus 64.5 years; P =.04). Patients with combined IPMNs with invasive cancer were older than their noninvasive counterparts (median, 67.5 versus 64 years), but this difference did not achieve statistical significance (P =.1). Because the epidemiologic and clinicopathologic characteristics of main-duct and combined IPMNs were very similar, main-duct and combined IPMNs were grouped together and compared with branch-duct IPMNs in multivariate analysis. Mucinous Cystic Neoplasms Versus Branch-Duct Intraductal Papillary Mucinous Neoplasms The clinicopathologic characteristics of these 2 groups are shown in Table 3. Patients with MCNs were significantly younger than those with branch-duct IPMNs (median, 44.5 versus 66 years; P =.0001), and they were almost exclusively women (95% versus 57%; P =.0001). The frequency of other malignant neoplasms (Supplementary Table 1) was higher in branch- duct IPMNs (20% versus 9%; P =.006). Practically all MCNs were located in the distal pancreas (97%), whereas most branch-duct IPMNs (52%) were in the proximal pancreas; 37% of branch-duct IPMNs were multifocal, but all MCNs were single cystic lesions. Overall, 72.5% of MCN patients and 65.5% of those with branch-duct IPMNs were symptomatic, and specific symptoms were significantly more frequent in branch-duct IPMNs. NIH-PA Author Manuscript The prevalence of invasive carcinoma was the same (11%) in the 2 groups. MCNs showed a higher frequency of adenoma (73% versus 44%) and a lower frequency of borderline neoplasms (10% versus 34%) and carcinoma in situ (6% versus 11%). Strikingly, no lymph node metastases were found associated with invasive MCNs, whereas 23.5% of patients with invasive branch-duct IPMNs did have metastatic nodes. Among all the factors found to be significantly different between MCNs and branch-duct IPMNs, age, gender, presence of acute pancreatitis, and distal pancreas as tumor site remained significant in the multivariate logistic model (Table 4). Combined, and Branch-Duct Intraductal Papillary Mucinous Neoplasms The logistic regression model (Table 2) showed that gender, weight loss, and the presence of an invasive tumor remained significant in differentiating these IPMN subtypes. NIH-PA Author Manuscript Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Tumor Recurrence and Survival Follow-up was available in 97% of the patients. The median follow-up for the entire cohort was 50 months (range, 2–233 months) and 61 months (range, 8–233 months) for living patients. The 5-year survival for all patients with MCNs, branch-duct IPMNs, main-duct IPMNs, and combined IPMNs was 94%, 91%, 65%, and 77%, respectively (Supplementary Figure 3). The 5-year disease-specific survival for patients with noninvasive branch-duct IPMNs was 100%, and it was 56% for those with invasive cancer (Figure 2a). Thirteen Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Page 5 Page 5 patients (8%) with branch-duct IPMNs had a recurrence. Of these, 6 patients with an adenoma developed a new (metachronous) branch-duct IPMN that was asymptomatic and small in size (<30 mm); these patients are being managed conservatively. The remaining 7 patients originally had an invasive carcinoma, which recurred after a mean of 28 months (range, 6–72 months) with distant metastases (liver and lungs), accounting for a recurrence rate of 41%. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Au The 5-year disease-specific survival was 95% for patients with noninvasive main-duct IPMNs and 51% for those with invasive carcinoma (Figure 2b). Overall, 19 patients (23.5%) developed a recurrence. One patient with carcinoma in situ who had total pancreatectomy because of an involvement of the entire gland developed histologically confirmed, intraperitoneal carcinomatosis with pseuodomyxoma peritonei 38 months after initial surgery. No invasive cancer was found in the resected total pancreatectomy specimen, and the patient subsequently died of metastatic disease. Seventeen of the 39 patients (43.5%) with invasive carcinoma developed local recurrence (n = 3) or liver metastases (n = 14) after a mean of 20.6 months (range, 4–50 months). In combined IPMNs, the 5-year disease- specific survival was 100% and 64% for noninvasive and invasive neoplasms, respectively (Figure 2c). Twenty-seven patients (18%) developed tumor recurrence. Of these, 25 patients originally had invasive carcinoma, accounting for a recurrence rate of 40% in this subgroup, and developed tumor recurrence after a mean of 18.5 months (range, 4–67 months). Twenty- two patients had metastatic disease, whereas the remaining 2 had only local recurrence. r Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript The 5-year disease-specific survival for MCNs was 100% and 58% for patients with noninvasive and invasive tumors, respectively (Figure 2d). Patients with noninvasive neoplasms had no recurrences. Tumor Recurrence and Survival Seven patients, comprising 37% of invasive carcinomas, developed tumor recurrence in the peritoneum or liver after a mean of 32.5 months (range, 4–99 months). Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Discussion The apparent incidence of MPNs of the pancreas, and particularly of IPMNs, has increased markedly during the past 15 years; these now represent one of the most common indications for pancreatic resection at high-volume centers.14–17 The higher numbers of reported cases might be due to improved imaging techniques, greater awareness of this pathology by the gastroenterological community, and increased incidental diagnosis among asymptomatic individuals. NIH-PA Author Manuscript NIH-PA Author Manuscript It is only in recent years that a clear distinction between MCNs and IPMNs and between branch-duct and main-duct IPMNs has emerged.13–18 Growing knowledge of their biologic behavior indicates that clear identification and distinction of MCNs and main-duct and branch-duct IPMNs are not only of taxonomic significance but have a practical impact on patient management. For example, branch-duct IPMNs appear to carry a much lower risk of malignant degeneration compared with main-duct IPMNs, and nonsurgical management with surveillance is feasible for many of these lesions, thereby avoiding “prophylactic” pancreatectomy with its associated risks.8,11,16,19–24 Nonetheless, in the past, a strict distinction was not made between the variants of IPMNs and MCNs. As yet there has been no consensus as to whether main-duct and branch-duct IPMNs are 2 different neoplasms or a spectrum of the same condition, and whether combined IPMNs are a progression of main-duct or branch-duct type or a distinct disease as well.11,14,17 The latter question is of strategic importance because if combined IPMNs turn out to be a progression from branch-duct IPMNs, this would mandate a closer long-term surveillance of branch-duct IPMNs than is currently advised. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Page 6 Page 6 NIH-PA Author Manuscript To provide clear-cut, reproducible distinctions between main-duct, branch-duct, and combined IPMNs and MCNs, we applied strict histopathologic criteria in our reviewing of 592 cases of MPNs of the pancreas. We excluded 35 mucinous lesions of indeterminate classification comprising 6% of the series. NIH-PA Author Manuscript N Our study showed that branch-duct IPMNs have a specific profile, likely representing an entity distinct from other IPMNs, and that combined IPMNs show close overlapping similarities with main-duct IPMNs in regard to clinicopathologic and epidemiologic characteristics. For example, we found that main-duct and combined IPMNs have the same sex ratio (female, 44%; male, 56%), opposite to that of branch-duct type (female, 57%; male, 43%). Discussion Although the median age at presentation was similar in the 3 groups, patients affected by main-duct and combined IPMNs with invasive cancer were significantly older than those with noninvasive neoplasms. This age difference suggests progression from adenoma to invasive carcinoma, a finding that was not present in branch-duct IPMNs. Furthermore, branch-duct IPMNs were more likely to be asymptomatic, whereas the majority of patients with main-duct and combined IPMNs were symptomatic. Finally, most patients with branch-duct IPMNs had an adenoma (44%), whereas the prevalence of cancer was 22% (invasive cancer, 11%). In contrast, main-duct and combined IPMNs contained malignant elements in 68% and 62%, respectively, with invasive cancer present in 48% and 42%. Considering these findings, we conclude that combined IPMNs likely represent an extension of main-duct IPMNs to the branch ducts of the pancreas. The similar age differential between noninvasive and invasive tumors14,18 and the greater frequency of malignancy in both main-duct and combined IPMNs suggest that these 2 IPMN subgroups share not only common morphology but also an aggressive biology characterized by progression to invasive cancer. No significant differences were found among the 3 groups with respect to disease-specific survival. The disease-specific survival rates found for all these types of IPMNs with invasive cancer appear to be higher than those seen in ductal adenocarcinoma of the pancreas and are consistent with other previously reported series.14,16,18 However, 5 No significant differences were found among the 3 groups with respect to disease-specific survival. The disease-specific survival rates found for all these types of IPMNs with invasive cancer appear to be higher than those seen in ductal adenocarcinoma of the pancreas and are consistent with other previously reported series.14,16,18 However, Schnelldorfer et al25 reported no differences in overall survival when comparing 63 patients with invasive IPMNs and 63 matched patients (by disease stage) with ductal adenocarcinoma (5-year survival, 31% versus 24%; P =.26). A disease-specific survival analysis was not performed in this study. Larger studies with longer follow-up and careful patient stratification by disease stage and histopathologic prognostic criteria are needed to confirm these findings. Schnelldorfer et al25 reported no differences in overall survival when comparing 63 patients with invasive IPMNs and 63 matched patients (by disease stage) with ductal adenocarcinoma (5-year survival, 31% versus 24%; P =.26). A disease-specific survival analysis was not performed in this study. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Discussion Larger studies with longer follow-up and careful patient stratification by disease stage and histopathologic prognostic criteria are needed to confirm these findings. NIH-PA Author Manuscript NIH-PA Author Manuscript A surprising observation was the peritoneal recurrence 38 months from initial surgery in a patient with main-duct IPMN with in situ carcinoma who underwent total pancreatectomy. In retrospect, the specimen was divided during resection, thereby allowing mucin to spill from the resected duct, and we presume that tumor cells were seeded at this time. This experience, albeit rare, raises a concern about allowing egress of duct contents that might harbor tumor cells. Local recurrence or metachronous lesions in the pancreatic remnant were detected in patients with both invasive and noninvasive IPMNs, hypothesizing a “field defect” in the entire pancreas that could mandate lifetime surveillance.11,26,27 A second end point of the study was to compare MCNs and branch-duct IPMNs because MCNs and branch-duct IPMNs can be potentially confused, at least in the preoperative setting.11–13 Our data suggest that when strict histologic criteria are applied, in particular the presence of ovarian-like stroma, these neoplasms have very distinct clinicopathologic and epidemiologic features. In multivariate analysis, age, gender, site, and the presence of acute pancreatitis were independent predictors useful to distinguish MCNs and branch-duct IPMNs. Typically, MCNs present as a large cyst located in the distal pancreas of a middle- Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Page 7 Page 7 aged woman and have no connection with the ductal system. However, the differential diagnosis of small cysts located in the distal pancreas might be difficult. Modern imaging techniques, particularly magnetic resonance with cholangiopancreatography and endoscopic ultrasound, might demonstrate pancreatic duct branches emanating from the cyst lesion, thereby defining it as an IPMN.17,28 Multifocal cysts also indicate IPMNs, inasmuch as MCNs are always single. NIH-PA Author Manuscript The distinction among main-duct, branch-duct, and combined IPMNs and MCNs has major implications in clinical practice. Acknowledgments Funding This study was supported by the International Hepato-Pancreato-Biliary Association (Warren Fellowship Award to S.C.), Fundacion Harvard en Mexico (to I.D.), Fondazione Italiana Malattie Pancreas. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Discussion Recent guidelines suggest that nonoperative management is safe for patients with asymptomatic branch-duct IPMNs <3 cm in size without nodules,11 whereas there is a general consensus that the risk of malignancy in any IPMN involving the MPD should be viewed with concerns (and resected).14,17,18 Our study indicated that the risk of cancer in MCNs (11% invasive and 6% in situ) is relatively low and potentially could allow for nonoperative management in the majority—those that are asymptomatic, less than 4 cm in diameter, and without solid components. However, because most of these are diagnosed in young women with long life expectancy, the cost-effectiveness and safety of this approach should be carefully considered and balanced with the potential costs of postoperative pancreatic endocrine insufficiency.13,15,16 anuscript NIH-PA Author Manuscript In summary, the results of this study showed that MCNs of the pancreas comprise 3 (not 4) different neoplasms: MCNs, branch-duct IPMNs, and main-duct IPMNs including the combined type. These tumors have specific clinical and morphologic features that allow a reasonable degree of accuracy in preoperative differential diagnosis and thereby influence the strategy for clinical management. NIH-PA Author Manuscript Supplementary Material Refer to Web version on PubMed Central for supplementary material. Abbreviations used in this paper NIH-PA Author Manuscript p p IPMN intraductal papillary mucinous neoplasm MCN mucinous cystic neoplasm MPD main pancreatic duct MPN mucin-producing neoplasm IPMN intraductal papillary mucinous neoplasm MCN mucinous cystic neoplasm MPD main pancreatic duct MPN mucin-producing neoplasm References 1. Ohashi K, Murakami Y, Murayama M, et al. Four cases of mucus secreting pancreatic cancer. Prog Dig Endoscopy. 1982; 20:348–351. 2. Warshaw AL, Compton CC, Lewandrowski K, et al. Cystic tumors of the pancreas: new clinical, radiologic, and pathologic observations in 67 patients. Ann Surg. 1990; 212:432–443. [PubMed: 2171441] 3. Yamaguchi K, Tanaka M. Mucin-hypersecreting tumor of the pancreas with mucin extrusion through an enlarged papilla. Am J Gastroenterol. 1991; 86:835–839. [PubMed: 2058624] Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Page 8 NIH-PA Author Manuscript 4. Kawarada Y, Yano T, Yamamoto T, et al. Intraductal mucin-producing tumors of the pancreas. Am J Gastroenterol. 1992; 87:634–638. [PubMed: 1317671] NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Auth 5. Kloppel, G.; Solcia, E.; Longnecker, DS., et al. World Health Organization international histological typing of tumors of the exocrine pancreas. Berlin: Springer-Verlag; 1996. p. 1-61. 6. Longnecker, DS.; Hruban, RH.; Kloppel, G. Intraductal papillary-mucinous neoplasms of the pancreas. In: Hamilton, SR.; Aaltonen, LA., editors. World Health Organization classification of tumors: pathology and genetics of tumors of the digestive system. Lyon: IARC Press; 2000. p. 237-241. 7. Fernandez-del Castillo C, Targarona J, Thayer SP, et al. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg. 2003; 138:427–433. [PubMed: 12686529] 8. Salvia R, Crippa S, Falconi M, et al. Branch-duct intraductal papillary mucinous neoplasms of the pancreas: to operate or not to operate? Gut. 2007; 56:1086–1090. [PubMed: 17127707] 9. Kobari M, Egawa S, Shibuya K, et al. Intraductal papillary mucinous tumors of the pancreas comprise 2 clinical subtypes: differences in clinical characteristics and surgical management. Arch Surg. 1999; 134:1131–1136. [PubMed: 10522860] 10. Terris B, Ponsot P, Paye F, et al. Intraductal papillary mucinous tumors of the pancreas confined to secondary ducts show less aggressive pathologic features as compared with those involving the main pancreatic duct. Am J Surg Pathol. 2000; 24:1372–1377. [PubMed: 11023098] 11. Tanaka M, Chari S, Adsay V, et al. International Association of Pancreatology: international consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology. 2006; 6:17–32. [PubMed: 16327281] 12. Reddy RP, Smyrk TC, Zapiach M, et al. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Abbreviations used in this paper Pancreatic mucinous cystic neoplasm defined by ovarian stroma: demographics, clinical features, and prevalence of cancer. Clin Gastroenterol Hepatol. 2004; 2:1026–1031. [PubMed: 15551256] 13. Crippa S, Salvia R, Warshaw AL, et al. Mucinous cystic neoplasm is not an aggressive entity: lessons from 163 resected patients. Ann Surg. 2008; 247:571–579. [PubMed: 18362619] 14. Salvia R, Fernandez-del Castillo C, Bassi C, et al. Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg. 2004; 239:678–685. [PubMed: 15082972] 15. Sonnenday CJ, Simeone DM. “Criminal” profiling of the pancreas: when is aggressive therapy indicated for a non-aggressive entity? Ann Surg. 2008; 247:580–582. [PubMed: 18362620] 16. Rodriguez JR, Salvia R, Crippa S, et al. Branch-duct intraductal papillary mucinous neoplasms: observations in 145 patients who underwent resection. Gastroenterology. 2007; 133:72–79. [PubMed: 17631133] NIH-PA Author Manuscript 17. Crippa S, Fernandez-del Castillo C. Management of intraductal papillary mucinous neoplasms of the pancreas. Curr Gastroenterol Rep. 2008; 10:136–143. [PubMed: 18462599] NIH-PA Author Manuscript 18. Sohn TA, Yeo CJ, Cameron JL, et al. Intraductal papillary mucinous neoplasms of the pancreas: an updated experience. Ann Surg. 2004; 239:788–797. [PubMed: 15166958] 19. Tanno S, Nakano Y, Nishikawa T, et al. Natural history of branch duct intraductal papillary- mucinous neoplasms of the pancreas without mural nodules: long-term follow-up results. Gut. 2008; 57:339–343. [PubMed: 17660227] 20. Levy P, Jouannaud V, O’Toole D, et al. Natural history of intraductal papillary mucinous tumors of the pancreas: actuarial risk of malignancy. Clin Gastroenterol Hepatol. 2006; 4:460–468. [PubMed: 16616351] 21. Palaez-Luna M, Chari ST, Smyrk TC, et al. Do consensus indications for resection in branch-duct intraductal papillary mucinous neoplasm predict malignancy? a study of 147 patients. Am J Gastroenterol. 2007; 102:1759–1764. [PubMed: 17686073] 22. Rautou PE, Levy P, Vuillierme MP, et al. Morphologic changes in branch duct intraductal papillary mucinous neoplasms of the pancreas: a midterm follow-up study. Clin Gastroenterol Hepatol. 2008; 6:807–814. [PubMed: 18304885] 23. Tang RS, Weinberg B, Dawson DW, et al. Evaluation of the guidelines for management of pancreatic branch-duct intraductal papillary mucinous neoplasm. Clin Gastroenterol Hepatol. 2008; 6:815–819. [PubMed: 18602036] Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Page 9 Page 9 NIH-PA Author Manuscript 24. Schmidt CM, White PB, Waters JA, et al. Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg. 2007; 246:644–654. [PubMed: 17893501] NIH-PA Author Manuscript NIH-PA A 25. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. 28. Waters JA, Schmidt CM, Pinchot JW, et al. CT vs MRCP: optimal classification of IPMN type and extent. J Gastrointest Surg. 2008; 12:101–109. [PubMed: 17917784] Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Abbreviations used in this paper Schnelldorfer T, Sarr MG, Nagorney DM, et al. Experience with 208 resections for intraductal papillary mucinous neoplasms of the pancreas. Arch Surg. 2008; 143:639–646. [PubMed: 18645105] 26. White R, D’Angelica M, Katabi N, et al. Fate of the remnant pancreas after resection of noninvasive intraductal papillary mucinous neoplasm. J Am Coll Surg. 2007; 204:987–995. [PubMed: 17481526] 27. Chari ST, Yadav D, Smyrk TC, et al. Study of recurrence after surgical resection of intraductal papillary mucinous neoplasm of the pancreas. Gastroenterology. 2002; 123:1500 –1507. [PubMed: 12404225] 28. Waters JA, Schmidt CM, Pinchot JW, et al. CT vs MRCP: optimal classification of IPMN type and extent. J Gastrointest Surg. 2008; 12:101–109. [PubMed: 17917784] NIH-PA Author Manuscript NIH-PA Author Manuscript CRIPPA et al. Page 10 NIH-PA Author Manuscript Figure 1. Examples of imaging of main-duct (A, B), branch-duct (C, D), combined IPMN (E), and MCN (F). (A) Endoscopic ultrasound features with mural nodule in a dilated MPD. (B) Main-duct IPMN at magnetic resonance cholangiopancreatography. (C) Branch-duct IPMN at endoscopic ultrasound. (D) Multifocal branch-duct IPMN at magnetic resonance cholangiopancreatography. (E) Radiologic features of combined IPMN at computed tomography scan. (F) Computed tomography features of an MCN. NIH-PA Author Manuscript NIH Figure 1. Examples of imaging of main-duct (A, B), branch-duct (C, D), combined IPMN (E), and MCN (F). (A) Endoscopic ultrasound features with mural nodule in a dilated MPD. (B) Main-duct IPMN at magnetic resonance cholangiopancreatography. (C) Branch-duct IPMN at endoscopic ultrasound. (D) Multifocal branch-duct IPMN at magnetic resonance cholangiopancreatography. (E) Radiologic features of combined IPMN at computed tomography scan. (F) Computed tomography features of an MCN. NIH-PA Author Manuscript CRIPPA et al. Page 11 Figure 2. Five-year disease-specific survival (DSS) comparing patients with noninvasive neoplasms including adenoma, borderline, and carcinoma in situ (black lines) and patients with invasive cancer (hatched lines) for different pancreatic MPNs. (A) DSS of 100% and 56% in noninvasive and invasive branch-duct IPMNs, respectively. (B) DSS of 95% and 51% in noninvasive and invasive main-duct IPMNs, respectively. (C) DSS of 100% and 64% in noninvasive and invasive combined IPMNs, respectively. (D) DSS of 100% and 56% in noninvasive and invasive branch-duct IPMNs, respectively. Figure 2. Five-year disease-specific survival (DSS) comparing patients with noninvasive neoplasms including adenoma, borderline, and carcinoma in situ (black lines) and patients with invasive cancer (hatched lines) for different pancreatic MPNs. (A) DSS of 100% and 56% in noninvasive and invasive branch-duct IPMNs, respectively. Abbreviations used in this paper (B) DSS of 95% and 51% in noninvasive and invasive main-duct IPMNs, respectively. (C) DSS of 100% and 64% in noninvasive and invasive combined IPMNs respectively (D) DSS of 100% and 56% in NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA A Figure 2. Figure 2. Five-year disease-specific survival (DSS) comparing patients with noninvasive neoplasms including adenoma, borderline, and carcinoma in situ (black lines) and patients with invasive cancer (hatched lines) for different pancreatic MPNs. (A) DSS of 100% and 56% in noninvasive and invasive branch-duct IPMNs, respectively. (B) DSS of 95% and 51% in noninvasive and invasive main-duct IPMNs, respectively. (C) DSS of 100% and 64% in noninvasive and invasive combined IPMNs, respectively. (D) DSS of 100% and 56% in noninvasive and invasive branch-duct IPMNs, respectively. NIH-PA Author Manuscript Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Table 1 Epidemiologic and Clinicopathologic Characteristics of Patients With Main-Duct, Branch-Duct, and Combined IPMNs Main-duct IPMNs (n = 81) Combined IPMNs (n = 149) Branch-duct IPMNs (n = 159) P value, main-duct vs combined P value, main-duct vs branch- duct P value, combined vs branch-duct Median age, y (range) 67 (37–85) 66 (31–87) 66 (35–90) .7 .9 .7 Page 12 Page 12 CRIPPA et al. Table 1 Epidemiologic and Clinicopathologic Characteristics of Patients With Main-Duct, Branch-Duct, and Combined IPMNs Main-duct IPMNs (n = 81) Combined IPMNs (n = 149) Branch-duct IPMNs (n = 159) P value, main-duct vs combined P value, main-duct vs branch- duct P value, combined vs branch-duct Median age, y (range) 67 (37–85) 66 (31–87) 66 (35–90) .7 .9 .7 Sex (%) Female 36 (44.5) 66 (44) 91 (57) .5 .04 .01 Male 45 (55.5) 83 (56) 68 (43) Family history of pancreatic cancer (%) Yes 6 (7.5) 12 (8) 16 (11) .5 .2 .2 No 75 (92.5) 137 (92) 126 (89) History of other neoplasm (%) Yes 18 (22) 29 (19.5) 32 (20) .3 .4 .4 No 63 (78) 120 (80.5) 127 (80) Tumor site (%) Proximal 52 (64) 100 (67) 82 (52) .7 .4 .1 Distal 26 (32) 34 (23) 40 (25) .1 .6 .3 Diffuse 3 (4) 15 (10) 37 (23) .1 .0001 .003 Entire pancreas along MPD 3 (4) 15 (10) 0 Multifocal lesions 0 0 37 (23) Incidental diagnosis (%) Yes 11 (13.5) 28 (19) 55 (34.5) .2 .0001 .001 No 70 (86.5) 121 (81) 104 (65.5) Abdominal pain (%)a Yes 45 (53) 88 (59) 72 (45) .2 .1 .1 No 38 (47) 61 (41) 87 (55) Presence of other symptoms (%)a Yes 59 (73) 89 (60) 72 (45) .032 .0001 .008 No 22 (27) 60 (40) 87 (65) Jaundice 14 (17) 25 (17) 7 (5) .5 .001 .001 Diabetes 10 (12) 16 (11) 14 (9) .4 .2 .3 Weight loss 41 (50.5) 60 (40) 37 (23) .08 .0001 .001 Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. NIH-PA Author Manuscript Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Table 1 Epidemiologic and Clinicopathologic Characteristics of Patients With Main-Duct, Branch-Duct, and Combined IPMNs Main-duct IPMNs (n = 81) Combined IPMNs (n = 149) Branch-duct IPMNs (n = 159) P value, main-duct vs combined P value, main-duct vs branch- duct P value, combined vs branch-duct Median age, y (range) 67 (37–85) 66 (31–87) 66 (35–90) .7 .9 .7 Page 13 Page 13 Main-duct IPMNs (n = 81) Combined IPMNs (n = 149) Branch-duct IPMNs (n = 159) P value, main-duct vs combined P value, main-duct vs branch- duct P value, combined vs branch-duct Acute pancreatitis 14 (17) 17 (11.5) 27 (17) .1 .5 .1 Pathology (%) Adenoma 9 (11) 12 (8) 71 (44) .5 .0001 .0001 Borderline 17 (21) 45 (30) 54 (34) .1 .05 .5 Carcinoma in situ 16 (20) 30 (20) 17 (11) .9 .08 .03 Invasive carcinoma 39 (48) 62 (42) 17 (11) .4 .0001 .0001 Presence of lymph node metastases (%)b 13 (33) 30 (48.5) 4 (23.5) .09 .3 .05 aSome patients complained of more than 1 symptom. bRate of lymph node metastases was calculated considering only patients with invasive cancer. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Main-duct IPMNs (n = 81) Combined IPMNs (n = 149) Branch-duct IPMNs (n = 159) P value, main-duct vs combined P value, main-duct vs branch- duct P value, combined vs branch-duct Acute pancreatitis 14 (17) 17 (11.5) 27 (17) .1 .5 .1 Pathology (%) Adenoma 9 (11) 12 (8) 71 (44) .5 .0001 .0001 Borderline 17 (21) 45 (30) 54 (34) .1 .05 .5 Carcinoma in situ 16 (20) 30 (20) 17 (11) .9 .08 .03 Invasive carcinoma 39 (48) 62 (42) 17 (11) .4 .0001 .0001 Presence of lymph node metastases (%)b 13 (33) 30 (48.5) 4 (23.5) .09 .3 .05 aSome patients complained of more than 1 symptom. bRate of lymph node metastases was calculated considering only patients with invasive cancer Main-duct IPMNs (n = 81) Combined IPMNs (n = 149) Branch-duct IPMNs (n = 159) P value, main-duct vs combined P value, main-duct vs branch- duct P value, combined vs branch-duct Acute pancreatitis 14 (17) 17 (11.5) 27 (17) .1 .5 .1 Pathology (%) Adenoma 9 (11) 12 (8) 71 (44) .5 .0001 .0001 Borderline 17 (21) 45 (30) 54 (34) .1 .05 .5 Carcinoma in situ 16 (20) 30 (20) 17 (11) .9 .08 .03 Invasive carcinoma 39 (48) 62 (42) 17 (11) .4 .0001 .0001 Presence of lymph node metastases (%)b 13 (33) 30 (48.5) 4 (23.5) .09 .3 .05 aSome patients complained of more than 1 symptom. bRate of lymph node metastases was calculated considering only patients with invasive cancer. Clin Gastroenterol Hepatol. Author manuscrip Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. CRIPPA et al. Table 1 Epidemiologic and Clinicopathologic Characteristics of Patients With Main-Duct, Branch-Duct, and Combined IPMNs Main-duct IPMNs (n = 81) Combined IPMNs (n = 149) Branch-duct IPMNs (n = 159) P value, main-duct vs combined P value, main-duct vs branch- duct P value, combined vs branch-duct Median age, y (range) 67 (37–85) 66 (31–87) 66 (35–90) .7 .9 .7 NIH-PA Author Manuscript Page 14 Page 14 CRIPPA et al. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. bRate of lymph node metastases was calculated considering only patients with invasive cancer. aSome patients complained of more than 1 symptom. Table 2 NIH-PA Author Manuscript Results of Multivariate Logistic Model Using Stepwise Selection Method for Patients With Main-Duct and Combined IPMNs Versus Those With Branch-Duct IPMNs Variable Hazard ratio (95% confidence interval) P value Gender 0.551 (0.353–0.859) .008 Weight loss 0.488 (0.301–0.793) .003 Invasive neoplasm versus noninvasive 0.167 (0.093–0.298) <.0001 f Multivariate Logistic Model Using Stepwise Selection Method for Patients With Main-Duct and d IPMNs Versus Those With Branch-Duct IPMNs anuscript NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ript NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Page 15 Page 15 CRIPPA et al. Table 3 Table 3 NIH-PA Author Manuscript Epidemiologic and Clinicopathologic Characteristics of Patients With MCNs Compa Branch-Duct IPMNs MCNs (n = 168) Branch-duct IPMNs (n = 159) P value Median age, y (range) 44.5 (16–82) 66 (35–90) .0001 Sex (%) Female 160 (95) 91 (57) .0001 Male 8 (5) 68 (43) Family history of pancreatic cancer (%) Yes 6 (3.5) 16 (11) .01 No 162 (96.5) 126 (89) History of other neoplasm (%) Yes 15 (9) 32 (20) .006 No 153 (91) 127 (80) Tumor site (%) Proximal 5 (3) 82 (52) .0001 Distal 163 (97) 40 (25) Multifocal lesions 0 37 (23) Incidental diagnosis (%) Yes 46 (27.5) 55 (34.5) .1 No 122 (72.5) 104 (65.5) Abdominal pain (%)a Yes 104 (62) 72 (45) .004 No 64 (38) 87 (55) Presence of other symptoms (%)a Yes 44 (26%) 72 (45%) .0001 No 124 (74%) 87 (65%) Jaundice 1 (0.5) 7 (5) .06 Diabetes 9 (5.5) 14 (9) .3 Weight loss 27 (16) 37 (23) .1 Acute pancreatitis 9 (5.5) 27 (17) .001 Pathology (%) Adenoma 122 (73) 71 (44) .0001 Borderline 17 (10) 54 (34) .001 Carcinoma in situ 10 (6) 17 (11) .2 Invasive carcinoma 19 (11) 17 (11) .8 Median tumor size, mm (range) 49 (8–150) 20 (5–100) .0001 Presence of lymph node metastases (%)b 0 4 (23.5) .08 aSome patients complained of more than 1 symptom. bRate of lymph node metastases was calculated considering only patients with invasive cancer. gic and Clinicopathologic Characteristics of Patients With MCNs Compared With Those With t IPMNs Epidemiologic and Clinicopathologic Characteristics of Patients With MCNs Compared With Those With Branch-Duct IPMNs NIH-PA Author Manuscript cript NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript bRate of lymph node metastases was calculated considering only patients with invasive cancer. Clin Gastroenterol Hepatol. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. Table 2 Author manuscript; available in PMC 2011 July 13. Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2011 July 13. NIH-PA Author Manuscript Page 16 Page 16 CRIPPA et al. Table 4 NIH-PA Author Manuscript Results of Multivariate Logistic Model by Using Stepwise Selection Method for Patients With MCNs Versus Those With Branch-Duct IPMNs Results of Multivariate Logistic Model by Using Stepwise Selection Method for Patients With MCNs Versus Those With Branch-Duct IPMNs Results of Multivariate Logistic Model by Using Stepwise Selection Method for Patients With MCNs Versus Those With Branch-Duct IPMNs Variable Hazard ratio (95% confidence interval) P value Age 1.130 (1.088–1.172) <.0001 Gender 3.168 (1.114–9.013) .03 Acute pancreatitis 10.75 (2.813–41.120) .0005 Distal pancreas 0.015 (0.005–0.050) <.0001 Variable Hazard ratio (95% confidence interval) P value Age 1.130 (1.088–1.172) <.0001 Gender 3.168 (1.114–9.013) .03 Acute pancreatitis 10.75 (2.813–41.120) .0005 Distal pancreas 0.015 (0.005–0.050) <.0001 NIH-PA Author Manuscript NIH-PA Author ript NIH-PA Author Manuscript NIH-PA Author Manuscript
https://openalex.org/W2035962911	https://figshare.com/articles/journal_contribution/Thermo_sensitive_nanoparticles_for_triggered_release_of_siRNA/1285709/2/files/1861925.pdf	English	null	Thermo-sensitive nanoparticles for triggered release of siRNA	Journal of biomaterials science. Polymer ed.	2,015	cc-by	378	Thermo-sensitive Nanoparticles for Triggered release of siRNA Zheng Yanga, c,1, Qiang Chengb,1, Qian Jiangb, Liandong Deng a, Zicai Liangb,** and Anjie Donga,c * a Department of Polymer Science and Technology and Key Laboratory of Systems Bioengineering of the Ministry of Education, School of Chemical Engineering and Technology, Tianjin University, Tianjin 300072, China b Laboratory of Nucleic Acid Technology, Institute of Molecular Medicine, Peking University, Beijing 100871, China. c Collaborative Innovation Center of Chemical Science and Engineering (Tianjin), Tianjin 300072, China. * Corresponding author. E-mail addresses: ajdong@tju.edu.cn (A. Dong) Fax: +86 22 27890710. Tel.: +86-22-27890706 ** Corresponding author. E-mail addresses: liangz@pku.edu.cn (Z. Liang) Fax: +86 10 62769862. [1]These authors contributed equally to this work. c Collaborative Innovation Center of Chemical Science and Engineering (Tianjin), Tianjin 300072, China. * Corresponding author. E-mail addresses: ajdong@tju.edu.cn (A. Dong) Tel.: +86-22-27890706 ** Corresponding author. E-mail addresses: liangz@pku.edu.cn (Z. Liang) Fax: +86 10 62769862. [1]These authors contributed equally to this work. Figure S1 The 13C NMR spectrum of mPEG45-b-PNIPAM110 . Figure S2 The GPC chromatogram of mPEG45 -CYCBD and mPEG45-b-PNIPAM110 . Figure S2 The GPC chromatogram of mPEG45 -CYCBD and mPEG45-b-PNIPAM110 . In order to investigate the stability of DENPs in blood，the diameter changes of DENPs in PBS 7.4 with or without 10% FBS were evaluated by DLS and shown in Figure S3 which showed that there was no signiﬁcant change in the size with desired 1 1 time as determined by DLS. It has been conﬁrmed that they are stable in a PBS solution with or without 10% FBS and that the mPEG shell around the hydrophobic core of DENPs can minimize the interactions with proteins, enzymes, and cells in blood, thus provide the stability of DENPs. Figure S3 The mean diameters of the micelles from DENPs in PBS 7.4 with (a) or without 10% FBS (b) with time as measured by DLS. Figure S3 The mean diameters of the micelles from DENPs in PBS 7.4 with (a) or without 10% FBS (b) with time as measured by DLS. Figure S4 The standard curve constructed using the peak areas by linear regression analysis. Figure S4 The standard curve constructed using the peak areas by linear regression analysis. Figure S4 The standard curve constructed using the peak areas by linear regression analysis. 2 2
https://openalex.org/W4385654655	https://rbc.inca.gov.br/index.php/revista/article/download/3318/2149	Portuguese	null	Tratamento da Dor Abdominal de Origem Neoplásica: Bloqueio Neurolítico do Plexo Celíaco	Revista Brasileira de Cancerologia	2,023	cc-by	4,661	Anestesiologista da CUnica de Dor do Instituto Mineiro de Oncologia (Hospital Mário Penna), Belo Horizonte, MG. Membro Consultor da CUnica de Dor do Hospital das Clínicas da Faculdade de Medicina da UFMG. Médico responsável pela CUnica de Bloqueios Nervosos e Terapia da Dor de Belo Horizonte, MG. ^Neurocirurgião da CUnica de Dor do instituto Mineiro de Oncologia (Hospital Mário Penna) e da CUnica de Dor do Hospital das Clinicas da Faculdade de Medicina da UFMG. Professor Assistente de Neurologia e Neurocirurgia da Faculdade de Medicina da UFMG. Endereço para correspondência: , Av. Afonso XUi, 925/301, Belo Horizonte, MG. 30.000. RESUMO Os autores descrevem a técnica de neurólise alcoólica do plexo ceKaco, para o tratamento radica! da dor visceral causada por neopiasias primárias ou metastáticas do abdome. Fazem comple ta revisão anatômica do plexo celíaco e seus elementos componentes. Apresentam os resultados clínicos obtidos em 78 pacientes oncológicos e 2 não oncoiógicos, no período de 3 anos. Con cluem que, na ausência de invasão metastática parietai, o bloqueio neurolítico do plexo celíaco é a técnica de eleição para o tratamento da dor oncoiógica das vísceras abdominais superiores. UNITERMOS: Dor abdominal crônica; plexo celíaco; nervos espiãncnicos; neurólise alcoólica; plexo solar; dor do câncer abdominal Rev. Bras. Cancerol. 1985; 31 (2): 107-114 Rev. Bras. Cancerol. 1985; 31 (2): 107-114 UNITERMOS: Dor abdominal crônica; plexo celíaco; nervos espiãncnicos; neurólise alcoólica; plexo solar; dor do câncer abdominal ANTÔNIO BENTO DE CASTRO, SEBASTIÃO GUSMÃO^ Instituto Mineiro de Oncologia e Clínica de Bloqueios Nervosos e Terapia da Dor — Belo Horizonte, MG. TRATAMENTO DA DOR ABDOMINAL DE ORIGEM NEOPLÂSICA: BLOQUEIO NEUROLITICO DO PLEXO CELIACO. ANTÔNIO BENTO DE CASTRO, SEBASTIÃO GUSMÃO^ AS BASES ANATÔMICAS Grande esplâncnico Pequeno esplâncnico Esplâncnico mínimo O plexo celíaco, também denominado plexo epigástrico, plexo esplâncnico ou plexo solar, é constituído pela porção terminal dos nervos esplâncnicos, por gânglios autônomos pré-verte- brais (gânglios celíacos, mesentéricos superiores e aórtico-renais) direitos e esquerdos, por uma vasta rede de fibras simpáticas, por um pequeno componente de fibras parassimpáticas vagais e pelas fibras nervosas aferentes nociceptivas vis cerais que respondem integralmente pela inerva- ção sensitiva das vísceras abdominais superiores. Localiza-se posteriormente ao estômago e ao peritônio, na região pré-vertebral, ao nível da metade inferior do corpo da 12a. vértebra torá- cica e de toda a porção anterior do corpo da primeira vértebra lombar, entre as glândulas suprarrenais, a vizinhança do tronco celíaco e a base da artéria mesentérica superior^. FIGURA 1 — Origem e constituição dos nervos esplâncnicos. no esplâncnicos fazem sinapse com corpos celu lares localizados no gânglio celíaco homólogo (Figura 2). Essas estruturas, nervosas estão envolvidas por tecido areolar frouxo, que permite a fácil difu são dos anestésicos locais e dos agentes neurolí- ticos através de suas estruturas componentes, quando esses agentes são depositados ao nível da porção ântero-lateral do corpo da primeira vértebra lombar. Algumas fibras provenientes do gânglio celía co, passando pelo mesmo sem fazer sinapse, vão ter ao gânglio mesentérico superior, seguin do algumas, através deste, ao gânglio aórtico-re nal (Figura 2), havendo também o entrecruza- mento de fibras de um dimídio para o outro. Um grande número de fibras simpáticas pré- ganglionares cujos corpos se localizam no corno lateral dos segmentos medulares T5 a T9 passam diretamente pelos respectivos gânglios simpáti cos paravertebrais, sem fazer sinapse e vão cons tituir o nervo grande esplâncnico (Figura 1). O conjunto de todas as fibras pós-gangliona- res, acompanhando os respectivos pedículos vasculares, forma sub-plexos ou plexos secun dários que vão ter às vísceras abdominais rela cionadas na Tabela I e também ao baço, ovário, fundo do útero, cordão espermático, aorta abdo minal, mesentério, intestino delgado e colo^. As fibras simpáticas de origem homóloga, ori ginárias dos segmentos medulares TIO e T11, unem-se para constituir o nervo pequeno es plâncnico. g Pequeno grupo de fibras parassimpáticas va gais provenientes da porção inferior do plexo esofágico vai ter a ambos os gânglios celíacos. As fibras aferentes que prov^ das vísceras abdominais dividem-se em dois diferentes gru pos. TABELA 1 - INDICAÇÕES DO BLOQUEIO neuroliYico do PLEXO CELIACO 1. Dor causada por neoplasía de: Estômago Duodeno Fígado Vesícula e vias biliares Pâncreas Glândulas suprarrenais 2. Dor causada pela pancreatite crônica 2. Dor causada pela pancreatite crônica INTRODUÇÃO nais magnos que levam estes pacientes ao médi co, em busca de diagnóstico e tratamento. Uma vez constatado o estadiamento adiantado da doença, resta apenas tratar a dor. Outra even tualidade comum é o encaminhamento do pa ciente ao consultório de dor por outro colega, após já ter sido feita a cirurgia, quimioterapia e irradiação ionizante, quando o médico assistente não mais consegue o alívio satisfatório da dor através do uso do propoxifeno e dos opiáceos. Nestes casos, cabe ao especialista no tratamento da dor verificar o diagnóstico e adotar a melhor estratégia e a alternativa mais indicada para cada um, mantendo o paciente sem dor durante a so- brevida que lhe resta. Uma das síndromes dolorosas mais comuns em clínica médica e em hospitais especializados em Oncologia é a dor crônica causada por neo- plasias malignas abdominais primárias ou metas táticas. O médico especialista no tratamento da dor que, a exemplo do que ocorre nos países desen volvidos, já exerce esta especialidade no Brasil há alguns anos, veio trazer substancial contribui ção ao tratamento da dor do paciente oncoló- gico. Em nosso meio, lamentavelmente, considerá vel número de pacientes com dor abdominal crô nica só procura ajuda médica quando em fase adiantada e tardia da doença, muitos já naquela fase dita fora de possibilidade terapêutica (FPT). A dor crônica resistente aos analgésicos comuns, 0 emagrecimento progressivo, a anorexia, a insô nia e a depressão psíquica são os sintomas e si- No grupo de pacientes com neoplasia abdomi nal sem invasão parietai, o método mais eficiente de tratamento da dor é o bloqueio neurolítico do plexo celíaco. Suas indicações consistem fun damentalmente no alívio da dor das vísceras ab dominais - 3,4, 5 relacionadas na Tabela e da dor causada pela pancreatite crônica^' 107 Rev. Bras. Cancerol. 31 (2): junho 1985 108 Grande esplâncnico Pequeno esplâncnico Esplâncnico mínimo FIGURA 1 — Origem e constituição dos nervos esplâncnicos. TABELA 1 - INDICAÇÕES DO BLOQUEIO neuroliYico do PLEXO CELIACO AS BASES ANATÔMICAS O grupo menor é constituído por fibras que acompanham as fibras vagais, conduzindo impulsos reflexos como a náusea e o vômito. O grupo maior e mais importante em nosso Pequeno grupo de fibras parassimpáticas va gais provenientes da porção inferior do plexo esofágico vai ter a ambos os gânglios celíacos. As fibras aferentes que prov^ das vísceras abdominais dividem-se em dois diferentes gru pos. O grupo menor é constituído por fibras que acompanham as fibras vagais, conduzindo impulsos reflexos como a náusea e o vômito. O grupo maior e mais importante em nosso As fibras homólogas do segmento TI2 consti tuem isoladamente o nervo esplâncnico mínimo. As fibras homólogas do segmento TI2 consti tuem isoladamente o nervo esplâncnico mínimo. As fibras constituintes do esplâncnico míni mo fazem sinapse com corpos celulares localiza dos no gânglio aórtico-renal homólogo, en quanto aquelas provenientes do grande e peque- p As fibras constituintes do esplâncnico míni mo fazem sinapse com corpos celulares localiza dos no gânglio aórtico-renal homólogo, en quanto aquelas provenientes do grande e peque- 109 Tratamento dor neoplásica; Castro e cot. cleo do/nervo vogo M. qran<le esplôncnico í-1 yEstômago renal Fígado pâncreas 5= Gl. suprarrenal Intestino '—’ delgado o Bexiga Testículo Pro'stata Fibra simpática preganglionar — — Fibra simpática pasganglionar Fibra parassimpa'tica preganglionar --- Fibra simpática posganglionar FIGURA 2 — Elementos constituintes do plexo celíaco e inervação simpática das vísceras abdominais. As fibras afe- rentes nociceptivas acompanham as fi bras simpáticas. Modificado de Boni- ca^. 1 yEstômago renal o Bexiga Pro'stata estudo é formado por fibras aferentes nocicep tivas — fundamentalmente responsáveis pela condução dos impulsos dolorosos viscerais. Es tas últimas fibras são prolongamentos periféri cos do neurônio pseudo-unipolar, cujo corpo se localiza no gânglio espinal da raiz posterior do nervo espinal correspondente. Acompanham o trajeto das fibras simpáticas e são, em última análise, aquelas que devem ser bloqueadas para o tratamento da dor abdominal crônica. Essas fibras têm seus receptores periféricos (nocicep- tores viscerais) localizados nas vísceras e condu zem potenciais de ação em sentido centrípeto. Passam pelo gânglio celíaco homolateral sem fazer sinapse, alcançam os gânglios simpáticos paravertebrais correspondentes, pelos quais pas sam diretamente e, através do ramo comunicante branco, vão ter ao gânglio espinal da raiz poste rior correspondente. Deste gânglio partem os prolongamentos centrais do neurônio pseudo- unipolar, que penetram no corno posterior da medula espinhal, em cujas lâminas fazem diver sas sinapses. FIGURA 2 — Elementos constituintes do plexo celíaco e inervação simpática das vísceras abdominais. As fibras afe- rentes nociceptivas acompanham as fi bras simpáticas. Modificado de Boni- ca^. AS BASES ANÃTOMO-FISIOLOGICAS Para o médico afeito aos bloqueios de condu ção dos impulsos nervosos, não poderia haver melhor local para o bloqueio das aferências noci ceptivas das vísceras abdominais superiores do que essa estação de passagem denominada gân glio celíaco. Uma vez feita a punção percutânea e injetado o anestésico local ou o agente neurolí- tico, este difunde-se e alcança os demais gânglios do plexo, bloqueando indiscriminadamente suas fibras sensitivas e simpáticas. re^' e a de Bonica'. Descreveremos, com pe quenas variações, a de Bonica, como é feita em nosso serviço. O paciente é mantido em jejum de 12 horas antes do bloqueio. Ao entrar no bloco cirúrgico, verificam-se e anotam-se o pulso e a pressão arte riais. Faz-se a flebopuntura de uma veia do ante braço com cânula descartável n° 16-G e insta la-se infusão de solução salina. Mantêm-se à mão fonte de oxigênio, material de entubação orotraqueal e aparelho para manutenção de res piração controlada. AS BASES ANATÔMICAS Ultrapassando o portão de Melzack e WalP, localizado nas lâminas I I e I I I (subs tância gelatinosa), onde os impulsos são modu lados, alcançam a lâmina V, onde fazem sinapse 110 Rev. Bras. Cancerol. 31 (2): junho 1985 FIGURA 3 — Corte sagital do abdome ao nível da primeira vértebra lombar. Observem-se os elementos anatômicos vizinhos ao plexo celía- co e as agulhas posicionadas para seu bloqueio. Modificado de Bonica'. com os corpos das células de transmissão T, cujas fibras, cruzando a comissura branca anterior, juntamente com as demais fibras nociceptivas de outros territórios orgânicos, ascendem até o tála- mo, constituindo o feixe espinotalâmico lateral, situado no quadrarrte ântero-lateral da medula. Desse conjunto de fibras, uma pequena parte (feixe neo-espinotalâmico) vai ter aos núcleos ventro-basais do tálamo, onde faz sinapse com células cujos axônios alcançam finalmente o cór- tex parietal, de cuja integração resulta a decodi- ficação têmporo-espacial da dor. A dor visceral, ao contrário da somática, é, quase sempre, difusa e mal localizada, apresentando-se, muitas vezes, como uma dor referida. Uma grande parte das mesmas fibras, constituindo o feixe paleoespino- talâmico, alcança os núcleos interlaminares (me diais) do tálamo, onde faz sinapse com corpos celulares cujos axônios, via sistema límbico, fa zem conexões finais com o lobo frontal, cuja ati vidade responde pela integração afetivo-emocio- nal e pelo fenômeno de fundamental importân cia da dor, que é o sofrimento. FIGURA 3 — Corte sagital do abdome ao nível da primeira vértebra lombar. Observem-se os elementos anatômicos vizinhos ao plexo celía- co e as agulhas posicionadas para seu bloqueio. Modificado de Bonica'. FIGURA 3 — Corte sagital do abdome ao nível da primeira vértebra lombar. Observem-se os elementos anatômicos vizinhos ao plexo celía- co e as agulhas posicionadas para seu bloqueio. Modificado de Bonica'. ELEMENTOS ANATOMICOS DE VIZINHANÇA Submetemos o paciente à anestesia peridural, em L3-L4, com 12 a 15ml de bupivacaína a 0,5% sem vasoconstritor, sendo mantido o de- cúbito dorsal durante 20 minutos, com controle de pulso e pressão arteriais. O bloqueio peridural prévio, adotado em nosso serviço desde o início, oferece numerosas vantagens: Há elementos anatômicos situados na vizi nhança do plexo celíaco (Figura 3), cujo even tual envolvimento é diretamente responsável pe los paraefeitos e complicações possíveis durante o bloqueio. A musculatura lombar, os gânglios simpáticos lombares paravertebrais, o músculo psoas maior, os espaços peridural e subaracnóideo lombares, a veia cava inferior, a aorta abdominal e a veia porta, os rins e as glândulas suprarrenais são ele mentos de vizinhança, cuja presença e localiza ção devem ser rigorosamente conhecidas e evi tadas no momento da punção. 1. Mantém o paciente totalmente sem dor du rante o bloqueio celíaco. Estes pacientes, quase sempre, chegam com dor ao bloco cirúrgico, to leram mal o decúbito ventral necessário ao blo queio celíaco e, sem o bloqueio peridural prévio para o alívio da dor, não permanecem quietos e dificilmente colaboram; 2. Evita a necessidade de infiltração dos pla nos por onde penetrará a agulha de punção; FIGURA 4 — Paciente posicio nado para o bloqueio celíaco, mostrando-se, de ambos os la dos, o local da punção per cutânea. EIPS = espinha ilíaca póstero-superior. A TÉCNICA Entre as técnicas propostas para o bloqueio do plexo celíaco, merecem destaque a de Moo- p p g p ç 3. Evita a dor intensa que se verifica no mo mento da injeção do álcool. 3. Evita a dor intensa que se verifica no mo mento da injeção do álcool. 111 Tratamento dor neoplásica; Castro e col. Tratamento dor neoplásica; Castro e col. Tratamento dor neoplásica; Castro e col. Tratamento dor neoplásica; Castro e col. Uma vez fixado o bloqueio peridural, coloca- se o paciente em decúbito ventral, com um ou dois travesseiros debaixo do abdome inferior, a fim de aumentar a distância entre as apófises espinhosas lombares. A cabeça e os membros superiores são colocados na posição melhor acei ta pelo paciente (Figura 4). passando pelo corpo do psoas maior, resvale pela porção lateral do corpo de LI (Figura 5) e vá situar-se a 1,5 a 2cm para frente da porção ante rior do corpo da mesma vértebra (Figura 6). Nesta situação, ambas as agulhas estarão loca lizadas na região pré-vertebral, retroperitoneal, que contém tecido areolar frouxo e os elementos do plexo celfaco. Uma linha horizontal é tirada de uma à outra espinha ilíaca póstero-superior. Não havendo anomalias anatômicas, tal linha cruzará medial- mente a apófise espinhosa de L4 ou o interespa- ço L4-L5''. A partir deste dado, contando para cima, encontraremos a apófise espinhosa de LI, de cuja porção superior tiraremos uma linha ho rizontal bilateral. Nesta linha, a 5cm da apófise espinhosa de LI, de ambos os lados, localizam-se os pontos de punção percutânea, que são marca dos com tinta indelével (Figura 4). Introduzindo, através de cada agulha, 3ml de contraste radiopaco, fixamos uma radiografia em perfil. Se posicionadas corretamente as agu lhas, tal contraste irá difundir-se por toda a por ção anterior dos corpos de TI2, LI e L2 (Figura 7), 0 que nos autoriza a fazer a injeção do agente neurolítico. Usamos atualmente 20ml de álcool absoluto através de cada agulha, sendo a injeção precedida de aspirações insistentes e repetidas, para descar tar a possibi lidade de injeção intravascular. Ato contínuo, injetamos 2ml de ar através de cada agulha, as quais são retiradas, sendo o paciente voltado para a posição de decúbito dorsal. A in trodução do ar tem por fim expulsar do interior das agulhas pequena quantidade de álcool que aí permanece após a injeção e que, se deixada nas estruturas paravertebrais no momento da O anestesiologista, já devidamente vestido e com luvas estéreis, fará rigorosa antissepsia re gional e colocará os campos cirúrgicos. De cada lado, no ponto de punção, uma agu lha n° 50x8 é introduzida verticalmente, até que toque a apófise transversa de LI, o que ocorre à profundidade de 3 a 4cm‘. É então recuada até o tecido subcutâneo e redirecionada a sua ponta ligeiramente para cima e para dentro, até que. INICIO E DURAÇÃO DA ANALGESIA A analgesia inicia-se alguns minutos após a in jeção e a neurólise total completa-se após 3 a 4 dias, sendo sua duração de 3 meses a 1 ano" . Em todos os nossos casos, após cessada a analgesia do bloqueio peridural, já se tinha estabelecido a ação analgésica do álcool. Temos dois pacientes portadores de pancreatite crônica que se encon tram totalmente sem dor há 10 e 18 meses após o bloqueio. Rev. Bras. Cancerol. 31 (2): junho 1985 FIGURA 5 — Paciente J.C.F. — Radiografia em AP, mostrando as agulhas corretamente posicio nadas ao nível da porção média do corpo da pri meira vértebra lombar. A agulha da esquerda foi ligeiramente recuada antes da injeção. fibras simpáticas viscerais, com vasodilatação e considerável seqüestração de sangue na área esplâncnica. II FIGURA 6 — Paciente M.S.B. — A imagem em perfil mostra o correto posicionamento das agulhas a 1-2cm além da porção anterior do corpo da vértebra LI. Neste caso, a técnica usa da foi a de Moore^. FIGURA 5 — Paciente J.C.F. — Radiografia em AP, mostrando as agulhas corretamente posicio nadas ao nível da porção média do corpo da pri meira vértebra lombar. A agulha da esquerda foi ligeiramente recuada antes da injeção. FIGURA 6 — Paciente M.S.B. — A imagem em perfil mostra o correto posicionamento das agulhas a 1-2cm além da porção anterior do corpo da vértebra LI. Neste caso, a técnica usa da foi a de Moore^. FIGURA 6 — Paciente M.S.B. — A imagem em perfil mostra o correto posicionamento das agulhas a 1-2cm além da porção anterior do corpo da vértebra LI. Neste caso, a técnica usa da foi a de Moore^. retirada das agulhas, poderia ocasionar graves neurites com dor intensa e de difícil tratamento. FIGURA 7 — Paciente A.M.O. — 6ml de contras te injetados disseminaram-se por toda a região pré-vertebral, onde se localiza o plexo celíaco. Usamos neste caso a técnica de Bonica'. Tratamento dor neoplásica; Castro e col. FIGURA 4 — Paciente posicio nado para o bloqueio celíaco, mostrando-se, de ambos os la dos, o local da punção per cutânea. EIPS = espinha ilíaca póstero-superior. FIGURA 4 — Paciente posicio nado para o bloqueio celíaco, mostrando-se, de ambos os la dos, o local da punção per cutânea. EIPS = espinha ilíaca póstero-superior. Rev. Bras. Cancerol. 31 (2): junho 1985 TABELA 2 - PARAEFEITOS E COMPLICAÇÕES, COM SUA INCIDÊNCIA EM NOSSA casuística De todos os casos, 28 (35,89%) apresentavam metástases peritoneais comprovadas per-operato- riamente ou por via endoscópica, sendo que, neste grupo, 15 pacientes (19,23%) mostravam, à palpação abdominal, nódulos endurecidos, dis seminados e fixos na parede abdominal ante rior. A Tabela 4 mostra os resultados obtidos com relação ao alívio da dor. 18 22,50% 1. Hipotensão arterial 2. Perfuração do ligamento amarelo 3. Perfuração da dura-máter 4. Perfuração do parênquima renal 5. Perfuração da suprarrenal 6. Punção vascular 7. Injeção intraperitoneal 8. Lombalgia aguda 9. Neurite alcoólica 13 16,25% 12 15,00% TABELA 4 - RESULTADOS ANALGÉSICOS DO BLOQUEIO NEUROLIYICO Casos % 59 73,75 1. Alívio total da dor 21 26,25 2. Alívio parcial da dor TABELA 4 - RESULTADOS ANALGÉSICOS DO BLOQUEIO NEUROLIYICO TABELA 4 - RESULTADOS ANALGÉSICOS DO BLOQUEIO NEUROLIYICO A neurite alcoólica é evitada pela injeção de 2ml de ar, através de cada agulha, antes de sua retirada. Alguns pacientes de nossa casuística apresen taram hipotensão arterial prévia ao bloqueio ce líaco, em função do bloqueio peridural. Os valo res mencionados na Tabela 2 referem-se à hipo tensão após 0 bloqueio celíaco. Os 21 pacientes cujo alívio foi parcial estavam todos incluídos no grupo que apresentava metás tases no peritônio parietal, no mesmo se incluin do 0 subgrupo dos 15 cujas metástases eram fa cilmente palpáveis. Sete pacientes com metásta ses comprovadas por cirurgia ou endoscopia, po rém não notadas à palpação abdominal, apresen taram alívio total da dor. Portanto, o exame pal- patório do abdome, em nossa casuística, mos trou-se extremamente conclusivo, ou seja, haven do metástases parietais palpáveis clinicamente, o bloqueio celíaco não produziu o alívio completo da dor. A lombalgia aguda, quando ocorre, desaparece após alguns dias e é tratada com analgésicos co muns. A punção vascular é detectada e corrigida por aspirações repetidas, antes da injeção do álcool. As demais complicações constantes da Tabela 2 são evitadas pelo rigoroso posicionamento das agulhas, sob controle radiológico. PARAEFEITOS E COMPLICAÇÕES Surgem em função do envolvimento dos ele mentos anatômicos vizinhos (Tabela 2). Coloca do novamente o paciente em decúbito dorsal, o pulso e a pressão arteriais são verificados de 3 em 3 minutos durante a primeira hora, porque é quase sempre imediatamente após o bloqueio, ou alguns minutos após, que se desencadeia a hipotensão arterial resultante do bloqueio das FIGURA 7 — Paciente A.M.O. — 6ml de contras te injetados disseminaram-se por toda a região pré-vertebral, onde se localiza o plexo celíaco. Usamos neste caso a técnica de Bonica'. 113 Tratamento dor neoplásica: Castro e coL Tratamento dor neoplásica: Castro e coL Tratamento dor neoplásica: Castro e coL de dor abdominal neoplásica e 2 portadores de pancreatite crônica com dor resistente aos anal gésicos comuns, foram submetidos ao bloqueio neurolítico do plexo celíaco, pelo método ante riormente descrito. A localização do processo neoplásico é vista na Tabela 3. As hipotensões moderadas são corrigidas com a infusão de solução salina. Quando intensas, o são com doses intermitentes endovenosas e in- tramusculares de aminas simpaticomiméticas de ação mista, até que a pressão arterial se mante nha em níveis fisiológicos. Nos pacientes mais jovens, a vasodilatação es- plâncnica é seguida de vasoconstrição compen- sadora extra-esplâncnica, na busca orgânica do reequilíbrio hemodinâmico. Em pacientes ido sos, devido à arteriosclerose, esse mecanismo é deficitário ou não se processa, sendo a hipoten- são mais intensa e duradoura^. Nestes casos, pro cedemos ao enfaixamento dos membros inferio res, por período de 3 dias, bem como mantemos o paciente em decúbito por igual período, a fim de evitar a hipotensão ortostática e suas con- seqüências, sendo a deambulação inicial observa da e protegida por um acompanhante. TABELA 3 - NATUREZA E ORIGEM DA DOENÇA TABELA 3 - NATUREZA E ORIGEM DA DOENÇA TABELA 3 - NATUREZA E ORIGEM DA DOENÇA Casos % 1. Neoplasia de Estômago Pâncreas Vesícula e vias biliares Fígado-neoplasia primitiva Fígado-neoplasia metastática 27 33,75 40,00 32 4 5,00 1,25 1 14 17,50 2. Pancreatite crônica 2 2,50 O diagnóstico definitivo foi estabelecido per- operatoriamente, por biópsia e exame anátomo- patológico, ou por endoscopia abdominal (lapa- roscopia). TABELA 2 - PARAEFEITOS E COMPLICAÇÕES, COM SUA INCIDÊNCIA EM NOSSA casuística Tratamento dor neoplásica: Castro e coL MATERIAL, MÉTODO E RESULTADOS No período de janeiro de 1982 a outubro de 1984, 78 pacientes do Instituto Mineiro de On- cologia e da Clínica de Bloqueios Nervosos e Terapia da Dor de Belo Horizonte, portadores Explicam-se facilmente tais achados. A aferen- tação da sensibilidade dolorosa da parede abdo minal, incluindo o peritônio parietal, é feita atra vés dos nervos somáticos intercostais, que não fíev. Bras. Cancero/. 31 (2): junho 1985 114 da equipe de tratamento da dor, o profissional a quem cabe a execução do bloqueio celíaco. Não usamos, na casuística apresentada, o blo queio prognóstico do plexo celíaco com anesté sico local previamente à execução do bloqueio neurol ítico. Quando um paciente nos é enca minhado, com diagnóstico etiológico per-opera- tório ou endoscópico, é feita cuidadosa palpação abdominal. Não sendo encontrados nódulos parietais palpáveis, é ele submetido diretamente ao bloqueio neurolítico. Detectados nódulos tumorais, indicando invasão metastática parie- tal, e dependendo de sua condição sócio-econô- mica, o paciente é submetido à implantação de reservatório para opiaceoterapia peridural con tínua, ou mantido com opiáceos por via oral ou, em última instância, submetido à neurólise al coólica intratecal, após bloqueio somático torá- cico paravertebral com anestésico local, para diagnóstico das raízes medulares envolvidas no processo doloroso. da equipe de tratamento da dor, o profissional a quem cabe a execução do bloqueio celíaco. são bloqueados durante a neurólise do plexo celíaco. da equipe de tratamento da dor, o profissional a quem cabe a execução do bloqueio celíaco. Não usamos, na casuística apresentada, o blo queio prognóstico do plexo celíaco com anesté sico local previamente à execução do bloqueio neurol ítico. Quando um paciente nos é enca minhado, com diagnóstico etiológico per-opera- tório ou endoscópico, é feita cuidadosa palpação abdominal. Não sendo encontrados nódulos parietais palpáveis, é ele submetido diretamente ao bloqueio neurolítico. Detectados nódulos tumorais, indicando invasão metastática parie- tal, e dependendo de sua condição sócio-econô- mica, o paciente é submetido à implantação de reservatório para opiaceoterapia peridural con tínua, ou mantido com opiáceos por via oral ou, em última instância, submetido à neurólise al coólica intratecal, após bloqueio somático torá- cico paravertebral com anestésico local, para diagnóstico das raízes medulares envolvidas no processo doloroso. Daqueles 21 pacientes com al ívio parcial, 11 estavam em estado físico muito precário e em fase final, tendo sido a dor residual combatida com 0 uso de opiáceos por via oral. U NITERMS: chronic abdominal pain, celiac plexus, alcohol neu- roiysis, abdominal câncer pain. REFERÊNCIAS BIBLIOGRÁFICAS; 1. Bonica, J. J.: The Management of Pain. Lea and Febiger, Philadelphia. 2. Melsack, R. and Wall, P. D.: Pain Mechanisms: A New Theo- ry.Science, 1965, 150:971-979. 3. Moore, D. C.: Celiac (Splanchnic) Plexus Block with Alcohol for Câncer Pain of the Upper Intra-abdominal Viscera In Bonica, J. J. and Ventafridda, V.: Advances in Pain Research and Therapy, vol. 2. Raven Press, New York, pág, 357-371. 1979. MATERIAL, MÉTODO E RESULTADOS Os demais 10 pacientes apresentavam estado geral compa tível com uma sobrevida maior, tendo sido 4 mantidos sem dor pela administração de opiá ceos por via oral e 6 submetidos à opiaceotera pia peridural intermitente, através de reservató rio implantado cirurgicamente no tecido sub- cutâneo e ligado, por um sistema de catóter espe cial, ao espaço peridural. A Tabela 5 mostra o período de sobrevida dos 59 pacientes que obti veram al ívio total da dor. TABELA 5 - SOBREVIDA DOS 59 PACIENTES COM ANALGESIA TABELA 5 - SOBREVIDA DOS 59 PACIENTES COM ANALGESIA Casos % 5,08 3 Até 1 mês 1 — 2 meses 2-3 meses 3 — 4 meses 4 — 5 meses 5 — 6 meses Sem follow-up após alta 10 meses (?) (Pancreatite) 18 meses, ainda vivo 18,64 13,56 15,25 16,95 11 8 9 10 6,78 4 12 20,34 1,70 1 1,70 1 TABELA 5 - SOBREVIDA DOS 59 PACIENTES COM ANALGESIA SUMMARY An usefui technique to perform neurolytic celiac plexus block for treatment ofpain due to eitherprimary or metastatic câncer of the upper abdominal víscera is described. A complete review of the regional anatomy is done and the clinicai resuits of 80 treated patients are presen- ted and analised. Um dos pacientes portadores de pancreatite crônica obteve analgesia durante 10 meses e, após tal período, perdeu contato conosco. O outro paciente com pancreatite crônica continua vivo e sem dor, após 18 meses de efetuado o blo queio. A sobrevida e outros dados daqueles pa cientes dessa casuística,, submetidos à opiaceo terapia peridural intermitente por reservatório implantado, terão oportunamente seus resulta dos analisados, juntamente com outros grupos portadores de dor neoplásica de outras áreas do organismo, submetidos também à mesma im plantação. In absence of peritoneal metastases, neurolytic celiac plexus block is the best technique for treatment of pain caused by câncer of the upper abdominal viscera. CONCLUSÃO Os resultados por nós obtidos com o bloqueio neurolítico do plexo cel íaco permitem-nos con cluir que, na ausência de invasão metastática pa- rietal, este é o método de escolha para os pacien tes portadores de dor abdominal crônica causada por neoplasias das vísceras abdominais supe riores. Dos pacientes da Tabela 5, dois vieram a apre sentar dor abdominal posterior e, submetidos ao bloqueio celíaco com anestésico local, não hou ve alívio da dor. Este fato foi interpretado como progressão do processo neoplásico com invasão peritoneal. Foram mantidos sem dor através da implantação cirúrgica de reservatório e catéter, seguida.de opiaceoterapia peridural intermitente. COMENTÁRIOS FINAIS 4. Moore, D. C.: Regional Block, 4th ed.. Charles C. Thomas, Springfield, Illinois, U.S.A.. 1965. O anestesiologista especializado na prática de bloqueios nervosos, em face de seus conheci mentos do sistema nervoso periférico, é, dentro 5. Singler, R. C. ; An improved Technique for Alcohol Neuro- lysis of the Celiac Plexus. Anesthesiology. 1982, 56:137-141.
https://openalex.org/W4245570600	https://pubs.lib.uiowa.edu/annals-of-iowa/article/id/6308/download/pdf/	English	null	The Making of Iowa	The Annals of Iowa/Annals of Iowa	1,900	public-domain	683	402 402 ANNALS OF IOWA. to Deoatur county, Iowa, sembly. Hi3 was a' member of the 27th General As- to Deoatur county, Iowa, sembly. Hi3 was a' member of the 27th General As- Miia. ANNIE TUBNEB WITTENMYER, illustrious for her care of sick- and wounded Iowa soldiers during the civil war, was born at Sandy Springs.. Adams county, Ohio. Aug. 26, 1827. She died at her home at Sanatoga, Pa., Feb. 2, 1900. (For a biographical sketch and portrait of this fumons woman, see ANNALS OF ÍOWA, 3d ser. v.; 4, pp. 277-288). NEW PUBLICATIONS. FRAGMENTS OF THE DEBATES OF THE IOWA CONSTITUTIOSAL CONVENTIONH OF ISU AND 1846, ALONG WITH\|PRES8 COMMENTS AND OTTIEP MATERIALS OF THE CONSTI- TUTIONS OF 1844 AND 1846. Compiled and edited by Henjnniin F. Shambaueh, A.' MM Ph. D., Professor of Government and Administration in tlio University of Iowa. Published by t-he State Historical Society of Iowa, Iowa (Jity. 1900. The title-page of this book fully explains its scope ond purpose. Up to its publi- cation it was possible for.a reader or student to learn bnt little about the Iowa Constitutional (./onventions of 1841 nnd '461 Tt is also a startling fact that blie con- tents of this important volume of over 4(K) octavo pages, were only to be found in the files of three territorial newspapers, which an accidental fire might have destroyed. No duplicates are in existence. Only a very few copies—we only know tlie wlierea- bouts of uot to exceed half-a-dozen—of tiie, journals of those conventions have como down to this time, and it is well kuown that the official journals are very meager aud unsatisfactory. The three papers referredlto—ï'/ie Iowa Standard and Bloomingioti Herald, whig—and Tfte Iowa Capital Reporter, democratic—in their weekly issues each presented a brief report of tlie proccediugs of those bodies, with some of the speeches of the members, and their own views of the various provisions which it was sougiit to embody in the fundauiental law. : It was a bright and sensible thought of Prof. Shambaugh to gather from these dusty old files everything which contained the proceedings of the two conventions or in any manner pertained to their rction. The Iowa Historical Society never did a wiser thing than thus to print iu ouo compact and beautiful volumo all of this most precious historical material. It gives "a fu- ture life" to the actors iu t:he conventions, who were in great danger of being utterly forgotten. No book has ¡hitherto been published in our State of higher importance historically, and we welcoine it as such. There are a few people who can see no rea- son for preserving files of the newspapers for future reference. But the great results which Prof. Shambaugh has accomplished through his search through these old Standards and Heralds and Reporters is a complete answer to all such cavillers. THE MAKING OF IOWA. By Henry Sabin, LL. D.. NEW PUBLICATIONS. Ex-State Superintendent of Public Instruction of Iowa, aiid Edwin L. Sabin. Chicago: A. Flanagan, publisher. Instruction of Iowa, aiid Edwin L. Sabin. Chicago: A. Flanagan, publisher. Here is a neat and beautifully illustrated volume of 282 pages, devoted to a history of "The MakiDg of Iowa."\| It is mainly intended for "the children in our schools," but it may be read with profit by people of any age. In thirty-four short chapters it presents a series of lively pictures of the origin aud development of our State from the earliest days until the\| close of the great civil war. As an epitome of Iowa history it covers the ground very completely, and will suffice to meet the demand until a more elaborate work appears. We trust that it may have a large sale, not alone as an encouragement to its industrious and painstaking authors, but upon its intrinsic merits. It is as interesting as the brightest novel, and he who dips into it will bo very apt to read it from the first page to the last, and in the meantime he will learn many things about our magnificent State that he never knew before.
https://openalex.org/W3044489808	https://journals.iucr.org/b/issues/2020/04/00/lo5066/lo5066.pdf	English	null	<i>ChemEnv</i>: a fast and robust coordination environment identification tool	Acta crystallographica. Section B, Structural science, crystal engineering and materials./Acta crystallographica. Section B, Structural science, crystal engineering and materials	2,020	cc-by	11,639	research papers research papers Edited by J. Lipkowski, Polish Academy of Sciences, Poland Edited by J. Lipkowski, Polish Academy of Sciences, Poland Edited by J. Lipkowski, Polish Academy of Sciences, Poland Coordination or local environments have been used to describe, analyze and understand crystal structures for more than a century. Here, a new tool called ChemEnv, which can identify coordination environments in a fast and robust manner, is presented. In contrast to previous tools, the assessment of the coordination environments is not biased by small distortions of the crystal structure. Its robust and fast implementation enables the analysis of large databases of structures. The code is available open source within the pymatgen package and the software can also be used through a web app available on http:// crystaltoolkit.org through the Materials Project. ‡ Present address: Matgenix SRL, Rue Armand Bury 185, B-6534 Goze´e, Belgium (david.war- oquiers@matgenix.com) Keywords: coordination environment; contin- uous symmetry measure; Voronoı¨; coordination number. Supporting information: this article has supporting information at journals.iucr.org/b Supporting information: this article has supporting information at journals.iucr.org/b ChemEnv: a fast and robust coordination environ- ment identification tool ISSN 2052-5206 ISSN 2052-5206 ISSN 2052-5206 David Waroquiers,a‡ Janine George,a Matthew Horton,b,c Stephan Schenk,d Kristin A. Persson,b,c Gian-Marco Rignanese,a Xavier Gonzea,e and Geoffroy Hautiera* David Waroquiers,a‡ Janine George,a Matthew Horton,b,c Stephan Schenk,d Kristin A. Persson,b,c Gian-Marco Rignanese,a Xavier Gonzea,e and Geoffroy Hautiera* Received 3 December 2019 Accepted 15 June 2020 Received 3 December 2019 Accepted 15 June 2020 aInstitute of Condensed Matter and Nanosciences, Universite´ catholique de Louvain, Chemin des E´toiles 8, 1348 Louvain- la-Neuve, Belgium, bEnergy Technologies Area, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA, cDepartment of Materials Science and Engineering, University of California, Berkeley, CA 94720, USA, dBASF SE, Digitalization of R&D, Carl-Bosch-Str. 38, 67056 Ludwigshafen, Germany, and eSkolkovo Institute of Science and Technology, Skolkovo Innovation Center, Nobel St. 3, Moscow, 143026, Russia. *Correspondence e-mail: geoffroy.hautier@uclouvain.be 1. Introduction Inorganic crystal structures are typically described by their structure prototype or by a more local concept of ‘coordina- tion environment’ (Mu¨ller, 2007; Allmann & Hinek, 2007). Coordination environments or local environments (e.g. octa- hedral, tetrahedral, etc.) are often used in structure visuali- zation as they clarify the crystal arrangement. These environments can also be used to understand crystal structures and their properties. P. Pfeiffer was the ﬁrst to transfer this concept of coordination environments from coordination complexes to crystals to rationalize crystals as large molecules (Pfeiffer, 1915, 1916). Very often these coordination envir- onments are determined in a non-automatic manner by the individual researcher. Local environments play a major role in solid state chemistry and physics as well as materials science. For instance, the famous Pauling rules, which have been used to understand and rationalize crystal structures for 90 years, rely heavily on this concept (Pauling, 1929). In the Pauling rules, the analysis of the coordination environments is used to determine the stability of a material. Electronic, optical, magnetic and other properties of crystals have also been related to and explained by local environments (Hoffmann, 1987, 1988; Lueken, 2013; Peng et al., 2015). In recent years, coordination environments have been discussed and used as structural descriptors to derive structure–property relation- ships via machine-learning methods (Jain et al., 2016; Zimmermann et al., 2017). Some of us have analyzed the coordination environments present in oxides in a statistical manner (Waroquiers et al., 2017). Such large-scale analyzes Acta Cryst (2020) B76 683–695 683 https://doi.org/10.1107/S2052520620007994 Acta Cryst. (2020). B76, 683–695 Acta Cryst. (2020). B76, 683–695 research papers present a unique environment or a mixture of several envir- onments. This approach which is robust to distortion will be described in detail in this paper. require an easily reproducible, robust and automatic deter- mination of coordination environments. Since the transfer of the concept of coordination environments from coordination complexes to crystals, various approaches to determine coor- dination numbers, coordination environments, or the distor- tion of coordination environments have been developed (Frank & Kasper, 1958; Brunner & Schwarzenbach, 1971; Carter, 1978; O’Keeffe, 1979; Hoppe, 1979; Pinsky & Avnir, 1998; Gun´ka & Zachara, 2019; Stoiber & Niewa, 2019). 1. Introduction However, the methods mentioned so far are not well suited for a robust and automatic assessment of coordination environ- ments in very large databases consisting of several thousands of crystal structures such as the Inorganic Crystal Structure Database (Bergerhoff & Brown, 1987, Zagorac et al., 2019), Pearson’s database (Villars & Cenzual, 2018) or the Cambridge Structural Database (Groom et al., 2016). Indeed, some of these methods can be sensitive to small distortions due to predeﬁned cut-offs while others rely on additional chemical information that is not directly available from the sole consideration of the geometry of the crystal. Moreover, some of these methods only deal with the identiﬁcation of the coordination number without assigning a speciﬁc environment to a given site. To ﬁll this gap we developed ChemEnv, a fast and robust tool to identify coordination environments. It has already been applied in the study of coordination environ- ments of oxides (Waroquiers et al., 2017) and in a rigorous assessment study of the Pauling rules (George et al., 2020). It is embedded in pymatgen – a Python library for materials analysis which is part of the Materials Project that aims at the accelerated design of new materials (Ong et al., 2013; Jain et al., 2013). Our approach relies on the similarity of such distorted polyhedra present in the crystal structure to ideal reference polyhedra. After a neighbor analysis, we identify potential local environments and compare them through a distance metric to a database of perfect local environments. Different algorithms called strategies are then used to decide on a local environment assignment and the ﬁnal result can 2.1. Aspects of coordination environments identification In the process of identifying coordination environments of a given atom, two main questions have to be considered: (a) What are the neighbors of this atom? (b) What is the overall arrangement of these neighbors around this atom? The ﬁrst question refers to what is called the coordination number while the second corresponds to the coordination or local environment. The answer to these questions is very clear when the local structure of the atom is close to a perfect environment. However, when relatively large distortions are present, the identiﬁcation can be much more difﬁcult. In particular, a given local environment can be identiﬁed as a mix of two or more coordination environments (which can be of the same coordination number or not). 2. Method/algorithm 2.1. Aspects of coordination environments identification 684 David Waroquiers et al. ChemEnv 2.2. Voronoı¨ analysis The neighbors of a given atom in a given structure are determined using a modiﬁed Voronoı¨ approach similar to what was proposed by O’Keeffe (1979). The Voronoı¨ analysis allows for the splitting of the space into regions that are closer to one atom than to any other one. In the standard Voronoı¨ approach for determining the neighbors of a given atom X, all the atoms {Y1, . . . ,Yn} whose regions are contiguous to the region of atom X are considered as coordinated to atom X. The distances between atom X and each of its neighbors are written fdX Y1; . . . dX Yng. The common faces ff X Y1; . . . f X Yng between the region of atom X and each of the regions of atoms {Y1, . . . ,Yn} deﬁne solid angles fX Y1; . . . X Yng subtended by these faces at atom X. The Voronoı¨ regions are easily understood by drawing the perpendicular area bisectors for each pair of atoms X and Y. Fig. 1 illustrates the concept in two dimensions (in which area bisectors are thus replaced by line bisectors). The example shown is a slightly distorted square lattice [see Fig. 1(a)] where the atoms at the corners (atoms 1, 3, 6 and 8) are displaced towards the central green atom (atom 0). The perfect square lattice is shown by the gray atoms. In Fig. 1(b), the perpen- dicular line bisectors (in red) are drawn for each segment from the central (green) atom and all other (black) atoms around it. The Voronoı¨ region of the central atom corresponds to the region in light green in Fig. 1(c). Fig. 1(d) shows the faces ff 0 1 ; . . . f 0 8 g attributed to each pair of atoms 0–i with i = 1 . . . 8. The solid angle is illustrated for neighbors 1 and 5 by 0 1 and 0 5, respectively. Figure 1 Voronoı¨ construction. In our modiﬁed approach, two additional cut-offs can be added as shown schematically in two dimensions in Fig. 2: (a) The ﬁrst cut-off excludes neighbors on the basis of the distance [Fig. 2(a)]. Let dX min ¼ minðfdX Y1; . . . dX YngÞ be the distance to the closest neighbor of atom X and 1.0 be the 684 David Waroquiers et al. 2.3. The shape recognition problem and the continuous symmetry measure The shape recognition problem consists in the identiﬁcation of the model environment to which a local and possibly distorted environment resembles the most. Fig. 3 illustrates this problem. A distorted octahedron is shown in Fig. 3(a). Whether this distorted octahedron is more similar to a perfect octahedron [see Fig. 3(b)] than to any other (model) shape is precisely the purpose of the shape recognition. This inherently implies that a list of model polyhedra to be compared to is In equation (1), the minimization has to be performed with respect to four different degrees of freedom: (i) Translation [see Fig. 4(a)]. This minimization is easily addressed by translating the local structures to their center of mass. (ii) Ordering of the atoms [see Fig. 4(b)]. The simplest method is to test all possible permutations of indices. This guarantees a correct value for the CSM but the number of permutations scales as N! making it time-consuming for large (N > 6) coordination numbers. The symmetry of the model polyhedra is used to reduce the number of independent (ii) Ordering of the atoms [see Fig. 4(b)]. The simplest method is to test all possible permutations of indices. This guarantees a correct value for the CSM but the number of permutations scales as N! making it time-consuming for large (N > 6) coordination numbers. The symmetry of the model polyhedra is used to reduce the number of independent Figure 2 Schematic representation of the cut-off parameters used in the Voronoı¨ analysis of neighbors: (a) distance cut-off and (b) angle cut-off. (a) Distance cut-off parameter . dX min is the distance to the closest neighbor (one of the dark blue atoms). Any atom that lies outside the sphere of radius dX min (in dashed orange) is not considered as a coordinated neighbor. Atoms at the corner (in light blue) are not considered as neighbors. (b) Angle cut-off parameter . X max is the largest solid angle to a neighbor atom. Any atom for which the solid angle is smaller than X max (in orange) is not considered as a coordinated neighbor. Atoms at the corner (in light blue) are not considered as neighbors. [Adapted with permission from D. Waroquiers et al. (2017).] Figure 3 The shape recognition problem. 2.2. Voronoı¨ analysis ChemEnv 684 David Waroquiers et al. ChemEnv Acta Cryst. (2020). B76, 683–695 research papers known a priori. We stick to the list of coordination environ- ments recommended by the IUPAC (Hartshorn et al., 2007) and by the IUCr (Lima-de Faria et al., 1990). This list of environments, their symbol, coordinates and additional meta- information are given as supplementary information. distance cut-off parameter. All atoms lying inside the sphere of radius dX min are considered as coordinated neighbors while those lying outside are disregarded. We deﬁne the normalized distance dX Yi of each neighbor Yi as dX Yi=dX min. i i (b) The second cut-off is based on the solid angles fX Y1; . . . X Yng introduced before [Fig. 2(b)]. Let X max ¼ maxðfX Y1; . . . X YngÞ be the biggest solid angle to a neighbor for atom X and 1.0 be the angle cut-off para- meter. All neighboring atoms with a solid angle smaller than X max are not considered as coordinated to atom X. We deﬁne the normalized angle X Yi of each neighbor Yi as X Yi=X max. i i (b) The second cut-off is based on the solid angles fX Y1; . . . X Yng introduced before [Fig. 2(b)]. Let X max ¼ maxðfX Y1; . . . X YngÞ be the biggest solid angle to a neighbor for atom X and 1.0 be the angle cut-off para- meter. All neighboring atoms with a solid angle smaller than X max are not considered as coordinated to atom X. We deﬁne the normalized angle X Yi of each neighbor Yi as X Yi=X max. In order to measure the closeness of a local environment to each perfect model environment, the Continuous Symmetry Measure (CSM) is used, as proposed by Pinsky & Avnir (1998). This CSM can be interpreted as a measure of similarity between shapes. For a given structure Q composed of N ¼ NQ atoms (vertices) with coordinates {qk, k = 1, 2, . . . , N}, the CSM SP Q ½ with respect to a model polyhedron P with N ¼ NP ¼ NQ vertices {pk, k = 1, 2, . . . with q ¼ 1 N PN k¼1 qk. with q ¼ 1 N PN k¼1 qk. with q ¼ 1 N PN k¼1 qk. With this deﬁnition, the value of the CSM is guaranteed to be in the [0.0, 100.0] interval. A value of 0.0 for the CSM indicates that the two shapes are identical, i.e. the structure Q corresponds to the perfect structure P. Instead, when the structure is distorted, the value of the CSM gives a degree of distortion of the structure Q with respect to the perfect structure P. As such, the CSM can be understood as one deﬁnition of a distance to a shape. 2.2. Voronoı¨ analysis , N} is deﬁned as: i It is possible to use both cut-offs at the same time in which case a given atom is not considered as a coordinated neighbor if either one of the cut-offs disregards it as a coordinated neighbor. SP Q ½ ¼ min P N k¼1 qk pk 2 P N k¼1 qk q 2 100 ð1Þ ð1Þ The modiﬁed Voronoı¨ procedure presented above allows for the determination of the coordinated neighbors of a given atom X for a given set of distance/angle parameters. The identiﬁcation of the coordinated neighbors of atom X deﬁnes the local environment of this atom. The identiﬁcation of the model environment which this local environment resembles the most is described in the next section. research papers based on the singular value decomposition (Kabsch, 1976; Kabsch, 1978). permutations for N 6. For larger N, a different approach is adopted (see Section 2.4). (iv) Size of the structure [see Fig. 5(b)]. A scaling factor is applied to the local structure to avoid size effects: the local structure is normalized to the root-mean square distance from the center of mass of the structure to all vertices. (iii) Orientation of the structure [see Fig. 5(a)]. The local (distorted) structure is rotated in order to minimize the numerator in equation (1) by using an alignment procedure Figure 4 Translational and ordering degrees of freedom for the minimization in equation (1). (a) Translation of the polyhedron and (b) ordering of the vertices. The minimization process presented above is equivalent to the point set registration algorithms used in shape or pattern recognition (Pomerleau et al., 2015). The main challenge comes from the fact that the correspondence between points in Q and P (i.e. the ordering problem described above) is unknown. In pattern recognition in which the number of points is usually large, algorithms based on pair correlation functions combined with statistical analysis are widely used [see Maiseli et al. (2017) and references therein]. In contrast, for small number of points, a different approach has to be adopted. As brieﬂy outlined above, the simplest solution (which is used for N 6) is to test all possible permutations of indices (ignoring symmetrically identical ones), while for larger N the number of permutations is reduced using the separation-plane algorithm (see Section 2.4). In any case, for a given permutation of points, the CSM can be obtained thanks to algorithm 1 (see Fig. 6, points in Q have been translated such that their center of mass coincide with that of P). The exact CSM is then the smallest one of all the CSM computed for each permutation considered. Figure 4 686 David Waroquiers et al. ChemEnv 2.3. The shape recognition problem and the continuous symmetry measure It consists in identifying whether the distorted octahedron in (a) is more similar to the perfect (model) octahedron in (b) than to any other model polyhedron. This presupposes that there exists a list of model polyhedra to be compared to. Figure 2 Figure 2 Schematic representation of the cut-off parameters used in the Voronoı¨ analysis of neighbors: (a) distance cut-off and (b) angle cut-off. (a) Distance cut-off parameter . dX min is the distance to the closest neighbor (one of the dark blue atoms). Any atom that lies outside the sphere of radius dX min (in dashed orange) is not considered as a coordinated neighbor. Atoms at the corner (in light blue) are not considered as neighbors. (b) Angle cut-off parameter . X max is the largest solid angle to a neighbor atom. Any atom for which the solid angle is smaller than X max (in orange) is not considered as a coordinated neighbor. Atoms at the corner (in light blue) are not considered as neighbors. [Adapted with permission from D. Waroquiers et al. (2017).] Figure 2 Schematic representation of the cut-off parameters used in the Voronoı¨ analysis of neighbors: (a) distance cut-off and (b) angle cut-off. (a) Distance cut-off parameter . dX min is the distance to the closest neighbor (one of the dark blue atoms). Any atom that lies outside the sphere of radius dX min (in dashed orange) is not considered as a coordinated neighbor. Atoms at the corner (in light blue) are not considered as neighbors. (b) Angle cut-off parameter . X max is the largest solid angle to a neighbor atom. Any atom for which the solid angle is smaller than X max (in orange) is not considered as a coordinated neighbor. Atoms at the corner (in light blue) are not considered as neighbors. [Adapted with permission from D. Waroquiers et al. (2017).] Figure 3 The shape recognition problem. It consists in identifying whether the distorted octahedron in (a) is more similar to the perfect (model) octahedron in (b) than to any other model polyhedron. This presupposes that there exists a list of model polyhedra to be compared to. David Waroquiers et al. ChemEnv 685 Acta Cryst. (2020). B76, 683–695 research papers 2.4. Separation-plane algorithm This idea is illu- Figure 7 Illustration of the separation plane algorithm. (a) Model and local (distorted) structure, (b) ﬁrst trial for separation plane algorithm and (c) second trial for separation plane algorithm. A separation is deﬁned by its separation plane Pperf passing through at least three points of the perfect polyhedron P and by the two separated groups of points Sperf and Tperf located on either side of the plane. The set of points in the plane is written as P = {pj, j = 1, . . . NP} while S = {sm, m = 1, . . . NS} and T = {tn, n = 1, . . . NT} stand for the two sets of points on either side of the plane. By construction, {qk} = {pj} [ {sm} [ {tn} and N = NP + NS + NT. We use perf = (NS, NP, NT) as an abridged notation for the separation. For the example illustrated in Fig. 7, the separation is noted (2, 2, 2). An illustration of two separation planes for the cubic and cuboctahedral environ- ments is provided in Fig. 8. The procedure for the computation of the CSM of envir- onments with more than six atoms is described in algorithm 2 which is shown in Fig. 9. Separation planes have been deﬁned Figure 9 Algorithm 2. The separation plane algorithm. Figure 9 Algorithm 2. The separation plane algorithm. Figure 7 Illustration of the separation plane algorithm. (a) Model and local (distorted) structure, (b) ﬁrst trial for separation plane algorithm and (c) second trial for separation plane algorithm. Figure 8 Examples of separation planes. (a) Separation (2, 4, 2) in the cubic environment: points A, B, H and E (in red) belong to the plane that separates points D and F (in green) from points C and G (in blue). (b) Separation (3, 6, 3) in a cuboctahedron: points A, I, G, D, L and F (in red) belong to the plane that separates points C, E and J (in blue) from points H, K and B (in green). Fi 8 Figure 8 g Examples of separation planes. (a) Separation (2, 4, 2) in the cubic environment: points A, B, H and E (in red) belong to the plane that separates points D and F (in green) from points C and G (in blue). 2.4. Separation-plane algorithm When the number N of coordinated neighbors increases, the number of permutations needed to minimize equation (1) scales as N!. When the correspondence of vertices between the local distorted structure and the perfect model polyhedron is not known (which is usually the case for the application of the procedure to large databases of structures), this makes the computation of the CSM almost infeasible for N > 10 and very g Translational and ordering degrees of freedom for the minimization in equation (1). (a) Translation of the polyhedron and (b) ordering of the vertices. Translational and ordering degrees of freedom for the minimization in equation (1). (a) Translation of the polyhedron and (b) ordering of the vertices. Figure 5 Rotational and size degrees of freedom for the minimization in equation (1). (a) Orientation and (b) size. Figure 6 Algorithm 1. Computation of the CSM for a given permutation. Fi 5 Figure 5 Rotational and size degrees of freedom for the minimization in equation (1). (a) Orientation and (b) size. Figure 6 Algorithm 1. Computation of the CSM for a given permutation. Acta Cryst. (2020). B76, 683–695 research papers time-consuming for 6 > N 10 with the standard procedure (e.g. 9! = 362 880, 12! = 479 001 600). strated in Fig. 7 for a two-dimensional case. The points of the perfect model shape are separated into three different groups: the set of points supposed to lie within the plane and the two sets of points on either side of the plane. The permutation space is thus reduced because N! is always larger than N1!N2!N3! if at least two of N1, N2, N3 are larger than or equal to 1. For the example in Fig. 7, the number of permutations is reduced from 6! = 720 to 2! 2! 2! = 8. Additionally, for larger environments in which the separating plane contains more than three points, these can be ordered using clockwise or counterclockwise ordering, hence reducing the number of permutations even further. In order to overcome this difﬁculty, the separation plane algorithm has been devised to drastically reduce the compu- tational time needed. The basic idea is to identify possible planes in the distorted structure that can be assigned to a plane in the model polyhedron in order to reduce the number of permutations needed to ﬁnd the right correspondence between points and hence the correct CSM. David Waroquiers et al. ChemEnv 687 research papers for all the perfect model environments above six atoms. Usually, more than one separation plane can be deﬁned in a given model polyhedron. In practice, the overall algorithm tests all the available separation planes that have been deﬁned for the polyhedron under consideration. The list of separation planes for each coordination environment is available as SI and is also easily viewable with a script provided in the ChemEnv subpackage of pymatgen. icosahedral environment, the separation plane contains four points and splits the other points into two groups of four points each). 2.5. Neighbor sets and distance/angle parameters maps 2.5. Neighbor sets and distance/angle parameters maps The distance and angle parameters deﬁned in Section 2.2 are very sensitive parameters for the determination of the neighbors of a given atom. Indeed, a very slight change in one of the parameters can change the atoms considered as neighbors and hence the coordination. Each neighbor set of atom A with coordination N is denoted by N, j(A). The j index comes from the fact that two different neighbor sets can have the same coordination N. A two-dimensional example of such a case is illustrated in Fig. 10 in which two sets of distance and angle cut-off parameters result in two different neighbor sets of the same coordination. The algorithm has been optimized by ordering the points of the separation plane in a clockwise or counterclockwise direction whenever possible. This makes it possible to reduce the number of permutations related to the separation plane. For example, for the separation (3, 6, 3) of the cuboctahedron shown in Fig. 8(b), the number of permutations of the points in the plane is 6! = 720. Ordering the points in the perfect and local environments makes it possible to reduce the number of trials to six. A similar optimization is also possible for the two separated groups of points for the separations in which these groups contain a sufﬁcient number of points (e.g. in the In order to ensure robustness with respect to the distance and angle cut-off parameters, the identiﬁcation procedure is performed in two steps. First, all sets of neighbors N, j(A) are obtained for all possible distance/angle parameters in the Voronoı¨ analysis. For each neighbor set, CSMs are computed with respect to each model polyhedron of the same coordi- nation. research papers Normalized distances to neighbors 1, 2, 3 and 4 are d0 1 ¼ d0 3 ¼ 1:0, d0 2 = 1.15 and d0 4 = 1.35. Normalized angles to neighbors 1, 2, 3 and 4 are 0 4 = 1.0, 0 1 ¼ 0 3 0:924 and 0 2 0:42. (b) Set of neighbors (1, 2 and 3) of atom 0 with N = 3. This set of neighbors is obtained with e.g. = 1.25 and = 0.3 cut-offs. (c) Another set of neighbors (1, 3 and 4) of atom 0 with N = 3. This set of neighbors is obtained with e.g. = 1.4 and = 0.5 cut-offs. Figure 11 Examples of distance/angle parameters maps for Si and O in -SiO2 (Materials Project id: mp-7000) and Cr and Te in Cr2Te4O11 (Materials Project id: mp-540537): (a) Si site in -SiO2, (b) O site in -SiO2, (c) Cr site in Cr2Te4O11 and (d) Te site in Cr2Te4O11. Each neighbor set corresponds to a region in which any distance/angle parameters combination result in the same set. The color level of each region gives an indication of the CSM value of the model polyhedron to which the corresponding neighbor set resembles the most (i.e. for which the CSM is the lowest). For the larger regions, this model polyhedron is indicated by its symbol. The square and triangle symbols correspond to ﬁxed distance and angle parameters respectively of 1.3/0.6 and 1.6/0.4, showing a clear ambiguity for the Te site in Cr2Te4O11 (see Section 2.6 on how to clarify such cases). Figure 11 Examples of distance/angle parameters maps for Si and O in -SiO2 (Materials Project id: mp-7000) and Cr and Te in Cr2Te4O11 (Materials Project id: mp-540537): (a) Si site in -SiO2, (b) O site in -SiO2, (c) Cr site in Cr2Te4O11 and (d) Te site in Cr2Te4O11. Each neighbor set corresponds to a region in which any distance/angle parameters combination result in the same set. The color level of each region gives an indication of the CSM value of the model polyhedron to which the corresponding neighbor set resembles the most (i.e. for which the CSM is the lowest). For the larger regions, this model polyhedron is indicated by its symbol. research papers This can be represented by a map of distance/angle parameters with regions deﬁned for each neighbor set (see Fig. 11 for examples of such maps for Si and O sites in SiO2 as well as for Cr and Te sites in Cr2Te4O11). The second step Figure 10 Illustration in two dimensions of two sets of neighbors having the same coordination number. (a) Local environment of atom 0. Normalized distances to neighbors 1, 2, 3 and 4 are d0 1 ¼ d0 3 ¼ 1:0, d0 2 = 1.15 and d0 4 = 1.35. Normalized angles to neighbors 1, 2, 3 and 4 are 0 4 = 1.0, 0 1 ¼ 0 3 0:924 and 0 2 0:42. (b) Set of neighbors (1, 2 and 3) of atom 0 with N = 3. This set of neighbors is obtained with e.g. = 1.25 and = 0.3 cut-offs. (c) Another set of neighbors (1, 3 and 4) of atom 0 with N = 3. This set of neighbors is obtained with e.g. = 1.4 and = 0.5 cut-offs. well as for Cr and Te sites in Cr2Te4O11). The second step 688 David Waroquiers et al. ChemEnv Acta Cryst. (2020). B76, 683–695 Figure 11 Examples of distance/angle parameters maps for Si and O in -SiO2 (Materials Project id: mp-7000) and Cr and Te in Cr2Te4O11 (Materials Project id: mp-540537): (a) Si site in -SiO2, (b) O site in -SiO2, (c) Cr site in Cr2Te4O11 and (d) Te site in Cr2Te4O11. Each neighbor set corresponds to a region in which any distance/angle parameters combination result in the same set. The color level of each region gives an indication of the CSM value of the model polyhedron to which the corresponding neighbor set resembles the most (i.e. for which the CSM is the lowest). For the larger regions, this model polyhedron is indicated by its symbol. The square and triangle symbols correspond to ﬁxed distance and angle parameters respectively of 1.3/0.6 and 1.6/0.4, showing a clear ambiguity for the Te site in Cr2Te4O11 (see Section 2.6 on how to clarify such cases). Figure 10 Illustration in two dimensions of two sets of neighbors having the same coordination number. (a) Local environment of atom 0. 2.4. Separation-plane algorithm (b) Separation (3, 6, 3) in a cuboctahedron: points A, I, G, D, L and F (in red) belong to the plane that separates points C, E and J (in blue) from points H, K and B (in green). David Waroquiers et al. ChemEnv 687 687 Acta Cryst. (2020). B76, 683–695 688 David Waroquiers et al. ChemEnv 2.6. Strategies For the ﬁnal step of the identiﬁcation procedure, strategies are used to reliably analyze the SE object and extract a usable and meaningful result. Reliability refers to the robustness of our algorithm in which the sensitivity of the identiﬁcation to the distance/angle parameters is tested and challenged. Hence, the local environments can be interpreted as one unique environment or as an intermediate between two (or more) coordination environments, each of which being attributed a fraction or percentage. Different strategies can be used depending on the goals, needs and constraints required by the user. This ﬂexibility provided by the strategies is one of the strengths of our identiﬁcation procedure. For visualization purposes, a strategy resulting in the identiﬁcation of a single coordination environment for each site has to be used while reviewing the most commonly observed environments can be done with a strategy allowing for multiple environments for the same site. One can also favor speciﬁc or larger/smaller environments depending on the project. In the following, two strategies are developed further. Figure 12 g Coordination environments for a distorted octahedron in which the bottom atom is at distance 1.45 times larger than the other ﬁve neighbors. When the distance cut-off is lower than 1.45, the bottom atom is not considered as a neighbor and the environment is identiﬁed as a square pyramid. When the distance cut-off is larger than 1.45, the bottom atom is taken into account and the environment is identiﬁed as an octahedron. Figure 13 Smooth distortion from octahedral to square-pyramidal environment by moving away the bottom atom. The deformation parameter = 0 corresponds to the perfect octahedron while for = 1, the bottom atom has been moved to a distance that is twice that of the distance to the other neighbors. The thin lines gives the fractions of octahedral and square- pyramidal environments obtained with the SimplestChemenvStrategy (with a distance cut-off of 1.4) while the thick lines correspond to the fractions obtained with the MultiWeightsChemenvStrategy. Octahedral d id l ti l h lid d d h d li 2.6.1. Fixed distance/angle cut-offs strategy. The simplest way to identify the environment is to use ﬁxed distance and angle cut-off parameters. In this SimplestChemenvStrategy, the set of neighbors is thus unique and the environment is iden- tiﬁed as the one for which the CSM is the lowest. research papers The square and triangle symbols correspond to ﬁxed distance and angle parameters respectively of 1.3/0.6 and 1.6/0.4, showing a clear ambiguity for the Te site in Cr2Te4O11 (see Section 2.6 on how to clarify such cases). Figure 11 Examples of distance/angle parameters maps for Si and O in -SiO2 (Materials Project id: mp-7000) and Cr and Te in Cr2Te4O11 (Materials Project id: mp-540537): (a) Si site in -SiO2, (b) O site in -SiO2, (c) Cr site in Cr2Te4O11 and (d) Te site in Cr2Te4O11. Each neighbor set corresponds to a region in which any distance/angle parameters combination result in the same set. The color level of each region gives an indication of the CSM value of the model polyhedron to which the corresponding neighbor set resembles the most (i.e. for which the CSM is the lowest). For the larger regions, this model polyhedron is indicated by its symbol. The square and triangle symbols correspond to ﬁxed distance and angle parameters respectively of 1.3/0.6 and 1.6/0.4, showing a clear ambiguity for the Te site in Cr2Te4O11 (see Section 2.6 on how to clarify such cases). g Illustration in two dimensions of two sets of neighbors having the same coordination number. (a) Local environment of atom 0. Normalized distances to neighbors 1, 2, 3 and 4 are d0 1 ¼ d0 3 ¼ 1:0, d0 2 = 1.15 and d0 4 = 1.35. Normalized angles to neighbors 1, 2, 3 and 4 are 0 4 = 1.0, 0 1 ¼ 0 3 0:924 and 0 2 0:42. (b) Set of neighbors (1, 2 and 3) of atom 0 with N = 3. This set of neighbors is obtained with e.g. = 1.25 and = 0.3 cut-offs. (c) Another set of neighbors (1, 3 and 4) of atom 0 with N = 3. This set of neighbors is obtained with e.g. = 1.4 and = 0.5 cut-offs. 688 David Waroquiers et al. ChemEnv Acta Cryst. (2020). B76, 683–695 research papers hedral environment when the distance cut-off is increased. Similarly, for ﬁxed distance and angle cut-offs, when an octa- hedron is smoothly distorted by moving away one of the atoms, the resulting environment from this simplest strategy changes abruptly from octahedral to square-pyramidal as shown in Fig. 13 (thin lines correspond to the SimplestCh- emenvStrategy). research papers It is thus very sensitive to small changes in the positions of the atoms. Nevertheless, with decent distance and angle parameters (e.g. = 1.4 and = 0.3), the identiﬁed environment is reasonably correct in about 85% of the cases. allows one to test the sensitivity of the distance/angle para- meters by means of strategies (see Section 2.6). While for the three ﬁrst cases in Fig. 11, the ‘correct’ environment is reasonably clear by just looking at the ﬁgure (assigning tetrahedral (T:4), angular (A:2) and octahedral (O:6) envir- onments, respectively, to Si in SiO2, O in SiO2 and Cr in Cr2Te4O11), the situation is more complex and the identiﬁca- tion is not so evident for Te in Cr2Te4O11. In this case, the environment could be seen as an intermediate between two different environments. The use of strategies can clarify such ambiguous cases. The neighbors in each set, the CSMs for each model poly- hedron in each set, and other data related to each neighbor set are stored in a so-called StructureEnvironments (see also Section 3) or SE (hereafter also symbolized by A for atom A) object. As exempliﬁed in Fig. 11, this SE is not very useful as such as it contains a lot of information that is difﬁcult to interpret directly. In the second step presented below, strate- gies are used to analyze the SE and extract usable and valu- able information from the SE. Figure 12 Coordination environments for a distorted octahedron in which the bottom atom is at distance 1.45 times larger than the other ﬁve neighbors. When the distance cut-off is lower than 1.45, the bottom atom is not considered as a neighbor and the environment is identiﬁed as a square pyramid. When the distance cut-off is larger than 1.45, the bottom atom is taken into account and the environment is identiﬁed as an octahedron. Acta Cryst. (2020). B76, 683–695 research papers environment ". The second term comes from the relative weight of the model polyhedron " within that speciﬁc neighbor set. Another illustration of this strategy is shown in Fig. 14 in which a triangular prism is smoothly distorted towards an octahedron by rotating the upper and lower triangular planes in opposite directions (thin lines correspond to the SimplestChemenvStrategy). In this case, the number of neighbors remains the same while the actual identiﬁed envir- onment switches abruptly from triangular prismatic to octa- hedral when the CSM of latter becomes smaller than that of the former. Once again, the sensitivity with respect to small changes in the positions of the atoms is critical in this strategy. f½Að"Þ ¼ f outer½A f inner½N Að"Þ ð3Þ ð3Þ In the following, the ﬁrst term is referred to as the outer weight (i.e. the weight that depends on other so-called outer neighbor sets) and the second term is referred to as the inner weight (i.e. the weight inside a speciﬁc neighbor set). 2.6.2. Strategy based on multiple weights. A second strategy is developed hereafter, in which special care has been taken to remove the artiﬁcial abrupt transitions observed with the SimplestChemenvStrategy. The idea is to smooth these transitions using a combination of smooth step functions. A given local environment can thus be identiﬁed either as one unique coordination environment if distortions are small, or as a mix of two or more environments for larger distortions. In practice, the local environment is described as a list of envir- onments, each being assigned a fraction or percentage. Inner weight. For a given neighbor set N A of atom A in a given coordination N, the relative weight (and hence fraction) of each model polyhedron is not straightforward. Let N be the set of K model environments with coordination N: N ¼ f"N 1 ; . . . ; "N i ; . . . ; "N Kg ð4Þ ð4Þ For example, the set 6 of six-coordinated model polyhedra [as reported by Hartshorn et al. (2007) and Lima-de Faria et al. (1990) and implemented in the ChemEnv package] is composed of the octahedron (symbolized O:6), the trigonal prism (symbolized T:6) and the pentagonal pyramid (symbo- lized PP:6). The percentage or fraction f"(A) of a given model coordi- nation environment " depends on the results (CSMs, Voronoı¨ parameters, . . . 2.6. Strategies The advantage of such a simple procedure is that it makes it possible to describe a local environment by its unique corre- sponding model environment, which is easier to use for visualization purposes. However, some (distorted or very distorted) local environments can be considered to be an intermediate between two or more model coordination poly- hedra. In such cases, this strategy will simply ‘choose’ one environment, depending on the distance and angle para- meters. As a simple illustration, Fig. 12 shows the sudden switch from the square-pyramidal environment to the octa- Figure 13 Figure 13 Smooth distortion from octahedral to square-pyramidal environment by moving away the bottom atom. The deformation parameter = 0 corresponds to the perfect octahedron while for = 1, the bottom atom has been moved to a distance that is twice that of the distance to the other neighbors. The thin lines gives the fractions of octahedral and square- pyramidal environments obtained with the SimplestChemenvStrategy (with a distance cut-off of 1.4) while the thick lines correspond to the fractions obtained with the MultiWeightsChemenvStrategy. Octahedral and square-pyramidal are respectively shown as solid and dashed lines. Figure 13 Smooth distortion from octahedral to square-pyramidal environment by moving away the bottom atom. The deformation parameter = 0 corresponds to the perfect octahedron while for = 1, the bottom atom has been moved to a distance that is twice that of the distance to the other neighbors. The thin lines gives the fractions of octahedral and square- pyramidal environments obtained with the SimplestChemenvStrategy (with a distance cut-off of 1.4) while the thick lines correspond to the fractions obtained with the MultiWeightsChemenvStrategy. Octahedral and square-pyramidal are respectively shown as solid and dashed lines. David Waroquiers et al. ChemEnv 689 Acta Cryst. (2020). B76, 683–695 research papers ) for each possible set of neighbors contained in A. For each model polyhedron "N i , the CSM S"N i ½N A with respect to the local environment N A is used to assign a weight to each model polyhedron thanks to the use of an adequately shaped function. Model environments with a lower CSM (i.e. more similar to the local environment) are assigned a larger weight. In particular, if one of the model environments has a CSM of 0.0 (i.e. the local environment is perfect), its weight should be inﬁnite so that it is the only model environment identiﬁed. The function should also allow for the assignment of a zero weight to a model polyhedron for which the CSM is larger than a given maximum value Smax. One example of such a function is the ‘modiﬁed’ inverse function deﬁned in equa- tion (5) and shown in Fig. 15. f"ðAÞ ¼ f½Að"Þ ð2Þ ð2Þ The procedure used to get the fraction of a model polyhedron " for a given local environment is then obtained as the product of two terms. Suppose " occurs in a given neighbor set . The ﬁrst term results from the relative weight of the neighbor set (as compared to the other neighbor sets) displaying model identiﬁed. The function should also allow for the assignment of a zero weight to a model polyhedron for which the CSM is larger than a given maximum value Smax. One example of such a function is the ‘modiﬁed’ inverse function deﬁned in equa- tion (5) and shown in Fig. 15. 690 d l h Figure 15 Weight function for the inner weight of model polyhedra. In this example, Smax is set to 8.0, so that the weight of any model polyhedron with a CSM larger than 8.0 is zero. Figure 14 Smooth distortion from triangular prismatic to octahedral environment by twisting the triangular prism around the principal axis. The deformation parameter = 0 corresponds to the perfect trigonal prism while for = 1, the upper (red ! orange) and lower (green ! cyan) triangles have been rotated respectively clockwise and counterclockwise by 30 , corresponding to an octahedron. The thin lines gives the fractions of triangular prismatic and octahedral environments obtained with the SimplestChemenvStrategy while the thick lines correspond to the fractions obtained with the MultiWeightsChemenvStrategy. research papers Octahedral and trian- gular prismatic are respectively shown as solid and dashed lines. Figure 14 Smooth distortion from triangular prismatic to octahedral environment by twisting the triangular prism around the principal axis. The deformation parameter = 0 corresponds to the perfect trigonal prism while for = 1, the upper (red ! orange) and lower (green ! cyan) triangles have been rotated respectively clockwise and counterclockwise by 30 , corresponding to an octahedron. The thin lines gives the fractions of triangular prismatic and octahedral environments obtained with the SimplestChemenvStrategy while the thick lines correspond to the fractions obtained with the MultiWeightsChemenvStrategy. Octahedral and trian- gular prismatic are respectively shown as solid and dashed lines. Figure 15 Weight function for the inner weight of model polyhedra. In this example, Smax is set to 8.0, so that the weight of any model polyhedron with a CSM larger than 8.0 is zero. Figure 14 Figure 14 Smooth distortion from triangular prismatic to octahedral environment by twisting the triangular prism around the principal axis. The deformation parameter = 0 corresponds to the perfect trigonal prism while for = 1, the upper (red ! orange) and lower (green ! cyan) triangles have been rotated respectively clockwise and counterclockwise by 30 , corresponding to an octahedron. The thin lines gives the fractions of triangular prismatic and octahedral environments obtained with the SimplestChemenvStrategy while the thick lines correspond to the fractions obtained with the MultiWeightsChemenvStrategy. Octahedral and trian- gular prismatic are respectively shown as solid and dashed lines. Figure 14 Smooth distortion from triangular prismatic to octahedral environment by twisting the triangular prism around the principal axis. The deformation parameter = 0 corresponds to the perfect trigonal prism while for = 1, the upper (red ! orange) and lower (green ! cyan) triangles have been rotated respectively clockwise and counterclockwise by 30 , corresponding to an octahedron. The thin lines gives the fractions of triangular prismatic and octahedral environments obtained with the SimplestChemenvStrategy while the thick lines correspond to the fractions obtained with the MultiWeightsChemenvStrategy. Octahedral and trian- gular prismatic are respectively shown as solid and dashed lines. Figure 15 Weight function for the inner weight of model polyhedra. In this example, Smax is set to 8.0, so that the weight of any model polyhedron with a CSM larger than 8.0 is zero. research papers Figure 15 Weight function for the inner weight of model polyhedra. In this example, Smax is set to 8.0, so that the weight of any model polyhedron with a CSM larger than 8.0 is zero. Figure 15 Weight function for the inner weight of model polyhedra. In this example, Smax is set to 8.0, so that the weight of any model polyhedron with a CSM larger than 8.0 is zero. 690 David Waroquiers et al. ChemEnv 690 Acta Cryst. (2020). B76, 683–695 690 research papers wSmaxðSÞ ¼ 1=Smax ðSSmaxÞ2 S if S Smax; 0:0 if S > Smax: ð5Þ Some of the partial neighbor set weights compare the CSMs of this neighbor set with the ones for the other neighbor sets. The simplest approach is to take the smallest CSM for each of the neighbor sets. In practice, to ensure continuity, an effective CSM is deﬁned. The effective CSM of a given neighbor set N A, denoted SeffðN AÞ, is obtained from a weighted average using the ‘modiﬁed’ inverse function deﬁned in equation (5) ð5Þ in which the numerator (S Smax)2 ensures the continuity at S = Smax while the prefactor 1/Smax arises from the normal- ization of the [0, Smax] to [0, 1]. Fractions of each model environment "i are then obtained from these weights using equation (6): SeffðN AÞ ¼ P "2N wSmaxðS"Þ S" P "2N wSmaxðS"Þ ð8Þ f inner½N Að"iÞ ¼ wSmaxðS"iÞ Pj¼K j¼1 wSmaxðS"jÞ ð6Þ ð8Þ ð6Þ A small example is also given in Fig. 15 in which CSMs for a ﬁctitious six-coordinated case are provided. in which S" is a short form for S"ðN AÞ, i.e. the CSM of the neighbor set with respect to the perfect environment ". When the coordination is clearly deﬁned (i.e. when only one neighbor set is identiﬁed using the procedure outlined in 2.5), the fractions of each model polyhedron are solely determined by this inner weight. On the other hand, when different neighbor sets are identiﬁed, an additional complexity arises from the fact that smaller environments usually tend to be more easily recognized as similar (i.e. having smaller CSMs). The extreme case is the single neighbor which is always assigned a CSM of zero. MultiWeightsChemenvStrategy:stats:articleweightsparametersðÞ Other weights have also been implemented in the ChemEnv package in pymatgen. ‘Distance–angle area’ weight. The idea is to restrict the neighbor sets to those originating from a speciﬁc range of values for the distance and angle cutoffs. For example, one might only consider distance cutoffs between 1.2 and 1.8. One might also consider that the Voronoı¨ angle towards a neighbor should always be between 0.3 and 0.8. In practice, a special area of distance–angle parameters is deﬁned such as the one shown in Fig. 16. Indeed, there is not much sense to allow for neighbors with a small angle parameter and a small distance parameter or with a large angle parameter and a large distance parameter. If the region of a given neighbor set (as deﬁned in Outer weight. The outer weight or neighbor set weight refers to the weight of a given neighbor set with respect to the other neighbor sets. This outer weight is deﬁned as a product of several ‘partial weights’ (the deﬁnition being general enough to allow for ﬂexibility in the choice of the weights): wouter½AðAÞ ¼ Y i¼nw i¼1 b wi wi½AðAÞ ð7Þ ð7Þ in which nw is the number of partial weights used. in which nw is the number of partial weights used. Figure 16 Schematic of the distance–angle area weight. The shaded area is used to determine which neighbor sets are considered. If the region of a given neighbor set is crossing the shaded area, the set is assigned a ‘distance– angle area’ weight of 1.0. In the opposite case, the set is assigned a weight of 0.0 (white regions). Acta Cryst. (2020). B76, 683–695 David Waroquiers et al. ChemEnv 691 Figure 16 Schematic of the distance–angle area weight. The shaded area is used to determine which neighbor sets are considered. If the region of a given neighbor set is crossing the shaded area, the set is assigned a ‘distance– angle area’ weight of 1.0. In the opposite case, the set is assigned a weight of 0.0 (white regions). Figure 17 Weight function for the Self-CSM outer weight of neighbor sets as deﬁned in equation (9). The default parameters for this weight are shown as blue while the green and purple curves illustrate other parameters. Arrows indicate thresholds above which values (i.e. Smax) of the effective CSM Seff each of the weight functions are set to zero. research papers For cases in which more than one neighbor set is present, the outer weight is used to determine the relative predominance of each of the neighbor sets (and hence their corresponding model polyhedron). Partial weights. In the following, the partial weights used in the ‘default’ multi-weights strategy [used in a previous publi- cation (Waroquiers et al., 2017)] are described. The strategy with these default parameters is easily obtained with the following class method (see examples in the tutorials provided in the supplementary material): MultiWeightsChemenvStrategy:stats:articleweightsparametersðÞ ‘Self CSM’ weight This weight makes use of the effective CSM Seff of each neighbor set deﬁned in equation (8). Each neighbor set is assigned a weight depending on the value of this effective Seff. The idea is to disfavor neighbor sets that are globally more distorted than others. One example function used to estimate this weight is deﬁned in equation (9) and shown in Fig. 17. in which x ¼ ðx aÞ=ðb aÞ is the scaled value of x mapping the [a,b] interval to the [0, 1] interval. Choice of partial weights. The default list of outer weights consists of the three above-mentioned partial weights. As an example and in particular to illustrate the need to use both the Self CSM weight and the Delta CSM weight, Fig. 19 shows the fractions of environments obtained for different choices of weights in the case of the smooth distortion from octahedral to square-pyramidal environment (see Fig. 13). wSmax;ðSeffÞ ¼ ðSeff 1:0Þ2 eSeff if Seff 1:0; 0:0 if Seff > 1:0: ð9Þ wSmax;ðSeffÞ ¼ ðSeff 1:0Þ2 eSeff if Seff 1:0; 0:0 if Seff > 1:0: ð9Þ where Seff is the normalized effective CSM deﬁned as Seff Smax. where Seff is the normalized effective CSM deﬁned as Seff Smax. max Delta CSM’ weight. The goal of this neighbor set weight is to reduce the importance of a given neighbor set N1 if another neighbor set N2 of larger coordination number N2 > N1 is present and not too distorted with respect to the ﬁrst one. In practice, this weight depends on the difference Seff between the effective CSMs [as deﬁned in equation (8)] of the neighbor sets N2 and N1: The upper left panel shows the CSM of the octahedral (increasing with the distortion) and square-pyramidal (always equal to 0.0). The middle left and lower left panels show the Self CSM and Delta CSM weights for both environments. The Self CSM weight for the square-pyramidal environment is always 1.0 as its CSM is always 0.0. Conversely, the Delta CSM weight for the octahedral environment is always 1.0 as there is no larger neighbor set to be compared to. ‘Self CSM’ weight As shown in the upper right panel, when the sole Self CSM weight is included, the fractions obtained are 50% octahedral and 50% square- pyramidal when no or little distortion is applied (while one would expect to have 100% octahedral and 0% square-pyra- midal). Indeed, for both environments, the value of the CSM is 0.0 and hence the Self CSM weight is 1.0. At variance, the middle right panel illustrates the fractions obtained when the sole Delta CSM weight is included. In that case, for large distortions, the fractions obtained are also 50% for each environment. Indeed, when the distortion is large, the Delta SeffðN1; N2Þ ¼ SeffðN2Þ SeffðN1Þ ð10Þ ð10Þ The Delta CSM weight is deﬁned as: w ;min;max½AðAÞ¼ min i2A; NðiÞ>NðAÞmin;max SeffðA;iÞ ð Þ ð11Þ w ;min;max½AðAÞ¼ min i2A; NðiÞ>NðAÞmin;max SeffðA;iÞ ð Þ ð11Þ ð11Þ in which is a sigmoid-like function (e.g. a smooth step or smoother step function), N() is the coordination of neighbor set and min, max are the edges used in the function. Figure 18 Smoother step function used in the Delta CSM weight. The ‘Delta CSM’ weight assigned to the 1 neighbor set is equal to 0.0 if the difference Seff(1, 2) between the effective CSM Seff(2) of the 2 neighbor set and its own effective CSM Seff(1) is lower than min. If the difference Seff(1, 2) is larger than max, the 1 set is assigned a weight of 1.0. The smoother step function is used between these two extremes. The min and max values can be changed if needed and examples of smoother step functions for different values are shown. 692 David Waroquiers et al ChemEnv Acta Cryst (2020) B76 683 695 Figure 18 Smoother step function used in the Delta CSM weight. The ‘Delta CSM’ weight assigned to the 1 neighbor set is equal to 0.0 if the difference Seff(1, 2) between the effective CSM Seff(2) of the 2 neighbor set and its own effective CSM Seff(1) is lower than min. If the difference Seff(1, 2) is larger than max, the 1 set is assigned a weight of 1.0. The smoother step function is used between these two extremes. The min and max values can be changed if needed and examples of smoother step functions for different values are shown. research papers An example of a function is the smoother step function shown in Fig. 18 and deﬁned as: Section 2.5) is crossing the above-mentioned area, the weight of this neighbor set is 1.0 (indicated in white on Fig. 16), otherwise it is set to 0.0. An extension of this weight could be to ensure it is continuous. smootherstep a;b ðxÞ ¼ 0:0 if x a; 6x5 15x4 þ 10x3 if a < x < b; 1:0 if x b: 8 < : ð12Þ ð12Þ MultiWeightsChemenvStrategy:stats:articleweightsparametersðÞ Figure 17 Weight function for the Self-CSM outer weight of neighbor sets as deﬁned in equation (9). The default parameters for this weight are shown as blue while the green and purple curves illustrate other parameters. Arrows indicate thresholds above which values (i.e. Smax) of the effective CSM Seff each of the weight functions are set to zero. Figure 17 Figure 16 Figure 17 Weight function for the Self-CSM outer weight of neighbor sets as deﬁned in equation (9). The default parameters for this weight are shown as blue while the green and purple curves illustrate other parameters. Arrows indicate thresholds above which values (i.e. Smax) of the effective CSM Seff each of the weight functions are set to zero. Figure 16 Schematic of the distance–angle area weight. The shaded area is used to determine which neighbor sets are considered. If the region of a given neighbor set is crossing the shaded area, the set is assigned a ‘distance– angle area’ weight of 1.0. In the opposite case, the set is assigned a weight of 0.0 (white regions). 691 David Waroquiers et al. ChemEnv Acta Cryst. (2020). B76, 683–695 692 David Waroquiers et al. ChemEnv ‘Self CSM’ weight Figure 19 Choice of partial weights: comparison and combination of Self CSM and Delta CSM weights in the case of the smooth distortion from octahedral to square-pyramidal environment. Curves in blue (green) correspond to the octahedral (square-pyramidal) environment. See text for details. Figure 19 Choice of partial weights: comparison and combination of Self CSM and Delta CSM weights in the case of the smooth distortion from octahedral to square-pyramidal environment. Curves in blue (green) correspond to the octahedral (square-pyramidal) environment. See text for details. Figure 19 Figure 18 g Smoother step function used in the Delta CSM weight. The ‘Delta CSM’ weight assigned to the 1 neighbor set is equal to 0.0 if the difference Seff(1, 2) between the effective CSM Seff(2) of the 2 neighbor set and its own effective CSM Seff(1) is lower than min. If the difference Seff(1, 2) is larger than max, the 1 set is assigned a weight of 1.0. The smoother step function is used between these two extremes. The min and max values can be changed if needed and examples of smoother step functions for different values are shown. Figure 19 Choice of partial weights: comparison and combination of Self CSM and Delta CSM weights in the case of the smooth distortion from octahedral to square-pyramidal environment. Curves in blue (green) correspond to the octahedral (square-pyramidal) environment. See text for details. Acta Cryst. (2020). B76, 683–695 692 David Waroquiers et al. ChemEnv 692 research papers CSM weight for the square-pyramidal environment reaches 1.0 as the larger environment is too distorted to disfavor the square-pyramidal environment. The lower right panel illus- trates the case when both the Self CSM and Delta CSM weights are included. on of the ChemEnv package. Directories are indicated in blac nded by a rectangle. Files are indicated in typewriter (blue fo s, purple for other ﬁles). The most important python object d i it li ( ) S t t f i f ti 3 CoordinationGeometry Generic class for the description of all the model coordi- nation geometries. An instance of this class is created for each model environment (from the json ﬁles stored in the coordinationgeometryfiles directory). It contains information about its perfect coordinates as well as its edges and faces, name(s), symbol(s), technical details for the iden- tiﬁcation procedure, . . . . 7 SimplestChemenvStrategy 7 SimplestChemenvStrategy Class used to apply the ﬁxed distance/angle cutoff strategy introduced in Section 2.6.1. 1 LocalGeometryFinder Main class used to identify the local environments in a structure. 2 AllCoordinationGeometries 3. Description of the package The ChemEnv module is written in Python and can be found in the pymatgen package (Ong et al., 2013) as part of the analysis submodule. The organization of the package is shown diagrammatically in Fig. 20. The description of each of the objects referenced as circled numbers in this ﬁgure is given hereafter: 1 LocalGeometryFinder 6 DetailedVoronoiContainer Class containing the information on the Voronoı¨ analysis (see Section 2.2) performed at the beginning of the identiﬁ- cation procedure in order to deﬁne the different possible neighbor sets. 4 StructureEnvironments Class containing the information (CSMs, neighbors, . . . ) on all possible neighbor sets for all sites in the structure as introduced in Section 2.5. This object is meant to be post- processed with a strategy in order to get relevant and usable data about the local environments of the structure. 5 LightStructureEnvironments Class containing the processed data from the Structure- Environments class using one strategy. This object lists the environment(s) and their corresponding fractions (in case of a strategy allowing for mixtures of environments) for each site of the structure. 6 DetailedVoronoiContainer 2 AllCoordinationGeometries Class containing the list of all the available model coordi- nation geometries (as CoordinationGeometry objects, see 3 3 CoordinationGeometry Class containing the list of all the available model coordi- nation geometries (as CoordinationGeometry objects, see 3 3 CoordinationGeometry Funding information Funding for this research was provided by: European Union’s Horizon 2020, Marie Skłodowska-Curie grant (grant No. 837910 to Janine George); US Department of Energy, Ofﬁce of Science, Ofﬁce of Basic Energy Sciences, Materials Sciences and Engineering Division [contract No. DE-AC02-05CH11231 (Materials Project program KC23MP) to Matthew Horton and Kristin A. Persson]. References Allmann, R. & Hinek, R. (2007). Acta Cryst. 63, 412–417. Allmann, R. & Hinek, R. (2007). Acta Cryst. 63, 412–417. Bergerhoff, G. & Brown, I. D. (1987). Crystallographic Databases, 360, 77–95. Brunner, G. O. & Schwarzenbach, D. (1971). Z. Kristallogr. 133, 127– 133. The web app is designed to offer one-to-one equivalent functionality to ChemEnv by directly calling the corre- sponding pymatgen interface, speciﬁcally using the Light- StructureEnvironments and SimplestChemenvStrategy, and allowing the user full interactive control over the distance and angle cut-offs. Each symmetrically distinct chemical environ- ment is shown in 3D using a custom atomic visualizer, along with Wyckoff label, IUPAC symbol, CSM, and human-read- able environment label. Oxidation states will be used in the analysis if atoms are appropriately annotated in the uploaded ﬁle or, if these are not supplied, oxidation states can be guessed on-the-ﬂy using pymatgen’s bond valence analysis algorithms. It will be hosted by the Materials Project, and is available at http://crystaltoolkit.org. Carter, F. L. (1978). Acta Cryst. B34, 2962–2966. Frank, F. C. & Kasper, J. S. (1958). Acta Cryst. 11, 184–1 George, J., Waroquiers, D., Di Stefano, D., Petretto, G., Rignanese, ( ) George, J., Waroquiers, D., Di Stefano, D., Petretto, G., Rignanese, G.-M. & Hautier, G. (2020). Angew. Chem. Int. Ed. 59, 7569–7575. Groom, C. R., Bruno, I. J., Lightfoot, M. P. & Ward, S. C. (2016). Acta Cryst. B72, 171–179. Gun´ka, P. A. & Zachara, J. (2019). Acta Cryst. B75, 86–96. Hartshorn, R. M., Hey-Hawkins, E., Kalio, R. & Leigh, G. J. (2007). Pure Appl. Chem. 79, 1779–1799. pp Hoffmann, R. (1987). Angew. Chem. Int. Ed. Engl. 26, 846–878 Hoffmann, R. (1988). Solids and Surfaces: A Chemist’s View of Bonding in Extended Structures. New York: VCH Publishers. g Hoppe, R. (1979). Z. Kristallogr. 150, 23–52. g Hoppe, R. (1979). Z. Kristallogr. 150, 23–52. Jain, A., Hautier, G., Ong, S. P. & Persson, K. (2016). J. Mater. Res. 31, 977–994. Jain, A., Ong, S. P., Hautier, G., Chen, W., Richards, W. D., Dacek, S., Cholia, S., Gunter, D., Skinner, D., Ceder, G. & Persson, K. A. (2013). APL Mater. 1, 011002. Kabsch, W. (1976). Acta Cryst. A32, 922–923. 6. Supporting information A tutorial for the ChemEnv package, in both pdf and jupyter- notebook format, is available in the supporting information. The list of all environments as well as some details about the implementation are also available in the supporting information. Combining this StructureEnvironments object with a strategy (e.g. SimplestChemenvStrategy or MultiWeightsChemenv- Strategy) leads to the LightStructureEnvironments object. This latter object contains the usable information about the environments in a structure, i.e. the environment or mix of environments (with their corresponding fractions) that is identiﬁed for each site. 8 MultiWeightsChemenvStrategy Class used to apply the strategy based on multiple weights as introduced in Section 2.6.2. The most relevant objects needed for the user of ChemEnv package are illustrated in Fig. 21. Figure 20 The LocalGeometryFinder object is the main class used to initialize and set up the structure as well as to compute the StructureEnvironments object (containing the raw coordina- tion environments data as introduced in Section 2.5). g Organization of the ChemEnv package. Directories are indicated in black and surrounded by a rectangle. Files are indicated in typewriter (blue for python ﬁles, purple for other ﬁles). The most important python objects are indicated in italic (green). See text for more information. g Organization of the ChemEnv package. Directories are indicated in black and surrounded by a rectangle. Files are indicated in typewriter (blue for python ﬁles, purple for other ﬁles). The most important python objects are indicated in italic (green). See text for more information. 693 David Waroquiers et al. ChemEnv Acta Cryst. (2020). B76, 683–695 research papers Figure 21 Main objects of the ChemEnv package. distance. From this grid of different distance and angle cutoffs, the coordination environments are determined with the help of a similarity metric to the shape of ideal polyhedra. Two different strategies are implemented to arrive at the ﬁnal assignment of the coordination environments. One of these strategies is especially robust against small distortions of the crystal structures making the algorithm particularly useful for automatic, unsupervised, local environment assignment. This new tool can be used as part of the open-source Python library (pymatgen) and within an interactive web app available on http://crystaltoolkit.org through the Materials Project. Figure 21 Main objects of the ChemEnv package. Figure 21 Main objects of the ChemEnv package. 4. Interactive web app An interactive web app has been developed to improve accessibility of the ChemEnv algorithms as part of the Mate- rials Projects Crystal Toolkit platform. While the Python interface is intuitive and well documented, not all scientists are Python users, and the web app enables use of ChemEnv by any user without installing custom software. The web app supports uploading of any ﬁle format supported by the pymatgen code, including Crystallographic Information Format (CIF). Alter- natively, structures can be loaded directly from the Materials Project database containing more than 100 000 inorganic materials. 694 David Waroquiers et al. ChemEnv Maiseli, B., Gu, Y. & Gao, H. (2017). J. Visual Commun. Image Represent. 46, 95–106. Mu¨ller, U. (2007). Inorganic Structural Chemistry. Wiley. O’Keeffe, M. (1979). Acta Cryst. A35, 772–775. Ong, S. P., Richards, W. D., Jain, A., Hautier, G., Kocher, M., Cholia, S., Gunter, D., Chevrier, V. L., Persson, K. A. & Ceder, G. (2013). Comput. Mater. Sci. 68, 314–319. Pauling, L. (1929). J. Am. Chem. Soc. 51, 1010–1026. Peng, H., Ndione, P. F., Ginley, D. S., Zakutayev, A. & Lany, S. (2015). Phys. Rev. X, 5, 021016. Pfeiffer, P. (1915). Z. Anorg. Allg. Chem. 92, 376–380. Pfeiffer, P. (1916). Z. Anorg. Allg. Chem. 97, 161–174. Pinsky, M. & Avnir, D. (1998). Inorg. Chem. 37, 5575–5582. David Waroquiers et al. ChemEnv 695 5. Conclusion Kabsch, W. (1978). Acta Cryst. A34, 827–828. Lima-de-Faria, J., Hellner, E., Liebau, F., Makovicky, E. & Parthe´, E. (1990). Acta Cryst. A46, 1–11. We have developed a tool that can analyze coordination or local environments of large numbers of crystal structures in a fast and robust manner. The analysis of the neighboring atoms relies on a modiﬁed Voronoı¨ approach based on a grid of Lueken, H. (2013). Magnetochemie: Eine Einfu¨hrung in Theorie und Anwendung. Teubner Studienbu¨cher Chemie. Vieweg+Teubner Verlag. 694 David Waroquiers et al. ChemEnv Acta Cryst. (2020). B76, 683–695 Acta Cryst. (2020). B76, 683–695 ( ) g g Pinsky, M. & Avnir, D. (1998). Inorg. Chem. 37, 5575–5582. O’Keeffe, M. (1979). Acta Cryst. A35, 772–775. y Pfeiffer, P. (1915). Z. Anorg. Allg. Chem. 92, 376–380. research papers research papers Pomerleau, F., Colas, F. & Siegwart, R. (2015). Found. Trends Robot. 1, 1–104. Stoiber, D. & Niewa, R. (2019). Z. Kristallogr. 234, 201–209. Villars, P. & Cenzual, K. (2018). Pearson’s Crystal Data: Crystal Structure Database for Inorganic Compounds. Release 2018/19 (on DVD). ASM International, Materials Park, Ohio, USA. Waroquiers, D., Gonze, X., Rignanese, G.-M., Welker-Nieuwoudt, C., Rosowski, F., Go¨bel, M., Schenk, S., Degelmann, P., Andre´, R., Glaum, R. & Hautier, G. (2017). Chem. Mater. 29, 8346–8360. g Glaum, R. & Hautier, G. (2017). Chem. Mater. 29, 8346–8360. Zagorac, D., Mu¨ller, H., Ruehl, S., Zagorac, J. & Rehme, S. (2019). J. Appl. Cryst. 52, 918–925. y Pfeiffer, P. (1915). Z. Anorg. Allg. Chem. 92, 376–380. Pfeiffer, P. (1916). Z. Anorg. Allg. Chem. 97, 161–174. Zimmermann, N. E. R., Horton, M. K., Jain, A. & Haranczyk, M. (2017). Front. Mater. 4, 34. ( ) Pinsky, M. & Avnir, D. (1998). Inorg. Chem. 37, 5575–5582. David Waroquiers et al. ChemEnv 695 Acta Cryst. (2020). B76, 683–695
https://openalex.org/W4200548835	https://www.nature.com/articles/s41467-022-34808-2.pdf	English	null	N6-methyladenosine modification governs liver glycogenesis by stabilizing the glycogen synthase 2 mRNA	Research Square (Research Square)	2,021	cc-by	13,562	Article https://doi.org/10.1038/s41467-022-34808-2 N6-methyladenosine modiﬁcation governs liver glycogenesis by stabilizing the glycogen synthase 2 mRNA Xiang Zhang 1,2,8, Huilong Yin 1,3,4,8, Xiaofang Zhang1, Xunliang Jiang1, Yongkang Liu1, Haolin Zhang1, Yingran Peng1, Da Li1, Yanping Yu1,5, Jinbao Zhang1, Shuli Cheng1,6, Angang Yang 3,4,7 & Rui Zhang 1,7 Xiang Zhang 1,2,8, Huilong Yin 1,3,4,8, Xiaofang Zhang1, Xunliang Jiang1, Yongkang Liu1, Haolin Zhang1, Yingran Peng1, Da Li1, Yanping Yu1,5, Jinbao Zhang1, Shuli Cheng1,6, Angang Yang 3,4,7 & Rui Zhang 1,7 Received: 26 November 2021 Accepted: 8 November 2022 Check for updates Received: 26 November 2021 Accepted: 8 November 2022 Check for updates Hepatic glycogen is the main source of blood glucose and controls the inter- vals between meals in mammals. Hepatic glycogen storage in mammalian pups is insufﬁcient compared to their adult counterparts; however, the detailed molecular mechanism is poorly understood. Here, we show that, similar to glycogen storage pattern, N6-methyladenosine (m6A) modiﬁcation in mRNAs gradually increases during the growth of mice in liver. Strikingly, in the hepatocyte-speciﬁc Mettl3 knockout mice, loss of m6A modiﬁcation disrupts liver glycogen storage. On the mechanism, mRNA of Gys2, the liver-speciﬁc glycogen synthase, is a substrate of METTL3 and plays a critical role in m6A- mediated glycogenesis. Furthermore, IGF2BP2, a “reader” protein of m6A, stabilizes the mRNA of Gys2. More importantly, reconstitution of GYS2 almost rescues liver glycogenesis in Mettl3-cKO mice. Collectively, a METTL3- IGF2BP2-GYS2 axis, in which METTL3 and IGF2BP2 regulate glycogenesis as “writer” and “reader” proteins respectively, is essential on maintenance of liver glycogenesis in mammals. Hepatic glycogen maintains the blood glucose concentration between meals. In humans, defects in glycogenesis cause different types of glycogen storage diseases, which may lead to failure to thrive in some pediatric patients1,2. Intriguingly, under physiological conditions, the hepatic glycogen content increases gradually from birth to adulthood in numerous mammals, such as rats, rabbits, sheep, and rhesus macaques3–5. And the blood glucose concentration has a similar pattern6. However, the detailed mechanism and biological meaning of this phenomenon remain unclear. Gys2, located at 12p12.1 in human, is conserved in chimpan- zee, rhesus monkey, dog, cow, mouse, rat, chicken, and zebraﬁsh. The protein encoded by this gene is liver glycogen synthase (GS), a key enzyme in glycogenesis, and catalyzes the addition of α−1,4- linked glucose to the growing glycogen chain. Mutations in this gene cause glycogen storage disease type 0 (GSD-0) in early childhood, with hypoglycemia and liver glycogen defect as symptoms1,7. However, little is known about regulation of Gys2 expression. N6-methyladenosine modiﬁcation governs liver glycogenesis by stabilizing the glycogen synthase 2 mRNA 1The State Key Laboratory of Cancer Biology, Department of Biochemistry and Molecular Biology, Fourth Military Medical University, Xi’an, Shaanxi 710032, China. 2The Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, Fourth Military Medical University, Xi’an, Shaanxi 710032, China. 3The Henan Key Laboratory of immunology and Targeted Therapy, School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, Henan 453003, China. 4The Xinxiang Key Laboratory of Tumor Microenvironment and Immunotherapy, School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, Henan 453003, China. 5The Second Ward of Gynecological Tumor, Shaanxi Provincial Tumor Hospital, Xi’an, Shaanxi 710000, China. 6The Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, Laboratory Center of Stomatology, Department of Ortho- dontics, College of Stomatology, Xi’an Jiaotong University, Xi’an, Shaanxi 710032, China. 7The State Key Laboratory of Cancer Biology, Department of Immunology, Fourth Military Medical University, Xi’an, Shaanxi 710032, China. 8These authors contributed equally: Xiang Zhang, Huilong Yin. e-mail: ruizhang@fmmu.edu.cn 1The State Key Laboratory of Cancer Biology, Department of Biochemistry and Molecular Biology, Fourth Military Medical University, Xi’an, Shaanxi 710032, China. 2The Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, Fourth Military Medical University, Xi’an, Shaanxi 710032, China. 3The Henan Key Laboratory of immunology and Targeted Therapy, School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, Henan 453003, China. 4The Xinxiang Key Laboratory of Tumor Microenvironment and Immunotherapy, School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, Henan 453003, China. 5The Second Ward of Gynecological Tumor, Shaanxi Provincial Tumor Hospital, Xi’an, Shaanxi 710000, China. 6The Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, Laboratory Center of Stomatology, Department of Ortho- dontics, College of Stomatology, Xi’an Jiaotong University, Xi’an, Shaanxi 710032, China. 7The State Key Laboratory of Cancer Biology, Department of Immunology, Fourth Military Medical University, Xi’an, Shaanxi 710032, China. 8These authors contributed equally: Xiang Zhang, Huilong Yin. e-mail: ruizhang@fmmu.edu.cn Nature Communications\| (2022) 13:7038 1 https://doi.org/10.1038/s41467-022-34808-2 Article Article Among the more than one hundred RNA modiﬁcations, N6- methyladenosine (m6A) was identiﬁed in the 1970s8. M6A is the most abundant modiﬁcation in eukaryotic mRNAs9 and functions as an epitranscriptomic regulator of target mRNAs through multiple mechanisms, including regulating mRNA stability and translation efﬁciency10. As early as in 1990s, MT-A70, also known as METTL3 these years, was reported having methyltransferases activity of m6A11. Genetic and pharmacological inhibition of Mettl3 simulates lack of glycogen in liver To investigate why mRNA m6A levels increase with age, we analyzed an RNA-seq dataset with different-aged mouse livers (GSE58827). Mettl3, but not other key m6A machinery components, was found having a signiﬁcant increase with age (Fig. 2a). And the elevation of METTL3 was also observed in protein level (Fig. 2b). To demonstrate the detailed mechanism between Mettl3 and glycogen storage, ﬁrstly, we generated a hepatocyte-speciﬁc Mettl3 knockout model, albumin-Cre Mettl3ﬂ/ﬂ(Supplementary Fig. 1a). As expected, the declines in METTL3 protein (Supplementary Fig. 1d) and in relative fold of global m6A mRNA (Supplementary Fig. 1c) were observed in cKO-mice’s liver tissues. Intriguingly, the relative fold of m6A mRNA had no signiﬁcant difference between WT (wild-type) and HET (heterozygous) mouse livers (Supplementary Fig. 1c), although they have different Mettl3 mRNA levels (Supplementary Fig. 1b). Gly- cogen content assay and periodic acid-Schiff (PAS) staining revealed that glycogen shortage in the liver was simulated in Mettl3-cKO mouse, but WT and HET mice had similar glycogen level in liver (Fig. 2c, d). Via transmission electron microscopy (TEM), almost no glycogen could be observed in hepatocytes of Mettl3-cKO mice (Fig. 2e). In addition, AQP8, a channel protein that was reported to have a close temporal and spatial correlation with glycogen accumulation in hepatocytes36, was reduced in Mettl3-cKO mice (Supplementary Fig. 1e). Considering that the most important function of liver glycogen is blood glucose maintenance, we measured the serum glucose level in mice of different genotypes and found that it was greatly reduced in Mettl3-cKO mice (Fig. 2f). Furthermore, Mettl3-cKO mice also had worse performance than WT and HET mice in the forced swim test (Fig. 2g). In summary, hepatocyte-speciﬁc Mettl3-cKO could simulate glycogen shortage in liver, although Mettl3-HET and Mettl3-WT had no signiﬁcant difference in glycogen and other associated phenotypes. Importantly, with deeply understanding the biochemical process of N6-methyladenosine modiﬁcation in the past decade, more studies have moved forward to explore the functional signiﬁcance of m6A in various biological processes, including DNA damage repair29, meiosis30, circadian clock31, and tumor immune surveillance32. Transcriptome-wide mapping of m6A modiﬁcation has revealed cell type-speciﬁc methylation targets, suggesting that m6A regulates cell type-speciﬁc processes33. Liver is an important metabolic organ in the body, and maintaining its functional homeostasis is essential for health. It has been reported that inhibition of m6A methylation decreases the m6A abundance in PPaRα and increases the lifetime and expression of PPaRα mRNA, reducing lipid accumulation in hepatocytes34. N6-methyladenosine modiﬁcation governs liver glycogenesis by stabilizing the glycogen synthase 2 mRNA However, approximately a decade ago, the identiﬁcation of the ﬁrst RNA demethylase, fat mass, and obesity-associated protein (FTO), revealed that N6-methyladenosine modiﬁcation is reversible12. And consequently, a methyltransferase complex consisting mainly of methyltransferase-like 3 (METTL3), methyltransferase-like 14 (METTL14) and Wilms tumor-associated protein (WTAP) has been proven to act as an m6A methyltransferase (“writer”) in mammalian cells13,14 with METTL3 being the essential catalytic component of the complex10,15–19. Furthermore, a group of YT521-B homology (YTH) domain-containing family proteins (YTHDFs) have been identiﬁed as m6A “readers” that control mRNA fate by regulating pre-mRNA spli- cing, facilitating mRNA translation and promoting mRNA degradation10,20–24. Strikingly, Huang et al. and other groups demon- strated that insulin-like growth factor 2 (IGF2) mRNA-binding proteins 1, 2, and 3 (IGF2BP1/2/3) preferentially recognized m6A-modiﬁed mRNAs and promoted the stability (and likely the translation) of thousands of potential target mRNAs in an m6A-dependent manner, thereby affecting global gene expression output25–28. transmission electron microscopy (TEM), only a few glycogen mole- cules were observed in hepatocytes from 4-week-old mice; however, hepatocytes from 8-week-old mice contained an abundance of glyco- gen in the cytoplasm (Fig. 1b). Glycogen content assay conﬁrmed this conclusion (Fig. 1c). Intriguingly, if we conjointly analyzed samples from different ages, the relative fold of m6A in livers’ mRNAs had an obvious positive relationship with glycogen content (Fig. 1d). Genetic and pharmacological inhibition of Mettl3 simulates lack of glycogen in liver In addition, m6A modiﬁcation can also orchestrate sex- dimorphic metabolic traits in liver. Loss of m6A control in male livers increases hepatic triglyceride stores, leading to a more ‘feminized’ hepatic lipid composition35. All the evidence supports that dynamic modiﬁcation of m6A is essential for the multiple physiological func- tions of liver tissues. STM2457 is a highly efﬁcient and selective catalytic inhibition on RNA methyltransferase METTL3. Eight-week-old male mice were sacriﬁced after treatment with vehicle or 50 mg/kg STM2457 each day for 5 days (Supplementary Fig. 2a). As excepted, relative fold of m6A mRNA was diminished in hepatocytes of STM2457-treated mice (Supplementary Fig. 2b). PAS staining (Supplementary Fig. 2c), trans- mission electron microscopy (Supplementary Fig. 2d) and glycogen content assay (Supplementary Fig. 2e) showed that STM2457-treated mice had much less glycogen in liver. Taken together, Mettl3-speciﬁc methyltransferase activity inhibition also simulate lack of glycogen in mouse liver. Here, we ﬁnd a positive relationship between m6A levels and glycogen contents in the hepatocytes during mouse growth. Strikingly, hepatic glycogen is almost completely absent in mice with liver- speciﬁc Mettl3 deletion. Analysis of m6A-methylated RNA immuno- precipitation sequencing with qRT-PCR (MeRIP-qPCR) shows that METTL3 induces an increase in the m6A level in Gys2 mRNA and pro- motes IGF2BP2-mediated Gys2 mRNA stability. Importantly, reintro- duction of exogenous GYS2 partially rescues glycogen storage in Mettl3-deﬁcient hepatocytes in vivo. Furthermore, co-expression of Mettl3 and Gys2 is associated with liver glycogen storage in other mammals, such as Sprague‑Dawley rats. Taken together, our study reveals that a METTL3-IGF2BP2-GYS2 axis potentially regulates the hepatic glycogen quantity. Identiﬁcation of Gys2 mRNA as a key target of METTL3 in mouse liver To investigate the role of m6A in liver glycogen storage, total RNA was isolated from samples of Mettl3-WT and Mettl3-cKO hepatocytes or liver tissues for m6A proﬁling by MeRIP-seq. Motif searching identiﬁed the consensus core “GGAC” motif within the m6A sites (Fig. 3a). The density of m6A peaks increased steadily along the transcript in the CDS and decreased along the 3’-UTR (Fig. 3b). Gene Ontology (GO) terms related to numerous metabolic processes were the most signiﬁcantly enriched with genes exhibiting m6A peak loss (Supplementary Fig. 3a) and downregulated expression (Supplementary Fig. 3b) in Mettl3-cKO liver tissue. These results suggested that m6A modiﬁcation has a considerable inﬂuence on metabolic pathways. Then, we obtained 26 Nature Communications\| (2022) 13:7038 Mouse pups have both low glycogen storage and low mRNA m6A level in liver d The relationship between relative fold of m6A mRNA and hepatic glycogen content at different age samples. Black, 4w; blue, 8w. n = 10 animals. Linear regression was performed to determine a difference. Source data are pro- vided as a Source data ﬁle. Fig. 1 \| Low content of mRNA m6A is related to a shortage of hepatic glycogen in mouse pups. a PAS staining of wild-type mouse livers in different ages (4w, 4 weeks; 6w, 6 weeks; 8w, 8 weeks). The percentage of positive area is measured by Image J and shown on the right. Bar, 50 μm. n = 5 animals. Data are presented as mean values +/−SEM. p < 0.05; p < 0.001 by one-way ANOVA. b Transmission electron microscope pictures of wild-type mouse livers in different ages. Bar: top, 4 μm; bottom, 2 μm. This experiment was repeated independently with similar results at least 3 times. c Hepatic glycogen content at different ages, as micrograms per milligram of tissue, n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.0006. d The relationship between relative fold of m6A mRNA and hepatic glycogen content at different age samples. Black, 4w; blue, 8w. n = 10 animals. Linear regression was performed to determine a difference. Source data are pro- vided as a Source data ﬁle. Two-sided Student s t test was performed to determine a difference among groups. *p = 0.0006. d The relationship between relative fold of m6A mRNA and hepatic glycogen content at different age samples. Black, 4w; blue, 8w. n = 10 animals. Linear regression was performed to determine a difference. Source data are pro- vided as a Source data ﬁle. pup and adult mouse livers might be attributed to different methyla- tion levels, but not transcription regulation (Supplementary Fig. 3g, h). In conclusion, Gys2, the key enzyme of glycogenesis in hepato- cytes, is a candidate target of METTL3-mediated m6A modiﬁcation in liver. And loss of m6A modiﬁcations perishes Gys2 mRNA expression in a post transcription manner. pup and adult mouse livers might be attributed to different methyla- tion levels, but not transcription regulation (Supplementary Fig. 3g, h). candidate genes from one MeRIP-seq dataset (from 8-week-old mouse hepatocytes) and three independent RNA sequencing (RNA-seq) datasets (from 8-week-old mouse hepatocytes, male liver tissues and female liver tissues respectively). Mouse pups have both low glycogen storage and low mRNA m6A level in liver All 26 genes exhibited both m6A peak loss and a pattern of downregulated expression (Fig. 3c). Among these 26 genes was fatty acid synthase (Fasn) (Fig. 3c, Supplementary Fig. 3c), whose mRNA was reported to be a substrate of METTL3 in hepatocytes37. Intriguingly, this gene set contained glycogen synthase 2 (Gys2), the key enzyme coding gene of glycogenesis in liver (Fig. 3c, d). In addition, MeRIP-qPCR, performed in HET and cKO mouse hepato- cytes, conﬁrmed that Gys2 mRNA had m6A modiﬁcation in a METTL3- dependent manner (Fig. 3e). m6A MeRIP-Seq revealed that, like Fasn (Supplementary Fig. 3c), Gys2 has highly enriched and speciﬁc m6A peaks among its coding sequence, but these peaks almost lost in Mettl3-cKO hepatocytes (Fig. 3d). In conclusion, Gys2, the key enzyme of glycogenesis in hepato- cytes, is a candidate target of METTL3-mediated m6A modiﬁcation in liver. And loss of m6A modiﬁcations perishes Gys2 mRNA expression in a post transcription manner. IGF2BP2 is involved in m6A mediated Gys2 mRNA stability Different functions of m6A modiﬁcation are reported to be mediated by different m6A binding proteins (i.e., readers), such as YTHDF1/2/3 and IGF2BP1/2/338. As shown in Fig. 3f, the Gys2 mRNA level was much lower in liver tissue in Mettl3-cKO mice than in control mice. To determine which reader proteins mediate the mRNA stability of Gys2, we independently depleted the six candidate readers in Hepa 1-6 (mouse hepatocellular carcinoma) cells and found that depletion of only IGF2BP2 reduced Gys2 mRNA expression (Fig. 4a, Supplementary Fig. 4a). Furthermore, mRNA decay assays demonstrated that a reduction in IGF2BP2 expression appreciably promoted the degrada- tion of Gys2 mRNA (Fig. 4b). Finally, IGF2BP2 antibody-based RNA Immunoprecipitation (RIP) assays uncovered that the binding between IGF2BP2 protein and Gys2 mRNA was m6A (METTL3) dependent (Fig. 4c, Supplementary Fig. 4d). However, Fasn, another target of Mettl3 in hepatocytes, had no signiﬁcant difference in IGF2BP2 RIP- qPCR assay (Supplementary Fig. 4b). To sum up, IGF2BP2 could combine and stabilize Gys2 mRNA in a METTL3-dependent manner. To investigate the binding site of IGF2BP2 and whether this On expression inﬂuence of m6A modiﬁcation, much lower Gys2 level at both mRNA (Fig. 3f) and protein (Fig. 3g) were found in livers of Mettl3-cKO mice. Particularly worth mentioning is that pre-mRNA (nascent mRNA) of Gys2 had no signiﬁcant different between Mettl3- HET and Mettl3-cKO mice (Supplementary Fig. 3d). Mouse pups have both low glycogen storage and low mRNA m6A level in liver Mice are usually weaned after 4 weeks of age and reach sexual maturity between 6 and 8 weeks. After 8 weeks of age, most mice have the ability to procreate. Here, we measured liver glycogen levels in C57BL/ 6 mice in a free diet at different ages and found that glycogen storage in the liver gradually increased with the growth of mice (Fig. 1a). Via Nature Communications\| (2022) 13:7038 2 https://doi.org/10.1038/s41467-022-34808-2 Article 4w 8w 6w a c b 4w 8w 4w 8w 6w Positive Area (%) Glycogen (μg/mg liver) 4w 8w Glycogen (μg/mg liver) Relative fold of m6A mRNA R = 0.9443, P < 0.0001 d Fig. 1 \| Low content of mRNA m6A is related to a shortage of hepatic glycogen in mouse pups. a PAS staining of wild-type mouse livers in different ages (4w, 4 weeks; 6w, 6 weeks; 8w, 8 weeks). The percentage of positive area is measured by Image J and shown on the right. Bar, 50 μm. n = 5 animals. Data are presented as mean values +/−SEM. p < 0.05; *p < 0.001 by one-way ANOVA. b Transmission electron microscope pictures of wild-type mouse livers in different ages. Bar: top, 4 μm; bottom, 2 μm. This experiment was repeated independently with similar results at least 3 times. c Hepatic glycogen content at different ages, as micrograms per milligram of tissue, n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.0006. d The relationship between relative fold of m6A mRNA and hepatic glycogen content at different age samples. Black, 4w; blue, 8w. n = 10 animals. Linear regression was performed to determine a difference. Source data are pro- vided as a Source data ﬁle. 4w 8w 6w a 4w 8w 6w Positive Area (%) a b 4w b c Glycogen (μg/mg liver) 4w 8w d 8w c A d 4w 8w Glycogen (μg/mg liver) Relative fold of m6A mRNA R = 0.9443, P < 0.0001 d Glycogen (μg/mg liver) results at least 3 times. c Hepatic glycogen content at different ages, as micrograms per milligram of tissue, n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. *p = 0.0006. Nature Communications\| (2022) 13:7038 Mouse pups have both low glycogen storage and low mRNA m6A level in liver It demonstrated that Mettl3 depletion mainly inﬂuenced post transcription process of Gys2 expression. In addition, we tested mature and nascent Gys2 mRNA in STM2457 or vehicle-treated mouse livers, and found that mature but not nascent Gys2 mRNA had signiﬁcant decrease under inhibition of METTL3 activity (Supplementary Fig. 3e, f). Finally, qRT-PCR assay illustrated that mature Gys2 mRNA was higher in 8-week-old mouse liver than 4-week-old ones (Fig. 3h). MeRIP-qPCR and nascent mRNA qPCR assays demonstrated the different expression of Gys2 between To investigate the binding site of IGF2BP2 and whether this binding is m6A dependent or not, we analyzed the sequences of dif- ferent m6A peaks in hepatocytes’ MeRIP-seq data by a SRAMP online Nature Communications\| (2022) 13:7038 3 Article https://doi.org/10.1038/s41467-022-34808-2 40kD 70kD a f e g Mettl3 Mettl14 Wtap Alkbh5 Fto Relative Expressoin Level b WT HET cKO d Positive Area (%) HET cKO WT Mettl3-HET Mettl3-cKO Glycogen (μg/mg liver) HET cKO WT c HET cKO WT Serum Glucose (mmol/L) in free diet Swimming time (sec) HET cKO WT 1.0 1.1 1.2 1.4 1.4 1.6 METTL3 β-actin 100kD Fig. 2 \| Mettl3 depletion simulates lack of glycogen in liver. a Relative expression levels (FPKM) of ﬁve key genes in m6A writing or erasing from a mouse liver- associated GEO dataset (GSE58827). n = 3 independent samples. Data are presented as mean values +/−SEM. Two-way ANOVA was performed to determine a difference among columns within a gene. p < 0.05. b Western blotting assay of Mettl3 protein level in wild-type mouse livers from different ages. This experiment was repeated independently with similar results at least 3 times. c Hepatic glycogen content at different ages, as micrograms per milligram of tissue, n = 5 animals. Data are pre- sented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between each column. ns, not signiﬁcant; *p < 0.001. d PAS staining of livers in 8-week-old mice with different Mettl3 genotypes. The percentage of positive area is measured by Image J and shown on the right. WT wild type, HET heterozygous, cKO conditional knockout (Albumin-cre). Bar, 50 μm. n = 5 animals. Data are presented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between each column. ns, not signiﬁcant; p < 0.001. e Transmission electron microscope pictures of livers in 8-week-old mouse with indicated Mettl3 genotypes. Bar: top, 4 μm; bottom, 2 μm. Mouse pups have both low glycogen storage and low mRNA m6A level in liver ns, not signiﬁcant; p < 0.001. Data are presented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between each column. ns, not signiﬁcant; p < 0.001. e Transmission electron microscope pictures of livers in 8-week-old mouse with indicated Mettl3 genotypes. Bar: top, 4 μm; bottom, 2 μm. This experiment was repeated independently with similar results at least 3 times. f Serum glucose level of 8-week-old mice with different Mettl3 genotypes. n = 5 animals. Data are pre- sented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between each column. ns, not signiﬁcant; p < 0.01. g Exhaustive swimming assay of 8-week-old mice with different Mettl3 genotypes. n = 6 ani- mals. Data are presented as mean values +/−SEM. One-way ANOVA was per- formed to determine a difference between each column. ns, not signiﬁcant; p < 0.001. Source data are provided as a Source data ﬁle. See also Supple- mentary Figs. 1 and 2. In conclusion, Gys2 mRNA should be a bona ﬁde substrate of METTL3 and that Gys2 mRNA is stabilized by IGF2BP2 in an m6A- dependent manner. tool (http://www.cuilab.cn/sramp), and found two candidate sites (Fig. 4d). Then, we built two different “A to U” (“A to T” for DNA) mutant constructs of mouse Gys2 CDS (Fig. 4d). Based on the Flag tag in N terminal, we designed speciﬁc qPCR primers to detect exogenous mRNA of WT or mutant constructs (Supplementary Table 2). qRT-PCR (Fig. 4e) and Western blot assay (Fig. 4f) in Hepa 1-6 cells showed that +1172, not +2111, is the site that inﬂuences expression of Gys2 mRNA. And this conclusion was conﬁrmed by dual luciferase report (DLR) assay (Fig. 4g). IGF2BP2-RIP-qPCR illustrated that mutation of +1172 site blocked the binding of IGF2BP2 protein to Gys2 mRNA (Fig. 4h, Supplementary Fig. 4c). Taken together, it depended on an m6A site (+1172 in CDS) that IGF2BP2 combined and stabilized Gys2 mRNA in mouse liver. tool (http://www.cuilab.cn/sramp), and found two candidate sites (Fig. 4d). Then, we built two different “A to U” (“A to T” for DNA) mutant constructs of mouse Gys2 CDS (Fig. 4d). Based on the Flag tag in N terminal, we designed speciﬁc qPCR primers to detect exogenous mRNA of WT or mutant constructs (Supplementary Table 2). qRT-PCR (Fig. 4e) and Western blot assay (Fig. Mouse pups have both low glycogen storage and low mRNA m6A level in liver 4f) in Hepa 1-6 cells showed that +1172, not +2111, is the site that inﬂuences expression of Gys2 mRNA. And this conclusion was conﬁrmed by dual luciferase report (DLR) assay (Fig. 4g). IGF2BP2-RIP-qPCR illustrated that mutation of +1172 site blocked the binding of IGF2BP2 protein to Gys2 mRNA (Fig. 4h, Supplementary Fig. 4c). Taken together, it depended on an m6A site (+1172 in CDS) that IGF2BP2 combined and stabilized Gys2 mRNA in mouse liver. Mouse pups have both low glycogen storage and low mRNA m6A level in liver This experiment was repeated independently with similar results at least 3 times. f Serum glucose level of 8-week-old mice with different Mettl3 genotypes. n = 5 animals. Data are pre- sented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between each column. ns, not signiﬁcant; p < 0.01. g Exhaustive swimming assay of 8-week-old mice with different Mettl3 genotypes. n = 6 ani- mals. Data are presented as mean values +/−SEM. One-way ANOVA was per- formed to determine a difference between each column. ns, not signiﬁcant; **p < 0.001. Source data are provided as a Source data ﬁle. See also Supple- mentary Figs. 1 and 2. 40kD 70kD a Mettl3 Mettl14 Wtap Alkbh5 Fto Relative Expressoin Level b Glycogen (μg/mg liver) HET cKO WT c 1.0 1.1 1.2 1.4 1.4 1.6 METTL3 β-actin 100kD a Mettl3 Mettl14 Wtap Alkbh5 Fto Relative Expressoin Level b 40kD 70kD b Glycogen (μg/mg liver) HET cKO WT c 1.0 1.1 1.2 1.4 1.4 1.6 METTL3 β-actin 100kD b a WT HET cKO d Positive Area (%) HET cKO WT e Mettl3-HET Mettl3-cKO e Mettl3-HET Mettl3-cKO f f HET cKO WT Serum Glucose (mmol/L) in free diet f e g g Swimming time (sec) HET cKO WT Fig. 2 \| Mettl3 depletion simulates lack of glycogen in liver. a Relative expression levels (FPKM) of ﬁve key genes in m6A writing or erasing from a mouse liver- associated GEO dataset (GSE58827). n = 3 independent samples. Data are presented as mean values +/−SEM. Two-way ANOVA was performed to determine a difference among columns within a gene. p < 0.05. b Western blotting assay of Mettl3 protein level in wild-type mouse livers from different ages. This experiment was repeated independently with similar results at least 3 times. c Hepatic glycogen content at different ages, as micrograms per milligram of tissue, n = 5 animals. Data are pre- sented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between each column. ns, not signiﬁcant; *p < 0.001. d PAS staining of livers in 8-week-old mice with different Mettl3 genotypes. The percentage of positive area is measured by Image J and shown on the right. WT wild type, HET heterozygous, cKO conditional knockout (Albumin-cre). Bar, 50 μm. n = 5 animals. Data are presented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between each column. Reconstitution of GYS2 rescues liver glycogenesis in Mettl3- cKO mice To verify the METTL3-IGF2BP2-GYS2 axis, we reconstituted GYS2 in the Mettl3-cKO mouse livers via adeno-associated virus (AAV)-medi- ated transduction. Compared to control AAV (AAV-luciferase, AAV- Luc), AAV-Gys2 restored the GYS2 protein level in Mettl3-cKO mice to the baseline level (Fig. 5a, b). Glycogen content assay (Fig. 5c), PAS staining (Fig. 5d), and transmission electron microscopy (Fig. 5e) Nature Communications\| (2022) 13:7038 4 4 https://doi.org/10.1038/s41467-022-34808-2 Article a b d c Gys2, Mlxipl, Egfr, Fasn et al. Gys2 locus e Gys2 mRNA HET cKO Relative Gys2 mRNA f g 1.0 0.2 1.0 0.2 GYS2 β-actin MeRIP/Input(%) IgG m6A h Relative Gys2 mRNA 4w 8w 40kD 70kD Fig. 3 \| Identiﬁcation of Gys2 mRNA by global N6-methyladenosine modiﬁca- tion analysis as a key substrate of METTL3 in mouse liver. a The most enriched sequence motif of m6A peaks in mRNAs from 8-week-old WT or cKO mouse hepatocytes (HC) or liver (LI) samples. b Distribution of m6A peaks along the 5′UTR, CDS, and 3′UTR regions of total mRNAs from 8-week-old mouse sam- ples after normalized with length. c RNA-Seq and MeRIP-Seq identiﬁed downregulated and m6A-lost genes in Mettl3-cKO liver tissue or hepatocytes comparing to wild-type samples. All the samples were from 8-week-old mice. MeRIP-seq data were from hepatocytes of male mice; RNA-seq data were from hepatocytes and liver tissues of male mice and liver tissues of female mice, respectively. d m6A MeRIP-Seq revealed the location of speciﬁc m6A peak in Gys2 locus in hepatocytes of wildtype or Mettl3-cKO mice. //, deletion of a long and uninformative intron for better exhibition. e m6A enrichment of Gys2 mRNA in mettl3-HET or cKO hepatocytes by m6A-RIP-qPCR. n = 3 independent experiments. Data are presented as mean values +/−SEM. Two-way ANOVA was performed to determine a difference among each two groups. p < 0.01 comparing with IgG:HET; ##p < 0.01 comparing with m6A:HET. f qRT-PCR of Gys2 mRNA levels (β-actin as reference) in 8-week-old mouse livers with indicated Mettl3 genotypes. n = 4 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.004. g Western blotting assay of GYS2 pro- tein levels in 8-week-old mouse livers with indicated Mettl3 genotypes. The ratio of GYS2 to β-actin were shown between two lanes. This experiment was repeated independently with similar results at least 3 times. ♂, male; ♀, female. Reconstitution of GYS2 rescues liver glycogenesis in Mettl3- cKO mice h qRT-PCR of Gys2 mRNA levels (β-actin as reference) in wildtype mouse livers with indicated ages. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.004. n = 4 animals. Data are presented as mean values +/−SEM. Source data are provided as a Source data ﬁle. a b c Gys2, Mlxipl, Egfr, Fasn et al. a b b c Gys2, Mlxipl, Egfr, Fasn et al. c a d Gys2 locus d e Gys2 mRNA MeRIP/Input(%) IgG m6A e ) HET cKO Relative Gys2 mRNA f g 1.0 0.2 1.0 0.2 GYS β-ac 40kD 70kD n h Relative Gys2 mRNA 4w 8w h A f g Fig. 3 \| Identiﬁcation of Gys2 mRNA by global N6-methyladenosine modiﬁca- tion analysis as a key substrate of METTL3 in mouse liver. a The most enriched sequence motif of m6A peaks in mRNAs from 8-week-old WT or cKO mouse hepatocytes (HC) or liver (LI) samples. b Distribution of m6A peaks along the 5′UTR, CDS, and 3′UTR regions of total mRNAs from 8-week-old mouse sam- ples after normalized with length. c RNA-Seq and MeRIP-Seq identiﬁed downregulated and m6A-lost genes in Mettl3-cKO liver tissue or hepatocytes comparing to wild-type samples. All the samples were from 8-week-old mice. MeRIP-seq data were from hepatocytes of male mice; RNA-seq data were from hepatocytes and liver tissues of male mice and liver tissues of female mice, respectively. d m6A MeRIP-Seq revealed the location of speciﬁc m6A peak in Gys2 locus in hepatocytes of wildtype or Mettl3-cKO mice. //, deletion of a long and uninformative intron for better exhibition. e m6A enrichment of Gys2 mRNA in mettl3-HET or cKO hepatocytes by m6A-RIP-qPCR. n = 3 independent experiments. Data are presented as mean values +/−SEM. Two-way ANOVA was performed to determine a difference among each two groups. p < 0.01 comparing with IgG:HET; ##p < 0.01 comparing with m6A:HET. f qRT-PCR of Gys2 mRNA levels (β-actin as reference) in 8-week-old mouse livers with indicated Mettl3 genotypes. n = 4 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.004. g Western blotting assay of GYS2 pro- tein levels in 8-week-old mouse livers with indicated Mettl3 genotypes. The ratio of GYS2 to β-actin were shown between two lanes. This experiment was repeated independently with similar results at least 3 times. ♂, male; ♀, female. Reconstitution of GYS2 rescues liver glycogenesis in Mettl3- cKO mice h qRT-PCR of Gys2 mRNA levels (β-actin as reference) in wildtype mouse livers with indicated ages. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.004. n = 4 animals. Data are presented as mean values +/−SEM. Source data are provided as a Source data ﬁle. Rats also have the METTL3-IGF2BP2-GYS2 axis in liver demonstrated that reconstitution of GYS2 partially restored liver glycogen storage in Mettl3-cKO mice. Systemically, both the serum glucose level in Mettl3-cKO mice in a free diet (Fig. 5f) and the blood glucose level in Mettl3-cKO mice after prolonged fasting (Fig. 5g) increased under AAV-Gys2 treatment. In addition, Mettl3-cKO mice with AAV-Gys2 intervention performed better in the forced swim test than Mettl3-cKO mice with AAV-Luc intervention, although a performance gap remained between these mice and HET mice (Fig. 5h). In summary, reconstitution of GYS2 partially reversed Mettl3-cKO-associated glycogen deﬁciency and the related pheno- types in mice. demonstrated that reconstitution of GYS2 partially restored liver glycogen storage in Mettl3-cKO mice. Systemically, both the serum glucose level in Mettl3-cKO mice in a free diet (Fig. 5f) and the blood glucose level in Mettl3-cKO mice after prolonged fasting (Fig. 5g) increased under AAV-Gys2 treatment. In addition, Mettl3-cKO mice with AAV-Gys2 intervention performed better in the forced swim test than Mettl3-cKO mice with AAV-Luc intervention, although a performance gap remained between these mice and HET mice (Fig. 5h). In summary, reconstitution of GYS2 partially reversed Mettl3-cKO-associated glycogen deﬁciency and the related pheno- types in mice. Liver glycogen storage is very important for almost all mammals. To investigate whether the axis we found in mouse exists in other mam- mals, we test the samples from Sprague‑Dawley (SD) rats. First, PAS staining (Fig. 6a) and glycogen content assay (Fig. 6b) revealed that glycogen storage in the liver is much lower in 4-week-old male rats than 8-week-old ones. It suggested that, similar to mouse, adult rats also have high level glycogen in liver comparing to pups. In addition, the relative fold of liver m6A mRNA had a similar pattern to that of glycogen storage at the indicated ages (Fig. 6c). Furthermore, qRT-PCR assay demonstrated that mRNA of Mettl3 (Fig. 6d) and Gys2 (Fig. 6e) in Nature Communications\| (2022) 13:7038 5 https://doi.org/10.1038/s41467-022-34808-2 Article a b c Relative Gys2 mRNA % Gys2 mRNA remaining Hours after treated by ActD d Gys2 mRNA e Relative Expression Level (Flag-Gys2/GFP) Mut #1 Mut #2 WT RIP/Input (%) f g h IGF2BP2 RIP Enrichment WT Gys2 mRNA 1.0 0.2 1.1 Relative Luciferase Activity Mut #1 Mut #2 WT Flag-tag 70kD GFP β-actin 35kD 55kD Fig. 4 \| N6-methyladenosine stabilizes Gys2 mRNA in an IGF2BP2-dependent manner. a qRT-PCR assay of relative Gys2 mRNA level (β-actin as reference) in siControl and indicated siRNAs. Rats also have the METTL3-IGF2BP2-GYS2 axis in liver n = 3 independent experiments. p < 0.01 com- paring with IGF2BP2:siControl. b qRT-PCR assay of Gys2 mRNA stability (β-actin as reference) in siControl and siIGF2BP2 Hepa1-6 cells treated with actinomycin D (Act D) at the indicated times. n = 3 independent experiments. p = 0.022 at hour 2; p = 0.039 at hour 4. c enrichment of Gys2 mRNA in mettl3-HET or cKO hepato- cytes by IGF2BP2-RIP-qPCR. n = 3 independent experiments. p < 0.01 com- paring with IgG:HET; ##p < 0.01 comparing with IGF2BP2:HET. d Two conserved candidate m6A sites were predicted by SRAMP (http://www.cuilab.cn/sramp), according to MeRIP-seq data. Mutant #1 and #2 were constructs with “A to U” mutation at different predicted sites. Luciferase (Luc) or Flag-tag were fused in N terminal of each construct. qP1 and qP2 were speciﬁc qRT-PCR primers to detect exogenous WT or Mutant Flag-Gys2 mRNAs. e, f Flag-Gys2-CDS WT or indicated Mut construct and GFP overexpression constructs were transfected into Hepa1-6 cells for 48 h. Exogenous constructs expression levels were measured by qRT-PCR (e) and western blotting (f). GFP was reference in both assays. In ﬁgure e, n = 3 independent experiments. ns, not signiﬁcant; p < 0.05. The experiment in f was repeated independently with similar results at least 3 times. g pmirGLO Luc-Gys2-WT or indicated Mut construct was transfected into HEK-293T cells for 48 h. Relative luciferase activity (Fluc/Rluc) was tested by DLR assay. n = 3 independent experiments. ns, not signiﬁcant; p < 0.01. h enrichment of Flag-Gys2-CDS WT in siControl or siIGF2BP2 Hepa1-6 cells by IGF2BP2-RIP-qPCR. n = 3 independent experiments. p = 0.007. For ﬁgure a–c, e, g, h, data are presented as mean values +/−SEM. For ﬁgure a, c, two-way ANOVA was performed to determine a difference among each two columns. For ﬁgure b, h, two-sided Student’s t test was performed to determine a difference between siControl and siIGF2BP2. For ﬁgure e, g, one-way ANOVA was per- formed to determine a difference between each column. Source data are pro- vided as a Source data ﬁle. Rats also have the METTL3-IGF2BP2-GYS2 axis in liver a b c Relative Gys2 mRNA % Gys2 mRNA remaining Hours after treated by ActD RIP/Input (%) Gys2 mRNA b c % Gys2 mRNA remaining Hours after treated by ActD RIP/Input (%) Gys2 mRNA a Relative Gys2 mRNA c RIP/Input (%) Gys2 mRNA b c a e Relative Expression Level (Flag-Gys2/GFP) Mut #1 Mut #2 WT d Gys2 mRNA d e f 1.0 0.2 1.1 Flag-tag 70kD GFP β-actin 35kD 55kD h IGF2BP2 RIP Enrichment WT g h IGF2BP2 RIP Enrichment WT Relative Luciferase Activity Mut #1 Mut #2 WT h t f g Fig. 4 \| N6-methyladenosine stabilizes Gys2 mRNA in an IGF2BP2-dependent into Hepa1-6 cells for 48 h. Exogenous constructs expression levels were measured by qRT-PCR (e) and western blotting (f). GFP was reference in both assays. In ﬁgure e, n = 3 independent experiments. ns, not signiﬁcant; p < 0.05. The experiment in f was repeated independently with similar results at least 3 times. g pmirGLO Luc-Gys2-WT or indicated Mut construct was transfected into HEK-293T cells for 48 h. Relative luciferase activity (Fluc/Rluc) was tested by DLR assay. n = 3 independent experiments. ns, not signiﬁcant; p < 0.01. h enrichment of Flag-Gys2-CDS WT in siControl or siIGF2BP2 Hepa1-6 cells by IGF2BP2-RIP-qPCR. n = 3 independent experiments. p = 0.007. For ﬁgure a–c, e, g, h, data are presented as mean values +/−SEM. For ﬁgure a, c, two-way ANOVA was performed to determine a difference among each two columns. For ﬁgure b, h, two-sided Student’s t test was performed to determine a difference between siControl and siIGF2BP2. For ﬁgure e, g, one-way ANOVA was per- formed to determine a difference between each column. Source data are pro- vided as a Source data ﬁle. Fig. 4 \| N6-methyladenosine stabilizes Gys2 mRNA in an IGF2BP2-dependent manner. a qRT-PCR assay of relative Gys2 mRNA level (β-actin as reference) in siControl and indicated siRNAs. n = 3 independent experiments. p < 0.01 com- paring with IGF2BP2:siControl. b qRT-PCR assay of Gys2 mRNA stability (β-actin as reference) in siControl and siIGF2BP2 Hepa1-6 cells treated with actinomycin D (Act D) at the indicated times. n = 3 independent experiments. p = 0.022 at hour 2; p = 0.039 at hour 4. c enrichment of Gys2 mRNA in mettl3-HET or cKO hepato- cytes by IGF2BP2-RIP-qPCR. n = 3 independent experiments. *p < 0.01 com- paring with IgG:HET; ##p < 0.01 comparing with IGF2BP2:HET. Rats also have the METTL3-IGF2BP2-GYS2 axis in liver d Two conserved candidate m6A sites were predicted by SRAMP (http://www.cuilab.cn/sramp), according to MeRIP-seq data. Mutant #1 and #2 were constructs with “A to U” mutation at different predicted sites. Luciferase (Luc) or Flag-tag were fused in N terminal of each construct. qP1 and qP2 were speciﬁc qRT-PCR primers to detect exogenous WT or Mutant Flag-Gys2 mRNAs. e, f Flag-Gys2-CDS WT or indicated Mut construct and GFP overexpression constructs were transfected into Hepa1-6 cells for 48 h. Exogenous constructs expression levels were measured by qRT-PCR (e) and western blotting (f). GFP was reference in both assays. In ﬁgure e, n = 3 independent experiments. ns, not signiﬁcant; p < 0.05. The experiment in f was repeated independently with similar results at least 3 times. g pmirGLO Luc-Gys2-WT or indicated Mut construct was transfected into HEK-293T cells for 48 h. Relative luciferase activity (Fluc/Rluc) was tested by DLR assay. n = 3 independent experiments. ns, not signiﬁcant; p < 0.01. h enrichment of Flag-Gys2-CDS WT in siControl or siIGF2BP2 Hepa1-6 cells by IGF2BP2-RIP-qPCR. n = 3 independent experiments. p = 0.007. For ﬁgure a–c, e, g, h, data are presented as mean values +/−SEM. For ﬁgure a, c, two-way ANOVA was performed to determine a difference among each two columns. For ﬁgure b, h, two-sided Student’s t test was performed to determine a difference between siControl and siIGF2BP2. For ﬁgure e, g, one-way ANOVA was per- formed to determine a difference between each column. Source data are pro- vided as a Source data ﬁle. breakdown in the liver maintain the homeostasis of blood glucose between meals, and disorders of liver glycogen metabolism often cause severe outcomes and even death in some pediatric patients1,2. Previous articles and our data (Figs. 1a–c, 6a, b) revealed that the concentration of glycogen in the liver increases gradually from birth to adulthood in numerous mammals, such as mice, rats, rabbits, sheep, and rhesus macaques3–5,36. And the blood glucose level exhibits a similar pattern6. However, the detailed mechanism and biological meaning of this phenomenon remain unclear. livers were high in 8-week-old rats and low in 4-week-old rats. Finally, we tested serum glucose of different age rats in free diet. As expected, 8-week-old rats have higher serum glucose than 4-week-old ones (Fig. 6f). Taken together, these results suggest that the METTL3- IGF2BP2-GYS2 axis we found in mouse may also exist in other mam- mals, such as rats. Discussion Under physiological conditions, human blood contains only 4 to 6 grams of glucose, while the daily consumption of glucose for a normal person is approximately 160 grams39. Glycogen synthesis and g p Among the more than one hundred RNA modiﬁcations, N6-methyladenosine (m6A) was identiﬁed in the 1970s8. M6A Nature Communications\| (2022) 13:7038 Nature Communications\| (2022) 13:7038 6 6 tion is the most abundant modiﬁcation in eukaryotic and functions as an epitranscriptomic regulator of target hrough multiple mechanisms, including enhancing stabi- translation efﬁciency10. Intriguingly, we found that the old of m6A mRNA had a very signiﬁcant positive correla- liver glycogen content among different ages (Fig 1d) It suggested that m6A modiﬁcation of mRNA might be invo glycogen metabolism. Approximately a decade ago, an important report identi ﬁrst RNA demethylase (m6A “eraser”), fat mass and obesity-ass protein (FTO), revealing that RNA modiﬁcation is reversible1 ALKBH5 was conﬁrmed as another m6A eraser in mammals40 a HET + Luc cKO + Luc cKO + Gys2 b d HET + Luc cKO + Luc cKO + Gys2 e HET + Luc cKO + Luc cKO + Gys2 f g h Serum Glucose (mmol/L) in free diet Blood Glucose (mmol/L) after prolonged fasting Swimming time (sec) c GYS2 β-actin Glycogen (ug/mg liver) Positive Area(%) Positive Area(%) 1.0 0.4 0.9 70kD 40kD https://doi.org/10.1038/s41467-022-3 https://doi.org/10.1038/s41467-022-34808-2 Article a GYS2 β-actin 1.0 0.4 0.9 70kD 40kD c Glycogen (ug/mg liver) a HET + Luc cKO + Luc cKO + Gys2 b c GYS2 β-actin Glycogen (ug/mg liver) Positive Area(%) 1.0 0.4 0.9 70kD 40kD c a b HET + Luc cKO + Luc cKO + Gys2 b Positive Area(%) d HET + Luc cKO + Luc cKO + Gys2 Positive Area(%) d d HET + Luc cKO + Luc cKO + Gys2 Positive Area(%) e HET + Luc e HET + Luc cKO + Luc cKO + Luc cKO + Gys2 e f Serum Glucose (mmol/L) in free diet f L) h Swimming time (sec) h ) g Blood Glucose (mmol/L) after prolonged fasting g L) suggested that m6A modiﬁcation of mRNA might be involved in glycogen metabolism. modiﬁcation is the most abundant modiﬁcation in eukaryotic mRNAs9 and functions as an epitranscriptomic regulator of target mRNAs through multiple mechanisms, including enhancing stabi- lity and translation efﬁciency10. Discussion Data are pre- sented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. *p < 0.001. c The levels of m6A mRNA were analyzed in rat livers of different ages. n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a differ- ence among groups. p < 0.001. d, e qRT-PCR assay of Mettl3 (d) and Gys2 (e) in rats’ livers of different ages (β-actin as reference). n = 5 animals. Data are pre- sented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.002 in (d); p < 0.001. f Serum glucose level of indicated ages of rats in normal diet. n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.005. Source data are provided as a Source data ﬁle. g yp g p g positive area is measured by Image J and shown in the right. Bar, 100 μm. n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. *p < 0.001. b Hepatic gly- cogen content assay of rat livers with indicated ages. n = 4 animals. Data are pre- sented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p < 0.001. c The levels of m6A mRNA were analyzed in rat livers of different ages. n = 5 animals. Data are presented as mean other hand, m6A methyltransferases (“writers”) in mammalian cells are complexes that contain various protein components. Methyltransferase-like 3 (METTL3) and methyltransferase-like 14 (METTL14) are still the core methyltransferases, although an increasing number of subunits have been veriﬁed10,38. An RNA-seq dataset with different-aged mouse livers (GSE58827) suggested that, Mettl3, but not other key components, had signiﬁcant correlation with age (Fig. 2a). Then, western blotting assay also conﬁrmed Mettl3’s elevation during growth (Fig. 2b). homeostasis of livers42,43. This discrepancy suggests a complicated regulatory network behind m6A modiﬁcation for controlling hepato- cytes, which needs to be further clariﬁed. In our study, Mettl3-cKO mice had very low glycogen content (Fig. 2c–e, Supplementary Fig. 1e), although Mettl3-WT and Mettl3- HET mice had no signiﬁcant different in glycogen storage (Fig. 2c, d). Discussion Intriguingly, we found that the relative fold of m6A mRNA had a very signiﬁcant positive correla- tion with liver glycogen content among different ages (Fig. 1d). It g y g Approximately a decade ago, an important report identiﬁed the ﬁrst RNA demethylase (m6A “eraser”), fat mass and obesity-associated protein (FTO), revealing that RNA modiﬁcation is reversible12. Then, ALKBH5 was conﬁrmed as another m6A eraser in mammals40. On the Nature Communications\| (2022) 13:7038 7 7 Article https://doi.org/10.1038/s41467-022-34808-2 *p < 0.001. f Serum glucose level of indicated groups of mice in free diet. n ≥4 animals. Data are presented as mean values +/−SEM. One-way ANOVA was per- formed to determine a difference between columns. p < 0.05; *p < 0.01. g Blood glucose level of indicated groups of mice after prolonged fasting. n ≥4 animals. Data are presented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between columns. p < 0.05; *p < 0.001. h Exhaustive swimming assay of indicated groups of mice. n ≥6 animals. Data are presented as mean values +/−SEM. One-way ANOVA was performed to determine a difference between columns. p < 0.001. Source data are provided as a Source data ﬁle. Fig. 5 \| Hepatic Gys2 overexpression alleviated glycogen shortage caused by Mettl3 knockout. a, b Western blotting assay (a) and IHC staining (b) reveal the effect of reconstitution of GYS2. Luc, Luciferase. For ﬁgure b, bar = 50 μm. n = 5 animals. Data are presented as mean values +/−SEM. One-way ANOVA was per- formed to determine a difference between columns. p < 0.001. c–e Hepatic glycogen content assay (c) PAS staining (d) and transmission electron microscope pictures (e) of mouse livers with indicated genotypes and a luciferase (Luc) or Gys2- overexpressing adeno-associated virus (AAV). Bar: 50 μm (d), 0.5 μm (e). n ≥4 animals. Data are presented as mean values +/−SEM. One-way ANOVA was per- formed to determine a difference between columns in ﬁgure (c) and (d). 4w 8w a 4w 8w 4w 8w 4w 8w 4w 8w c d e Relative Mettl3 mRNA Relative fold of m6A mRNA Positive Area (%) 4w 8w f Serum Glucose (mmol/L) in free diet Relative Gys2 mRNA 4w 8w b Glycogen (μg/mg liver) 6 \| The METTL3-IGF2BP2-GYS2 axis is related to liver glycogen storage in . a PAS staining of wild-type rat livers in different ages. Discussion The percentage of tive area is measured by Image J and shown in the right. Bar, 100 μm. n = 5 mals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was ormed to determine a difference among groups. p < 0.001. b Hepatic gly- en content assay of rat livers with indicated ages. n = 4 animals. Data are pre- ed as mean values +/−SEM. Two-sided Student’s t test was performed to rmine a difference among groups. p < 0.001. c The levels of m6A mRNA were yzed in rat livers of different ages. n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a differ- ence among groups. p < 0.001. d, e qRT-PCR assay of Mettl3 (d) and Gys2 (e) in rats’ livers of different ages (β-actin as reference). n = 5 animals. Data are pre- sented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.002 in (d); p < 0.001. f Serum glucose level of indicated ages of rats in normal diet. n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. p = 0.005. Source data are provided as a Source data ﬁle. 4w 8w Positive Area (%) 4w 8w b Glycogen (μg/mg liver) 4w 8w Positive Area (%) 4w 8w b Glycogen (μg/mg liver) b 4w a 8w a 4w 8w c Relative fold of m6A mRNA 4w 8w d Relative Mettl3 mRNA 4w 8w e 4w 8w f Serum Glucose (mmol/L) in free diet Relative Gys2 mRNA 4w 8w e Relative Gys2 mRNA 4w 8w f Serum Glucose (mmol/L) in free diet d A f c e e Fig. 6 \| The METTL3-IGF2BP2-GYS2 axis is related to liver glycogen storage in Fig. 6 \| The METTL3-IGF2BP2-GYS2 axis is related to liver glycogen storage in rats. a PAS staining of wild-type rat livers in different ages. The percentage of positive area is measured by Image J and shown in the right. Bar, 100 μm. n = 5 animals. Data are presented as mean values +/−SEM. Two-sided Student’s t test was performed to determine a difference among groups. ***p < 0.001. b Hepatic gly- cogen content assay of rat livers with indicated ages. n = 4 animals. Nature Communications\| (2022) 13:7038 Discussion Furthermore, the serum glucose levels in Mettl3-cKO mice were much lower than other mice (Fig. 2f), and Mettl3-cKO mice also had worse performance in the forced swim test (Fig. 2g). Finally, liver glycogen defect was observed in a Mettl3 catalytic activity inhibition (STM2457 treatment) model (Supplementary Fig. 2a–e). Taken together, liver- speciﬁc depletion of Mettl3 could simulate glycogen shortage in liver, and this should be associated with loss of catalytic activity. To investigate whether METTL3 plays an important role in liver glycogen storage, we generated a hepatocyte-speciﬁc Mettl3 knockout model, albumin-Cre Mettl3ﬂ/ﬂ(Supplementary Fig. 1a–d). Notably, while our manuscript was in preparation, the ﬁndings we present here differ from the results of published data from Xu et al.41. Their results showed that albumin-Cre Mettl3ﬂ/ﬂmice could only survival until 8 weeks old, and the expression of METTL3 decreased in wildtype mouse livers from 4-week-old to 8-week-old. We speculate that the reasons for this discrepancy may lie in the following: the Mettl3 allele used in our strategy deleted the second and third exons in the Mettl3 gene (Sup- plementary Fig. 1a). Different strategies for the construction of Mettl3ﬂ/ ﬂmice may lead to inconsistent results. The diverse microbiome on account of different breeding environments also might inﬂuence the To identify substrates of METTL3 in the liver, we extracted total RNA from hepatocytes and liver tissues from wild-type (WT) and conditional knockout (cKO) mice. MeRIP-seq and input RNA-seq revealed that numerous metabolic processes were dysregulated (Supplementary Fig. 3a, b), suggesting that the principal differences in this model were established here. To enhance the representativeness of the screening, we used four different datasets to take the intersec- tion. The meRIP-seq dataset contained methylation-downregulated genes in hepatocytes between Mettl3-cKO and Mettl3-WT mice (Fold Nature Communications\| (2022) 13:7038 8 Article https://doi.org/10.1038/s41467-022-34808-2 change >= 2000, P value <1e−15). The other three RNA-seq datasets came from downregulated genes in hepatocytes, male liver tissues and female liver tissues of 8-week-old Mettl3-cKO mice, respectively. With this stringent strategy, we got 26 candidate genes (Fig. 3c). Mlxipl, Egfr, Fasn and Gys2, which were reported to be associated with glycogen metabolism, were in this 26-genes set (Fig. 3c). It suggested that they should be bona ﬁde candidates. Mlxipl is a deleted gene in Williams- Beuren syndrome, however, glycogen storage defect and hypoglyce- mia (two main phenotypes of Mettl3-cKO mice) are not symptoms of this syndrome44. Discussion According to IMPC (International Mouse Phenotyping Consortium), a famous mouse phenotype website (https://www. mousephenotype.org/), glycogen storage defect and hypoglycemia are not phenotype of Egfr-KO mice. Fasn, a key enzyme in fatty acid synthesis, is thought to be less associated with glycogen synthesis, although glycometabolism and lipid metabolism are connected. Finally, we focused on Gys2 which is liver glycogen synthase and cat- alyzes the rate-limiting step in the synthesis of glycogen. Furthermore, loss-of-function mutations of Gys2 cause type 0 Glycogen Storage Disease (GSD) in children, who have glycogen storage defect and hypoglycemia as main symptoms1,7. glycogen deﬁciency. Here, reconstitution of GYS2 in hepatocytes of Mettl3-cKO mice by adeno-associated virus (AAV)-mediated transduc- tion partially enhanced the accumulation of glycogen in the liver (Fig. 5c–e), improved serum glucose in free diet-fed mice (Fig. 5f), and increased blood glucose in mice after prolonged fasting (Fig. 5g). Moreover, the performance of Mettl3-cKO mice in the forced swim test was enhanced under AAV-GYS2 intervention (Fig. 5h). In conclusion, reconstitution of GYS2 partially rescued the unfavorable phenotypes associated with Mettl3-cKO in mice. glycogen deﬁciency. Here, reconstitution of GYS2 in hepatocytes of Mettl3-cKO mice by adeno-associated virus (AAV)-mediated transduc- tion partially enhanced the accumulation of glycogen in the liver (Fig. 5c–e), improved serum glucose in free diet-fed mice (Fig. 5f), and increased blood glucose in mice after prolonged fasting (Fig. 5g). Moreover, the performance of Mettl3-cKO mice in the forced swim test was enhanced under AAV-GYS2 intervention (Fig. 5h). In conclusion, reconstitution of GYS2 partially rescued the unfavorable phenotypes associated with Mettl3-cKO in mice. So far, our study demonstrated a METTL3-IGF2BP2-GYS2 axis that controls glycogenesis in liver. However, we could not completely exclude other factors that may also facilitate METTL3-associated gly- cogen storage, since liver contains various effectors to regulate gly- cogenesis. Life is complicated, and it usually have diverse mechanisms to regulate important phenotypes. For example, on core mechanism of m6A-regulated macrophage activation, we found SPRED2 was target of METTL324, however, other team found IRAKM could be another key gene in this process45. Does the METTL3-IGF2BP2-GYS2 axis exist in other mammals, such as rats? We investigated samples from male rats in different ages, and found that adult rats indeed have more glycogen storage than pups (Fig. 6a, b). As expected, the relative fold of m6A mRNA in livers have similar patterns to glycogen storage in indicated ages (Fig. 6c). Methods Mice/rats Like other epigenetic modiﬁcations, the functions of RNA m6A modiﬁcation are carried out by RNA-binding proteins called m6A readers. Previously, a group of YT521-B homology (YTH) domain- containing family proteins (YTHDFs) were identiﬁed as m6A readers that control mRNA fate by regulating pre-mRNA splicing, facilitating mRNA translation and promoting mRNA decay10,20–24. Later, an increasing number of readers were identiﬁed38. Among these readers, insulin-like growth factor 2 (IGF2) mRNA-binding proteins 1, 2, and 3 (IGF2BP1/2/3) were reported by Huang et al. to preferentially recognize m6A-modiﬁed mRNAs and promote the stability (and probably also the translation) of thousands of potential mRNA targets in an m6A- dependent manner, thereby affecting global gene expression output25. In our study, a striking effect of Mettl3 depletion was a substantially diminished Gys2 mRNA level (Fig. 3f). Thus, we focused on readers that can stabilize target mRNAs. IGF2BP2, but not the other candidate proteins (IGF2BP1/3, YTHDF1/2/3), was essential to Gys2 mRNA expression in Hepa 1-6 cells (Fig. 4a, Supplementary Fig. 4a). In addi- tion, knockdown of IGF2BP2 in Hepa 1-6 cells could signiﬁcantly shorten half-life of Gys2 mRNA (Fig. 4b). Then, IGF2BP2-meRIP-qPCR assay conﬁrmed binding of IGF2BP2 and Gys2 mRNA, and this binding was METTL3 and m6A site-dependent (Fig. 4c, h, Supplementary Fig. 4c, d). In summary, IGF2BP2 emerged as a reader protein in METTL3-mediated Gys2 mRNA stability. Methyltransferase-like 3 (Mettl3)-ﬂoxed mice were generated by Beijing Biocytogen Co., Ltd. Albumin (Alb)-Cre mice purchased from the Jack- son Laboratory were crossed with Mettl3-ﬂoxed mice to generate Alb- cre Mettl3-/- (wild-type, WT), Alb-cre Mettl3ﬂ/- (HET) and Alb-cre Mettl3ﬂ/ﬂ (KO) mice. The PCR primers used for genotyping of each mouse strain are listed in Supplementary Table 1. All mice were on the C57BL/6 genetic background and were housed in individual cages. Littermate WT or HET mice were used as the control animals in each experiment. Experimental Sprague‑Dawley (SD) rats were purchased from Lab Ani- mal Center of the Fourth Military Medical University. Without special instructions, experimental mice/rats were bred and maintained under speciﬁc pathogen-free conditions, fed standard laboratory chow, and kept on a 12 h light/dark cycle (zeitgeber time[ZT]0-ZT24). All animal experiments were approved by the Animal Experiment Administration Committee of the Fourth Military Medical University. Nature Communications\| (2022) 13:7038 Discussion Furthermore, Mettl3 and Gys2 also have much higher expression in livers of adult rats than pups (Fig. 6d, e). In addition, serum glucose of 8-week-old rats is higher than that of 4-week-old ones (Fig. 6f). Taken together, the phenomenon and mechanism, we found in mice, could also exist in other mammals, such as rats. Similar to Fasn, a known substrate of METTL3 in liver, meRIP-seq peaks and MeRIP-qPCR revealed the enrichment of m6A modiﬁcation in Gys2 mRNA of Mettl3-WT, but much less in Mettl3-cKO (Fig. 3d, e, Supplementary Fig. 3c). As a result, loss of the enrichment of m6A peaks in Gys2 mRNA accompanied by less Gys2 mRNA and protein levels (Fig. 3f, g). Transcription regulation should be excluded, since no signiﬁcant changes were observed in pre-mRNA of Gys2 between genotypes (Supplementary Fig. 3d). The results from METTL3 activity inhibition experiments also conﬁrm these conclusions above (Sup- plementary Fig. 3e, f). What’s more, the construct with mutation of the potential METTL3 binding site in the Gys2 CDS retained a much lower expression level than the WT construct (Fig. 4e–g). Finally, we observed 8-week-old mice had more mature Gys2 mRNA than 4-week- old mice (Fig. 3h), but no signiﬁcant difference in pre-mRNA of Gys2 between ages (Supplementary Fig. 3h). And meRIP-qPCR assay demonstrated much more enrichment of m6A modiﬁcation in 8-week- old mouse hepatocytes (Supplementary Fig. 3g). Taken together, these results indicated that Gys2 mRNA should be a bona ﬁde substrate of METTL3 in the mouse liver, and played an important role in glycogen regulation between pups and adults. In summary, we revealed a METTL3-IGF2BP2-GYS2 axis that con- trolled glycogenesis in mammalian liver. On the one hand, this axis limited liver glycogen storage in mammalian pups to a very low level. As a result, a shortage of glycogen in the liver could improve the safety of animal pups in the wild by necessitating a short interval between feedings by their parents. On the other hand, this axis increases liver glycogen storage in adult mammals. Interestingly, under this condi- tion, the abundance of glycogen in the liver could also improve the safety and facilitate the survival of adult mammals by allowing a long interval between meals in the wild (Fig. 7). Animal studies H i l Hepatic glycogen content. Each 10 mg liver tissues were homo- genized with 200 μL 30% KOH on ice and the homogenate was boiled for 10 min to inactivate enzymes. The boiled samples were centrifuged at 13,400 × g for 10 min at 4 °C to remove insoluble materials and the supernatant was ready for the assay using a Glycogen Assay Kit II (colorimetric) (Abcam, ab169558), and the results were normalized to the weight of initial tissues. Logically, if the METTL3-IGF2BP2-GYS2 axis exists in cells, recon- stitution of GYS2 would rescue Mettl3-cKO-associated hepatic Nature Communications\| (2022) 13:7038 9 Article https://doi.org/10.1038/s41467-022-34808-2 An An An An Gys2 mRNA IGF2BP2 Glycogen Low Mettl3 High Mettl3 m6A Gys2 mRNA IGF2BP2 Glycogen An An An An m6A Fig. 7 \| Model for m6A regulation of Gys2 mRNA in the liver. METTL3-IGF2BP2- GYS2 axis controls glycogenesis in mammalian liver. On the one hand, this axis limited liver glycogen storage in mammalian pups to a very low level. On the other hand, this axis increases liver glycogen storage in adult mammals. Fig. 7 \| Model for m6A regulation of Gys2 mRNA in the liver. METTL3-IGF2BP2- GYS2 axis controls glycogenesis in mammalian liver. On the one hand, this axis limited liver glycogen storage in mammalian pups to a very low level. On the other hand, this axis increases liver glycogen storage in adult mammals. Glycogen periodic acid-Schiff (PAS) staining and histological detection Qualitative assessment of liver tissue glycogen was performed using periodic acid-Schiff (PAS) staining. Mice/rats with the indicated genotypes or ages (n ≥5) were sacriﬁced. The livers were rapidly harvested, and slices of the left and medial lobes were obtained and post ﬁxed overnight with 4% paraformaldehyde in phosphate- buffered saline. Liver tissues were embedded in parafﬁn, sectioned (4 µm), and stained with PAS following the protocol of Vesselinovitch et al.47. Immunohistochemical assays were performed on FFPE sections as reported previously48. Antibodies against Gys2 (1:100, 22371-1-AP, Proteintech®) were used. Staining intensities were mea- sured using Image J software (National Institutes of Health, Bethesda, MD, USA). Transmission electron microscopy (TEM) Serum glucose detection (mice/rats). Normal diet-fed mice with the indicated genotypes (8-week-old male mice, n ≥5) were sacriﬁced during ZT9-11. For rats, normal diet-fed ones with the indicated ages (male, n ≥5) were sacriﬁced during ZT9-11. Total blood was collected and centrifuged (1500 g/min, 5 min) to isolate serum. The serum glu- cose level was measured by Servicebio, Inc. Liver samples were obtained from the left lobe and were ﬁxed with 2.5%glutaraldehyde (pH = 7.2) and 1% osmium tetroxide and processed as described previously49. The slices were examined with a transmis- sion electron microscope (JEM-1230, JEOL Ltd., Tokyo, Japan). Images were acquired by a technician blinded to the treatment. Blood glucose detection. Mice with the indicated genotypes (8-week- old male mice, n ≥5) fasted for 12–24 h. Blood glucose was measured using blood collected from mouse tail veins under sedation during ZT9-11. Isolation of hepatocytes Mice were perfused with 15 mL of prewarmed collagenase type I (0.1% w/v, Gibco) through the portal vein for 15 min. Livers were then removed and minced, and hepatocytes were pelleted by centrifugation at 50 × g for 3 min three times. The purity of hepatocytes exceeded 90%. Forced swim test. Mice with the indicated genotypes (8-week-old male mice, n ≥5) were tested with a method based on a previous report46. AAV vector production Adeno-associated virus (AAV)-mediated reconstitution of liver- speciﬁc glycogen synthase (Gys2). AAVs containing luciferase (Luc) or Gys2 constructs were injected i.v. into mice with the indicated genotypes (8-week-old male mice, n ≥6). Three weeks after injection, mice were evaluated by the indicated assays. Recombinant AAV vectors were produced by a standard triple- transfection calcium phosphate precipitation method using AAV- 293 cells. The production plasmids (AAV-MCS, AAV-DJ, and pHel- per) were from the AAV-DJ Helper Free Expression System (CELL BIOLABS, VPK-410-DJ), and the AAV-Luc and AAV-Gys2 constructs were generated from AAV-MCS. Puriﬁcation was performed with clariﬁed AAV-293 cell lysates using a ViraBind™AAV Puriﬁcation Mega Kit (CELL BIOLABS, VPK-141). Viral genome (vg) titers were determined with a QuickTiter™AAV Quantitation Kit (CELL BIO- LABS, VPK-145). Cell culture Hepa 1-6 (mouse hepatocellular carcinoma) and HEK-293T cells were maintained in Dulbecco’s modiﬁed Eagle’s medium (DMEM; Gibco BRL, USA) supplemented with 10% fetal calf serum (FCS; Gibco BRL, USA) and antibiotics (complete medium). Cells were incubated in a humidiﬁed atmosphere of 5% CO2 in air at 37 °C. Mettl3 inhibitor (STM2457) assay. Eight-week-old male C57BL/6 mice were i.p. treated daily for 5 days with either vehicle or 50 mg/kg STM2457 (SelleckTM, S9870). Then, mice were sacriﬁced to detect glycogen or others. Reporting summary Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article. lative quantiﬁcation of mRNA m6A methylation Relative quantiﬁcation of mRNA m6A methylation mRNA was isolated using the DynabeadsTM mRNA Direct Puriﬁcation Kit (61006, Invitrogen). Methylation of puriﬁed mRNA was quantiﬁed using an EpiQuik m6A RNA Methylation Quantiﬁcation Kit (P-9005, EpiGentek) according to the manufacturer’s protocol. A different-age mouse liver RNA-seq dataset with the GEO series accession number GSE58827 was download from NCBI’s Gene Expression Omnibus. Dual-luciferase reporter assay N6-methyladenosine (m6A)-sequencing (m6A-seq) and quanti- ﬁcation of mRNA methylation by m6A-methylated RNA immu- noprecipitation sequencing with RT-qPCR (MeRIP-qPCR) Dual-luciferase reporter assay Transfection was performed using Lipofectamine 2000 (Invitrogen). pmirGLO Fluc-Gys2 WT or indicated Mutant construct was transfected into HEK-293T cells for 48 h. Cell extracts were prepared and luciferase activity was measured using the Dual Luciferase Reporter Assay Sys- tem (Promega, Madison, WI, USA). The relative ﬁreﬂy luciferase (Fluc) activity was normalized with its respective Renilla luciferase (Rluc) activity. Total RNA was isolated from cells using TRIzol (Invitrogen). MeRIP-Seq was performed by Cloudseq Biotech Inc. (Shanghai, China) according to the published procedure with slight modiﬁcations. Brieﬂy, m6A RNA immunoprecipitation was performed with the GenSeqTM m6A RNA IP Kit (GenSeq Inc., China) by following the manufacturer’s instructions. Both the input sample without immunoprecipitation and the m6A IP samples were used for RNA-seq library generation with NEBNext® Ultra II Directional RNA Library Prep Kit (New England Biolabs, Inc., USA). The library quality was evaluated with BioAnalyzer 2100 system (Agi- lent Technologies, Inc., USA). Library sequencing was performed on an illumina Hiseq instrument with 150 bp paired-end reads. Western blot analysis The resulting ﬁnal product was used for qRT-PCR. The primers used to amplify mouse mature Gys2 mRNA are listed in Supplementary Table 2. For MeRIP-qPCR, poly(A)+ mRNA was isolated using a DynabeadsTM mRNA Direct Puriﬁcation Kit (61006, Invitrogen). Puriﬁed RNA (2 μg) was used for enrichment of m6A-containing mRNA with a Magna MeRIPTM m6A Kit (17-10499-1, Millipore, 5 μg antibody per sample), and the RNA was puriﬁed according to the manufacturer’s protocol. The resulting ﬁnal product was used for qRT-PCR. The primers used to amplify mouse mature Gys2 mRNA are listed in Supplementary Table 2. Data availability Raw data for RNA-sequencing and m6A-RIP sequencing have been deposited in NCBI’s Gene Expression Omnibus and are accessible through GEO Series accession number GSE207566. Sequencing reads were mapped to themousemm10 genome. A different-age mouse liver RNA-seq dataset with GEO Series accession number GSE58827 was obtained from NCBI’s GEO. All other data analyzed or generated during this study are included in this published article and its supplementary information ﬁles. Source data are provided with this paper. RNA immunoprecipitation-qPCR (RIP-qPCR) p p q q This procedure was performed according to a previously published report24. Hepa 1-6 cells or mettl3-HET/cKO hepatocytes were washed twice with PBS and lysed in lysis buffer (150 mM KCl, 10 mM HEPES (pH 7.6), 2 mM EDTA, 0.5% NP-40, 0.5 mM dithiothreitol (DTT), 1:100 protease inhibitor cocktail, 400 U/ml RNase inhibitor). The cell lysates were centrifuged. A 50-μl aliquot of the cell lysate was saved as input, and the remaining sample was incubated with 20 µl of protein A beads previously bound to 5 μg IgG or an anti-insulin-like growth factor 2 mRNA-binding protein 2 (IGF2BP2) antibody (ProteintechTM) for 4 h at 4 °C. The beads were washed 2 times with wash buffer (50 mM Tris, 200 mM NaCl, 2 mM EDTA, 0.05% NP40, 0.5 mM DTT, RNase inhi- bitor). RNA was eluted from the beads with 50 μl of RLT buffer and puriﬁed with RNeasy columns (217004, QIAGEN). RNA was eluted in 100 µl of RNase-free water and reverse transcribed into cDNA using a Prime Script qRT-PCR Kit (Takara) according to the manufacturer’s instructions. The fold enrichment was determined by qRT-PCR. The primers used for amplifying mouse mature Gys2 and Fasn mRNA are listed in Supplementary Table 2. Statistical analysis Data were analyzed using GraphPad Prism (Version 6.02). Linear regression was performed to judge the relationship between relative fold of m6A mRNA and hepatic glycogen content at different age samples in Fig. 1d. Kolmogorov-Smirnov test was performed to determine signiﬁcance in Supplementary Fig. 3a, b. Two-tailed Stu- dent’s t-test, one-way ANOVA, and two-way ANOVA were performed with P < 0.05 considered signiﬁcant. Exact information was in legends of indicated ﬁgures. Western blot analysis Cells were harvested and lysed with RIPA buffer. The protein con- centration was determined using a BCA kit. Samples were separated on 10% SDS-PAGE gels and blotted onto nitrocellulose membranes (Millipore). Membranes were incubated at 4 °C overnight with pri- mary antibodies at the following concentrations: anti-GYS2 (1:2000, 22371-1-AP, Proteintech®), anti-IGF2BP2 (1:1000, 11601-1-AP, Pro- teintech®), anti-METTL3 (1:1000, ab195352, EPR18810, Abcam), anti- Flag-tag (1:1000, F1804, Sigma), anti-GFP (1:1000, 50430-2-AP, Pro- teintech®), and anti-β-actin (1:4000, Sigma). Membranes were then washed three times with TBST and incubated with HRP-conjugated anti-mouse IgG (1:10,000, 7076, Cell Signaling Technology) or anti- rabbit IgG (1:10,000, 7074, Cell Signaling Technology) diluted in TBST containing 1% non-fat milk at room temperature for 1 h. After a ﬁnal wash with TBST, the membranes were developed with ECL reagents and visualized using a Tanon 5500 imaging system. The ratio of the expression of the indicated molecule to that of β-actin was determined using ImageJ software (National Institutes of Health, Bethesda, MD, USA). Brieﬂy, Paired-end reads were harvested from Illumina HiSeq 4000 sequencer, and were quality controlled by Q30. After 3’ adapter- trimming and low-quality reads removing by cutadapt software (v1.9.3). First, clean reads of all libraries were aligned to the reference genome (UCSC MM10) by Hisat2 software (v2.0.4). Methylated sites on RNAs (peaks) were identiﬁed by MACS software. Differentially methylated sites were identiﬁed by diffReps. These peaks identiﬁed by both softwares overlapping with exons of mRNA were ﬁgured out and chosen by home-made scripts. GO and Pathway enrichment analysis were performed by the differentially methylated protein-coding genes. Brieﬂy, Paired-end reads were harvested from Illumina HiSeq 4000 sequencer, and were quality controlled by Q30. After 3’ adapter- trimming and low-quality reads removing by cutadapt software (v1.9.3). First, clean reads of all libraries were aligned to the reference genome (UCSC MM10) by Hisat2 software (v2.0.4). Methylated sites on RNAs (peaks) were identiﬁed by MACS software. Differentially methylated sites were identiﬁed by diffReps. These peaks identiﬁed by both softwares overlapping with exons of mRNA were ﬁgured out and chosen by home-made scripts. GO and Pathway enrichment analysis were performed by the differentially methylated protein-coding genes. For MeRIP-qPCR, poly(A)+ mRNA was isolated using a DynabeadsTM mRNA Direct Puriﬁcation Kit (61006, Invitrogen). Puriﬁed RNA (2 μg) was used for enrichment of m6A-containing mRNA with a Magna MeRIPTM m6A Kit (17-10499-1, Millipore, 5 μg antibody per sample), and the RNA was puriﬁed according to the manufacturer’s protocol. Bioinformatic analysis Figure 3a, b: Motif analysis was performed using HOMER(Version 4.10)50 to search motifs in each set of m6A peaks. Metagene proﬁles were generated as described51. Peak density plot was visualized by R package Trumpet (https://github.com/skyhorsetomoon/Trumpet)52. Supplementary Fig. 3a, b: Gene Ontology (GO) biological process (BP) enrichment was analyzed by CloudSeq Biotech; p < 0.05 was con- sidered to indicate signiﬁcant enrichment. Quantitative real-time PCR (qRT-PCR) Total RNA was isolated from cells using TRIzol (Invitrogen). For qRT- PCR analysis of nascent and mature mRNAs, ﬁrst-strand cDNA was synthesized using a Prime Script qRT-PCR Kit (Takara). The ampliﬁ- cation signal of qPCR data was acquired by Bio-Rad CFX Manager 3.1. The expression levels of the target genes were determined by ampli- ﬁcation with speciﬁc primers. The primers used are listed in Supple- mentary Table 2. Nature Communications\| (2022) 13:7038 10 https://doi.org/10.1038/s41467-022-34808-2 Article References Boccaletto, P. et al. MODOMICS: a database of RNA modiﬁcation pathways. 2021 update. Nucleic Acids Res. 50, D231–D235 (2022). 34. Zhong, X. et al. Circadian clock regulation of hepatic lipid meta- bolism by modulation of mA mRNA methylation. 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This work was supported by grants from the National Natural Science Foundation of China (81630069, 81421003, and 31771439 to A.G.Y.; 81773262, 81572763 and 82173046 to R.Z.; 82173162 to X.Z.; 31801128 to H.L.Y.); the Grant of Youth Training Project of PLA Medical Science and Technology, China (18QNP018 to X.Z.); the Key Research and Develop- ment Project of Shaanxi Province (2020SF-137 to X.Z.); and the Fund of State Key Laboratory of Cancer Biology (CBSKL2015Z15 to X.Z.). Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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https://openalex.org/W2086043593	https://www.nature.com/articles/srep09898.pdf	English	null	The effect of triamcinolone acetonide on laser-induced choroidal neovascularization in mice using a hypoxia visualization bio-imaging probe	Scientific reports	2,015	cc-by	6,039	SUBJECT AREAS: ANGIOGENESIS FLUORESCENCE IMAGING Received 28 October 2014 Accepted 17 March 2015 Published 30 April 2015 1Department of Biofunctional Evaluation, Molecular Pharmacology, Gifu Pharmaceutical University, 1-25-4 Daigaku-nishi, Gifu, 501-1196, Japan, 2Department of Biomolecular Engineering, Graduate School of Bioscience and Biotechnology, Tokyo Institute of Technology, 4259 Nagatsuta-cho, Midori-ku, Yokohama, Kanagawa, 226-8503, Japan, 3Department of Organic and Medicinal Chemistry, Pharmaceutical and Medicinal Chemistry, 1-25-4 Daigaku-nishi, Gifu, 501-1196, Gifu, Japan. Correspondence and requests for materials should be addressed to H.H. (hidehara@gifu- pu.ac.jp) Hypoxic stress is a risk factor of ocular neovascularization. Hypoxia visualization may provide clues regarding the underlying cause of angiogenesis. Recently, we developed a hypoxia-specific probe, protein transduction domain-oxygen-dependent degradation domain-HaloTag-Rhodamine (POH-Rhodamine). In this study, we observed the localization of HIF-1a proteins by immunohistochemistry and the fluorescence of POH-Rhodamine on RPE-choroid flat mounts. Moreover, we compared the localization of POH-Rhodamine with pimonidazole which is a standard reagent for detecting hypoxia. Next, we investigated the effects of triamcinolone acetonide (TAAC) against visual function that was evaluated by recording electroretinogram (ERG) and choroidal neovascularization (CNV) development. Mice were given laser-induced CNV using a diode laser and treated with intravitreal injection of TAAC. Finally, we investigated POH-Rhodamine on CNV treated with TAAC. In this study, the fluorescence of POH-Rhodamine and HIF-1a were co-localized in laser-irradiated sites, and both the POH-Rhodamine and pimonidazole fluorescent areas were almost the same. Intravitreal injection of TAAC restored the reduced ERG b-wave but not the a-wave and decreased the mean CNV area. Furthermore, the area of the POH-Rhodamine-positive cells decreased. These findings indicate that POH-Rhodamine is useful for evaluating tissue hypoxia in a laser-induced CNV model, suggesting that TAAC suppressed CNV through tissue hypoxia improvement. These authors contributed equally to this work. A A ge related macular degeneration (AMD) is the leading cause of blindness among elderly people in Western countries1,2. Most severe vision loss is caused by pathological choroidal neovascularization (CNV). The process of CNV formation involves immature new blood vessels penetrating the Bruch’s membrane from choriocapillaries and extending into the sub-retinal and/or sub-retinal pigment epithelium (sub-RPE) space. Although CNV pathogenesis remains elusive, it is known that vascular endothelial growth factor (VEGF) plays a pivotal role in CNV formation3. Oxygen deprivation promotes hypoxia-inducible factor-1 (HIF-1) stabiliza- tion4,5 and induces the expression of VEGF6. Laser-induced CNV model is a well-known animal model of exudative AMD. These authors contributed equally to this work. Correspondence and requests for materials should be addressed to H.H. (hidehara@gifu- pu.ac.jp) Results Usefulness of fluorescent imaging with POH-Rhodamine in a laser-induced CNV model and comparison of POH-Rhodamine with pimonidazole. In the present study, we tried to visualize hypoxia using POH-Rhodamine in a laser-induced CNV model. The fluorescence of POH-Rhodamine was observed around CNV lesions. HIF-1a was distributed in the same manner, and both fluorescence signals were almost co-localized (Fig. 1A). There was non-fluorescence of HIF-1a in the negative control (Fig. 1B). Moreover, we compared POH-Rhodamine with pimonidazole, which is a traditional hypoxia visualization bio-imaging probe, by immunohistochemistry in CNV lesions. Both POH-Rhodamine and pimonidazole stained the hypoxic area around CNV lesions, and each stained area was almost the same (Fig. 1C). Additionally, POH-positive cells were present in the CNV and were co-localized with FITC-dextran stained cells (Fig. 1D). These findings indicate that POH-Rhodamine detected HIF-1a-positive cells in a laser- induced CNV model. Figure 1 \| Localization of HIF-1a and POH-Rhodamine in RPE-choroid- sclera flat mounts and localization of POH-Rhodamine and pimonidazole stain. Fluorescent staining of FITC-dextran (green) and POH-Rhodamine (red), and immunohistochemical analyses of HIF-1a (blue) and pimonidazole (blue) in RPE-choroid-sclera flat mounts on day 3 after laser photocoagulation. The images wereshown that the localization of POH-Rhodamine and HIF1a (A), HIF1a negative control (B), the localization of POH-Rhodamine and pimonidazole (C). The localization of POH-Rhodamine-, FITC-dextran- and Hoechst33342-stained cells in CNVare demonstrated in 300 3 magnifications (D). The color dotted lines represent the edge of the area of CNV lesions or the stained area. (A) (B) (C) Scale bar 5 100 mm, (D) scale bar 5 50 mm (left) and 10 mm (right). Figure 1 \| Localization of HIF-1a and POH-Rhodamine in RPE-choroid- sclera flat mounts and localization of POH-Rhodamine and with vehicle 7 and 14 d after laser treatment (Fig. 3A, 3B), and the reduction rates were 34.2 and 41.8%, respectively. Effects of TAAC on POH-Rhodamine probed hypoxia around CNV lesions. To assess the relationship between POH-Rhodamine probed hypoxia and CNV and the effect of TAAC under hypoxia, we measured Rhodamine fluorescent areas 3 d after laser photocoagulation. Intravitreal injection of TAAC significantly decreased the area of POH-Rhodamine fluorescence around the CNV lesion (Fig. 4A and 4B). The effects of TAAC in functional analysis using ERG. To evaluate the effects of TAAC on visual function in a laser-induced CNV model, we performed electroretinogram (ERG) measurement. SUBJECT AREAS: ANGIOGENESIS FLUORESCENCE IMAGING At 3 d after laser photocoagulation, HIF-1a mRNA expression and macrophage infiltration reach the peak and CNV starts to develop7–9. At 5–7 d after laser photocoagulation, VEGF expression reaches the peak8. Therefore, to start early-stage treatment and prevent serious vision loss, it is necessary to detect hypoxic conditions in choroid and retinal pigment epithelium (RPE) of AMD patients. g Triamcinolone acetonide (TAAC) is an intermediate-acting glucocorticoid in suspension form. Glucocorticoids have anti-inflammatory effects and are widely used in clinical practice. In ophthalmology, they are commonly used to treat of ocular pathologies associated with vascular leakage and ocular neovasculariza- tion10,11. Recently, intravitreal injections of TAAC have become commonly used in combination with other antivascular strategies for treatment of exudative AMD with CNV and macular edema12,13. TAAC decreases vascular leakage, CNV size, and macular thickness14–16. Dexamethasone, one of the glucocorticoids, significantly SCIENTIFIC REPORTS \| 5 : 9898 \| DOI: 10.1038/srep09898 1 www.nature.com/scientificreports Figure 1 \| Localization of HIF-1a and POH-Rhodamine in RPE-choroid- sclera flat mounts and localization of POH-Rhodamine and pimonidazole stain. Fluorescent staining of FITC-dextran (green) and POH-Rhodamine (red), and immunohistochemical analyses of HIF-1a (blue) and pimonidazole (blue) in RPE-choroid-sclera flat mounts on day 3 after laser photocoagulation. The images wereshown that the localization of POH-Rhodamine and HIF1a (A), HIF1a negative control (B), the localization of POH-Rhodamine and pimonidazole (C). The localization of POH-Rhodamine-, FITC-dextran- and Hoechst33342-stained cells in CNVare demonstrated in 300 3 magnifications (D). The color dotted lines represent the edge of the area of CNV lesions or the stained area. (A) (B) (C) Scale bar 5 100 mm, (D) scale bar 5 50 mm (left) and 10 mm (right). inhibited HIF-1a levels in cultured bovine hyalocytes under hypoxic conditions17. On the other hand, little has been reported on the effect of TAAC on HIF-1a expression in intraocular cells. inhibited HIF-1a levels in cultured bovine hyalocytes under hypoxic conditions17. On the other hand, little has been reported on the effect of TAAC on HIF-1a expression in intraocular cells. In our previous report, a hypoxia visualization bio-imaging probe, protein transduction domain [PTD]-oxygen dependent degradation domain [ODD]-HaloTag (POH), detected HIF-1a active cells18. It is composed of PTD-ODD and HaloTag proteins. PTD contributes to efficient POH entry into cells. Under normoxic conditions, POH is rapidly degraded after the ODD binds to the von Hippel-Lindau tumor-suppressor protein (VHL), and then the POH-labeled fluor- escence disappears. SUBJECT AREAS: ANGIOGENESIS FLUORESCENCE IMAGING VHL binding is dependent on hydroxylation by prolyl hydroxylase domain protein 2 (PHD2). On the other hand, under hypoxic conditions, POH is stabilized by the decrease of PHD2 activity, and fluorescence accumulation is detected in the cells. We have reported successful fluorescent monitoring of HIF-active microenvironments in cancer of living animals using POH18. In the present study, we used POH-Rhodamine which is a POH-labeled HaloTag with NHS-Rhodamine (5/6-carboxy-tetramethyl-rhoda- mine succinimidyl ester; Ex/Em 5 552/575 nm) dyes. Therefore, the purposes of the present study were to evaluate the usefulness of POH-Rhodamine and the effects of TAAC using a mouse laser- induced CNV model and in vitro human-derived retinal pigment epithelial (ARPE-19) cells. Results The amplitudes of both the a- and b-waves increased in a light intensity- dependent manner in the non-treated group. However, b-waves were significantly attenuated in the laser photocoagulation plus vehicle- treated group compared with the non-treated group. In contrast, a- waves were not changed in the laser-induced CNV model. Compared to treatment with vehicle, intravitreal injection of TAAC significantly reduced attenuation of b-wave amplitudes but not a- wave amplitudes (Fig. 2A–C). At the 21.92 and 0.98 b-wave data points, there were no significant differences between the TAAC- treated group and the vehicle-treated group. Moreover, at the first b-wave data point at 22.92, there was no significant difference between the TAAC-treated group and the non-treated group. Effects of TAAC on hypoxia-induced HIF-1a expression. We assessed the effect of TAAC on HIF-1a expression in vitro. Compared to the group incubated under normoxic conditions, there was a significant increase in HIF-1a expression under hypoxic conditions. The peak expression of HIF-1a was observed at 3 h under hypoxic conditions (Fig. 5A). Then, in the following experiments, the evaluation point was set to 3 h after hypoxic stimulation. Western blot analysis showed that the addition of TAAC decreased HIF-1a expression (Fig. 5B). Finally, TAAC significantly reduced Rhodamine fluorescent intensity (Fig. 5C). The effects of TAAC on CNV formation in the laser-induced CNV model mice. We first demonstrated that TAAC improved visual function in Fig 2. Second, we studied the effect of TAAC on CNV formation in the laser-induced CNV model mice. Measurement of CNV area in masked fashion showed that intravitreal injection of TAAC resulted in significantly smaller CNV lesions than treatment Discussion h In the present study, we succeeded in imaging hypoxic conditions in the RPE-choroid complex using POH-Rhodamine in a laser-induced SCIENTIFIC REPORTS \| 5 : 9898 \| DOI: 10.1038/srep09898 2 www.nature.com/scientificreports Figure 2 \| Measurement of dark-adapted ERG amplitudes 15 d after laser treatment in the retina of laser-induced CNV model mice. (A) Representative ERG tracing from normal, or laser plus vehicle- and laser plus TAAC-treated groups. Amplitudes of (B) a-waves and (C) b-waves from the laser photocoagulation plus vehicle-treated group vs. the laser photocoagulation plus TAAC-treated group. Data are presented as means 6 SE (n 5 7 to 10). ## p , 0.01 vs. normal. * p , 0.05, ** p , 0.01 vs. laser photocoagulation plus vehicle-treated group (Student’s t-test). Figure 2 \| Measurement of dark-adapted ERG amplitudes 15 d after laser treatment in the retina of laser-induced CNV model mice. (A) Representative ERG tracing from normal, or laser plus vehicle- and laser plus TAAC-treated groups. Amplitudes of (B) a-waves and (C) b-waves from the laser photocoagulation plus vehicle-treated group vs. the laser photocoagulation plus TAAC-treated group. Data are presented as means 6 SE (n 5 7 to 10). ## p , 0.01 vs. normal. * p , 0.05, ** p , 0.01 vs. laser photocoagulation plus vehicle-treated group (Student’s t-test). CNV model. Moreover, we showed that POH-Rhodamine was no less useful than pimonidazole, which is a standard for staining hyp- oxic areas. Next, we observed that intravitreal injection of TAAC significantly reduced attenuation of b-wave amplitudes and decreased CNV areas 7 and 14 d after laser photocoagulation. The Rhodamine fluorescent areas were co-localized with the HIF-1a- positive cells around CNV area. In a TAAC-treated group, the area of HIF-1a-active cells that was detected by POH-Rhodamine was significantly decreased. Furthermore, TAAC significantly reduced the HIF-1a expression in vitro. oxic areas. Next, we observed that intravitreal injection of TAAC Figure 3 \| TAAC-suppressed CNV formation in laser-induced CNV model mice. (A) Representative micrographs of CNV lesions in the RPE- choroid flat mounts from vehicle and TAAC-treated mice 3, 7, and 14 d after laser photocoagulation. CNV is indicated by green fluorescence (FITC-dextran) angiography. Scale bar 5 100 mm. (B) The color dotted lines represent the edge of area of CNV lesions or stained area. Analysis included the total areas within the dotted lines. Data are presented as means 6 SE (n 5 5 to 8). Discussion h * p , 0.05, ** p , 0.01 vs. vehicle-treated group (Student’s t-test). Although pimonidazole showed a high sensitivity due to Alexa FluorH, which was used in immunostaining, it requires many processes after enucleation of the eyeball. On the other hand, POH-Rhodamine does not need such a procedure. Furthermore, POH-Rhodamine is available for observation in living cells and enu- cleated eyes without any additional process. This indicates that the POH probe is useful for evaluating tissue hypoxia in a laser-induced CNV model. In the present study, we failed to detect hypoxia in living animal. Because either POH-Rhodamine did not have enough fluor- escent intensity to be detected by the fundus camera or the fundus camera did not have enough resolving power. If more sensitive sub- stances that are alternatives to Rhodamine are developed, the prob- lem of sensitivity would be resolved. To evaluate the effect of TAAC on retinal dysfunction by laser irradiation, we used ERG in the late phase of CNV. In ERG, the a-wave provides information about photoreceptor function, whereas the b-wave provides information about the functional activity of Müller cells and/or bipolar cells. In the present laser-induced CNV model, while 15 d after laser photocoagulation strongly reduced b-waves, the reduction rate of a-waves was mild. In this study, we treated laser photocoagulation at only 6 spots in ocular fundus and used full field ERG. Therefore, we might be unable to detect the change of a-wave in CNV area. TAAC significantly protected the reduction of b-waves, but not a-waves, after laser irradiation com- pared with a vehicle-treated group. CNV extends from the chorio- capillary layer to the retina through the neuroepithelial layer, and then reaches the inner nuclear layer (INL), which contains Müller and bipolar cells 15 d after laser photocoagulation. Moreover, reduced b-wave could also be due to the inflammation, and anti- inflammation of TAAC might rescue b-wave reduction. Therefore, the results indicate that intravitreal administration of TAAC inhib- ited CNV extension and inflammation, and the function of INL in Figure 3 \| TAAC-suppressed CNV formation in laser-induced CNV model mice. (A) Representative micrographs of CNV lesions in the RPE- choroid flat mounts from vehicle and TAAC-treated mice 3, 7, and 14 d after laser photocoagulation. CNV is indicated by green fluorescence (FITC-dextran) angiography. Scale bar 5 100 mm. (B) The color dotted lines represent the edge of area of CNV lesions or stained area. Discussion h Analysis included the total areas within the dotted lines. Data are presented as means 6 SE (n 5 5 to 8). * p , 0.05, ** p , 0.01 vs. vehicle-treated group (Student’s t-test). Figure 3 \| TAAC-suppressed CNV formation in laser-induced CNV Figure 3 \| TAAC-suppressed CNV formation in laser-induced CNV model mice. (A) Representative micrographs of CNV lesions in the RPE- choroid flat mounts from vehicle and TAAC-treated mice 3, 7, and 14 d after laser photocoagulation. CNV is indicated by green fluorescence (FITC-dextran) angiography. Scale bar 5 100 mm. (B) The color dotted lines represent the edge of area of CNV lesions or stained area. Analysis included the total areas within the dotted lines. Data are presented as means 6 SE (n 5 5 to 8). * p , 0.05, ** p , 0.01 vs. vehicle-treated group (Student’s t-test). SCIENTIFIC REPORTS \| 5 : 9898 \| DOI: 10.1038/srep09898 3 www.nature.com/scientificreports www.nature.com/scientificreports Figure 4 \| TAAC decreased POH-Rhodamine stained area around laser injury sites. (A) Representative micrographs of CNV lesions in the RPE- choroid flat mounts 3 d after laser photocoagulation. POH-Rhodamine- stained area indicated HIF-1a positive cells. (B) Measurement of the POH- Rhodamine-stained area around the laser injury sites. The color dotted lines represent the edge of area of CNV lesions or stained area. Analysis included the total areas within the dotted lines. Data are presented as means 6 SE (n 5 8). * p , 0.05 vs. vehicle-treated group (Student’s t-test). Scale bar 5 100 mm. It is well known that TAAC has an anti-inflammatory effect through binding to the glucocorticoid receptor19,20. It has also been reported that administration of TAAC reduced accumulation of macrophages and various inflammatory cytokines in the eye21–23. There is some possible involvement of inflammation signals in CNV formation; however, our results suggest that TAAC may have not only an anti-inflammatory effect but also a promoting effect on the proteasome system of HIF-1a degradation. In normoxia, HIF-1a receives hydroxylation of 2 proline residues and acetylation of a lysine residue in the oxygen-dependent degradation domain and then promotes interaction with the von Hippel-Lindau (pVHL) ubi- quitin E3 ligase complex24,25. Consequently, HIF-1a is polyubiquiti- nated and degraded by the 26S proteasome. TAAC may act on any site of this pathway, and as a result, there is HIF-1a degradation and suppression of VEGF expression. Methods P i Figure 4 \| TAAC decreased POH-Rhodamine stained area around laser Figure 4 \| TAAC decreased POH-Rhodamine stained area around laser injury sites. (A) Representative micrographs of CNV lesions in the RPE- choroid flat mounts 3 d after laser photocoagulation. POH-Rhodamine- stained area indicated HIF-1a positive cells. (B) Measurement of the POH- Rhodamine-stained area around the laser injury sites. The color dotted lines represent the edge of area of CNV lesions or stained area. Analysis included the total areas within the dotted lines. Data are presented as means 6 SE (n 5 8). * p , 0.05 vs. vehicle-treated group (Student’s t-test). Scale bar 5 100 mm. Preparation of POH-Rhodamine probes. POH-Rhodamine probes were made according to our previous report18. This probe becomes fluorescent in HIF-1 positive cells. Animals. All investigations were performed in accordance with the Association for Research in the Vision and Ophthalmology statement for the use of animals in ophthalmic and vision research, and experiments were approved and monitored by the institutional animal care and use committee of Gifu Pharmaceutical University. Laser-induced CNV model. CNV was induced in 8- to 10-week-old male C57BL/6J mice. Mice were anesthetized for all procedures by intramuscular injection of ketamine and xylazine (43. 8 and 2.5 mg/kg, respectively), and their pupils were dilated with 0.5% tropicamide (Santen, Osaka, Japan). Laser photocoagulation (647 nm, 120 mW, 100 ms, 50 mm; MC500, NIDEC, Aichi, Japan) was used to generate 6 laser spots in each eye. more distal positions from the choroid was improved. A recent study showed that intravitreal injection of TAAC protects photoreceptor degeneration26. The improvement in this study may be partially associated with its direct effect on neuroprotection. Drug administration. TAAC (Wako, Osaka, Japan) was suspended in saline (20 mg/ ml). Immediately after laser photocoagulation, mice received intravitreal injection of TAAC in their right eyes. Sterile 33-gauge needles (Terumo, Tokyo, Japan) were attached to fine-bore tubes (Natsume Seisakusho, Tokyo, Japan) and filled with the TAAC suspension. A microsyringe was connected to the opposite side of the tube. Under microscopic guidance, the limbus of the cornea was pricked toward the posterior segment with a needle, and then 2 mL of the TAAC suspension was administered into the vitreous cavity. After intravitreal injections, the sclera was disinfected with 0.5% levofloxacin (Santen). p TAAC treatment resulted in co-localization of POH-Rhodamine and FITC fluorescent areas. Discussion h Thus, the result of the present study might come from 1) inhibition of inflammation, 2) improve- ment of hypoxia and down regulation of HIF-1a expression due to inhibition of inflammation or a promoting effect on the proteasome system of HIF-1a degradation or 3) down regulation of VEGF to decrease CNV size by TAAC. In conclusion, in the present study, we clarified that POH- Rhodamine is useful for evaluating tissue hypoxia in a laser-induced CNV model and that TAAC suppressed CNV through tissue hypoxia improvement. POH probe technology may become applicable in a clinical setting for early diagnosis of disorders triggered by hypoxic pathologies, such as exudative age-related macular degeneration. However, to detect the fluorescence of POH- Rhodamine in living mice, more sensitive study POH probe will need to be developed. Methods P i This result suggests that TAAC may recover tissue around CNV to reduce the extent of CNV. To examine how TAAC rescues tissue around CNV, we investigated the effect of TAAC against HIF-1a. HIF-1a expression reached the peak after 3 h under hypoxic conditions, and TAAC decreased this peak in vitro. In a supplementary examination, POH-Rhodamine did not affect against VEGF-induced cell proliferation and cell death (Supplementary Figures 1 and 2). This result suggests that POH- Rhodamine contributed little to cell number change and TAAC purely reduced HIF-1a expression. In the present study, the incuba- tion for 24 h after medium change, even though under normoxia, increased the expression of HIF-1a. Then, we have demonstrated the cellular staining of POH-Rhodamine and quantitatively analyze cell hypoxia 3, 12, and 24 h after culturing cells in normoxia and hypoxia. The result showed that an intensity of POH-Rhodamine increased at 3 and 12 h after incubation under hypoxia and also at 24 h after incubation under normoxia (Supplementary Figure 3). Normoxia group was also treated with 1% FBS and cultured confluent for long time. Therefore, even though under normoxia, deprivation of nutri- tion and oxygen by incubation for long time under normoxia might be increased the expression of HIF-1a compared with control. Fluorescent imaging of CNV. CNV lesion sizes were measured on RPE-choroid- sclera flat mounts. At 3,7, and 14 d after laser photocoagulation, mice were deeply anaesthetized and received intravenous injection of 0.5-ml phosphate-buffered saline (PBS) containing 20-mg/ml fluorescein isothiocyanate-dextran (MW 5 2000 kDa, Sigma-Aldrich, St. Louis, MO, USA). Eyes were enucleated and fixed in 4% paraformaldehyde for 12 h. The entire retina was carefully dissected from the eyecup, and the eyecups were flat-mounted in FluoromountTM (Diagnostic BioSystems, Pleasanton, CA, USA) with the RPE layer facing up. CNV lesions were observed with a fluorescence confocal microscope (FV10i, Olympus Tokyo, Japan; 3 10 objective and 3 3 digital zoom). The CNV-related neovascular areas were outlined and measured within the dotted line using imaging software OLYMPUS FLUOVIEW- ASW Version 02. 01 (Olympus) for FV10i with the operator that was unaware of treatment groups. Analysis included the total areas within the dotted lines. Three days after laser treatment, the area of the POH-Rhodamine fluorescent region around CNV lesions in mice was also measured. Then 2 nmol of POH- Rhodamine was intravenously injected 6 h before FITC-dextran injection. Methods P i The cropped blots are used in this Figure and the full-length blots are presented in Supplementary Figure S4. Technologies Japan, Tokyo, Japan). After 3 washes in PBS, the samples were mounted with FluoromountTM. Fluorescent images were taken using a confocal microscope (FV10i). dim red light, and mice were kept warm during the entire procedure. The amplitude of the a-wave was measured from the baseline to the maximum a-wave peak, and the b-wave was measured from the maximum a-wave peak to the maximum b-wave peak. Immunohistochemistry. To investigate HIF-1a expression and the distribution of POH-Rhodamine in the CNV model as well as to compare POH-Rhodamine with pimonidazole which is a traditional hypoxia visualization bio-imaging probe, immunohistochemical staining of HIF-1a and pimonidazole was performed. Three days after laser photocoagulation, mice were deeply anaesthetized and received intravenous injection of 2-nmol POH-Rhodamine. Subsequently, mice were intravenous injection of pimonidazole at 60 mg/kg. Six hours after the injection, mice were also injected with 0.5-ml PBS containing 20-mg/ml fluorescein isothiocyanate- dextran. Mice were then killed humanely, enucleated, and the eyes fixed in 4% paraformaldehyde (PFA) for 12 h. After RPE-choroid-sclera flat mounts were made, they were blocked with 10% normal goat serum and 0.3% Triton X-100 (Nacalai Tesque, Kyoto, Japan) for 1 h at room temperature. Primary antibodies against mouse HIF-1a (15100, Novus Biologicals Ltd., Littleton, CO, USA) or rabbit anti- pimonidazole (1520, HypoxyprobeTM-1 CAS# 70132-50-3, Cosmo Bio Co., Ltd., Tokyo, Japan) were incubated overnight at 4uC. After 3 washes in PBS, immunoreactivity was visualized by incubation for 1 h at room temperature with goat anti-mouse (secondary antibody) conjugated with Alexa-633 (151,000, Life Cell culture. A transformed human retinal pigment epithelial cell line (ARPE-19) was obtained from American Type Culture Collection (Manassas, VA, USA). The cells were maintained in Dulbecco’s Modified Eagle’s Medium (DMEM)/Ham’s F-12 (Sigma-Aldrich) containing 10% fetal bovine serum (FBS), 100 U/ml of penicillin (Meiji Seika Kaisha Ltd., Tokyo, Japan), and 100-mg/ml streptomycin (Meiji Seika). Cultures were maintained at 37uC in a humidified atmosphere of 95% air and 5% CO2. The ARPE-19 cells were passaged by trypsinization every 3 to 4 d28. Western blotting. The ARPE-19 cells (2.0 3 105 cells/well) were seeded in 12-well plates and incubated for 24 h. The entire medium was then replaced with fresh medium containing 1% FBS. TAAC was added into cell cultures to provide a final concentration of 1 mg/ml containing 0.1% ethanol. Methods P i Three days after laser treatment, the area of the POH-Rhodamine fluorescent region around CNV lesions in mice was also measured. Then 2 nmol of POH- Rhodamine was intravenously injected 6 h before FITC-dextran injection. ERG recording. ERG measurement was performed as described previously27. ERG was recorded 15 d after laser photocoagulation. All procedures were performed in SCIENTIFIC REPORTS \| 5 : 9898 \| DOI: 10.1038/srep09898 4 www.nature.com/scientificreports C decreased the level of HIF-1a and the fluorescent intensity of POH-Rhodamine in ARPE-19 cells under hypoxic conditions. ndent change of HIF-1a levels. ARPE-19 cells were exposed to normoxia or hypoxia for the indicated times. The individual protein levels ified and normalized by b-actin levels. Data are shown as means 6 SE (n 5 4 or 5). * p , 0.05 vs. normoxia (Student’s t-test). (B) Western HIF-1a levels. Vehicle or TAAC (1 mg/ml) were added to ARPE-19 cells and incubated under hypoxic condition for 3 h. Data are shown as 5 4). ## p , 0.01 vs. normal, * p , 0.05 vs. vehicle-treated group (Student’s t-test). (C) Measurement of the fluorescent intensity with an gth of 550 nm/573 nm after incubation of ARPE-19 cells with POH-Rhodamine under hypoxic condition for 3 h. Data are shown as 0.01 vs. normal, ** p , 0.01 vs. vehicle-treated group (Student’s t-test). The cropped blots are used in this Figure and the full-length blots n Supplementary Figure S4. Figure 5 \| TAAC decreased the level of HIF-1a and the fluorescent intensity of POH-Rhodamine in ARPE-19 cells under hypoxic conditions. (A) Time-dependent change of HIF-1a levels. ARPE-19 cells were exposed to normoxia or hypoxia for the indicated times. The individual protein levels were semiquantified and normalized by b-actin levels. Data are shown as means 6 SE (n 5 4 or 5). * p , 0.05 vs. normoxia (Student’s t-test). (B) Western blot analysis of HIF-1a levels. Vehicle or TAAC (1 mg/ml) were added to ARPE-19 cells and incubated under hypoxic condition for 3 h. Data are shown as means 6 SE (n 5 4). ## p , 0.01 vs. normal, * p , 0.05 vs. vehicle-treated group (Student’s t-test). (C) Measurement of the fluorescent intensity with an Ex/Em wavelength of 550 nm/573 nm after incubation of ARPE-19 cells with POH-Rhodamine under hypoxic condition for 3 h. Data are shown as means. ## p , 0.01 vs. normal, ** p , 0.01 vs. vehicle-treated group (Student’s t-test). Methods P i The cells were incubated under normoxic (21% O2) or hypoxic (1% O2) conditions. A previous report was used as a reference with some modifications29. At 0, 1, 3, 6, and 12 h, the cells were washed with PBS twice. Then, the cells were lysed with a cell-lysis buffer including protease inhibitor (Sigma-Aldrich) and phosphatase inhibitor cocktails (Sigma-Aldrich). The BCA Protein Assay Kit (Pierce Biotechnology, Rockford, IL, USA) was used to immunoreactivity was visualized by incubation for 1 h at room temperature with goat anti-mouse (secondary antibody) conjugated with Alexa-633 (151,000, Life SCIENTIFIC REPORTS \| 5 : 9898 \| DOI: 10.1038/srep09898 5 www.nature.com/scientificreports www.nature.com/scientificreports 14. Criswell, M. H., Hu, W. Z., Steffens, T. J., Li, R. & Margaron, P. Comparing pegaptanib and triamcinolone efficacy in the rat choroidal neovascularization model. Arch Ophthalmol 126, 946–52 (2008). measure the protein concentration. About 5 mg of total protein per sample was diluted with sample buffer with 20% 2-mercaptoethanol (Wako). After heating at 95uC for 5 min, the samples were electrophoresed with 5–20% sodium dodecyl sulfate-polyacrylamide electrophoresis gel (Wako). The separated proteins were electroblotted onto polyvinylidene difluoride membrane (Immobilon-P; Millipore Corporation, Bedford, MA, USA). The membrane was blocked with 50-mg/ml fat- free milk (Morinaga Milk Industry, Tokyo, Japan) in PBS for 1 h at room temperature. Mouse anti-HIF-1a antibody (15500; Novus Biologicals Ltd.) and mouse anti-b-actin antibody (1510000 dilution; Sigma-Aldrich) were used to detect each protein and blotted with a goat anti-mouse HRP-conjugated secondary antibody (152000). The immunoreactive bands were visualized using SuperSignal West Femto Maximum Sensitivity Substrate (Thermo Fisher Scientific Inc., Waltham, MA, USA). The band intensity was measured using a Lumino Imaging Analyzer (LAS-4000; Fujifilm, Osaka, Japan). p 15. Falkenstein, I. A. et al. Toxicity and intraocular properties of a novel long-acting anti-proliferative and anti-angiogenic compound IMS2186. Curr Eye Res 33, 599–609 (2008). 16. Kato, A. et al. Suppression of laser-induced choroidal neovascularization by posterior sub-tenon administration of triamcinolone acetonide. Retina 25, 503–9 (2005). 17. Hata, Y. et al. Vascular endothelial growth factor expression by hyalocytes and its regulation by glucocorticoid. Br J Ophthalmol 92, 1540–4 (2008). 18. Kuchimaru, T. et al. In vivo imaging of HIF-active tumors by an oxygen- dependent degradation protein probe with an interchangeable labeling system. PLoS One 5, e15736 (2010). 19. Biddie, S. C. et al. Transcription factor AP1 potentiates chromatin accessibility and glucocorticoid receptor binding. Mol Cell 43, 145–55 (2011). Measurement of fluorescent intensity in vitro. Author contributions S.T., T.M., S.N., M.S., H.N. and H.H. designed the experiments. S.T. and T.M. performed the experiments. S.T., T.M., K.T. and M.S. performed analysis. S.T., T.M., K.T., M.S. and H. H. wrote the paper. S.T. and T.M. prepared all figures. T.K. and S.K. contributed to making the POH-Rhodamine probe. All authors contributed to the editing of the paper and to scientific discussions. 7. Sakurai, E., Anand, A., Ambati, B. K., van Rooijen, N. & Ambati, J. Macrophage depletion inhibits experimental choroidal neovascularization. Invest Ophthalmol Vis Sci 44, 3578–85 (2003). 8. Yang, X. M. et al. Role of PI3K/Akt and MEK/ERK in mediating hypoxia-induced expression of HIF-1alpha and VEGF in laser-induced rat choroidal neovascularization. Invest Ophthalmol Vis Sci 50, 1873–9 (2009). neovascularization. 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After incubation, medium was changed to DMEM/Ham’s F-12 containing 1% FBS. In advance, medium for hypoxia-treated group was deaerated by N2 gas for 1 h. Then, TAAC (final concentration: 1 mg/ml) or vehicle was added, and the cells were incubated under normoxic or hypoxic condition for 2 h. About 500 nM of POH-Rhodamine was added and incubation continued for an additional 1 h. The cells were lysed with 200 mL of RIPA buffer. Fluorescent intensity was measured using a microplate reader (Varioskan Flash 2.4; Thermo Fisher Scientific Inc.) at the excitation/emission wavelengths of 552/575 nm. 20. Haller, J., Mikics, E. & Makara, G. B. The effects of non-genomic glucocorticoid mechanisms on bodily functions and the central neural system. A critical evaluation of findings. Front Neuroendocrinol 29, 273–91 (2008). 21. Ishibashi, T., Miki, K., Sorgente, N., Patterson, R. & Ryan, S. J. 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Supplementary information accompanies this paper at http://www.nature.com/ scientificreports Supplementary information accompanies this paper at http://www.nature.com/ scientificreports Supplementary information accompanies this paper at http://www.nature.com/ scientificreports p 10. Gillies, M. C. et al. Intravitreal triamcinolone for refractory diabetic macular edema: two-year results of a double-masked, placebo-controlled, randomized clinical trial. Ophthalmology 113, 1533–8 (2006). How to cite this article: Takata, S. et al. The effect of triamcinolone acetonide on laser-induced choroidal neovascularization in mice using a hypoxia visualization bio-imaging probe. Sci. Rep. 5, 9898; DOI:10.1038/srep09898 (2015). How to cite this article: Takata, S. et al. The effect of triamcinolone acetonide on laser-induced choroidal neovascularization in mice using a hypoxia visualization bio-imaging probe. Sci. Rep. 5, 9898; DOI:10.1038/srep09898 (2015). How to cite this article: Takata, S. et al. The effect of triamcinolone acetonide on laser-induced choroidal neovascularization in mice using a hypoxia visualization bio-imaging probe. Sci. Rep. 5, 9898; DOI:10.1038/srep09898 (2015). 11. Jonas, J. B., Degenring, R. F., Kreissig, I., Friedemann, T. & Akkoyun, I. Exudative age-related macular degeneration treated by intravitreal triamcinolone acetonide. A prospective comparative nonrandomized study. Eye (Lond) 19, 163–70 (2005). This work is licensed under a Creative Commons Attribution 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permissionfrom the licenseholderin order toreproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/ p p p y y 12. Krieglstein, T. R., Kampik, A. & Ulbig, M. Intravitreal triamcinolone and laser photocoagulation for retinal angiomatous proliferation. Br J Ophthalmol 90, 1357–60 (2006). 13. Krebs, I., Krepler, K., Stolba, U., Goll, A. & Binder, S. Retinal angiomatous proliferation: combined therapy of intravitreal triamcinolone acetonide and PDT versus PDT alone. Graefes Arch Clin Exp Ophthalmol 246, 237–43 (2008). SCIENTIFIC REPORTS \| 5 : 9898 \| DOI: 10.1038/srep09898 6
https://openalex.org/W2134124154	https://europepmc.org/articles/pmc4391334?pdf=render	English	null	Methylation array data can simultaneously identify individuals and convey protected health information: an unrecognized ethical concern	Clinical epigenetics	2,014	cc-by	5,250	RESEARCH Open Access Philibert et al. Clinical Epigenetics 2014, 6:28 http //www clinicalepigeneticsjournal com/conten Philibert et al. Clinical Epigenetics 2014, 6:28 http //www clinicalepigeneticsjournal com/conten Philibert et al. Clinical Epigenetics 2014, 6:28 Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 Abstract Background: Genome-wide methylation arrays are increasingly used tools in studies of complex medical disorders. Because of their expense and potential utility to the scientific community, current federal policy dictates that data from these arrays, like those from genome-wide genotyping arrays, be deposited in publicly available databases. Unlike the genotyping information, access to the expression data is not restricted. An underlying supposition in the current nonrestricted access to methylation data is the belief that protected health and personal identifying information cannot be simultaneously extracted from these arrays. Results: In this communication, we analyze methylation data from the Illumina HumanMethylation450 array and show that genotype at 1,069 highly informative loci, and both alcohol and smoking consumption information, can be derived from the array data. Conclusions: We conclude that both potentially personally identifying information and substance-use histories can be simultaneously derived from methylation array data. Because access to genetic information about a database subject or one of their relatives is critical to the de-identification process, this risk of de-identification is limited at the current time. We propose that access to genome-wide methylation data be restricted to institutionally approved investigators who accede to data use agreements prohibiting re-identification. Keywords: Genetics, DNA methylation, Ethics, Methylation array, Confidentiality © 2014 Philibert et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Methylation array data can simultaneously identify individuals and convey protected health information: an unrecognized ethical concern Robert A Philibert1,2, Nicolas Terry3, Cheryl Erwin4, Winter J Philibert1, Steven RH Beach5,6 and Gene H Brody5 Correspondence: robert-philibert@uiowa.edu 1Department of Psychiatry, University of Iowa, Rm 2-126 MEB, 500 Newton Road, Iowa City, IA 52242, USA 2Behavioral Diagnostics Inc, 316 E. Court St., Iowa City, IA 52244, USA Full list of author information is available at the end of the article © 2014 Philibert et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 This development, in combination with other isolated but related issues, such as the sequencing of the commonly used HeLa cell line, which unintentionally allowed the conveyance of the likely genetic vulnerabilities of close relatives of Henrietta Lacks, have led to changes in the way genome-wide gen- etic information is handled [5]. However, the severity of these concerns has been tempered by the fact that, with the exception of isolated instances, protected information regarding diseases status has not been compromised. That is, the ability of genome-wide data to both uniquely identify an individual and infer disease status is relatively limited. Nevertheless, as a precaution, access to full genetic information is restricted [6]. In contrast, the deposition of genome-wide methylation data, such as that of the Illumina HumanGenome450 BeadArray to the Gene Omnibus Expression (GEO) repository has largely escaped scrutiny [7]. The ration- ale for this relative lack of concern is the unwritten supposition that methylation data cannot be used to uniquely identify individuals or convey sensitive protected health information. Using the sequence information contained in the Illu- mina probe annotation files and the sequence alignment algorithm of the University of California, Santa Clara (UCSC) Genome Browser, we mapped the CpG residue targeted by each of the probes back to the genome to determine whether or not the position occupied by the cytosine nucleotide was known to be polymorphic. In 29 of the top 30 cases, the position of the CpG residue targeted by the probe was the site of a known highly informative C to T transition polymorphism whose USCS Genome Browser-listed heterozygosity closely matched that ob- served in our study. The sole exception in that group of 30 was with respect to cg19214707, which instead con- tained several polymorphisms within the probe binding site. A review of a random sampling of the rest 1,069 probes listed in Additional file 1: Table S1 showed a high correlation between the heterozygosity observed in our sample of 111 subjects and that reported on the UCSC genome browser. Unfortunately, emerging data indicate that both of these assumptions may be incorrect. Recently, our consortium has demonstrated that consumption histories of both tobacco and alcohol can be accurately inferred from the DNA methylation signature of peripheral white blood cells [8-11]. Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 In the more exacting second approach to inferring genotype, we attempted to build on the prior observations by Shoemaker and colleagues who noted nearly com- plete, stoichiometric losses of the methylation signal in response to cytosine polymorphisms in heavily methyl- ated (approximately 95 to 100%) CpG residues, [12] by identifying those sites with ideal beta value distributions for genotyping inference (that is, 100%, 50% or 0% methy- lation). First, the cleaned beta values for all 485,577 loci interrogated by the Illumina HumanMethylation450 array in our recent study of the effects of smoking on DNA methylation in a cohort of 111 African American females were binned into three groups, X, Y and Z (X >0.7, 0.7 < Y <0.3, Z <0.25), which potentially represent the genotypes CC, CD, or DD where ‘D’ represents an A, G or T, at the putative cytosine position of the CpG dinucleotide pair, respectfully [13]. A total of 1,383 probes with at least 106 (95%) of the values mapping to those bins and having at least four observations in both Bin X and Bin Z were identified. The binning values were converted to geno- types and then analyzed for minor allele frequency and compliance with the Hardy Weinberg Equilibrium (HWE). A total of 1,069 had HWE P values >0.01, with their minor allele frequencies ranging from 0.105 to 0.5. A listing of the 30 most informative loci is given in Table 1, and a complete listing of all 1,069 probes, including probe sequence information is given in Additional file 1: Table S1. Histograms of the beta value distribution at 30 most informative loci are given in Additional file 2: Figure S1. With respect to the latter supposition, there was an erroneous expectation that anonymized genome-wide genetic data contained within repositories could not be linked to identifiable individuals. Recent developments in bioinformatics have shown clearly that the assumption that genotype data in public repositories cannot be tied to identifiable individuals is not correct in all cases. For example, Gymek and col- leagues reported a method to triangulate the identity of a sample donor using genomic data and surnames from publicly available databases [4]. Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 In this communication, we describe a method by which information from a DNA methylation array could be used to generate individually identifying genetic profiles and also to infer the substance-use consumption of study participants. We then discuss the potential for the misuse of this data by those with access to genetic information of the study participants or their close relatives. Background of genome-wide genetic data are routinely utilized in meta-analyses of cardiopulmonary, endocrinological and mental health disorders. An underlying supposition in making genome-wide genetic data publicly available is the belief that the information contained within them cannot be used to both infer disease status and uniquely identify individuals. The rationale for the first assumption rests on a firm foundation of medical evidence which shows that for the vast majority of non-autosomal domin- ant disorders, genetic information alone cannot be used to absolutely determine whether a given individual actually has a medical disorder. For the more common complex disorders, this is undoubtedly true. For example, with respect to Type 2 Diabetes (T2DM), which is perhaps the best understood common complex medical disorder from a genetic point of view, individual genotyping data is of relatively little value in determining whether a given individual is at risk, let alone currently ill [2,3]. The balance between the right to privacy and the public interest in advancing medical science is a dynamic rela- tionship. This is particularly true for studies of complex medical disorders. Over the past decade, vast databases of biological information, both private and governmental, have been established. A major factor in their rapid growth has been policies mandating the deposition of all genome-wide array data in publicly available repositories, such as those administered by the National Center for Biotechnology Information (NCBI) [1]. Without a doubt, these policies have led to significant advances in many areas including evolutionary biology and healthcare. With respect to medical illness, repositories * Correspondence: robert-philibert@uiowa.edu 1Department of Psychiatry, University of Iowa, Rm 2-126 MEB, 500 Newton Road, Iowa City, IA 52242, USA 2Behavioral Diagnostics Inc, 316 E. Court St., Iowa City, IA 52244, USA Full list of author information is available at the end of the article Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 Page 2 of 6 Results The suitability of Illumina array DNA methylation data for use in genotyping was explored in two ways. As a first approximation of the total variation, the beta values for all 21,969 probes mapping to chromosome 16 were plotted and visually inspected for possible genetic influ- ences on methylation. Overall, 707 probes displayed a tri-modal distribution roughly consistent with an additive effect of genotype on DNA methylation. To formally determine whether allele binning of methy- lation signal corresponded to actual genotypes, we geno- typed 12 random Family and Community Health Studies (FACHS) subjects at two of the loci (cg10695549 and cg21028319) using conventional MspI restriction endo- nuclease digestion. The results from each of the agarose Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 Page 3 of 6 Table 1 Location and heterozygosity of the top thirty Illumina probes Illumina ID CHR Position (bp)1 Observed heterozygosity UCSC2 heterozygosity cg11036359 6 29759078 0.55 0.45 cg03115532 6 28185726 0.46 0.43 cg10695549 8 18432000 0.53 0.50 cg22309983 17 3497580 0.53 0.31 cg09533869 8 97747124 0.48 0.45 cg13078798 1 92203667 0.41 0.46 cg23603995 6 157198648 0.54 0.41 cg27467876 8 22266134 0.50 0.50 cg27625131 13 113105794 0.58 0.21 cg26690318 10 100167465 0.56 0.46 cg16999994 11 1001560 0.56 0.50 cg27056740 14 101507727 0.56 0.49 cg18816122 5 164064 0.45 0.50 cg13821051 2 101124858 0.52 0.46 cg06688803 19 45457306 0.46 0.49 cg18662228 2 236867804 0.52 0.50 cg27076160 10 64431533 0.62 0.30 cg22953237 7 31425682 0.44 0.02 cg16814680 8 91681699 0.44 0.50 cg18239511 14 96563269 0.55 0.39 cg13379757 10 22717154 0.46 0.30 cg19214707 7 3157722 0.48 0.19 cg11019791 22 48896579 0.48 0.45 cg04506342 2 160463692 0.51 0.48 cg25046571 6 29794657 0.51 0.50 cg10117599 7 624424 0.51 0.48 cg16398051 15 100821466 0.51 0.50 cg18514595 22 49579968 0.51 0.49 cg16675926 1 233518998 0.50 0.49 cg02299007 8 1140574 0.46 0.48 1Position of CpG residue according to Genome Build 37. 2Heterozygosity as reported by UCSC Genome Browser. Table 1 Location and heterozygosity of the top thirty Illumina probes Figure 1 The relationship between DNA methylation at cg05575921 and self-reported Smoking Status. Figure 1 The relationship between DNA methylation at cg05575921 and self-reported Smoking Status. methylation at cg05575921. As the figure demonstrates, methylation status at this residue is highly correlated with self-reported smoking status. Discussion h f Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 To use that genetic information to identify an individual person, one would need either a genetic sample of the individual to match, or else one would need to know that a given individual participated in a methylation study and have genetic information from a close relative, such as a sibling or first cousin. In our opinion, this is not a likely possibility at the current time. The GEO database only list 3,559 arrays of human peripheral blood methylation. Still, given the rapid growth of this database, on-line genetic information and the bitterness sometimes seen in divorce proceedings or other situations in which considerable sums of money or prestige are involved, it is not incon- ceivable that this could happen in the future. Furthermore, if our ability to identify individuals in open access genetic databases accelerates or if individuals begin to make non-anonymized genomes more common, the ability to identify those who have contributed to genome-wide methylation studies will become correspondingly easier. Not everyone who has contributed to these databases needs to be alarmed. Although the current status of a number of medical disorders can be imputed from these arrays is growing, [19,20] it is the recent demonstrations that these methylation arrays can be used to infer substance-use histories that may cause the greatest con- cerns. With respect to mental health information, only tobacco and alcohol consumption information can be accurately gleaned from these arrays at the current time [9,21]. However, it is highly likely that our ability to assess other substance consumption, such as that of cannabis use, or other mental health status will be developed in the near future. To use that genetic information to identify an individual person, one would need either a genetic sample of the individual to match, or else one would need to know that a given individual participated in a methylation study and have genetic information from a close relative, such as a sibling or first cousin. In our opinion, this is not a likely possibility at the current time. The GEO database only list 3,559 arrays of human peripheral blood methylation. Still, given the rapid growth of this database, on-line genetic information and the bitterness sometimes seen in divorce proceedings or other situations in which considerable sums of money or prestige are involved, it is not incon- ceivable that this could happen in the future. Availability of supporting data The methylation data used in this study are freely avail- able via the Gene Expression Omnibus repository [GEO Accession: GSE53045]. A listing of all 1069 polymorphic sites discussed in this manuscript is contained in the Additional files. Conclusions In summary, we report that both highly informative genetic profiles and substance-use histories can be developed from the same Illumina HumanGenome450 arrays. We suggest that policy changes be initiated to address potential loss of confidentiality. Currently, the identities of the donors of these data are not protected from discovery. Protection under the Healthcare Improvement and Portability Act (HIPAA) Privacy rule only applies to protected health information held by covered entities such as health care institutions [22]. However, to be protected the information must be ‘individually identifiable.’ HIPAA does not generally protect data held in publicly available repositories because the Privacy rule generally does not apply to de-identified health information [23]. The current demonstration that extensive genotype and substance-use profiles can be ex- tracted from these arrays challenges this de-identification hypothesis and calls into question the lack of privacy protection. Discussion h f Furthermore, if our ability to identify individuals in open access genetic databases accelerates or if individuals begin to make non-anonymized genomes more common, the ability to identify those who have contributed to genome-wide methylation studies will become correspondingly easier. advocated ‘a focus on strong security measures and the adoption of strict prohibitions and legal sanctions against the unauthorized re-identification of individuals from DNA sequences.’ [26]. In 2012, the Presidential Commission for the Study of Bioethical Issues called for more consistent privacy baseline rules and a focus on data security [27]. Neither report resulted in regulatory reform. There are several potential solutions to the re- identification risks posed by methylation data. One of them is to require data use agreements and to restrict access of array or similarly informative data to those investigators appropriately vetted by their institutions. There are many examples of data use prohibitions on re-identification, such as the National Practitioner Data Bank’s conditions for the use of its Public Use Data File [28]. Another would be to remove the data for the most genetically informative markers from the database. Though the two approaches are not mutually exclusive, vetting of applicants might be the preferred mechanism. Institutional Review Boards are already available to the vast majority of researchers who would seek this type of data. It is also possible to implement the second mechanism as well. However, if this mechanism is to be completely effective ethnically inclusive examinations to determine which data should be removed must be undertaken. Not everyone who has contributed to these databases needs to be alarmed. Although the current status of a number of medical disorders can be imputed from these arrays is growing, [19,20] it is the recent demonstrations that these methylation arrays can be used to infer substance-use histories that may cause the greatest con- cerns. With respect to mental health information, only tobacco and alcohol consumption information can be accurately gleaned from these arrays at the current time [9,21]. However, it is highly likely that our ability to assess other substance consumption, such as that of cannabis use, or other mental health status will be developed in the near future. Discussion h f The frequent use of information from public databases in many of the most highly cited scientific papers highlights the value of these repositories. Nevertheless, recent advances in our ability to infer information about the hu- man subject participants who contributed to those studies raises concerns for potential abuse of that information. At the current time, the capability to link the disease status information contained within these arrays to indi- viduals is relatively limited. However, as the current exer- cise demonstrates, this is not due to the lack of potential genetic markers in the Illumina array. Our rudimentary analysis that focused on identifying highly informative loci that were fully methylated, half methylated or fully demethylated as a function of genetic variation at or near the CpG site, generated over 1,000 informative loci. However, this is likely a gross underestimate of the number of informative loci. Our manual survey of chromosome 16 shows that if the stringency was relaxed to include those sites that were normally not fully methyl- ated or were less informative than those in Table 1, the number of potential loci of that could be used to infer genotype would markedly increase. Indeed, Shoemaker noted over 200,000 annotated SNPs that map to CpG sites [12]. Hence, it is highly likely many more genetically informative probes could be identified if more advanced methods were use to ‘bin’ alleles. gel based assessments showed complete correspondence to that imputed from the arrays. As a demonstration of the usefulness of these arrays to assess substance-use consumption status for those unfamiliar, we repeated our previously published ana- lysis of the relationship of methylation at cg05575921 to self-reported smoking status in these 111 individuals. We and others have shown that assessment of methyla- tion status at cg05575921, which targets a CpG residue in the aryl hydrocarbon receptor repressor, can be used to assess smoking history [8-11,13-18]. Figure 1 illustrates the relationship between smoking status and DNA Because a relatively small set of loci can be used to match one genetic sample to another, it should be possible using the thousand or so markers that we have already identified, to develop a robust, unique, genetic profile of any anonymous genome-wide methylation array donor. Page 4 of 6 Page 4 of 6 Philibert et al. References 1. Wheeler DL, Church DM, Edgar R, Federhen S, Helmberg W, Madden TL, Pontius JU, Schuler GD, Schriml LM, Sequeira E: Database resources of the National Center for Biotechnology Information: update. Nucleic Acids Res 2004, 32:D35. Genotyping at cg10695549 and cg21028319 was conducted using a standard restriction enzyme digest approach. In brief, we searched the key sequence infor- mation provided in the probe annotation files of the 50 most informative loci to identify those with CpG sites that could be potentially recognized by the restriction enzyme MspI (which cuts at CCGG tetramers). Primers flanking each CpG site at two of these sites, F- GCT GTAATTATACATCCAGCTATGG and R- TTTTTGTT TCCCTTCTGAGC for cg10695549; and F- TTGCAAA CGATGAGAACTGAG and R- CGTTTACCAGCCCAT GCTA for cg21028319; were used to amplify the locus using DNA from 12 random FACHS subjects. Aliquots of the resulting PCR products were then digested using 3 u of MspI under the conditions suggested by the manufac- turer (New England Biolabs, Ipswich, MA, USA). The resulting products were then electrophoresed on standard 2% agarose gel and the resulting genotypes called by personnel blinded to methylation allele status. 2. de Miguel-Yanes JM, Shrader P, Pencina MJ, Fox CS, Manning AK, Grant RW, Dupuis J, Florez JC, D’Agostino RB, Cupples LA, Miegs JB, MAGIC Investigators, Diagram Investigators: Genetic risk reclassification for type 2 diabetes by age below or above 50 years using 40 type 2 diabetes risk single nucleotide polymorphisms. Diabetes Care 2011, 34:121–125. nucleotide polymorphisms. 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References Shenker NS, Polidoro S, van Veldhoven K, Sacerdote C, Ricceri F, Birrell MA, Belvisi MG, Brown R, Vineis P, Flanagan JM: Epigenome-wide association study in the European Prospective Investigation into Cancer and Nutrition (EPIC-Turin) identifies novel genetic loci associated with smoking. Hum Mol Genet 2013, 22:843–851. smoking. Hum Mol Genet 2013, 22:843–851. 9. Philibert RA, Beach SR, Brody GH: Demethylation of the aryl hydrocarbon receptor repressor as a biomarker for nascent smokers. Epigenetics 2012, 7:1331–1338. Received: 16 August 2014 Accepted: 29 October 2014 Published: 19 November 2014 Received: 16 August 2014 Accepted: 29 October 2014 Published: 19 November 2014 Binning of beta values was conducted using Excel (Microsoft, Redmond, WA, USA). Plotting of data values was accomplished using JMP Version 11 (SAS, Cary, SC, USA). Authors’ contributions 14. Elliott H, Tillin T, McArdle W, Ho K, Duggirala A, Frayling T, Davey Smith G, Hughes A, Chaturvedi N, Relton C: Differences in smoking associated DNA methylation patterns in South Asians and Europeans. Clinical Epigenetics 2014, 6:4. RAP conceived the ideas, conducted a large part of the analyses and wrote the initial draft of the paper. NT helped conceive the ideas, wrote sections of the manuscript and revised the paper. CE helped conceive the ideas and revised the manuscript. WJP performed some of the data analyses and revised the manuscript. SRHB helped conceive the ideas and revised the manuscript. GB helped conceive the ideas and revised the manuscript. All authors have read and approved the final manuscript. 15. Zeilinger S, Kühnel B, Klopp N, Baurecht H, Kleinschmidt A, Gieger C, Weidinger S, Lattka E, Adamski J, Peters A, Strauch K, Waldenberger M, Illig T: Tobacco smoking leads to extensive genome-wide changes in DNA methylation. PLoS One 2013, 8:e63812. y 16. Shenker NS, Ueland PM, Polidoro S, van Veldhoven K, Ricceri F, Brown R, Flanagan JM, Vineis P: DNA methylation as a long-term biomarker of exposure to tobacco smoke. Epidemiology 2013, 24:712–716. Additional files 10. Monick MM, Beach SR, Plume J, Sears R, Gerrard M, Brody GH, Philibert RA: Coordinated changes in AHRR methylation in lymphoblasts and pulmonary macrophages from smokers. Am J Med Genet B Neuropsychiatr Genet 2012, 159B:141–151. Additional file 1: Table S1. A listing of 1069 Genetically Informative Methylation Probes. Additional file 1: Table S1. A listing of 1069 Genetically Informative Methylation Probes. 11. Joubert BR, Håberg SE, Nilsen RM, Wang X, Vollset SE, Murphy SK, Huang Z, Hoyo C, Midttun Ø, Cupul-Uicab LA, Ueland PM, Wu WC, Nystad W, Bell DA, Peddada SD, London SJ: 450K epigenome-wide scan identifies differential DNA methylation in newborns related to maternal smoking during pregnancy. Environ Health Perspect 2012, 120:1425–1431. Additional file 2: Figure S1. Binning histograms for the 50 genetically most informative probes. Additional file 2: Figure S1. Binning histograms for the 50 genetically most informative probes. Competing interests 12. Shoemaker R, Deng J, Wang W, Zhang K: Allele-specific methylation is prevalent and is contributed by CpG-SNPs in the human genome. Genome Res 2010, 20:883–889. p g The use of DNA methylation to assess tobacco and alcohol consumption status is covered by US patent 8,637,652 and other pending claims. Dr. Philibert is a potential royalty recipient on those intellectual right claims. Dr. Philibert is an officer and stockholder of Behavioral Diagnostics (www.bdmethylation.com). Dr. Erwin is a consultant with Behavioral Diagnostics. 13. Dogan MV, Shields B, Cutrona C, Gao L, Gibbons FX, Simons R, Monick M, Brody G, Tan K, Philibert R: The effect of smoking on DNA methylation of peripheral blood mononuclear cells from African American women. BMC Genomics 2014, 15:151. Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 Page 5 of 6 Page 5 of 6 Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 The genome-wide methylation data consists of 111 assessments of peripheral mononuclear cell DNA of 111 African-American females using the Illumina Human- Methylation450 BeadChip (Illumina, San Diego, CA, USA), which contains 485,577 probes recognizing at least 20,216 transcripts, potential transcripts or CpG islands. The procedures and protocols used in the preparation of the DNA and cleaning of the data have been described in detail previously [13]. Author details 1 1Department of Psychiatry, University of Iowa, Rm 2-126 MEB, 500 Newton Road, Iowa City, IA 52242, USA. 2Behavioral Diagnostics Inc, 316 E. Court St., Iowa City, IA 52244, USA. 3Indiana University, 530 W. New York St., Robert H. McKinney School of Law, Indianapolis, IN 46202, USA. 4Departments of Medical Education and Psychiatry, 3601 4th St., Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA. 5Center for Family Research, 1905 College Station Road, University of Georgia, Athens, GA 30602, USA. 6Department of Psychology, 125 Baldwin St., University of Georgia, Athens, GA 30602, USA. 6Department of Psychology, 125 Baldwin St., University of Georgia, Athens, GA 30602, USA. Methods The DNA methylation information contained in this study was derived and deposited as part of the study plan for the National Institutes for Health (NIH)-funded study ‘The Effects of Smoking on DNA Methylation in Primary Human Lymphocytes’ (R21DA034457, [GEO Accession: GSE53045]). All procedures and protocols in that study were approved by the University of Iowa Institutional Review Board. Self-reported smoking data on the 111 female subjects was obtained using an adapted version of the Semi-Structured Assessment for the Genetics of Alcoholism, Version II [29]. Biomaterial for the methylation analyses was obtained via phlebot- omy at the time of the interview. The risk of re-identification is well known and should not take precedence over the rights of individual research subjects [24]. In 2010, Benitez and Malin quantified substantial differential risks of re-identification based on state-by-state variations in voter registries (their chosen triangulation datasets) [25]. The narrower question of potentially identifying genetic information has been the subject of several proposals for regulatory reform. For example, in 2009 an Institute of Medicine committee Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 17. Philibert R, Beach SR, Li K-M, Brody G: Changes in DNA methylation at the aryl hydrocarbon receptor repressor may be a new biomarker for smoking. Clinical Epigenetics 2013, 5:19–26. 18. Besingi W, Johansson A: Smoke-related DNA methylation changes in the etiology of human disease. Hum Mol Genet 2014, 23:2290–2297. Rakyan VK, Beyan H, Down TA, Hawa MI, Maslau S, Aden D, Daunay 19. Rakyan VK, Beyan H, Down TA, Hawa MI, Maslau S, Aden D, Daunay A, Busato F, Mein CA, Manfras B, Dias KR, Bell CG, Tost J, Boehm BO, Beck S, Leslie RD: Identification of type 1 diabetes–associated DNA methylation variable positions that precede disease diagnosis. PLoS Genet 2011, 7:e1002300. 20. Toperoff G, Aran D, Kark JD, Rosenberg M, Dubnikov T, Nissan B, Wainstein J, Friedlander Y, Levy-Lahad E, Glaser B, Hellman A: Genome-wide survey reveals predisposing diabetes type 2-related DNA methylation variations in human peripheral blood. Hum Mol Genet 2012, 21:371–383. 21. Philibert R, Penaluna B, White T, Shires S, Gunter TD, Liesveld J, Erwin C, Hollenbeck N, Osborn T: A pilot examination of the genome-wide DNA methylation signatures of subjects entering and exiting short-term alcohol dependence treatment programs. Epigenetics 2014, 9:1212–1219. 22. Code of Federal Regulations. In Book Code of Federal Regulations, Office of the Federal Register. Title 45, Parts 160 and 164. http://www.gpo.gov/fdsys/ pkg/CFR-2007-title45-vol1/content-detail.html. p g 23. McGraw D: Building public trust in uses of Health Insurance Portability and Accountability Act de-identified data. J Am Med Inform Assoc 2013, 20:29–34. 24. World Heath Organization: Declaration of Helsinki. JAMA 2013, 310:2191–2194. 25. Benitez K, Malin B: Evaluating re-identification risks with respect to the HIPAA privacy rule. J Am Med Inform Assoc 2010, 17:169–177. 26. Gostin LO, Levit LA, Nass SJ: Beyond the HIPAA Privacy Rule: Enhancing Privacy. Improving Health Through Research. Washington, DC, USA: National Academies Press; 2009. 27. Privacy and Progress in Whole Genome Sequencing. In Privacy and Progress in Whole Genome Sequencing. 2012. http://bioethics.gov/sites/ default/files/PrivacyProgress508_1.pdf. 28. The National Practitioner Databank: Data Use Agreement. http://www.npdb.hrsa.gov/resources/publicData.jsp. 28. The National Practitioner Databank: Data Use Agreement. http://www.npdb.hrsa.gov/resources/publicData.jsp. 29. Bucholz KK, Cadoret R, Cloninger CR, Dinwiddie SH, Hesselbrock VM, Nurnberger JI Jr, Reich T, Schmidt I, Schuckit MA: A new, semi-structured psychiatric interview for use in genetic linkage studies: a report on the reliability of the SSAGA. J Stud Alcohol 1994, 55:149–158. 29. Acknowledgements This work was supported by R21DA03445. Page 6 of 6 Page 6 of 6 Philibert et al. Clinical Epigenetics 2014, 6:28 http://www.clinicalepigeneticsjournal.com/content/6/1/28 Bucholz KK, Cadoret R, Cloninger CR, Dinwiddie SH, Hesselbrock VM, Nurnberger JI Jr, Reich T, Schmidt I, Schuckit MA: A new, semi-structured psychiatric interview for use in genetic linkage studies: a report on the reliability of the SSAGA. J Stud Alcohol 1994, 55:149–158. doi:10.1186/1868-7083-6-28 Cite this article as: Philibert et al.: Methylation array data can simultaneously identify individuals and convey protected health information: an unrecognized ethical concern. Clinical Epigenetics 2014 6:28. 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https://openalex.org/W2904594701	https://aip.scitation.org/doi/pdf/10.1063/1.5064732	English	null	The metal-insulator transition in ZrTe5 induced by temperature	AIP advances	2,018	cc-by	4,479	The metal-insulator transition in ZrTe5 induced by temperature Wei Wang; Xiaoqian Zhang; Yafei Zhao; Huanfeng Xu; QiangSheng Lu; Chang Liu; Xiaoying Hu; Ion Cristian Edmond Turcu; Liang He  ; Wenqin Zou ; Yongbing Xu AIP Advances 8, 125110 (2018) https://doi.org/10.1063/1.5064732 Articles You May Be Interested In First-principles study of lattice thermal conductivity in ZrTe5 and HfTe5 J. Appl. Phys. (May 2018) Enhanced thermopower and low thermal conductivity in p-type polycrystalline ZrTe5 Appl. Phys. Lett. (August 2017) Transport and thermal properties of polycrystalline ZrTe5 J. Appl. Phys. (June 2020) RESEARCH ARTICLE \| DECEMBER 07 2018 Articles You May Be Interested In First-principles study of lattice thermal conductivity in ZrTe5 and HfTe5 24 October 2024 04:04:36 by temperature Wei Wang,1 Xiaoqian Zhang,1 Yafei Zhao,1 Huanfeng Xu,1 QiangSheng Lu,2,3 Chang Liu,2 Xiaoying Hu,4 Ion Cristian Edmond Turcu,1 Liang He,1,a Wenqin Zou,5,a and Yongbing Xu1 1Jiangsu Provincial Key Laboratory of Advanced Photonic and Electronic Materials, Collaborative Innovation Center of Advanced Microstructures, School of Electronic Science and Engineering, Nanjing University, Nanjing 210093, People’s Republic of China 2Department of Physics Southern University of Science and Technology, Shenzhen, Guangdong 518055, China 3Department of Physics and Astronomy, University of Missouri, Columbia, Missouri 65211, USA 4College of Science and Laboratory of Materials Design and Quantum Simulation, Changchun University, ChangChun 130022, China 5National Lab of Solid State Microstructures, Department of Physics, Nanjing University, Nanjing 210093, PR China (Received 8 October 2018; accepted 29 November 2018; published online 7 December 2018) Wei Wang,1 Xiaoqian Zhang,1 Yafei Zhao,1 Huanfeng Xu,1 QiangSheng Lu,2,3 Chang Liu,2 Xiaoying Hu,4 Ion Cristian Edmond Turcu,1 Liang He,1,a Wenqin Zou,5,a and Yongbing Xu1 1Jiangsu Provincial Key Laboratory of Advanced Photonic and Electronic Materials, Collaborative Innovation Center of Advanced Microstructures, School of Electronic Science and Engineering, Nanjing University, Nanjing 210093, People’s Republic of China 2Department of Physics Southern University of Science and Technology, Shenzhen, Guangdong 518055, China 3Department of Physics and Astronomy, University of Missouri, Columbia, Missouri 65211, USA 4College of Science and Laboratory of Materials Design and Quantum Simulation, Changchun University, ChangChun 130022, China 5National Lab of Solid State Microstructures, Department of Physics, Nanjing University, Nanjing 210093, PR China (Received 8 October 2018; accepted 29 November 2018; published online 7 December 2018) (Received 8 October 2018; accepted 29 November 2018; published online 7 December 2018) The ZrTe5 is known as a high mobility thermoelectric material. In 2014, Weng et al. predicted theoretically that the monolayer ZrTe5 is also a 2D topological insulator. In early works, scientists were focused on the abnormal metal-insulator transition as the temperature decreases. However, the physics nature of this phenomenon is still under debate. Here we have explained this by temperature-induced swapping of the dominating carriers from holes to electrons, evidenced by magneto-transport and angle-resolved photoemission spectroscopy (ARPES) measurements on single crystal ZrTe5 samples. Both methods indicate that the Fermi level of ZrTe5 raises from the top of the valance band across the conduction band as the temperature decreases. This is also accompanied by changes of the lattice constants. by temperature Our ﬁrst principle calculation suggests that the shift of the Fermi level comes from the band structure change caused by the temperature variation. © 2018 Author(s). All article content, except where otherwise noted, is licensed under a Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/). https://doi.org/10.1063/1.5064732 24 October 2024 04:04:36 AIP ADVANCES 8, 125110 (2018) aAuthors to whom correspondence should be addressed. Electronic addresses: heliang@nju.edu.cn, wqzou@nju.edu.cn 2158-3226/2018/8(12)/125110/7 8, 125110-1 © Author(s) 2018 aAuthors to whom correspondence should be addressed. Electronic addresses: heliang@nju.edu.cn, wqzou@nju.edu.cn I. INTRODUCTION The Transition-Metal Pentatelluride ZrTe5, similar to the well-known 3D topological insulators, Bi2Se3 orBi2Te3,1–3 wasstudiedasathermoelectricmaterialforseveraldecades.4 In2014,Wengetal. predicted theoretically that the monolayer ZrTe5 is also a 2D topological insulator with a bulk direct band gap of 0.4 eV.5 That could explain the rather high mobilities of ZrTe5 at low temperatures. Due to the outstanding performance, scientists turned their attention to its unusual transport properties.6,7 One such property is the large anomalous resistance8–10 peak of ZrTe5 below room temperature. Several studies tried to explain the transport anomaly by charge density wave (CDW),11 structural phase transition8,10 or semimetal-semiconductor phase transition.12 However, these explanations fail to explore the physics nature of this phenomenon. Here, we report the temperature dependent band structures measured by angle-resolved photoe- mission spectroscopy (ARPES). We have observed that as the temperature decreases its Fermi level shifts from the valance band towards the conduction band, and this is accompanied by swapping the dominating carriers from holes to electrons evidenced by the temperature dependent non-linear Hall effect, similar to the gate dependent ambipolar effect. We believe this change of carriers causes 8, 125110-1 2158-3226/2018/8(12)/125110/7 125110-2 Wang et al. Wang et al. AIP Advances 8, 125110 (2018) the temperature dependent resistance anomaly. We have further found that the change is induced by the reduced lattice constants at low temperatures, which is also supported by our ﬁrst principle calculation. II. EXPERIMENTAL DETAILS The single crystals of ZrTe5 were prepared from 99.99% Zr and 99.999% Te purchased from Alfa Aesar. Single crystals were obtained by means of chemical transport reactions, using iodine as the transport agent.8,13–17 The longitudinal and transverse resistance Rxx and Rxy were measured by a standard six-point Hall bar geometry in a Quantum Design physical properties measurement system (PPMS-9T). The electrical characteristics were measured using resistivity option with a current of 10 µA. Our ARPES data were taken with a PHOIBOS 150 Hemispherical Energy Analyzer at room temperature. A He I α (21.2 eV) resonance emission line, from a high ﬂux UVS300 He lamp was used to excite the photoelectrons from the sample surface. The UV radiation angle of incidence was 45◦relative to the sample normal and the spot size was 0.5mm x 1mm. All of the photoelectron measurements were performed with an angular resolution better than 0.2◦in the wide-angle mode (15◦) of the analyzer while the analyzer energy resolution was 30 meV. The calculation was performed within the framework of density functional theory by using the CASTEP package. The Norm-conserving wave pseudopotentials and the Perdew-Burke-Ernzerhof (PBE) function of the generalized gradient approximation (GGA) are used for the electron-ion interactions and exchange-correlation potential, respectively. The calculation adopted a primitive unit cell of ZrTe5 containing 4 Zr and 20 Te atoms. The parameters such as cutoff energy for the plane-wave basis and the sampling grid for the Brillouin zone are controlled in order to ensure the convergence. 24 October 2024 04:04:36 III. RESULTS AND DISCUSSION Figure1ashowsthelongitudinalresistanceasafunctionoftemperatureforaZrTe5 sample.Asthe temperature decreases below 300 K, the resistance ﬁrst increases exponentially like a semiconductor. At 140 K, the resistance reaches a maximum, and then it decreases as the temperature decreases, demonstrating a metal-like behavior. We have estimated the temperature dependent activation energy from the Arrhenius plot of ln(Rxx) vs 1/T in the “semiconductor” range, as shown in Fig. 1a inset. We observe that Ea rises as the temperature decreases, and reaches the maximum of 43 meV at 180 K, and then it decreases to zero at 140 K, where the metal-insulator transition occurs. The variation of Ea may be caused by the raising of the Fermi level from close to the valence band to across the conduction band. At 180 K, the Fermi level reaches the middle of the bulk band-gap. More directly, we have observed the rise of the Fermi level as the temperature decreases by ARPES which will be discussed below. At the same time, non-linear Hall resistance at all the temperatures (Fig. 1b–d) have also been obtained. For non-magnetic materials, the non-linear Hall resistance normally suggests multiple conducting channels.18–20 In this case, the parallel Hall conductance is given by: Gxy ≡ Rxy R2xy + R2s = X i Gi (1) (1) (1) Where Rxy is the Hall resistance, Rs is the sheet resistance, Gi are the Hall conductance of different channels. In addition, each channel can be written as a semi classical expression:20,21 Where Rxy is the Hall resistance, Rs is the sheet resistance, Gi are the Hall conductance of different channels. In addition, each channel can be written as a semi classical expression:20,21 G = en2Dµ2B 1 + µ2B2 (2) (2) Where n2D is the 2D carrier density and µ is the mobility for each channel. We found that the Hall conductance of ZrTe5 sample can be ﬁtted well by equation (1). Here, we separate transport parameters into three different temperature regimes: regime I (T < 20 K), regime II (20 K < T < 140 K) and regime III (140 K < T < 300 K). Where n2D is the 2D carrier density and µ is the mobility for each channel. We found that the Hall conductance of ZrTe5 sample can be ﬁtted well by equation (1). III. RESULTS AND DISCUSSION Here, we separate transport parameters into three different temperature regimes: regime I (T < 20 K), regime II (20 K < T < 140 K) and regime III (140 K < T < 300 K). AIP Advances 8, 125110 (2018) 125110-3 Wang et al. Wang et al. FIG. 1. (a) The temperature dependent resistance of the ZrTe5 sample. The current is parallel to the crystalline needle axis (I//a). Left Inset: The photograph of ZrTe5, The scale bar is 1 mm. Right Inset: The Arrhenius plot, which yields an activation energy of 40 meV in the temperature range of 160-200 K. Hall conductance Gxy of ZrTe5 samples. The transport properties of four different channels: G1, G2, G3 and G4 are also show: (b) 2 K, (c) 125 K, (d) 200 K. Open red circles are the experimental data and the solid line are the ﬁtted results. 24 October 2024 04:04:36 FIG. 1. (a) The temperature dependent resistance of the ZrTe5 sample. The current is parallel to the crystalline needle axis (I//a). Left Inset: The photograph of ZrTe5, The scale bar is 1 mm. Right Inset: The Arrhenius plot, which yields an activation energy of 40 meV in the temperature range of 160-200 K. Hall conductance Gxy of ZrTe5 samples. The transport properties of four different channels: G1, G2, G3 and G4 are also show: (b) 2 K, (c) 125 K, (d) 200 K. Open red circles are the experimental data and the solid line are the ﬁtted results. In regime I (T < 20 K), the longitudinal resistance (Rxx) remains unchanged, as shown in Fig. 1a. To ﬁt the data (Fig. 1b), we have used two electron channels: channel 1 and 2, and the 2D carrier densities of these channels are 1.59 × 1016 cm-2, and 4.06 × 1015 cm-2 at T = 2 K respectively. The corresponding mobilities are 68300 cm2 V-1s-1 and 19300 cm2 V-1s-1. In regime I (T < 20 K), the longitudinal resistance (Rxx) remains unchanged, as shown in Fig. 1a. To ﬁt the data (Fig. 1b), we have used two electron channels: channel 1 and 2, and the 2D carrier densities of these channels are 1.59 × 1016 cm-2, and 4.06 × 1015 cm-2 at T = 2 K respectively. The corresponding mobilities are 68300 cm2 V-1s-1 and 19300 cm2 V-1s-1. III. RESULTS AND DISCUSSION In regime II (20 K < T < 140 K), the sample shows a metal-like longitudinal resistance The transport properties become more complicated and the two-channel model no longer ﬁts the Hall conductance well. Thus we need two electron and one hole channels to describe the total conductance, as shown in Fig. 1c for the temperature of 125 K. The carrier density of channel 1 decreases from 1.9×1016 cm-2 to 1.03×1015 cm-2 as the temperature increases from 20 to 130 K. The carrier density of channel 2 increases from 2.04×1015 cm-2 to 1.18×1016 cm-2, following a classic Fermi-Dirac distribution nbulk = n0 eEa/kBT+1, where Ea = 1.31 meV, as shown by the blue line in Fig. 2a. Mobilities of both channels decrease as the temperature increases. The activation behavior of channel 2 can be explained by the Fermi level shifting down form the conduction band minimum as the temperature rises. Mobilities of both channels decrease as the temperature increases, probably due to phonon scattering, as shown in Fig. 1a. In regime III (140 K < T < 300 K), the metal-semiconductor transition appears, and the contri- bution of the two electron channels vanish gradually. In this case, two hole channels are needed to describe the total conductance, called the channel 3 and 4 (Fig. 1d). Interestingly, the carrier densities of both channels follow the Fermi-Dirac distribution, as shown by the red and green lines in Fig. 2a. The activation energies Ea are 17 meV and 31.6 meV, respectively, the activation energy of channel 4 is in good agreement with the activation energy calculated above. This suggests that these conducting channels are thermally activated holes. AIP Advances 8, 125110 (2018) 125110-4 Wang et al. Wang et al. FIG. 2. (a) 2D carrier densities (n) and (b) mobilities (µ) of four different conducting channels at various temperatures. The red, green and blue solid lines in (a) represent the Fermi-Dirac distribution of the carrier densities. The red and green solid lines in (b) show the mobility reduction with rising temperature. This may be caused by phonon scattering at high temperatures. 24 October 2024 04:04:36 24 October 2024 04:04:36 FIG. 2. (a) 2D carrier densities (n) and (b) mobilities (µ) of four different conducting channels at various temperatures. The red, green and blue solid lines in (a) represent the Fermi-Dirac distribution of the carrier densities. III. RESULTS AND DISCUSSION The red and green solid lines in (b) show the mobility reduction with rising temperature. This may be caused by phonon scattering at high temperatures. The temperature dependence of the activation energies Ea and the unusual changes in carrier type can be explained by the shifting of Fermi level at various temperatures. If this is correct, we should observe Fermi level variations as a function of temperatures in the ARPES measurement. The temperature dependence of the activation energies Ea and the unusual changes in carrier type can be explained by the shifting of Fermi level at various temperatures. If this is correct, we should observe Fermi level variations as a function of temperatures in the ARPES measurement. The ARPES measurement provides directly the electron structure as a function of temperatures, as shown in Fig. 3a–e. Close to the Γ point, the band structures show a linear E-K dispersion in the whole temperature range, as expected for a Dirac semimetal. The Fermi level has touched the valence band maximum at Γ point at high temperature (T = 270 K, Fig. 3e), which indicates a hole dominated electronic structure. This is in agreement with previous ARPES22,23 and transport works.24,25 The bands at the Γ point exhibit a strong temperature dependence. The overall band structure shifts down to higher binding energy with decreasing temperature, as shown in Fig. 3a–e.22,23,26 To quantitatively analyze the temperature dependent band shift, we present (Fig. 3f) the energy distribution curves (EDCs) at Γ point measured as a function of temperature. A systematic shift to lower energy of the EDCs can be observed when the temperature decreases. The peaks (shown by red arrows in Fig. 3f) demonstrate a linear dependence on temperatures (Fig. 3g). This curve overlaps perfectly with our theoretical calculation (black line in Fig. 3g). We have also noticed that the overall energy shift form 270 K to 80 K is the order of 50 meV. This value is in good agreement with Yan Zhang et al.’s work.22 According to previous theoretical works,27,28 the band structure of ZrTe5 is easily altered by the lattice parameters. Also, previous studies of powder X-ray diffraction data29 have reported that the lattice parameters of ZrTe5 show a strong dependence on temperatures. III. RESULTS AND DISCUSSION 125110-6 Wang et al. AIP Advances 8, 125110 (2018) AIP Advances 8, 125110 (2018) ACKNOWLEDGMENTS This work is supported by the National Key Research and Development Program of China (No. 2016YFA0300803), the National Basic Research Program of China (No. 2014CB921101), the National Natural Science Foundation of China (Nos. 61474061, 61674079, 11574137 and 61427812), and the National Science Foundation of Jiangsu Province (BK20140054). 24 October 2024 04:04:36 1 H. Zhang, C.-X. Liu, X.-L. Qi, X. Dai, Z. Fang, and S.-C. Zhang, Nature Physics 5(6), 438–442 (2009). 2 Y. Chen, J. Analytis, J. Chu, Z. Liu, S. Mo, X. Qi, H. Zhang, D. Lu, X. Dai, and Z. Fang, arXiv preprint arXiv:0904.182 (2009). 3 3 C.-X. Liu, H. Zhang, B. Yan, X.-L. Qi, T. Frauenheim, X. Dai, Z. Fang, and S.-C. Zhang, Physical Review B 81(4), 04130 (2010). ( ) 4 N. D. Lowhorn, T. M. Tritt, E. E. Abbott, and J. W. Kolis, Applied Physics Letters 88(2), 022101 (2006). 5 H. Weng, X. Dai, and Z. Fang, Physical Review X 4(1), 011002 (2014). H. 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Ido, Journal of the Physical Society of Japan 49(2), 839–840 (1980). 11 11 T. S. S. Okada, M. Ido, Y. Tazuke, R. Aoki, and O. Fujita, J. Phys. Soc. Jpn. 51, 460 (1982). 12 D. N. McIlroy, S. Moore, D. Zhang, J. Wharton, B. Kempton, R. Littleton, M. Wilson, T. M. Tritt, and C. G. IV. CONCLUSIONS We use the transport, ARPES measurement and ﬁrst principle analysis to study the origin of this anomalous metal-insulator transition in ZrTe5. Nonlinear Hall effect in the whole temperature range has been observed, which is caused by the multi-channel conductance. The majority carriers change from holes to electrons at the anomalous resistance peak. This is similar to the ambipolar effect on thin ﬁlm FET.34 From ARPES, temperature dependent band shift of 50 meV has been observed. The Fermi level moves from the top of the valance band across the conduction band, as the temperature decreases. There are several other reasons that could cause the temperature dependent band shift. First is the environmental and photon doping. Before the ARPES measurement, our samples are cleaved in the ultra-high vacuum chamber to avoid any contamination from the ambient environment. We have also conﬁrmed our results after several temperature cycles in order to eliminate the photon doping effect which should be an accumulating effect. Second is the defect effect. According to previous work,24 the Te vacancies are expected as n-type dopants in ZrTe5 crystal. When temperature decreases, the carriers will be frozen in the impurity level. That may drive the Fermi level to the lower energy which is opposite to our results. In that case, the temperature dependent evolution of the band structures is the intrinsic properties of ZrTe5. We believe such band structure shift can be identiﬁed as the Lifshitz transition, and is caused by the the lattice distortion induced by the temperature, which is supported by our ﬁrst principle calculation. III. RESULTS AND DISCUSSION Therefore, we try to relate the change of band structure to the change of lattice constants, similar to the traditional 2D material: MoS2.30–32 It is found that the calculated valence band structure is in good agreement with the experimental band dispersions, as shown in Fig. 4a. Temperature dependent band structures around the Γ point (black box in Fig. 4a) have been shown in Fig. 4b. The lattice constants at various temperatures are 125110-5 Wang et al. AIP Advances 8, 125110 (2018) FIG. 3. (a-e) Temperature-dependent band structures along the ka direction: a systematical shift to higher energy as temper- ature increasing can be observed. (f) The energy distribution curves (EDCs) at Γ point at different temperatures. The peaks are marked by red arrows. (g) Temperature dependence of the energy shift ∆E = E - E(T = 270 K) (red triangle) obtained from ﬁgure f (the error bars are obtained from the phonon energy). The theoretical calculations are also marked as solid black circles. 24 October 2024 04:04:36 FIG. 3. (a-e) Temperature-dependent band structures along the ka direction: a systematical shift to higher energy as temper- ature increasing can be observed. (f) The energy distribution curves (EDCs) at Γ point at different temperatures. The peaks are marked by red arrows. (g) Temperature dependence of the energy shift ∆E = E - E(T = 270 K) (red triangle) obtained from ﬁgure f (the error bars are obtained from the phonon energy). The theoretical calculations are also marked as solid black circles. adoptedfrompreviouswork.29 Atroomtemperature(293K),theFermileveltouchesthetopofvalence band (red line in Fig. 4b). The band structures systematically shift down as the temperature decreases. And the Fermi level crosses the conduction band at low temperatures (10 K). The temperature dependent shift of the valence band maximum (EVBM in Fig. 3g) agrees well with our experimental data.33 Thus we conclude that the Fermi level shift comes from the band structure change caused by the temperature variation. FIG. 4. (a) The band structure measured at 80 K, the red dash line is the calculation result which matches the experimental data. (b) The calculated band structures of bulk ZrTe5 within the black box in ﬁgure a at different temperatures. FIG. 4. (a) The band structure measured at 80 K, the red dash line is the calculation result which matches the experimental data. (b) The calculated band structures of bulk ZrTe5 within the black box in ﬁgure a at different temperatures. ACKNOWLEDGMENTS Olso Journal of Physics: Condensed Matter 16(30), L359–L365 (2004). 13 13 M. Izumi, K. Uch´ınokura, S. Harada, R. Yoshizaki, and E. Matsuura, Molecular Crystals and Liquid Crystals 81(1), 141–148 (1982). 14 14 G. N. Kamm, D. J. Gillespie, A. C. Ehrlich, T. J. 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https://openalex.org/W2797922378	https://europepmc.org/articles/pmc5892042?pdf=render	English	null	“We are like co-wives”: Traditional healers' views on collaborating with the formal Child and Adolescent Mental Health System in Uganda	BMC health services research	2,018	cc-by	7,719	Akol et al. BMC Health Services Research (2018) 18:258 https://doi.org/10.1186/s12913-018-3063-4 Akol et al. BMC Health Services Research (2018) 18:258 https://doi.org/10.1186/s12913-018-3063-4 “We are like co-wives”: Traditional healers' views on collaborating with the formal Child and Adolescent Mental Health System in Uganda Angela Akol1,2* , Karen Marie Moland1, Juliet N. Babirye2 and Ingunn Marie S. Engebretsen1 © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. * Correspondence: angela_akol@yahoo.com 1Center for International Health, University of Bergen, Bergen, Norway 2Makerere University School of Public Health, Kampala, Uganda Background disorders [14]. Conversely, biomedical service providers think that the difficulty around establishing the scientific validity of traditional and faith healers’ practices makes referral to traditional healers very difficult [15]. These at- titudes reflect a lack of trust between traditional healers and biomedical providers. Yet trust drives cooperation between agents of the health system; without it, collab- oration breaks down, corroding the interactive nature of health systems [16]. Early identification and management of mental illness in childhood and adolescence is important for averting debilitating mental illness in adulthood [1]. Child and Adolescent Mental Health (CAMH) refers to a range of mental, neurological and substance use (MNS) disorders that occur in childhood and adolescence. Mental health has been a neglected global health area and the attention given to CAMH has until recently been disproportion- ately low, compared to mental disorders in adults and the elderly [2]. As a result, a huge treatment gap for CAMH conditions persists, one that could be addressed by improving access to CAMH care in LMIC [3]. The interaction between the different agents of health care is embodied by the classical Explanatory Models of Illness theory proposed by Kleinman and others. Under this model, patient satisfaction with care is more likely with providers who explore and address patients’ ex- planatory models of illness [17]. Thus, health care is composed of different sectors each with its unique insti- tutions and each relying on different patient explanatory models (Fig. 1). The model states that while the profes- sional / biomedical sector is one sought by patients who ascribe illness to biological causes, the folk and popular sectors tend to attract clients who attach a social or a cultural explanation to illness. Each of the sectors offers unique remedies, related both to the expertise of pro- viders within the sector and to the perceived cause of ill- ness. Clients may utilise a combination of two or more sectors for a single episode of illness and therefore, an interaction between the sectors is required to achieve access to and satisfaction with care [18]. The importance of access to mental health services for all is accentuated by the UN Sustainable Development Goals (SDGs), which acknowledge mental health as a de- velopment priority for which service coverage indicators are imperative [4]. Abstract Background: Early identification and management of mental illness in childhood and adolescence helps to avert debilitating mental illness in adulthood but the attention given to Child and Adolescent Mental Health (CAMH) has until recently been low. Traditional healers are often consulted by patients with mental illness and in Uganda, up to 60% of patients attending traditional healers have moderate to severe mental illness. Poor access to CAMH care in Uganda creates a treatment gap that could be met through enhanced collaboration between traditional healers and biomedical health systems. The aim of this study was to explore traditional healers’ views on their collaboration with biomedical health systems so as to inform the implementation of strategies to improve access to CAMH services in Uganda. Methods: In-depth interviews with 20 purposively selected traditional healers were conducted in November 2015. A semi-structured interview guide was used to explore: 1) The experiences of traditional healers with mental ill- health in children and adolescents; 2) their willingness to collaborate with the formal health system; and 3) their perception of clinicians’ willingness to collaborate with them. Interviews were conducted in local languages and tape recorded. Data were analysed using thematic analysis. Results: Traditional healers described several experiences managing children and adolescents with mental illness, which they ascribed to spiritual and physical causes. The spiritual explanations were a consequence of unhappy ancestral spirits, modern religions and witchcraft, while physical causes mentioned included substance abuse and fevers. No traditional healer had received a patient referred to them from a medical clinic although all had referred patients to clinics for non-mental health reasons. Traditional healers expressed distrust in biomedical health systems and believed their treatments were superior to medical therapies in alleviating mental suffering. They expressed willingness to collaborate with biomedical providers. However, traditional healers believe clinicians disregard them and would not be willing to collaborate with them. Conclusion: Potential for collaboration between traditional healers and biomedical health systems for improving access to CAMH services in Uganda exists, but is undermined by mutual mistrust and competition between traditional healers and clinicians. Keywords: Traditional healers, Mental health, Child and adolescent, Health system * Correspondence: angela_akol@yahoo.com 1Center for International Health, University of Bergen, Bergen, Norway 2Makerere University School of Public Health, Kampala, Uganda Akol et al. BMC Health Services Research (2018) 18:258 Page 2 of 9 Page 2 of 9 Background The inclusion of mental health in the SDGs came in the wake of global discussions in the last decade on eliminating barriers to equitable care [5–7], a position adopted by the World Health Organization (WHO) in 2001 [2]. Access to mental health services is important for Primary Health Care (PHC) [2]. This opinion is rein- forced by the 2008 World Health Report which revis- ited the Alma Ata goals and emphasised the need for engaging culturally competent providers who respect patient beliefs [8]. By providing care in line with indi- genous knowledge and belief systems, traditional healers fit this description [9, 10]. Two WHO strat- egies currently endorse the involvement of traditional healers in care: the WHO’s traditional and comple- mentary medicine strategy 2014–2023 which high- lights traditional healers as a potential solution to achieving universal health coverage [11]; and the WHO mental health action plan 2013–2020 which encourages greater collaboration with traditional healers to promote mental wellbeing [12]. However, there are no clear exam- ples of collaboration between traditional healers and the biomedical health system for mental health care. Estimates indicate that more than 80% of African pop- ulations attend traditional healers for health reasons and that 40–60% of these have some kind of mental illness [11, 19]. In fact, traditional healers are the first recourse for approximately half of individuals seeking care for mental disorders in Africa [20]. In Uganda, available Fig. 1 Three sectors of health care, adapted from Kleinmann A (1980) Collaboration between traditional healers and clini- cians in alleviating mental suffering among children and adolescents is particularly important in settings where access to CAMH services is poor, such as Uganda, which has fewer psychiatric facilities than the global average [13]. However, hindrances to successful collaboration between traditional healers and biomedical mental health systems are cited in qualitative studies. For in- stance, traditional healers express a preference for refer- ring clients to another healer rather than to a clinician, maintaining an ‘internal’ referral network. Other trad- itional healers express skepticism regarding the value of biomedical psychiatric treatments because of their per- ceptions of the underlying spiritual cause of mental Fig. 1 Three sectors of health care, adapted from Kleinmann A (1980) Akol et al. BMC Health Services Research (2018) 18:258 Akol et al. Methods Design This qualitative study employed semi-structured inter- views with 20 purposively selected traditional healers, held in November 2015. Twenty was the number of participants designated before the onset of the study, based on local estimates of traditional healers with CAMH experience. Twenty was also deemed an ap- propriate sample size for achieving saturation [26] while preserving validity. Study participants were se- lected by the leader of the traditional healers in the Eastern region of Uganda, based on his knowledge of traditional healers engaged in mental health treatment. The traditional healers ranged in age from 26 to 80, with a mean age of 53. Six of them were female, and the median years of practice was 23 (range 6–52). All except one traditional healer had directly managed children and adolescents with mental illness, with 11 as the mean number of reported patients. Transcripts were imported into QSR NVivo 11 (QSR International Pty Ltd. Version 11, 2015). Open coding was then conducted by a single coder to categorise data and organise it into themes. An iterative process of labelling and extraction of data into themes and sub- themes, comparing and contrasting them with other themes followed. Coding and analysis were led by the lead author (AA), a medical doctor with broad experi- ence of the public health system. The last author (IMSE) reviewed all interview transcripts. Data analysis Interviews were transcribed directly into English by the same research assistant who conducted the interviews, while taking care to preserve important local language concepts. Data were analysed using thematic analysis. In keeping with this methodology, the transcripts were read and re-read to obtain immersion and a good under- standing of the data. Data collection Interviews were conducted in local languages (Lumasaaba and Luganda) by a research assistant with a sociology background, experienced in qualitative research. The re- search assistant was selected based on residence in the area, fluency in the two local languages and experience conducting research with traditional healers. Prior to con- ducting the interviews, the PI trained the research assist- ant on the main objectives of the study and the study tool. The PI did not participate in the interviews due to lan- guage limitations and because we believed that the pres- ence of a medical doctor might inhibit the traditional healers’ responses and restrict access to their premises. Traditional healers are widely consulted worldwide for treatment of various ailments and practice traditional medicine, which is defined as knowledge and remedies based on beliefs indigenous to different cultures used in the prevention, diagnosis or management of physical and mental illness [11]. For purposes of this paper, trad- itional medicine refers to such practices applied with the aim of diagnosing, treating or otherwise alleviating men- tal suffering among children and adolescents. In this paper, the term ‘bio medical personnel’ is used inter- changeably with ‘clinicians’. The aim of this study was to explore traditional healers’ views on their collaboration with biomedical health systems so as to inform the im- plementation of strategies to improve access to CAMH services in Uganda. Specifically, we aimed to examine the experiences of traditional healers with CAMH; their perception of and attitude towards collaboration with biomedical mental health systems. All interviews were tape recorded. Interviews lasted approximately 45 min and were held at a location con- venient to the traditional healer, mostly at their homes and workplaces. Background BMC Health Services Research (2018) 18:258 Page 3 of 9 research indicates that up to 60% of Ugandan patients attending traditional healers’ shrines have moderate to severe mental illness [21]. Several studies have documented positive outcomes among adults of mental health care from traditional healers in sub Saharan Africa [21–23], a factor which could explain traditional healer popularity. The wide- spread use of traditional healers could also be attributed to the accessibility of traditional healers relative to medical professionals; across sub Saharan Africa, there is a trad- itional healer for every 500 people, compared to a doctor: population ratio of 1: 40,000 [24]. While it has not been possible to determine the total number of traditional healers in Uganda, estimates indicate that compared to a doctor: population ratio of 1:8547, there is one traditional healer for 700 Ugandans [25]. An interview guide (Additional file 1) developed by the principal investigator (PI) was used to explore: 1) The experiences of traditional healers with mental ill- health in children and adolescents; 2) Their willingness to collaborate with biomedical health systems; and 3) their perceptions about the willingness of clinicians to collaborate with traditional healers. Semi-structured in- terviews were selected as the method of choice because of their ability to elicit rich descriptions of individual ex- periences (31). Mixed explanations of mental illness “What I know is that some of the mental health problems in children and young people is caused by ancestral clan spirits, especially if these spirits want the person initiated into being a traditional healer and the person resists… and not until this person is initiated into traditional healing his mental disorder never heals” – Traditional healer 13, twenty-seven years’ practice Worms and maggots growing in the child’s brain, were also widely implicated, as explained by the elderly trad- itional healer: “once a child starts getting difficulty in breathing it means that he has a maggot in his brain…as the child grows the maggot also grows…this can bring about terrible mental disorder.” We found that many of the treatments described by the traditional healers were aimed at expelling these maggots; unless the maggot was expelled, the patient would not get well. In keeping with traditional healers’ belief in ancestors’ ability to interfere in the lives of the living, ancestral spirits played a major role in explaining mental illness. All traditional healers cited unhappy ancestral spirits as a cause of mental ill-health among children and adoles- cents. A commonly held view was that ancestral spirits were unhappy because ancient customs and rituals have been abandoned; and that children and adolescents who resisted their destiny to become traditional healers inev- itably developed mental illness, which was only curable by initiation into traditional healing. “…usually those who have a maggot in the brain, when it moves, they become very violent … but once the maggot comes out then that person gets completely healed… I remember very well was a 14-year-old girl, who was brought to my place when very violent. So, what I did, I mixed herbs and I poured it through her nose… later she sneezed and two maggots popped out of her nose…” Traditional healer 09, eleven years’ practice. Treating mental illness – A culturally founded skill g y Traditional healers’ narrative on their experiences treat- ing mental illness focused on: explanations for mental suffering in children and adolescents and accounts of their interactions with biomedical health systems. The two issues are closely interlinked. As will be illustrated in this section, different explanations of illness based on different epistemologies resulted in treatment regimes that determined the nature of interaction with the for- mal health system. A common view was one of unsanitary conditions at birth and early childhood leading to mental illness. The pathway through which such conditions were believed to cause mental disease is through breathing difficulty, as illustrated by this elderly traditional healer with 45 years of practice, “I know that if a baby is born in a dirty environment, or…if a child’s head is not protected from the cold air…that child automatically gets a mental disorder when he grows up…the child’s brain is affected directly…begins by having difficulties in breathing… with time this child gets worse and then one realises that a mental disorder has set in” . Ethical considerations The study received approval from the Makerere School of Public Health Higher Degrees Research and Ethics Committee and from the Uganda National Council for Science and Technology. All ethical guidelines involv- ing human subjects were adhered to throughout this Page 4 of 9 Page 4 of 9 Akol et al. BMC Health Services Research (2018) 18:258 Page 4 of 9 study. All interviews were tape recorded after obtain- ing participants’ consent. mental ill-health among children and adolescents. Other causes mentioned by all traditional healers were ghosts, spirits and witchcraft, which are sent by enemies and encountered by people who walk outside the house at night, causing them to descend into mental illness. Pros- perous families were considered particularly prone to witchcraft from jealous people, leading to mental illness among children. Results Two main themes arise from the data: 1) Treating mental illness is cultural; and 2) Mistrust hampers collaboration. The theme “Treating mental illness is cultural” presents data on epistemologies of mental illness in children and adolescents; and on interactions between traditional healers and biomedical providers. “Mistrust hampers col- laboration” is categorized into two sub-themes: willingness to collaborate and barriers to collaboration. Traditional healers also ascribed mental ill-health to non-spiritual and non-social causes. All traditional healers implicated substance abuse as a cause of mental illness among adolescents. Substances mentioned were a local potent brew, waragi; narcotic drugs - enjaga; to- bacco and aviation fuel, taken singly or in combination. Most also cited high fever and cerebral malaria as a cause of mental disturbances in children. According to them, this category of mental illness was best treated in hospitals and clinics. Mixed explanations of mental illness We also found prevalent perceptions of mental suffer- ing being consequent to conflict between traditional cus- toms and modern ‘born again’ religions, as illustrated by this excerpt “…it happens very much especially to those people who have abandoned issues with traditions and opted for the religion of born again…” This conflict be- tween traditional and modern ‘born again’ religions was considered responsible in particular, for protracted In summary, three types of explanations for mental illness were found to be part of the epistemology of the traditional healer: Spiritual explanations including ancestors and neo-Pentecostal worship; social expla- nations including witchcraft and evil-eye, and physical Page 5 of 9 Akol et al. BMC Health Services Research (2018) 18:258 or natural agents like maggots, infections and sub- stance abuse. or natural agents like maggots, infections and sub- stance abuse. Despite great skepticism of the effectiveness of bio- medicine on mental illness, some traditional healers in- tegrate biomedical elements into their mental health treatment regime. One example is the traditional healer who professed to routine use of largactil® on violent patients who were brought to him, prior to administer- ing his herbal treatments: No interaction with the formal health system “There is one …in the main hospital who one time directed a man with his son to me for management, I hear they had gone to the hospital several times but the boy never got well… I worked on him and he became okay…”- Traditional healer 17, twenty years’ practice. No interaction with the formal health system “…nobody should deceive you that mental illness can be managed by hospitals….” Traditional healer 04, eight years’ practice “…nobody should deceive you that mental illness can be managed by hospitals….” Traditional healer 04, eight years’ practice “…I love using it because it really puts a person to sleep…I’m a traditional healer but I have found out that [largactil®] is a very effective drug when it comes to calming down the person with mental health disorders especially when they are violent...” – Traditional healer 02, forty-five years’ practice “…I love using it because it really puts a person to sleep…I’m a traditional healer but I have found out that [largactil®] is a very effective drug when it comes to calming down the person with mental health disorders especially when they are violent...” – Traditional healer 02, forty-five years’ practice Traditional healers’ interaction with clinicians was characterised by views about referral to and from health clinics, and by opinions about the competence of clinical practitioners. We found all traditional healers believed that traditional medicine is the only effective treatment for mental ill-health, due to the spiritual nature of the condition. Several traditional healers cited the inability of clinical providers to expel maggots from patients’ brains. The view that clinical practitioners are not competent to manage mental health conditions was unanimous. The reasons cited were that clinical practitioners do not comprehend spiritual matters and are poorly placed to treat conditions with a spiritual origin. It was widely acknowledged that they could manage conditions that arose from malaria and other fevers. To prove this point, many of the traditional healers cited examples of pa- tients who had been repeatedly treated at health clinics but only got better after visiting traditional healers. According to the traditional healers, the remedies pro- vided in clinics are temporary; the only lasting effect was believed to come from traditional healers. We found very little experience of referral from health clinics to traditional healers. Two participants reported such referral for mental ill-health, after re- peated treatments at the medical clinics had failed to make them better: “There is one …in the main hospital who one time directed a man with his son to me for management, I hear they had gone to the hospital several times but the boy never got well… I worked on him and he became okay…”- Traditional healer 17, twenty years’ practice. Mistrust hampers collaboration “I don’t see it happening easily because those doctors despise all our work. They regard it as satanic and dirty” – Traditional healer 09, eleven years’ practice. However, self-referrals were commonly reported, in which patients discharged themselves from health clinics to consult traditional healers. Although biomedicine was considered limited in ap- proach, addressing only the physical causes of disease, all informants had referred patients to biomedical clinics. The commonly cited reasons for referral were for rehydration, or for blood transfusion. Others referred patients whom they deemed to have biomedical condi- tions, particularly malaria, which they were not well suited to manage. One older, more experienced trad- itional healer mentioned that it was his policy to treat a patient thrice only, following which he would refer to medical clinics. However, such referrals were reportedly not well received by clinicians, if it was known that the patient had consulted a traditional healer: Even if nearly all traditional healers expressed willing- ness to collaborate with clinicians in alleviating mental suffering in children and adolescents, their willingness was conditional on clinicians’ reciprocating this good- will, which was considered unlikely. All the participants believed that clinical providers are not willing to collab- orate with traditional healers as they consider them dirty, unsanitary and of a lower education status: “You know they regard us as …illiterate and of low class…they regard themselves as people of high class…” – Traditional healer 02, forty-five years’ practice “You know they regard us as …illiterate and of low class…they regard themselves as people of high class…” – Traditional healer 02, forty-five years’ practice “You know they regard us as …illiterate and of low class…they regard themselves as people of high class…” – Traditional healer 02, forty-five years’ practice “One time I referred a child to Mbale Hospital after I had smeared herbs on the child. On arrival, the doctors chased the patient away accusing them of being dirty…I always send patients to them for management, but for them they have never done so.” Traditional healer 10, ten years’ practice Different from their views on clinicians, we found the traditional healers unanimous in their conviction that patients would welcome their collaboration with the for- mal health system. According to the traditional healers, all patients needed was to get well, so it did not matter through which means they received treatment. They also Page 6 of 9 Page 6 of 9 Akol et al. BMC Health Services Research (2018) 18:258 argued that patients would cease to consult them in se- crecy once collaboration was implemented. “What I see is that the formal health worker will only take our ideas and use them, therefore, this will only benefit them by them getting more money and traditional healers will not benefit at all.” – Traditional healer 13, twenty-seven years’ practice “What I see is that the formal health worker will only take our ideas and use them, therefore, this will only benefit them by them getting more money and traditional healers will not benefit at all.” – Traditional healer 13, twenty-seven years’ practice “I see that they will be happy for the collaboration because they will no longer come to the traditional healers in hiding as they do now. They will consult us openly as they do with the clinics” – Traditional healer 12, ten years’ practice. “I see that they will be happy for the collaboration because they will no longer come to the traditional healers in hiding as they do now. They will consult us openly as they do with the clinics” – Traditional healer 12, ten years’ practice. To eliminate barriers, necessary conditions for collab- oration were described. Most of the traditional healers mentioned the government as needing to take a lead in integrating them with formal health systems, without which collaboration wouldn’t be possible. “…If a law is put in place then they will accept.”- Traditional healer 6, fourteen years’ practice “What I would like to tell you is that a real traditional healer does not advertise him / herself over the radio or TV, so once you see one doing this, then know that this person is incompetent in his work…you know there is a lot of joblessness in Uganda, so we have so many who call themselves that they are traditional healers, when they are not, they are simply looking money so that they are able to put food on the table.” – Traditional healer 07, thirty-four years’ practice. Alongside laws and policies, increased recognition by government, sensitisation of communities, traditional healers and medical providers was cited as a necessary condition for successful collaboration. “You know they regard us as …illiterate and of low class…they regard themselves as people of high class…” – Traditional healer 02, forty-five years’ practice The required government intervention mostly suggested was a law or policy recognising traditional healers and compelling clinicians to collaborate with traditional healers; We found several perceived barriers to collaboration among the traditional healers. Some of the barriers such as the competence of peers were intrinsic to the trad- itional healers themselves. Traditional healers viewed their peers who are not ‘specialized’ in mental illness as largely being incompetent for handling CAMH and mental ill-health in general. Advertisement in news media was viewed as a sign of incompetence. It was widely held that competent traditional healers need no advertisement to enhance their reputation; Competence was thought to increase with experience and years of practice. “Once government makes a policy for us to be recognized as formal health workers things will just fall in place”- Traditional healer 15, thirty-seven years’ practice “…If a law is put in place then they will accept.”- Traditional healer 6, fourteen years’ practice “…If a law is put in place then they will accept.”- Traditional healer 6, fourteen years’ practice Discussion What hasn’t been widely reported, however, is the cross- over between biomedical and traditional treatments, exemplified in the present study by the traditional healer who routinely uses largactil®, a brand name for chlorpro- mazine. The use of biomedical remedies by traditional healers reinforces the notion that epistemologies are not clear cut – one sector of health care may borrow technologies from another. It also further highlights Kleinman’s conceptual overlap between the professional and folk sectors of care. As suggested by Kleinman therefore, this overlap is one that can be explored in enhancing collaboration between the two sectors. by other studies in Uganda and elsewhere [19, 29, 30]. What hasn’t been widely reported, however, is the cross- over between biomedical and traditional treatments, exemplified in the present study by the traditional healer who routinely uses largactil®, a brand name for chlorpro- mazine. The use of biomedical remedies by traditional healers reinforces the notion that epistemologies are not clear cut – one sector of health care may borrow technologies from another. It also further highlights Kleinman’s conceptual overlap between the professional and folk sectors of care. As suggested by Kleinman therefore, this overlap is one that can be explored in enhancing collaboration between the two sectors. spiritual matters. This finding is in sharp contrast to their belief that clinicians regard them as inferior; and suggests that adoption of biomedical explanatory models, treat- ments and remedies by traditional healers is as unlikely as the adoption of traditional models by clinicians might be. At first look this would appear to raise a conflict that would constrain collaboration. However, viewed in light of the different sub-sectors of health care sug- gested by Kleinman [17, 18], this finding reinforces the need for a collaborative model, in which the rela- tive competencies of the different sub sectors are rec- ognized and respected. Traditional healers perceive their devaluation by bio- medical providers as a hindrance to collaboration. On the other hand, traditional healers also tend to devalue doctors’ CAMH epistemologies, even as they borrow certain treatments from the biomedical sector. This sug- gests that traditional healers, whilst professing superior knowledge, find value in biomedical sector therapies. This contradiction is one that appears to mask a willing- ness to collaborate more with biomedical providers. In fact, willingness to collaborate has been documented elsewhere [15, 34, 35]. Discussion The fact that willingness in this study is conditional on traditional healers’ contributions not being overshadowed by the clinical providers sug- gests strongly that an element of competition exists between the two categories of provider. Competition is counter to the Explanatory Models of Illness theory which is more collaborative than competitive. It is worth noting that whereas the traditional healers’ attitude to biomedical epistemologies is dismissive, clinicians are perceived as less of a threat than ‘neo-Pentecostalism’. As in this study, Van Niekerk et al., (2014) reported a low level of referral from clinical practitioners to trad- itional healers in South Africa. Likewise, Musyimi et al., (2016) found that traditional healers in Kenya had no ex- perience of referral from clinical practitioners [15, 31]. In keeping with Kleinman’s theory [17], the most preva- lent referrals found are self- referrals. Patients appear to use the traditional and biomedical sectors interchange- ably, possibly depending on factors that may include access and illness interpretation. p The low levels of referral between traditional healers and clinicians could be related to the lack of mutual trust between traditional healers and clinical practi- tioners found in this study. As noted, trust is a pre- requisite for successful collaboration between health care managers and practitioners [16, 32, 33]. In this study, the mistrust is limited to mental health condi- tions, exemplified by the non-mental health referrals being made. Lack of trust for mental health services has been found elsewhere [15, 34], and is justified by recent findings from sub Saharan Africa that confirm clinicians’ perception of traditional healers as dirty and unprofes- sional [15, 34, 35]. Suggested ways of addressing this negativity is creating means for dialogue between trad- itional healers and clinical providers, which has been successful in Kenya (30). Specifically, the health system needs to address the negativity with which patients referred from traditional healers are received at biomed- ical clinics. Trust of other traditional healers is also poor, and may seem surprising until one considers the high mean age of 53 in this sample; older, more experienced traditional healers whose reputation is based on years of practice could be wary of younger healers who advertise their services and charge exorbitantly for their services, jeopardizing the quality of their occupation. However, this finding suggests too that traditional healers are not homogenous, and potential for competition exists along- side potential for collaboration. Discussion The main findings of the study were: 1) Epistemologies of mental illness in children and adolescents are shared by traditional healers; 2) traditional healers have limited interactions with the biomedical health system for mental illness; and 3) traditional healers’ willingness to collaborate with biomedical providers is hampered by mistrust. Whereas previous studies [21, 27] have ad- dressed traditional healers’ views on help-seeking behav- iour and have characterised mental health conditions and outcomes, this is the first study in Uganda that has explored the views of CAMH-experienced traditional healers on their integration with formal health systems. Another intrinsic barrier perceived by the traditional healers is their lack of English language knowledge. According to the traditional healers, clinical providers would use English language as a means for excluding the less educated traditional healers “The barrier I foresee…our counterparts the doctors want always to use English so as to push us away…I see that as a problem” – Traditional healer 07, thirty- four years’ practice. In line with the classical Explanatory Models theory proposed by Kleinman, the epistemological view of men- tal illness among traditional healers was tinged by their belief systems. Specifically, their reliance on spiritual and supernatural explanations of mental disorders is in line with their identity as traditional healers. This has been found in other studies as well [28]. Nevertheless, some causes of CAMH illness they identified, namely substance abuse and fevers, are shared by biomedical practitioners, illustrating the intersection between the traditional and professional sectors of CAMH care. We found that traditional healers did not trust bio- medical practitioners. In addition to the belief that medical providers viewed them negatively, most trad- itional healers thought that clinicians would extract knowledge from the traditional healers and use it for their own credit. “Working with them is not easy because they don’t like us at all, we are like co-wives who don’t like each other and share one man…” – Traditional healer 18, fifty years’ practice That traditional healers are engaged in managing CAMH cases is unsurprising and has been documented Page 7 of 9 Page 7 of 9 Page 7 of 9 Akol et al. BMC Health Services Research (2018) 18:258 by other studies in Uganda and elsewhere [19, 29, 30]. Discussion The results of this study have several implications for improving access to CAMH services through traditional healers’ collaboration with clinical mental health sys- tems. First, advocates for collaboration should consider the different explanatory models existent among the two categories of provider; and find mutually acceptable ways to stimulate collaboration, recognising that the two cat- egories have a complementary role to play in stimulating access to CAMH services. This should involve, among others, improving clinicians’ acceptance of traditional healers’ explanatory models for illness; and vice versa. Secondly, trust between the two categories of provider needs to be enhanced to improve interaction between the two sectors, which currently operate in isolation. In particular, the perceived negativity by clinicians of trad- itional healers needs to be addressed. Thirdly, quality of care by traditional healers needs to be addressed to improve hygiene and eliminate unethical practices like extortion of money from clients. These could form suggestions for inclusion in policy suggested by trad- itional healers to guide collaboration between the two sectors of care. In this study, traditional healers believe themselves to be superior to biomedical providers in treating CAMH disor- ders, as biomedical providers possess no understanding of Page 8 of 9 Page 8 of 9 Akol et al. BMC Health Services Research (2018) 18:258 Page 8 of 9 Some strengths of this study are recognised. The use of a purposive sample of traditional healers with CAMH experiences provides experience-based views. Thus, we believe that these views are transferable to all traditional healers with CAMH experience in Uganda considering that the health system and policy context is uniform across the country. Also, given that traditional healers believe they are disliked by clinicians, conducting inter- views at traditional healers’ place of work and the use of a non-medical interviewer probably improved the trad- itional healers’ ability to express their views freely. As limitations, we note that clinicians’ views were not sought to validate traditional healers’ impressions; how- ever, the aim of this study was to explore CAMH ser- vices from the traditional healers’ perspective. Secondly, we recognize that the reliance on a single coder, and the direct translation of interviews into English during transcription could have introduced a bias resulting from the coder’s and transcriber’s own interpretation of the data; and threatened linguistic equivalence since back-translation of local language transcripts was not done. References 1. Patel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young people: a global public-health challenge. Lancet. 2007;369(9569):1302–13. 1. Patel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young people: a global public-health challenge. Lancet. 2007;369(9569):1302–13. 2. World Health Organization. The World Health Report 2001: Mental health: new understanding, new hope. World Health Organization; 2001. 3. World Health Organization, World Psychiatric Association, International Association for Child, Adolescent Psychiatry, Allied Professions. Atlas: child and adolescent mental health resources: global concerns, implications for the future. World Health Organization; 2005. g 4. Votruba N, Eaton J, Prince M, et al. The importance of global mental health for the Sustainable Development Goals. J Ment Health. 2014;23:283-6. 5. Becker AE, Kleinman A. Mental health and the global agenda. N Engl J Med ( ) 4. Votruba N, Eaton J, Prince M, et al. The importance of global mental health for the Sustainable Development Goals. J Ment Health. 2014;23:283-6. , , , p g for the Sustainable Development Goals. J Ment Health. 2014;23:283-6. 5. Becker AE, Kleinman A. Mental health and the global agenda. N Engl J Med. 2013;369(1):66–73. p 5. Becker AE, Kleinman A. Mental health and the global agenda. N Engl J Med. 2013;369(1):66–73. Funding This study was made possible by funding from the Norwegian Research Council RCN #220887 ‘SeeTheChild – Mental Child Health in Uganda’ study and from Lanekassen, the Norwegian state loan fund. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests Th h d l h The authors declare that they have no competing interests. Abbreviations CAMH: Child and Adolescent Mental Health; LMIC: Low- and Middle-Income Countries; MNS: Mental, Neurological and Substance Use; PHC: Primary Health Care; PI: Principal Investigator; THETA: Traditional and Modern Health Practitioners Together Against AIDS; WHO: World Health Organisation 10. Wreford J. Missing each other: problems and potential for collaborative efforts between biomedicine and traditional healers in South Africa in the time of AIDS. Soc Dyn. 2005;31(2):55–89. 11. World Health Organization. WHO traditional medicine strategy 2014–2023. Geneva: World Health Organization; 2013. p. 2015. 12. World Health Organization. Mental health action plan 2013–20 Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Availability of data and materials The datasets analysed during the current study are available from the corresponding author on reasonable request. Authors’ contributions AA, IMSE and KMM contributed to the conception and design of the study. AA coded the data, led the analysis and interpretation of the data; and drafting the paper. IMSE, KMM and JNB drafted sections of the manuscript. All authors approved the final manuscript Additional file 6. Patel V, Goel DS, Desai R. Scaling up services for mental and neurological disorders in low-resource settings. Int Health. 2009;1(1):37–44. g 7. Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet. 2007;370(9594):1241–52. 8. Van Lerberghe W. The world health report 2008: primary health care: now h W ld H l h O i i 2008 7. Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet. 2007;370(9594):1241–52. Additional file 1: In-depth Interview guide: A semi-structured question guide to facilitate interviews with traditional healers. (DOCX 16 kb) a call for action. Lancet. 2007;370(9594):1241–52. 8. Van Lerberghe W. The world health report 2008: primary health care: now more than ever. World Health Organization; 2008. 8. Van Lerberghe W. The world health report 2008: primary health care: now more than ever. World Health Organization; 2008. 9. Cooper S. Research on help-seeking for mental illness in Africa: dominant approaches and possible alternatives. Transcult Psychiatry. 2016;53(6):696–718. Discussion Thirdly, the absence of the PI at inter- views might have limited deeper enquiry into the sub- ject matter as the data were collected. Conclusion These findings show that potential for collaboration between traditional healers and biomedical health sys- tems for improving access to CAMH in Uganda exists, based on shared epistemologies and technologies; and patients’ movement across the two sectors. However this potential is undermined by the prevailing mutual mis- trust and competition between traditional healers and clinicians. The findings highlight the need for implemen- tation of strategies that harness the complementarity of traditional and biomedical sectors of mental health care as a means of improving access to CAMH services. Received: 12 October 2016 Accepted: 27 March 2018 Ethics approval and consent to participate The study received approval from the Makerere School of Public Health Institutional Review Board and from the Uganda National Council for Science and Technology under research registration number HS 1874. Prior to the interviews individual traditional healers provided signed written informed consent, improvised with a thumbprint for those who were not able to write. Akol et al. BMC Health Services Research (2018) 18:258 Akol et al. BMC Health Services Research (2018) 18:258 faith healers in the provision of mental health care in Ghana. Int Rev Psychiatry. 2010;22(6):558–67. faith healers in the provision of mental health care in Ghana. Int Rev Psychiatry. 2010;22(6):558–67. 15. Musyimi CW, Mutiso VN, Nandoya ES, Ndetei DM. Forming a joint dialogue among faith healers, traditional healers and formal health workers in mental health in a Kenyan setting: towards common grounds. J Ethnobiol Ethnomed. 2016;12(1):1. 16. Gilson L. Trust and the development of health care as a social institution. Soc Sci Med. 2003;56(7):1453–68. 17. Kleinman A. Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. Univ of California Press; 1980. 18. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88(2):251–8. 19. Patel V. Traditional healers for mental health care in Africa. Action. 2011;4 https://doi.org/10.3402/gha.v4i0.7956. 20. Burns JK, Tomita A. Traditional and religious healers in the pathway to care for people with mental disorders in Africa: a systematic review and meta- analysis. Soc Psychiatry Psychiatr Epidemiol. 2015;50(6):867–77. 21. Abbo C. Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of eastern Uganda. Glob Health Action. 2011;4 https://doi.org/10.3402/gha.v4i0.7117. 22. Sorketti EA, Zainal NZ, Habil MH. The treatment outcome of psychotic disorders by traditional healers in Central Sudan. Int J Soc Psychiatry. 2013; 59(4):365–76. 23. Shibre T, Spångéus A, Henriksson L, Negash A, Jacobsson L. Traditional treatment of mental disorders in rural Ethiopia. Ethiop Med J. 2008;46(1):87–91 24. Abdullahi AA. Trends and challenges of traditional medicine in Africa. African journal of traditional, complementary, and alternative medicines. Afr J Tradit Complement Altern Med. 2011;8(5 Suppl):115. 25. Kasilo O, Trapsida J, Mwikisa C, Lusamba-Dikassa P. An overview of the traditional medicine situation in the African region. The African health monitor, magazine of the World Health Organization regional Office for Africa (WHOAFRO). 2010. 26. Guest G. How many interviews are enough?: an experiment with data saturation and variability. Field Methods. 2006;18(1):59–82. 27. Nsereko JR, Kizza D, Kigozi F, Ssebunnya J, Ndyanabangi S, Flisher AJ, et al. Stakeholder's perceptions of help-seeking behaviour among people with mental health problems in Uganda. Int J Ment Heal Syst. 2011;5(1):1. 28. van Duijl M, Kleijn W, de Jong J. Akol et al. BMC Health Services Research (2018) 18:258 Akol et al. BMC Health Services Research (2018) 18:258 Unravelling the spirits’ message: a study of help-seeking steps and explanatory models among patients suffering from spirit possession in Uganda. Int J Ment Heal Syst. 2014;8(1):1. 29. Abera M, Robbins JM, Tesfaye M. Parents’ perception of child and adolescent mental health problems and their choice of treatment option in Southwest Ethiopia. J Child Adolesc Psychiatr Ment Health Nurs. 2015;9(1):1–11. 30. Bakare M. Pathway to care: first points of contact and sources of referral among children and adolescent patients seen at neuropsychiatric Hospital in South-Eastern Nigeria. Niger J Med. 2013;22(1):52–6. 31. Van Niekerk M, Dladla A, Gumbi N, Monareng L, Thwala W. Perceptions of the traditional health Practitioner's role in the management of mental health care users and occupation: a pilot study. S Afr J Occup Ther. 2014; 44(1):20–4. 32. Illingworth P. Trust: the scarcest of medical resources. J Med Philos. 2002; 27(1):31–46. 33. Brown PR, Calnan MW. Chains of (dis) trust: exploring the underpinnings of knowledge‐sharing and quality care across mental health services. Sociology of health & illness. 2016;38(2):286-305. 34. Sorsdahl K, Stein D, Flisher A. Predicting referral practices of traditional healers of their patients with a mental illness: an application of the theory of planned behaviour. Afr J Psychiatry. 2013;16(1):35–40. Submit your next manuscript to BioMed Central and we will help you at every step: Acknowledgements 13. World Health Organization. Mental health atlas 2014: World Health Organization; 2015. 13. World Health Organization. Mental health atlas 2014: World Health Organization; 2015. We acknowledge the contributions of the organization Traditional and Modern Health Practitioners Together Against AIDS (THETA) in enabling access to traditional healers. The study participants are appreciated for their willingness to share their views and experiences. 14. Ae-Ngibise K, Cooper S, Adiibokah E, Akpalu B, Lund C, Doku V, et al. ‘Whether you like it or not people with mental problems are going to go to them’: a qualitative exploration into the widespread use of traditional and 14. Ae-Ngibise K, Cooper S, Adiibokah E, Akpalu B, Lund C, Doku V, et al. ‘Whether you like it or not people with mental problems are going to go to them’: a qualitative exploration into the widespread use of traditional and Page 9 of 9 Submit your next manuscript to BioMed Central and we will help you at every step: Submit your next manuscript to BioMed Central and we will help you at every step: • We accept pre-submission inquiries • Our selector tool helps you to ﬁnd the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit and we will help you at every step: 35. Campbell-Hall V, Petersen I, Bhana A, Mjadu S, Hosegood V, Flisher AJ, et al. Collaboration between traditional practitioners and primary health care staff in South Africa: developing a workable partnership for community mental health services. Transcult Psychiatry. 2010;47(4):610–28.
https://openalex.org/W4238970678	https://www.qeios.com/read/7UAOI7/pdf	English	null	Microneedle Drug Delivery System	Definitions	2,020	cc-by	79	Qeios · Definition, February 2, 2020 Open Peer Review on Qeios Open Peer Review on Qeios Microneedle Drug Delivery System National Cancer Institute Qeios ID: 7UAOI7 · https://doi.org/10.32388/7UAOI7 Source National Cancer Institute. Microneedle Drug Delivery System. NCI Thesaurus. Code C156666. A drug delivery device consisting of an adhesive-like patch covered with solid or hollow projections (microneedles), usually ranging in length from 50 to 900 micrometers, designed to deliver therapeutic agents through the skin. Qeios ID: 7UAOI7 · https://doi.org/10.32388/7UAOI7 1/1
https://openalex.org/W4232460432	https://zenodo.org/record/1550658/files/article.pdf	English	null	METEOROLOGICAL OBSERVATIONS AT THE UNIVERSITY OF CALIFORNIA	Monthly weather review	1,913	public-domain	800	ANN ARBoR Electrical Machine Design. By ALEXANDER GRAY. McGraw Hill Book Company. " Electrical Machine Design," by Alexander Gray, discusses the theory of operation and design of direct current generators and motors of both interpole and non-interpole type, alter- nating current generators, induction motors and transformers. Five hundred and seven pages are not enough to cover such a range of subjects satisfactorily, and when the analysis of theory is carried to the extent attempted by Mr. Gray the result can not be a success. Considered as a text-book, it would be un- suited to the average fourth-year student, not because the analyses are too involved for such. but because their introductions are too brief. The calculation of temperature gradient may be taken as an example. If a few paragraphs had been inserted discussing the laws govern- ing flow of heat, and containing perhaps a simple application, the subsequent treatment would have been much more easily under- stood. The same criticism is applicable to the chapter on armature reactions in alternators. Considered as a book for reference pur- poses, this work contains much matter of value, both to the student and to the designer. Discussions of sueh questions as noise of in- duction motors, comparative value of shell and core type transformers, short pitch windings The book compares favorably with the other books on design in our language, but when it is contrasted with the simple and extremely logical treatments to be found in the works of Arnold, its own shortcomings are most ap- parent. C. W. GREEN C. W. GREEN SCIENCE SCIENCE 800 [N. S. VOL. XXXVII. No. 960 [N. S. VOL. XXXVII. No. 960 uncle, but not till after his classical "Rap- port" (of 1867, not 1868, as on pp. 201, 234, 426); quite rightly, he is always referred to in the text by his paternal name, without the later addition, and should be so noted in the index. Under "Schiller" philosophy has been substituted for history. "LuEnesidemus " is correctly printed under " Schulze, G. E.i" in- correctly on p. i of the index. Under "Ueber- weg," T. M. should be substituted for J. M. Lindsay; and " Taylor " should read Tayler. The caption " Cause and effect defined" should be thoroughly revised and extended. There are several references in the text of far greater importance than the single one re- corded in the index. uncle, but not till after his classical "Rap- port" (of 1867, not 1868, as on pp. 201, 234, 426); quite rightly, he is always referred to in the text by his paternal name, without the later addition, and should be so noted in the index. Under "Schiller" philosophy has been substituted for history. "LuEnesidemus " is correctly printed under " Schulze, G. E.i" in- correctly on p. i of the index. Under "Ueber- weg," T. M. should be substituted for J. M. Lindsay; and " Taylor " should read Tayler. The caption " Cause and effect defined" should be thoroughly revised and extended. There are several references in the text of far greater importance than the single one re- corded in the index. in direct current machines, are really valuable and are not to be found readily elsewhere. The subjects of commutation and insulation are very well developed. The arrangement of subject matter is usu- ally excellent. The treatment of the induction motor had better have followed that of the transformer instead of preceding it. Such an arrangement would have made possible the consideration of the induction motor as a transformer, a most practical and effective method. The theory of operation and con- struction of each type of apparatus is first de- veloped. This is followed by the procedure in design, the discussion of special types of ma- chines, and a chapter on specifications. Ex- amples accompany the text and should aid the student materially in his comprehension of the subject. R. M. WENLEY METEOBOLOGICAL OBSERVATIONS AT THE UNIVERSITY OF CALIFORNIA IT is probably due to the fact that the public interest in meteorology is centered around weather forecasts that the science has re- ceived so little attention from the universities of the United States. The University of Cali- fornia is one of the relatively small number which has maintained a regular series of obser- vations for a considerable period. p Until July 1, 1912, when the routine meteor- ological work at Berkeley was transferred to the department of geography under which the courses in meteorology and climatology are listed, the astronomy departments, the Lick Observatory at Mount Hamilton and the Stu- dents' Observatory at Berkeley, carried on the principal meteorological observations of the university. Meteorological observations have always been a part of the regular work of the Lick Observatory and, when the Students' Ob- servatory was established at Berkeley. its ac-
https://openalex.org/W4237845112	http://jurnal.unpad.ac.id/jmi/article/download/18543/pdf	Indonesian	null	Klasifikasi Status Kinerja Bank yang Terdaftar di BEI dengan Pendekatan Winsorized Modified One-step M-estimator	Jurnal matematika integratif/Jurnal Matematika Integratif	2,019	cc-by-sa	4,058	2000 Mathematics Subject Classiﬁcation: 47N30 Received: 2018-09-03, accepted: 2019-01-08 p-ISSN:1412-6184, e-ISSN:2549-903 doi:10.24198/jmi.v14.n2.2018.135-142 p-ISSN:1412-6184, e-ISSN:2549-903 doi:10.24198/jmi.v14.n2.2018.135-142 Jurnal Matematika Integratif. Vol. 14, No. 2 (2018), pp. 135–142. Keywords :Robust Linear Discriminant Analysis, Normality, Homoscedasticity, Ro- bust, outlier, winsorized modiﬁed one-step M-estimator. Abstract Assessment of the performance of a bank with ﬁnancial statement anal- ysis is not eﬃcient for the supervisory (BI, community or investor), because the analysis of ﬁnancial statements can only assess banks indi- vidually. Therefore, it is necessary to classify the performance status of banks that can assess banks simultaneously. The data used for classiﬁ- cation is the ﬁnancial report data of each bank listed on the IDX. Simul- taneous assessment can bring out extreme data ( outliers), because there are diﬀerences in operational capabilities between reputable banks and not. The method used for classiﬁcation of bank performance status is linear discriminant analysis. Discriminant analysis must ﬁll normal as- sumptions (normality) and similarities in the variance-covariance ma- trix (homoscedasticity), but this method is very sensitive to data con- taining outliers so that they do not meet assumptions. Robust linear dis- criminant analysis using the winsorized modiﬁed one-step M-estimator approach is a method that can overcome data outliers and assumptions are not fulﬁlled. The results obtained are two robust linear discriminant functions, where all independent variables have a positive inﬂuence that can increase the discriminant score. Both functions are used to classify the performance status of banks listed on the IDX with an opportunity of errors of 34,72 1. Pendahuluan Abstrak Penilaian kinerja suatu bank dengan analisis laporan keuangan tidaklah eﬁsien bagi pihak pengawas (BI, masyarakat atau investor), karena analisis laporan keuangan hanya dapat menilai bank secara perseorangan. Oleh karena itu, perlu adanya klasiﬁkasi status kinerja bank yang dapat menilai bank termasuk berstatus kin- erja baik atau tidak secara bersamaan. Data yang digunakan untuk klasiﬁkasi adalah data laporan keuangan setiap bank yang terdaftar di BEI. Penilaian secara bersamaan memungkinkan munculnya data ekstrim (outlier), karena ada perbedaan kemampuan operasional antara bank ternama dan tidak. Metode yang digunakan untuk klasiﬁkasi status kinerja bank adalah analisis diskriminan linear. Analisis diskriminan harus memenuhi asumsi kenormalan (normalitas) dan kesamaan ma- triks varians-kovarians (homoskedastisitas), namun metode ini sangat sensitif ter- hadap data yang mengandung outlier sehingga tidak memenuhi asumsi. Anali- sis diskriminan linear robust dengan pendekatan winsorized modiﬁed one-step M- estimator merupakan metode yang dapat mengatasi data outlier dan tidak ter- penuhinya asumsi. Hasil yang diperoleh adalah dua buah fungsi diskriminan liner robust, dimana semua variabel bebas mempunyai pengaruh positif yang dapat meningkatkan skor diskriminan. Kedua fungsi digunakan untuk klasiﬁkasi status kinerja bank yang terdaftar di BEI dengan ketepatan sebesar 65,28%. Berdasarkan perhitungan presss Q fungsi diskriminan robust yang terbentuk memiliki hasil yang akurat dan stabil. Kata kunci: Analisis diskriminan linear robust, Normalitas, Homoskedastisitas, out- lier, winsorized modiﬁed one-step M-estimator. 135 136 Authors, JMI Vol 14 No 2, Oktober 2018, pp. 135-142,doi:10.24198/jmi.v14.n2.2018.135-142 1. Pendahuluan Pasal 29 Undang-Undang No. 10 tahun 1998 menyatakan bahwa mengingat bank bekerja dengan dana dari masyarakat yang disimpan pada bank atas dasar kepercayaan, setiap bank perlu terus menjaga kesehatannya dan memelihara kepercayaan masyarakat padanya [1]. Upaya suatu bank untuk menjaga kesehatannya dilakukan dengan menilai atau memprediksi kinerja bank tersebut dengan menggunakan analisis laporan keuangan. Pada dasarnya, analisis lapo- ran keuangan hanya mampu menilai kinerja pada satu bank saja, sehingga bank tidak dapat membandingkan posisi dengan bank lainnya. Selain itu, bagi pihak pengawas (Bank Indonesia, masyarakat, dan investor) cara ini tidak cukup efektif. Oleh karena itu, perlu adanya prediksi status kinerja untuk setiap bank yang dapat dijadikan sebagai bahan evaluasi oleh bank untuk terus meningkatkan kinerjanya. Hal tersebut juga dapat dijadikan acuan masyarakat untuk menaruh kepercayaan kepada bank yang tepat serta dijadikan acuan untuk pihak pengawas dalam menilai kinerja suatu bank. Memprediksi status kinerja bank sama dengan menen- tukan klasiﬁkasi individu ke dalam suatu kelompok. Salah satu metode yang digunakan untuk mengklasiﬁkasi individu ke dalam salah satu kelompok dari dua kelompok atau lebih adalah analisis diskriminan [1]. Analisis diskriminan yang sering digunakan adalah analisis diskrimi- nan linear. Pada analisis diskriminan linear harus memenuhi dua asumsi, yaitu variabel bebas berdistribusi normal multivariat, matriks varians-kovarians dari kedua kelompok data yang diamati homogen. Analisis diskriminan klasik (linear dan kuadrartik) tidak dapat bekerja den- gan baik jika data yang dianalisis mengandung outlier [8]. [5] juga menuliskan bahwa analisis diskriminan sangat sensitif terhadap ketidaknormalan dan/atau heteroskedastisitas. Adanya outlier, ketidaknormalan dan heteroskedastisitas berpengaruh pada keakuratan hasil pengklasi- ﬁkasian analisis diskriminan. Agar analisis diskriminan tetap optimal meskipun dalam kondisi tersebut, maka diperlukan suatu penaksir yang robust. Analisis diskriminan yang menggu- nakan penaksir robust selanjutnya disebut sebagai analisis diskriminan robust. Sharipah, et. al (2016) memperkenalkan metode baru yang dapat mengatasi keduanya untuk mengklasiﬁkasi Klasiﬁkasi Status Kinerja Bank yang Terdaftar di BEI 137 kebangkrutan bank yang ada di Malaysia. Pada penelitian ini, penulis mengklasiﬁkasi status kinerja bank yang terdaftar di Bursa Efek Indonesia (BEI) menggunakan analisis diskriminan linear robust dengan pendekatan winsorized modiﬁed one-step M-estimator (WMOM) [11] den- gan bantuan aplikasi Maple 15. Metode ini akan membentuk fungsi diskriminan linear robust yang digunakan sebagai dasar klasiﬁkasi status kinerja bank. 2. Metode Penelitian Untuk menganalisis data dengan analisis diskriminan linear haruslah dilakukan pengujian asumsi terhadap kenormalan, kesamaan matriks varians-kovarians dan keberadaan outlier. Hal ini dilakukan untuk menentukan apakah metode yang akan digunakan adalah analisis diskrim- inan linear klasik atau robust. 2.1. Uji Kenormalan Multivariat. Menurut Johnson dan Wichern (2002), pada beberapa analisis di multivariat, biasanya diasumsikan bahwa variabel independen harus berdistribusi normal. Ada beberapa metode untuk menguji kenormalan multivariat salah satunya adalah mencari nilai jarak mahalanobis (jarak kuadrat) untuk setiap observasi. Jarak mahalanobis dihitung dengan: d2 i(R) = X(R) −¯X(R)T S−1 X(R) −¯X(R) (1) (1) Kenormalan multivariat diperoleh dengan menghitung nilai korelasi Pearson untuk melihat hubungan linear antara d2 z dengan χp(gz) · χp(gz) adalah nilai Chi-Kuadrat dengan gz = (z−0,5) n dan derajat kebebasan (dk) = p, dimana Kenormalan multivariat diperoleh dengan menghitung nilai korelasi Pearson untuk melihat hubungan linear antara d2 z dengan χp(gz) · χp(gz) adalah nilai Chi-Kuadrat dengan gz = (z−0,5) n dan derajat kebebasan (dk) = p, dimana d2 i(R) : nilai jarak mahalanobis untuk setiap observasi ke-i dari kelompok ke- R, i = 1, 2, ..., n ( ) ¯X(R) : matriks vektor rata-rata variabel yang ke-k dari kelompok ke-R(i × p) g S−1 gab : kebalikan (inverse) matriks varians-kovarians Sgab(p × p). g Jika terdapat hubungan linear antara jarak mahalanobis dengan Chi-Kuadrat maka terpenuhinya asumsi kenormalan 2.2. Uji Kesamaan Matriks Varians-Kovarians. Kesamaan matriks varians-kovarians meru- pakan salah satu asumsi yang harus dipenuhi pada analisis diskriminan linear. Untuk menguji kesamaan matriks varians-kovarians (P) antar kelompok, digunakan hipotesis: [10] 2.2. Uji Kesamaan Matriks Varians-Kovarians. Kesamaan matriks varians-kovarians meru- pakan salah satu asumsi yang harus dipenuhi pada analisis diskriminan linear. Untuk menguji kesamaan matriks varians-kovarians (P) antar kelompok, digunakan hipotesis: [10] H0 : P 1 = P 2 = · · · = P r (matriks varians-kovarians untuk semua kelompok sama) H S dikit d t k l k t ik i k i b b d (P) g [ ] H0 : P 1 = P 2 = · · · = P r (matriks varians-kovarians untuk semua kelompok sama) H1 : Sedikitnya ada satu kelompok yang matriks varians-kovariansnya berbeda Uji kesamaan matriks varians-kovarians dihitung dengan statistik BoxM yaitu: lnM = 1 2 r X R=1 V (R)ln S(R) −1 2 r X R=1 V (R) ! 2. Metode Penelitian ln \|Sgab\| (2) (2) lnM dapat didekati dengan distribusi F dengan aturan sebagai berikut: Jika C2 > C2 1 ,maka Fh = −2u1lnM lnM dapat didekati dengan distribusi F dengan aturan sebagai berikut: Jika C2 > C2 1 ,maka Fh = −2u1lnM p Fh = −2u1lnM Jika C2 < C2 1 maka Fh = − 2a2u1lnM a1(1+2u2lnM) dengan nilai a1, a2, u1, u2, C1, C2 sebagai berikut: Jika C2 < C2 1 maka Fh = − 2a2u1lnM a1(1+2u2lnM) dengan nilai a1, a2, u1, u2, C1, C2 sebagai berikut: C1 =    r X R=1 1 V (R) 2 − 1 Pr R=1 V (R) 22    2p2 + 3p −1 6(p + 1)(r −1) ! (3) C2 = (p −1)(p + 2 6(r −1)    r X R=1 1 V (R) 2 − 1 Pr R=1 V (R) 22    (4) a1 = 1 2(r −1)p(p + 1) (5) (3) (4) a1 = 1 2(r −1)p(p + 1) (5) (5) 138 Authors, JMI Vol 14 No 2, Oktober 2018, pp. 135-142,doi:10.24198/jmi.v14.n2.2018.135-142 a2 = a1 + 2 \|C2 −C2 1\| (6) u1 = 1 −C1 −a1/a2 a1 (7) u2 = 1 −C1 + 2/a2 a2 (8) (6) (7) (8) Apabila Fh < F(a1,a2,α) maka H0 diterima dan dapat dinyatakan bahwa semua kelompok mempunyai matriks varians-kovarians yang sama. Sebaliknya bila Fh > F(a1,a2,α) maka H0 ditolak. 2.3. Pendeteksian outlier. Menurut Gimnez et al. (2012), pendekatan klasik untuk mende- teksi adanya outlier adalah dengan menghitung jarak mahalanobis dari masing-masing penga- matan. Jarak mahalanobis dideﬁnisikan pada persamaan (1). Jika nilai d2 i(R) > χp(1−α) maka data observasi ke-i pada kelompok (R) merupakan outlier. 2.4. Analisis Diskriminan Linear. Menurut Johnson dan Wichern (2002), analisis diskrim- inan merupakan salah satu metode dalam analisis multivariat dan termasuk dalam teknik dependensi (hubungan antarvariabel dimana sudah dapat dibedakan mana variabel dependen dan mana variabel independen). Analisis diskriminan digunakan untuk mengklasiﬁkasikan in- dividu ke dalam salah satu dari dua kelompok atau lebih, dimana variabel respon berupa data kualitatif dan variabel penjelas berupa data kuantitatif. Analisis diskriminan yang sering di- gunakan adalah analisis diskriminan linear. Ada dua asumsi utama yang harus dipenuhi pada analisis diskriminan linear ini, yaitu variabel penjelas harus berdistribusi normal dan matriks varians-kovarians variabel penjelas berukuran p × p pada kedua kelompok harus sama. dimana ˆµ : modiﬁed one-step M-estimator 2. Metode Penelitian Fungsi diskriminan dideﬁnisikan sebagai berikut: L(R)(X) = c(R) 1 X1 + c(R) 2 X2 + c(R) 3 X3 + · · · + c(R) k Xk + · · · + c(R) p Xp + C(R) 0 (9) na: L(R)(X) = ( ¯X(R))T S−1 gabX −1 2( ¯X(R))T S−1 gab ¯X + ln n(R) n (10) L(R)(X) = c(R) 1 X1 + c(R) 2 X2 + c(R) 3 X3 + · · · + c(R) k Xk + · · · + c(R) p Xp + C(R) 0 (9) (9) dimana: L(R)(X) = ( ¯X(R))T S−1 gabX −1 2( ¯X(R))T S−1 gab ¯X + ln n(R) n (10) (10) 2.5. Analisis Diskriminan Linear Robust dengan winsorized modiﬁed one-step M- estimator. Analisis diskriminan linear robust adalah analisis diskriminan yang memiliki fungsi diskriminan berupa linear dan asumsi-asumsi pada analisis diskriminan tidak terpenuhi dan/atau terdapat outlier pada data. Metode winsorized modiﬁed one-step M-estimator digunakan untuk membentuk penaksir rata-rata baru sebagai salah satu cara memperkuat fungsi diskriminan. Bahkan dalam proses winsorizing, secara tidak langsung metode ini mengatasi outlier. dengan g n : jumlah observasi untuk seluruh kelompok g n : jumlah observasi untuk seluruh kelompok j p q : jumlah observasi yang diprediksi secara tepat,q = n(1)(1) + n(2)(2) b k k l k q : jumlah observasi yang diprediksi secara tepat,q = n(1)(1) + n(2)(2) r : banyaknya kelompok Jika, Presss Q> χ2 (α,1) maka pengklasiﬁkasian akurat dan fungsi diskriminan yang terbentuk stabil. Jika, Presss Q> χ2 (α,1) maka pengklasiﬁkasian akurat dan fungsi diskriminan yang terbentuk stabil. 2.6. Evaluasi Hasil Analisis Diskriminan Linear. 2.6.1. Apparent Error Rate (APER). Menurut Johnson and Wichern (2002), cara penting un- tuk menilai kinerja dari setiap prodesur klasiﬁkasi adalah menghitung tingkat kesalahan atau probabilitas kesalahan klasiﬁkasi. Metode untuk menghitung probabilitas kesalahan klasiﬁkasi adalah Apparent Error Rate (APER) sebagai berikut: Apparent Error Rate = n(1)(2) + n(2)(1) n(1) + n(2) (14) (14) dengan n(1)(2) : banyaknya observasi yang kelompok sebenarnya 1 dan kelompok prediksinya 2 n(2)(1) : banyaknya observasi yang kelompok sebenarnya 2 dan kelompok prediksinya 1 n(1) : banyaknya observasi pada kelompok satu n(1) : banyaknya observasi pada kelompok dua 2.6.2. Menilai Keakuratan Prediksi Keanggotaan Kelompok. Akurasi merupakan nilai yang diperhatikan untuk mendapatkan hasil klasiﬁkasi yang terbaik. Jika nilai akurasi semakin be- sar maka semakin tepat hasil klasiﬁkasinya. Menurut Hair, et al. (2006) statistik uji Presss Q membandingkan antara jumlah ketepatan klasiﬁkasi dengan total pengamatan dan banyaknya kelompok. PresssQ = [n −(qr)]2 n(r −1) (15) p PresssQ = [n −(qr)]2 n(r −1) (15) d (15) 2. Metode Penelitian Wilcox dan Keselman (2003) mengenalkan modiﬁed one-step M-estimator dengan nilai k = 2.24 yang eﬁsien untuk n ≤100 yaitu sebagai berikut: ˆµ = Pn−t2 t=t1+1 xt n −t1 −t2 (11) (11) dimana : modiﬁed one-step M-estimator dimana ˆµ : modiﬁed one-step M-estimator 1 : banyaknya pengamatan yang memenuhi xi −Median(xi) < −2, 24 · MAD 2 : banyaknya pengamatan yang memenuhi xi −Median(xi) > 2, 24 · MAD Berdasarkan t1 : banyaknya pengamatan yang memenuhi xi −Median(xi) < −2, 24 · MAD b k hi M d ( ) 2 24 MAD Berdasarkan t1 : banyaknya pengamatan yang memenuhi xi −Median(xi) < −2, 24 · MAD t2 : banyaknya pengamatan yang memenuhi xi −Median(xi) > 2, 24 · MAD Berdasarkan t2 : banyaknya pengamatan yang memenuhi xi −Median(xi) > 2, 24 · MAD modiﬁed one-step M-estimator pada persamaan (11), Haddad et al (2013) membuat alternatif lain yaitu dengan membangun winsorized sample dengan aturan sebagai berikut: ( ) modiﬁed one-step M-estimator pada persamaan (11), Haddad et al (2013) membuat alternatif lain yaitu dengan membangun winsorized sample dengan aturan sebagai berikut: Klasiﬁkasi Status Kinerja Bank yang Terdaftar di BEI 139 Klasiﬁkasi Status Kinerja Bank yang Terdaftar di BEI 139 w(R) tk =        x(R) (t1+1)k, x(R) tk ≤x(R) (t1+1)k x(R) tk , x(R) (t1+1)k < x(R) tk < x(R) (n−t2)k x(R) (n−t2)k, ≥x(R) (n−t2)k (12) (12) w(R) tk : observasi baru ke-t untuk variabel ke- k pada kelompok ke -R (winsorized sample) t : nomor urut dariyang telah diurutkan dari nilai terkecil hingga terbesar dengan t = 1, 2, · · · n t1 : banyaknya pengamatan yang memenuhi xi −Median(xi) < −2, 24 · MAD t2 : banyaknya pengamatan yang memenuhi xi −Median(xi) > 2, 24 · MAD Berdasarkan persamaan (12), terbentuk winsorized sample, sehingga perumusan winsorized modiﬁed one-step M-estimator w(R) tk : observasi baru ke-t untuk variabel ke- k pada kelompok ke -R (winsorized sample) t : nomor urut dariyang telah diurutkan dari nilai terkecil hingga terbesar dengan t = 1, 2, · · · n t1 : banyaknya pengamatan yang memenuhi xi −Median(xi) < −2, 24 · MAD t2 : banyaknya pengamatan yang memenuhi xi −Median(xi) > 2, 24 · MAD w(R) tk : observasi baru ke-t untuk variabel ke- k pada kelompok ke -R (winsorized sample) t2 : banyaknya pengamatan yang memenuhi xi −Median(xi) > 2, 24 · MAD Berdasarkan persamaan (12), terbentuk winsorized sample, sehingga perumusan winsorized modiﬁed one-step M-estimator ¯w(R) ik = n(R) X t=1 w(R) tk n(R) (13) (13) dimana, ¯w(R) ik : penaksir rata-rata baru untuk variabel ke-k pada kelompok ke R w(R) tk : observasi baru ke-t untuk variabel ke-k pada kelompok ke R (winsorized sample) t : nomor urut dari x(R) ik yang telat diurutkan dari nilai terkecil hingga terbesar denga , ¯w(R) ik : penaksir rata-rata baru untuk variabel ke-k pada kelompok ke R w(R) tk : observasi baru ke-t untuk variabel ke-k pada kelompok ke R (winsorized sample) t : nomor urut dari x(R) ik yang telat diurutkan dari nilai terkecil hingga terbesar dengan 2.6. 2. Metode Penelitian Evaluasi Hasil Analisis Diskriminan Linear. 3. Hasil dan Pembahasan Data yang digunakan adalah data sekunder mengenai laporan keuangan setiap bank yang terdaftar di Bursa Efek Indonesia (BEI) tahun 2016-2017, yang diperoleh dari web resmi BEI (www.idx.co.id). Variabel independen yang digunakan adalah kondisi keuangan bank yang tercatat dalam BEI berdasarkan pertumbuhan laba. Bank yang memiliki pertumbuhan laba 140 Authors, JMI Vol 14 No 2, Oktober 2018, pp. 135-142,doi:10.24198/jmi.v14.n2.2018.135-142 140 menurun atau bernilai negatif diberikan kategori 1 sedangkan bank yang memiliki pertumbuhan laba naik atau bernilai positif diberikan kategori 2. Untuk variabel dependen yang digunakan adalah capital adequency ratio, net-performing loan, net proﬁt margin, return on assets, net interest margin, biaya operasional terhadap pendapatan operasional, dan loan to deposits ratio. menurun atau bernilai negatif diberikan kategori 1 sedangkan bank yang memiliki pertumbuhan laba naik atau bernilai positif diberikan kategori 2. Untuk variabel dependen yang digunakan adalah capital adequency ratio, net-performing loan, net proﬁt margin, return on assets, net interest margin, biaya operasional terhadap pendapatan operasional, dan loan to deposits ratio. 3.1. Hasil Uji Kenormalan Multivariat. Nilai korelasi Pearson antara jarak mahalanobis dan chi-kuadrat adalah sebesar 0,90566. Nilai r tabel dengan α = 0, 05 dan dk = 34 yaitu r1 = 0, 329 . Oleh karena itu, keputusan uji adalah menolak H0 karena rh > rt , artinya terdapat hubungan linear antara jarak mahalanobis dan nilai chi-kuadrat, dengan demikian asumsi kenormalan terpenuhi. 3.1.1. Hasil Uji Kesamaan Matriks Varians-Kovarians. Uji asumsi kesamaan matriks varians- kovarians dilakukan karena asumsi kenormalan data terpenuhi. Hasil pengujian kesamaan matriks varians-kovarians dengan menggunakan Uji Boxs M pada persamaan (2) sampai dengan (8) dapat dilihat pada Tabel 1 Tabel 1. Hasil Perhitungan Uji Kesamaan Matriks Varians-Kovarians Tabel 1. Hasil Perhitungan Uji Kesamaan Matriks Varians-Kovarians Perhitungan Boxs M Nilai lnM -73,1016 C1 0,0252 C2 0,0923 a1 28 a2 327 u1 0,0318 u2 0,003 Fh 4,643 F(a1,a2,α) 1,511 Perhitungan Boxs M Nilai lnM -73,1016 C1 0,0252 C2 0,0923 a1 28 a2 327 u1 0,0318 u2 0,003 Fh 4,643 F(a1,a2,α) 1,511 Berdasarkan Tabel 1 diperoleh nilai lnM yaitu -73,1016 dengan nilai Fh = 4, 4643 . Nilai Ftdengan alpha = 0, 05, a1 = 28 dan a2 = 327 adalah 1,51. Berdasarkan hipotesis: rdasarkan Tabel 1 diperoleh nilai lnM yaitu -73,1016 dengan nilai Fh = 4, 4643 . Berdasarkan Tabel 1 diperoleh nilai lnM yaitu -73,1016 dengan nilai Fh = 4, 4643 . Nilai Ftdengan alpha = 0, 05, a1 = 28 dan a2 = 327 adalah 1,51. 1 2 Berdasarkan Tabel 2 didapat nilai APER sebesar 0,3472 atau 34,72%, ini berarti hasil ketepatan klasiﬁkasi sebesar 65,28%. Selain itu, angka Presss Q didapatkan dengan persamaan (15) yaitu sebesar 6,722. Berdasarkan Tabel Chi Kuadrat, didapat χ2 (0,05;1) = 3, 84 dengan α = 0, 05 dan derajat kebebasan dk = 1, karena PresssQ> χ2 (0,05;1) artinya pengklasiﬁkasian dengan menggunakan analisis diskriminan linear robust akurat dan fungsi diskriminan linear robust yang terbentuk stabil. 3. Hasil dan Pembahasan Berdasarkan hipotesis: H0 : P 1 = P 2 = · · · = P r (matriks varians-kovarians untuk semua kelompok sama) Nilai Ftdengan alpha = 0, 05, a1 = 28 dan a2 = 327 adalah 1,51. Berdasarkan hipotesis: H0 : P 1 = P 2 = · · · = P r (matriks varians-kovarians untuk semua kelompok sama) t g p , , 1 2 , H0 : P 1 = P 2 = · · · = P r (matriks varians-kovarians untuk semua kelompok P 1 P 2 P r ( H1 : Sedikitnya ada satu kelompok yang matriks varians-kovariansya berbeda sehingga keputusan uji adalah menolak H0 karena Fh = 4, 643 dan Ft = 1, 51 se- hingga Fh > Ft , artinya terdapat sedikitnya satu kelompok yang matriks varians-kovariansnya berbeda, atau dapat disebut matriks varians-kovarians bersifat heterogen, sehingga uji ke- samaan matriks varians-kovarians tidak terpenuhi. sehingga keputusan uji adalah menolak H0 karena Fh = 4, 643 dan Ft = 1, 51 se- hingga Fh > Ft , artinya terdapat sedikitnya satu kelompok yang matriks varians-kovariansnya berbeda, atau dapat disebut matriks varians-kovarians bersifat heterogen, sehingga uji ke- samaan matriks varians-kovarians tidak terpenuhi. 3.2. Analisis Diskriminan Linear Robust dengan Winsorized modiﬁed one step M-estimator. Vektor winsorized modiﬁed one-step M-estimator dengan menggunakan per- samaan (13) diperoleh sebagai berikut: 3.2. Analisis Diskriminan Linear Robust dengan Winsorized modiﬁed one step M-estimator. 4. Simpulan Hasil dari penelitian ini dapat disimpulkan sebagai berikut: (1) Analisis diskriminan linear robust dengan pendekatan winsorized modiﬁed one-step M-estimator pada data bank yang terdaftar di Bursa Efek Indonesia menghasilkan fungsi diskriminan linear robust pada persamaan (18) dan (19) yang digunakan un- tuk memprediksi baik-buruknya status kinerja bank. Berdasarkan uji Presss Q fungsi diskriminan linear robust yang telah terbentuk memiliki ketepatan klasiﬁkasi yang aku- rat dan stabil. 2) (2) terdaftar di Bursa Efek Indonesia, 15 diklasiﬁkasikan mempunyai kinerja buruk (per- tumbuhan laba negatif) sisanya yaitu 57 diklasiﬁkasikan mempunyai kinerja baik (per- tumbuhan laba positif) dengan ketepatan klasiﬁkasi sebesar 65,28%. (2) terdaftar di Bursa Efek Indonesia, 15 diklasiﬁkasikan mempunyai kinerja buruk (per- tumbuhan laba negatif) sisanya yaitu 57 diklasiﬁkasikan mempunyai kinerja baik (per- tumbuhan laba positif) dengan ketepatan klasiﬁkasi sebesar 65,28%. 3. Hasil dan Pembahasan Vektor winsorized modiﬁed one-step M-estimator dengan menggunakan per- samaan (13) diperoleh sebagai berikut: ¯w(2) = 21, 121 2, 465 6, 589 0, 594 5, 58 90, 618 87, 1 (16) (16) ¯w(2) = 21, 272 1, 627 13, 1732 1, 296 5, 3 84, 456 87, 114 (17) Karena telah didapat vektor WMOM lalu didapat fungsi diskriminan pertama dan kedua yaitu: L(2) i = −262, 621+1, 425Xi1+12, 771Xi2+3, 6965Xi3+0, 06Xi4+1, 674Xi5+3, 258Xi6+1, 6743Xi7 (18) (17) ¯w(2) = 21, 272 1, 627 13, 1732 1, 296 5, 3 84, 456 87, 114 (17) Karena telah didapat vektor WMOM lalu didapat fungsi diskriminan pertama dan kedua yaitu: L(2) i = −262, 621+1, 425Xi1+12, 771Xi2+3, 6965Xi3+0, 06Xi4+1, 674Xi5+3, 258Xi6+1, 6743Xi7 (18) L(2) i = −262, 621+1, 406Xi1+11, 073Xi2+3, 71Xi3+0, 0479Xi4+1, 435Xi5+3, 298Xi6+1, 63Xi7 (19) L(2) i = −262, 621+1, 406Xi1+11, 073Xi2+3, 71Xi3+0, 0479Xi4+1, 435Xi5+3, 298Xi6+1, 63Xi7 (19) (2) i = −262, 621+1, 406Xi1+11, 073Xi2+3, 71Xi3+0, 0479Xi4+1, 435Xi5+3, 298Xi6+1, 63Xi7 (19) Klasiﬁkasi Status Kinerja Bank yang Terdaftar di BEI 141 Pada dua fungsi yang terbentuk dapat dinyatakan bahwa setiap variabel bebas memiliki pen- garuh positif yang meningkatkan skor diskriminan. 3.3. Hasil Klasiﬁkasi. Fungsi diskriminan yang telah terbentuk selanjutnya digunakan untuk memprediksi status kinerja bank di BEI dengan menggunakan data testing. Cara mengklasi- ﬁkannya adalah dengan menghitung skor diskriminan pada setiap fungsi kelompok yaitu fungsi diskriminan satu dan fungsi diskriminan dua. Suatu observasi diklasiﬁkasikan pada kelompok yang mempunyai skor diskriminan tertinggi. Setelah mengklasiﬁkasi status kinerja bank ter- masuk ke dalam status baik atau buruk, selanjutnya menilai ketepatan klasiﬁkasinya dengan membandingkan dengan kelompok sebenarnya. Setelah itu akan dilihat seberapa baik fungsi diskriminan linear robust mengklasiﬁkasikan status kinerja bank dengan tepat. Hal ini dapat dilihat pada Tabel 2. Tabel 2. Klasiﬁkasi Kelompok Tabel 2. Klasiﬁkasi Kelompok Kelompok yang sebenarnya Jumlah observasi pada setiap kelompok Kelompok prediksi 1 2 1 34 12 22 2 38 3 35 ompok yang sebenarnya Jumlah observasi pada setiap kelompok Kelompok prediksi 142 Authors, JMI Vol 14 No 2, Oktober 2018, pp. 135-142,doi:10.24198/jmi.v14.n2.2018.135-142 [6] Haddad, F. S., Yahaya, S. S. S., and Alfaro, J. L. 2013. Alternative hotelling’s T2 charts using winsorize modiﬁed one-step M-estimator Quality Reliability Eng Int 29: 583-593 DOI: 10 1002/qre 1407 Daftar Pustaka [1] Bank Indonesia. 1998. UU No.10 tahun 1998, Tentang Perubahan Terhadap UU No. 7 tahun 1992, Jakarta [1] Bank Indonesia. 1998. UU No.10 tahun 1998, Tentang Perubahan Terhadap UU No. 7 tahun 1992, Jakarta [2] Bursa Efek Indonesia. 2016. Laporan Keuangan. www.idx.co.id. Diakses pada hari Jumat, tanggal 13 April 2018. [3] Bursa Efek Indonesia. 2017. Laporan Keuangan. www.idx.co.id. Diakses pada hari Jumat, tanggal 13 April 2018. [4] Gimnez, E., Crespi, M., Garrido, S., and Gil, A.J., 2012, Multivariate outlier detection based on robust computation of Mahalanobis distances, International Journal of Applied Earth Observation and Geoinfor- mation 16, 94-100 [5] Glele Kakai, R.M., Pelz, D., and Palm, R., 2010. The eﬃciency of the linear classiﬁcation rule in multigroup discriminant analysis. Afr. J. Math. Comput.Sci. Res., 3: 019-025 142 Authors, JMI Vol 14 No 2, Oktober 2018, pp. 135-142,doi:10.24198/jmi.v14.n2.2018.135-142 [ ] , , y , , , g g modiﬁed one-step M-estimator. Quality Reliability Eng. Int., 29: 583-593. DOI: 10.1002/qre.1407 modiﬁed one-step M-estimator. Quality Reliability Eng. Int., 29: 583-593. DOI: 10.1002/qre.1407 [7] Hair. J. F., Black. W. C., Babin. B. J., Anderson R. E. 2006. Multivariate Data Analysis. Seventh Edition. Pearson Education Prentice Hall. Inc [8] Hawkins, D.M, 1997, Identiﬁcation of outliers, Chapman and Hall, New York [9] Johnson, R.A. dan Wichern, D.W. 2002. Applied Multivariate Statistical Analysis. 5th Ed., Prentice Hall. New Jersey y [10] Rencher, A. C. 2002. Methods of Multivariate Analysis. Second Edition. Wiley-Interscience publication [11] Sharipah, S.S.Y., Yai-Fung, L., Hazlina, A., Et al, 2016.Robust Linear Discriminant Analysis. Science Public (4): 312.316 DOI: 10.3844/jmssp.2016.312.316 ( ) / [12] Wilcox, R.R. and Keselman, H. J., 2003. Repeated measures one-way ANOVA based on a mod- iﬁed one-step M-estimator. British Mathematical and Statistical Psychology, 56: 15-26. DOI: 10.1348/0007110033216453133
https://openalex.org/W1985160631	https://europepmc.org/articles/pmc3810490?pdf=render	English	null	The Incidence of Hypogonadotropic Hypogonadism in Type 2 Diabetic Men in Polish Population	BioMed research international	2,013	cc-by	5,544	MichaB Rabijewski,1 Lucyna Papierska,2 Wojciech ZgliczyNski,2 and PaweB Pidtkiewicz1 1 Department of Internal Diseases, Diabetology and Endocrinology, Warsaw Medical University, Kondratowicza Street 8, 03 242 W P l d 2 Department of Endocrinology, Medical Centre for Postgraduate Education, Warsaw, Poland Correspondence should be addressed to Michał Rabijewski; mirab@cmkp.edu.pl Received 30 April 2013; Revised 27 August 2013; Accepted 16 September 2013 Academic Editor: Gabriel F. Anhe Copyright © 2013 Michał Rabijewski et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The aim of this study was to investigate the incidence of hypogonadotropic hypogonadism (HH) in type 2 diabetic men (T2DM) in population of Polish men and examine the possible influence of estradiol levels and glycemic control. We evaluated TT, cfT, estradiol, and glycemic control (HbA1c) in 184 diabetic men and in 149 nondiabetic control group. The mean HbA1c was 8.6 ± 0.2% and 6.1 ± 0.3% and cfT concentration was 0.315 ± 0.08 nmol/L and 0.382 ± 0.07 nmol/L, respectively. T2DM had higher E2 concentration than nonobese control men (29.4± 3.7 pg/mL versus 24.5 ± 2.9 pg/mL). Forty-six percent of T2DM were hypogonadal and 93% had HH. We observed inverse relationship between BMI and cfT (𝑟= −0.341, 𝑃< 0.01) and positive between BMI and E2 (𝑟= 0.329, 𝑃< 0.01). E2 concentration was higher in T2DM with HH versus T2DM with normal TT/cfT concentration (34.5 ± 5.2 versus 27.4 ± 3.4 pg/mL). We observed negative correlation between HbA1c and cfT (𝑟= −0.336, 𝑃< 0.005) but positive between HbA1c and E2 levels (𝑟= 0.337, 𝑃< 0.002). The prevalence of obesity, hypertension, and CVD was higher in men with hypogonadism. High incidence of hypogonadotropic hypogonadism in type 2 diabetic men in Polish population is associated with poor glycemic control and can be secondary to an increase in estradiol concentrations. Hindawi Publishing Corporation BioMed Research International Volume 2013, Article ID 767496, 6 pages http://dx.doi.org/10.1155/2013/767496 Hindawi Publishing Corporation BioMed Research International Volume 2013, Article ID 767496, 6 pages http://dx.doi.org/10.1155/2013/767496 Hindawi Publishing Corporation BioMed Research International Volume 2013, Article ID 767496, 6 pages http://dx.doi.org/10.1155/2013/767496 1. Introduction (ED), low libido, fatigue, sarcopenia, and depression [4]. The origin of these findings is complex, but about 25–40% type 2 diabetic men (T2DM) have low testosterone concentra- tions in association with inappropriately low or normal LH and FSH concentrations and diagnosis of hypogonadotropic hypogonadism (HH) can be established. About 4% of T2DM have subnormal testosterone concentrations with elevated LH and FSH concentrations, which can be associated with primary testis dysfunctions [4].h The prevalence of diabetes mellitus is rapidly increasing. By the year 2030, there are expected to be almost twice as many older persons with diabetes in developing countries compared to the more developed ones [1]. Incidence of dia- betes in Poland is higher than observed in Western European countries. In the general Polish population aged 20–74 years diabetes was diagnosed in 6.8% individuals, including 7.4% men and 6.2% women. Incidence of diabetes increases with age: in men from 0.7% in those aged 20–29 years to 16.3% in those aged >60 years [2]. In Polish-Norwegian Study (PONS) performed among people aged 45–64 diabetes was diagnosed in 12.2% males and 6.4% females [3]. The possible pathophysiological mechanisms underlying HH in T2DM are still unknown. Low testosterone levels in men are associated with insulin resistance and reduced insulin sensitivity [5]. Moreover, low testosterone levels have also been found to predict insulin resistance and the future development of type 2 diabetes [6]. In study of a large number of obese men (mean age 60 years) 44% of T2DM and 33% of age-matched nondiabetic men had subnormal testosterone concentrations [7]. Testosterone levels are inversely related Type 2 diabetes in men is associated with lower total testosterone (TT) and free testosterone (fT) levels in cross- sectional studies, and the majority of these men have signs and symptoms of hypogonadism such as erectile dysfunctions BioMed Research International 2 2 luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), fasting plasma glucose (FPG), and HbA1c. All men had their total testosterone (TT), LH, FSH, and PRL levels checked at least once. TT, LH, FSH, and PRL were measured by chemiluminescent immunometric assays (Immulite 2000; DPC USA and Coat-a-Coat; Siemens USA). The normal value for testosterone was 8–28 nmol/L (sensitivity—4 ng/dL), for LH: 2–6 mIU/L (sensitivity— 0.05 mIU/L), for FSH: 3–10 mIU/L (sensitivity—0.1 mIU/L), and for PRL: 12–24 ng/mL (sensitivity—0.16 ng/mL). 1. Introduction Cal- culated free testosterone (cFT) was calculated from SHBG, serum albumin, and TT using the method of Vermeulen and colleagues [16]. A free testosterone level <0.255 nmol/L was taken as low. TT concentration <8 nmol/L was considered to be low, and between 8 and 12 nmol/L was considered to be borderline low. HH was defined as TT levels <12 nmol/L LH levels <6 mIU/mL, and FSH levels <8 mIU/mL. Primary hypogonadism was defined as TT levels <12 nmol/L, LH levels >6 mIU/mL, and FSH levels >8 mIU/mL. to body mass index (BMI), but the testosterone deficiency in T2DM was not dependent upon obesity, because 25% of nonobese patients also had HH [8]. HH is relatively rare in type 1 diabetes and therefore is not a function of diabetes or hyperglycemia itself [9]. Thus, in view of the inverse relationship between BMI and testosterone concentrations in both type 1 and type 2 diabetes, HH is probably related to insulin resistance [4, 5]. Testosterone can be converted to estradiol in the adipose tissue, and it has been suggested that excessive estrogen secretion in the obese may suppress secretion of GnRH and LH [10]. However, in recent studies estradiol levels in men with HH were significantly lower than in those without HH [11]. Low testosterone concentration in T2DM is associated with two to three times elevated risk of cardiovascular events and death [12]; therefore, serum testosterone should be measured in men with type 2 diabetes mellitus with symptoms suggestive of testosterone deficiency [13]. Sexual function was assessed according to the Interna- tional Index of Erectile Function (IIEF-5) questionnaire. Pos- sible scores on the IIEF-5 are 1 to 25 and erectile dysfunction was classified into 5 categories based on the scores, namely, severe—1 to 7, moderate—8 to 11, mild to moderate—12 to 16, mild—17 to 21 and none—22 to 25. The high prevalence of diabetes mellitus in population of Polish men is well documented, but the prevalence of HH in T2DM is now unknown. In our earlier study we showed that in a cohort of Polish men with poor health status the prevalence of testosterone deficiency in elderly men with ED is higher than in other countries [14]. 1. Introduction So, we hypothesize that the incidence of HH in T2DM also can be higher than in other studies and is associated with late identification of patients with type 2 diabetes and improper glycemic control.h Statistical analysis was performed using statistica soft- ware. Data are presented as mean ± SE. Mann Whitney rank sum test was used to compare nonparametric data, and Student’s 𝑡test was used to compare parametric data. Spearman correlation (for nonparametric data) or Pearson correlation (for parametric data) was used to establish cor- relations. All relationships were assessed by linear univariate and multivariate regression analysis to reduce bias in a cross-sectional study. Results were considered statistically significant at 𝑃< 0.05. Therefore, the aim of this study was to investigate the incidence of hypogonadotropic hypogonadism in T2DM in Polish population and examine the possible influence of estradiol levels and glycemic control. 2. Material and Methods This was a cross-sectional study of 184 type 2 diabetic men, aged >45 years (age range 47–63 years), who were registered with the Department of Endocrinology, Medical Centre of Postgraduate Education, Warsaw, Poland. All patients gave written informed consent, and the local research ethics com- mittee approved the protocol (CMKP/501-2-1-07-21/2009). 3. Results Parameter T2DM with HH T2DM with PH T2DM with normal TT/cfT All T2DM 𝑃∗ Nondiabetic control group 𝑃∗∗ Number of patients 82 5 99 184 149 Age (years) 56.4 ± 3.2 5.4 ± 3.1 57.6 ± 2.7 58.5 ± 2.3 NS 59.6 ± 3.2 NS TT (mmol/L) 10.3 ± 1.2 11.1 ± 1.3 16.4 ± 1.95 13.3 ± 1.65 0.002 17.1 ± 1.7 0.001 cfT (nmol/L) 0.225 ± 0.05 0.287 ± 0.06 0.375 ± 0.05 0.315 ± 0.08 0.002 0.382 ± 0.07 0.01 SHBG (nmol/L) 31.3 ± 2.1 30.3 ± 2.6 29.7 ± 2.3 30.9 ± 1.98 0.05 28.7 ± 2.04 0.05 LH (mIU/L) 3.5 ± 0.3 10.3 ± 1.2 7.3 ± 0.3 6.5 ± 0.2 0.02 7.6 ± 0.3 0.02 FSH (mIU/L) 5.8 ± 0.6 13.4 ± 1.8 9.2 ± 0.45 8.8 ± 0.3 0.02 8.6 ± 0.8 NS Estradiol (pg/mL) 34.5 ± 3.1 32.5 ± 3.7 27.4 ± 3.4 29.4 ± 3.7 0.002 24.5 ± 2.9 0.001 BMI (kg/m2) 32.4 ± 1.4 31.1 ± 2.2 30.6 ± 1.3 31.4 ± 0.9 0.05 27.6 ± 1.2 0.02 HbA1c (%) 8.9 ± 1.4 8.8 ± 1.3 8.4 ± 1.2 8.6 ± 1.3 0.002 6.1 ± 0.3 0.002 FPG (mmol/L) 8.3 ± 0.7 8.2 ± 0.6 7.6 ± 0.5 7.9 ± 0.7 0.05 5.3 ± 0.4 0.001 ∗𝑃shows differences between patients with HH and with normal testosterone levels 0 25 50 75 100 Normal testosterone Hypogonadotropic hypogonadism Primary hypogonadism Figure 1: The incidence percentage of normal testosterone levels compared with patients with HH and primary hypogonadism in T2DM in Polish population. versus 27.4 ± 3.4 pg/mL, resp.), but we did not observed statistical significant differences between T2DM with normal TT/cfT concentration and nonobese control men (27.4 ± 3.4 versus 28.2 ± 3.2 pg/mL, resp.). These results were significant after adjustment for BMI and age.i t We observed statistically significant negative correlation between HbA1c and TT and between FPG and TT concen- trations (𝑟= −0.346, 𝑃< 0.002 and 𝑟= −0.345, 𝑃< 0.002, resp.) and significant negative correlation between HbA1c and cfT concentrations (𝑟= −0.336; 𝑃< 0.005) but there was no correlation between FPG and cfT concentrations. There was also positive correlation between HbA1c and BMI and between HbA1c and E2 levels (𝑟= 0.382, 𝑃< 0.02 and 𝑟= 0.337; 𝑃< 0.002, resp.). After adjusting for age, TT/E2 ratio was negatively associated with BMI (𝑃< 0.001). 3. Results A total of 184 T2DM and 149 nondiabetic control men were evaluated in the study. Characteristics of all T2DM men, patients with HH, primary hypogonadism, normal testos- terone concentration, and nonobese control group are shown in Table 1. The mean age in T2DM group and nonobese control group was 58.5 ± 2.3 years and 59.6 ± 3.2 years; mean body mass index (BMI) was 31.4 ± 0.5 kg/m2 and 27.6 ± 1.2 kg/m2, and mean HbA1c was 8.6 ± 0.2% and 6.1 ± 0.3%, respectively. The mean TT concentration was 13.3 ± 1.65 nmol/L and 17.1 ± 1.7 nmol/L, and cfT concentration was 0.315 ± 0.08 nmol/L and 0.382 ± 0.07 nmol/L. We observed statistically higher E2 concentration in T2DM group than in nonobese control men (29.4 ± 3.7 pg/mL and 24.5 ± 2.9 pg/mL, 𝑃< 0.001). Patients with known history of hypogonadism, panhy- popituitarism, chronic debilitating disease, or were already receiving hormone replacement therapy were excluded from the study. Demographic parameters, clinical history includ- ing the duration of diabetes, medications, and the presence of erectile dysfunction and coronary artery disease were collected, and height, weight, fasting glucose, and HbA1c were measured. Type 2 diabetes was diagnosed according to WHO criteria [15]. Nine patients were treated with diet alone, 77 with insulin, and 98 with oral hypoglycemic agents. Height and weight were measured, and BMI was calculated. Cardio- vascular disease was defined as self-reported coronary artery disease, cerebrovascular disease, congestive heart failure, or arrhythmia. Thus, we showed that TT and cfT concentrations in all T2DM group were statistically significantly lower than in nondiabetic control group with the same average age (Table 1). Forty-six percent of T2DM (𝑛 = 86) were hypogonadal, and in 82 of these patients (93%) LH and FSH levels were significantly lower when compared with patients y Fasting blood samples were then obtained between 8:00 and 10:00 A.M. to measure serum total testosterone (TT), estradiol (E2), sex hormone binding globuline (SHBG), BioMed Research International 3 BioMed Research International Table 1: Characteristics of all T2DM, patients with HH, primary hypogonadism (PH), and with normal testosterone concentration (normal TT/cfT) and nondiabetic control men. 3. Results Parameter T2DM with HH T2DM with PH T2DM with normal TT/cfT All T2DM 𝑃∗ Nondiabetic control group 𝑃∗∗ Number of patients 82 5 99 184 149 Age (years) 56.4 ± 3.2 5.4 ± 3.1 57.6 ± 2.7 58.5 ± 2.3 NS 59.6 ± 3.2 NS TT (mmol/L) 10.3 ± 1.2 11.1 ± 1.3 16.4 ± 1.95 13.3 ± 1.65 0.002 17.1 ± 1.7 0.001 cfT (nmol/L) 0.225 ± 0.05 0.287 ± 0.06 0.375 ± 0.05 0.315 ± 0.08 0.002 0.382 ± 0.07 0.01 SHBG (nmol/L) 31.3 ± 2.1 30.3 ± 2.6 29.7 ± 2.3 30.9 ± 1.98 0.05 28.7 ± 2.04 0.05 LH (mIU/L) 3.5 ± 0.3 10.3 ± 1.2 7.3 ± 0.3 6.5 ± 0.2 0.02 7.6 ± 0.3 0.02 FSH (mIU/L) 5.8 ± 0.6 13.4 ± 1.8 9.2 ± 0.45 8.8 ± 0.3 0.02 8.6 ± 0.8 NS Estradiol (pg/mL) 34.5 ± 3.1 32.5 ± 3.7 27.4 ± 3.4 29.4 ± 3.7 0.002 24.5 ± 2.9 0.001 BMI (kg/m2) 32.4 ± 1.4 31.1 ± 2.2 30.6 ± 1.3 31.4 ± 0.9 0.05 27.6 ± 1.2 0.02 HbA1c (%) 8.9 ± 1.4 8.8 ± 1.3 8.4 ± 1.2 8.6 ± 1.3 0.002 6.1 ± 0.3 0.002 FPG (mmol/L) 8.3 ± 0.7 8.2 ± 0.6 7.6 ± 0.5 7.9 ± 0.7 0.05 5.3 ± 0.4 0.001 ∗𝑃shows differences between patients with HH and with normal testosterone levels. ∗∗𝑃shows differences between TD2M and nonobese control group. Pearson coefficient of BMI and TT: 𝑟= −0.362; 𝑃< 0.01 in all T2DM group. Pearson coefficient of BMI and cfT: 𝑟= −0.341, 𝑃< 0.01 in all T2DM group. Pearson coefficient of BMI and E2: 𝑟= 0.329; 𝑃< 0.01 in all T2DM group. Pearson coefficient of HbA1c and TT: 𝑟= −0.346, 𝑃< 0.002 in all T2DM group. Pearson coefficient of HbA1c and cfT: 𝑟= −0.336; 𝑃< 0.005 in all T2DM group. Pearson coefficient of HbA1c and E2: 𝑟= 0.337; 𝑃< 0.002 in all T2DM group.fi Table 1: Characteristics of all T2DM, patients with HH, primary hypogonadism (PH), and with normal testosterone concentration (normal TT/cfT) and nondiabetic control men. Table 1: Characteristics of all T2DM, patients with HH, primary hypogonadism (PH), and with normal testosterone concentration (normal TT/cfT) and nondiabetic control men. TT/cfT) and nondiabetic control men. 3. Results Figure 1: The incidence percentage of normal testosterone levels compared with patients with HH and primary hypogonadism in T2DM in Polish population. g y Multivariate linear regression analysis showed that obe- sity negatively correlated with TT levels with a mean decrease of 25 ng/dL per 1 kg/m2 increase in BMI score (𝑃< 0.005). Also, age negatively correlated with TT and cfT levels with a mean decrease of 1.8 ng/dL and 0.003 nmol/L for each year of additional age over 45 years old, respectively (𝑃< 0.002).h with normal TT/cfT levels (3.5 ± 0.3 versus 7.3 ± 0.3 mIU/mL for LH and 5.8 ± 0.6 versus 9.2 ± 0.45 mIU/mL for FSH; 𝑃 < 0.02), and only 4 men had testosterone, LH, and FSH concentrations characteristic to primary hypogonadism. Figure 1 shows the percentage of patients with normal TT/cfT levels and patients with HH and primary hypogonadism.fi The degree of erectile dysfunction in all T2DM group was mild in 24% of cases, mild to moderate in 31.5%, moderate in 24.5%, and severe in 20% (Table 2), and there were significant differences between patients with normal TT/cfT concentrations and patients with hypogonadism (𝑃< 0.02). IIEF-5 score and TT showed a statistically inverse relationship (𝑟= −0.3149, 𝑃< 0.05). p p y yp g Pearson coefficients of BMI and TT concentration showed a statistically significant inverse relationship (𝑟= −0.362; 𝑃< 0.01). Also inverse relationship between BMI and cfT concentration (𝑟= −0.341, 𝑃< 0.01) was observed. There was also positive correlation between BMI and E2 (𝑟= 0.329; 𝑃< 0.01). SHBG correlated inversely with BMI (𝑟= −0.277; 𝑃< 0.05) but positively with age (𝑟= 0.538; 𝑃 < 0.001) and TT (𝑟 = 0.543; 𝑃 < 0.001). E2 concentration was significant higher in T2DM with HH versus T2DM with normal TT/cfT concentration (34.5 ± 5.2 In Table 3, we presented prevalence of tobacco use, hyper- tension, dyslipidemia, obesity, and cardiovascular disease (CVD) in all T2DM. The prevalence of each condition, except tobacco use, was above 60% and prevalence of obesity, BioMed Research International 4 Table 2: Degree of erectile dysfunction (number of patients; percentage) according to IIEF-5 scale in all T2DM, patients with HH and with normal TT/cfT. 4. Discussion We evaluated the incidence of HH in Polish population of 184 T2DM. It was the first study performed in the relative large population of men in Poland. To our knowledge, this is the first report showing such high incidence of HH in population of T2DM with poor health status. In our cohort 46% patients were hypogonadal and 93% of these patients covered criteria for recognizing of HH. g g Dhindsa et al. [8] described the association of HH with type 2 diabetes in 103 T2DM in mean age 54.7 years. Authors revealed that 33% of studied T2DM were hypogonadal, and LH and FSH levels were significantly lower in the hypogonadal group compared with patients with normal testosterone levels. In study of Rhoden et al. [17] in 116 diabetic men TT serum levels were subnormal in 34% of patients, and TT levels were strongly associated with elevated BMI. Corona et al. [18] in an investigation of 1200 patients with ED (16% with type 2 diabetes) observed HH in 24.5% diabetic men versus 12.6% in the rest of the group. Differences in the prevalence of hypogonadism retained significance after adjustment for age and BMI. In cross-sectional study of 355 type 2 diabetic men aged >30 years Kapoor et al. [19] observed low testosterone levels in diabetic men, and a significant proportion of these men had symptoms of hypogonadism. In a cross-sectional survey of 580 men with type 2 diabetes Laaksonen et al. [20] found that 43% of men with type 2 diabetes had a reduced TT concentration, and low testosterone levels were independently associated with insulin resistance. In patients with type 2 diabetes hypogonadism is sec- ondary in origin (hypogonadotropic), but possible patho- physiological mechanisms underlying HH in these patients remain partly unexplained. Testosterone in the male can be converted through the action of aromatase to estradiol (E2) and estrone (E1) in the mesenchymal cells, preadipocytes, and adipocytes of adipose tissue. Because obesity is closely connected with diabetes and aging, it has been suggested that excessive E2 secretion due to high aromatase activity in the obese patients may suppress testosterone synthesis as a result of suppression of the hypothalamic secretion of GnRH [10]. But in previous study this hypothesis was not confirmed. In European male aging study estradiol levels in hypogonadal men were significantly lower than in eugonadal men [11], but only few percent of these men were diabetic. 3. Results IIEF-5 Men with HH (𝑛= 82) Normal TT/cfT (𝑛= 99) All men (𝑛= 184) Mild 16 (19) 29 (29) 44 (24) Mild to moderate 28 (34) 29 (29) 58 (31.5) Moderate 18 (22.5) 22 (23) 45 (24.5) Severe 20 (24.5) 19 (19) 37 (20) Significant differences between patients with normal testosterone concentration and patients with hypogonadism (𝑃< 0.02). Variables of IIEF-5 score and TT: 𝑟= −0.3149, 𝑃< 0.05. Table 3: Clinical characteristics (number of patients; percentage) of all T2DM, patients with HH and with norm haracteristics (number of patients; percentage) of all T2DM, patients with HH and with normal TT/cfT concen Table 3: Clinical characteristics (number of patients; percentage) of all T2DM, patients with HH and with normal TT/cfT concentration. Parameter Men with HH (𝑛= 82) Normal TT/cfT (𝑛= 99) All men (𝑛= 184) 𝑃value Obesity 79 (96) 72 (73) 151 (82) 0.002 Current smoker 62 (76) 75 (76) 137 (75) NS Hypertension 65 (79) 62 (62) 127 (69) 0.005 Dyslipidemia 61 (74) 65 (65) 126 (69) 0.02 CVD 57 (70) 61 (61) 118 (64) 0.05 𝑃value shows significant differences between patients with normal testosterone concentration and patients with hypogonadism. CVD: cardiovascular disease. atients; percentage) of all T2DM, patients with HH and with normal TT/cfT concentration. The incidence of hypogonadism among patients with type 2 diabetes was significantly greater in our study than observed in studies cited above. Hypogonadism can be associated with diabetes per se, but vascular factors, drugs, tobacco, alcohol, and systemic diseases such as hypertension, heart diseases, and dyslipidemia can be risk factors of testosterone deficiency. In our study we observed high prevalence of tobacco use, hypertension, dyslipidemia, cardiovascular dis- ease, and obesity (over 60% for each condition). Very high prevalence of these diseases, higher than in cited studies, can be one of the explanation of differences in incidence of hypogonadism between population of Polish men and patients in Western Europe countries and the United States. In our earlier publication we showed [14] that late-onset hypogonadism (LOH) was very common in population of Polish men presenting ED and correlated negatively with age, obesity, and dyslipidemia. These results can also be associated with poor health status of Polish population, like in this study. hypertension, and CVD was significantly higher in men with hypogonadism compared with eugonadal patients. 3. Results The most common metabolic disorders were obesity (79% in men with hypogonadism and 93% in men with normal TT/cfT levels) and hyperlipidemia (51% and 93%, resp.). 4. Discussion In population of T2DM with normal weight Dhindsa et al. observed no association of HH with elevated E2 concentration [8]. Although in all cited studies above 5 BioMed Research International testosterone concentrations were inversely related to BMI but low testosterone concentration was not closely depended upon high BMI. In our study, we also observed statistically significant inverse relationship between TT, cfT, and BMI as well as positive correlation between BMI and E2; however, T2DM with HH had significantly higher E2 concentration and lower TT/E2 ratio than eugonadal T2DM. These obser- vations can be in part associated with very high prevalence of obesity in our population (96%) and higher BMI than in other studies (mean BMI 32.4 kg/m2). However, Mogri et al. [21] in population of obesity pubertal and postpubertal males showed that obese males had significantly lower TT and cfT concentrations as compared to lean males, but fT concentrations were positively related to age. Interestingly, total and free estradiol levels were significantly lower in males with subnormal testosterone concentrations. So, in this study obesity in young males was associated with low testosterone concentrations, which were not secondary to an increase in estradiol concentrations. In our study we measured total but not free or bioavailable estradiol concentration, while these fractions of estradiol in other studies were directly related to testosterone concentrations in T2DM. We observed significant differences in the degree of erectile dysfunction according to IIEF-5 score between eugonadal patients and men with hypogonadism. Moreover, IIEF-5 score and TT concentrations showed a statistically inverse relationship. In the absence of modifiable etiology of hypogonadism and contraindications to treatment, testosterone replacement therapy may be taken into account [13, 30]. Short-term studies in men have shown that testosterone supplementation may improve insulin sensitivity [31–33], but the balance of benefits and risks is still unknown.f i A couple of the issues affecting its accuracy can be cited as weaknesses in our data set. First of all our model in no way established a causal link between hypogonadism and type 2 diabetes, because the two conditions might simply overlap and they may have probably separate pathophysiologic path- ways. In Polish population hypogonadism is closely connected with type 2 diabetes and routine testosterone screening should be performed in all T2DM. Our study results strongly justify this practice. 4. Discussion The Endocrine Society and the Interna- tional Society for the Study of the Aging Male (ISSAM) now recommend the measurement of testosterone in patients with type 2 diabetes as a routine basis [13, 30], but this practice is not common and widely accepted in Poland. In previous study, the prevalence of hypogonadism was not dependent on severity of hyperglycemia assessed as glycosylated hemoglobin (HbA1c) levels [1–8, 8–19]. We observed significant negative correlation between HbA1c and testosterone concentration; thus, in population of Polish T2DM severity of hyperglycemia probably can influence the incidence of HH. These findings can also be associated with relative late identification of diabetic patients in our country (mean HbA1c level in all group was 8.4% and in HH patients—8.9%). In conclusion, we observed high incidence of hypogo- nadotropic hypogonadism in type 2 diabetic men in Polish population which is associated with poor glycemic control and can be secondary to an increase in estradiol concentra- tions. Acknowledgments This study was supported by research Grant no. 501-2-1- 07-21/09 of the Medical Centre of Postgraduate Education, Poland. Conflict of Interests Hypogonadism in men is associated with insulin resis- tance [5], visceral obesity, the risk of metabolic syndrome [22, 23], vascular complications of diabetes [24], and risk for developing type 2 diabetes [6, 24]. Also in nondiabetic men testosterone levels were inversely associated with insulin levels and HOMA [25]. These observations confirmed the hypothesis that testosterone levels in diabetic men may be influenced by insulin resistance (a key feature of type 2 diabetes) and may play an important role in pathogenesis of HH. 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https://openalex.org/W2126119516	https://www.epj-conferences.org/articles/epjconf/pdf/2014/05/epjconf_icas2013_00031.pdf	English	null	The Value Compressive Strength and Split Tensile Strength on Concrete Mixture With Expanded Polystyrene Coated by Surfactant Span 80 as a Partial Substitution of Fine Aggregate	EPJ web of conferences	2,014	cc-by	4,038	2. Research Significance The purpose of this study was to analyze the influence of a mixture of normal concrete by reducing the fine aggregate material for later substituted with EPS, and EPS coated by surfactant span 80. In the concrete mixtures, will be reviewed against the weight of concrete, concrete compressive strength and split tensile strength. Along with technological developments in the field of construction, using concrete materials are commonly used as a material that supports the building structure . Theoretically, the concrete material is able to resist high compressive strength, but not good enough to resist tensile strength. The value of the density normal concrete which ranges between 2200-2400 kg/m3, this will affect the total weight of the building structure. The decreasing density of the concrete will reduce the weight of the building. The expected benefits are the results of this research can be developed to generate concrete composition of lighter material with the compressive strength of concrete is higher than the EPS concrete mix that is not coated with surfactant. To reduce the density of normal concrete, concrete toward research that has less weight is being carried out at several universities or in the concrete mix design company. One way to reduce the density of normal concrete by reducing the fine aggregate, material to be added Expanded Polystyrene (EPS) in the concrete mix. So in this way is expected that the resulting concrete material has a light density. Park and Chisholm use polystyrene as fine aggregate and has a less specific gravity ranges from 520 to 1040 kg/m3 has a very low compressive strength, which is in the range 0.7 MPa to 6.7 MPa The following are the limitations issue in this research is the cement used was Portland cement type 1, the design methods used to using SNI 03-2834-2000 with plan compressive strength of 25 MPa, the concrete samples will be formed with a cylindrical mold with 30 cm high and 15 cm in diameter, the size of EPS used 1-2 mm diameter, material substitution EPS composition was 5%, 10%, 15%, 20%, 25%, the surfactant used is span 80. DOI: 10.1051/ C ⃝Owned by the authors, published by EDP Sciences, 2014 , / 00031 (2014) 201 68 epjconf EPJ Web of Conferences 46800031 DOI: 10.1051/ C ⃝Owned by the authors, published by EDP Sciences, 2014 , / 00031 (2014) 201 68 epjconf EPJ Web of Conferences 46800031 DOI: 10.1051/ C ⃝Owned by the authors, published by EDP Sciences, 2014 , / 00031 (2014) 201 68 epjconf EPJ Web of Conferences 46800031 The Value Compressive Strength and Split Tensile Strength on Concrete Mixture With Expanded Polystyrene Coated by Surfactant Span 80 as a Partial Substitution of Fine Aggregate Irpan Hidayat1, Alice Siauwantara1 1Bina Nusantara University, KH Syahdan 9, West Jakarta 11480, Indonesia Abstract. The value of the density normal concrete which ranges between 2200-2400 kg/m3. Therefore the use of Expanded Polystyrene (EPS) as a subitute to fine aggregate can reduce the density of concrete. The purpose this research is to reduce the density of normal concrete but increase compressive strength of EPS concrete, with use surfactant as coating for the EPS. Variables of substitution percentage of EPS and EPS coated by surfactant are 5%,10%,15%,20%,25%. Method of concrete mix design based on SNI 03-2834-2000 “Tata Cara Pembuatan Rencana Campuran Beton Normal (Provisions for Proportioning Normal Concrete Mixture)”. The result of testing, every increase percentage of EPS substitution will decrease the compressive strength around 1,74 MPa and decrease density 34,03 kg/m3. Using Surfactant as coating of EPS , compressive strength increase from the EPS’s compressive strength. Average of increasing compressive strength 0,19 MPa and increase the density 20,03 kg/m3,average decrease of the tensile split strength EPS coated surfaktan is 0,84 MPa. This is an Open Access article distributed under the terms of the Creative Commons Attribution License 2.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Article available at http://www.epj-conferences.org or http://dx.doi.org/10.1051/epjconf/20146800031 A = cross-sectional area of the test sample (cm2) The steps compressive strength testing that prepare specimens already in curing many as 3 samples, consider and record the weight of the sample, place the sample in the testing test, providing a constant load on the concrete until the concrete failure and noted the ability to resist maximum concrete compressive strength, tests performed at 28 days. 3. Test Program and Measurements The reduced density of the concrete mixture will cause a decrease in the compressive strength of concrete. In this study will be seen how much the decrease of weight in the normal concrete mix if the substitution EPS is done on fine aggregate. To increase the compressive strength in concrete mix using EPS material substitution, we will perform an EPS coating material with chemical additives are surfactants span 80. So expect the presence of EPS coating with surfactant span 80 can increase the value of the concrete compressive strength. Testing to be performed in this study is testing the compressive strength and split tensile strength. Based on the results, the study will be analyzed value of density, compressive strength and split tensile strength for normal concrete mixes, concrete mixes with EPS, and concrete mixture that surfactant span 80 as coating of EPS. The following concrete testing to be performed : This is an Open Access article distributed under the terms of the Creative Commons Attribution License 2.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. EPJ Web of Conferences used is the Universal Testing Machine. Provisions of tensile strength testing of concrete by SNI 03-2491-2002. Tensile strength of concrete formula: 3.2 Split Tensile Strength Tensile strength of concrete is the ability to resist the concrete tensile strength. Tensile test equipment that is Table 1 Proportion Mixed Concrete Variabel Volume Proportion Mixed Concrete Coarse Aggregate (kg) Fine Aggregate (kg) Cement (kg) Water (L) Subtitution Fine Aggregate EPS (gr) Sand (Kg) Normal 1m3 1164,92 505,29 355,77 159,01 - 505,29 EPS 5% 1m3 1140,65 589,06 355,77 99,53 358,02 559,61 EPS 10% 1m3 1141,55 549,55 355,77 138,13 668,01 494,59 EPS 15% 1m3 1140,65 589,06 355,77 99,53 1074,05 500,70 EPS 20% 1m3 1140,65 537,27 355,77 151,31 1306,17 429,82 EPS 25% 1m3 1140,65 589,06 355,77 99,53 1790,09 441,79 EPS surfactant 5% 1m3 1151,99 504,10 355,77 173,14 593,39 478,90 EPS surfactant 10% 1m3 1151,99 515,32 355,77 161,92 1213,18 412,25 EPS surfactant 15% 1m3 1121,36 515,73 355,77 192,15 1821,21 438,37 EPS surfactant 20% 1m3 1121,36 515,73 355,77 192,15 2428,28 412,58 EPS surfactant 25% 1m3 1117,96 529,79 355,77 181,48 3118,15 397,35 Table 1 Proportion Mixed Concrete Table 1 Proportion Mixed Concrete From the results of laboratory tests performed on the data obtained by the compressive strength and split tensile strength of concrete at 28 days. Tests carried out for 3 samples for each variable. Here are the results of testing the compressive strength and tensile strength of normal concrete, with EPS concrete mixture, and mix concrete with EPS coated by surfactant span 80. 4. Test Results and Analysis Concrete mixture proportion is designed under the provisions of SNI 03-2834-2002, Tata Cara Pembuatan Rencana Campuran Beton Normal (Provisions for Proportioning Normal Concrete Mixture). The material proportions required per m3 for each EPS percentage are shown in the Table 1. Concrete mixture proportion is designed under the provisions of SNI 03-2834-2002, Tata Cara Pembuatan Rencana Campuran Beton Normal (Provisions for Proportioning Normal Concrete Mixture). The material proportions required per m3 for each EPS percentage are shown in the Table 1. 3.1 Compressive Strength Compressive strength is the ability of concrete to resist compressive strength with a certain weight on the concrete surface area. The tools are used for testing the compressive strength test is a compression test. Compressive strength formula are used by SNI 03-1974- 2000: fct : (2) i ti (2) Description: fct = split tensile strength (MPa) fct = split tensile strength (MPa) P = maximum test load (N) Compressive strength concrete : P A (1) Description: Compressive strength concrete : P A (1) Description: (1) L = length of the sample (mm) D = diameter of the sample (mm) Description: The steps tensile strength testing of concrete that prepare 3 pieces of concrete sample at concrete age of 28 days and perform tensile testing of concrete by using Universal Testing Machine tools. P = maximum load (kg) P = maximum load (kg) A = cross-sectional area of the test sample (cm A = cross-sectional area of the test sample (cm2) 4.1 Compressive Strength Test Results Tables 2 and 3 are the results of testing the compressive strength of concrete mix for EPS and EPS were coated by surfactant. 00031-p.2 ICASCE 2013 Table 2 Compressive Strength Concrete EPS at 28 days Table 2 Compressive Strength Concrete EPS at 28 days No Variabel Volume Sample (m3) Area Sampel (mm2) Weight (kg) Experi ment Test Results (kN) Compressive Strength at 28 days (MPa) Compressive Strength Average (MPa) Weight Average (kg) Density (kg/m3) = = (P) f’c= (Px1000)/A f’cr br br/v 1 EPS 0% 0,0053 17662,5 11,43 420 23,78 24,53 11,58 2184,79 11,675 450 25,48 11,625 430 24,35 2 EPS 5% 0,0053 17662,5 11,438 350 19,82 19,63 11,2 2113,14 11,129 350 19,82 11,024 340 19,25 3 EPS 10% 0,0053 17662,5 11,05 330 18,68 18,12 11,07 2089,11 11,02 330 18,68 11,139 300 16,99 4 EPS 15% 0,0053 17662,5 10,796 310 17,55 16,99 11 2076,34 11,107 290 16,42 11,103 300 16,99 5 EPS 20% 0,0053 17662,5 10,879 280 15,85 16,23 10,88 2053,06 10,867 290 16,42 10,89 290 16,42 6 EPS 25% 0,0053 17662,5 10,565 320 18,12 15,85 10,68 2014,63 10,58 290 16,42 10,88 230 13,02 Table 3 Compressive Strength Concrete EPS Coated by Surfactant at 28 Days No Variabel Volume Sample (m3) Area Sampel (mm2) Weight (kg) Experi ment Test Results (kN) Compressive Strength at 28 days (MPa) Compressive Strength Average (MPa) Weight Average (kg) Density (kg/m3) = = (P) f’c= (Px1000)/A fcr br br/v 1 EPSS 5% 0,0053 17662,5 11,112 350 19,82 19,48 11,34 2140,65 11,43 350 19,82 11,458 350 19,82 2 EPSS 10% 0,0053 17662,5 11,08 320 18,12 18 11,18 2109,32 11,311 320 18,12 11,245 330 18,68 3 EPSS 15% 0,0053 17662,5 11,197 310 17,55 17,1 11,05 2085,54 11,291 300 16,99 10,874 300 16,99 4 EPSS 20% 0,0053 17662,5 10,988 300 16,99 16,42 10,97 2070,94 10,918 290 16,42 10,974 280 15,85 5 EPSS 25% 0,0053 17662,5 10,822 260 14,72 15,63 10,87 2051,84 10,900 310 17,55 10,777 290 16,42 Table 3 Compressive Strength Concrete EPS Coated by Surfactant at 28 Days 00031-p.3 EPJ Web of Conferences Figure 3 Density EPS vs. 4.1 Compressive Strength Test Results Concrete Compressive Strength 2000 2020 2040 2060 2080 2100 2120 2140 2160 2180 2200 0% 5% 10% 15% 20% 25% Density (kg/m3) Precentage of substitution (%) EPS coated by surfactant EPS 15 16 17 18 19 20 21 22 23 24 25 2000 2050 2100 2150 2200 Compressive Strength (MPa) Density (kg/m3) EPS 23 24 25 MPa) EPS coated by Figure 1 Percentage of EPS VS Density 2000 2020 2040 2060 2080 2100 2120 2140 2160 2180 2200 0% 5% 10% 15% 20% 25% Density (kg/m3) Precentage of substitution (%) EPS coated by surfactant EPS 2000 2020 2040 2060 2080 2100 2120 2140 2160 2180 2200 0% 5% 10% 15% 20% 25% Density (kg/m3) Precentage of substitution (%) EPS coated by surfactant EPS 15 16 17 18 19 20 21 22 23 24 25 2000 2050 2100 2150 2200 Compressive Strength (MPa) Density (kg/m3) EPS Figure 3 Density EPS vs. Concrete Compressive Strength Figure 4 Density vs EPS coated by surfactant Concrete Compressive Strength 15 2000 2050 2100 2150 2200 Com Density (kg/m3) 16 17 18 19 20 21 22 23 24 25 2000 2050 2100 2150 2200 Compressive strength (MPa) Density (kg/m3) EPS coated by Surfactant Density (kg/m3) Figure 3 Density EPS vs. Concrete Compressive Strength 16 17 18 19 20 21 22 23 24 25 2000 2050 2100 2150 2200 Compressive strength (MPa) Density (kg/m3) EPS coated by Surfactant Figure 3 Density EPS vs. Concrete Compressive Strength 4.1 Compressive Strength Test Results Concrete Compressive Strength Figure 4 Density vs EPS coated by surfactant Concrete Compressive Strength I T bl 4 th diff dditi f i 15 16 17 18 19 20 21 22 23 24 25 2000 2050 2100 2150 2200 Compressive Strength (MPa) Density (kg/m3) EPS 16 17 18 19 20 21 22 23 24 25 2000 2050 2100 2150 2200 Compressive strength (MPa) Density (kg/m3) EPS coated by Surfactant Figure 1 Percentage of EPS VS Density According to the testing, Figure 1 can be shown that with the increasing percentage of substitution EPS will be reduced the density of the concrete. The density value will increase with the addition of a surfactant span 80 as coating of EPS in the concrete mix. Increasing the density of the concrete mixture EPS were coated surfactant also affect the compressive strength (figure 2). The compressive strength of concrete increases due to the influence of surfactant span 80 as coating of EPS, so the EPS granules become harder. Figure 3 Density EPS vs. Concrete Compressive Strength Figure 4 Density vs EPS coated by surfactant Concrete Compressive Strength In Table 4, the difference or addition of compressive strength of concrete mix concrete EPS and EPS coated by surfactant having an average increase of concrete compressive strength of 0,19 MPa. From this testing it can be shown that the concrete mixture that EPS coated 2000 2020 2040 2060 2080 2100 2120 2140 2160 2180 2200 0% 5% 10% 15% 20% 25% Density (kg/m3) Precentage of substitution (%) EPS coated by surfactant EPS 19 21 23 25 mpresive strength (MPa) EPS coated by surfactant EPS 15 16 17 18 19 20 21 22 23 24 25 2000 2050 2100 2150 2200 Compressive Strength (MPa) Density (kg/m3) EPS 16 17 18 19 20 21 22 23 24 25 2000 2050 2100 2150 2200 Compressive strength (MPa) Density (kg/m3) EPS coated by Surfactant Figure 1 Percentage of EPS VS Density Figure 3 Density EPS vs. Figure 1 Percentage of EPS VS Density Figure 1 Percentage of EPS VS Density According to the testing, Figure 1 can be shown that with the increasing percentage of substitution EPS will be reduced the density of the concrete. The density value will increase with the addition of a surfactant span 80 as coating of EPS in the concrete mix. Increasing the density of the concrete mixture EPS were coated surfactant also affect the compressive strength (figure 2). The compressive strength of concrete increases due to the influence of surfactant span 80 as coating of EPS, so the EPS granules become harder. Figure 2 Percentage Compressive Strength vs EPS 15 17 19 21 23 25 0% 5% 10% 15% 20% 25% Compresive strength (MPa) Precentage of substitution (%) EPS coated by surfactant EPS Figure 4 Density vs EPS coated by surfactant Concrete Compressive Strength In Table 4, the difference or addition of compressive strength of concrete mix concrete EPS and EPS coated by surfactant having an average increase of concrete compressive strength of 0,19 MPa. From this testing it can be shown that the concrete mixture that EPS coated by surfactant can increase the compressive strength of concrete, but the value is not significant. Table 4 Comparison of Concrete Compressive Strength EPS and EPS Coated by Surfactant % Subtitution EPS (MPa) EPS surfactant (MPa) Deviation (MPa) 0% 24,53 24,53 0,00 5% 19,63 19,82 0,19 10% 18,12 18,31 0,19 15% 16,99 17,17 0,19 20% 16,23 16,42 0,19 25% 15,85 16,23 0,38 Average 0,19 Table 4 Comparison of Concrete Compressive Strength EPS and EPS Coated by Surfactant Figure 2 Percentage Compressive Strength vs EPS Based on Figures 3 and 4, the increasing density of the concrete will increase the value of the compressive strength of concrete. This behavior occurs for concrete mixes with EPS and the EPS coated by surfactant span 80. Figure 1 Percentage of EPS VS Density 00031-p.4 ICASCE 2013 Table 5 Comparison of Mixed Concrete Concrete Density EPS and EPS Coated by Surfactant % Subtit ution EPS (MPa) EPS surfactant (MPa) Deviation (MPa) 0% 2184,79 2184,79 0,00 5% 2113,14 2138,869 25,73 10% 2089,11 2115,971 26,86 15% 2076,34 2098,734 22,40 20% 2053,06 2068,412 15,35 25% 2014,63 2044,444 29,82 Average 20,03 Table 5 Comparison of Mixed Concrete Concrete Density EPS and EPS Coated by Surfactant Whereas decrease of the percentage substitution EPS 5 % were coated by surfactant in concrete mix, the average decrease in compressive strength of concrete of 1,66 MPa and a decrease in the average density of 28,07 kg/m3. In Table 7, it can be shown that any decrease in the density of the concrete it will also decrease the compressive strength of concrete. Table 7 Difference of Decline Compressive Strengt and Density EPS Coated by Surfactant Variabel f’c (MPa) Density (Kg/m3) Decrease Deviation EPS each 5% f’c (MPa) Density (Kg/m3) 0% 24,53 2184,79 5% 19,82 2138,87 4,72 45,92 10% 18,31 2115,97 1,51 22,90 15% 17,17 2098,73 1,13 17,24 20% 16,42 2068,41 0,75 30,32 25% 16,23 2044,44 0,19 23,97 Average 1,66 28,07 Table 7 Difference of Decline Compressive Strength and Density EPS Coated by Surfactant Table 7 Difference of Decline Compressive Strength and Density EPS Coated by Surfactant Table 6 explain that every 5% decrease in EPS for fine aggregate substitute in concrete mixtures obtained an average reduction of compressive strength of 1,74 MPa and an average density of 34,03 kg/m3. Decreasing in the compressive strength of normal concrete mix concrete to the proportion of 5% EPS amounted to 4,91 MPa, the values differences by a margin decline EPS another substitution proportion (10%, 15%, 20%, 25%). Table 6 Difference of Decline Compressive Strength and Density EPS Table 6 Difference of Decline Compressive Strength and Density EPS Variabel f’c (MPa) Density (Kg/m3) Decrease Deviation EPS each 5% Compressive Strength (MPa) Density (Kg/m3) 0% 24,53 2184,79 - - 5% 19,63 2113,14 4,91 71,65 10% 18,12 2089,11 1,51 24,03 15% 16,99 2076,34 1,13 12,77 20% 16,23 2053,06 0,75 23,28 25% 15,85 2014,63 0,38 38,44 Average 1,74 34,03 Table 6 Difference of Decline Compressive Strength and Density EPS 4.2 Split Tensile Strength Test Results Table 8 Split Tensile Strength Concrete EPS at 28 days Variabel Height (mm) Diameter (mm) Volume (m3) Weight (kg) Experi ment Test Results (kN) Compressive Strength at 28 Days (MPa) Split Tensile Strength Average (MPa) Weight Average (kg) Density (kg/m3) L D = P (2P)/(LD) Fcr br br/v Normal 150 300 0,0053 11,022 170 7,56 7,85 11,13 2099,74 11,103 180 8,00 11,253 180 8,00 EPS 5% 150 300 0,0053 11,038 180 8,00 7,11 11,02 2079,11 10,988 150 6,67 11,024 150 6,67 EPS 10% 150 300 0,0053 11,050 110 4,89 6,22 10,96 2068,98 11,139 160 7,11 Table 8 Split Tensile Strength Concrete EPS at 28 days 00031-p.5 00031-p.5 EPJ Web of Conferences 10,700 150 6,67 EPS 15% 150 300 0,0053 10,796 160 7,11 5,93 10,91 2059,61 10,841 100 4,44 11,103 140 6,22 EPS 20% 150 300 0,0053 10,879 100 4,44 5,48 10,85 2046,77 10,767 140 6,22 10,890 130 5,78 EPS 25% 150 300 0,0053 10,353 130 5,78 5,63 10,73 2025,51 10,965 120 5,33 10,880 130 5,78 Table 9 Split Tensile Strength Concrete EPS Coated by Surfactant 28 days Variabel Height (mm) Diameter (mm) Volume (m3) Weight (kg) Experi ment Test Results (kN) Compressive Strength at 28 days MPa Split Tensile Strength Average (MPa) Weight Average (kg) Density (kg/m3) L D = P (2P)/(LD) Fcr br br/v EPSS 5% 150 300 0,0053 11,021 140 6,22 5,93 11,08 2090,18 11,012 140 6,22 11,193 120 5,33 EPSS 10% 150 300 0,0053 10,943 120 5,33 5,19 11,02 2080,11 11,128 120 5,33 10,995 110 4,89 EPSS 15% 150 300 0,0053 10,997 100 4,44 4,89 10,99 2074,1 11,091 110 4,89 10,882 120 5,33 EPSS 20% 150 300 0,0053 10,988 110 4,89 4,74 10,91 2059,01 10,918 110 4,89 10,825 100 4,44 EPSS 25% 150 300 0,0053 10,882 110 4,89 4,59 10,85 2047,97 10,779 100 4,44 10,894 100 4,44 Table 9 Split Tensile Strength Concrete EPS Coated by Surfactant 28 days Figure 6 Percentage EPS to Split Tensile Strength 4 5 5 6 6 7 7 8 8 9 0% 5% 10% 15% 20% 25% Split Tensile Strength (MPa) Precentage of EPS substitution EPS coated by surfactant EPS On Figure 6, can be shown a decline in the percentage of each additional substitution EPS and EPS were coated by surfactant as substitution the fine aggregate material. 4.2 Split Tensile Strength Test Results In addition to compressive strength test, the testing was also made of concrete split tensile strength test at the age of 28 days. The data will be obtained from tensile strength test of concrete mixtures with EPS and EPS were coated by surfactant as material substitution as fine aggregate. gg g The results of the split tensile strength testing for concrete at 28 days can be shown in Table 8. While in table 9, a split tensile strength and its density to mix concrete with EPS were coated by surfactant. 4.2 Split Tensile Strength Test Results The addition of the surfactant as coating of EPS reduces the value of the tensile strength of the concrete of EPS. Figure 6 Percentage EPS to Split Tensile Strength 4 5 5 6 6 7 7 8 8 9 0% 5% 10% 15% 20% 25% Split Tensile Strength (MPa) Precentage of EPS substitution EPS coated by surfactant EPS 5. Conclusion Based on the results obtained the following conclusions: The substitution EPS of the fine aggregate in concrete mix then reduce the compressive strength, tensile strength and density of the normal concrete mix. The addition of surfactant` span 80 as coating of EPS then increase compressive strength and density of the concrete mix, although not approaching the compressive strength and density of the normal concrete mix. The decrease of the average compressive strength when substitution EPS 5 % of the fine aggregate with value 1,74 MPa, and the decrease of average density in the concrete mix is 34,03 kg/m3. Figure 6 Percentage EPS to Split Tensile Strength 00031-p.6 ICASCE 2013 The decrease of the average compressive strength when subtitution EPS 5 % coated by surfactant of fine aggregate with value 1,66 MPa, and a decrease in the average density of its concrete at 28,07 kg/m3. References 1. Badan Standardisasi Indonesia .SNI 03-2834-2000 : Tata Cara Pembuatan Rencana Campuran Beton Normal (Provisions for Proportioning Normal Concrete Mixture). Bandung : Badan Standardisasi Indonesia.( 2000). The increase of the average compressive strength of the concrete mixes with EPS and EPS coated by surfactant is 0,19 MPa, and the increase in average density between EPS and EPS coated by surfactant in concrete mix is 20,03 kg/m3. 2. Badan Standarisasi Indonesia. (2002). SNI 03- 6815-2002 : Tata Cara Mengevaluasi Hasil Uji Kekuatan Beton (Provisions for Procedures for Evaluating Concrete Strength Test Results) . Bandung : Badan Standardisasi Indonesia. The maximum value of density and the compressive strength of concrete mix with EPS coated by surfactant is substituted EPS 5 % of the fine aggregate. Where the value compressive strength and density of EPS coated by surfactant is 19,38 MPa and 2140,565 kg/m3. 3. Badan Standardisasi Indonesia. (2004). SNI 15- 2049-2004 : Semen Portland. Bandung : Badan Standardisasi Indonesia. 4. Park, S.G., and Chisholm, D.H. (1999). Polystyrene Aggregate Concrete. Study Report No. 85. Building Research Levy. The addition of EPS coated by surfactant can reduces the split tensile strength values of 0.84 MPa for the split tensile strength of concrete mix with EPS. 5. Giri, I. B. D., Sudarsana, I. K., dan Tutarani, N. M. Kuat Tekan Dan Modulus Elastisitas Beton Dengan Penambahan Styrofoam (Styrocon). Jurnal Ilmiah Teknik Sipil, 12(1), pp75-pp85. (2008). The maximum value of split tensile strength of concrete mixtures EPS when substitution EPS 5% without surfactant, with a split tensile strength value of 7,11 MPa. This value is still less than the split tensile strength of normal concrete mix (7,85 MPa). 6. Yusuf, R. (2011). Pengaruh Penggantian Pasir Dengan Expanded Polystyrene Terhadap Kuat Tekan Dan Berat Jenis Beton. Jakarta : Universitas Bina Nusantara. 7. Setyo, Dimas dan Puripangestuti, Risa (2007). Pengaruh Precoating Surfaktan Pada Expanded Polystyrene Sebagai Agregat Terhadap Struktur dan Properti Komposit Beton .Surabaya : ITS 00031-p.7
https://openalex.org/W4281486887	https://www.frontiersin.org/articles/10.3389/fenvs.2022.898922/pdf	English	null	Social Acceptance of Smart City Projects: Focus on the Sidewalk Toronto Case	Frontiers in environmental science	2,022	cc-by	3,771	Edited by: Brian Webb, Cardiff University, United Kingdom Edited by: Brian Webb, Cardiff University, United Kingdom Reviewed by: Olaf Schroth, Weihenstephan-Triesdorf University of Applied Sciences, Germany INTRODUCTION In recent years, the movement toward implementing smart city projects has gained momentum around the world (Camero and Alba, 2019; Cugurullo, 2020; Toli and Murtagh, 2020). For example, in Copenhagen (Denmark), big data is used for energy management and technological innovations (Bjørner, 2021; Ipsen et al., 2019). In Barcelona (Spain), information technology mitigates the serious problem of insufﬁcient parking space (Lanza et al., 2016; Sotres et al., 2019). While these initiatives have gained momentum, there remains some major challenges: One is the issue of social acceptance of the projects. Speciﬁcally, there have been scattered cases where citizens have negative attitudes toward smart city projects and those business operators, including company and government ofﬁcials (e.g., Ji and Chan, 2020; Keymolen and Voorwinden, 2020; Shimizu et al., 2021b). Factors associated with the degree of social acceptance include trust in business operators and the perceived risk, beneﬁt, necessity, and fairness (e.g., Iliopoulos et al., 2020; Kim et al., 2019; Shimizu et al., 2022; Sonnberger and Ruddat, 2017). The lack of trust in the business operators signiﬁcantly impacts on the decline in social acceptance (Corsini et al., 2019; Julsrud and Krogstad, 2020; Shimizu et al., 2021a). We undertake a detailed examination of the relationship between trust and social acceptance of smart city projects. OPINION published: 25 May 2022 doi: 10.3389/fenvs.2022.898922 Social Acceptance of Smart City Projects: Focus on the Sidewalk Toronto Case Yuho Shimizu 1, Shin Osaki 2, Takaaki Hashimoto 3 and Kaori Karasawa 1 1Graduate School of Humanities and Sociology, The University of Tokyo, Tokyo, Japan, 2Graduate School of Frontier Scienc The University of Tokyo, Tokyo, Japan, 3Faculty of Sociology, Toyo University, Tokyo, Japan Keywords: smart city, social acceptance, trust, Sidewalk Toronto, case study Keywords: smart city, social acceptance, trust, Sidewalk Toronto, case study PURPOSE AND METHODS Correspondence: Yuho Shimizu yuhos1120mizu@gmail.com We focus on the case in Toronto, Canada (called Sidewalk Toronto) as one of the representative examples where a lack of trust led to strong citizen opposition. Sidewalk Toronto is a large-scale smart city project by Toronto Waterfront Revitalization Corporation (Waterfront Toronto), which selected Google’s sister company, Sidewalk Labs, as the development partner. Waterfront Toronto and Sidewalk Labs aimed to implement smart city in a section of the Waterfront area (i.e., Quayside). There are two main reasons for selecting Sidewalk Toronto as the focus of this research. First, Sidewalk Toronto has been extensively discussed in previous studies as a representative example of a large-scale smart city project whose decline in social acceptance may have caused its cancellation (e.g., Keymolen and Voorwinden, 2020; Tenney et al., 2020; Zhang et al., 2022). Second, although Sidewalk Toronto is a public utility, the development involved the sister company of Google, a global data giant with a head ofﬁce outside of Canada. When a company strongly pursues its own interests, people generally become suspicious of a project and have difﬁculty trusting it (e.g., the company is deceptive; Bhattacharjee et al., 2017; Silver et al., 2020). In addition, there might be a distrust that the individual data acquired from Quayside would be misused or leaked to an unspeciﬁed audience by Sidewalk Labs, further reducing social acceptance. Therefore, we focus on Sidewalk Toronto case and examine the relationship between trust in business operators and social acceptance. Specialty section: This article was submitted to Environmental Citizen Science, a section of the journal Frontiers in Environmental Science Received: 18 March 2022 Accepted: 04 May 2022 Published: 25 May 2022 Received: 18 March 2022 Accepted: 04 May 2022 Published: 25 May 2022 Citation: Shimizu Y, Osaki S, Hashimoto T and Karasawa K (2022) Social Acceptance of Smart City Projects: Focus on the Sidewalk Toronto Case. Front. Environ. Sci. 10:898922. doi: 10.3389/fenvs.2022.898922 May 2022 \| Volume 10 \| Article 898922 1 Frontiers in Environmental Science \| www.frontiersin.org Sidewalk Toronto Social Acceptance Shimizu et al. TABLE 1 \| Summary timeline of the Sidewalk Toronto case. Date (m/d/y) Event 3/17/2017 WT launched a call for business operators to develop Quayside 10/16/2017 Sidewalk Labs became a partner company 2/2/2018 Sidewalk Labs announced a public engagement plan 3/20/2018 The ﬁrst roundtable was held 5/2/2018 The Canadian Press published an opposing article on Sidewalk Toronto 5/3/2018 The second roundtable was held 8/14,15/2018 The third roundtable was held 10/5/2018 Muzaffar resigned from the Digital Strategy Advisory Panel 12/8/2018 The fourth roundtable was held 2/15/2019 Sidewalk Labs was criticized for trying to reduce taxes/costs 2/25/2019 #BlockSidewalk began an opposition campaign toward Sidewalk Toronto 4/16/2019 CCLA ﬁled a lawsuit against the governments and WT 6/24/2019 WT released a draft of Sidewalk Labs MIDP 10/31/2019 WT announced compliance with all laws and data will remain in Canada 5/8/2020 Sidewalk Labs withdrew from Sidewalk Toronto Note. WT, Waterfront Toronto; CCLA, Canadian Civil Liberties Association; MIDP, Master Innovation and Development Plan. TABLE 1 \| Summary timeline of the Sidewalk Toronto case. public facilities (Sidewalk Labs, 2021). On February 2, 2018, Sidewalk Labs announced the public engagement plan and held its ﬁrst roundtable on March 20, 2018. Citizens at the meeting expressed opinions such as “data collection should be transparent and based on sufﬁcient consensus (Waterfront Toronto, 2020).” On May 2, 2018, the Canadian Press published an opposition article to Sidewalk Labs’ plan. The article argued Canadians risk that their individual data will be collected under laws outside Canada (The Canadian Press, 2018a). However, during the second (May 3, 2018) and third (August 14 and 15, 2018) roundtables, very limited responses were given to the citizens regarding the management of data containing personal information (Boisvert, 2018; Wylie, 2018). g p y Subsequently, the resignation of Saadia Muzaffar from Waterfront Toronto’s Data Strategy Advisory Panel occurred on October 5, 2018 (The Canadian Press, 2018b). Saadia Muzaffar strongly criticized Sidewalk Labs for not adequately discussing the topic of data management at the roundtables. Citation: At the fourth roundtable held on December 8, 2018, citizens expressed their concerns and lack of understanding of the operation of the non-proﬁt organization managing the data (Waterfront Toronto, 2020). On February 15, 2019, the Canadian Press published an article criticizing Sidewalk Labs for its efforts to reduce property taxes/development costs and to receive some proﬁts from rising land prices, instead of investing money in their proposed Light Rail Transit (i.e., the new form of energy-efﬁcient tram transportation; The Canadian Press, 2019a). Note. WT, Waterfront Toronto; CCLA, Canadian Civil Liberties Association; MIDP, Master Innovation and Development Plan. Our assessment of Sidewalk Toronto details the history of interactions between the business operators and citizens to determine the impact of a lack of trust on the decline in the social acceptance. We also discuss what points should be considered by business operators of smart city projects to enhance the social acceptance. A case study provides a valuable opportunity for assessing the contextual background with a wide range of mediating variables (George and Bennett, 2005; Noble and Smith, 2015). Therefore, a case study analysis is the appropriate method to use in this research. We reviewed the data from various sources, such as press releases, online reports, and academic papers that addressed the case of Sidewalk Toronto. Speciﬁcally, we examined a wide range of materials published by the government, Waterfront Toronto, Sidewalk Labs, the citizens’ group #BlockSidewalk, the human rights group Canadian Civil Liberties Association (CCLA), and the media, such as the Canadian Press. Meanwhile, methodological limitations will be described later. In this study, we provide a new perspective for studies that aim to broadly identify the determinants of social acceptance of smart city projects in a variety of ﬁelds such as environmental science, urban planning, and psychology. Considering the above issues, the #BlockSidewalk began opposition activities on February 25, 2019. On April 16, 2019, the CCLA ﬁled a lawsuit against the national, provincial, and municipal governments and Waterfront Toronto. On June 24, 2019, Waterfront Toronto released a draft of the Master Innovation and Development Plan (MIDP), which was produced by Sidewalk Labs. The MIDP included a policy to expand the project’s implementation area and Waterfront Toronto expressed some concerns over the expansion policy (The Canadian Press, 2019b). DISCUSSION The following section details Sidewalk Toronto and the relationship between business operators and citizens in this project, and the timeline of events is presented in Table 1. On March 17, 2017, Waterfront Toronto launched a call for business operators to develop Quayside. Sidewalk Labs was selected as the development partner. Speciﬁcally, the goal of this project was to create a city that is both sustainable and expected to grow economically by using the latest technology throughout the region, including advances in housing and mobility (Sidewalk Labs, 2021). In addition, the project aimed to capture and utilize a wide range of individual data, including the citizens’ daily travel routes and usage history of Citation: On October 31 2019, Waterfront Toronto announced that all the individual data will be stored in Canada and that Waterfront Toronto will comply with all existing and future laws (Waterfront Toronto, 2019). However, Waterfront Toronto’s attempts to appease community sentiment were in vain. On May 8 2020, Sidewalk Labs withdrew from Quayside, stating the COVID-19 pandemic delayed the project and caused it not to be proﬁtable anymore. Bjørner, T. (2021). The Advantages of and Barriers to Being Smart in a Smart City: The Perceptions of Project Managers within a Smart City Cluster Project in Greater Copenhagen. Cities 114, 103187. doi:10.1016/j.cities.2021.103187 Boisvert, N. (2018). Sidewalk Labs Has Unveiled its Bold Vision for Quayside: Just Don’t Ask How It’ll Get Built. Available from: https://www.cbc.ca/news/canada/ toronto/sidewalk-labs-master-plan-1.4789279 (Accessed March 17, 2022). Limitation and Future Directions We did not conduct interviews with multiple stakeholders, such as the citizens of Toronto. Interviews with a variety of stakeholders would provide more meaningful data to investigate their subjective responses and should be conducted in the future. In addition, we excluded the information that is not available on the ofﬁcial websites of each stakeholder. Moreover, our survey was limited to a single case study, Sidewalk Toronto. Focusing on one case study can be problematic: Researchers are more likely to focus on a case with particular and/or rare outcomes which are not general representative cases (George and Bennett, 2005; Noble and Smith, 2015). Accordingly, future assessments should compare the case of Sidewalk Toronto with other smart city projects to improve the generalizability of our ﬁndings. We focused on Sidewalk Toronto, where the lack of trust in the business operators declined the social acceptance of the project. To increase the social acceptance of smart city projects, the results indicate that business operators should rigorously handle individual data, transparently implement projects, and provide an appropriate scope for the public authority. This research provides new perspectives for a wide range of research areas (e.g., environmental science, urban planning, and psychology) that aim to enhance the social acceptance of smart city projects. This research is also meaningful for business operators who work with the community. Future research will compare a variety of cases using interviews with citizens residing in cities with failed/successful smart city projects. We did not conduct interviews with multiple stakeholders, such as the citizens of Toronto. Interviews with a variety of stakeholders would provide more meaningful data to investigate their subjective responses and should be conducted in the future. In addition, we excluded the information that is not available on the ofﬁcial websites of each stakeholder. Moreover, our survey was limited to a single case study, Sidewalk Toronto. Focusing on one case study can be problematic: Researchers are more likely to focus on a case with particular and/or rare outcomes which are not general representative cases (George and Bennett, 2005; Noble and Smith, 2015). Accordingly, future assessments should compare the case of Sidewalk Toronto with other smart city projects to improve the generalizability of our ﬁndings. Bhattacharjee, A., Dana, J., and Baron, J. (2017). Anti-proﬁt Beliefs: How People Neglect the Societal Beneﬁts of Proﬁt. J. Personality Soc. Psychol. 113, 671–696. doi:10.1037/pspa0000093 How to Increase the Social Acceptance of Smart City Projects An important strategy for enhancing the social acceptance of smart city projects is to increase the trust in business operators. As suggested by many previous studies (e.g., Corsini et al., 2019; Julsrud and Krogstad, 2020; Shimizu et al., 2021a), trust is strongly related to social acceptance, and business operators should strive to gain trust from the citizens. Additionally, the lack of trust was related to diverse concerns by the citizens (data management, plan execution processes, and monetization methods). Therefore, we suggest the following three strategies to effectively increase social acceptance. The ﬁrst suggestion is to handle individual data in a rigorous manner, following the laws of the citizens’ country. Business operators should ensure that the data is effectively managed within a framework that is safely protected by the laws of the local country, irrespective of that of other countries. The second suggestion is to implement projects transparently. The perceived integrity of business operators is signiﬁcantly associated with higher levels of trust (Bronfman et al., 2012; Kitt et al., 2021). When a large amount of personal information is obtained and utilized in smart city projects, trust between the business operators and citizens is very important for a smooth implementation. Therefore, it is important for business operators to respond with integrity and not ignore the citizens’ concerns. In addition, monitoring and disclosure of all activities of the business operators by a third-party organization may also contribute to increasing social acceptance. ACKNOWLEDGMENTS The third suggestion is to ensure an appropriate scope of public authority by the business operators. When a business operator has an excessive public authority, it is easy for citizens to be concerned that the project implementation will proceed to beneﬁt only the operator. Unlike solitary localized public works, smart city projects are often large-scale and are closely associated This research is partly based on a graduation thesis submitted by Yuki Ono to Faculty of Letters, The University of Tokyo, in the year 2021. We would like to express our gratitude in which he has contributed to the preliminary conception of this article. AUTHOR CONTRIBUTIONS YS, SO, TH, and KK contributed to the conception and design of the study. YS wrote the ﬁrst draft of the manuscript. YS, SO, TH, and KK contributed to manuscript revision, read, and approved the submitted version. Trust and Social Acceptance of Sidewalk Toronto The vital relationship between trust in business operators and social acceptance of Sidewalk Toronto can be summarized as follows. Initially, it is believed that there was distrust that the individual data, including the citizens’ daily travel routes and usage history of public facilities (Sidewalk Labs, 2021), would be misused or leaked to an unspeciﬁed audience by Sidewalk Labs, the sister company of Google. Next, as the project gradually progressed, the following three concerns were considered to have arisen. The ﬁrst concern May 2022 \| Volume 10 \| Article 898922 Frontiers in Environmental Science \| www.frontiersin.org 2 Sidewalk Toronto Social Acceptance Shimizu et al. involved data management. Citizens were concerned that the individual data acquired by Quayside would be stored in the U.S. (where Sidewalk Labs is based) and Canadian laws would no longer apply. The second concern involved the execution processes. Citizens were concerned that Sidewalk Labs did not provide sufﬁcient and sincere answers regarding data management. The third concern involved monetization methods. Citizens were concerned that Sidewalk Labs may be able to inﬂuence public authority over its policies, as demonstrated by its requests to reduce property taxes/development costs and expand the project’s implementation area. As a result of these major concerns, the original distrust in Sidewalk Labs seemed to amplify, further reducing the social acceptance of the project. The mechanism by which trust in business operators and concerns by citizens interact should be examined in more detail in future research. with the daily lives of many citizens. Therefore, it is important to moderate the rights of the business operators to limit their authority. In addition, if the operators are strongly pursuing their own interests, the citizens can form negative attitudes toward them (Bhattacharjee et al., 2017; Silver et al., 2020), and become concerned that the beneﬁts enjoyed by citizens may be greatly reduced. REFERENCES May 2022 \| Volume 10 \| Article 898922 Frontiers in Environmental Science \| www.frontiersin.org 3 Sidewalk Toronto Social Acceptance Shimizu et al. Bronfman, N. C., Jiménez, R. B., Arévalo, P. C., and Cifuentes, L. A. (2012). Understanding Social Acceptance of Electricity Generation Sources. Energy Policy 46, 246–252. doi:10.1016/j.enpol.2012.03.057 Sotres, P., Lanza, J., Sánchez, L., Santana, J. R., López, C., and Muñoz, L. (2019). Breaking Vendors and City Locks through a Semantic-Enabled Global Interoperable Internet-Of-Things System: A Smart Parking Case. Sensors 19, 229. doi:10.3390/s19020229 Camero, A., and Alba, E. (2019). Smart City and Information Technology: A Review. Cities 93, 84–94. doi:10.1016/j.cities.2019.04.014 Tenney, M., Garnett, R., and Wylie, B. (2020). A Theatre of Machines: Automata Circuses and Digital Bread in the Smart City of Toronto. Can. Geogr./Le Géogr. Can. 64, 388–401. doi:10.1111/cag.12636 Corsini, F., Certomà, C., Dyer, M., and Frey, M. (2019). Pa Corsini, F., Certomà, C., Dyer, M., and Frey, M. (2019). Participatory Energy: Research, Imaginaries and Practices on People’ Contribute to Energy Systems in the Smart City. Technol. Forecast. Soc. Change 142, 322–332. doi:10.1016/j. techfore.2018.07.028 g The Canadian Press (2018a). Sidewalk Labs’ Proposed Neighbourhood Remains a Lightning Rod for Privacy Concerns. Available from: https://www.cbc.ca/news/ canada/toronto/sidewalk-labs-privacy-concerns-1.4644449 (Accessed March 17, 2022). Cugurullo, F. (2020). Urban Artiﬁcial Intelligence: From Automation to Autonomy in the Smart City. Front. Sustain. Cities 2, 38. doi:10.3389/frsc.2020.00038 George, A. L., and Bennett, A. (2005). Case Studies and Theory Development in the Social Sciences. MIT Press. The Canadian Press (2018b). Sidewalk Labs’ Advisory Panel Member Resigns Citing ‘profound Concern’ about Project. Available from: https://www.cbc.ca/news/ canada/toronto/sidewalk-labs-panel-resigns-1.4852223 (Accessed March 17, 2022). Iliopoulos, N., Esteban, M., and Kudo, S. (2020). Assessing the Willingness of Residential Electricity Consumers to Adopt Demand Side Management and Distributed Energy Resources: A Case Study on the Japanese Market. Energy Policy 137, 111169. doi:10.1016/j.enpol.2019.111169 The Canadian Press (2019a). Sidewalk Wants Cut of Property Taxes and Development Fees for Quayside Project. Available from: https://www.cbc.ca/ news/canada/toronto/sidewalk-labs-taxes-fees-1.5020936 (Accessed March 17, 2022). Ipsen, K. L., Zimmermann, R. K., Nielsen, P. S., and Birkved, M. (2019). Environmental Assessment of Smart City Solutions Using a Coupled Urban Metabolism-Life Cycle Impact Assessment Approach. Int. J. Life Cycle Assess. 24, 1239–1253. doi:10.1007/s11367-018-1453-9 The Canadian Press (2019b). Sidewalk Labs Releases Plan for Controversial Toronto Development amid Concerns about Privacy. Available from: https://www.cbc.ca/ news/canada/toronto/toronto-sidewalk-labs-plan-1.5187877 (Accessed March 17, 2022). Ji, W., and Chan, E. H. W. (2020). REFERENCES Between Users, Functions, and Evaluations: Exploring the Social Acceptance of Smart Energy Homes in China. Energy Res. Soc. Sci. 69, 101637. doi:10.1016/j.erss.2020.101637 Toli, A. M., and Murtagh, N. (2020). The Concept of Sustainability in Smart City Deﬁnitions. Front. Built Environ. 6, 77. doi:10.3389/fbuil.2020.00077 Julsrud, D. T. E., and Krogstad, D. J. R. (2020). Is There Enough Trust for the Smart City? Exploring Acceptance for Use of Mobile Phone Data in Oslo and Tallinn. Technol. Forecast. Soc. Change 161, 120314. doi:10.1016/j.techfore.2020.120314 Waterfront Toronto (2019). Open Letter from Waterfront Toronto Board Chair. Available from: https://waterfrontoronto.ca/nbe/portal/waterfront/Home/ waterfronthome/newsroom/newsarchive/news/2019/october/open+letter+ from+waterfront+toronto+board+chair+-+october+31%2C+2019 (Accessed March 17, 2022). Keymolen, E., and Voorwinden, A. (2020). Can We Negotiate? Trust and the Rule of Law in the Smart City Paradigm. Int. Rev. Law, Comput. Technol. 34, 233–253. doi:10.1080/13600869.2019.1588844 Kim, Y., Lee, J., and Ahn, J. (2019). Innovation towards Sustainable Technologies: A Socio-Technical Perspective on Accelerating Transition to Aviation Biofuel. Technol. Forecast. Soc. Change 145, 317–329. doi:10.1016/j.techfore.2019.04.002 Waterfront Toronto (2020). Pre-MIDP Public Consultation Feedback Summary Report. 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Big Data Analytics, Resource Orchestration, and Digital Sustainability: A Case Study of Smart City Development. Gov. Inf. Q. 39, 101626. doi:10.1016/j.giq.2021.101626 Noble, H., and Smith, J. (2015). Issues of Validity and Reliability in Qualitative Research. Evid. Based Nurs. 18, 34–35. doi:10.1136/eb-2015-102054 Conﬂict of Interest: The authors declare that the research was conducted in the absence of any commercial or ﬁnancial relationships that could be construed as a potential conﬂict of interest. Conﬂict of Interest: The authors declare that the research was conducted in the absence of any commercial or ﬁnancial relationships that could be construed as a potential conﬂict of interest. Shimizu, Y., Ishizuna, A., Osaki, S., Hashimoto, T., Tai, M., Tanibe, T., et al. (2022). Frontiers in Environmental Science \| www.frontiersin.org REFERENCES The Social Acceptance of Smart Health Services in Japan. Int. J. Environ. Res. Public Health 19, 1298. doi:10.3390/ijerph19031298 Shimizu, Y., Osaki, S., Hashimoto, T., and Karasawa, K. (2021a). The Social Acceptance of Collecting and Utilizing Personal Information in Smart Cities. Sustainability 13, 9146. doi:10.3390/su13169146 Publisher’s Note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their afﬁliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Shimizu, Y., Osaki, S., Hashimoto, T., and Karasawa, K. (2021b). How Do People View Various Kinds of Smart City Services? Focus on the Acquisition of Personal Information. Sustainability 13, 11062. doi:10.3390/su131911062 Sidewalk Labs (2021). Sidewalk Toronto. Available from: https://www.sidewalklabs. com/toronto (Accessed March 17, 2022). Copyright © 2022 Shimizu, Osaki, Hashimoto and Karasawa. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Silver, I., Newman, G., and Small, D. A. (2020). Inauthenticity Aversion: Moral Reactance toward Tainted Actors, Actions, and Objects. Consum. Psychol. Rev. 4, 70–82. doi:10.1002/arcp.1064 Sonnberger, M., and Ruddat, M. (2017). Local and Socio-Political Acceptance of Wind Farms in Germany. Technol. Soc. 51, 56–65. doi:10.1016/j.techsoc.2017. 07.005 May 2022 \| Volume 10 \| Article 898922 Frontiers in Environmental Science \| www.frontiersin.org
W3107953472.txt	http://www.scielo.br/pdf/mr/v23n6/1516-1439-mr-23-6-e20190687.pdf	en		Influence of Si on the Structural, Electrical, and Optical Properties of (Al, Ti, Si)N Films Deposited Via Reactive DC Sputtering	Materials research	2,020	cc-by	3,775	Materials Research. 2020; 23(6): e20190687 DOI: https://doi.org/10.1590/1980-5373-MR-2019-0687 Influence of Si on the Structural, Electrical, and Optical Properties of (Al, Ti, Si)N Films Deposited Via Reactive DC Sputtering A.M. Guzman Palaciosa, J.J. Olayaa , J.E. Alfonsob*  Universidad Nacional de Colombia, Facultad de Ingeniería, Bogota, Colombia Universidad Nacional de Colombia, Departamento de Física, Grupo de Ciencia de Materiales y Superficies, Bogota, Colombia a b Received: December 20, 2019; Revised: September 28, 2020; Accepted: October 16, 2020 The physical and chemical properties of multifunctional materials have been extensively studied in the last few years especially the mechanical and tribological applications and less attention has taken the electrical and optical properties. Therefore, in this work presents the growth of (Al, Ti, Si)N films deposited on common glass substrates with a maximum thickness of 1024 nm, via reactive DC magnetron sputtering, to analyze the influence of the silicon content on their crystallographic structure, optic and electric behavior. The microstructure of the films was characterized by X-ray diffraction (XRD). The films morphology was evaluated through scanning electronic microscopy (SEM). The optical measurements were carried out by means UV-vis spectroscopy, and the electrical properties were analyzed using a four-point probe. XRD analysis indicated that the films changed from a crystalline phase to an amorphous phase, and the electrical and optical response indicated that the films with higher Si content have l223.6 Ω.cm of resistivity with an energy gap of approximately 1.0 eV and an optical energy gap of 1.5 eV. This electrical property has not been previously reported in these films. Keywords: Multifunctional, films, sputtering, optical and electrical properties. 1. Introduction Ceramic films of transition metal nitrides grown via Physical Vapor Deposition (PVD) have been widely used in various engineering applications. Specifically, (Ti,Al,Si)N nanostructured coatings have been attracted a lot of attention given their metallic nature associated with an fcc-TiN, along with their dielectric behavior of AlN in the wurtzite crystal structure, and amorphous silicon nitride-α-Si3N41-3. Additionally, these materials have been used for several industrial applications as protective coatings for tooling and cutting operations4-7, in diffusion barrier coatings in energy devices6, and in spectrally selective solar absorbers, where TiN and (Ti,Al)N are chemically inert and have spectral and protective selectivity against corrosion8-13. The composites with TiN that have a resistivity under of 10 Ω-m are part of the conductive ceramics that are used for electrical discharge equipment14. The electrical resistivity in these composites depend primarily on the content of the TiN phase and on the microstructure formed during its production15. For example, the electrical conductivity of Si3N4-TiN presents a percolation behavior, which is characterized by a decrease in resistivity for low content of TiN16. The concentration of TiN that enables the formation of a conductive network is called percolation threshold17. This behavior may be regarded as a second-order phase transformation. Lux describes the models for the evaluation of the percolate behavior, in mixtures with a high insulating matrix and dispersed conductive phase18. Apart from the electrical conductivity, *e-mail: jealfonsoo@unal.edu.co many of the properties of the materials show a large range of values at or near the percolation threshold19. On the other hand, in recent work the addition of a third element, in small quantities, to the crystallographic lattice of metal nitrides has modified its crystallographic structure, determining changes in the chemical-physical properties of these nitrides. A chemical element that has been widely used is silicon (Si)20-23. The addition of this element to the nitride atomic lattice has shown that it affects the morphology, microstructure and functional properties of the coating due to the formation of a nanocomposite structure, which consists of two phases, a nanocrystalline and another amorphous24. These materials have been shown to have a combination of excellent mechanical properties (high hardness and fracture toughness), high thermal stability, high oxidation resistance, high corrosion resistance and good tribological properties (friction coefficients between 0.5 to 0.7) compared to transition metal nitrides25,26. However, there are few works that study the optical and electrical behavior of films (Ti, Al, N) Si. Therefore, in this work, (Al,Ti,Si)N films were grown via reactive DC magnetron sputtering, and their electrical and optical properties were evaluated as a function of their Si content. 2. Experimental Method The films were grown via reactive DC sputtering technique from a TiAl (Ti50%-Al50%), Plasmaterial.INC target. In this target were placed one and two quadrangular Si pieces of 0.508 cm2. The deposition conditions of the films 2 Palacios et al. were: initial pressure of 5 x 10-6 mbar and the final pressure of 3.46 x 10-4 mbar (Ar+N2 pressures), the power applied to the target was fixed at 200 W (current density of 9.34 mA.cm-2). The distance between the target and the glass substrate (1cm x 1.5 cm) was kept constant in 5 cm, the substrate temperature was 150°C (measured with K-type thermocouple), and time deposition was of one hour. In Table 1 is summarize this deposit conditions. The morphological characterization was performed with a FEI Quanta 200 scanning electron microscope equipped with an energy dispersive X-ray (EDX) probe. The X-ray diffraction (XRD) patterns were registered with Phillips X-Pert Pro Panalytical equipment, working in Bragg-Brentano (θ-2θ) configuration and Cu K⍺ radiation (λ=1.540998 Å). XRD patterns were taken for a 2θ range between 10 and 90º in steps of Δ2θ=0.02, and a Cary Varian 5000 UV-VIS-NIR spectrophotometer was used to study the optical properties of the films. The transmittance measurements were made from 200 to 2.500 nm wavelength range and the electrical measurements were made using four-point equipment, varying DC voltage between -20 to 20V. The measure the thickness of the film was carried out with a Bruker Contour GT-K 3D optical microscope. 3. Results and Discussion Figure 1 shows scanning electronic microscopy (SEM) micrographs of (Al,Ti,Si)N film surfaces and their transversal sections. The morphology of the surfaces of films deposited without Si and with one Si piece is smooth and no evident droplets or porosities. This morphology is typical of the films deposited with sputtering technique. On the surface of the films, that grew with two Si pieces have droplets with different radius. Moreover, the transversal sections that show in figures b and d indicate that the growth mechanism is columnar, while the film growth with more Si presents a coalescence mechanism growth. Representative EDX spectrum of the (Al, Ti, Si)N films is shown in Figure 2. In this spectrum is evident the presence of lines Kα of X-ray of N (392.40 ev), Al (1.48 keV), Si (1.73) and Ti (4.51 Kev). Additionally, appear X-ray lines of the glass substrate. Table 2 shows the composition of (Al,Ti,Si)N films that were deposited on glass substrates and analyzed by means EDX. The analysis shows that the Table 1. Deposition conditions of the (Ti, Al, N) Si films. Deposit Parameters. Initial pressure (mbar) Final pressure (mbar) Power (W) Current density (mA/cm2) Substrate Temperature (°C) Deposition Time (h) 5 x 10-6 3.46 x 10-4 200 9.34 150 1 Materials Research atomic percentage of Si increases and that of Al decreases in the films. The difference in composition could be attributed to the different sputtering yields (0.33 for Al, 0.18 for Si and 0.15 for Ti, values calculate for ions energies of 200 eV). The contents of Ti and N maintain a relative stable value of 11±1 at. % and 49±1 at.%, respectively. The values of the atomic percentage of Nitrogen make it possible to establish that the chemical composition of the films is formed by mixed TiN, AlN, and SiN phases. A considerable amount of residual oxygen (≈ 4.0 at. %) were detected in all coatings, which may be due to the surface contamination of the targets when the deposition chamber was brought to air for sample transfer. Figure 3, shows the XRD patterns from (Al,Ti,Si)N films deposited on a common glass substrates at 150ºC. The peak observed at 2θ = 33.7º was index with a w-AlN phase with the space group P63mc (ICDD-00-046-1200). The dotted line in the XRD patterns indicates the position of ( 1010 ) reflections for AlN with a formation energy of -1.595 eV27. However, the slightly shifted peak position could be attributed to a substitution from Ti to Al and residual stresses in the films. In lower formation energies, it is possible to obtain an arrangement of atoms in a larger metal sub-lattice (the so-called “special quasi-random structure” or SQS); this structure has been found in TiAlN films28. When Al contents exceed the solubility limit (for molar fraction AlN > 0.70), resulting in a dual phase structure of c/w-Ti1-xAlxN29. The XRD patterns for films with one piece of Si (at.% 3.49) have two peaks: the w-AlN phase (peak at 2θ = 33.06º), and the (Al,Ti,Si)N, rock-salt B1 structure with the space group Fm3m , in solid solution (peak at 2θ = 36.6º (ICDD-37-1140)). The difference in the orientation of the peaks can result from the addition of silicon and the formation of amorphous Si3N4. The silicon in the (Al,Ti)N film refined the grains and consequently increased the strain energy. When the number of atoms in a grain is reduced, an excess of surface free energy is generated30. This grain can reduce this excess free energy by changing its preferential orientation to one that has less surface free energy31. The diminution of the crystallite size or defects caused by strain between substrate and film can lead to peak broadening30. In XRD patterns, no peaks corresponding to Si3N4 or Ti-Si compounds, suggesting that Si can be incorporated to either Ti/Al in the c/w-TiSiAlN nano-crystallites or in amorphous Si-N accumulated at the (Ti,Al)N nano-crystallites. These results are in accordance with those found by Chen et al.8, who reported a solid solution of Si substitution for Al; in w-AlN and the nanocomposite, structure of nc-TiAlN/α-Si3N4 has been widely accepted32. Finally, the films growing with two Si pieces have a broad and low-intensity hump, ranging from 2θ ~ 20 to 30°, which indicates an amorphous phase (see Figure 3). These results are agreement with Yu et al. work33, who found that with the increasing of Si content, segregation of TiAlN nanocrystals in an amorphous Si3N4 matrix led Table 2. Compositions of the (Al,Ti,Si) N films (at.%) analyzed by EDX. TiAlN TiAlN+1Si TiAlN+2Si Ti (at.%) 10.9 13.2 10.4 Al (at.%) 35.2 31.8 28.9 Si (at.%) 0.8(substrate) 3.4 6.0 N (at.%) 48.8 48.4 50.2 O (at.%) 4.3 3.2 4.5 Influence of Si on the Structural, Electrical, and Optical Properties of (Al, Ti, Si)N Films Deposited Via Reactive DC Sputtering 3 Figure 1. SEM micrograph of the (Al, Ti,Si)N film surface and transverse sections deposited on common glass (a) and (b) Without Si, (c) and (d) with one Si piece, and (e) and (f) with two Si pieces. Figure 2. EDX spectrum of (Al,Ti,Si)N films deposited on glass substrate. to the formation of a composition of a mixture of the solid solution Ti(AlSi)N and Ti(AlSi)N/α-Si3N4. Additionally, determined that coatings deposited with 7.95 Si At %, loss the crystallinity and coatings with 22 at.% of Si be amorphized. Figure 4 shows an example that how was measured of the cross section using an optical microscopy image of (Ti,Al,Si) N coating and Table 3 summarizes the mean thickness of the films. The thickness of the films increases from 639 to 1024 nm. When the film grows from two-silicon pieces, the thickness drops to 953 nm, possibly due to the development of amorphous morphology features33. Growth rates of deposition were also calculated by using deposition time. I-V characteristics curves of the (Al,Ti,Si)N films grown on common glass are shown in Figures 5a and 5b. These figures show ohmic behavior of the films, while Figure 5c shows that films deposited with a higher Si content have the electrical behavior of a semiconductor. The electrical resistivity of (Al,Ti)N was 12.551 Ω.cm (see Figure 5a). By adding one 4 Palacios et al. Table 3. Thickness of (AlTiSi) N films with different contents of Silicon. Thickness (nm) TiAlN TiAlN-1Si TiAlN-2Si 639 1024 953 Growth rate (nm/min) 10.6 17.1 15.1 Figure 3. XRD patterns of (Al,Ti,Si)N films with varying silicon contents. Figure 4. Example of 3D profilometer image of coating (Ti,Al,Si)N Materials Research silicon piece into (Al,Ti)N, the electrical resistivity of films drops to about 223.6 Ω.cm (see Figure 4b). It is reasonable to consider that the electrical resistivity of (Al,Ti)N films somewhat increased upon adding AlN to TiN, because AlN is a well-known insulating material with a very high electrical resistivity (1015 Ω cm)26. Another reason for this electrical behavior is possibly the microstructural variations in (Al,Ti)N and (Al,Ti)N+1Si films. Electrical resistivity could depend on the connectivity of the c-(Al,Ti,Si)N phase mixtures throughout the composite and the concentration of w-(Al,Si)N and possibly α-Si3N4 (isolate material), so the so-called percolate behavior described by Lux18 occurs. The energy gap of 1.0 eV determined the semiconductor behavior of the film, with more Si content (see Figure 5c), which can be related to conduction jumps among the different potential barriers produced by the crystallites of c-(Ti, Al, Si) N and the intrinsic defects of the films that separate these metallic domains. These defects cause strong changes in the electronic structure and metal-semiconductor transitions, resulting in a hopping process in the transport of electrical charge34. Figure 6a shows the transmittance behavior of the (Al,Ti,Si)N film as a function of the wavelength and as a study parameter, the Si amount. The figure shows that the films begins to have transmittance at about 300 nm and reaches 70% at 2,500 nm in films that were grown without Si, whereas the transmittance percentage drops to approximately 10% in films that were grown with two pieces of Si, at the same wavelength. These results show that the addition of Si to (Al, Ti)N films produces opacity in them35, which may occur because the films observed in SEM micrographs have homogeneity, suggesting high optical density. The transmittance behavior of the films deposited without Si corresponds with the results of other studies3,11,31. However, introducing Si into the (Al, Ti) N matrix could produce optic absorption across the entire electromagnetic spectrum. In a defect-free crystalline semiconductor, the absorption spectrum edge terminates at the energy gap. In contrast, in an amorphous semiconductor, a tail encroaches in the absorption spectrum into the gap region. This tail arises because the crystallographic disorder of amorphous semiconductors makes the absorption edge of these semiconductors difficult to define experimentally36. Influence of Si on the Structural, Electrical, and Optical Properties of (Al, Ti, Si)N Films Deposited Via Reactive DC Sputtering 5 Figure 5. Current vs voltage of the (Al,Ti,Si)N films deposited on common glass (a) without Si, (b) 1 piece of Si and c- 2 Si. Figure 6. (a) Transmittance as a function of wavelength and (b) (αhν)1/2 Vs photon energy of the (Al,Ti,Si)N films deposited on common glass, taking as study parameter the Si content. The Tauc model is the most used to calculate the optical gap of an amorphous semiconductor. Assuming that conduction and valence bands obey a square root-distributions, an extrapolation of (αhν)1/2 to the horizontal axis defines the energy gap (Eg indirect gap), observed in amorphous semiconductors37. Figure 6b shows a determination of this Tauc gap; a dotted line represents these extrapolations, reaching a value of 1.5 eV. This result is in agreement with the physical process, because the optical gap energy must be higher than the electrical gap energy. The Tauc model suggests that the mean energy gap should be used as a measure of the optical gap associated with an amorphous semiconductor, and that it is directly related to a parameter that characterizes physically reasonable distributions of electronic states37. The results discussed evidence shows that the silicon incorporated in the crystallographic lattice of TiAlN films 6 Palacios et al. determined drastically the physical properties of them, since the their structure crystalline change to amorphous and the electrical behavior shows changes the ceramic material to semiconductor material. 4. Conclusions This paper presents a study on the effects of Si addition on structural, electrical, and optical properties of c/w-(Al,Ti) N films, where Si plays a role both as a substitutional solid solution and as in the formation of amorphous coatings. These structural changes modified the electrical and optical properties of the films since these change their electrical properties of ceramics to semiconductors. Additionally, the results show that the transmittance decreases when the Si content increases. The electrical behavior make it possible to think of using these films as potential solar cells, since their energy gap is low. 5. Acknowledgments The authors would like to acknowledge the financial support of División de Investigación y Extension of Universidad Nacional de Colombia (DIEB) through Project 35939. 6. References 1. Biró D, Papp S, Jakab-farkas L. Microstructural modification of (Ti 1-x Al x Si y) N thin film coatings as a function of nitrogen concentration. Acta Universitatis Sapientiae Electrical and Mechanical Engineering. 2010;2:146-58. 2. Panjan P, Miha Č. The influence of growth defects in sputterdeposited TiAlN hard coatings on their tribological behavior. Surf Coat Tech. 2016;288:171-8. 3. 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Improved thermal stability and oxidation resistance of Al – Ti – N coating by Si addition. Thin Solid Films. 2014;556:369-75. 9. Wang SQ, Chen L, Yang B, Chang KK, Du Y, Li J, et al. Effect of Si addition on microstructure and mechanical properties of Ti–Al–N coating. Int J Refract Met Hard Mater. 2010;28:5936. 10. Feng J, Zhang S, Lu Y, Yu H, Kang L, Wang X, et al. The spectral selective absorbing characteristics and thermal stability of SS/TiAlN/TiAlSiN/Si3N4 tandem absorber prepared by magnetron sputtering. Sol Energy. 2015;111:350-6. 11. Rebouta L, Capela P, Andritschky M, Matilainen A, Santilli P, Pischow K, et al. Characterization of TiAlSiN/TiAlSiON/ SiO2 optical stack designed by modelling calculations for 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. Materials Research solar selective applications. Sol Energy Mater Sol Cells. 2012;105:202-7. Wattoo AG, Xu C, Yang L, Ni C, Yu C, Nie X, et al. 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Models proposed to explain the electrical conductivity of mixtures made of conductive and insulating materials. J Mater Sci. 1993;28:285-301. Veprek S, Veprek-Heijman MGJ, Karvankova P, Prochazka J. Different approaches to superhard coatings and nanocomposites. Thin Solid Films. 2005;476:1-29. Chen YI, Chang SC, Chang LC. Oxidation resistance and mechanical properties of Zr–Si–N coatings with cyclic gradient concentration. Surf Coat Tech. 2017;320:168-73. Choi H, Jang J, Zhang T, Kim JH, Park IW, Kim KH. Effect of Si addition on the microstructure, mechanical properties and tribological properties of Zr–Si–N nanocomposite coatings deposited by a hybrid coating system. Surf Coat Tech. 2014;259:707-13. Martin PJ, Bendavid A, Cairney JM, Hoffman M. Nanocomposite Ti-Si-N, Zr-Si-N, Ti-Al-Si-N, Ti-Al-V-Si-N thin film coatings deposited by vacuum arc deposition. Surf Coat Tech. 2005;200(7):2228-35. Musil J, Daniel R, Zeman P, Takai O. Structure and properties of magnetron sputtered Zr–Si–N films with a high (≥25 at.%) Si content. Thin Solid Films. 2005;478(1–2):238-47. Musil J. Hard nanocomposite coatings: thermal stability, oxidation resistance and toughness. Surf Coat Tech. 2012;207:50-65. Ferreira CP, Castro MMR, Tentardini EK, Lins VFC, Saliba PA. Silicon influence on corrosion resistance of magnetron sputtered ZrN and ZrSiN thin films. Surf Eng. 2018;0(0):1-8. Dang C, Li J, Wang Y, Yang Y, Wang Y, Chen J. Influence of Ag contents on structure and tribological properties of TiSiN-Ag nanocomposite coatings on Ti–6Al–4V. Appl Surf Sci. 2017;394:613-24. Materials Project [homepage on the Internet]. 2018 [cited 2018 Nov 14]. Available from: https://materialsproject.org Petrman V, Houska J. Trends in formation energies and elastic moduli of ternary and quaternary transition metal nitrides. J Mater Sci. 2013;48:7642-51. Zauner L, Ertelthaler P, Wojcik T, Bolvardi H, Kolozsvári S, Mayrhofer PH, et al. 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https://openalex.org/W1969971683	https://www.frontiersin.org/articles/10.3389/fmicb.2015.00167/pdf	English	null	High-grain feeding causes strong shifts in ruminal epithelial bacterial community and expression of Toll-like receptor genes in goats	Frontiers in microbiology	2,015	cc-by	10,303	ORIGINAL RESEARCH ARTICLE bli h d 02 M h 2015 ORIGINAL RESEARCH ARTICLE bli h d 02 M h 2015 published: 02 March 2015 doi: 10.3389/fmicb.2015.00167 High-grain feeding causes strong shifts in ruminal epithelial bacterial community and expression of Toll-like receptor genes in goats The changes in the ruminal epithelial bacterial community and expression of TLRs during long-term (7 weeks) HG feeding were determined using pyrosequencing and quantitative real-time polymerase chain reaction. Principal coordinate analysis and analysis of molecular variance (AMOVA) results showed that HG feeding caused a strong shift in bacterial composition and structure. At the genus level, our data revealed that it increased the relative abundance of taxa Butyrivibrio, unclassiﬁed Clostridiales, Mogibacterium, unclassiﬁed Anaerolineaceae, and Succiniclasticum, and decreased the proportion of unclassiﬁed Ruminococcaceae, unclassiﬁed Rikenellaceae, unclassiﬁed Erysipelotrichaceae, Howardella, and unclassiﬁed Neisseriaceae. The HG-fed goats also exhibited upregulation of the relative mRNA expression of TLR2, TLR3, and TLR5 in the rumen epithelium (P < 0.05). Correlation analysis revealed that the increase in TLR expression was associated with changes in the relative abundance of ruminal epithelial bacteria. This study provides a ﬁrst insight into the adaptive response of ruminal epithelial bacterial populations to HG feeding in goats and shows that these changes were associated with alterations in TLR expression. These ﬁndings provide new insight into understanding of host–microbial relationships in ruminants. Correspondence: p Sheng-yong Mao, Department of Animal Nutrition and Feed Science, Laboratory of Gastrointestinal Microbiology, College of Animal Science and Technology, Nanjing Agricultural University, Weigang No. 1, Nanjing 210095, China e-mail: maoshengyong@163.com Keywords: high-grain feeding, bacterial community, ruminal epithelium, Toll-like receptors, goat High-grain feeding causes strong shifts in ruminal epithelial bacterial community and expression of Toll-like receptor genes in goats Jun-hua Liu , Gao-rui Bian, Wei-yun Zhu and Sheng-yong Mao Department of Animal Nutrition and Feed Science, Laboratory of Gastrointestinal Microbiology, College of Animal Science and Technology, Nanjing Agricultural University, Nanjing, China Jun-hua Liu , Gao-rui Bian, Wei-yun Zhu and Sheng-yong Mao* Department of Animal Nutrition and Feed Science, Laboratory of Gastrointestinal Microbiology, College of Animal Science and University, Nanjing, China eed Science, Laboratory of Gastrointestinal Microbiology, College of Animal Science and Technology, Nanjing Agricultural High-grain (HG) feeding used in intensive goat production can affect the physiology of the rumen wall, but the changes induced in the epimural bacterial community and host Toll-like receptors (TLRs) are not well understood. In this study, 10 male goats were randomly allocated to two groups and fed either a hay diet (0% grain; n = 5) or an HG diet (65% grain; n = 5). The changes in the ruminal epithelial bacterial community and expression of TLRs during long-term (7 weeks) HG feeding were determined using pyrosequencing and quantitative real-time polymerase chain reaction. Principal coordinate analysis and analysis of molecular variance (AMOVA) results showed that HG feeding caused a strong shift in bacterial composition and structure. At the genus level, our data revealed that it increased the relative abundance of taxa Butyrivibrio, unclassiﬁed Clostridiales, Mogibacterium, unclassiﬁed Anaerolineaceae, and Succiniclasticum, and decreased the proportion of unclassiﬁed Ruminococcaceae, unclassiﬁed Rikenellaceae, unclassiﬁed Erysipelotrichaceae, Howardella, and unclassiﬁed Neisseriaceae. The HG-fed goats also exhibited upregulation of the relative mRNA expression of TLR2, TLR3, and TLR5 in the rumen epithelium (P < 0.05). Correlation analysis revealed that the increase in TLR expression was associated with changes in the relative abundance of ruminal epithelial bacteria. This study provides a ﬁrst insight into the adaptive response of ruminal epithelial bacterial populations to HG feeding in goats and shows that these changes were associated with alterations in TLR expression. These ﬁndings provide new insight into understanding of host–microbial relationships in ruminants. High-grain (HG) feeding used in intensive goat production can affect the physiology of the rumen wall, but the changes induced in the epimural bacterial community and host Toll-like receptors (TLRs) are not well understood. In this study, 10 male goats were randomly allocated to two groups and fed either a hay diet (0% grain; n = 5) or an HG diet (65% grain; n = 5). Reviewed by: Reviewed by: Xun Suo, China Agricultural University, China Qendrim Zebeli, University of Veterinary Medicine Vienna, Austria Edited by: Edited by: Lee Mark Wetzler, Boston University School of Medicine, USA Edited by: Lee Mark Wetzler, Boston University School of Medicine, USA Reviewed by: Xun Suo, China Agricultural University, China Qendrim Zebeli, University of Veterinary Medicine Vienna, Austria *Correspondence: Sheng-yong Mao, Department of Animal Nutrition and Feed Science, Laboratory of Gastrointestinal Microbiology, College of Animal Science and Technology, Nanjing Agricultural University, Weigang No. 1, Nanjing 210095, China e-mail: maoshengyong@163.com Lee Mark Wetzler, Boston University School of Medicine, USA REAL-TIME QUANTITATIVE PCR (qPCR) Total RNA was extracted from the rumen epithelium tissue with acid using TRIzol (Takara Bio, Otsu, Japan), as described by Chomczynski and Sacchi (1987). The RNA concentration was then quantiﬁed using a NanoDrop spectrophotometer (ND- 1000UV-Vis; Thermo Fisher Scientiﬁc, Waltham, MA). The absorption ratio (260/280 nm) of all of the samples was between 1.8 and 2.0, indicating high RNA purity. Aliquots of RNA sam- ples were subjected to electrophoresis through a 1.4% agarose– formaldehyde gel to verify integrity. The concentration of RNA was adjusted to 1 μg/μl based on optical density and stored at −80◦C. Total RNA (1 μg) was reverse-transcribed using a PrimeScript® RT Reagent Kit with gDNA Eraser (Takara Bio) according to the manufacturer’s instructions. INTRODUCTION sequencing, polymerase chain reaction and denaturing gradient gel electrophoresis (PCR-DGGE), and quantitative reverse tran- scription PCR (qRT-PCR) analysis (Sadet-Bourgeteau et al., 2010; Chen et al., 2011), that ruminal epithelial bacterial population and diversity can be affected by dietary changes. Nevertheless, information on epimural bacterial community numbers has been limited, due to the low throughput of the traditional 16S rRNA clone library method and ﬁngerprint proﬁles. Determining 16S rRNA short variable tags using a high-throughput sequencing technology such as 454 pyrosequencing has provided an unprece- dented sequencing depth, with tens to thousands of reads per sample. As a result, there has been renewed interest in measuring and comparing the composition and richness of microbial taxa in epimural samples in ruminant. However, only one published report to date has investigated changes in epimural bacterial richness and diversity in HG-fed heifers using high-throughput pyrosequencing techniques (Petri et al., 2013). In addition, little is known about the changes in epimural bacterial community of meat goats during HG diet feeding, especially depending on the high-throughput technique. In current intensive goat production, to meet the energy demand for fast-growing goats, high-grain (HG) diet feeding has become common practice in the nutritional management of meat goats in China. It is well known that HG diet feeding affects ruminal fermentation characteristics and the structure of the content- associated rumen microbial population (Russell and Rychlik, 2001; Callaway et al., 2010; Hook et al., 2011; Metzler-Zebeli et al., 2013; Petri et al., 2013; Zened et al., 2013). However, similar information regarding ruminal epithelial (epimural) bacteria is incomplete compared to knowledge of the bacterial community in rumen content. Through the use of electron microscopy and culture- dependent (McCowan et al., 1978, 1980; Cheng and Wallace, 1979) and culture-independent (Cheng et al., 1980; Sadet et al., 2007; Li et al., 2012) techniques, it has been found that epimural bacteria are different from those associated with rumen contents in dairy cattle, steer, and sheep. The epimural bacterial com- munity has some speciﬁc functions, such as hydrolysis of urea, scavenging of oxygen, and recycling of epithelial tissue (Cheng and Wallace, 1979; Wallace et al., 1979; Dinsdale et al., 1980; Petri et al., 2013). MATERIALS AND METHODS h l d d The experimental design and procedures were approved by the Animal Care and Use Committee of Nanjing Agricultural University, in compliance with the Regulations for the Administration of Affairs Concerning Experimental Animals (The State Science and Technology Commission of P. R. China, 1988). INTRODUCTION Some studies have demonstrated, using 16S rRNA Toll-like receptors (TLRs) make up a group of pattern recogni- tion receptors that are commonly identiﬁed in the gastrointestinal March 2015 \| Volume 6 \| Article 167 \| 1 www.frontiersin.org Epimural bacteria and Toll-like receptors Liu et al. tissues of monogastric animals (Abreu, 2010; Malmuthuge et al., 2012). Recently, Malmuthuge et al. (2012) reported that TLRs1– 10 can express in the rumen epithelium of calves. It is well known that TLRs can recognize the sensing of host epimural bacteria and bacterial products and trigger an immune response, which is critical for maintaining host–microbial homeostasis in monogas- tric animals (Hooper et al., 2012). Dysregulation of this process can cause chronic inﬂammatory and epithelial barrier dysfunc- tion (Abreu, 2010; Ulluwishewa et al., 2011). Our previous study demonstrated that HG diet feeding caused massive barrier dys- function and local inﬂammation in the rumen epithelium (Liu et al., 2013). If results from monogastric intestinal tissues are applied to the rumen epithelium, it seems that HG-induced rumen epithelial barrier dysfunction is associated with dysregu- lation of host TLR signaling. Furthermore, the changes in rumen epithelial TLR expression might be linked to the host epimural bacterial community (Chen et al., 2012). Thus, in the present study, we hypothesized that (1) HG feeding can cause an alter- ation in epimural bacterial community and (2) such a change might be associated with variation in the rumen epithelial TLRs expression. Therefore, the objective of this study was to investi- gate changes in the richness and diversity of epimural bacterial communities and the expression of host TLR genes during HG feeding in goats. in body weight gain (0.30 ± 0.26 vs. 1.02 ± 0.52 kg, P = 0.248) or dry matter intake were observed between the hay and HG groups during the feeding trial. MORPHOMETRIC ANALYSIS Fixed rumen papillae was prepared for electron microscopy using methodology reported by Graham and Simmons (2005). Samples were then examined using scanning electron microscopy (Hitachi Model S-3000N, Hitachi Technologies, Tokyo, Japan) and transmission electron microscopy (Hitachi H-7650, Hitachi Technologies, Tokyo, Japan). SAMPLE COLLECTION On day 50, 4–5 h after the last feeding according to the normal continuous feeding protocol, the goats were euthanized by cap- tive bolt stunning followed by exsanguination from the carotid arteries. Within 5 min, a segment of the rumen epithelial tissue was collected and immediately washed three times in ice-cold phosphate-buffered saline. The samples were divided into two portions. The ﬁrst portion of the tissue sample was cut into smaller pieces (approximately 0.5 × 0.5 cm) and immediately frozen in liquid nitrogen for RNA extraction. The second tissue sample portion was cut to approximately 2 × 2 cm and scraped from the underlying tissue using a germ-free glass slide, imme- diately transferred into liquid N, and then stored at −80◦C until DNA extraction. Washed rumen papillae were immediately ﬁxed in 2.5% glutaraldehyde for microscopic analysis. ANIMALS, DIETS, AND EXPERIMENTAL DESIGN This animal experiment was carried out at the experimental station of Nanjing Agricultural University in Jiangsu Province, China. The experimental design was previously described in detail (Liu et al., 2013). Brieﬂy, ten rumen-cannulated, castrated male goats (Boer × Yangtze River Delta White) aged 2–3 years were used in this experiment. Prior to the experiment, all of the goats were fed pure hay ad libitum for 5 weeks to ensure adaptation to the low-energy hay diet. The goats were then randomly assigned to groups fed either a hay diet (Hay; n = 5) or an HG diet (HG; n = 5), and placed in individual pens (1.2 × 1.2 m) with free access to water. Adaptation to the HG diet was carried out over 5 d with progressively increasing amounts of grain for 65%. The diet (750 g dry matter per animal per day) was offered in equal amounts at 08:30 and 16:30 daily for 7 weeks. Hay fed in this experiment originated from one batch. The metabolic energy citation(ME) intake of the goats in the hay group (30 kg body weight; 8.31 MJ/kg dry matter) was slightly above the require- ment for maintenance, and that of the goats in the HG group (30 kg body weight; 11.31 MJ/kg dry matter) permitted a growth rate of 200 g/day according to guidelines on the nutrient require- ments of goats (NY/Y816-2004; Ministry of Agriculture of China, 2004). The nutrient compositions of the hay and HG diets are summarized in Supplementary Table 1. No signiﬁcant differences The primers used for TLR2 (forward – 5′-CTGTGTGCGTC TTCCTCAGA-3′ and reverse – 5′-TCAGGGAGCAGAGTAACCA GA-3′), TLR3 (forward – 5′-TCTTTTCGGGACTGTTGACC- 3′ and reverse – 5′-AAATCCCCCATCCAAGGTAG-3′), TLR4 (forward – 5′-GGTTTCCACAAAAGCCGTAA-3′ and reverse – 5′-AGGACGATGAAGATGATGCC-3′), and TLR5 (forward – 5′-TCAATGGGAGCCAGATTTTC-3′ and reverse – 5′-CCTTCAGCTCCTGGAGTGTC-3′) were described by Charavaryamath et al. (2011), and the primer used for GAPDH (forward – 5′-GGGTCATCATCTCTGCACCT-3′ and reverse – 5′-GGTCATAAGTCCCTCCACGA-3′) was described by Wang et al. (2009). All of the primers were synthesized by Invitrogen Life Technologies (Shanghai, China). Real-time qPCR of the target genes and GAPDH was performed using an ABI 7300 real-time PCR system (Applied Biosystems, Foster City, CA) March 2015 \| Volume 6 \| Article 167 \| 2 Frontiers in Microbiology \| Microbial Immunology Epimural bacteria and Toll-like receptors Liu et al. http://www.mothur.org/wiki/). 16S rRNA reads were decoded based on the 5 bp sample-speciﬁc barcodes and processed to remove poor-quality sequences. STATISTICAL ANALYSIS Statistical analysis were carried out by conducting tests using the SPSS software package (SPSS version 16, SPSS, Inc.). The normality of the distribution of variables was tested using the Shapiro–Wilk test. The microbial diversity data, some data of taxa richness, and the relative mRNA expression of TLRs and cytokines found to have a normal distribution were analyzed by the independent-samples t-test procedure, according to the fol- lowing model: Y = μ+ C + e, where μ is the mean, C is the effect of diet, and e is the residual error. The Kruskal–Wallis test was used to analyze variables found to have a non-normal dis- tribution (some data of taxa richness), and the statistical model used: H = 12 n(n+1) k i = 1 Ri2 ni −3(n + 1) where H is the Kruskal- Wallis test; n is the number of measurements; Ri is the sum of the ranks; ni is the number of experiments. Signiﬁcance was declared at P < 0.05. Double dendrograms were constructed using the compara- tive functions and multivariate hierarchical clustering methods of NCSS 2007 (NCSS), on the basis of the abundance of bacte- rial groups at different taxonomic levels. Clustering with all OTUs was performed using the Ward’s minimum variance method with no scaling. Correlations between the relative mRNA expression ANIMALS, DIETS, AND EXPERIMENTAL DESIGN To reduce sequencing errors, the shhh.ﬂows command was applied, which is the MOTHUR implementation of the AmpliconNoise algorithm (Quince et al., 2011). Quality ﬁlters were applied to trim and remove sequences with the following characteristics: less than 200 bp in length; average quality score less than 35; homopolymers longer than eight nucleotides; and more than two different bases to the primer. In order to obtain a non-redundant set of sequences, unique sequences were determined, and used to align against the SILVA reference alignment database (Pruesse et al., 2007); chimeras were removed using chimera.uchime (http://drive5. com/uchime); sequences identiﬁed as being of eukaryotic origin were removed; the candidate sequences were screened and pre- clustered to eliminate outliers; and a distance matrix was gener- ated from the resulting sequences. Sequences were clustered into operational taxonomic units (OTUs) using the furthest neighbor algorithm. Representative sequences from OTUs at a 0.03 dis- tance were obtained and classiﬁed using the Ribosomal Database Project’s Bayesian classiﬁer (Wang et al., 2007). Rarefaction curve was generated at the level of 3%, which was calculated by the distance-based OTU (Schloss et al., 2011), and Rarefaction curves and Good’s coverage were calculated to quantify the coverage and sampling effort. Community diversity was estimated with the unnormalized reads using the based coverage estimator (ACE), Chao1, and Shannon indices. The unweighted UniFrac distance method (Lozupone and Knight, 2005) was used to perform a principal coordinates analysis (PCOA) with all OTUs, and a distance-based analysis of molecular variance (AMOVA) was conducted to assess signiﬁcant differences between samples. with ﬂuorescence detection of SYBR green dye. Ampliﬁcation conditions were as follows: 95◦C for 30 s followed by 40 cycles of 5 s at 95◦C and 31 s at 57.5◦C (for GAPDH) or 62◦C (for the TLRs). Each sample contained 1–10 ng cDNA in 2 × SYBRGreen PCR Master Mix (Takara Bio) and 200 nmol/L of each primer in a ﬁnal volume of 20 μL. All measurements were performed in triplicate. A reverse-transcription-negative blank of each sample and a no-template blank served as negative controls. The relative amount of each studied mRNA was normalized to GAPDH mRNA levels as a housekeeping gene, and the data were analyzed according to the 2−△△CT method. MICROBIAL DNA ISOLATION One gram of underlying rumen epithelial tissue was used for DNA extraction. The DNA was extracted by a bead-beating method using a mini-bead beater (Biospec Products, Bartlesville, OK), followed by phenol–chloroform extraction (Sun et al., 2008). The solution was precipitated with ethanol, and the pellets were suspended in 50 μL Tris-EDTA buffer. The DNA samples were quantiﬁed using a NanoDrop spectrophotometer (Nyxor Biotech, Paris, France). DNA PYROSEQUENCING Bacterial amplicons were sequenced using the 454 GS FLX Titanium chemistry at the Majorbio Bio-Pharm Technology Co., Ltd., Shanghai, China. PCR ampliﬁcation of the V1–V3 region of bacterial 16S rRNA was performed using univer- sal primers (27F 5′-AGAGTTTGATCCTGGCTCAG-3′, 533R 5′- TTACCGCGGCTGCTGGCAC-3′) incorporating FLX Titanium adapters and a sample barcode sequence. The primers were synthesized by Invitrogen Life Technologies (Shanghai, China). The PCR ampliﬁcation was conducted in a 50 μL C1000 ther- mal cycler (Bio-Rad, USA) containing 10 µL 5-fold reaction buffer, 50 ng of total genomic DNA, 0.4 µM of each primer, 0.5U Pfu polymerase (TransStart-FastPfu DNA Polymerase, TransGen Biotech, Beijing, China) and 2.5 mMdNTPs. The cycling param- eters were as follows: 5 min initial denaturation at 95◦C; 25 cycles of denaturation at 95◦C (30 s), annealing at 55◦C (30 s), elongation at 72◦C (30 s); and ﬁnal extension at 72◦C for 5 min. Three separate PCR reactions of each sample were pooled for pyrosequencing. Amplicons from the two microbial groups were quantiﬁed ﬂuorometrically, normalized per sam- ple and pooled per microbial group. A total of 1 μg DNA of each of the four resulting pools was loaded onto agarose gel (1% wt: vol). Bands were visualized and excised under blue light transillumination, and amplicons were gel puriﬁed using a QIAquick Gel Extraction Kit (Qiagen, Hilden, Germany). Amplicons were then quantiﬁed using a Quant-iT PicoGreen dsDNA Assay Kit (Invitrogen, Carlsbad, CA) according to the manufacturer’s instructions. Equal concentrations of amplicons were pooled from each sample. Emulsion PCR of pooled samples was done with the GS FLX Titanium Lib-L LV emPCR Kit (Roche Applied Science, Indiananpolis, IN) following the manufacturer’s recommendations. The 16S sequencing data for all the samples analyzed in this study was submitted to the Sequence Read Archive (SRA; http:// www.ncbi.nlm.nih.gov/Traces/sra/), under accession SRP052769. EPIMURAL BACTERIAL COMMUNITY OF GOATS In total, 55,633 reads were obtained for the 16S rRNA genes in rumen epithelium of all goats, and 38013 reads were valid correspondingly, accounting for 68.3% of their raw reads. The sequences were further analyzed by MOTHUR software, and these valid sequences were classiﬁed into 7673 OUTs at sequence divergences of 0.03. The average number of OTUs was 1364 ± 138, with an average coverage of 85.25 ± 1.72%. The Chao1 richness, ACE, and Shannon diversity indexes were on 2953 ± 360, 4764 ± 660, and 6.02 ± 0.13, respectively. Within the bacterial population, 18 phyla were found across all samples. Firmicutes, Bacteroidetes, and Proteobacteria, were the dominant phyla, representing 53.12%, 20.88%, and 13.35%, respectively. Actinobacteria, Chloroﬂexi, and Tenericutes represented average percentages of 2.79%, 2.25%, and 1.32%, respectively, of the total sequences. The proportion of some phyla (Spirochaetes, Fibrobacteres, Synergistetes, and Planctomycetes) was less than 1% of total microbial community, and other phyla (Lentisphaerae, Elusimicrobia, Chlamydiae, Cyanobacteria, Deinococcus-Thermus, Fusobacteria, and Nitrospirae) were not consistently present in all of the different host populations. In the Firmicutes phylum, the most dominant class was Clostridia (average of 48.45%, respec- tively, of the total sequences), represented mainly by families Lachnospiraceae, unclassiﬁed Clostridiales, and Ruminococcaceae (average of 27.14%, 10.48%, and 8.09%, respectively, of the total sequences). In the Bacteroidetes phylum, the most domi- nant class was Bacteroidia (average of 20.38%, respectively, of the total sequences), represented mainly by families Prevotellaceae, g g g pp y g As is shown in Table 1, the results indicated a decrease in OTU numbers (P = 0.016), ACE (P = 0.047), and Chao1 rich- ness (P = 0.028), but not in community evenness [Shannon’s (P = 0.117) and Simpson’s (P = 0.465)] during HG diet feeding. At the phylum level, HG feeding caused a higher proportion of Firmicutes (P = 0.008) and Chloroﬂexi (P = 0.008) and a neg- ative effect on Actinobacteria (P = 0.008) and Tenericutes (P = 0.008) phyla; the Bacteroidetes and Proteobacteria phyla were not affected signiﬁcantly (P > 0.05) (Supplementary Figure 4). At the genus level, a total of 100 taxa were examined, 24 of which exhibited signiﬁcant variability across diets. RESULTS The rarefaction curves of epimural bacterial communities are shown in Supplementary Figure 2. At dissimilarity levels of 0.03, the rarefaction analysis revealed that HG feeding decreased bac- terial diversity in the rumen epithelium compared with the hay group. The unweighted UniFrac metric in MOTHUR was used to evaluate β-diversity across the samples (Figure 1). The PCOA result exhibited that the goats fed the hay diet were distinctly separated from those fed the HG diet in the plot (Figure 1A; axis 1 + axis 2 = 37.3%). The further analysis indicated that the diet signiﬁcantly affected the epimural microbial communi- ties (AMOVA, Fs = 2.75, P < 0.001). Mean pairwise unweighted UniFrac distance showed that there was no signiﬁcant differ- ence in sample-to-sample variation among replicates between the hay and HG groups (Figure 1B; 0.63 ± 0.01 vs. 0.62 ± 0.01; P = 0.482). The hay vs. HG comparison variation was greater than the sample-to-sample variation among replicates in the hay group (Figure 1B; 0.73 ± 0.01 vs. 0.63 ± 0.01; P < 0.001) and the HG group (Figure 1B; 0.73 ± 0.01 vs. 0.62 ± 0.01; P = 0.482). In addition, the Venn proﬁle revealed that there were 299 unique OTUs belonging to the hay-fed goats and 227 unique OTUs belonging to the HG-fed goats (Supplementary Figure 3). The body weight gain (0.30 ± 0.26 vs. 1.02 ± 0.52 kg, P = 0.248) or dry matter intake were not affected by experimental diet during the feeding trial. PYROSEQUENCING DATA ANALYSIS The sequences were processed using the MOTHUR program (Schloss et al., 2009, 2011; version 1.29.0; University of Michigan; March 2015 \| Volume 6 \| Article 167 \| 3 www.frontiersin.org www.frontiersin.org Epimural bacteria and Toll-like receptors Liu et al. Liu et al. of TLRs and the relative abundance of epimural bacteria and cytokine mRNA expression were assessed by Pearson’s correlation test (γ = XY−( X)−( Y) n ( X2−( X)2 n )( Y2−( Y)2 n ) ), where γ is the Pearson correlation coefﬁcient; X is the relative mRNA expression of TLRs; Y is the epimural bacteria data found to have a normal distribution or cytokine mRNA expression; n is the number of experiments) or Spearman’s rank test (γ = 1- 6 d2 n3−n , where γ is Spearman’s Rank correlation coefﬁcient; d is the difference in rank between the relative mRNA expression of TLRs and the epimural bacteria data found to have a non-normal distribution, n is the number of measurements) depending on data normal- ity using GraphPad Prism version 5.00 (GraphPad Software, San Diego, CA). Signiﬁcance was declared at P < 0.05. of TLRs and the relative abundance of epimural bacteria and cytokine mRNA expression were assessed by Pearson’s correlation XY ( X)−( Y) Rikenellaceae, and unclassiﬁed Bacteroidales (average of 10.92%, 4.69%, and 4.51%, respectively, of the total sequences). In the Proteobacteria phylum, the major classes were Deltaproteobacteria and Betaproteobacteria (average of 5.74% and 5.35%, respec- tively, of the total sequences), represented mainly by families Desulfobulbaceae, Comamonadaceae, and Neisseriaceae (average of 5.51%, 2.90%, and 2.36%, respectively, of the total sequences). At the genus level, 100 taxa were detected over the entirety of the samples; the most dominant genus was Butyrivibrio (aver- age of 11.01% of the total sequences), followed by the genera Desulfobulbus (5.51%), Mogibacterium (4.33%), and Prevotella (4.01%). For clarity and visualization purposes, the top 30 bac- terial taxa are presented in a heat map (Supplementary Figure 1). RUMINAL pH AND CONCENTRATIONS OF VOLATILE FATTY ACIDS, LACTATE, AND LIPOPOLYSACCHARIDES The data of rumen fermentation of experimental goats were reported in our previous study (Liu et al., 2013) (Supplementary Table 2). Brieﬂy, HG feeding decreased (P < 0.001) the rumi- nal pH, and increased (P < 0.001 to <0.019) the concentrations of propionate, butyrate, valerate, isovalerate, total volatile fatty acids, lactate, and lipopolysaccharides signiﬁcantly. EPIMURAL BACTERIAL COMMUNITY OF GOATS There was a signiﬁcant increase in relative abundance of dominant genera Butyrivibrio (P = 0.008), unclassiﬁed Clostridiales (P = 0.008), Mogibacterium (P = 0.008), unclassiﬁed Anaerolineaceae (P = 0.008), Succiniclasticum (P = 0.008), and Ruminococcus (P = 0.008) associated with HG feeding, and the proportion of Butyrivibrio was almost three times higher in the HG group than in the hay group (Table 2). Conversely, there was a correspond- ing decrease in the proportion of unclassiﬁed Ruminococcaceae (P = 0.008), unclassiﬁed Rikenellaceae (P = 0.008), unclassiﬁed March 2015 \| Volume 6 \| Article 167 \| 4 Frontiers in Microbiology \| Microbial Immunology Epimural bacteria and Toll-like receptors Liu et al. FIGURE 1 \| Differences in the ruminal epithelial (epimural) bacterial structure between hay and high-grain (HG)-fed goats. (A) Unweighted UniFrac principal coordinate analysis (PCoA) of epimural microbiota based on the operational taxonomic unit data from 454 pyrosequencing run. The marks relate to the diets of donor goats: hay diet (◦), HG diet (•). (B) Mean pairwise unweighted UniFrac distance for subsets of samples (means ± SEM, n = 5). Hay, sample-to-sample variation among replicates in hay group; HG, sample-to-sample variation among replicates in HG group; Hay vs. HG, hay vs. HG comparison variation. ∗∗∗P < 0.001. Table 1 \| Effects of high-grain (HG) diet feeding on the diversity of ruminal epithelial bacterial community at the 3% dissimilarity level. 16.9% of the OTUs appeared in all samples belonging to Butyrivibrio (6.47% of total sequences), Desulfobulbus (3.84% of total sequences), unclassiﬁed Erysipelotrichaceae (2.91% of total sequences), unclassiﬁed Prevotellaceae (2.90% of total sequences), Comamonas (2.45% of total sequences), and Howardella (2.26% of total sequences). We also compared the unique OTUs associ- ated with hay and HG diet. In the hay group, 47.2% of the OTUs were found to be unique to this diet. Unclassiﬁed Neisseriaceae was found to be (4.48% of total sequences) unique in the goats fed the hay diet, but it was not found in HG-fed goats. During the HG diet feeding, 35.9% of the OTUs were found to be unique to this diet: unclassiﬁed Lachnospiraceae (4.56% of total sequences), unclassiﬁed Clostridiales (4.19% of total sequences), and Butyrivibrio (3.97% of total sequences). Genus Ruminococcus (1.32% of total sequences) was found to be unique to the HG-fed goats. EFFECTS OF HG FEEDING ON RELATIVE mRNA EXPRESSION OF TLR AND CYTOKINE GENES The marks relate to the diets of donor goats: hay diet (◦), HG diet (•). (B) Mean pairwise unweighted UniFrac distance for subsets of samples (means ± SEM, n = 5). Hay, sample-to-sample variation among replicates in hay group; HG, sample-to-sample variation among replicates in HG group; Hay vs. HG, hay vs. HG comparison variation. ∗∗∗P < 0.001. CORRELATION ANALYSIS The relationships between TLR expression and the relative abun- dance of epimural bacteria and cytokine expression are shown in Figure 3. The data revealed that the abundance levels of 11 taxa were correlated (P < 0.05) with the relative mRNA expression levels of TLR2 [six negative (unclassiﬁed Mollicutes, unclassi- ﬁed Coriobacteriaceae, unclassiﬁed Erysipelotrichaceae, unclassi- ﬁed Bacteria, Howardella, and unclassiﬁed Ruminococcaceae) and ﬁve positive (Ruminococcus, Butyrivibrio, Mogibacterium, unclas- siﬁed Prevotellaceae, and Succiniclasticum)]; the abundance levels of 10 taxa were correlated (P < 0.05) with the relative mRNA expression levels of TLR5 [ﬁve negative (unclassiﬁed Mollicutes, unclassiﬁed Coriobacteriaceae, unclassiﬁed Erysipelotrichaceae, unclassiﬁed Bacteria, and unclassiﬁed Ruminococcaceae) and ﬁve positive (Ruminococcus, Butyrivibrio, Mogibacterium, unclassiﬁed Prevotellaceae, and Succiniclasticum)]; the abundance levels of eight taxa were correlated (P < 0.05) with the rela- tive mRNA expression levels of TLR3 [ﬁve negative (unclas- siﬁed Mollicutes, unclassiﬁed Erysipelotrichaceae, unclassiﬁed Rikenellaceae, Howardella, and unclassiﬁed Ruminococcaceae) and three positive (unclassiﬁed Clostridiales, Ruminococcus, and Butyrivibrio)]; the abundance of one taxa (unclassiﬁed Anaerolineaceae) was negatively associated (P < 0.05) with the rel- ative mRNA expression of TLR4. In addition, the relative mRNA Table 1 \| Effects of high-grain (HG) diet feeding on the diversity of ruminal epithelial bacterial community at the 3% dissimilarity level. Table 1 \| Effects of high-grain (HG) diet feeding on the diversity of ruminal epithelial bacterial community at the 3% dissimilarity level. OTU ACE Chao Shannon Evenness 1 value index Hay 1615 ± 227 5821 ± 1069 3561 ± 599 6.24 ± 0.23 0.77 ± 0.01 HG 1113 ± 56 3708 ± 507 2345 ± 200 5.79 ± 0.05 0.75 ± 0.00 P-value 0.016 0.047 0.028 0.117 0.602 Values shown are means ± SEM, n = 5. OTU, operational taxonomic units; ACE, abundance-based coverage estimator. Erysipelotrichaceae (P = 0.008), Howardella (P = 0.008), and unclassiﬁed Neisseriaceae (P = 0.008) (Table 2). All of the anal- ysis results showed that HG feeding had a considerable effect on epimural bacterial composition and diversity. EFFECTS OF HG FEEDING ON RELATIVE mRNA EXPRESSION OF TLR AND CYTOKINE GENES The relative mRNA expression of TLR genes, measured by qRT- PCR, are shown in Figure 2. The results revealed that the HG-fed goats indicated upregulation of the relative mRNA expression of TLR2 (P = 0.005), TLR3 (P = 0.004), and TLR5 (P = 0.001) in rumen epithelia compared with the hay-fed goats. HG feed- ing had no signiﬁcant effect on the relative mRNA expression of TLR4 (P = 0.089). The relative expression of cytokine in rumen epithelium were reported in our previous study (Liu et al., 2013). Brieﬂy, the data exhibited that the relative expression of TNF-α (P = 0.017) and IFN-γ (P = 0.012) of HG-fed goats were higher than that of hay-fed goats signiﬁcantly, and HG feeding had no signiﬁcant effect on the relative expression of IL-1β (P = 0.066), IL-6 (P = 0.082), and IL-10 (P = 0.894) genes. FIGURE 1 \| Differences in the ruminal epithelial (epimural) bacterial structure between hay and high-grain (HG)-fed goats. (A) Unweighted FIGURE 1 \| Differences in the ruminal epithelial (epimural) bacterial structure between hay and high-grain (HG)-fed goats. (A) Unweighted UniFrac principal coordinate analysis (PCoA) of epimural microbiota based on the operational taxonomic unit data from 454 pyrosequencing run. The marks relate to the diets of donor goats: hay diet (◦), HG diet (•). (B) Mean pairwise unweighted UniFrac distance for subsets of samples (means ± SEM, n = 5). Hay, sample-to-sample variation among replicates in hay group; HG, sample-to-sample variation among replicates in HG group; Hay vs. HG, hay vs. HG comparison variation. ∗∗∗P < 0.001. FIGURE 1 \| Differences in the ruminal epithelial (epimural) bacterial structure between hay and high-grain (HG)-fed goats. (A) Unweighted UniFrac principal coordinate analysis (PCoA) of epimural microbiota based on the operational taxonomic unit data from 454 pyrosequencing run. The marks relate to the diets of donor goats: hay diet (◦), HG diet (•). (B) Mean pairwise unweighted UniFrac distance for subsets of samples (means ± SEM, n = 5). Hay, sample-to-sample variation among replicates in hay group; HG, sample-to-sample variation among replicates in HG group; Hay vs. HG, hay vs. HG comparison variation. ∗∗∗P < 0.001. FIGURE 1 \| Differences in the ruminal epithelial (epimural) bacterial structure between hay and high-grain (HG)-fed goats. (A) Unweighted UniFrac principal coordinate analysis (PCoA) of epimural microbiota based on the operational taxonomic unit data from 454 pyrosequencing run. CORE EPIMURAL BACTERIAL COMMUNITY The OTU detected across all samples was deﬁned as the core epimural bacterial community. The results indicated that March 2015 \| Volume 6 \| Article 167 \| 5 www.frontiersin.org Epimural bacteria and Toll-like receptors Liu et al. Table 2 \| Effects of high-grain (HG) feeding on average relative abundance of genus level (% of total sequences) in rumen epithelium, ranked by alphabetical order of ﬁrst letter of phylum, family and genus name. Phylum Family Genus Abundance (%) P-value Hay HG Actinobacteria Coriobacteriaceae Unclassiﬁed Coriobacteriaceae 3.10 ± 0.54 0.86 ± 0.22 0.008 Bacteroidetes Prevotellaceae Prevotella 4.36 ± 0.79 3.66 ± 0.50 0.548 Unclassiﬁed Prevotellaceae 5.34 ± 0.39 8.30 ± 0.80 0.056 Rikenellaceae Unclassiﬁed Rikenellaceae 5.80 ± 0.56 3.59 ± 0.50 0.016 Unclassiﬁed Bacteroidales Unclassiﬁed Bacteroidales 5.00 ± 0.25 4.02 ± 0.44 0.095 Chloroﬂexi Anaerolineaceae Unclassiﬁed Anaerolineaceae 1.05 ± 0.06 2.84 ± 0.53 0.008 Firmicutes Lachnospiraceae Acetitomaculum 2.23 ± 0.34 1.33 ± 0.29 0.095 Butyrivibrio 4.48 ± 0.43 17.55 ± 2.05 0.008 Howardella 3.68 ± 0.53 1.75 ± 0.23 0.008 Syntrophococcus 1.71 ± 0.34 1.13 ± 0.08 0.151 Unclassiﬁed Lachnospiraceae 9.82 ± 0.77 9.50 ± 0.78 1.000 Ruminococcaceae Ruminococcus 0.45 ± 0.05 2.20 ± 0.52 0.008 Unclassiﬁed Ruminococcaceae 8.36 ± 0.85 4.97 ± 0.77 0.016 Unclassiﬁed Clostridiales Mogibacterium 3.30 ± 0.37 5.36 ± 0.56 0.016 Unclassiﬁed Clostridiales 4.75 ± 0.72 7.91 ± 0.85 0.032 Veillonellaceae Succiniclasticum 1.16 ± 0.22 3.21 ± 0.35 0.008 Erysipelotrichaceae Unclassiﬁed Erysipelotrichaceae 5.08 ± 0.46 2.76 ± 0.31 0.008 Proteobacteria Comamonadaceae Comamonas 2.59 ± 0.37 2.69 ± 0.34 1.000 Neisseriaceae Unclassiﬁed Neisseriaceae 4.57 ± 2.10 0.14 ± 0.05 0.008 Desulfobulbaceae Desulfobulbus 5.74 ± 1.26 5.27 ± 0.63 1.000 Campylobacteraceae Campylobacter 2.27 ± 0.23 1.96 ± 0.48 0.841 Tenericutes Unclassiﬁed Mollicutes Unclassiﬁed Mollicutes 2.27 ± 0.21 0.30 ± 0.07 0.008 Only results obtained for the predominant bacterial genera (relative abundance >1% in at least one sample) are presented. Values shown are means ± SEM, n = 5. Only results obtained for the predominant bacterial genera (relative abundance >1% in at least one sample) are presented. Values shown are means ± SEM, n = 5. FIGURE 2 \| Effects of high-grain feeding on the relative mRNA expression of Toll-like receptors in the rumen epithelium of goats (means ± SEM, n = 5). All analyses were performed in triplicate. ∗∗P < 0.01, NS: not signiﬁcant. goats examined in this study, followed by Bacteroidetes (20.88%) and Proteobacteria (13.35%). CORE EPIMURAL BACTERIAL COMMUNITY This ﬁnding conﬁrmed the ﬁndings reported in previous studies that phylum Firmicutes are relatively common in tissue-adherent populations (Sadet-Bourgeteau et al., 2010; Chen et al., 2011; Petri et al., 2013). In addition, the rela- tive abundance of phylum Proteobacteria was higher than that in rumen content (the relative abundance of phylum Proteobacteria was 0.54% in rumen content; unpublished data), which was consistent with previous studies on sheep and heifers (Chen et al., 2011; Petri et al., 2013). The greater abundance of phylum Proteobacteria in the rumen epithelium was believed to be caused by the trace amounts of oxygen diffused through the tissue, which might favor a higher density of Proteobacteria, as many members of this phylum are microaerophiles or facultative anaerobes, and hence, not sensitive to oxygen toxicity (Sadet-Bourgeteau et al., 2010). FIGURE 2 \| Effects of high-grain feeding on the relative mRNA expression of Toll-like receptors in the rumen epithelium of goats (means ± SEM, n = 5). All analyses were performed in triplicate. ∗∗P < 0.01, NS: not signiﬁcant. It is well known that diet inﬂuences ruminal fermentation characteristics and the structure of content-associated rumen microbial population (Russell and Rychlik, 2001; Sadet et al., 2007; Hook et al., 2011; Huo et al., 2014). However, the effects of diet on the epimural bacterial community remain controver- sial. A previous study, using PCR-DGGE technology, reported that the epimural community in lambs was less inﬂuenced by diet than were the microbiota associated with rumen contents (Sadet et al., 2007). Using PCR-DGGE and qRT- PCR analysis, Chen et al. (2011) demonstrated that an HG diet affects the diversity, but not density, of epimural bacteria in heifers. Petri et al. (2013) demonstrated, through pyrosequencing, that less than 5% of the levels of cytokines IL-1β, IL-6, and IFN-γ were positively associ- ated with the relative mRNA expression levels of TLR2 and TLR3 (P < 0.05); the relative mRNA expression of cytokine IFN-γ was positively correlated with TLR5 expression (P < 0.05); and TNF- α mRNA expression was negatively associated with TLR4 mRNA expression (P < 0.05). DISCUSSION At the phylum level, Firmicutes (53.12%) were the most abun- dant bacteria detected in the epimural bacterial community in the March 2015 \| Volume 6 \| Article 167 \| 6 Frontiers in Microbiology \| Microbial Immunology Epimural bacteria and Toll-like receptors Liu et al. Liu et al. FIGURE 3 \| Correlation analysis between the relative mRNA expression of Toll-like receptors (TLRs) and relative abundance of epithelium-associated microbiota (at the genus level) and mRNA expression of cytokines. Only results obtained for the predominant bacterial ( l i b d i l l ) f hi h h abundance was signiﬁcantly associated with TLRs are shown. Cells are colored based on Pearson’s correlation coefﬁcient. Red represents a signiﬁcant positive correlation (P < 0.05), blue represents a signiﬁcant negative correlation (P < 0.05), and green represents a non-signiﬁcant l i (P ) FIGURE 3 \| Correlation analysis between the relative mRNA expression of Toll-like receptors (TLRs) and relative abundance of epithelium-associated microbiota (at the genus level) and mRNA expression of cytokines. Only results obtained for the predominant bacterial genera (relative abundance >1% in at least one sample) for which the abundance was signiﬁcantly associated with TLRs are shown. Cells are colored based on Pearson’s correlation coefﬁcient. Red represents a signiﬁcant positive correlation (P < 0.05), blue represents a signiﬁcant negative correlation (P < 0.05), and green represents a non-signiﬁcant correlation (P > 0.05). FIGURE 3 \| Correlation analysis between the relative mRNA expression of Toll-like receptors (TLRs) and relative abundance of epithelium-associated microbiota (at the genus level) and mRNA expression of cytokines. Only results obtained for the predominant bacterial genera (relative abundance >1% in at least one sample) for which the abundance was signiﬁcantly associated with TLRs are shown. Cells are colored based on Pearson’s correlation coefﬁcient. Red represents a signiﬁcant positive correlation (P < 0.05), blue represents a signiﬁcant negative correlation (P < 0.05), and green represents a non-signiﬁcant correlation (P > 0.05). total OTUs identiﬁed exhibited signiﬁcant variability across diets in heifers. In the present study, the data revealed that HG feed- ing decreased epimural bacterial diversity and caused a strong shift in bacterial structure and composition. Furthermore, the Venn proﬁle indicated that there were 299 unique OTUs belong- ing to the hay-fed goats and 227 unique OTUs belonging to the HG-fed goats. DISCUSSION These results, which provide evidence that HG feeding inﬂuences the epimural bacterial community, are some- what inconsistent with those of previous studies (Chen et al., 2011; Petri et al., 2013). might be smaller in the present study. Second, variations in the type of grain in the diet might also have resulted in the differences in epimural bacterial response. Wheat was grain component for the sheep study (Sadet-Bourgeteau et al., 2010) and barley used as the concentrated diet in the heifer studies (Chen et al., 2011; Petri et al., 2013), while corn and wheat were the grain components in our present study. The differences in ruminal degradation of these cereal grains might contribute to the variations in epimu- ral bacterial response. Third, and perhaps most important, we must take into consideration the HG-induced changes in rumen epithelial structure when comparing our results to those of Petri et al. (2013). Our previous study demonstrated that the HG diet used in this study caused parakeratosis, budding, and exten- sive sloughing of the stratum corneum (Liu et al., 2013), which potentially increases the availability of attachment sites for oppor- tunistic bacteria (Plaizier et al., 2012) (Supplementary Figure 5). In addition, many previous studies have demonstrated that parakeratosis is linked with quantitative changes in the epimu- ral microbial ﬂora (Semjen et al., 1982; Steele et al., 2009). Thus, disruption of the rumen epithelial structure might account for the increased effect in the present study. Finally, the differences might be smaller in the present study. Second, variations in the type of grain in the diet might also have resulted in the differences in epimural bacterial response. Wheat was grain component for the sheep study (Sadet-Bourgeteau et al., 2010) and barley used as the concentrated diet in the heifer studies (Chen et al., 2011; Petri et al., 2013), while corn and wheat were the grain components in our present study. The differences in ruminal degradation of these cereal grains might contribute to the variations in epimu- ral bacterial response. Third, and perhaps most important, we must take into consideration the HG-induced changes in rumen epithelial structure when comparing our results to those of Petri et al. (2013). DISCUSSION Furthermore, as epithelial Butyrivibrio release butyrate close to the epithelium, they might enhance butyrate bioavailability for the host, which is useful for rumen epithe- lial proliferation (Sakata and Tamate, 1978; Shen et al., 2004). Therefore, an increase in the relative abundance of Butyrivibrio in the rumen epithelium might be an adaptation response to repair a damaged rumen epithelium by increasing epithelial prolifera- tion during long-term HG feeding. Mogibacterium are anaerobic, Gram-positive, non-fermentative bacteria, ﬁrst identiﬁed in the rumen epithelium by Li et al. (2012); the function of this genus in the rumen epithelium is unknown. Many previous studies have reported that this genus was commonly associated with peri- odontal disease and infected root canals in the human mouth (Nakazawa et al., 2000; Sato et al., 2012). Furthermore, Chen et al. (2012) reported that Mogibacterium was enriched in the colonic mucosa of colorectal cancer patients. Thus, these ﬁnd- ings imply that the increase in the abundance of Mogibacterium during HG feeding could have some deleterious effects on rumen epithelial health. Ruminococcus are Gram-positive bacteria that were once considered to be cellulose-degrading bacteria in rumen content. Some Ruminococcus species are able to degrade mucin and are linked to gastrointestinal disease in humans (Crost et al., 2013; Wang et al., 2013). However, the physiological roles of Ruminococcus associated with rumen epithelium are unknown. This indicates the need for more research on the interac- tions between rumen epimural bacterial community and rumen epithelium function. It has been reported that epimural bacterial composition regu- lates the expression of epithelial TLRs (Hooper et al., 2012), which triggers the production of cytokines in the intestine of mono- gastrics (Abreu, 2010). If the results of studies on intestinal tissue can be applied to ruminal tissue, it seems that the increase in expression of cytokines, reported in our previous study (Liu et al., 2013), might be associated with the activation of TLRs during HG diet feeding in goats. Our correlation results also conﬁrmed this inference. However, it is not conclusive whether variations of epimural bacterial community and host TLR genes are the factors that contribute to the initial development of local inﬂammation in the rumen epithelium during HG diet feeding. DISCUSSION Thus, the observed upregulation of TLR5 expression might be dependent on the overgrowth of bacteria rich in ﬂagellin, such as Butyrivibrio. Furthermore, many studies on humans have indicated that TLR5 is expressed only on the basolateral surface, where it can trigger the production of cytokines in response to basolateral ﬂagellin (Abreu, 2010). Another study demonstrated that luminal ﬂagellin was only able to activate TLR5 after injury to the epithelial barrier (Rhee et al., 2005). Thus, the epithelial barrier also determines whether the bacteria and their prod- ucts access the basolateral surface and trigger TLR5 expression. In our previous study, the HG diet increased rumen epithelial permeability (Liu et al., 2013), allowing bacteria or bacterial prod- ucts from the rumen lumen to enter the mucosal tissue, which can stimulate host immune responses. Our correlation results revealed that the relative mRNA expression of TLR5 was positively associated with IFN-γ production. Therefore, the observed dif- ferences in TLR5 expression and antimicrobial defense molecules between the two diets might be a result of increased permeabil- ity that allows the exposure of pattern recognition receptors and secretory molecules to epimural bacteria. It has also been reported that altered epithelial permeability is associated with changes in gastrointestinal microbes, which can subsequently affect host metabolism and rumen health (Ulluwishewa et al., 2011). p Most of the effects of the HG diet were observed at the genus level. The present study found that an HG feeding sup- ports a higher proportion of members of several genera in the rumen epithelium, including Butyrivibrio, Succiniclasticum, Mogibacterium, and Ruminococcus (Table 2). The effect of the HG diet on the abundance of Succiniclasticum, Mogibacterium, and Ruminococcus was consistent with the results of Petri et al. (2013). However, the effect of HG feeding on the abundance of Butyrivibrio was inconsistent with the results of that study, in which the dietary change from a low-grain to an HG diet were much larger than ours (Petri et al., 2013). Those researchers found that HG feeding decreased the relative abundance of Butyrivibrio ﬁbrisolvens in the rumen epithelium. This discrepancy might be associated with the differences in diet formulation and ruminant species, as mentioned earlier. Also, previous study demonstrated many Butyrivibrio species are amylolytic (Cotta, 1988), which may be an important potential reason for the increase in the abundance of rumen epithelial Butyrivibrio during HG feeding in the present study. DISCUSSION Our previous study demonstrated that the HG diet used in this study caused parakeratosis, budding, and exten- sive sloughing of the stratum corneum (Liu et al., 2013), which potentially increases the availability of attachment sites for oppor- tunistic bacteria (Plaizier et al., 2012) (Supplementary Figure 5). In addition, many previous studies have demonstrated that parakeratosis is linked with quantitative changes in the epimu- ral microbial ﬂora (Semjen et al., 1982; Steele et al., 2009). Thus, disruption of the rumen epithelial structure might account for the increased effect in the present study. Finally, the differences There are several possible reasons for the discrepancies between our results and those of previous studies. First, the dif- ferences in ruminant species might contribute to the variations in the epimural bacterial changes detected. Because the epimu- ral bacteria inhabit the host tissues, it is suggested that the host species might play a role in regulating bacterial diversity and den- sity. In the previous studies, the strong host effect might have masked the diet effect in sheep and heifers (Sadet et al., 2007; Sadet-Bourgeteau et al., 2010; Chen et al., 2011). The individual difference of goats was smaller than that of sheep and cattle (Liu et al., 2013), and thus, the diet effect masked by the host effect March 2015 \| Volume 6 \| Article 167 \| 7 www.frontiersin.org www.frontiersin.org Liu et al. Epimural bacteria and Toll-like receptors in analysis techniques, DNA extraction methods and sampling methods between our study and previous studies may also play a role in the discrepancies. Although the function of these epimural bacteria is not yet fully understood (Chen et al., 2012), the observed correlations between relative abundance of epimural bacteria and expression of the TLR genes support our speculation that epimural bac- teria play a role in stimulating the innate immune response of the rumen epithelium in goats. Our study demonstrated that the HG diet increased the relative expression levels of TLR2, TLR3, and TLR5. A previous study indicated that TLR-2 is mainly involved in responses to cell wall components of Gram-positive bacteria (Melmed et al., 2003). Therefore, the increased expres- sion of TLR2 might be dependent on the overgrowth of Gram- positive bacteria Butyrivibrio, Succiniclasticum, Mogibacterium, and Ruminococcus members of the Firmicutes. TLR-5 has a role in the recognition of bacterial ﬂagellin (Rhee et al., 2005; Abreu, 2010). Frontiers in Microbiology \| Microbial Immunology REFERENCES McCowan, R. P., Cheng, K. J., Bailey, C. 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AUTHOR CONTRIBUTIONS JL carried out the majority of the experiment including animal care, VFA analysis, RNA isolation and real-time PCR; GB, JL and SM were responsible for pyrosequencing data processing, analysis and interpretation; SM and WZ contributed to the conception of the project; The manuscript was prepared by JL and SM. Huo, W., Zhu, W., and Mao, S. (2014). Impact of subacute ruminal acidosis on the diversity of liquid and solid-associated bacteria in the rumen of goats. World J. Microb. Biot. 30, 669–680. doi: 10.1007/s11274-013-1489-8 Li, M. J., Zhou, M., Adamowicz, E., Basarab, J. A., and Guan, L. L. (2012). Characterization of bovine ruminal epithelial bacterial communities using 16S rRNA sequencing, PCR-DGGE, and qRT-PCR analysis. Vet. Microbiol. 155, 72–80. doi: 10.1016/j.vetmic.2011.08.007 ACKNOWLEDGMENTS Liu, J. H., Xu, T. T., Liu, Y. J., Zhu, W. Y., and Mao, S. Y. (2013). A high- grain diet causes massive disruption of ruminal epithelial tight junctions in goats. Am. J. Physiol. Regul. Integr. Comp. Physiol. 305, R232–R241. doi: 10.1152/ajpregu.00068.2013 Funding support: National Natural Science Foundation of China (No. 31172228) and Jiangsu Planned Projects for Postdoctoral Research Funds (No. 1402149C). Lozupone, C., and Knight, R. (2005). UniFrac: a new phylogenetic method for com- paring microbial communities. Appl. Environ. Microbiol. 71, 8228–8235. doi: 10.1128/AEM.71.12.8228-8235.2005 SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found online The Supplementary Material for this article can be found online at: http://www.frontiersin.org/journal/10.3389/fmicb.2015. 00167/abstract Malmuthuge, N., Li, M., Fries, P., Griebel, P. J., and Guan, L. L. (2012). Regional and age dependent changes in gene expression of Toll-like receptors and key antimi- crobial defence molecules throughout the gastrointestinal tract of dairy calves. Vet. Immunol. Immunopathol. 146, 18–26. doi: 10.1016/j.vetimm.2012.01.010 CONCLUSION In general, although a relatively low number of animals were used in the current study, we observed that HG diet feeding causes a strong shift in the epimural bacterial community, and that these changes are associated with alterations in the rela- tive expression of TLRs in the rumen epithelium. This study provides a ﬁrst insight into the adaptive response of epimural bacterial populations to HG feeding in goats, using the pyrose- quencing technique, and shows that these changes were associated with alterations in TLR expression. These ﬁndings lead to new insight into host–microbial relationships in ruminants and pro- vide new opportunities to improve ruminant health under the current intensive production system. Dinsdale, D., Cheng, K. J., Wallace, R. J., and Goodlad, R. A. (1980). Digestion of epithelial tissue of the rumen wall by adherent bacteria in infused and conventionally fed sheep. Appl. Environ. 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Science 336, 1268–1273. doi: 10.1126/science.1223490 DISCUSSION Indeed, a very recent study regarding expression of genes and proteins with key protection functions in the rumen epithelium of goats fed low and high grain revealed that a mismatch in gene and protein expres- sion in response to grain level (Hollmann et al., 2013), indicating the upregulation in the expression of TLR genes may not result in an increase in the expression of corresponding proteins. In addition, a previous study showed that a certain degree of upreg- ulation of TLR genes may activate the mucosal innate system in It is well known that TLRs can recognize the sensing of host epimural bacteria and bacterial products and trigger immune responses critical for maintaining host–microbial homeostasis in monogastric animals (Hooper et al., 2012). Dysregulation of this process can result in chronic inﬂammation of the gastrointesti- nal tract (Abreu, 2010). 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https://openalex.org/W2211084416	https://ria.ua.pt/bitstream/10773/17500/1/Subjective%20Memory%20Complaint%20and%20Depressive%20Symptoms%20.pdf	English	null	Subjective Memory Complaint and Depressive Symptoms among Older Adults in Portugal	Current gerontology and geriatrics research	2,015	cc-by	4,859	Hindawi Publishing Corporation Current Gerontology and Geriatrics Research Volume 2015, Article ID 296581, 6 pages http://dx.doi.org/10.1155/2015/296581 Hindawi Publishing Corporation Current Gerontology and Geriatrics Research Volume 2015, Article ID 296581, 6 pages http://dx.doi.org/10.1155/2015/296581 Correspondence should be addressed to M´onica Sousa; m.sousa@ua.pt Correspondence should be addressed to M´onica Sousa; m.sousa@ua.pt Received 25 October 2015; Accepted 21 December 2015 Academic Editor: Gjumrakch Aliev Received 25 October 2015; Accepted 21 December 2015 Received 25 October 2015; Accepted 21 December 2015 Academic Editor: Gjumrakch Aliev Academic Editor: Gjumrakch Aliev Copyright © 2015 M´onica Sousa et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Older adults report subjective memory complaints (SMCs) but whether these are related to depression remains controversial. In this study we investigated the relationship between the SMCs and depression and their predictors in a sample of old adults. Methods. This cross-sectional study enrolled 620 participants aged 55 to 96 years (74.04 ± 10.41). Outcome measures included a sociodemographic and clinical questionnaire, a SMC scale (QSM), a Geriatric Depression Scale (GDS), a Mini-Mental Status Examination (MMSE), and a Montreal Cognitive Assessment (MoCA). Results. The QSM mean total score for the main results suggests that SMCs are higher in old adults with depressed symptoms, comparatively to nondepressed old adults. The GDS scores were positively associated with QSM but negatively associated with education, MMSE, and MoCA. GDS scores predicted almost 63.4% of variance. Scores on QSM and MoCA are significantly predicted by depression symptomatology. Conclusion. Depression symptoms, lower education level, and older age may be crucial to the comprehension of SMCs. The present study suggested that depression might play a role in the SMCs of the older adults and its treatment should be considered. 3. Statistical Analysis The present study explores how old adults with SMC and depressive or nondepressive symptoms rate their levels of memory complaint. In Portuguese older adults, there was a particular interest in whether SMCs are associated with poor performance in screening tests such as the Mini- Mental Status Examination (MMSE) [19] and the Montreal Cognitive Assessment (MoCA) [20] and whether SMCs are associated with measures of gender, age, education, and depression was also investigated in order to examine the factors that influence these SMCs. Moreover, to the best of our knowledge, most of the Portuguese research investigating the relationship between SMC and depression symptoms generally use homogenous or clinical patients samples [4] and excluded patients with major depression [5, 9]. For that reason, the central question of this study was to verify the difference in older adults with depressive symptomatology through the comparison with older adults without depressive symptomatology. It was further hypothesized that SMC is related to depression and we expected that older adults with depression are of older age and female, have a lower education level, and show lower scores in screenings tests. Descriptive statistics are presented as means with standard deviations for continuous variables and as percentages for categorical variables. The analysis of differences between the two groups (nondepressed and depressed) was conducted by Chi-squared and independent t-tests. We examined the Pearson’s correlation coefficients for the associations between demographic variables (age, gender, and education), MMSE, and MoCA, with the GDS and QSM total score. Linear regres- sion models were used to predict SMC and depression perfor- mance scores adjusted by independent variables, namely, age, gender, education, MMSE, and MoCA, considering the Enter method. All tests were two-tailed and a 𝑝value < 0.05 was assumed as statistically significant. i We performed the statistical analysis with the Statistical Package for the Social Sciences (SPSS) v22.0 package for Windows. 4. Results Table 1 provides the sample characteristics and results of the neuropsychological assessment. The 620 participants included 449 women and 171 men with a mean age of 74.04 years (SD ± 10.41). The mean education level of the entire group was 3.61 ± 3.38 years. A total of 548 (88.4%) of participants only completed primary school or less, and 72 (11.6%) had secondary school education or higher. The mean total score of the SMC was 7.69 ± 4.28 and most of the participants had SMC (78.9%). Clinically significant depression symptoms were present in 46.3% (𝑛= 287) of the participants.hi Current Gerontology and Geriatrics Research 2.2.2. Depressive Symptoms. The presence of depressive mood was evaluated using Geriatric Depression Scale (GDS) [22]. A score < 10 in the GDS was used to consider the absence of depression symptoms. 2.2.2. Depressive Symptoms. The presence of depressive mood was evaluated using Geriatric Depression Scale (GDS) [22]. A score < 10 in the GDS was used to consider the absence of depression symptoms. mortality, it was strongly associated with depression [14, 18]. According to Singh-Manoux [18], reporting to the doctor about memory complain was related to risk of mortality. However, this active seek for help can reflect more worries about memory [8].h y There is a consistent evidence that untreated depression may lead to physical, cognitive, functional, and social impair- ment, as well as decreased quality of life. Appropriate treat- ment may allow the curing of depression; however the effect of this treatment on subsequent cognitive functioning is not well understood [12].h 2.2.3. Cognitive Domain. The global cognitive status was assessed with the MMSE [19] and the MoCA [20], following the respective correspondence of the validation studies for Portuguese population participants scoring. 1. Introduction clinic setting the SMCs have no differences in the conversion to dementia [9]. Notably, a recent systematic review shows that approximately 2.3%–6.6% of older adults with SMCs will develop mild cognitive impairment (MCI) and dementia per year [10]. Therefore, it is believed that there is no treatment that can stop the progress of dementia, but with the early detection of signs the medical treatment can slow down this disease process [11].h The aging process is complex and dynamic. For this reasons the cognitive performance over the lifespan is a hetero- geneous process, associated with interindividual variability (diversity) and intraindividual variability (dispersion) [1, 2]. This complexity is also present in the controversial topic of the subjective memory complaint (SMC). The SMCs are complains about memory problems of peo- ple in the absence, or not, of cognitive impairment [3]. Pre- vious Portuguese studies have reported that 75.9% [4] and/or 80.4% [5] of older adults complain of memory problems. The presence of preclinical AD in individuals with SMCs reinforces the importance of identifying modifiable risk factors associated with cognitive decline in middle-aged pop- ulations [12]. The recent study of the World Health Organ- ization (WHO) [13] reveled that depression in the community is around 5%. In late life, depression is common [14]; however it is not a natural part of aging. There is still a dispute over whether SMCs reflect depressive disorder [14–17], rather than early memory impairment [7], or if depression can be an early marker of brain changes that characterize dementia [12]. Based on several meta-analyses, systematic reviews, and research studies, evidence that suggests that SMCs are asso- ciated with an increased risk of dementia is inconclusive [3]. Most postulate that SMCs increase with advancing of age, are a core cognitive criteria for the early diagnosis of MCI and prodromal Alzheimer disease (AD), and have value as a predictor of dementia [6, 7]. On the other hand, it is considered that SMC could not predict future conversion to dementia [8]. A Portuguese study shows that in a memory Besides age, sex, and level of education, the most promi- nent factor strongly associated with SMC is depression [14– 17]. Although SMC is not associated with greater risk of 2 Current Gerontology and Geriatrics Research Current Gerontology and Geriatrics Research 2. Methods 2.1. Study Design and Participants. This is a cross-sectional study with a convenience sample recruited at the local health center and nursing homes of different regions of Portugal (Coimbra and island of Madeira) where it was conducted.h The inclusion criteria included were old adults with age of 55 years and older willing to participate in the present study. The exclusion criteria were (i) age less than or equal to 54 years, (ii) presence of neurological or psychiatric disorder, (iii) chronic alcohol or drug abuse, (iv) inability to under- stand and cooperate, and (v) being nonnative Portuguese. There is no statistically significant association between gender and depression symptoms (𝜒2(1) = 2.723, 𝑝= 0.09). Depression symptoms were more frequent in SMC partici- pants (𝜒2(1) = 46.712, 𝑝= 0.00) with lower education level (𝜒2(5) = 44.370, 𝑝= 0.00; 𝑡(618) = 3.833, 𝑝= 0.00) and older age (𝑡(610.82) = −3.965, 𝑝= 0.00). The depressed par- ticipants showed significant improvement in QSM score (𝑡(618) = 17.981, 𝑝= 0.00) but a significant decrease in MMSE score (𝑡(618) = −13.408, 𝑝= 0.00) and MoCA 𝑡(618) = 30.722, 𝑝= 0.00 (Table 1). p g g Informed consent was obtained from all participants and the study received ethical approval from the University of Aveiro and Institutional Ethics Committee. 2.2. Procedures. A semi-structured interview was conducted by a trained psychologist to record sociodemographic and clinical information, psychiatric and neurological history, past habits, and medical history. A standard protocol com- prising test and scales of neuropsychological assessment was carried out. 𝑝= 0.00 (Table 1). Table 2 shows that there were no significant differences between both groups only in items (5) (Do you often use notes to avoid forgetting things?; 𝜒2(2) = 44.370, 𝑝= 0.18) and (7) (Did you ever lose your way in neighborhood?; 𝜒2(1) = 0.009, 𝑝= 0.92). The analysis of the other items suggests that 2.2.1. Memory Complaint. The Portuguese version of SMC scale (QSM) [21] was used for the assessment of SMC. Scores ≥4 indicate clinically significant SMC. Current Gerontology and Geriatrics Research 3 Table 1: Demographics and test scores of the study groups. Whole sample (𝑛= 620) GDS 𝑝 Not depressed (GDS < 10; 𝑛= 333) Depressed (GDS ≥11; 𝑛= 287) Age (years) M ± SD 74.04 ± 10.41 72.52 ± 10.48 75.80 ± 10.06 0.00b Female 𝑛(%) 449 (72.4) 232 (69.7) 217 (75.6) 0.09a Education (years) M ± SD 3.61 ± 3.38 4.27 ± 3.55 2.85 ± 2.99 0.00b No education completed 𝑛(%) 178 (28.7) 61 (18.3) 117 (40.8) 0.00a Primary school 𝑛(%) 370 (59.7) 249 (74.8) 159 (55.4) Secondary school 𝑛(%) 56 (9) 9 (2.7) 9 (3.1) High school/university 𝑛(%) 16 (2.6) 14 (4.2) 2 (0.7) MMSE M ± SD (range) 24.85 ± 5.61 (6–30) 26.61 ± 4.38 22.80 ± 6.17 0.00b MoCA M ± SD (range) 18.20 ± 7.93 (1–31) 20.97 ± 6.64 14.98 ± 8.08 0.00b QSM M ± SD (range) 7.69 ± 4.28 (0–18) 5.80 ± 3.26 9.87 ± 4.29 0.00b Clinically significant SMC 𝑛(%) 489 (78.9) 228 (68.5) 261 (90.9) 0.00a GDS M ± SD (range) 9.28 ± 4.95 (0–20) MMSE: Mini-Mental State Examination; MoCA: Montreal Cognitive Assessment; QSM: Portuguese version of SMC scale; GDS: Geriatric Depression Scale. aChi-square test. bIndependent 𝑡-tests. Table 1: Demographics and test scores of the study groups. Table 1: Demographics and test scores of the study groups. 15.00 20.00 10.00 5.00 QSM (total score) Not depressed Depressed 0.00 Figure 1: Total QSM score in the depressed and not depressed old adults. 15.00 20.00 10.00 5.00 QSM (total score) Not depressed Depressed 0.00 Figure 1: Total QSM score in the depressed and not depressed old adults. positive correlation with GDS (𝑟 = 0.54, 𝑝 < 0.001). Education (𝑟= −0.13, 𝑝< 0.001), MMSE, and MoCa (𝑟= −0.34, 𝑝< 0.001) have significant weak negative correlation with QSM (Table 3). Two multivariate logistic regressions were performed to identify the predictors of QSM and GDS scores. 𝑝= 0.00 (Table 1). According to the results shown in Table 4, the QSM score was only influenced by education (𝛽= 0.14, 95% confidence interval (CI) = −0.823–0.475), MMSE (𝛽= −0.11, 95% CI = 0.034– 0.241), and GDS scale scores (𝛽= 0.40, 95% CI = −0.112– 0.59). Age, gender, and MoCA were not influenced by QSM score (Table 3). The GDS performance were predicted by MoCA (𝛽= −0.402, 95% CI = −0.341–−0.162) and QSM (𝛽= −0.419, 95% CI = −0.408–0.561). These logistic regression models predicted 63.4% of total variations of GDS score and 31% of SMC score (Table 3). Figure 1: Total QSM score in the depressed and not depressed old adults. 5. Discussion In the present study, we analyzed SMC and depression, and their relationship to sociodemographic and to the scores in MMSE and MoCA. The initial hypothesis that SMCs would be more reported by depressed old adults, as compared to nondepressed, was confirmed. However, in both groups, few participants had zero in the QSM total score. These findings are consistent with previous research on community samples, in which few participants also reported none memory diffi- culties measured by QSM [8]. depressed patients had generally answered the last option of the scoring. As indicated in Figure 1, old adults with depression had higher scores on total SMC (9.87±4.29; 0–14), comparatively to old adults without depression (5.80 ± 3.26; 0–18). Only one (0.3%) participant without depression symptoms and eight (2.8%) depression participants reported no memory complaint, in other words, had QSM equal to 0.i GDS score obtained significant weak negative correlation with education (𝑟= −0.29, 𝑝< 0.001), MMSE (𝑟= −0.43, 𝑝< 0.001), and MoCa (𝑟= −0.49, 𝑝< 0.001) and only a significant weak positive correlation with age (𝑟= 0.24, 𝑝< 0.001). QSM score showed a significant, weak, and positive correlation with age (𝑟= 0.14, 𝑝< 0.001) and moderate On whole sample, the frequencies of SMC and depression are in line with those observed in other studies [14, 15, 18], highlighting the higher frequencies in the Portuguese old adults, independently of the characteristics of participants and settings where they are recruited [4, 5, 8, 9, 23]. Current Gerontology and Geriatrics Research 4 Table 2: Results of the QSM. Table 2: Results of the QSM. Table 2: Results of the QSM. Item Subscore range Participants score answers, % 𝜒2 𝑝 Not depressed (GDS < 10; 𝑛= 333) Depressed (GDS ≥11; 𝑛= 287) (1) Do you have any complaints concerning your memory? 0–3 0 = 6.9; 1 = 48.6; 2 = 26.4; 3 = 18 0 = 4.2; 1 = 19.5; 2 = 37.3; 3 = 39 69.541 0.00 (2) Do other people find you forgetful? 0–2 0 = 60.7; 1 = 27.3; 2 = 12 0 = 40.1; 1 = 31.7; 2 = 28.2 34.547 0.00 (3) Do you ever forget names of family members or friends? 0–3 0 = 69.4; 1 = 19.2; 2 = 9.6; 3 = 1.8 0 = 45.3; 1 = 19.5; 2 = 26.5; 3 = 8.7 55.253 0.00 (4) Do you often forget where things are left? 5. Discussion 0–3 0 = 20.7; 1 = 51.7; 2 = 18.6; 3 = 9 0 = 25.1; 1 = 20.6; 2 = 28.9; 3 = 25.4 73.324 0.00 (5) Do you often use notes to avoid forgetting things? 0–2 0 = 84.4; 1 = 14.1; 2 = 1.5 0 = 82.9; 1 = 13.2; 2 = 3.8 3.371 0.18 (6) Do you ever have difficulties in finding particular words? 0-1 0 = 82; 1 = 18 0 = 59.9; 1 = 40.1 37.000 0.00 (7) Did you ever lose your way in neighborhood? 0-1 0 = 97; 1 = 3.0 0 = 96.9; 1 = 3.1 0.009 0.92 (8) Do you think more slowly than you used to? 0–2 0 = 28.2; 1 = 62.5; 2 = 9.3 0 = 11.8; 1 = 46.7; 2 = 41.5 92.862 0.00 (9) Do your thoughts ever become confused? 0–2 0 = 62.5; 1 = 29.7; 2 = 7.8 0 = 23.7; 1 = 31; 2 = 45.3 138.228 0.00 (10) Do you have concentration problems? 0–2 0 = 60.4; 1 = 30.6; 2 = 9 0 = 22; 1 = 36.6; 2 = 41.5 122.603 0.00 GDS: Geriatric Depression Scale; 𝜒2: Chi-square test. Scoring of items (1), (3), and (4): 0: no; 1: yes, but no problem; 2: yes, problem; 3: yes, serious problem. Scoring of items (2) and (5): 0: no; 1: yes, sometimes; 2: yes, often. Scoring of items (6) and (7): 0: no; 1: yes. Scoring of items (8)–(10): 0: no; 1: yes; 2: yes, serious problem. g y Scoring of items (8)–(10): 0: no; 1: yes; 2: yes, serious problem. Table 3: Correlation for the main variables and measures. Table 3: Correlation for the main variables and measures. GDS QSM Age 0.24∗∗ 0.14∗∗ Education −0.29∗∗ −0.13∗∗ MMSE −0.43∗∗ −0.34∗∗ MoCA −0.49∗∗ −0.34∗∗ GDS 0.54∗∗ MMSE: Mini-Mental State Examination; MoCA: Montreal Cognitive Assess- ment; QSM: Portuguese version of SMC scale; GDS: Geriatric Depression Scale. ∗∗𝑝< 0.001. and the MoCA, and had slightly minor QSM score than the participants with depression [14]. The poor cognitive func- tion and inclination to SMC might be a reflection of a negative mental status and cognitive changes produced by anxiety and depression [14]. Therefore, overall, the Portuguese population of women over 64 years who completed primary education have a higher longevity [25, 26]. 5. Discussion This research, based on self- reported measures of SMC and in a convenience sampling, illustrated this phenomenon. For this reason, these factors should be considered in the interpretation of the results.if Concerning the gender, no statistically significant differ- ences were found for both SMC and depression symptoms. The influence of gender is not clear. Studies have demon- strated that there are no differences [8, 23], others that males have higher number of complaints [24], and others that women are at great risk for SMC [16]. Several studies have shown that older adults with depres- sive symptoms had significantly more SMCs, compared to older adults without these symptoms [15, 18, 24]. In this study, thus, depressive symptoms appear to be an important predictor of SMC and depression, age, education, and both screening instruments were significantly associated with QSM score. Despite the weak association, this result is anal- ogous to the Portuguese studies [4, 23], observing positive correlations of depression with QSM score, and emphasizes that the lower cognitive performance influences the reports of memory dysfunction [14, 16].hi g Contrarily to previous research, in QSM items (5) (Do you often use notes to avoid forgetting things?) and (7) (Did you ever lose your way in neighborhood?), independently of whether depressed or nondepressed, few participants answered positively. Assessing the SMC with the same instrument [21], participants who were nonconverters to dementia had higher scores in item (5) [9] and participants from clinical and community sample also tend to score lower in item (7) [8]. A recent study performed in our population revealed the same higher option zero (0) in items (5) and (7) [5]. It also demonstrated that item (5) increased with The main findings were that participants without depres- sion had more education, had higher scores on the MMSE Current Gerontology and Geriatrics Research 5 Table 4: Regression analysis of predictors of SMC and depression performance. QSM (𝑛= 620) GDS (𝑛= 620) 𝛽 (CI 95%) 𝑝 𝛽 (CI 95%) 𝑝 Age −0.008 3.790 10.632 0.649 −0.041 −0.056 0.017 0.296 Gender −0.174 −0.042 0.026 0.599 −0.026 −0.980 0.413 0.425 Education 0.14 −0.823 0.475 0.009 −0.061 −0.200 0.023 0.118 MMSE −0.11 0.034 0.241 0.035 0.074 −0.046 0.177 0.249 MoCA −0.026 −0.215 −0.008 0.546 −0.402 −0.341 −0.162 0.000 GDS 0.40 −0.112 0.059 0.000 QSM 0.419 0.408 0.561 0.000 𝑅2 31 63.4 𝐹(7.612) = 39.242. 𝑝< 0.001 𝐹(6.613) = 68.659. 5. Discussion 𝑝< 0.001 𝛽: beta coefficient; 95% CI: 95% confidence interval; MMSE: Mini-Mental State Examination; MoCA: Montreal Cognitive Assessment; QSM: Portuguese version of SMC scale; GDS: Geriatric Depression Scale; 𝑅2: Nagelkerke 𝑅Square. Table 4: Regression analysis of predictors of SMC and depression performance. Table 4: Regression analysis of predictors of SMC and depression performance. because this kind of complaints can be part of a scenario in which mood disorder is a symptom. the level of education and may be related to cognitive reserve and external strategies (listing dates or using schedules) [5]. In addition, the controversy between SMC and depres- sion emphasizes that SMCs may have clinical usability to identify early cognitive changes self-described by old people [3, 6] but not so far detected in neuropsychological assess- ment. It also emphasizes that that depression can also increase the risk for dementia [12]. This study has significant implica- tions for clinical practice, namely, the SMCs which should be considered clinically meaningful because they may have the potential to identify depressive symptoms. Conflict of Interests The authors declare that there is no conflict of interests regarding the publication of this paper. References [1] L. Vaughan, I. Leng, D. Dagenbach et al., “Intraindividual vari- ability in domain-specific cognition and risk of mild cognitive impairment and dementia,” Current Gerontology and Geriatrics Research, vol. 2013, Article ID 495793, 10 pages, 2013. p y p y p Other possible limitations of the present investigation were the convenience sampling and the use of two cognitive screening tests. Future studies should include a larger sample that represents the Portuguese population, adopt random sampling, and should be evaluated with a comprehensive neuropsychological battery. However, the MMSE and MoCA were widely brief instruments that can provide important cognitive screening and are cost-effective for the clinical evaluation of adults’ cognitive state [27]. This cross-sectional study might not provide causal information among variables and the majority of the sample was four years of education, opening the possibility to the presence of false positives. For this reason, we suggest that future studies should have a longitudinal design to deeply identify this causal relationship. [2] R. S. Siegler, “Inter- and intra-individual differences in problem solving across the lifespan,” in Lifespan Cognition: Mechanisms of Change, pp. 285–296, University Press Scholarship Online, 2006. [3] M. D. Mendonca, L. Alves, and P. Bugalho, “From subjective cognitive complaints to dementia: who is at risk?: a systematic review,” American Journal of Alzheimer’s Disease and Other Dementias, 2015. [4] S. Gin´o, T. Mendes, J. Maroco et al., “Memory complaints are frequent but qualitatively different in young and elderly healthy people,” Gerontology, vol. 56, no. 3, pp. 272–277, 2010. [5] A. A. Jo˜ao, J. Maroco, S. Gin´o, T. Mendes, A. de Mendonc¸a, and I. P. Martins, “Education modifies the type of subjective mem- ory complaints in older people,” International Journal of Geri- atric Psychiatry, 2015. Current Gerontology and Geriatrics Research 6 [23] T. Mendes, S. Gin´o, F. Ribeiro et al., “Memory complaints in healthy young and elderly adults: reliability of memory report- ing,” Aging & Mental Health, vol. 12, no. 2, pp. 177–182, 2008. [9] D. Silva, M. Guerreiro, C. Faria, J. Maroco, B. A. Schmand, and A. De Mendonc¸a, “Significance of subjective memory complaints in the clinical setting,” Journal of Geriatric Psychiatry and Neurology, vol. 27, no. 4, pp. 259–265, 2014. [24] J. Holmen, E. M. Langballe, K. Midthjell et al., “Gender dif- ferences in subjective memory impairment in a general popu- lation: the HUNT study, Norway,” BMC Psychology, vol. 1, no. 1, article 19, 2013. [10] A. J. Mitchell, H. Beaumont, D. Ferguson, M. Yadegarfar, and B. Stubbs, “Risk of dementia and mild cognitive impairment in older people with subjective memory complaints: Meta-anal- ysis,” Acta Psychiatrica Scandinavica, vol. 130, no. 6, pp. 439–451, 2014. [25] Instituto Nacional de Estat´ıstica (INE), Portuguese Official Statistics, Instituto Nacional de Estat´ıstica, Lisbon, Portugal, 2011. [11] C. Jonker, M. I. Geerlings, and B. Schmand, “Are memory com- plaints predictive for dementia? A review of clinical and pop- ulation-based studies,” International Journal of Geriatric Psychi- atry, vol. 15, no. 11, pp. 983–991, 2000. [26] A. Mota-Pinto, V. Rodrigues, A. Botelho et al., “A socio-demo- graphic study of aging in the Portuguese population: the EPEPP study,” Archives of Gerontology and Geriatrics, vol. 52, no. 3, pp. 304–308, 2011. [12] M. Baumgart, H. M. Snyder, M. C. Carrillo, S. Fazio, H. Kim, and H. Johns, “Summary of the evidence on modifiable risk factors for cognitive decline and dementia: a population-based perspective,” Alzheimer’s & Dementia, vol. 11, no. 6, pp. 718–726, 2015. [27] M. Sousa, A. Pereira, R. Costa, and L. Rami, “Initial phase of adaptation of Memory alteration Test (M@T) in a Portuguese sample,” Archives of Gerontology and Geriatrics, vol. 61, no. 1, pp. 103–108, 2015. [13] WHO, “Depression is a common illness and people suffering from depression need support and treatment,” WHO, http:// www.who.int/mediacentre/news/notes/2012/mental health day 20121009/en/. [14] Y. Balash, M. Mordechovich, H. Shabtai, N. Giladi, T. Gurevich, and A. D. Korczyn, “Subjective memory complaints in elders: depression, anxiety, or cognitive decline?” Acta Neurologica Scandinavica, vol. 127, no. 5, pp. 344–350, 2013. [15] O. H. Del Brutto, R. M. Mera, V. J. 6. Conclusion Our findings suggest that Portuguese old adults with age of 55 and older experience clinically significant depression symptoms and, as their age advances, lower education and lower cognitive function were significant predictors of the SMC. Approximately 78.9% of participants report significant SMC, with an increase form not depressed patients to depressed patients.i [6] F. Jessen, B. Wiese, C. Bachmann et al., “Prediction of dementia by subjective memory impairment: effects of severity and temporal association with cognitive impairment,” Archives of General Psychiatry, vol. 67, no. 4, pp. 414–422, 2010. [7] M. R¨onnlund, A. Sundstr¨om, R. Adolfsson, and L.-G. Nilsson, “Subjective memory impairment in older adults predicts future dementia independent of baseline memory performance: evi- dence from the Betula prospective cohort study,” Alzheimer’s & Dementia, vol. 11, no. 11, pp. 1385–1392, 2015. Based on these findings, we recommend that the clini- cians, frequented by old adults with complaints of memory problems who seek help, should consider the different pre- ventative measures and interventions that can be adopted to delay or reverse depression, and consequently the SMCs, [8] C. Pires, D. Silva, J. Maroco et al., “Memory complaints asso- ciated with seeking clinical care,” International Journal of Alzheimer’s Disease, vol. 2012, Article ID 725329, 5 pages, 2012. Current Gerontology and Geriatrics Research Current Gerontology and Geriatrics Research Submit your manuscripts at http://www.hindawi.com Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 MEDIATORS INFLAMMATION of Endocrinology International Journal of Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Disease Markers The Scientific World Journal Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Immunology Research Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Journal of Diabetes Research Journal of Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Gastroenterology Research and Practice Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 MEDIATORS INFLAMMATION of Hindawi Publishing Corporation http://www.hindawi.com Disease Marker The Scientific World Journal Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Diabetes Research Journal of Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Gastroenterology Research and Practice Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Disease Markers The Scientific World Journal Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 The Scientific World Journal Hindawi Publishing Corporation Endocrinology International Journal of Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Current Gerontology and Geriatrics Research Del Brutto et al., “Influence of depression, anxiety and stress on cognitive performance in community-dwelling older adults living in rural Ecuador: results of the Atahualpa Project,” Geriatrics & Gerontology Inter- national, vol. 15, no. 4, pp. 508–514, 2015. 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Sim˜oes, L. Alves, and I. Santana, “Montreal Cognitive Assessment (MoCA): normative study for the Por- tuguese population,” Journal of Clinical and Experimental Neu- ropsychology, vol. 33, no. 9, pp. 989–996, 2011. [21] S. Gin´o, T. Mendes, F. Ribeiro, A. Mendonc¸a, M. Guerreiro, and C. Garcia, “Escala de Queixas de Mem´oria,” in Escalas e Testes na Demˆencia, A. Mendonc¸a and M. Guerreiro, Eds., pp. 117–120, GEECD, Lisbon, Portugal, 2007. [22] J. Barreto, A. Leuschner, F. Santos, and M. Sobral, “Escala de depress˜ao geri´atrica,” in Escalas e Testes na Demˆencia, A. Mendonc¸a and M. Guerreiro, Eds., pp. 69–72, GEECD, Lisbon, Portugal, 2007. 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https://openalex.org/W2046271817	http://nrl.northumbria.ac.uk/id/eprint/71/1/Zebbiche%20K%2C%20Khelifi%20F%2C%20Bouridane%20A%20-%20An%20efficient%20watermarking%20technique%20for%20the%20protection%20of%20fingerprint%20images%20-%20article.pdf	English	null	An Efficient Watermarking Technique for the Protection of Fingerprint Images	EURASIP Journal on Multimedia and Information Security	2,008	cc-by	13,181	Published by: Springer : http://dx.doi.org/10.1155/2008/918601 <http://dx.doi.org/10.1155/2008/918601> This version was downloaded from Northumbria Research Link: https://nrl.northumbria.ac.uk/id/eprint/71/ Northumbria University has developed Northumbria Research Link (NRL) to enable users to access the University’s research output. Copyright © and moral rights for items on NRL are retained by the individual author(s) and/or other copyright owners. 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Northumbria Research Link Citation: Zebbiche, Khalil, Khelifi, Fouad and Bouridane, Ahmed (2008) An efficient watermarking technique for the protection of fingerprint images. EURASIP Journal on Information Security. p. 20. ISSN 1687-4161 Hindawi Publishing Corporation EURASIP Journal on Information Security Volume 2008, Article ID 918601, 20 pages doi:10.1155/2008/918601 Correspondence should be addressed to K. Zebbiche, kzebbiche01@qub.ac.uk Received 12 February 2008; Revised 7 July 2008; Accepted 11 September 2008 Recommended by D. Kirovski This paper describes an eﬃcient watermarking technique for use to protect ﬁngerprint images. The rationale is to embed the watermarks into the ridges area of the ﬁngerprint images so that the technique is inherently robust, yields imperceptible watermarks, and resists well against cropping and/or segmentation attacks. The proposed technique improves the performance of optimum multibit watermark decoding, based on the maximum likelihood scheme and the statistical properties of the host data. The technique has been applied successfully on the well-known transform domains: discrete cosine transform (DCT) and discrete wavelet transform (DWT). The statistical properties of the coeﬃcients from the two transforms are modeled by a generalized Gaussian model, widely adopted in the literature. The results obtained are very attractive and clearly show signiﬁcant improvements when compared to the conventional technique, which operates on the whole image. Also, the results suggest that the segmentation (cropping) attack does not aﬀect the performance of the proposed technique, which also provides more robustness against other common attacks. Copyright © 2008 K. Zebbiche et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. K. Zebbiche,1 F. Kheliﬁ,2 and A. Bouridane1 1School of Electronics, Electrical Engineering, and Computer Science, Queen’s University of Belfast, Belfast BT7 1NN, Northern Ireland, UK 2Department of Electronic Imaging and Media Communications (EIMC), School of Informatics, University of Bradford, Richmond Road, Bradford, West Yorkshire, BD7 1DP, UK Correspondence should be addressed to K. Zebbiche, kzebbiche01@qub.ac.uk 1. INTRODUCTION (a:1) (a:2) (a:3) (b:1) (b:2) (b:3) Figure 3: Test images with diﬀerent ridges area size from DB2: (a, b: 1) original images (a: Image 71 4, b: Image 75 7), (a, b: 2) segmentation masks, (a, b: 3) watermarking masks. (a:1) (a:3) (b:1) (b:3) (b:2) (b:1) (b:3) (b:2) (b:3) (b:1) Figure 2: Test images with diﬀerent ridges area size from DB1: (a, b: 1) original images (a: Image 98 2, b: Image 20 1), (a, b: 2) segmentation masks, (a, b: 3) watermarking masks. Figure 3: Test images with diﬀerent ridges area size from DB2: (a, b: 1) original images (a: Image 71 4, b: Image 75 7), (a, b: 2) segmentation masks, (a, b: 3) watermarking masks. (a:1) (a:2) (a:3) (b:1) (b:2) (b:3) Figure 4: Test images with ridges area size from DB3: (a, b: 1) original images (a: Image 47 3, b: Image 73 7), (a, b: 2) segmentation masks, (a, b: 3) watermarking masks. (a:2) (a:3) (a:3) Researchers in watermarking domain have focused their works on two fundamental issues: watermark detection and watermark decoding (extraction). In the latter, usually referred to as multibit watermarking, a full decoding is carried out to extract the hidden message, which can be an ownership identiﬁers, transaction dates, a serial numbers, and so forth. Such a watermarking can be found in ﬁnger- printing, steganography, and the protection of intellectual property rights. In multibit watermarking, errors may occur when extracting the hidden message. Error probability can be used as a measure of the watermarking system performance. In the literature, optimum decoders have been proposed and are based on a statistical modeling of the host data. Hernandez et al. propose a structure of optimum decoder for additive watermarks embedded within the DCT coeﬃcients, modeled by a generalized Gaussian distribution (GGD). The problem of optimum decoding for multiplicative multibit watermarking has been addressed in [17–19]. In [17], the authors propose a new optimum decoder of watermarks embedded in the DFT coeﬃcients modeled using a Weibull distribution, while Song in [18] proposes a general statistical procedure based on the total eﬃcient score vector for both GGD and Weibull distribution. In [19], a new optimum decoder based on GGD has been proposed for extracting watermarks embedded within DWT coeﬃcients. (a:1) Researchers in watermarking domain have focused their works on two fundamental issues: watermark detection and watermark decoding (extraction). 1. INTRODUCTION use them for identiﬁcation and classiﬁcation purposes (see Figure 1). Biometric-based authentication systems that use physio- logical characteristics (ﬁngerprint, face, iris, etc.) and/or behavioral traits (signature, voice, etc.) of persons are gaining more and more interest in the last years since they are based on information that is permanently associated with a person. Among various commercially available biometric- based systems, ﬁngerprint-based techniques are the most mature, extensively studied, and widely deployed. While biometric-based techniques have inherent advantages over other authentication techniques such as token-based or knowledge-based techniques, ensuring the security and integrity of data is a paramount issue. Recently, water- marking techniques have been introduced and shown to be promising for protecting ﬁngerprint data and increasing the security level of ﬁngerprint-based systems [1–5]. For example, watermarking of ﬁngerprint images can be used to secure central databases from which ﬁngerprint images are transmitted on request to intelligence agencies in order to Depending on the embedding domain, existing algo- rithms for image watermarking usually operate either in the spatial domain [6, 7] or in a transform domain such as the discrete cosine transform (DCT) [8, 9] and the discrete wavelet transform (DWT) [10, 11]. However, most research works have been proposed in the transform domain because of its energy compaction property which suggests that the distortions introduced by the watermarks into the transform coeﬃcients will spread over all the pixels in the spatial domain so as the changes introduced in these pixels values are visually less signiﬁcant. Also, depending on the embedding rule used, the watermarks are often embedded using either an additive or a multiplicative rule. Additive rule has been broadly used in the literature due to its simplicity [8, 9, 12]. On the other hand, multiplicative rule is more eﬃcient because it is image dependent and exploits the characteristics of the human visual system (HVS) in a better way [13–16]. EURASIP Journal on Information Security 2 Fingerprint image Watermark encoder Channel Watermark decoder Extracted ID Verification Image rejected No Yes Fingerprint-based identification system ID Figure 1: Block diagram of a watermarking application for ﬁngerprint images. Fingerprint image Image rejected Figure 1: Block diagram of a watermarking application for ﬁngerprint images. (a:1) (a:2) (a:3) (b:1) (b:2) (b:3) Figure 2: Test images with diﬀerent ridges area size from DB1: (a, b: 1) original images (a: Image 98 2, b: Image 20 1), (a, b: 2) segmentation masks, (a, b: 3) watermarking masks. 1. INTRODUCTION In the latter, usually referred to as multibit watermarking, a full decoding is carried out to extract the hidden message, which can be an ownership identiﬁers, transaction dates, a serial numbers, and so forth. Such a watermarking can be found in ﬁnger- printing, steganography, and the protection of intellectual property rights. In multibit watermarking, errors may occur when extracting the hidden message. Error probability can be used as a measure of the watermarking system performance. (a:3) (a:1) (b:3) (b:2) (b:1) In the literature, optimum decoders have been proposed and are based on a statistical modeling of the host data. Hernandez et al. propose a structure of optimum decoder for additive watermarks embedded within the DCT coeﬃcients, modeled by a generalized Gaussian distribution (GGD). The problem of optimum decoding for multiplicative multibit watermarking has been addressed in [17–19]. In [17], the authors propose a new optimum decoder of watermarks embedded in the DFT coeﬃcients modeled using a Weibull distribution, while Song in [18] proposes a general statistical procedure based on the total eﬃcient score vector for both GGD and Weibull distribution. In [19], a new optimum decoder based on GGD has been proposed for extracting watermarks embedded within DWT coeﬃcients. (b:3) (b:1) (b:2) Figure 4: Test images with ridges area size from DB3: (a, b: 1) original images (a: Image 47 3, b: Image 73 7), (a, b: 2) segmentation masks, (a, b: 3) watermarking masks. 3 K. Zebbiche et al. 3 ebbiche et al. 1. INTRODUCTION 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 550 500 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 71 4 (c) 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 75 7 (d) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 500 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 73 7 Proposed technique Conventional technique (f) Figure 5: BER as a function of the number of coeﬃcients per bit for the test images. Watermark applied in the DCT domain. 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 20 1 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 75 7 550 500 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 71 4 BER for image 75 7 BER for image 71 4 Number of coeﬃcients per information bit Number of coeﬃcients per information bit 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 47 3 500 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 73 7 BER for image 47 3 BER for image 73 7 BER Number of coeﬃcients per information bit (f) (e) Figure 5: BER as a function of the number of coeﬃcients per bit for the test images. 1. INTRODUCTION Watermark applied i s a function of the number of coeﬃcients per bit for the test images. Watermark applied in the DCT domain. In this work, the main contribution consists of embed- ding the watermark within the foreground or the ridges area by avoiding to embed it in the background area. This is motivated by the following facts. from the background). Consequently, a part/portion of the watermark which is embedded within the background area can be removed, thus aﬀecting the robustness of the watermark. Furthermore, to remove a watermark embedded in the ridges area, an attacker needs to apply strong attacks (such as additive noise and ﬁltering) on that area, resulting in severe degradations of the quality of the image, thus, making it useless. (i) Embedding watermarks into the ridges area increases its robustness because an attacker is interested in that area only (i.e., segmentation or cropping attack is usually performed to extract the ridges area EURASIP Journal on Information Security 4 EURASIP Journal on Information Secu 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 71 4 (c) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 75 7 (d) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 73 7 Proposed technique Conventional technique (f) Figure 6: BER as a function of the number of coeﬃcients per bit for the test images. Watermark applied in the DWT domain. 1. INTRODUCTION 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 20 1 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 BER for image 20 1 BER 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 71 4 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 75 7 BER for image 75 7 BER for image 71 4 BER BER Number of coeﬃcients per information bit Number of coeﬃcients per information bit (d) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 73 7 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 47 3 BER for image 47 3 BER for image 73 7 BER BER Number of coeﬃcients per information bit Number of coeﬃcients per information bit Proposed technique Conventional technique (e) (f) (e) Figure 6: BER as a function of the number of coeﬃcients per bit for the test images. Watermark applied in th s a function of the number of coeﬃcients per bit for the test images. Watermark applied in the DWT domain. (ii) The human eye is less sensitive to noise and changes in the texture regions; this makes sense to select the ridges area for watermark embedding and ensures imperceptibility of the embedded watermarks. segmentation results in a binary mask called segmentation mask. This mask is then partitioned into nonoverlapping blocks, where only the blocks belonging to the ridges area are used to carry the watermark. This is represented by another binary mask called watermarking mask. The proposed technique has been introduced to increase the performance of the optimum watermark decoder, whose structure is theoretically based on a maximum-likelihood The proposed technique starts by ﬁrst extracting the ridges area using the segmentation technique proposed by Wu et al. [20], which has been modiﬁed to generate adap- tive thresholds instead of ﬁxed ones. The output of the 5 5 K. Zebbiche et al. 1. INTRODUCTION 600 550 500 450 400 350 300 250 200 Number of hidden information bits 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 200 180 160 140 120 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 500 450 400 350 300 250 200 150 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 71 4 (c) 400 350 300 250 200 150 100 Number of hidden information bits 10−3 10−2 10−1 BER BER for image 75 7 (d) 600 500 400 300 200 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 450 350 250 150 50 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 73 7 Proposed technique Conventional technique (f) Figure 7: BER as function of total amount of hidden information bits. Watermark applied in the DCT domain. 600 550 500 450 400 350 300 250 200 Number of hidden information bits 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 200 180 160 140 120 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 20 1 BER 400 350 300 250 200 150 100 Number of hidden information bits 10−3 10−2 10−1 BER BER for image 75 7 500 450 400 350 300 250 200 150 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 71 4 BER for image 75 7 BER for image 71 4 BER (d) 600 500 400 300 200 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 47 3 450 350 250 150 50 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 73 7 BER for image 47 3 BER BER Number of hidden information bits Number of hidden information bits Number of hidden information bits Proposed technique Conventional technique (f) Proposed technique Conventional technique (e) (f) (e) gure 7: BER as function of total amount of hidden information bits. Watermark applied in the DCT domain. (ML) estimation scheme. 1. INTRODUCTION For the sake of illustration, the process of watermarking is applied in both the DCT and the DWT domains, where the transform coeﬃcients in each domain are statistically modeled using a GGD that has been shown, in the literature, to be the most accurate statistical model. The results obtained in this work clearly demonstrate the performance improvements achieved by the proposed technique. Also, the segmentation process, which can be thought of as an attack for ﬁngerprint images, is shown (ML) estimation scheme. For the sake of illustration, the process of watermarking is applied in both the DCT and the DWT domains, where the transform coeﬃcients in each domain are statistically modeled using a GGD that has been shown, in the literature, to be the most accurate statistical model. The results obtained in this work clearly demonstrate the performance improvements achieved by the proposed technique. Also, the segmentation process, which can be thought of as an attack for ﬁngerprint images, is shown to have no inﬂuence on the overall performance of the optimum decoder. The paper is organized as follows. Section 2 describes the technique used to extract the region of interest. A brief description of watermark generation and the embedding process for both the DCT and the DWT domains is given in Section 3. Then, in Section 4, the multibit watermark decoding (extraction) issue is addressed. 1. INTRODUCTION The inﬂuence of attacks on the overall performance of the optimum decoder EURASIP Journal on Information Security 6 EURASIP Journal on Information 600 550 500 450 400 350 300 250 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 200 180 160 140 120 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 500 450 400 350 300 250 200 150 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 71 4 (c) 450 400 350 300 250 200 150 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 75 7 (d) 600 500 400 300 200 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 550 450 350 250 150 50 Number of hidden information bits 10−2 10−1 100 BER BER for image 73 7 Proposed technique Conventional technique (f) Figure 8: BER as a function of total amount of hidden information bits. Watermark applied in the DWT domain. 200 180 160 140 120 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 20 1 600 550 500 450 400 350 300 250 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 98 2 BER for image 20 1 BER BER 450 400 350 300 250 200 150 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 75 7 500 450 400 350 300 250 200 150 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 71 4 BER for image 75 7 BER for image 71 4 BER BER Number of hidden information bits (d) (c) 600 500 400 300 200 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 47 3 ( ) 550 450 350 250 150 50 Number of hidden information bits 10−2 10−1 100 BER BER for image 73 7 BER for image 47 3 BER for image 73 7 BER Proposed technique Conventional technique (e) Proposed technique Conventional technique (f) (f) (e) gure 8: BER as a function of total amount of hidden information bits. Watermark applied in the DWT domain. is assessed through experimentation whose results and analysis are reported in Section 5. 1. INTRODUCTION Finally, conclusions are drawn in Section 6. the borders of the image is called the background area. An extraction of the ridges area can be carried out by using a segmentation technique whose objective is to decide whether a part of the ﬁngerprint image belongs to the foreground (which is of our interest) or belongs to the background. Several methods and techniques have been proposed in the literature for segmenting ﬁngerprint images [21, 22]. However, in our case, the technique must be robust to common watermarking attacks in the sense that it also detects the same ridges area even if a ﬁngerprint image is 2. RIDGES AREA DETECTION AND EXTRACTION These results are necessary since the computed watermarking mask (i.e., the selected blocks) will be used to carry the watermark. The ﬁrst column of Table 2 reports the highest compression ratio (in bits per pixel) below which the technique was able to provide the same watermarking mask. The second column of Table 2 shows the results obtained for an AWGN attack. In the case of the mean ﬁltering, the results are shown in the third column of Table 2. For each database, the mean peak signal-to-noise ratio (PSNR) values are also shown for each type of attack in order to assess the distortions introduced. The output of the segmentation process yields a seg- mented image and/or a segmentation mask. Since Harris point features method is a pointwise method, the segmen- tation mask is a binary mask (i.e., 1 if the pixel is assigned to the foreground area and 0 otherwise) of the same size as the original image. Once the ridges area is extracted, one has to ensure that the watermark will be embedded within this extracted area. We propose to divide the segmentation mask into nonoverlapping blocks, where each block is classiﬁed as ridge block or background block according to the number of foreground pixels belonging to the block at hand (in this paper, a block is considered to be a ridge block if and only if all the block’s pixels are classiﬁed as a ridge pixel). Finally, a binary watermarking mask is produced with a value of 1 if the block belongs to the ridges area and 0 otherwise. Let I[n] = I[n1, n2], 0 ≤n1 < N1, 0 ≤n2 < N2 be a two-dimensional (2D) data representing the luminance component of the image with size N1 × N2 pixels and SM[n] be 2D binary matrix representing the segmentation mask with N1×N2 components. SM[n] is partitioned into nb1×nb2 nonoverlapping blocks Bij, 0 ≤i < nb1, 0 ≤j < nb2, of m × m pixels, where nb1 = ⌊N1/m⌋and nb2 = ⌊N2/m⌋. Let WMij, where 0 ≤i < nb1 and 0 ≤j < nb2 be 2D binary sequence representing the watermarking mask. 2. RIDGES AREA DETECTION AND EXTRACTION A captured ﬁngerprint image usually consists of two areas: the foreground and the background. The foreground or ridges area is the component that originates from the contact of a ﬁngertip with the sensor. The noisy area at K. Zebbiche et al. 7 Table 1: Technologies used for the collection of FVC2004 databases. Database Sensor type Image size Resolution (dpi) DB1 Optical sensor 640 × 480 500 DB2 Optical sensor 328 × 364 500 DB3 Thermal sweeping sensor 300 × 480 500 Table 1: Technologies used for the collection of FVC2004 databases. subjected to attacks such as compression, ﬁltering, noise addition. Unfortunately, most of these techniques are not robust enough to resist image manipulations. In this work, we propose to use Harris corner point features to segment the ﬁngerprint images. A Harris corner detector is based on a local autocorrelation function of a signal to measure the local changes of the signal with patches shifted by a small amount in diﬀerent directions [23]. It has been found in [20] that the strength of a Harris point in the foreground area is much higher than that in the background area. However, the authors proposed to use diﬀerent thresholds, which are determined experimentally for each image. Also, they noticed that some noisy regions are likely to have a higher strength which cannot be eliminated even by using high threshold value and proposed to use a heuristic algorithm based on the corresponding Gabor response. In our case, we found that an adaptive threshold can be obtained by using Otsu thresholding method [24] which provides an excellent threshold for ﬁngerprint images from diﬀerent databases. When some morphological methods are applied to eliminate the noisy regions, excellent segmented images are obtained. images. The choice has been done on the basis of the variability of the ridges area size. Since the watermarks are inserted in the 8 × 8 DCT blocks, the size of a block is chosen to be a multiple of 8. The experiments carried out have indicated that m must be above 32 (m ≥32) to provide the same mask even in the presence of attacks. Furthermore, extensive experiments were carried out to determine the limitations of each database in the presence of attacks such as wavelet scalar quantization (WSQ) compression [26], additive white Gaussian noise (AWGN), and mean ﬁltering. 2. RIDGES AREA DETECTION AND EXTRACTION Then, WMij is obtained as follows: As can be seen from Table 2, all test images that form the three databases are robust to mean ﬁltering attack and the technique can extract the same watermarking mask even for a ﬁltering attack with a window size of 7 × 7. However, the test images from database DB2 are more sensitive to WSQ compression and AWGN attacks than the images from the other databases. Images from DB1 are very robust to WSQ compression and images from DB3 are less sensitive to AWGN. 3. WATERMARK GENERATION AND EMBEDDING As mentioned previously, the DCT and DWT domains are used to embed the watermark. The DCT can be applied either to the entire image or blocks as in the JPEG standard [27] as well as the DWT. The watermarking algorithm considered in this work relies on the embedding of a spread spectrum watermark, which spreads the spectrum of the hidden signal over many frequencies making it diﬃcult to detect [28]. The embedding stage starts by decomposing the ﬁngerprint image into blocks as described in the previous section (i.e., spatial blocks of m × m pixels) and only the ridges area blocks are selected to carry the watermark. Thus, using a watermarking mask WM, if WMi = 1, then block Bi is selected; otherwise, it remains unchanged. WMij = +1, if Bij belongs to the ridges area; 0, otherwise. (1) (1) To verify whether the segmentation technique extracts the ridges area accurately, we have assessed this technique using real ﬁngerprint images from the FVC2004 databases (DB1, DB2, and DB3) [25]. The images properties for all selected databases are shown in Table 1. For the sake of illustration, only the results obtained on two ﬁngerprint images (Figures 2, 3, and 4) from each database are reported because similar performances have been achieved while considering other Assuming that the watermark carries a hidden message M with information that can be used, for instance, to identify the intended recipient of the protected image; this message EURASIP Journal on Information Security 8 (a:1) (a:2) (b:1) (b:2) Figure 9: Test images from DB1 (a: Image 98 2, b: Image 20 1): (a:1, b:1) diﬀerence image between original image and watermarked image, (a:2, b:2) diﬀerence image without the ridges area. Watermark applied in the DCT domain with PSNR > 40 using the conventional technique. (a:2) (a:1) (a:1) (a:2) (b:2) (b:1) (b:1) (b:2) Figure 9: Test images from DB1 (a: Image 98 2, b: Image 20 1): (a:1, b:1) diﬀerence image between original image and watermarked image, (a:2, b:2) diﬀerence image without the ridges area. Watermark applied in the DCT domain with PSNR > 40 using the conventional technique. (a:1) (a:2) (b:1) (b:2) Figure 10: Test images from DB2 (a: Image 71 4, b: Image 75 7): (a:1, b:1) diﬀerence image between original image and watermarked image, (a:2, b:2) diﬀerence image without the ridges area. 3. WATERMARK GENERATION AND EMBEDDING Watermark applied in the DCT domain with PSNR > 40 using the conventional technique. (a:1) (a:2) (a:2) (b:1) (b:2) (b:1) (b:2) Figure 10: Test images from DB2 (a: Image 71 4, b: Image 75 7): (a:1, b:1) diﬀerence image between original image and watermarked image, (a:2, b:2) diﬀerence image without the ridges area. Watermark applied in the DCT domain with PSNR > 40 using the conventional technique. Figure 10: Test images from DB2 (a: Image 71 4, b: Image 75 7): (a:1, b:1) diﬀerence image between original image and watermarked image, (a:2, b:2) diﬀerence image without the ridges area. Watermark applied in the DCT domain with PSNR > 40 using the conventional technique. K. Zebbiche et al. 9 Table 2: Watermarking mask extraction in the presence of attacks. The highest attack strength survived by the mask detection is given. Database WSQ AWGN Mean ﬁltering Bit rate (bpp) PSNR SNR (dB) PSNR Kernel size (k × k) PSNR DB1 0.50 32.72 25 25.70 7 × 7 23.87 DB2 0.50 25.67 22 26.20 7 × 7 20.23 DB3 1 21.51 25 31.71 7 × 7 12.71 Table 2: Watermarking mask extraction in the presence of attacks. The highest attack strength survived by the ction in the presence of attacks. The highest attack strength survived by the mask detection is given. (a:1) (a:2) (b:1) (b:2) Figure 11: Test images from DB3 (a: image 47 3, b: image 73 7): (a:1, b:1) diﬀerence image between original image and watermarked image, (a:2, b:2) diﬀerence image without the ridges area. Watermark applied in the DCT domain with PSNR > 40 using the conventional technique. (a:1) (a:2) 3.1. DCT domain After selecting the blocks to be watermarked, a DCT transform is applied on blocks of 8 × 8 pixels, as in the JPEG algorithm [29]. Speciﬁcally, the application of the DCT on 8 × 8 blocks leads to 64 coeﬃcients which are zigzag scanned (i.e., arranged in decreasing order) to obtain one dimensional vector X[N] representing the entire set of the DCT coeﬃcients to be watermarked (the DC component for each block is not used). In order to increase the security level, we propose to introduce some uncertainty about the selected coeﬃcients altered by permuting the coeﬃcients in X[N] using a key K1. g y The information bits b are hidden as follows. (i) The sequence X[N] is partitioned into Nb nonover- lapping sets {Si}Nb i=1. In the following we denote by xi[k] the coeﬃcients belonging to the set Si, where xi[k] ∩xj[k] = ∅for i /= j and Nb i=1xi[k] = X[N]. (a:1) (a:2) (a:2) (b:1) (b:2) (ii) The watermark sequence W[N] is divided into Nb nonoverlapping chunks {wi[k]}Nb i=1, where wi[k] ∩ wj[k] = ∅for i /= j and Nb i=1wi[k] = W[N], so that each chunk wi[k] is associated to one block xi[k] and both are used to carry one information bit bi. (ii) The watermark sequence W[N] is divided into Nb nonoverlapping chunks {wi[k]}Nb i=1, where wi[k] ∩ wj[k] = ∅for i /= j and Nb i=1wi[k] = W[N], so that each chunk wi[k] is associated to one block xi[k] and both are used to carry one information bit bi. (iii) Each element of a chunk wi[k] is multiplied by +1 or −1 according to its associated information bit bi. The result of this multiplication is an amplitude- modulated watermark wi[k]bi. (iv) The watermark is embedded using a multiplicative rule as follows: (b:1) (b:2) yi[k] = 1 + λwi[k]bi xi[k], (2) (2) Figure 11: Test images from DB3 (a: image 47 3, b: image 73 7): (a:1, b:1) diﬀerence image between original image and watermarked image, (a:2, b:2) diﬀerence image without the ridges area. Watermark applied in the DCT domain with PSNR > 40 using the conventional technique. where xi[k] and yi[k] represent the set of the original coeﬃcients and the associated watermarked coeﬃ- cients belonging to the set Si, respectively. 4. OPTIMUM WATERMARKING DECODER where Γ(·) is a Gamma function, Γ(z) = ∞ 0 e−ttz−1dt, z > 0. The parameter α is referred to as the scale parameter representing the width of the PDF peak (standard deviation) and β is called the shape parameter which is inversely proportional to the decreasing rate of the peak. Note that β = 1 and β = 2 yield Laplacian and Gaussian distributions, respectively. The parameters α and β can be estimated as described in [34]. Practically, β can be estimated by solving the following equations of [34] In the watermark decoding process, the decoder obtains an estimate b of the hidden message b embedded in the watermarked coeﬃcients Y[N]. By assuming that all possible messages {bj}2Nb j=1 are equiprobable, a maximum-likelihood (ML) criterion can be used to minimize the error probability and hence derive a structure for an optimum decoder. An optimum ML decoder would decide b ∈{bj}2Nb j=1, such that β = F−1 m1 √m2 , (9) β = F−1 m1 √m2 , (9) b = arg j=1,...,2Nb max fY Y[N] \| W[N], bj , (3) (3) (9) where m1 = (1/L) L i=1\|xi\| and m2 = (1/L) L i=1x2 i are the estimates of the mean absolute value and the variance of the sample dataset, respectively. L is the length of the dataset x. The function F is deﬁned as where fY(Y\|W, bj) is the PDF of the set Y[N] conditioned to the events W[N] and bj. By assuming that (i) the coef- ﬁcients Y[N] are statistically independent, this assumption is justiﬁed for the DCT coeﬃcients given the uncorrelated properties of the DCT for common images and also justiﬁed for the DWT coeﬃcients, and (ii) the hidden sequence b and the values in W[N] are independent of each other, (3) can be written as where fY(Y\|W, bj) is the PDF of the set Y[N] conditioned to the events W[N] and bj. By assuming that (i) the coef- ﬁcients Y[N] are statistically independent, this assumption is justiﬁed for the DCT coeﬃcients given the uncorrelated properties of the DCT for common images and also justiﬁed for the DWT coeﬃcients, and (ii) the hidden sequence b and the values in W[N] are independent of each other, (3) can be written as F(t) = Γ(2/t) Γ(1/t)Γ(3/t). (10) (10) In practical situations, the solution of (9) can be found quickly by using an interpolation and a look-up table. 4. OPTIMUM WATERMARKING DECODER Once the value of β is estimated, α is computed using the following expression: b = arg j=1,...,2Nb max Nb i=1 fyi yi[k] \| wi[k], bji , (4) (4) α = β L L i=1 \|xi\|β 1/β . (11) where yi[k] indicates the coeﬃcients of the set Si carrying the bit bi, and wi[k] is a set from W[N] associated to the same bit bi. The decision criterion for the bit bi can be expressed as (11) Substituting (8) in (7), one obtains Substituting (8) in (7), one obtains bi = arg bi∈{−1,+1} max Si fyi yi[k] \| wi[k], bi = sign ln Si fyi(yi[k] \| wi[k], +1) Si fyi(yi[k] \| wi[k], −1) . (5) bi = sign Si ln 1 −λwi[k] 1 + λwi[k] + 1 α βi i Si yi[k] 1 −λwi[k] βi − yi[k] 1 + λwi[k] βi . (12) (5) According to the multiplicative rule used to embed the watermark, the PDF fy(y) of a marked coeﬃcient yi[k] subject to a watermark value wi[k] and bi can be expressed as (12) 3.1. DCT domain λ is a gain factor used to control the strength of the watermark by amplifying or attenuating the watermark eﬀect on each DCT coeﬃcient, so that the watermark energy is maximized while the alterations suﬀered by the image are kept invisible. is mapped by an encoder into a binary sequence b = {b1b2 ...bNb} of Nb bits (by denoting +1 for bit 1 and −1 for bit 0). The hidden watermark can be retrieved if one knows (a) the entire procedure through which the watermark has been generated, (b) the secret key K2 used to initialize the PRSG, and (c) the second key K1 which is used to permute the coeﬃcients. Thus, an attacker will not be able to extract the watermark without knowledge of the secrete keys K1 and K2, even if the entire watermark generation and embedding process are known. Let W[N] be a pseudorandom sequence uniformly distributed in [−1, +1], generated using a pseudorandom sequence generator (PRSG) initialized by a secret key K2. This pseudorandom sequence is the spreading sequence of the system. Every bit from the sequence b is then multiplied by a set from the sequence W[N] in order to generate an amplitude-modulated watermark, consisting of the spread of the bits b. EURASIP Journal on Information Security 10 where fx(x) indicates the PDF of the original, nonwater- marked coeﬃcients. Substituting (6) in (5), the estimate bit bi is given by [19] 3.2. DWT domain Each block selected to carry the watermark is transformed using the DWT at a level l, which produces (i) a low- resolution subband (LL), (ii) high-resolution horizontal subbands (HLl, HLl−1, ..., HL1), (iii) high-resolution verti- cal subbands (LHl, LHl−1, ..., LH1), and (iv) high-resolution diagonal subbands (HHl, HHl−1, ..., HH1). A watermark should be embedded in the high-resolution subbands, where the human eye is less sensitive to noise and distortions [30, 31]. In this work, all coeﬃcients of the high-resolution subbands are used to carry the watermark sequence and the set of coeﬃcients to watermarked X[N] is deﬁned as { l i=1HLi}∪{ l i=1LHi}∪{ l i=1HHi}. The watermark is then embedded by following the same steps described above for the DCT domain. bi = sign Si ln 1 −λwi[k] 1 + λwi[k] + Si ln fx(yi[k]/(1 + λwi[k])) fx(yi[k]/(1 −λwi[k])) . (7) (7) The host coeﬃcients of the DCT and the DWT can be modeled by the Laplacian model [32, 33]. However, they are widely modeled using a zero-mean GGD whose PDF is given by fx(xi; α, β) = β 2αΓ(1/β) exp − \|xi\| α β , (8) (8) 5. EXPERIMENTAL RESULTS 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 75 7 (a) 550 500 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 71 4 BER for image 75 7 BER for image 71 4 BER Number of coeﬃcients per information bit Number of coeﬃcients per information bit (c) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 12 BER f i f h b f ﬃi bi (d) 500 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 73 7 BER for image 73 7 BER for image 47 3 BER Number of coeﬃcients per information bit Number of coeﬃcients per information bit (f) (e) Figure 12: BER as a function of the number of coeﬃcients per bit for the segmented images. Watermark applied in the DCT domain. Figure 12: BER as a function of the number of coeﬃcients per bit for the segmented images. Watermark appl FVC2004 (DB1, DB2, and DB3). In the DWT domain, the images were transformed using Daubechies9/7 wavelets [35] at the 3rd decomposition level and all coeﬃcients of the high-resolution subbands (HLl, LHl, and HHl subbands of the levels l = 1, 2, 3) were used to carry the watermark. Daubechies9/7 wavelets were used because they have been adopted by the FBI as part of the WSQ compression standard for ﬁngerprint images [36]. In all experiments, a blind watermark decoding is used so that the parameters αi and βi of each set Si are directly estimated from the DCT and the DWT coeﬃcients of the watermarked images since the strength λ is chosen to be suﬃciently small to not alter the visual quality of the original images. 5. EXPERIMENTAL RESULTS fyi yi[k] \| wi[k], bi = 1 1 + λwi[k]bi fx yi[k] 1 + λwi[k]bi , (6) To gauge the eﬀectiveness of our proposed technique, exper- iments were performed with test images from the databases K. Zebbiche et al. 11 . Zebbiche et al. 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 550 500 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 71 4 (c) 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 75 7 (d) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 500 450 400 350 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 73 7 Proposed technique Conventional technique (f) Figure 12: BER as a function of the number of coeﬃcients per bit for the segmented images. Watermark applied in the DCT domain. 5. EXPERIMENTAL RESULTS 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 20 1 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 BER for image 20 1 BER (a) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 71 4 (b) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 75 7 BER for image 75 7 BER for image 71 4 BER BER Number of coeﬃcients per information bit Number of coeﬃcients per information bit (d) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 73 7 (c) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 47 3 BER for image 47 3 BER for image 73 7 BER BER Number of coeﬃcients per information bit Number of coeﬃcients per information bit Proposed technique Conventional technique (e) (e) (f) Figure 13: BER as a function of the number of coeﬃcients per bit for the segmented images. Watermark applied in the DWT domain. function of the number of coeﬃcients per bit for the segmented images. Watermark applied in the DWT doma Figure 13: BER as a function of the number of coeﬃcients per bit for the segmented images. Watermark appl related the test images shown in Figures 2, 3, and 4 are plotted because the results from other images are very similar. area: the larger the ridges area is, the more bits can be hidden, and vice versa. Table 4 shows an example of the number of bits that test images can carry with the number of coeﬃcients per set Si = 500. As can be seen, images with large ridges area (image 98 2, image 71 4, and image 47 3) allow more bits to be hidden than images with relatively smaller ridges area (image 20 1, image 75 7, and image 73 7). 5. EXPERIMENTAL RESULTS For the sake of fair comparison, the performance of the proposed technique is compared against the conventional technique using the same decoder. By conventional watermarking, it is meant a technique which operates on the whole transform coeﬃcients as described in [10, 19]. The performance is assessed by the bit error rate (BER), that is, the average number bit errors. For the sake of illustration, only results EURASIP Journal on Information Security 12 2 EURASIP Journal on Information Secur 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 300 250 200 150 100 50 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 71 4 (c) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−3 10−2 10−1 100 BER BER for image 75 7 (d) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 1000 900 800 700 600 500 400 300 200 100 Number of coeﬃcients per information bit 10−2 10−1 100 BER BER for image 73 7 Proposed technique Conventional technique (f) Figure 13: BER as a function of the number of coeﬃcients per bit for the segmented images. Watermark applied in the DWT domain. 5. EXPERIMENTAL RESULTS 600 550 500 450 400 350 300 250 200 Number of hidden information bits 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 200 180 160 140 120 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 20 1 BER ( ) 500 450 400 350 300 250 200 150 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 71 4 400 350 300 250 200 150 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 75 7 BER for image 75 7 BER for image 71 4 BER BER (d) (c) (c) 600 500 400 300 200 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 47 3 (d) 450 350 250 150 50 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 73 7 BER for image 73 7 BER for image 47 3 BER Proposed technique Conventional technique (e) Proposed technique Conventional technique (f) (f) (e) ure 14: BER as a function of total amount of hidden information bits. Watermark applied in the DCT domain. for the extraction of the hidden message with low BER and (b) determine the number of bits that an image can hold. The results shown by Figures 5 and 6 were obtained by averaging out 100 watermark sequences randomly generated. The value of λ was set to obtain a PSNR value ≈40 for all test images. This is justiﬁed by the fact that a larger set provides more redundancy in the sense that each bit is carried by a higher number of coeﬃcients. Furthermore, from the view point of implementation, a large set can be accurately modeled and the distribution of its coeﬃcients is well approximated. However, in the case of the conventional technique operating on images from DB1 (i.e., image 98 2 and image 20 1, where the background is almost white), the BER is high and almost unchanged against an increase of the size of Si. One can explain this by the fact that, in general, since As can be seen from Figures 5 and 6, the proposed technique outperforms the conventional one, even without applying any attack. 5. EXPERIMENTAL RESULTS As mentioned earlier, embedding the watermark in the ridges area (highly textured area) allows the use of a higher strength λ than that used by the conventional technique at the same imperceptibility level measured by PSNR. This is illustrated by Table 3. In the ﬁrst analysis, the BER as a function of the number of coeﬃcients in the set Si is investigated and assessed. This will help to (a) estimate the number of coeﬃcients necessary It is worth noting that, in the proposed method, the number of bits that an image can carry is image dependent; more precisely it depends heavily on the size of the ridges K. Zebbiche et al. 13 biche et al. 600 550 500 450 400 350 300 250 200 Number of hidden information bits 10−4 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 200 180 160 140 120 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 500 450 400 350 300 250 200 150 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 71 4 (c) 400 350 300 250 200 150 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 75 7 (d) 600 500 400 300 200 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 450 350 250 150 50 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 73 7 Proposed technique Conventional technique (f) Figure 14: BER as a function of total amount of hidden information bits. Watermark applied in the DCT domain. 5. EXPERIMENTAL RESULTS Another point that should be raised is the inﬂuence of the size of sets Si on the performance of the decoder: the larger the set, the better the results. EURASIP Journal on Information Security 14 EURASIP Journal on Information 600 550 500 450 400 350 300 250 200 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 200 180 160 140 120 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 20 1 (b) 500 450 400 350 300 250 200 150 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 71 4 (c) 450 400 350 300 250 200 150 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 75 7 (d) 600 500 400 300 200 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 550 450 350 250 150 50 Number of hidden information bits 10−2 10−1 100 BER BER for image 73 7 Proposed technique Conventional technique (f) Figure 15: BER as a function of total amount of hidden information bits. Watermark applied in the DWT domain. 200 180 160 140 120 100 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 20 1 600 550 500 450 400 350 300 250 200 Number of hidden information bits 10−3 10−2 10−1 100 BER BER for image 98 2 BER for image 20 1 BER BER ( ) 500 450 400 350 300 250 200 150 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 71 4 450 400 350 300 250 200 150 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 75 7 BER for image 71 4 BER for image 75 7 Number of hidden information bits Number of hidden information bits (d) (c) 600 500 400 300 200 100 Number of hidden information bits 10−2 10−1 100 BER BER for image 47 3 550 450 350 250 150 50 Number of hidden information bits 10−2 10−1 100 BER BER for image 73 7 BER for image 47 3 BER for image 73 7 Proposed technique Conventional technique (e) Proposed technique Conventional technique (f) (f) (e) ure 15: BER as a function of total amount of hidden information bits. 5. EXPERIMENTAL RESULTS Watermark applied in the DWT domain. a white background and smooth areas produce large number of null coeﬃcients in both the DCT and DWT domains and according to the multiplicative rule used, these null coeﬃcients cannot carry signiﬁcant portion of watermark, thereby making these coeﬃcients not reliable for decoding. that for the conventional one in the case of small number of bits. However, as the number of bits becomes higher, the conventional technique outperforms the proposed one. This is justiﬁed by the fact that the proposed technique provides coeﬃcients with higher amplitudes, allowing the embedding of watermarks with higher amplitudes. Therefore, for small number of bits, the proposed technique can provide enough coeﬃcients for each bit. On the other hand, the conventional technique has more coeﬃcients than the proposed one. Consequently, for large number of bits, the set Si is much y g g We have also investigated the variations of BER against the total number of hidden information bits. The results are plotted in Figures 7 and 8 for the DCT and the DWT domains, respectively. As can be seen, for images form DB2 and DB3, the BER is lower for the proposed technique than K. Zebbiche et al. 15 K. Zebbiche et al. 0.5 0.75 1 1.25 1.5 (bpp) 10−3 10−2 10−1 100 BER BER for image 98 2 (a) 0.5 0.75 1 1.25 1.5 (bpp) 10−2 10−1 100 BER BER for image 98 2 (b) 0.5 0.75 1 1.25 1.5 (bpp) 10−2 10−1 100 BER BER for image 71 4 (c) 0.5 0.75 1 1.25 1.5 (bpp) 10−1 100 BER BER for image 71 4 (d) 1 1.25 1.5 1.75 2 (bpp) 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 1 1.25 1.5 1.75 2 (bpp) 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (f) Figure 16: Robustness against WSQ compression with decreasing bit per pixel. Left side: the DCT domain. 5. EXPERIMENTAL RESULTS First, we have investigated the dispersion of the watermarks EURASIP Journal on Information Security 16 40 35 30 25 SNR (dB) 10−4 10−3 10−2 10−1 100 BER BER BER for image 98 2 (a) 40 35 30 25 SNR (dB) 10−3 10−2 10−1 100 BER BER for image 98 2 (b) 40 35 30 25 SNR (dB) 10−3 10−2 10−1 BER BER for image 71 4 (c) 40 35 30 25 SNR (dB) 10−2 10−1 100 BER BER for image 71 4 (d) 40 35 30 25 SNR (dB) 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 40 35 30 25 SNR (dB) 10−2 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (f) Figure 17: Robustness against white Gaussian Noise with increasing SNR. Left side: the DCT domain. Right side: the DWT domain. 40 35 30 25 SNR (dB) 10−3 10−2 10−1 100 BER BER for image 98 2 (b) BER for image 71 4 40 35 30 25 SNR (dB) 10−4 10−3 10−2 10−1 100 BER BER BER for image 98 2 BER for image 98 2 BER 40 35 30 25 SNR (dB) 10−3 10−2 10−1 BER BER for image 71 4 40 35 30 25 SNR (dB) 10−2 10−1 100 BER BER for image 71 4 BER for image 71 4 BER for image 71 4 40 35 30 25 SNR (dB) 10−2 10−1 100 BER BER for image 47 3 40 35 30 25 SNR (dB) 10−2 10−1 100 BER BER for image 47 3 BER BER Proposed technique Conventional technique (f) (e) (f) ness against white Gaussian Noise with increasing SNR. Left side: the DCT domain. Right side: the DWT domain Figure 17: Robustness against white Gaussian Noise with increasing SNR. Left side: the DCT domain. Right as explained above, this is due to the fact that a white background produces null coeﬃcients thereby ruling it out for any eﬀective watermark embedding. embedding in the DWT domain are very similar. As can be seen, a relatively large part of the watermark is embedded within the background area, especially images with small ridges area (i.e., image 75 7 and image 73 7), which can be easily removed by segmenting the image. 5. EXPERIMENTAL RESULTS Right side: the DWT domain 0.5 0.75 1 1.25 1.5 (bpp) 10−3 10−2 10−1 100 BER BER for image 98 2 0.5 0.75 1 1.25 1.5 (bpp) 10−2 10−1 100 BER BER for image 98 2 BER (a) 0.5 0.75 1 1.25 1.5 (bpp) 10−2 10−1 100 BER BER for image 71 4 (b) 0.5 0.75 1 1.25 1.5 (bpp) 10−1 100 BER BER for image 71 4 BER for image 71 4 BER for image 71 4 BER BER ( ) 1 1.25 1.5 1.75 2 (bpp) 10−1 100 BER BER for image 47 3 ( ) 1 1.25 1.5 1.75 2 (bpp) 10−1 100 BER BER for image 47 3 BER BER Proposed technique Conventional technique (e) Proposed technique Conventional technique (f) (f) (e) Figure 16: Robustness against WSQ compression with decreasing bit per pixel. Left side: the DCT domain. Right side: the DWT domain. s against WSQ compression with decreasing bit per pixel. Left side: the DCT domain. Right side: the DWT dom Figure 16: Robustness against WSQ compression with decreasing bit per pixel. Left side: the DCT domain. Rig larger than that of the proposed technique, thus allowing for the decoding of the watermark with lower BERs. For images DB1, the proposed technique outperforms the conventional one for both the DCT and DWT domains. in the spatial domain in the case of the conventional technique before showing the portions/parts of the image removed by the segmentation process (i.e., the portion of the watermark removed by the segmentation). Figures 9, 10, and 11(a:1, b:1) show the diﬀerence images between the original images and the corresponding watermarked images while Figures 9, 10, and 11(a:2, b:2) represent this diﬀerence image without the watermarked ridges area, which corresponds to the removed watermark. Here, we only display the results related to the DCT domain as the results obtained from As mentioned previously, a common attack that one can apply to ﬁngerprint images is the segmentation because this technique preserves most of the ridges area and removes the background (i.e., removes the watermark embedded within the background while keeping the ridges area unaltered). 5. EXPERIMENTAL RESULTS In addition, it can be said that images from database DB1 make the exception so that most of the watermark is embedded within the ridges area and, thus, the segmentation process will not aﬀect signiﬁcantly the decoding performance and, The next analysis consists of extending the previous experiments but on the segmented images. The results of the ﬁrst experiment are plotted in Figures 12 and 13 for the DCT and DWT domains, respectively, while the results of the second experiment are plotted in Figures 14 and 15 for the DCT and the DWT domains, respectively. In the case of our 17 17 K. Zebbiche et al. 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 98 2 (a) 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 98 2 (b) 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 71 4 (c) 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 71 4 (d) 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (e) 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 47 3 Proposed technique Conventional technique (f) Figure 18: Robustness against Mean ﬁltering with increasing ﬁlter size. Left side: the DCT domain. Right side: the DWT domain. 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 98 2 (b) 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 98 2 BER BER 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 71 4 BER BER 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 47 3 7 × 7 5 × 5 3 × 3 Filter size 10−1 100 BER BER for image 47 3 BER BER Proposed technique Conventional technique (e) Proposed technique Conventional technique (f) (f) (e) Figure 18: Robustness against Mean ﬁltering with increasing ﬁlter size. Left side: the DCT domain. Right side: tness against Mean ﬁltering with increasing ﬁlter size. Left side: the DCT domain. 6. CONCLUSIONS several times by varying the attack strength and reporting the average value of BER over 100 diﬀerent pseudorandom watermarks. Note that results related to one image from each database are plotted since results of other images are similar. This paper proposes an eﬃcient technique for use in ﬁnger- print images watermarking. The rationale of the technique consists of embedding the watermark into the ridges area of the ﬁngerprint images which constitutes the region of interest. The key features of the proposed technique are to (i) preserve the watermark from segmentation which can be considered as a special case of the cropping attack, (ii) increase the robustness of the watermark against known attacks such as ﬁltering, noise, and compression, and (iii) allow to embed imperceptible watermarks by embedding in highly textured areas. The technique starts by ﬁrst extracting the ridges area from ﬁngerprint images using the segmentation technique proposed by Wu et al. [20], which has been modiﬁed to generate adaptive thresholds instead of ﬁxed ones, thereby making it more practical. This leads to a binary mask referred to as the segmentation mask. In order to ensure that the full watermark is embedded into the ridges area, the segmentation mask is partitioned into blocks, represented by another binary mark called watermarking mask. Robustness against WSQ compression is assessed by iter- atively applying the WSQ compression on the watermarked images using the WSQ viewer [37] varying the bit-rate value measured by bits per pixel (bpp). The results for the embed- ded watermark in the DCT and DWT domains are illustrated by Figure 16. Due to the segmentation technique used to extract the ridges area (see Section 2), the compression ratio is varied between 1.5 bpp and 0.5 bpp for images from DB1 and DB2, and between 1 bpp and 2 bpp for images from DB3. It is worth mentioning that for all images and the two domains, the WSQ compression does not aﬀect signiﬁcantly the ridges; the visual alterations are more severe in the background especially around the ridges area. This is due to the fact that the human eye is less sensitive to changes in textured areas. As can be seen from Figure 16, the proposed technique outperforms the conventional technique for all compression ratios. Figure 17 shows the results for BER of watermarked ﬁngerprint images corrupted by AWGN in the DCT and the DWT domains. 5. EXPERIMENTAL RESULTS Right side: the DWT domain. Extensive experiments have also been conducted to gauge the performance of the proposed technique with respect to robustness in comparison with the conventional technique. Three sets of experiments have been carried out to measure the robustness of the watermark against the common attacks, namely, WSQ compression, mean ﬁltering, and AWGN. In all these experiments, the value of the strength λ is chosen in such a way to obtain PSNR value ≈40 and the number of coeﬃcients per bit is set to 500. Each attack has been applied proposed technique, it can be seen from the ﬁgures that the BER is similar to that of the ﬁrst experiment, thereby, con- ﬁrming that the segmentation process has no inﬂuence on the performance of the decoding process and the watermark remains unaltered. For the conventional technique, the BER increases signiﬁcantly and the segmentation process causes a considerable loss of the watermark information for images from databases DB2 and DB3. However, as expected, the BER is unchanged in the case of images from DB1. proposed technique, it can be seen from the ﬁgures that the BER is similar to that of the ﬁrst experiment, thereby, con- ﬁrming that the segmentation process has no inﬂuence on the performance of the decoding process and the watermark remains unaltered. For the conventional technique, the BER increases signiﬁcantly and the segmentation process causes a considerable loss of the watermark information for images from databases DB2 and DB3. However, as expected, the BER is unchanged in the case of images from DB1. EURASIP Journal on Information Security 18 Table 3: Strength of the watermark λ with PSNR ≈40 for both the proposed technique and the conventional technique. Database Image Technique DCT domain DWT domain DB1 Image 98 2 Proposed 0.52 0.40 conventional 0.47 0.32 Image 20 1 Proposed 0.55 0.50 conventional 0.45 0.35 DB2 Image 71 4 Proposed 0.31 0.21 conventional 0.28 0.18 Image 75 7 Proposed 0.34 0.23 conventional 0.31 0.21 DB3 Image 47 3 Proposed 0.17 0.13 conventional 0.15 0.11 Image 73 7 Proposed 0.21 0.15 conventional 0.17 0.13 watermark λ with PSNR ≈40 for both the proposed technique and the conventional technique. Table 4: Number of bits per image. Watermark embedded using the proposed technique. are blurred using mean ﬁlter with diﬀerent sizes. 5. EXPERIMENTAL RESULTS It is worth noting that mean ﬁltering causes a signiﬁcant degradation to the visual quality of the images even for window size of 3 × 3. In addition, this process aﬀects severely the embedded watermark and the decoder produces high error rates. For both transform domains, the proposed technique performs signiﬁcantly better than the conventional one for images from DB1 (improvement of 0.25 for ﬁlter window size 3 × 3) while the diﬀerences are very marginal for databases DB2 and DB3 (around 0.01 in terms of BER). Table 4: Number of bits per image. Watermark embedded using the proposed technique. Database Image DCT domain DWT domain DB1 Image 98 2 120 131 Image 20 1 98 106 DB2 Image 71 4 100 108 Image 75 7 80 88 DB3 Image 47 3 126 137 Image 73 7 38 48 REFERENCES [1] A. K. Jain and U. Uludag, “Hiding biometric data,” IEEE Transactions on Pattern Analysis and Machine Intelligence, vol. 25, no. 11, pp. 1494–1498, 2003. [16] X. Huang and B. Zhang, “Statistically robust detection of mul- tiplicative spread-spectrum watermarks,” IEEE Transactions on Information Forensics and Security, vol. 2, no. 1, pp. 1–13, 2007. [2] N. K. Ratha, J. H. Connell, and R. M. Bolle, “Secure data hiding in wavelet compressed ﬁngerprint images,” in Proceedings of the ACM Workshops on Multimedia Conference, pp. 127–130, Los Angeles, Calif, USA, October-November 2000. [17] M. Barni, F. Bartolini, A. De Rosa, and A. Piva, “Optimum decoding and detection of multiplicative watermarks,” IEEE Transactions on Signal Processing, vol. 51, no. 4, pp. 1118–1123, 2003. [18] K.-S. Song, “Blind eﬃcient scores detection and decoding of multibit watermarks,” in Mathematics of Data/Image Coding, Compression, and Encryption VIII, with Applications, vol. 5915 of Proceedings of SPIE, pp. 1–10, San Diego, Calif, USA, August 2005. [3] B. Gunsel, U. Uludag, and A. M. Tekalp, “Robust watermark- ing of ﬁngerprint images,” Pattern Recognition, vol. 35, no. 12, pp. 2739–2747, 2002. [4] K. Zebbiche, L. Ghouti, F. Kheliﬁ, and A. Bouridane, “Protect- ing ﬁngerprint data using watermarking,” in Proceedings of the 1st NASA/ESA Conference on Adaptive Hardware and Systems (AHS ’06), pp. 451–456, Istanbul, Turkey, June 2006. [19] K. Zebbiche, F. Kheliﬁ, and A. Bouridane, “Multibit decoding of multiplicative watermarking for ﬁngerprint images,” in Proceedings of the 4th IET International Conference on Visual Information Engineering (VIE ’07), pp. 1095–1103, London, UK, July 2007. [5] K. Zebbiche, F. Kheliﬁ, and A. Bouridane, “Optimum detec- tion of multiplicative-multibit watermarking for ﬁngerprint images,” in Proceedings of the 2nd International Conference on Advances in Biometrics (ICB ’07), vol. 4642 of Lecture Notes in Computer Science, pp. 732–741, Seoul, Korea, August 2007. [20] C. Wu, S. Tulyakov, and V. Govindaraju, “Robust point-based feature ﬁngerprint segmentation algorithm,” in Proceedings of the 2nd International Conference on Biometrics (ICB ’07), vol. 4642 of Lecture Notes in Computer Science, pp. 1095–1103, Seoul, Korea, August 2007. [6] M. Yoshida, T. Fujita, and T. Fujiwara, “A new optimum detection scheme for additive watermarks embedded in spatial domain,” in Proceedings of International Conference on Intel- ligent Information Hiding and Multimedia Signal Processing (IIH-MSP ’06), pp. 101–104, Pasadena, Calif, USA, December 2006. [21] X. Chen, J. Tian, J. Cheng, and X. 6. CONCLUSIONS The Gaussian noise is added with diﬀerent value of signal-to-noise ratio (SNR). For all images and both domains, our proposed technique provides attractive results and signiﬁcantly outperforms the conventional technique. The results for degradations due to a linear mean ﬁltering are presented in Figure 18. The watermarked ﬁngerprint images The proposed technique has been applied to the opti- mum multibit, multiplicative watermark decoding. The watermark is embedded in the well-known transform domains, namely, the DCT and the DWT. The optimum decoder is based on the ML scheme and the coeﬃcients of the two domains are modeled by a generalized Gaussian distribution. It is worth mentioning that the number of bits 19 K. Zebbiche et al. of Proceedings of SPIE, pp. 816–826, San Jose, Calif, USA, January 2004. that an image can carry is image dependent (i.e., it depends on the ridges area meaning that a larger area allows more bits to be embedded and vice versa). The results obtained clearly show the improvements introduced by the proposed technique even in the absence of attacks. Furthermore, as the segmentation technique removes the part of the watermark embedded within the background area, it aﬀects the performance of the conventional optimum decoder. However, this attack has no eﬀect on the proposed technique. Moreover, the proposed technique provides more robustness in the presence of attacks such as WSQ compression, mean ﬁltering, and additive white noise. [11] F. Kheliﬁ, A. Bouridane, F. Kurugollu, and A. I. Thompson, “An improved wavelet-based image watermarking technique,” in Proceedings of IEEE International Conference on Advanced Video and Signal Based Surveillance (AVSS ’05), pp. 588–592, Como, Italy, September 2005. [12] Q. Cheng and T. S. Huang, “An additive approach to transform-domain information hiding and optimum detec- tion structure,” IEEE Transactions on Multimedia, vol. 3, no. 3, pp. 273–284, 2001. [13] M. Barni, F. Bartolini, A. De Rosa, and A. Piva, “A new decoder for the optimum recovery of nonadditive watermarks,” IEEE Transactions on Image Processing, vol. 10, no. 5, pp. 755–766, 2001. Finally, it should be mentioned that the proposed technique can be easily applied to other biometric images such as face, hand, and iris, since this type of images has only one deﬁned region of interest. Also, it can be used to some natural images whose region of interest can be deﬁned and extracted. [14] Q. Cheng and T. S. 6. CONCLUSIONS Huang, “Robust optimum detection of transform domain multiplicative watermarks,” IEEE Transac- tions on Signal Processing, vol. 51, no. 4, pp. 906–924, 2003. [15] F. Kheliﬁ, A. Bouridane, and F. Kurugollu, “On the optimum multiplicative watermark detection in the transform domain,” in Proceedings of IEEE International Conference on Image Processing (ICIP ’06), pp. 1373–1376, Atlanta, Ga, USA, October 2006. REFERENCES Yang, “Segmentation of ﬁngerprint images using linear classiﬁer,” EURASIP Journal on Applied Signal Processing, vol. 2004, no. 4, pp. 480–494, 2004. [7] I. G. Karybali and K. Berberidis, “Eﬃcient spatial image watermarking via new perceptual masking and blind detection schemes,” IEEE Transactions on Information Forensics and Security, vol. 1, no. 2, pp. 256–274, 2006. [22] F. Alonso-Fernandez, J. Fierrez-Aguilar, and J. Ortega-Garcia, “An enhanced gabor ﬁlter-based segmentation algorithm for ﬁngerprint recognition systems,” in Proceedings of the 4th International Symposium on Image and Signal Processing and Analysis (ISPA ’05), vol. 15, pp. 239–244, Zagreb, Croatia, Septembre 2005. [8] J. R. Hernandez, M. Amado, and F. Perez-Gonzalez, “DCT- domain watermarking techniques for still images: detectorper- formance analysis and a new structure,” IEEE Transactions on Image Processing, vol. 9, no. 1, pp. 55–68, 2000. [23] C. Harris and M. Stephens, “A combined corner and edge detector,” in Proceedings of the 4th Alvey Vision Conference, vol. 15, pp. 147–151, Manchester, UK, September 1988. [9] A. Briassouli and M. G. Strintzis, “Locally optimum nonlin- earities for DCT watermark detection,” IEEE Transactions on Image Processing, vol. 13, no. 12, pp. 1604–1617, 2004. [24] N. Otsu, “A threshold selection method from gray-level his- tograms,” IEEE Transactions on Systems, Man and Cybernetics, vol. 9, no. 1, pp. 62–66, 1979. [10] T. M. Ng and H. K. Garg, “Wavelet domain watermarking using maximum-likelihood detection,” in Security, Steganog- raphy, and Watermarking of Multimedia Contents VI, vol. 5306 [25] Fingerprint veriﬁcation competition, http://biometrics.cse. msu.edu/fvc04db/index.html. EURASIP Journal on Information Security 20 [26] U.S. Federal Bureau of Invetigation, “WSQ gray-scale ﬁnger- print image comprssion speciﬁcation,” February 1993. [27] M. Nelson, The Data Compression Book, MT Press, New York, NY, USA, 1992. [28] J. G. Proakis, Digital Communications, McGraw Hill, New York, NY, USA, 2000. [29] G. K. Wallace, “The JPEG still picture compression standard,” IEEE Transactions on Consumer Electronics, vol. 38, no. 1, pp. 18–34, 1992. [30] X.-G. Xia, C. G. Boncelet, and G. R. Arce, “Wavelet transform based watermark for digital images,” Optics Express, vol. 3, no. 12, pp. 497–511, 1998. [31] G. C. Langelaar, I. Styawan, and R. L. Lagendijk, “Watermark- ing digital image and video data: a state-of-the-art overview,” IEEE Signal Processing Magazine, vol. 17, no. 5, pp. 20–46, 2000. [32] D. Simitopoulos, S. A. Tsaftaris, N. V. Boulgouris, A. Brias- souli, and M. G. [37] WSQ viewer (version 2.7), http://www.cognaxon.com/index. php?page=wsqview. Preliminaryȱcallȱforȱpapers The 2011 European Signal Processing Conference (EUSIPCOȬ2011) is the nineteenth in a series of conferences promoted by the European Association for Signal Processing (EURASIP, www.eurasip.org). This year edition will take place in Barcelona, capital city of Catalonia (Spain), and will be jointly organized by the Centre Tecnològic de Telecomunicacions de Catalunya (CTTC) and the Universitat Politècnica de Catalunya (UPC). EUSIPCOȬ2011 will focus on key aspects of signal processing theory and li ti li t d b l A t f b i i ill b b d lit applications as listed below. Acceptance of submissions will be based on quality, relevance and originality. Accepted papers will be published in the EUSIPCO proceedings and presented during the conference. Paper submissions, proposals for tutorials and proposals for special sessions are invited in, but not limited to, the following areas of interest. Areas of Interest • Audio and electroȬacoustics. • Design, implementation, and applications of signal processing systems. l d l d d • Multimedia signal processing and coding. • Image and multidimensional signal processing. • Signal detection and estimation. • Sensor array and multiȬchannel signal processing. • Sensor fusion in networked systems. • Signal processing for communications. • Medical imaging and image analysis. • NonȬstationary, nonȬlinear and nonȬGaussian signal processing. REFERENCES Strintzis, “Fast watermarking of MPEG-1/2 streams using compressed-domain perceptual embedding and a generalized correlator detector,” EURASIP Journal on Applied Signal Processing, vol. 2004, no. 8, pp. 1088–1106, 2004. [33] T. M. Ng and H. K. Garg, “Maximum-likelihood detection in DWT domain image watermarking using Laplacian model- ing,” IEEE Signal Processing Letters, vol. 12, no. 4, pp. 285–288, 2005. [34] M. N. Do and M. Vetterli, “Wavelet-based texture retrieval using generalized Gaussian density and Kullback-Leibler dis- tance,” IEEE Transactions on Image Processing, vol. 11, no. 2, pp. 146–158, 2002. [35] A. Cohen, I. Daubechies, and J.-C. Feauveau, “Biorthogonal bases of compactly supported wavelets,” Communications on Pure and Applied Mathematics, vol. 45, no. 5, pp. 485–560, 1992. [36] T. Hopper, C. Brislawn, and J. Bradley, “Wsq grey-scale ﬁngerprint image compression speciﬁcation, version 2.0,” Tech. Rep., Criminal Justice Information Services, Federal Bureau of Investigation, Washington, DC, USA, February 1993. [37] WSQ viewer (version 2.7), http://www.cognaxon.com/index. php?page=wsqview. Photographȱ©ȱTurismeȱdeȱBarcelonaȱ/ȱJ.ȱTrullàs OrganizingȱCommittee HonoraryȱChair MiguelȱA.ȱLagunasȱ(CTTC) GeneralȱChair AnaȱI.ȱPérezȬNeiraȱ(UPC) GeneralȱViceȬChair CarlesȱAntónȬHaroȱ(CTTC) TechnicalȱProgramȱChair XavierȱMestreȱ(CTTC) Technical Program CoȬChairs TechnicalȱProgramȱCo Chairs JavierȱHernandoȱ(UPC) MontserratȱPardàsȱ(UPC) PlenaryȱTalks FerranȱMarquésȱ(UPC) YoninaȱEldarȱ(Technion) SpecialȱSessions IgnacioȱSantamaríaȱ(Unversidadȱ deȱCantabria) MatsȱBengtssonȱ(KTH) Finances Montserrat Nájar (UPC) MontserratȱNájarȱ(UPC) Tutorials DanielȱP.ȱPalomarȱ (HongȱKongȱUST) BeatriceȱPesquetȬPopescuȱ(ENST) Publicityȱ StephanȱPfletschingerȱ(CTTC) MònicaȱNavarroȱ(CTTC) Publications AntonioȱPascualȱ(UPC) CarlesȱFernándezȱ(CTTC) I d i l Li i & E hibi IndustrialȱLiaisonȱ&ȱExhibits AngelikiȱAlexiouȱȱ (UniversityȱofȱPiraeus) AlbertȱSitjàȱ(CTTC) InternationalȱLiaison JuȱLiuȱ(ShandongȱUniversityȬChina) JinhongȱYuanȱ(UNSWȬAustralia) TamasȱSziranyiȱ(SZTAKIȱȬHungary) RichȱSternȱ(CMUȬUSA) RicardoȱL.ȱdeȱQueirozȱȱ(UNBȬBrazil) Preliminaryȱcallȱforȱpapers Submissions Submissions Procedures to submit a paper and proposals for special sessions and tutorials will be detailed at www.eusipco2011.org. Submitted papers must be cameraȬready, no more than 5 pages long, and conforming to the standard specified on the EUSIPCO 2011 web site. First authors who are registered students can participate in the best student paper competition. ImportantȱDeadlines: p P l f i l i 15 D 2010 Webpage:ȱwww.eusipco2011.org Proposalsȱforȱspecialȱsessionsȱ 15ȱDecȱ2010 Proposalsȱforȱtutorials 18ȱFeb 2011 Electronicȱsubmissionȱofȱfullȱpapers 21ȱFeb 2011 Notificationȱofȱacceptance 23ȱMay 2011 SubmissionȱofȱcameraȬreadyȱpapers 6ȱJun 2011 P l f i l i 15 D 2010 Webpage:ȱwww.eusipco2011.org Proposalsȱforȱspecialȱsessionsȱ 15ȱDecȱ2010 Proposalsȱforȱtutorials 18ȱFeb 2011 Electronicȱsubmissionȱofȱfullȱpapers 21ȱFeb 2011 Notificationȱofȱacceptance 23ȱMay 2011 SubmissionȱofȱcameraȬreadyȱpapers 6ȱJun 2011

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